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If Your Doctor Leaves Your Health Plan, You Can't Easily Follow

NPR Health Blog - 4 hours 2 min ago
If Your Doctor Leaves Your Health Plan, You Can't Easily Follow June 02, 2015 9:50 AM ET

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Michelle Andrews

This week, I addressed a grab bag of questions related to insurance coverage of hearing aids, doctors who drop out of a plan midyear and what happens if you receive subsidies for exchange coverage but learn later on you were eligible for Medicaid all along.

My doctor is leaving my provider network in the middle of the year. Does that unexpected change mean I can switch to a new plan?

Some life changes entitle you to switch plans outside your health plan's regular annual open enrollment period—losing your on-the-job coverage is one example—but losing access to your doctor generally doesn't qualify.

There are some exceptions, however. Several states have so-called continuity of care laws that allow people to keep seeing a specific doctor after the physician leaves a provider network if patients are undergoing treatment for a serious medical condition, have a terminal illness or are pregnant, among other things. How long a patient is allowed to continue to see that doctor varies by state. It may be 90 days, for the duration of treatment or the end of a pregnancy, for example.

State continuity of care laws don't apply to self-funded plans that pay their employees' claims directly.

Some seniors in private Medicare Advantage plans may also be allowed to change plans midyear if their physicians or other providers leave their current network, according to rules that went into effect this year.

When my 8-year-old son's elementary school conducted a hearing and eye exam, he failed the hearing portion and we learned he has moderate to severe hearing loss. I called our insurance company only to find out that it doesn't cover hearing-related issues or costs associated with devices because it's deemed not medically necessary. What are middle-income families supposed to do? I can't be the only mom who can't come up with $6,000 for the devices and at least that for the specialists he needs to see.

Insurance coverage for hearing aids and related services for children and adults is often lacking.

"It is amazing to me that a health plan is happy to pay for Viagra, but can't pay for hearing aids so a child can go to school and hear well," says Anna Gilmore Hall, executive director of the Hearing Loss Association of America, an advocacy group.

There are programs that provide financial assistance to help parents afford hearing aids for their children, but they are often limited to low-income families. Some states mandate hearing aid coverage, typically providing up to about $1,500 per year per child, says Suzanne D'Amico, the northeast region Walk4Hearing coordinator at the hearing loss association.

When D'Amico's daughter was diagnosed with hearing loss seven years ago at age 4, she and her husband put the child's hearing aids and other services on a credit card. She subsequently lobbied her husband's company to add a rider to the company health plan that covers a portion of the cost, and now they pay for the rest using pre-tax dollars from their flexible spending account.

"Hearing loss tends to be an invisible condition," D'Amico says. "It's about educating the people around you."

What are the possible repercussions of accepting a tax credit and cost-sharing reductions for coverage on the health insurance exchange and then finding out at the end of the year that your income qualified you for Medicaid?

You won't face any negative consequences. When you visit the health insurance marketplace, the first item of business is to figure out if you're eligible for Medicaid. If you live in one of the roughly three dozen states that has expanded Medicaid coverage, you could qualify if you earn up to 138 percent of the federal poverty level, or about $16,000 annually. If the exchange estimates that your income will be too high to qualify for Medicaid and sends you to look for subsidized coverage on the exchange instead, you're in the clear. Under federal rules, you won't have to repay any premium tax credit or cost-sharing subsidies you received.

But it could be in your best interest to pay attention to how much money you're making in any case.

"If in the course of the year you realize your income has significantly gone down, you may want to check out your eligibility for Medicaid," says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

Medicaid, after all, may be cheaper or offer better coverage than your exchange plan.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Texas Puts Brakes On Telemedicine — And Teladoc Cries Foul

NPR Health Blog - 10 hours 14 min ago
Texas Puts Brakes On Telemedicine — And Teladoc Cries Foul June 02, 2015 3:38 AM ET

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Diagnosis by text or a phone call is often convenient and popular with patients. But is it good medicine?

Apriori/iStockphoto

On a recent trip to Chicago, Patti Broyles felt like she was looking at the world from the bottom of a fish bowl.

"This weather was really cold and rainy and I had a lot of pressure in my sinus areas," Broyles says.

Since she was nowhere near her primary care doctor in Dallas, she called Teladoc, the largest telemedicine provider in the U.S., for advice. Patients whose employers or insurers have deals with the Dallas-based company can call any time and be connected with a physician on duty within minutes.

"The rules, as they're written today, only allow a physician who has seen a patient in person to interact with them remotely. That's basically saying you can't go shop anywhere else."

Broyles says the doctor on the call gave her a prescription for antibiotics that soon cleared up her sinus infection.

Jason Gorevic, Teladoc's chief executive officer, says such encounters use familiar technology, "whether it's your cellphone, your laptop that has a webcam built in to it, or simply the phone."

In Texas, hundreds of employers offer Teladoc's services to more than 2 million employees, Gorevic says.

But new rules from the Texas Medical Board could make it a lot harder for people like Broyles to get antibiotics that way. In response to the board's restrictions, Teladoc has filed a lawsuit that accuses the medical board of artificially limiting supply and increasing prices.

"No one would think, if they showed up at their doctor's office, they would go back to a room, have the doctor stand on one side of the door, they would stand on the other, tell the doctor their symptoms and the doctor would slip a prescription out from under the door. No one would think that was good care."

"The rules, as they're written today, only allow a physician who has seen a patient in person to interact with them remotely," Gorevic says. "That's basically saying you can't go shop anywhere else."

The rules do allow for certain exceptions that would permit a physician to diagnose or prescribe medications via phone or video. It would be OK, for example, if the patient were at a medical clinic, or another health care worker were with the patient and could do a sort of surrogate exam. There's also an exemption for remote mental health visits.

Mari Robinson, executive director of the Texas Medical Board, says the rules aren't meant to stifle competition. They're meant to ensure patient safety.

"How can a physician make an accurate diagnosis when they have no objective diagnostic data?" Robinson asks. "All they have is what the patient has told them.

And that's not enough information, she says.

"No one would think if they showed up at their doctor's office they would go back to a room, have the doctor stand on one side of the door, they would stand on the other, they would tell the doctor their symptoms and the doctor would slip a prescription out from under the door. No one would think that was good care," says Robinson. "That is exactly the same as doing it over the telephone or over some system where a physician can't get objective diagnostic information."

But Dallas health care attorney Brenda Tso says that if you peek behind the curtain, the strict rules aren't just about patient safety.

"Doctors are trying to protect their practice from telemedicine, basically," she says.

Still, Tso says she thinks Teladoc's motivations are also financial.

All Tech Considered The Doctor Will Video Chat With You Now: Insurer Covers Virtual Visits

The medical board is not suggesting that telemedicine should be completely stopped, Tso says. "That would be stupid. And nobody is saying that. Now, what the Texas Medical Board and the doctors are saying [is], 'Well, we should use it in a limited sense, as long as it doesn't affect the standard of care.' "

While the Texas Medical Board doesn't think it's good practice for patients to be sending photos, videos and text messages to unfamiliar doctors, attorney Rene Quashie points out that other states permit all those activities.

National Security For Ailing Vets In Rural Areas, Telemedicine Can Be The Cure Shots - Health News Doctors Make House Calls On Tablets Carried By Houston Firefighters

"If you look at states like Virginia, Maryland and New Mexico, they have laws and regulations that really facilitate the greater use of telemedicine," Quashie says. "Texas is not one of those states."

He says that maybe especially in a state like Texas, where 200 counties are considered medically underserved, and more than a dozen counties have just one primary care doctor — there's a larger role for telemedicine.

"There's a huge underinsured population in Texas," Quashie says. "Even people who have insurance, sometimes have problems accessing care. So we're balancing access to care along with patient safety issues — misdiagnosis and over-prescription. But we also want to allow companies to innovate in this space."

Access to doctors is the main reason insurer Blue Shield partnered with Teladoc in California. Executive Vice President Janet Widmann says that, initially, telemedicine was meant to help rural members reach specialists.

"Now there's quite a bit of interest from our members in having the convenience of a telehealth visit. Folks want that," she says.

By next year, 800,000 of the Blue Shield of California's 3.5 million members will be able to use Teladoc.

In Texas, the medical board has already received more than 200 comments on the change of rules. It says key players, such as the Texas Medical Association, support the stringent regulations. Teladoc points out, on the other hand, that the vast majority of the comments were in opposition. The new rules governing virtual visits were supposed to go into effect June 3rd, but have been delayed until the case goes to trial.

This story is part of NPR's reporting partnership with local member stations and Kaiser Health News.

Copyright 2015 KERA Unlimited. To see more, visit http://www.kera.org/.
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What It's Like To Choose Transgender Sex Reassignment Surgery

NPR Health Blog - Mon, 06/01/2015 - 6:36pm
What It's Like To Choose Transgender Sex Reassignment Surgery June 01, 2015 6:36 PM ET

It wasn't until Deborah Svoboda dated someone who is trans that she understood how little she understood about being transgender. "I realized how very misunderstood they were, including by me," she says. And that comes from someone who identifies as queer and has lived and worked in diverse communities.

So Svoboda decided to use her skills as a multimedia journalist to learn about one aspect of transition: sex reassignment surgery. Surgery is something that people tend to fixate on. The "Did she or didn't she?" aspect of it even came up in Vanity Fair's coverage of Caitlyn Jenner's transition.

The Two-Way 'Call Me Caitlyn': Bruce Jenner Reveals New Name

Svoboda put flyers up in LGBT health clinics in the San Francisco area, asking people if they would be willing to let her document the experience. Jamie Nelson, who says he identifies as a transgender male who is queer, and Jetta'Mae Carlisle, who says she identifies as a straight woman, said yes. Both were preparing to have surgery, and were willing to let Svoboda follow them through the process.

"They also both wanted to tell their stories for the purpose of breaking down fears and misunderstandings around trans people," says Svoboda, who lives in Emeryville, Calif. "I could see that these two people both had an incredible amount of courage and openness that I knew we needed to tell such an intimate and in-depth story."

The Two-Way Jenner: 'For All Intents And Purposes, I Am A Woman'

She met with Nelson and Carlisle for almost a year. As the surgery dates grew closer, she met with them daily to photograph, video or gather audio. Carlisle flew to Phoenix for her surgery, "So I drove there and spent a week documenting her experience, physical and emotional."

In the end, Svoboda says, she learned an incredible amount. "The lengths they have had to go through in order to be themselves inspire me," she says. "They've been forced to ask for what they need, to face criticism, rejection and even degradation. They've gone through pain and confusion and still they find a way to hold their heads up and say, 'This is who I am.' "

The video originally appeared on KQED's State of Health blog.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Those Yoga Poses May Not Be Ancient After All, And Maybe That's OK

NPR Health Blog - Mon, 06/01/2015 - 2:35pm
Those Yoga Poses May Not Be Ancient After All, And Maybe That's OK June 01, 2015 2:35 PM ET Listen to the Story 37:33
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Yoga practitioners celebrate the solstice in New York's Times Square in 2011.

