Nora Zamichow says if she and her husband, Mark Saylor, had known how doctors die, they might have made different treatment decisions for him toward the end of his life.Maya Sugarman/KPCC
Dr. Kendra Fleagle Gorlitsky recalls the anguish she felt performing CPR on elderly, terminally ill patients.
It looks nothing like what we see on TV. In real life, ribs often break and few survive the ordeal.
"I felt like I was beating up people at the end of their life," she says. "I would be doing the CPR with tears coming down sometimes, and saying, 'I'm sorry, I'm sorry, goodbye.' Because I knew that it very likely not going to be successful. It just seemed a terrible way to end someone's life."Shots - Health News Pain And Suffering At Life's End Are Getting Worse, Not Better
Gorlitsky wants something different for herself and for her loved ones. And most other doctors do too: A Stanford University study shows almost 90 percent of doctors would forgo resuscitation and aggressive treatment if facing a terminal illness.
It was about 10 years ago, after a colleague had died swiftly and peacefully, that Dr. Ken Murray first noticed doctors die differently than the rest of us.Shots - Health News Videos On End-Of-Life Choices Ease Tough Conversation
"He had died at home, and it occurred to me that I couldn't remember any of our colleagues who had actually died in the hospital," Murray says. "That struck me as quite odd, because I know that most people do die in hospitals."
Murray then began talking about it with other doctors.
"And I said, 'Have you noticed this phenomenon?' They thought about it, and they said, 'You know? You're right.' "
In 2011, Murray, a retired family practice physician, shared his observations in an online article that quickly went viral. The essay, "How Doctors Die," told the world that doctors are more likely to die at home with less aggressive care than most people get at the end of their lives. That's Murray's plan, too.
"I fit with the vast majority of physicians that want to have a gentle death and don't want extraordinary measures taken when they have no meaning," Murray says.
A majority of seniors report feeling the same way. Yet, they often die while hooked up to life support. And only about 1 in 10 doctors report having conversations with their patients about death.
A family portrait of Nora Zamichow, husband Mark Saylor and their daughter, Zia Saylor.Maya Sugarman/KPCC
Goldman is a palliative care specialist at Providence Saint Joseph's Medical Center in in Burbank, Calif., and he says that having the tough talk may feel like a doctor is letting a family down. "I think it's sometimes easier to give hope than to give reality," Goldman says.
Goldman, now 35, read Murray's essay as part of his residency. He says that he, too, would prefer to die without heroic measures, and he believes that knowing how doctors die is important information for patients.
"If they know that this is what we'd want for ourselves and for our own families, that goes a long way," he says.
In addition, Medicare does not pay doctors for end-of-life planning meetings with patients.Shots - Health News Hello, May I Help You Plan Your Final Months?
Nora Zamichow wishes she had read Murray's essay sooner. The Los Angeles-based freelance writer says she and her husband, Mark Saylor, likely would have made different treatment decisions about his brain tumor if they had.
Zamichow says that an arduous regimen of chemo and radiation left her 58-year-old husband unable to walk, and ultimately bedridden in his final weeks. "And at no point did any doctor say to us, 'You know, what about not treating?' "
Zamichow realized after reading Murray's essay that doing less might have offered her husband more peace in his final days.
"What Ken's article spelled out for me was, 'Wait a minute, you know, we did not get the full range of options,' " she says.
But knowing how much medical intervention at the end of life is most appropriate for a particular person requires wide-ranging conversations about death.
Murray says he hopes his essay will spur more physicians to initiate these difficult discussions with patients and families facing end-of-life choices.
This story is part of a reporting partnership with NPR, KPCC and Kaiser Health News.Copyright 2015 Southern California Public Radio. To see more, visit http://www.kpcc.org/.
Most of the people who got measles in last year's outbreaks hadn't been vaccinated with the MMR vaccine.Photo illustration by Justin Sullivan/Getty Images
Nothing like a good measles outbreak to get people thinking more kindly about vaccines.