Richard Drew/AP

That yoga pose you've been practicing may not be as ancient as you thought. In fact, journalist Michelle Goldberg says that most of the poses that we do in modern yoga classes have no antecedent beyond 150 years ago.

"Probably the greatest myth is when you do these poses, when you do sun salutations or the warrior poses, that that there's some sort of continuity to what yogis were doing 3,000 years ago on the banks of the Ganges, and that's just not true," Goldberg tells Fresh Air's Terry Gross.

Michelle Goldberg is a senior contributing writer for The Nation.

Matt Ipcar

Goldberg is the author of The Goddess Pose: The Audacious Life of Indra Devi, the Woman Who Helped Bring Yoga to the West. Her book traces the modern Western practice of yoga to a Russian woman named Indra Devi, who was born in 1899 with the birth name Eugenia Peterson. Devi became interested in yoga after reading about it in book written by an American new-age thinker. She studied the practice in India before introducing it to political leaders in Russia and Shanghai and, in 1947, bringing it to America, where her students included Hollywood celebrities like Greta Garbo and Gloria Swanson.

"[Devi] was the one who took yoga from being, what people in the West tended to imagine as sword swallowing and circus tricks and domesticated it," Goldberg says. "The idea of yoga as a system of wellness for modern women that helps you [to] better equip yourselves for the many challenges of the modern world, that all comes back to her."

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The Audacious Life of Indra Devi, the Woman Who Helped Bring Yoga to the West

by Michelle Goldberg

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On the book, 14 Lessons in Yogi Philosophy and Oriental Occultism, by American William Walter Atkinson, which sparked Indra Devi's interest in Yoga

Indra Devi discovers this book in the library of a Russian aristocrat. ... This was the sort of book you would find in the library of a bohemian Russian aristocrat. She finds this book, she thinks that it's a sort of dispatch from this other-worldly land. It kindles a fascination with India that will carry her throughout almost a century, but really it's Indian wisdom as refracted through a sort of American self-help writer, and I think that exemplifies, again, the sort of mash-up that we see both in her life and her thinking, but also in yoga as it has come to us today.

On why yoga is aerobic

Krishnamacharya was the yogi in-residence at the Mysore Palace, and the Maharaja of Mysore was this very progressive nationalist figure who really wanted to unite the best of the East and the best of the West. And so he sponsored Krishnamacharya to run a yoga school in the palace. Krishnamacharya — because a lot of his students were young, royal boys — created a system that would sort of capture the animal energy of an 8- or 9- or 10-year-old boy. So he put in things that if you do yoga now are really familiar to you — the jump backs and the chaturanga, which is the sort of half-push-ups and these very fast, flowing movements that we call Vinyasa — he created a lot of those things.

On Krishnamacharya teaching Devi

She was a woman in her 30s by the time she came to [Krishnamacharya]. At first he wanted nothing to do with her. ... He said, "I don't teach women and I don't teach Westerners." He wanted her to go away and she basically went over his head. She went to her friend, the Maharaja. She had this lifelong talent for cultivating people, for getting people to want to do her favors. Probably the most supernatural thing about her was her astonishing charisma. She went over his head, she went to the Maharaja. The Maharaja basically said, "Krishnamacharya, you have no choice, you have to teach her." He finally gave in, he grudgingly started giving her lessons. And when he saw how dedicated she was, he sort of relented and eventually developed enormous affection for her. And after he had taught her many of his secrets, he kind of came around ... and saw that yoga had a lot to offer people outside of his own purview and he charged her with teaching a lot of what he had taught her.

On Devi teaching yoga in the U.S. in 1947

First she goes to Shanghai and she has a yoga studio in a villa that had been owned by Madame Chiang Kai-shek, and she's there during the Japanese occupation. After the war, she sails for Hollywood and she opens up one of the first yoga studios. There had been a couple of yoga teachers here and there in the United States. There was a brief yoga panic in the United States in the 1920s. ... You can see a lot of tabloid news stories about lecherous yogis luring women away from their marriages and families, but there hadn't really been very many yoga teachers in part because the Alien Exclusion Act kept South Asian immigrants from coming to the United States. So she opens a studio in Hollywood. She has some connections from her Shanghai days, people who are now in California who introduce her to various figures in Hollywood. They introduce her to Aldous Huxley, who is a famous writer who has kind of a longtime interest in Eastern spirituality. And so she opens this studio. And soon she has all sorts of famous actors and actresses as clients who are doing headstands on the sets or sitting in lotus pose, and she becomes a sort of minor celebrity.

Additional Information: More On Yoga All Tech Considered Innovation: Smart Yoga Mat Could Help You Find Your Zen Shots - Health News When A Yoga Teacher Ticks You Off, Is It Rude To Walk Out? Shots - Health News Dr. Yogi: Physicians Integrate Yoga Into Medical Practice Author Interviews The Risks And Rewards Of Practicing Yoga

On the idea of the "self" and yoga

One of the transmutations that's happened as yoga has made its way from East to West and back again and back again is that the idea of "self." In most interpretations of classical yoga philosophy or Hindu philosophy "self" means the connection to the divine, the things that transcend the ego or the things that transcend individual subjectivity. But "self" in the Western interpretation obviously is understood very differently and is understood as kind of the ultimate in individual subjectivity. So classical yoga, which had originally been about obliterating the "self," obliterating individuality, obliterating everything that connects you to the world, becomes — as Indra Devi teaches it and as its gradually assimilated to the West — a way of having greater efficacy in the world and kind of developing your own personality. It's a complete inversion of how it would be understood in classical Hinduism, but anyone who has any familiarity with American self-help culture will know what I'm talking about right away. This has become so much a part of the culture you barely even notice it.

On how modern yoga compares to ancient yoga

There's no mention of warrior poses or sun salutations in any ancient text at all. That might be a little disillusioning to some people, [but] what I hope and what it ultimately meant to me, is we don't have to feel so anxious about the authenticity of our modern practices because like anything ... it's a modern adaptation and that might, I hope, let people feel a little less anxious about adapting it for their own needs.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Training Doctors To Talk About Vaccines Fails To Sway Parents

NPR Health Blog - Mon, 06/01/2015 - 10:58am
Training Doctors To Talk About Vaccines Fails To Sway Parents June 01, 201510:58 AM ET

from

Lisa Aliferis

The question of how to communicate with parents about vaccines is getting increasing interest from academia.

iStockphoto

As more and more parents choose to skip vaccinations for their children, public health professionals and researchers have been looking at new ways to ease the concerns of parents who are hesitant.

But that turns out to be tough to do. Studies have found that simply educating parents about the safety and efficacy of vaccines doesn't increase the likelihood that they will get children vaccinated.

Since numerous studies show that doctors are the most trusted communicators of information about vaccines, the Group Health Research Institute in Seattle wanted to see if it would help to train doctors and other providers on how they communicate with mothers hesitant about vaccines.

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"The intervention was designed to involve parents and respect where they were coming from, respect that they wanted what was best for their child and the provider wanted that, too," said the study's lead author, Nora Henrikson, a research associate with the institute. The goal, she said, was to help doctors address parents' concerns but "still make a strong recommendation for vaccines."

It was a lofty goal, but the upshot is this: It didn't work.

There was no sign that what the researchers did in the study helped to reduce vaccine hesitancy.

But that's doesn't mean the end of this approach.

Scientists like to say that finding out that something doesn't work can be just as important as finding out what does. Both researchers involved with the study and those who had nothing to do with it say that's the case here.

Let's look first at what Group Health Research did in its study, what they say is the first randomized trial to test improving hesitancy about vaccination by directly targeting doctors.

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The centerpiece of the approach was a 45-minute training session with doctors and other health care providers. Participants also received written support material, monthly emails and assistance upon request.

The parents themselves did not receive training. The goal was to see if giving doctors better communication skills would reduce hesitancy in mothers.

In the study, 347 mothers of healthy newborn babies were randomized into two groups. Some received care in clinics where doctors had received the training, and the rest went to clinics where they had not.

Vaccine hesitancy declined somewhat in both groups over the six months of the study, but there was no statistically significant difference between the groups. During the study period, there was a whooping cough outbreak in Washington, as well as a new law requiring a doctor's note to opt out of vaccines, and the decline in vaccine hesitancy may have been related to those events, rather than anything in the study.

The study was published in the journal Pediatrics and was funded by the Group Health Foundation and the Bill and Melinda Gates Foundation.

"Obviously we were hopeful that it would improve vaccine hesitancy, so we would have preferred to see a different effect," Henrikson said, "but it really raised more questions about what other projects we could do moving forward."

The Two-Way Australia To Stop Payments To Families Who Refuse Child Vaccinations

Brendan Nyhan, a professor of government at Dartmouth who studies communication about vaccines, was positive about the research despite the lack of impact.

"We're headed in the right direction," he said. "We're starting to ask better questions, and part of real science is that sometimes our experiments don't work out the way we expect."

The study "required careful consideration and should be seen as the start, not the end of the story," according to an accompanying editorial by Julie Leask, an associate professor at the University of Sydney's School of Public Health who studies vaccine attitudes, and Dr. Paul Kinnersley, a professor at the Institute of Medical Education at the University of Cardiff, Wales, who teaches medical students how to talk to patients. It pointed to a "clear need to develop new approaches to vaccine consultation," they wrote.

One of Henrikson's big questions is whether the 45-minute training session was "a big enough dose of the intervention. It's not a bad intervention," she said. "But a more intense version of it might be able to make a difference."

Since the overwhelming majority of parents do vaccinate their children, Henrikson said another area for future research could be identifying ways to "help providers make time for parents who do have more questions and need more time."

Concerns about vaccines are not an all-or-nothing proposition, Henrikson said; it's a continuum. On one end are people who support vaccines and make sure their children receive all recommended vaccinations. On the other end are people who refuse all vaccines. "Then there are people in between," she said, "and we're still understanding that, and at what point do people really have all the information they need?"

This story was produced by State of Health, KQED's health blog.

Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
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New Hearing Technology Brings Sound To A Little Girl

NPR Health Blog - Mon, 06/01/2015 - 3:35am
New Hearing Technology Brings Sound To A Little Girl June 01, 2015 3:35 AM ET

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Jiya Bavishi's auditory brainstem implant is helping her hear some sounds for the first time.

Lauren Silverman/KERA

Jiya Bavishi was born deaf. For five years, she couldn't hear and she couldn't speak at all. But when I first meet her, all she wants to do is say hello. The 6-year-old is bouncing around the room at her speech therapy session in Dallas. She's wearing a bright pink top; her tiny gold earrings flash as she waves her arms.

"Hi," she says, and then uses sign language to ask who I am and talk about the ice cream her father bought for her.

Jiya is taking part in a clinical trial testing a new hearing technology. At 12 months, she was given a cochlear implant. These surgically implanted devices send signals directly to the nerves used to hear. But cochlear implants don't work for everyone, and they didn't work for Jiya.

Health Cochlear Implants Redefine What It Means To Be Deaf

"The physician was able to get all of the electrodes into her cochlea," says Linda Daniel, a certified auditory-verbal therapist and rehabilitative audiologist with HEAR, a rehabilitation clinic in Dallas. Daniel has been working with Jiya since she was a baby. "However, you have to have a sufficient or healthy auditory nerve to connect the cochlea and the electrodes up to the brainstem."

Jiya's connection between the cochlea and the brainstem was too thin. There was no way for sounds to make that final leg of the journey and reach her brain.

Auditory brainstem implant

A microphone behind the ear sends signals through a magnet to electrodes implanted on the brain's brainstem.

Credit: Courtesy of Massachusettes Eye And Ear/Harvard Medical School

Usually, the story would end here. If cochlear implants don't work, you turn to sign language. And the Bavishis did — for years they communicated with their daughter through sign language. But then they heard about an experimental procedure called an auditory brainstem implant.

Rehabilitative audiologist Linda Daniel has been working with Jiya since she was a baby.

Lauren Silverman/KERA

It is a very rare procedure, according to Dr. Daniel Lee, director of the pediatric ear, hearing and balance center at Harvard Medical School. "There have been less than 200 of these implanted worldwide in children," he says. In the U.S., auditory brainstem implants are approved by the Food and Drug Administration for adults and teenagers who have lost their hearing owing to nerve damage, but they have not been approved for use in younger children.

Surgeons in Europe have pioneered the use of the auditory brainstem implant in children who are born deaf and can't receive a cochlear implant, Lee says. "And those data look pretty encouraging."

Additional Information: Jiya is able to hear and repeat some sounds.

Therapist Linda Daniel works with Jiya on vowel sounds.

Listen

So in 2013, the FDA approved the first clinical trial in the U.S. for young children. The Bavishis decided to apply for Jiya. It wasn't an easy decision. It would involve surgery to place a tiny microchip into Jiya's brainstem.

"The family was at a crossroads," Daniel says. Did they want to take a chance on a risky, experimental procedure to give their daughter a chance to hear? They decided to try the procedure and traveled from their home in Frisco, Texas, to Chapel Hill, N.C., for the eight-hour surgery. The University of North Carolina is one of four institutions investigating the implant.

Jiya's mom, Jigna Bavishi, pulls back her daughter's purple headband to reveal two of the three parts of the device.

There's the piece that sits on her ear, which works like a microphone to pick up sounds. That microphone is attached to a small black magnet that rests on her head. What you can't see is what the magnet is connected to. And this is what makes it different from a cochlear implant. Below the skin, there's a receiver, and down in the brain stem is the microchip. The idea is that the sounds picked up from the microphone on her ear end up in the implant in the brainstem.

"It's a rectangular-shaped element," says rehabilitative audiologist Daniel. "It has two rows of electrodes and each electrode is responsible for a band of frequencies." The electrodes transmit signals directly into the brain.

Shots - Health News Deaf Jam: Experiencing Music Through A Cochlear Implant

Daniel says we don't know exactly what Jiya hears.

"I think we could assume that it doesn't sound crisp, distinct, clearly interpretable," she says. "It would take longer to learn to interpret the sound."

Doctors told the Bavishis not to expect any changes for a year or two. But Jiya didn't take that long to start recognizing and mimicking sounds. On the day I visit, Jiya is playing with a yellow toy car. "Beep, beep," she says.

"They actually had to tell us, even though she's doing so good right now, we have to still be careful where we set our expectations," says Jigna.

Doctors will monitor Jiya, and four other children taking part in the study, for the next few years. They'll be studying how their brains develop and incorporate sounds and speech. There are two other clinical trials investigating auditory brainstem implants in children: one at Children's Hospital in Los Angeles, and the other at the New York University School of Medicine.

Copyright 2015 KERA Unlimited. To see more, visit http://www.kera.org/.
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Does Your Neighborhood Doom You To An Early Death?

NPR Health Blog - Sun, 05/31/2015 - 7:08am
Does Your Neighborhood Doom You To An Early Death? May 31, 2015 7:08 AM ET Kelli Dunham Raymond Biesinger for NPR

For almost a decade I worked as a nurse home visitor in Philadelphia with a well-regarded program that pairs nurses with first-time moms. In the morning I would put on my backpack full of child-development accoutrements, grab my baby scale and jump on the 23 bus.

In the Center City/downtown area where I lived, life expectancy was 78 to 80 years. When I got off the 23 bus less than 15 minutes later in lower North Philadelphia, it was less than 70 years.

Source: City of Philadelphia, Vital Statistics Report 2012

Credit: Matt Stiles/NPR

If you didn't mind exposure to snow, sleet, rain, beating sun and the occasional family pet slobbering a little bit on your paperwork, the job itself was a gem among nursing jobs. We got to spend time, substantial time, with patients (we called them clients), and got to witness first-time parents work what seemed like miracles.

Partnering with young moms meant I had the enormous privilege of witnessing many first breaths, first steps. I also got to attend more than my fair share of high school graduation ceremonies, rites of passage that my clients fought hard to reach.

T.S. was one 16-year-old who as she said "was not going to become a statistic." She went into labor early and her baby was extremely premature, born 15 weeks early. Although it would be months before the baby could eat by mouth, T.S., who I'm identifying by her initials because she was a minor, immediately began pumping her breast milk and saving it in the hospital's NICU freezer.

She stayed with the baby every minute they allowed her to during her immediate postpartum period, and when she returned to school six weeks after the baby was born, she continued to pump during the school day, visiting the nurse's office between classes.

When school dismissed at 3:15, she rode the bus to the Center City hospital where her baby was in the NICU and stayed until after 10 each night. If I stopped by on my way home, I'd often find her almost asleep, holding her baby in her arms while poring over a textbook propped on a tray table.

At six months, her baby was strong and healthy enough to leave the hospital. T.S. continued her junior year.

Three weeks before she was to graduate from high school, I got a call from T.S. She was crying.

"I did everything I could do to make my baby healthy and now our house poisoned my baby!"

"My house has lead in it and now my baby has lead poisoning." I waited for her to continue. "I did everything I could do to make my baby healthy and now our house poisoned my baby!"

She had been conscientious about taking the baby for checkups, and a simple blood test had caught the rising lead level before it could do permanent damage to her growing child. But the lead in the house's pipes and paint made the house unsafe. Her family had to temporarily double up with extended family until they could get a new apartment. T.S. spent her graduation night sleeping with her baby on her cousin's couch.

She was right; her house had poisoned her baby. In North Philadelphia, much of the housing stock is older and still contains lead paint. Programs to address the problem and help with lead abatement are under constant budgetary attack.

As health care providers, we can work hard to provide good care and even advocate for expanded access to health care, but that there are a myriad of other greater factors that contribute to people dying early. Those factors aren't within any individual's control; they that can only be addressed by the larger society. But as a culture it seems like we've decided that we're okay with not addressing environmental factors, which means we're okay with T.S's baby having a life expectancy that is almost a decade less than a baby born the next neighborhood over.

These geographic health disparities aren't just happening in Philadelphia. Late last month, the Robert Wood Johnson Foundation released a set of maps that reveal the startling differences in life expectancies among people in major American cities, including New Orleans, Kansas City, Mo., and Washington, D.C.

Do our six stops on the subway or 15 minutes on the bus protect us too much?

The RWJF website calls the maps "conversation starters," and from a policy standpoint that makes great sense. But as a health care provider working long term in areas we call "at risk" (a not very kind euphemism for "under-resourced,") I do wish the fact that we let so much of our population die so young were a conversation stopper instead.

I wish that if I started showing the RWJF maps around the average middle-class cocktail party that all talking would cease, the partygoers silenced in horror by the inequity. But instead of silence, I'm pretty sure the greatest result would be knowing nods and helpless shrugs and rescinded invitations from future middle-class cocktail parties.

Do our six stops on the subway or 15 minutes on the bus protect us too much? I would hope that hearing a hard-working mom cry "my house poisoned my baby" would move us from talking to doing.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Seeing What Isn't There: Inside Alzheimer's Hallucinations

NPR Health Blog - Sat, 05/30/2015 - 5:05pm
Seeing What Isn't There: Inside Alzheimer's Hallucinations May 30, 2015 5:05 PM ET Listen to the Story 4:19
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In this episode of NPR's series Inside Alzheimer's, we hear from Greg O'Brien about his struggle to deal with the hallucinations that are an increasing part of his illness. O'Brien, a longtime journalist in Cape Cod, was diagnosed with early-onset Alzheimer's disease in 2009.

Inside Alzheimer's

Greg O'Brien sees things that he knows aren't there, and these visual disturbances are becoming more frequent. That's not uncommon; up to 50 percent of people who have Alzheimer's disease experience hallucinations, delusions or psychotic symptoms, recent research suggests.

At first, he just saw spider-like forms floating in his peripheral vision, O'Brien says. "They move in platoons."

But in the last year or so, the hallucinations have been more varied, and often more disturbing. A lion. A bird. Sprays of blood among the spiders. Over the past five months, O'Brien has turned on an audio recorder when the hallucinations start, in hopes of giving NPR listeners insight into what Alzheimer's feels like.

For now, he says, "I'm able to function. But I fear the day, which I know will come, when I can't."

Interview Highlights

The Lion

March 17, 2015

[It's] St. Patrick's Day, about 9 o'clock in the morning in my office, and they're coming again. Those hallucinations. Those things that just come into the mind when the mind plays games.

And then I see the bird flying in tighter and tighter and tighter circles. And all of a sudden, the bird — beak first — it darted almost in a suicide mission, exploding into my heart.

Today I'm just seeing this thing in front of me. It looks like a lion, almost looks like something you'd see in The Lion King, and there are birds above it. It's floating, and it disintegrates ... it disintegrates ... it disintegrates.

This time it's somewhat playful, but a lot of times it isn't. There are times when you sense it coming on. It's like a numbing sensation, a tingling in the back of your brain.

The Spiders

April 4, 2015

Oh [no], here they come again those ... spiders. I can't seem to shake them. It's about close to 10 o'clock in the morning and I see these freaking things again.

Shots - Health News After Alzheimer's Diagnosis, 'The Stripping Away Of My Identity'

They're insect-like. They're spider-like. They have stringy, hairy legs. They crawl. They're crawling along the top of the ceiling toward me, now walking into the bedroom, into the living room to see if I can escape.

The Bird

Recently, I woke up in the morning — wide awake — and there was a bird flying in my bedroom. And I see this bird flying, and I'm saying how the hell do I get the bird out of here?