One third of parents say they think vaccines have more benefit than they did a year ago, according to a poll conducted in May.Credit: NPR, Source: C.S. Mott Children's Hospital National Poll on Children's Health, 2015
That's compared to the 5 percent of parents who said they now think vaccines have fewer benefits and 61 percent who think the benefits are the same.
Vaccine safety also got a boost, with 25 percent of parents saying they believe vaccines are safer than they thought a year ago, compared to 7 percent of parents who think they're less safe. Sixty-eight percent didn't change their minds.
The numbers came from a poll of 1,416 parents around the country conducted by the C.S. Mott Children's Hospital.
So far this year 178 people have come down with measles, and many became infected after visiting two Disney theme parks in California, according to the federal Centers for Disease Control and Prevention. Most of those people were not vaccinated.Credit: NPR, Source: C.S. Mott Children's Hospital National Poll on Children's Health, 2015
Even though the Disney outbreaks got wide attention, 2014 was actually worse for measles, with 23 outbreaks including 383 cases among unvaccinated Amish communities in Ohio. In both 2014 and this year, measles is thought to have been brought to the U.S. by unvaccinated travelers.
Polls typically find that people's opinions change very little in the course of a year, according to Matthew Davis, a pediatrician who directs the C.S. Mott poll. "These numbers are incredibly high, and suggest that parents are hearing about the outbreaks and responding."
Doctors should know that parents' opinions can change relatively quickly, Davis says, though in his medical practice, he still sees parents with a wide range of beliefs about vaccine safety.
"It's important for the medical community to realize that parents care deeply about their children's well being," Davis told Shots. "And that is reflected in a wide range of opinions about vaccination."Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Following the money trail is pretty easy with doctors, but nurses are another story.Adrianna Williams/Getty Images
A nurse practitioner in Connecticut pleaded guilty in June to taking $83,000 in kickbacks from a drug company in exchange for prescribing its high-priced drug to treat cancer pain. In some cases, she delivered promotional talks attended only by herself and a company sales representative.
But when the federal government released data Tuesday on payments by drug and device companies to doctors and teaching hospitals, the payments to nurse practitioner Heather Alfonso, 42, were nowhere to be found.
That's because the federal Physician Payment Sunshine Act doesn't require companies to publicly report payments to nurse practitioners or physician assistants, even though they are allowed to write prescriptions in most states.
Nurse practitioners and physician assistants are playing an ever-larger role in the health care system. While registered and licensed practice nurses are not authorized to write prescriptions, those with additional training and advanced degrees often can.
A ProPublica analysis of prescribing patterns in Medicare's prescription drug program, known as Part D, shows that these two groups of providers wrote about 10 percent of the nearly 1.4 billion prescriptions in the program in 2013. They wrote 15 percent of all prescriptions nationwide (not only Medicare) in the first five months of the year, according to IMS Health, a health information company.
For some drugs, including narcotic controlled substances, nurse practitioners and physician assistants are among the top prescribers.
"Nurse practitioners see patients, order tests, recommend procedures and prescribe medications," Dr. Walid Gellad, an associate professor of medicine at the University of Pittsburgh and co-director of its Center for Pharmaceutical Policy and Prescribing, wrote in an email. "It seems straightforward to think that their relationships with the pharmaceutical and device industries are of as much relevance as physicians, dentists, chiropractors, etc."
He added, "If the purpose of the act is to shine a light on the relationship between industry and the health care sector, then you've left out an important component of that sector."
When the Sunshine Act was drafted, those involved say, nurse practitioners weren't part of the discussion. "Physician groups were among the stakeholders who were very engaged," said Allan Coukell, senior director for health programs at the Pew Charitable Trusts. "Nursing groups weren't part of the policy discussions and weren't ultimately covered by the law."
Still, Coukell said, "to the extent that a lot of prescribing now is done by health professionals who aren't physicians, and a lot of marketing is directed at them, they ideally should also be part of the disclosure."
Asked whether payments to these providers should be reported, a spokesman for the Centers for Medicare and Medicaid Services, which manages the disclosure system, said: "Nurse practitioners and physician assistants are currently not covered recipients under the statute for Open Payments."