And then I see the bird flying in tighter and tighter and tighter circles. And all of a sudden the bird — beak first — it darted almost in a suicide mission, exploding into my heart.

Then I realized it wasn't real.

Greg O'Brien and his family will share more of their experiences with Alzheimer's in coming installments of "Inside Alzheimer's" on Weekend All Things Considered, and here on Shots.

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Categories: NPR Blogs

When Are Employee Wellness Incentives No Longer Voluntary?

NPR Health Blog - Fri, 05/29/2015 - 5:18pm
When Are Employee Wellness Incentives No Longer Voluntary? May 29, 2015 5:18 PM ET Listen to the Story 4:38
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There are legal questions about how far employers can go to encourage participation in wellness programs.

Bjorn Rune Lie/Ikon Images/Getty Images

Scotts Miracle-Gro makes products for the care and health of lawns. The Marysville, Ohio, company says it wants to nurture its 8,000 employees the same way.

"It's very much of a family culture here," says Jim King, a spokesman for the Scotts company, which offers discounted prescriptions, annual health screenings and some free medical care.

In states where it's legal, the company refuses to hire people who smoke.

"We've been screening for tobacco use for about a decade," King says. "We no longer employ tobacco users."

That provision landed the company in court several years ago. A new hire failed a urine test for nicotine, lost his job offer and sued the company, arguing it was meddling in private affairs to drive down costs. He lost on appeal in 2012.

Scotts is among the majority of medium to large employers that offer some sort of wellness program for their workers.

About 80 percent of Scotts employees submit to health screenings, and those deemed to be making unhealthful choices pay more for health insurance.

King says Scotts' wellness policy attracted outside scrutiny, but its employees embrace it.

"Once people understood what the program actually was, they recognized that it wasn't anything like Big Brother at all," he says. "And, in fact, what we were doing was providing them tools."

Participation in the wellness program at Scotts is not mandatory. In fact, under the law, such programs must be voluntary. But regulators are now trying to define what "voluntary" means.

Some hospitals require their workers to get flu shots, which is controversial among those who can't or don't want to get vaccines. Beyond that, there are questions about money. For example, is a big financial penalty for nonparticipation too coercive? What about incentives for completing health screenings?

Nico Pronk, chief science officer at HealthPartners, a hospital system, researches the effectiveness of wellness programs and says their design matters.

$(function() { var pymParent = new pym.Parent( 'responsive-embed-health-incentives-20150529', 'http://apps.npr.org/dailygraphics/graphics/health-incentives-20150529/child.html', {} ); });

Incentives can work, he says, but you have to be careful not to overdo it. "Once the incentive amounts go over a certain threshold, it may become a little bit more coercive," Pronk says.

Last year, the Equal Employment Opportunity Commission sued several companies, alleging their policies were too heavy-handed. They argue those companies required health screenings or made nonparticipants bear the full cost of health insurance.

Christopher Kuczynski, associate legal counsel at the EEOC, notes that in a separate proceeding, the commission is considering regulations to define what companies are allowed to do to encourage participation in wellness programs.

"Limited incentives are permissible," Kuczynski says, "as long as the maximum incentive for participating doesn't exceed 30 percent of the total cost of coverage."

Kuczynski adds that employers must make sure their programs comply with many laws, including those governing the privacy of health and genetic information, the Affordable Care Act and the Americans with Disabilities Act. Employers can't use workers' health against them.

"There are opportunities for discrimination," Kuczynski says. "This information that's collected as part of a wellness program can't cross over to anyone who deals with making employment decisions."

Business groups say they are striking a balance between encouraging participation and protecting the choice of their workers.

Additional Information: Shots - Health News Targeting Overweight Workers With Wellness Programs Can Backfire Government Says Bosses Can't Force Workers To Get Health Tests Shots - Health News The Boss Can Force You To Buy Company's Health Insurance

Brian Marcotte is president and CEO of the National Business Group on Health, a policy group representing large employers. He says most health care costs are lifestyle related, and employers want to reduce costs. But that's not the only calculation companies are making.

"At the end of the day, employers want healthy, productive, engaged, resilient employees, and the most competitive workforce possible," Marcotte says. "And investments in health and well-being are part of that equation."

Nancy Hammer, government affairs counsel for the Society for Human Resource Management, says employers want to draw in, not compel workers.

"Health care and wellness is an employee benefit," she says. "So you've got to do something that is attractive to your employees."

No one benefits, she says, if no one uses the programs.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Texas Politicians And Businesses Feud Over Medicaid Expansion

NPR Health Blog - Fri, 05/29/2015 - 4:19pm
Texas Politicians And Businesses Feud Over Medicaid Expansion May 29, 2015 4:19 PM ET Listen to the Story 6:43
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Around the Nation Texas Loses Billions To Treat The Poor By Not Expanding Medicaid, Advocates Say

Dallas's Parkland Hospital treats a lot of people without health insurance. On a November day in 1963, emergency room doctors at this county hospital frantically tried to save an American president who could not be saved. These days, emergency room doctors frantically try to treat 240,000 patients every year.

"So you can see we have every treatment area filled up. Beds are in the hallways and the rooms are all full," says Dr. John Pease, chief of emergency services.

While governor of Texas, Rick Perry refused to accept federal funds to expand Medicaid.

Rick Wilking/Reuters/Landov

In Texas, about 1 in 4 people is uninsured. By federal law, the county hospital's emergency room cannot turn sick patients away, no matter their ability to pay, so Parkland opens its arms.

Last year it cost Parkland Hospital three quarters of a billion dollars to provide what is called "uncompensated care" — mostly treating patients without health insurance. Parkland is hardly some 90-pound weakling, but $765 million of red ink will strain any hospital. Dallas County Judge Clay Jenkins, who oversees the county hospital, says it doesn't have to be this way.

"A huge chunk of that could be paid for," Jenkins says. "It's about $580 million a year that would be brought in by the Medicaid expansion monies."

Expanding Medicaid was intended to be a key element of the Affordable Care Act. Medicaid expansion covers uninsured adults, mostly working poor, who don't make enough to buy health insurance on the exchanges. Twenty-nine states and the District of Columbia have taken up the charge of Medicaid expansion. But when the U.S. Supreme Court gave the individual states the option to opt of Medicaid expansion, then-Texas-Gov. Rick Perry could not opt out fast enough.

Texas hospitals had to eat $5.5 billion in uncompensated care last year. The reason is this: After the Affordable Care Act passed, the amount of money the federal government provides to hospitals for uncompensated care was significantly reduced.

Shots - Health News Texas Medicaid Debate Complicated By Politics And Poverty

In 2013, while contemplating a second run at the presidency, Perry had a message for Tea Party conservatives across the nation.

"Thank you all for being here," he started. "The first day of April. Seems to me an appropriate April Fool's Day — makes it perfect to discuss something as foolish as Medicaid expansion and to remind everyone that Texas will not be held hostage by the Obama administration's attempt to force us into this fool's errand of adding more than a million Texans to a broken system."

Perry's speech was a clear message to the Republican-dominated state Legislature: Medicaid expansion is part of Obamacare, and Texas hates Obamacare. The problem is that in hating the Affordable Care Act, the state is leaving on the table as much as $100 billion of federal money over 10 years — money that could pay for health insurance for more than 1 million of its working poor.

This is driving many in the state's business community bonkers.

"It's our money that we are sending to Washington, D.C.," says Bill Hammond, CEO of the Texas Association of Business, which includes many of the state's richest and most powerful business owners. "We are not getting it back," he says. "We pay for it with corporate income tax, we pay for it with our personal income tax and we pay it in the fact that our premiums are higher than they would be if everyone was insured."

Shots - Health News Houston Gears Up For Obamacare, Despite GOP Opposition

Texas has the second-highest health insurance premiums in the country, right behind Florida. And Texas has the third-highest property taxes in the country. In Dallas, for example, more than half of property owners' county property tax bill goes to reimburse Parkland Hospital for the uncompensated care it has to provide.

"Texas businesses pay almost 63 percent of all state and local taxes," Hammond says.

He says if the state expanded Medicaid it would save Texas business billions of dollars a year that could be invested in upgrading equipment, hiring new employees, providing raises and rewarding shareholders.

For every dollar the state would pay into Medicaid expansion, it would earn back $1.30 from the economic activity created, according to an analysis by Ray Perryman. He's an economist who has consulted for the Texas Legislature and six governors. That economic activity would top out at $3 billion in 10 years, creating 300,000 new jobs each year, he says.

Politics Health Officials Decry Texas' Snubbing Of Medicaid Billions

"It's infused in some areas that have direct impact on the economy in a lot of fundamental ways that extends beyond the year in which it occurs," Perryman explains. "You may be prolonging someone's work life 10 or 15 years, or maybe solving a chronic illness problem that's going to drain hundreds of thousands of dollars from the system over time that's avoidable if people get health care earlier."

Totally aside from the health benefits, Perryman says, when you look at the numbers, "You look at them and you say, 'This is a no-brainer. We need to be doing this.' It's really an apolitical situation. It's just math."

But it's much more than just the math. As the 84th session of the Texas Legislature comes to a close, there's been no debate at all about Medicaid expansion. The issue seems to be settled and the answer is an unqualified no.

"We've got a very conservative Legislature which would like to prioritize tax relief over meeting some of the infrastructure needs of the state," says John Hawkins, a vice president with the Texas Hospital Association.

Hawkins says the state's uncompensated bills cost everybody. The hospitals can't eat that kind of loss, so they shift some of that cost to their insured patients. "Probably $1,800 of the family premium each year can be attributable to the cost of the uninsured in the state," he says.

It's fair to say that Texas Republicans are not big on entitlements. Nevertheless, $100 billion is a lot of money to turn your back on.

Shots - Health News One Nation, Two Health Care Extremes

Republican Rep. John Zerwas is himself an anesthesiologist who represents a conservative suburb southwest of Houston. Like all his Republican colleagues in the Texas House and Senate, Zerwas opposes the Affordable Care Act. Nevertheless, he's trying to find a way for Texas to take the Medicaid expansion money by reclassifying it as something else, like a federal block grant or something other mechanism — anything that's not called Obamacare.

"I try to argue that when you look at where those monies are invested and how that translates into job growth and economic growth, the health care sector is a very good place for that investment to be made," Zerwas says.

But some very politically powerful people in Texas don't believe it.

"Expanding government programs doesn't create jobs," says John Davidson, director of the health care policy center at the Texas Public Policy Foundation in Austin, a conservative think tank. "The government can't create jobs. So it's fundamentally flawed from an economic point of view."

Davidson and the Texas Public Policy Foundation not only say no to Obama's Medicaid expansion, they want the administration to give Texas more control over regular Medicaid so the state can toughen standards.

"Personal responsibility, work requirements, narrower benefits, penalizing inappropriate use of the ER," Davidson says. "These [are the] kinds of things that we and other conservative groups wanted to bring into the Medicaid program to try to incentivize certain behaviors on the part of the patients."