A representative of the Pharmaceutical Research and Manufacturers of America, the industry trade group, declined comment.
Although payments to nurse practitioners are not required to be reported under the law, a handful of companies did so anyway. Of the 606,000 providers who received payments in 2014, several hundred self-identified as nurse practitioners or physician assistants. The rest were doctors, dentists, optometrists, podiatrists and chiropractors. (Some of the self-identified nurse practitioners and physician assistants actually appear to be doctors, but have misclassified themselves.)
Alfonso was employed as an advanced-practice nurse at Comprehensive Pain and Headache Treatment Center in Derby, Conn. An investigation revealed that she was a heavy prescriber of Subsys, an expensive drug used to treat cancer pain, the U.S. Attorney's Office for Connecticut said. Between January 2013 and March 2015, she wrote more than $1 million in Subsys prescriptions to Medicare patients alone, more than any other prescriber in Connecticut, prosecutors alleged.
"Interviews with several of Alfonso's patients, who are Medicare Part D beneficiaries and who were prescribed the drug, revealed that most of them did not have cancer, but were taking the drug to treat their chronic pain," the U.S. attorney's office said in a press release.
Prosecutors said Alfonso was paid as a promotional speaker by Subsys' maker, Insys Therapeutics Inc., for more than 70 dinner programs at a rate of about $1,000 per event. "In many instances, the dinner programs were only attended by Alfonso and a sales representative for the drug manufacturer," the U.S. attorney said in the release. "In other instances, the programs were attended by individuals, including office staff and friends, who did not have licenses to prescribe controlled substances. For the majority of these dinner programs, Alfonso did not give any kind of presentation about the drug at all."
The charge against Alfonso carries a maximum sentence of five years in prison and a fine of up to $250,000. Sentencing is scheduled for September.
Alfonso could not be reached for comment and her attorney has not returned a phone call. A phone call to Insys was also not returned, though the company said in a statement to The New York Times that it was committed to promoting Subsys "lawfully and appropriately."
A ProPublica report last year identified Alfonso as among the top 20 prescribers nationally of the most-potent controlled substances within Medicare's Part D program in 2012. At the time, we noted that she had been reprimanded and fined by the Connecticut health department in July 2014 for allegedly failing to examine a patient before prescribing/refilling narcotics.
Elissa Ladd, an associate professor of nursing at the MGH Institute of Health Professions in Boston, surveyed 263 nurse practitioners several years ago about their interactions with the pharmaceutical industry. Her survey, published in 2010 in the American Journal of Managed Care, found that nearly all had regular contact with drug company sales representatives. Nine in 10 believed that it was acceptable to attend lunch and dinner events sponsored by the industry.
Ladd said she supports mandatory disclosure of payments for nurse practitioners and physician assistants.
"Nurse practitioners think that they're somewhat immune to this but I think that we're no different than any other provider," she said. "If nurse practitioners were reported on, I think that would be a huge concern for them. I don't think they want to be perceived in a negative light."
Look up your doctor in our Dollars for Docs interactive database to see if he or she has received payments from drug or device companies in 2013-2014. Also read our story about doctors who had the most interactions with industry.Copyright 2015 ProPublica. To see more, visit .
Nurses Katherine Malinak and Amy Young lift Louis DeMattio, a stroke patient, out of his hospital bed using a ceiling-mounted lift at the Cleveland Clinic.Dustin Franz for NPR
When Kate Klein began working as a nurse in the Cleveland Clinic's Neurointensive Care Unit, one of the first things she noticed was that her patients spent a lot of time in bed. She knew patients with other injuries benefitted from getting up and moving early on, and she wondered why not patients with brain injuries.
"I asked myself that question. I asked my colleagues that question," Klein says. "Why aren't these patients getting out of bed? Is there something unique about patients with neurologic injury?"Shots - Health News Patients Do Better After Surgery If They Do 'Prehab' First
Doctors have long encouraged their surgical patients to get out of bed as soon as it's safe to do so. Movement increases circulation, reduces swelling, inflammation and the risk of blood clots, and it speeds healing.