Shots - Health News State Legislatures Quarrel Over Whether To Expand Medicaid

This is precisely the position the new Texas governor, lieutenant governor and Texas Senate have taken. And Republicans in the Texas House and Senate who are open to Medicaid expansion fear if they support it, it will earn them the wrath of Texas Tea Party Republicans. Zerwas says he hears this a lot.

"Generally the issue comes as politically, how is this going to affect me in my next election?" Zerwas says. "Anything that is seen to be taking advantage of a provision in the health care law is going to be seen as something that's propping up Obamacare."

Political districts in Texas are now so heavily gerrymandered and turnout so low that Tea Party voters can have outsized influence. Last election, for example, more than a half-dozen Republican incumbents in the Texas House were beaten because they were deemed not conservative enough. For now, Medicaid expansion in Texas is dead. But if Texas won't consider taking the money, other states will. A growing number of Republican legislatures — Arkansas, Arizona, North Dakota and Montana — recently voted to accept Medicaid expansion money. Utah, Florida and Alaska are discussing it.

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Breath-Holding In The Pool Can Spark Sudden Blackouts And Death

NPR Health Blog - Fri, 05/29/2015 - 9:48am
Breath-Holding In The Pool Can Spark Sudden Blackouts And Death May 29, 2015 9:48 AM ET Angus Chen

Competitive swimmers often practice breath holding to increase endurance.

iStockphoto

There's a dare that floats out on hot days by the pool: Who can hold their breath the longest? In shallow water, the challenge sounds fun or at least harmless. Competitive swimmers and divers crouch under the surface all the time to build endurance. But the practice can cause swimmers to faint and drown without warning and before anyone notices.

Whitner Milner, a recreational diver, drowned at age 25.

Courtesy Rhonda Milner

Whitner Milner was one of those people. The 25-year-old recreational diver and spear-fisher from Atlanta was training to hold his breath for three minutes. On April 16, 2011, he got into the family pool alone. His mother found his body the next evening, locked in a breath-holding position, one hand crossed over his chest and the other resting at his throat.

The medical examiner determined that a blackout brought on by holding his breath was a likely cause of death by drowning.

The phenomenon is getting increased scrutiny, with the Centers for Disease Control and Prevention issuing a report May 22 saying that shallow-water blackouts can cause unexpected injury or death for swimmers of all levels. On Tuesday, a former Australian Navy diver drowned in a New Jersey pool while doing breath-hold training. The cause of death is being investigated.

The report documents 16 shallow-water blackouts in New York State from 1988 to 2011, four of which ended in death. The accidents typically happen when people attempt training exercises either for fitness or to expand lung capacity, like in Whitner Milner's case. About one third come from games or spontaneous breath-holding competitions by recreational swimmers.

Holding your breath underwater seems deceptively benign, says Rhonda Milner, a physician and Whitner's mother, and victims don't realize they're about to black out. "It's something that comes on with really no warning," she says.

That's because we start craving air only when carbon dioxide levels in the body have risen over a certain threshold, says Christopher Boyd, the lead author on the CDC report and a researcher at the New York City Department of Health and Mental Hygiene. People will often hyperventilate before training or playing games, taking many deep breaths. That purges their bodies of carbon dioxide and staves off the urge to breathe.

"It's very quiet, so it's very difficult to detect. Even in swimming pools with a lifeguard on duty."

But that also means carbon dioxide levels might not rise high enough to signal for air before oxygen levels drop low enough for the person to pass out. Before they realize they need to "surface and take another breath, the person is already unconscious," Boyd says. The situation is even more likely if the swimmer is using more oxygen than normal from exercising or remaining underwater for long periods of time.

Since people don't struggle, it can be hard for companions or lifeguards to realize someone is in danger. "It's very quiet, so it's very difficult to detect," Rhonda Milner says. "Even in swimming pools with a lifeguard on duty." She speculates this may have been the case for two Navy SEALs who drowned doing breath-holding exercises in a shallow pool in Virginia last month.

After her son's death, Rhonda Milner founded an organization to promote awareness of the risks, including a video with Olympic champion Michael Phelps and a national prevention day this Sunday.

"We didn't understand the full danger of it. We discussed it at one point and brushed it off."

New York City is about to post warnings about the risks of underwater breath-holding at its public pools. "It is an entirely preventable injury," Boyd says. Swimmers need to be aware, he says, and parents and coaches need to diligently monitor anyone holding their breath in the water while playing or training.

Cason Milner, Whitner's brother, says if they just had a better idea of how unsafe their games and training were, that knowledge could have saved his brother's life. "We didn't understand the full danger of it. We discussed it at one point and brushed it off." Because the pool was shallow and they were expert swimmers, there was a false sense of security. Now, he says, he's much more careful.

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CDC Investigates Live Anthrax Shipments

NPR Health Blog - Thu, 05/28/2015 - 5:30pm
CDC Investigates Live Anthrax Shipments May 28, 2015 5:30 PM ET Listen to the Story 2:29
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A security fence surrounds the main part of the U.S. Army's Dugway Proving Ground, a testing laboratory in the Utah desert. The Army says it mistakenly shipped live anthrax from Dugway to several labs in the U.S. and Korea.

George Frey/Getty Images

The Centers for Disease Control and Prevention is still trying to figure out how the military managed to ship anthrax spores that were apparently live from one of its facilities to more than a dozen labs across the United States.

"We have a team at the [military] lab to determine what may have led to this incident," says CDC spokesman Jason McDonald. In addition, he says, the agency is working with health officials in nine states to make sure the potentially live samples are safely disposed of and the labs affected are decontaminated.

Spores of the anthrax bacteria (Bacillus anthracis) can survive for decades in the soil, scientists say. The spores, shown here under a scanning electron microscope, are tough to kill.

Reuters/Landov

McDonald says four workers in three states are being treated for possible anthrax exposure. Separately, the military says that 22 individuals at Osan Air Base, a U.S. facility in South Korea, are also receiving treatment. The workers were apparently sent the samples — which where supposed to have been killed via radiation before being shipped — to use as part of routine laboratory training.

So far it appears nobody has gotten sick from the anthrax.

The anthrax spores were sent from the Army's Dugway Proving Ground in Utah to 18 labs around the country. The samples, which the military says were shipped commercially, were for use in determining whether a new detection test for anthrax and other organisms works as expected. But one lab in Maryland discovered that at least some spores in its anthrax sample were still alive. It reported the problem to the CDC late Friday night.

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The incident is worrying, but not entirely surprising, says Paul Keim, a biologist at Northern Arizona University who studies anthrax.

"Anthrax is one of the most difficult microorganisms to kill," he says. The bacteria can survive for years in the form of tough spores. Once these spores get into the body of an animal or a person, the CDC says, the water, sugars and other nutrients there can activate the spores, turning them into active, growing cells.

The Army facility zapped the anthrax with radiation, which is supposed to render anthrax spores permanently inert. Obviously, Keim says, something went wrong: Maybe they didn't do it long enough to kill everything.

"One of the things that can happen is that they set it up, and they do it, and they find out later that it only kills 99.99 percent," Keim says. That's more than enough if you're killing 100 spores: "But if you're doing it to 10 billion spores," he says, "you're going to have some escapes."

Shots - Health News Feds Tighten Lab Security After Anthrax, Bird Flu Blunders

If just a few spores were still alive in each of the samples sent out, Keim says, then they probably aren't dangerous. It takes a lot of anthrax bacteria to make people sick, he says. Nevertheless, he wonders why the Army lab failed to notice that some spores in the samples were still alive. Testing should be routine before shipments.

The CDC has had its own problems with anthrax. Last year, the agency revealed that as many as 75 workers in its labs may have been exposed because the spores were not properly killed.

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What We Know About Tattoo Reactions Only Goes Skin-Deep

NPR Health Blog - Thu, 05/28/2015 - 4:24pm
What We Know About Tattoo Reactions Only Goes Skin-Deep May 28, 2015 4:24 PM ET

A tattoo that starts as a personal statement can sometimes have medical consequences.

Meredith Rizzo/NPR

For about as long as there have been humans, it seems there have been tattoos.

Ötzi the Iceman, the 5,000-year-old mummy discovered in the Alps in 1991, had 61 tattoos covering his body. And a quick look around the local coffee shop reveals they're just about as popular today. By one estimate, about a quarter of U.S. adults have at least one tattoo.

Yet doctors say we still don't understand the full extent of the skin's reaction to tattoos. There are lots of individual reports of bad reactions to tattoos, some short-lived and others chronic, in the medical literature. And a few European studies lately have tried to put firmer numbers on the extent of those reactions.

"Nobody knows how common these things are," says Dr. Marie Leger, an assistant professor in the Ronald O. Perelman department of dermatology at New York University School of Medicine. "I was really curious."

With the help of two medical students, Leger surveyed more than 300 people they came across in New York City's Central Park.

What did researchers find? Among the tattooed park-goers, 31, or 10 percent, said they'd experienced some sort of adverse reaction after a tattoo. About 4 percent had a problem that didn't last very long, such as pain, infection or swelling. And 6 percent said they'd had a problem that persisted longer than four months, such as itching or scaly skin.

The proportion that reported chronic reactions surprised Leger. "I think that's pretty interesting," she tells Shots. Leger has treated quite a few patients for tattoo reactions. Antibiotics can help with infections and steroids (both creams and injections) can relieve other symptoms.

The findings were published online Wednesday by the journal Contact Dermatitis.

The Central Park survey had some obvious limitations. Foremost among them, the people surveyed described the problems themselves and they weren't independently assessed by doctors as part of the study.

Even when doctors do get involved, it's a challenge to definitively diagnose allergic reactions to tattoo inks, in particular. The reactions can vary quite a bit, and patch testing of inks, a standby in dermatology, isn't very reliable, Leger says.

While there are some well-known tattoo risks, such as infections from needles that aren't sterile, there are lots of open questions.

Tattoo inks, for instance, aren't regulated by the Food and Drug Administration. Agency researchers looking into the inks have learned that a yellow pigment used in inks can be broken down by the body, which might explain why the yellow portions of some tattoos can fade with time.

Still, most people who get tattoos don't have any problems with them, as the Central Park survey found. "It's been my experience that true allergic reactions to the ink are uncommon," says Dr. Elizabeth McBurney, a dermatologist in Lafayette, La., who wasn't involved in the Central Park study.

She's been removing tattoos since the 1970s, and says about 40 percent of her practice now involves helping patients de-ink.

No more than 5 or 10 percent of her patients have medical problems with their tattoos, she says. "The majority of people who come in want the tattoo removed for economic, social or professional reasons," she says. A lawyer or doctor who got a fraternity tattoo in college may want it taken off.

Most often, McBurney uses a laser to remove tattoos. The process requires as many as a half-dozen sessions, which cost hundreds of dollars apiece. "Think before you ink," she says of tattoos. "It's a lot cheaper to put them on than to take them off."

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Depression Treatments Inspired By Club Drug Move Ahead In Tests

NPR Health Blog - Thu, 05/28/2015 - 11:29am
Depression Treatments Inspired By Club Drug Move Ahead In Tests May 28, 201511:29 AM ET Listen to the Story 1:34
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Experimental medicines related to ketamine, an anesthetic and club drug, are making progress in clinical tests.

Wikipedia

Antidepressant drugs that work in hours instead of weeks could be on the market within three years, researchers say.

"We're getting closer and closer to having really, truly next-generation treatments that are better and quicker than existing ones," says Dr. Carlos Zarate, a researcher at the National Institute of Mental Health.

The new drugs are based on the anesthetic ketamine, which is also a popular club drug known as Special K. Unlike current antidepressants, which can take weeks to work, ketamine-like drugs have an immediate effect. They also have helped people with depression who didn't respond to other medications.

The drug that is furthest along is esketamine, a chemical variant of ketamine that has been designated a potential breakthrough by the Food and Drug Administration. Esketamine is poised to begin Phase 3 trials, and the drug's maker, Johnson & Johnson, plans to seek FDA approval in 2018.

Shots - Health News Can Ketamine Keep Depression At Bay?

Another ketamine-like drug on the horizon is rapastinel. It has completed Phase 2 studies, which showed "rapid, substantial, and sustained reductions in depressive symptoms," according to the drug's maker, Naurex.

"I think it's highly probable that we'll see some version of one of these treatments being approved in the relatively near future," says Dr. Gerard Sanacora, director of the Yale Depression Research Program. "In my mind it is the most exciting development in mood disorder treatment in the last 50 years."

Sanacora has done consulting work for both Naurex and Johnson & Johnson. He is also an investigator for a study in which esketamine will be given to suicidal patients.

Shots - Health News 'I Wanted To Live': New Depression Drugs Offer Hope For Toughest Cases

The new drugs come nearly a decade after Zarate and other researchers from the National Institutes of Health published a study showing that ketamine helped most people with major depression in less than two hours. "When we saw the first initial responses you say, wow, this will definitely revolutionize our treatments for mental illness," Zarate says.

Since then, many other studies have confirmed that ketamine usually works even when other drugs have failed. "At this point I think it's incontrovertible that the drug has clear, robust rapid antidepressant effect," Sanacora says. Studies suggest that effect usually lasts for a week or so.

But ketamine itself has shortcomings. It can cause hallucinations, and it's a drug that is frequently abused.

Also, from the perspective of drug companies, ketamine is problematic because it is already available as an inexpensive generic drug. So companies including Naurex and Johnson & Johnson began searching for compounds they could patent that would have a similar effect in the brain.

If esketamine and repastinel reach the market, they could be blockbuster sellers. Johnson & Johnson included esketamine on a list of drugs with potential annual sales of more than $1 billion.

In the meantime, many psychiatrists are already prescribing ketamine to severely depressed patients who haven't been helped by other drugs, even though ketamine hasn't been approved by the FDA for that purpose. This sort of "off-label" prescribing is common in psychiatry, Zarate says.

"I don't think it's necessarily irresponsible," says Sanacora, who has prescribed off-label ketamine to some of his own patients. But it's important that patients who get the drug understand that it's still experimental and are warned of potential risks. He also recommends that patients who want to try ketamine enter a clinical trial.

One looming question about all the ketamine-like drugs is whether they will be safe and effective after months or years of use. "Maintaining is going to be key," Zarate says.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

How Much Does A Colonoscopy Cost In California? Help Find Out

NPR Health Blog - Thu, 05/28/2015 - 9:22am
How Much Does A Colonoscopy Cost In California? Help Find Out May 28, 2015 9:22 AM ET

from

Lisa Aliferis

The colonoscopy: It may be the most dreaded screening test out there, and it's the next step in KQED's PriceCheck project.

On PriceCheck, we're crowdsourcing prices of common health tests and procedures. KQED, along with our colleagues at KPCC in Los Angeles and ClearHealthCosts.com, a health cost transparency startup in New York, are asking people in California to share what they've paid for various health care procedures.

We turned to crowdsourcing because health care prices are wildly variable and opaque. It sometimes stuns people to find out there is no central database of prices. Gag clauses in contracts between doctors and insurers forbid both parties to disclose prices.

People who live in California can use this form to help bring prices into the open. Just get the explanation of benefits your insurance company sent for the colonoscopy and enter price charged, price the insurance company paid and your copay (which should be zero for a screening colonoscopy — more on that below.)

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Our PriceCheck database already contains entries for colonoscopy prices, which range from $1,000 to $5000 in the Bay Area. Surprised by that range? It's in line with the price variations reported both by policy experts and our PriceCheck community for other procedures.

After we get more shared prices (usually in a few weeks), we'll report them back to you at KQED's health blog and on Shots.

Under the Affordable Care Act, colonoscopy and certain other screening tests are required to be covered at no cost to the patient. But we should all care about the wild variation in prices because as health care costs rise, health insurance premiums go up. If you have employer-sponsored health insurance, that can mean your own part of the premium will go up. Public insurance programs like Medicare and Medicaid get more expensive, too, and those are paid for through taxes.

Colonoscopy is "a messy one," says Maribeth Shannon with some irony. She specializes in market transparency and accountability at the California HealthCare Foundation.

She's not just referring to the procedure itself. Colonoscopy is messy because of the way it's billed. Here are some things to ask about before you go in for the procedure:

Screening or diagnostic: In a screening colonoscopy, a doctor threads a flexible tube with an attached camera into the colon to look for abnormalities, like a polyp. If a polyp is found, it can be removed during the procedure. But some doctors and hospitals initially argued that removal made the colonoscopy a treatment procedure. Patients were charged for a "diagnostic" colonoscopy and were on the hook for a big bill. Federal rules have since clarified that "polyp removal is an integral part of a colonoscopy" and must be included at no cost to the patient. Still, Maribeth Shannon says that "consumers should check with their health plan and ask 'what happens if a polyp is found — you're going to treat that as preventive, right?' "

Shots - Health News Feds Tell Insurers To Pay For Anesthesia During Screening Colonoscopies

Anesthesia: You might think that anesthesia would be included with the price of a colonoscopy. After all, it's not surprising that many patients would want to be anesthetized. But for quite awhile, patients were being billed for anesthesia, which by itself can run $1,000 or more.

That's what happened to Gareth Tyrnauer of Sebastopol, Calif. He was delighted when his insurer sent him a letter that said a colonoscopy would be covered 100 percent. "I'd be a fool not to do this," he recalls thinking. But after the procedure, he got a $1,200 bill — just for the anesthesia. He called his insurer's customer service to fight the bill, saying he told the representative, "I've got a piece of paper right here and it says 'it's 100 percent covered.' What part of 100 percent don't I understand?" He ultimately won.

Earlier this month, the federal government stepped in again and issued a clarification that insurers may not charge for anesthesia used in connection with a preventive colonoscopy.

In-network is key: Make sure you know in advance who is involved in the procedure, warns Dena Mendelsohn, a health policy analyst with Consumers Union in San Francisco. "Consumers should be sure to confirm that the facility where they're going is in-network and the provider they will have is in-network."

Quality: In health care, determining quality of a procedure can be as difficult as determining how much it might cost. A strong predictor of quality is volume of procedures. A doctor or facility that has high volume is likely to be doing a higher quality job. Mendelsohn says many health insurance plans have tools for their customers on their websites and sometimes that includes volume. How much is the right amount? Hard to know, she says, but consumers could compare "hundreds or thousands versus dozens."

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Mendelsohn also recommends avoiding a large university medical center for a colonoscopy. "Large universities are tailored toward more complicated procedures," she says. "Since a screening colonoscopy is more routine, it's not necessarily the case that going to a large university will get you a better colonoscopy."

Other options: If you've been dreading have a colonoscopy, you're not alone. But there are other non-invasive options for colon cancer screening, including the fecal occult blood test. If you've been avoiding a colonoscopy, you may want to learn more about this option.

This story was produced by State of Health, KQED's health blog.

Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
Categories: NPR Blogs

A Top Medical School Revamps Requirements To Lure English Majors

NPR Health Blog - Wed, 05/27/2015 - 4:33pm
A Top Medical School Revamps Requirements To Lure English Majors May 27, 2015 4:33 PM ET

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Dr. David Muller, dean of medical education at Mount Sinai, believes that including in each medical school class some students who have a strong background in the humanities makes traditional science students better doctors, too.

Cindy Carpien for NPR

You can't tell by looking which students at Mount Sinai's school of medicine in New York City were traditional pre-meds as undergraduates and which weren't. And that's exactly the point.

Most of the class majored in biology or chemistry, crammed for the medical college admission test and got flawless grades and scores.

Shots - Health News Medical Schools Reboot For 21st Century

But a growing percentage came through a humanities-oriented program at Mount Sinai known as HuMed. As undergraduates, they majored in things like English or history or medieval studies. And though they got good grades, too, they didn't take the MCAT, because Mount Sinai guaranteed them admission after their sophomore year of college.

Adding students who are steeped in more than just science to the medical school mix is a serious strategy at Mount Sinai.

Dr. David Muller is Mount Sinai's dean for medical education. One wall of his cluttered office is a massive whiteboard covered with to-do tasks and memorable quotations. One quote reads: "Science is the foundation of an excellent medical education, but a well-rounded humanist is best suited to make the most of that education."

People who look at the same problems through different lenses will make us better in the long run.

The HuMed program dates back to 1987, when Dr. Nathan Kase, who was dean of medical education at the time, wanted to do something about what had become known as pre-med syndrome. Schools across the country were worried that the striving for a straight-A report card and high test scores was actually producing sub-par doctors. Applicants — and, consequently, medical students — were too single-minded.

Kase, according to Muller, "really had a firm belief that you couldn't be a good doctor and a well-rounded doctor — relate to patients and communicate with them — unless you really had a good grounding in the liberal arts."

So Mount Sinai began accepting humanities majors from a handful of top-flight liberal arts schools after their second year of college. These students are expected to continue to follow their nonscientific interests for the remainder of their college careers.

Mount Sinai takes care of teaching these students the science they need, during the summers. Interestingly, it's not exactly the same courses that are studied in most pre-med programs.

First-year medical students Keith Love (left) and Jimmy Murphy both studied environmental science as undergraduates, before joining Mount Sinai's HuMed program.

Cindy Carpien for NPR

The usual pre-med sciences — including several semesters of chemistry, physics, and calculus — date from the early 1900s, when an educator named Abraham Flexner revolutionized medical school by turning it into a truly scientific endeavor.

Shots - Health News Hospitals Fight Proposed Changes In The Training Of Doctors

But those core science courses haven't changed much since Flexner, Muller says, while science has.

Shots - Health News California Experiments With Fast-Tracking Medical School

"The science for 1910 is only nominally relevant today; yet that's the filter through which everyone has to come," he says.

And that filter often weeds out people who could make excellent practitioners. Too frequently, Muller says, "if you can't get an A-minus in organic chemistry, you're not going to be a doctor."

Such artificial barriers "exclude people from medical school that we desperately need," he says.

Studies have shown that the students in Mt. Sinai's Humanities in Medicine program are just as successful in medical school as the students who take more science classes in college. And they are slightly more likely to choose primary care or psychiatry as a specialty — both areas of high need.

At a recent end-of-year party thrown by the medical students for professors and administrators, even the teachers had trouble remembering who was a "HuMed" student and who wasn't.

Someone finally points out Virginia Flatow. She's a second-year student from New York. She majored in psychology at Bates College in Maine. But she was also on the debate team. That meant lots of traveling to tournaments. Flatow says she would never have been able to do that if she'd been on the classical pre-med track.

"There are very few [medical school] courses — maybe, I can think of one off the top of my head — where doing a lot of science in college helps you," Flatow says. "The rest of it is just a matter of, 'How well do you study?' "

Flatow agrees with a growing number of medical educators that organic chemistry is largely irrelevant for medical school, and that its difficulty discourages many students.

"I know so many people who took one semester of organic chemistry [and] dropped pre-med," she says. "My brother was one of them."

John Rhee, another second-year HuMed student, majored in public policy at Cornell and says he was even thinking about going into hotel management. But he decided to become a doctor after taking a summer job at a hospice.

"The experience was so deep for me," he says, "partnering with a patient through end-of-life care."

Keith Love, a first-year HuMed student from Colby College in Maine, says he originally gave himself a "zero percent chance" of going to medical school. He studied environmental science and anthropology in college, and still escapes Manhattan some early mornings to go birding. But, he says, "I thought about what I really wanted to get out of a career — and it was medicine."

These non-traditional students serve yet another role: They round out what could otherwise be a class full of science wonks.

"I think the cross-fertilization of ideas that goes on ... ultimately everyone benefits from it," says Harsh Chawla, a third-year student from Danville, Calif. He did the traditional pre-med program, majoring in biology at the University of Southern California.

The effort has worked so well, in fact, that Mount Sinai is expanding it, opening it to students in any major from any college or university. Eventually half the class will be admitted via a slightly reconfigured program, which has a new name: FlexMed.

Back in his 13th-floor office, Muller shows visitors his commanding view of the East River and East Harlem, "which is sort of the core community we serve as a medical school."

And while he describes his own pre-med training as "cookie cutter," Muller has done his own share of thinking outside the box. Among other things, he is nationally recognized for helping create the nation's largest academic home-visiting program for patients.

But what would he have pursued in college had he not headed straight to the science track?

He thinks for a moment. "Literature — English lit," he says, wistfully. "I read voraciously as a kid, and that almost came to a complete standstill in college because there was just no time to breathe."

Can pursuing different interests really make a better doctor? Of that Muller is confident.

"People who look at the same problems through different lenses will make us better in the long run," he says. "Now, can I prove that's going to be the case? No. But I'd like to believe that it is."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

Supreme Court Says Locals Can Make Pill-Makers Pay For Drug Disposal

NPR Health Blog - Wed, 05/27/2015 - 1:40pm
Supreme Court Says Locals Can Make Pill-Makers Pay For Drug Disposal May 27, 2015 1:40 PM ET

from

Scott Shafer

Tuesday's decision by the U.S. Supreme Court to not review an ordinance passed by Alameda County, California, means that drug makers will now need to pay for collection and disposal of unused drugs in the county.

iStockphoto

Many of us have old prescription drugs sitting around in medicine cabinets — so what's the best way to get rid of them?

Some folks simply toss old pills in the garbage, or down the toilet.

"Drugs are dangerous in a home where you have elderly people who lose track of what they're doing, and where you have others — children — in the house. There are health, safety and environmental problems."

Both of those options can lead to medications in the ocean, bays or rivers. Three years ago Alameda County, across the bay from San Francisco, became the first county in the nation to require pharmaceutical manufacturers to pay for safe disposal of prescription drugs. Drug companies sued and lost in lower courts. Tuesday the U.S. Supreme Court refused to hear the case, meaning that drug makers will now need to pay for collection and disposal of unused drugs.

"I think that this is an important step forward for protecting our marine resources as well as our drinking water," says Miriam Gordon with Clean Water Action, an advocacy group.

Actually, the FDA says it's OK to flush many kinds of old pills down the toilet. Regulators say the risk that kids or pets will get into medicine left around the house is much worse than any impact on our water.

Shots - Health News California County Pushes Drugmakers To Pay For Pill Waste

Still, Art Shartsis, an attorney representing Alameda County, says the drug disposal law costs pharmaceutical companies very little to implement.

Shots - Health News Trash Can May Be Greenest Option For Unused Drugs

"Drugs are dangerous in a home where you have elderly people who lose track of what they're doing, and where you have others – children — in the house," he says. "There are health, safety and environmental problems."

Attorney Richard Semp, with the Washington Legal Foundation, is a strong opponent of the drug disposal law. He calls it "selfish," because it forces others to pay for something that should be paid for locally, and says it also interferes with interstate commerce.

"The whole point of the Commerce Clause is that we have one national economy," he says. "If you had every jurisdiction around the country trying to impose its waste disposal costs on other jurisdictions, it would lead to chaos."

Semp says Tuesday's Supreme Court decision could ultimately be the law's undoing, as other counties around the nation pass similar laws and are sued.

"If, at the end of the day, you have conflicting lower court decisions, then almost surely the U.S. Supreme Court will have to jump in," he says.

San Francisco and San Mateo counties now have similar drug disposal laws, with dozens of locations to drop off old pills. Other California counties, including Los Angeles and Santa Barbara, are looking into it.

Meanwhile, most states have some sort of legislation, enacted or in the works, that encourages the reclamation and, in some cases, recycling of many types of leftover medication. And the federal Drug Enforcement Agency has sponsored take-back programs, in conjunction with some local law enforcement agencies, to help get expired or unused pain medication that has the potential for abuse off the streets.

This story was produced by State of Health, KQED's health blog.

Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
Categories: NPR Blogs

Paralyzed By Doubt? Here's A Guide For The Worrier In Us All

NPR Health Blog - Wed, 05/27/2015 - 11:16am
Paralyzed By Doubt? Here's A Guide For The Worrier In Us All May 27, 201511:16 AM ET Courtesy of Andrews McMeel Publishing

Feeling anxious? A bit panicky? Fear not — cartoonist and self-proclaimed World Champion Overthinker Gemma Correll is here to help you laugh about it.

In A Worrier's Guide to Life, Correll dishes out her dubious and droll advice on everything from health and hypochondria to attaboy stickers for grownups. (Sample: "I did the laundry.")

She should know. Correll, a 30-year-old British illustrator based in Norfolk, England, has dealt with an anxiety disorder and depression throughout her life. Plus: "I'm the type of person who worries about lots of insignificant things," she says.

Correll often tackles mental illness in her comics, including a detailed explanation of panic attacks and a sardonic take on those ubiquitous "Keep Calm" posters: "I can't keep calm and carry on because I have an anxiety disorder."

A Worrier's Guide makes light of serious mental health issues as well as the everyday angst that affects us all. Our conversation has been edited for length and clarity.

When did you decide it was OK to get funny about anxiety?

I'm a freelance illustrator, and a few years ago I started drawing things for myself and posting online. I noticed that people reacted really well to the cartoons and comics that were about anxiety and worrying and everyday problems.

Courtesy of Andrews McMeel Publishing

Do you think your work resonates with people who have dealt with similar mental health issues?

Yeah, I think people are really glad to find somebody who's had the same kind of experience. Anxiety and depression can make you feel quite isolated.

Your comics portray both diagnosable mental conditions and the types of worries that every young person feels. Like in the valentines: "You'll Do" and "I Don't Hate You" are some of my favorites.

One of my favorite illustrations is the noncommittal Valentine's Day cards. It was one of the first comics that I did for myself and posted online, and it was the first time that I realized that people would find my work funny.

I didn't want the book to be one-note. For people who don't have an anxiety disorder, there are a couple of comics in the book that I hope will explain the condition to them a little bit more and help them understand.

Courtesy of Andrews McMeel Publishing

But I also have things about student debt and body image and all these everyday things — and I hope everyone finds it funny just on a general level.

Why joke about illnesses that can be very painful?

I always find that laughing helps put things in perspective.

But, you know, it wasn't always easy to take that approach. When I was a teenager, dealing with anxiety felt very isolating. And the Internet wasn't around so much, so I couldn't just Google my symptoms like you can now.

I did always find solace in drawing, even though at the time I wasn't necessarily drawing stuff about anxiety. Just making comics in any form helped me deal with my mental health problems.

How did you make the leap into darker themes?

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I grew up reading comics like Snoopy — very lighthearted comics. But when I went to art school, I discovered people who were making more subversive comics. I got really into [Simpsons creator] Matt Groening, and Gary Larson, who did 'The Far Side', and [cartoonist] Lynda Barry.

I saw their work and realized that this was something I could do myself.

A lot of the comics in your book are about being a millennial. You've got the Sallie Mae Lil' Graduate doll that comes with a fast-food restaurant uniform. Do you feel like young people now are more stressed out than they used to be?

I don't know if we necessarily worry more. But we've got more to worry about, with things like debt and high unemployment and all the difficulty getting jobs. It's natural for everyone to be anxious about these things.

For people who have issues with anxiety, the good thing is, we probably have better support systems these days. We have more access to information and better mental health systems in place.

Even if you're not able to talk about your issues with a therapist, there are so many places you can go online, where you can find people who're going through similar things as you. That's something I really wish I'd had as a teenager.

Courtesy of Andrews McMeel Publishing Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

How A Claim That A Childhood Vaccine Prevents Leukemia Went Too Far

NPR Health Blog - Wed, 05/27/2015 - 9:32am
How A Claim That A Childhood Vaccine Prevents Leukemia Went Too Far May 27, 2015 9:32 AM ET Tara Haelle

Controversy over childhood vaccines may make it too easy to embrace what appear to be new vaccine benefits.

Dmitry Naumov/iStockphoto

Sometimes a story takes odd turns as you report it. Every once in while it goes off the rails. That's what happened as I reported on a new study purporting to explain how a childhood vaccine helps prevent leukemia. The experience reaffirmed the lessons I've learned in my years of reporting on vaccines and other scientific research: Be wary of grand claims, get outside perspectives on new research and never, ever rely only on the press release.

Of course, the press release headline was captivating: "Study Explains How Early Childhood Vaccination Reduces Leukemia Risk." Multiple news stories were already sharing how the Hib vaccine, which prevents a horrific, often fatal disease known as Haemophilus influenza Type b, could help prevent childhood cancer. It's always thrilling to come across a new way that existing vaccines can benefit people, such as using the tetanus vaccine to enhance immunotherapy for brain tumors. So I eagerly dove into reporting on this development.

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Yet something confused me: The press release stated that "the cancer protection offered by the Hib vaccine has been well established in epidemiological studies." I had never heard that vaccines reduced leukemia risk, despite having read hundreds of studies on vaccines. But I'm also a journalist, not a researcher or clinician. My expertise is in finding the right experts to talk to me about research, not knowing the whole research base. I expected the experts would shed some light.

First I spoke to the study author, Dr. Markus Müschen, a professor at the University of California, San Francisco. The way he explained the mechanism made sense. Early exposure to slight challenges to the immune system, such as vaccines and minor infections from daycare, keep the immune system in check, he said. Without that, the immune system can kick into high gear with a major infection, such as Hib, and cause two enzymes in particular to overreact.

And it just so happens that these two enzymes also apparently play a role in the development of acute lymphoblastic lymphoma, or ALL, one of the most common childhood cancers. Müschen's experiments in mice showed that these enzymes, when activated by repeated inflammation, might cause pre-leukemic cells to develop into leukemia.

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But when Müschen said it was "common knowledge that vaccines protect against cancer and leukemia," a "fact had been known for many years," alarm bells rung in my head.

Only two vaccines are clearly known to prevent cancer. The HPV vaccine prevents cervical and other cancers, such as oral and anal cancers, caused by human papillomavirus infections, The hepatitis B vaccine can prevent liver cancer by preventing hepatitis B, one cause of liver cancer.

I wasn't aware of any vaccine that prevented leukemia.

Further, a quote from Müschen in the press release said his "experiments help explain why the incidence of leukemia has been dramatically reduced since the advent of regular vaccinations during infancy." But I couldn't find evidence of this dramatic reduction in government health statistics.

"I think this research is very interesting and thought-provoking, but I can't connect the data they're presenting to how Hib vaccine may reduce the risk of childhood leukemia."

When I turned to outside experts, I discovered my confusion was justified.

I asked Dr. Walter Orenstein, associate director of the Emory Vaccine Center, if he could help or recommend others. He sent me to Dr. Art Reingold, head of epidemiology at the University of California, Berkeley, School of Public Health, and Dr. Martha Arellano, an oncologist specializing in leukemia at the Winship Cancer Institute of Emory University. Arellano also suggested I speak with Dr. Edmund Waller, an immunologist and oncologist also at Emory's Winship Cancer Institute.

Every one of them conveyed the same message: Nothing in this paper proves that the Hib vaccine reduces leukemia risk, much less helps prevent ALL.

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In fact, the word "vaccine" appears only once in the entire paper, to cite a handful of observational studies that have shown a correlation between Hib vaccination and lower leukemia rates. But the first rule of science journalism (and science) is that correlation doesn't equal causation.

"I think this research is very interesting and thought-provoking, but I can't connect the data they're presenting to how Hib vaccine may reduce the risk of childhood leukemia," Arellano said. "I think it's a jump."

Reingold said something similar and pointed out another limitation. Müschen's experiments involved mice, and, well, mice aren't humans. "People have raised increasing doubts about whether mouse immunology, however elegant, is representative of human immunology," he told me. The study did test leukemia-infected human tissue for the gene expression caused by the two enzymes, but again, that's only an association.

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Reingold also confirmed that the HPV and hepatitis B vaccines were the only vaccines known to reduce risk of specific cancers. "Those are infectious agents that we know produce chronic infection and that does result in cancer in some people," Reingold said. "But if one is making a statement beyond that, that is highly dubious and it wouldn't hold up to scrutiny among people who study vaccines. I think this is an instance where one should be more cautious in making a connection."

Waller concurred with Arellano and Reingold: "What I see from the paper does not prove a causal or protective relationship of the Hib vaccine in preventing ALL because I don't see the data that would support that." While we were on the phone, he pulled up the supplementary materials for the paper to be sure we weren't missing something. Nope.

I also asked Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia and an outspoken supporter of childhood immunizations, if he had heard of the leukemia-preventing powers of the Hib vaccine. If anyone knew of a side benefit of vaccines that might improve their public image, it would be Offit. But nope. He, too, hadn't heard that vaccines reduce leukemia risk.

So I returned to Müschen and told him of the skepticism I had heard from others. "As we had discussed," he told me, "the protective effects of the Hib vaccine were shown in many previous studies, not ours. Our study provides a potential mechanism of how the protective effect can work" — the mechanism driven by those two enzymes. But the press release contains no ambiguity on this point. It clearly suggests that Müschen's findings prove Hib vaccines prevent childhood leukemia, and he appeared to confirm this idea in our initial interview.

Most news organizations reported that the prevention occurs because a Hib infection stimulates the overreaction of these enzymes, so preventing Hib prevents that overreaction. But Reingold told me the characterization of Hib as chronic in the study is inaccurate. It's an acute infection: "You're only infected for a few days before you get better or die," he said.

In short, this study's press release greatly oversold the findings, and in my first interview with him, Müschen didn't discourage this conclusion. Was the research interesting? Yes. Does it add to our understanding about how leukemia begins? Yes. Can other researchers build on what Müschen and his colleagues demonstrated? Yes. Does it show that the Hib vaccine helps prevent cancer? Absolutely not.

Then why all the media attention? I suspect it has something to do with the huge public attention on vaccine refusal, especially after this year's measles outbreak in unvaccinated people. That might make people too eager to embrace what appear to be new vaccine benefits. "We all support vaccination, and we as physicians from various specialties believe they're one of the greatest advances of medicine in the 20th century," Waller said. "To see that being rolled back in the 21st century is very concerning."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

A Neurosurgeon Reflects On The 'Awe And Mystery' Of The Brain

NPR Health Blog - Tue, 05/26/2015 - 2:30pm
A Neurosurgeon Reflects On The 'Awe And Mystery' Of The Brain May 26, 2015 2:30 PM ET Listen to the Story 37:12
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Thomas Dunne Books

Henry Marsh was the subject of the Emmy Award winning 2007 documentary The English Surgeon, which followed him in Ukraine, trying to help patients and improve conditions at a rundown hospital.

Thomas Dunne Books

Neurosurgeon Henry Marsh has opened heads, cut into brains and performed the most delicate and risky surgeries on the part of the body that controls everything — including breathing, movement, memory and consciousness.

"What is, I think, peculiar about brain surgery is it's so dangerous," Marsh tells Fresh Air's Terry Gross. "A very small area of damage to the brain can cause catastrophic disability for the patient."

Over the course of his career, Marsh, a consulting neurosurgeon at Atkinson Morley's/St. George's Hospital in London since 1987, has learned firsthand about the damage that his profession can cause. While many of the surgeries he has performed have been triumphs, there is always a risk of leaving the patient severely disabled.

In the memoir Do No Harm, Marsh confesses to the fears and uncertainties he's dealt with as a surgeon, revisits his triumphs and failures and reflects on the enigmas of the brain and consciousness. Despite his decades on the job — or perhaps because of them — Marsh says that much of the brain remains beyond his grasp. He likens the mystery of the brain to that of the big-bang theory. "We're all sitting on an equally great mystery within ourselves, each of us, in this microcosm of our own consciousness, and I find that a quite nice thought," he says.

Interview Highlights Additional Information: Do No Harm

Stories of Life, Death, and Brain Surgery

by Henry Marsh

Hardcover, 277 pages | purchase

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Stories of Life, Death, and Brain Surgery
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On the danger of brain surgery

You can nick the liver, you can remove bits of the lung, you can remove bits of the heart and the organ goes on working. But with the brain, although some areas can suffer some damage without terrible consequences for the patient, in general terms, it's very dangerous. Which means the decision-making is very important and ... in my experience over the years, when things have gone wrong, it's not because of [we] cut the wrong blood vessel or dropped an instrument or something like that. The mistakes made — the mistakes are in the decision-making — whether to operate or when to operate.

On the computer navigation system used in brain surgery

One of the ways brain surgery is different from surgery elsewhere is you can't explore the brain. If you do an abdominal operation you actually put your hands — nowadays a lot of it is done visually ... but when I trained many years ago in abdominal surgery you actually put your hands into the patient's abdomen and feel around. You feel for the abnormality. You clearly can't do that with the brain and [that's] why brain surgery was very limited until the modern era — we didn't have brain scans. It wasn't exactly guesswork as to where to go, but it was very difficult. Now with so called computer navigation there's not a real-time method but it's a way you can see on the brain scan done just before the operation where you are with your instruments in the patient's brain.

On how the brain creates pain

A lot of what we think is real and obvious, in fact, is, well you could call it an illusion in a way. If I got pain in my hand the pain is not actually in the hand, the pain is my brain. My brain creates a three-dimensional model of the world and associates the nerve impulses coming from the pain receptors in my hand with pain in the hand and it create this illusion that the pain is actually in the hand itself, and it isn't. The more you look into neuroscience the more strange and confusing it becomes.

On patients watching their own surgery

I'll ask my patients, "Do you want to see your own brain?" and some of them say, "Yes," and some say, "No." If they say "Yes," I'll say, "Well, now you're going to be one of the few members of the human race who has ever actually seen their own brain." It's a strange, strange thing to experience. I've actually had an operation on the visual areas of the brain, with the patient awake, at the back of the brain. I've had some of my patients — the visual cortex looking at itself on a television screen — and you feel there should be a philosophical equivalent of acoustic feedback.

On the mysteries of human consciousness

My thoughts don't feel like electric chemistry, but that is what they are. I find it quite a consoling thought that our modern scientific view of the world which has explained so much, we can't even begin to explain how consciousness, how sensation arises out of electric chemistry, but the fact of the matter is it does. ...

"If you don't have conventional religious belief, as I don't, I think in a way thinking about the mystery of one's own consciousness and the universe is a sort of compensation for that in some ways."

The sense of awe and mystery, for some reason, has gotten greater as I've got older. I'm not sure why. Maybe because many of us, as we get older, we start thinking more about the fact our life is going to come to an end, and we become a bit more religious and philosophical. If you don't have conventional religious belief, as I don't, I think in a way thinking about the mystery of one's own consciousness and the universe is a sort of compensation for that in some ways.

On being open about his mistakes

The public need to understand that medicine actually is often a very uncertain process. It's not like going to a car dealer and buying a car or getting things fixed. It's very uncertain. It's very difficult, and there's a lot of talk in this country as there is in the States about duty of candor and guilt-free culture and transparency, and I thought, "Well, I'm going to write a book," (which is based on a diary I've kept all my life) "which says what it's really like with no holds back, the good things and the bad things." Again, some of my operations are great triumphs and tremendous, but they're only triumphs because they're also disasters. If all operations were easy and safe and straightforward there'd be nothing very special about them.

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