But that wasn't the thinking with brain injuries, explains Edward Manno, director of the Neurointensive Care Unit at the Cleveland Clinic and one of the neurologists who works with Klein. "The predominant thinking was that rest was better suited for the brain," Manno says.
Often the damaged brain is susceptible to lack of blood flow. Increased activity may make things worse if initiated too quickly, Manno says. "So many of us thought for quite some time that we needed to put the brain to rest after the initial insult of stroke or other neurologic injury."
Nancy Albert, Kate Klein and Nancy Kaser collaborated on a study of early mobility for patients with brain injuries.Dustin Franz for NPR
But some doctors, including Manno, suspected patients with brain injuries could benefit from getting out of bed sooner. They just didn't have any proof.
Although plenty of research had been done on early mobilization of patients with other injuries, Klein discovered that no one had actually studied whether it was safe or beneficial for patients with brain injuries caused by seizures, stroke or head trauma to start rehabilitation right away. So she designed a study of her own.
Over the course of a year, Klein tracked more than 600 patients with brain injury, getting more than half of them up and out of bed as early as the first day they were admitted to the ICU. What she found was that getting up and moving had clear benefits. Patients who started their rehabilitation earlier spent less time in the ICU and less time in the hospital. "They have less pressure ulcers, less infections and spend less time on the ventilator if they need ventilator therapy," says Klein. And most say they feel a lot better.
One of the barriers to getting patients with brain injury up is how difficult it is. It took two nurses more than half an hour to get patient Patricia Weeden out of bed and into a chair to visit with her daughter. Weeden, 66, from Cleveland, has suffered severe seizures that damaged her brain. She's hooked to a ventilator, so she can't speak. And she's unable to sit, stand or walk on her own.
"It is difficult to get these patients up," explains Klein.
As a result of her study, the Cleveland Clinic has installed ceiling mounted lifts at each patient's bedside in the Neurointensive Care Unit. Nurses receive other equipment and training to make moving patients safer and easier.
And although it seems like a lot of effort for a few steps from bedside to chair, Klein says it represents huge progress for a patient like Weeden. The benefits may go beyond preventing bed sores or infections. Manno says it may also speed the recovery of the brain.
The brain rewires itself, explains Jeffrey Kleim, an associate professor of biomedical engineering at Arizona State University who studies what happens to the brain after injury.Shots - Health News A Drug Might Heal Spinal Injuries By Sparking Nerve Growth
"And it does this by forming new synapses, forming new connections," says Kleim. "The neural circuits begin to change and adapt, and that's how these new functions begin to emerge in the remaining brain areas."
That neuroplasticity has been shown to be heightened immediately after injury in studies with animals. If the same is true in humans, the sooner patients get up and engage their brains the better their chances of recovery.
Kleim says much of the animal research has been focused on finding ways to jumpstart the rewiring process with drugs or electrical stimulation. But in people, he says, there is a much simpler way to drive the recovery process.
By getting patients up and out of bed early, even taking them outside, Klein and Manno say they are attempting to provide the sort of familiar experiences that are already known to stimulate the brain's natural rewiring process. Those experiences can be powerful, explains Klein, recalling a patient who suddenly began to speak after being outside for the first time.
"She was listening to the traffic, feeling the wind on her face, and then her sons came and they said 'Hi Mom,' and she looked up and said, 'Well, how are you doing?' Those were her first words," Klein says.
But as dramatic as those moments are, Manno says they only illustrate how much we still don't know about the recovery of the brain. For example, it's still unclear if all kinds of brain injuries can or should be treated the same.
"We are just scratching the surface here," says Manno. "There's a tremendous amount of work to be done in this area."Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Officer Ted Simola, a member of the LAPD mental evaluation unit, responds to a call in February.Maya Sugarman/KPCC
The Los Angeles Police Department's mental evaluation unit is the largest mental health policing program of its kind in the nation, with 61 sworn officers and 28 mental health workers from the county.
The unit has become a vital resource for the 10,000-person police force in Los Angeles.Shots - Health News Mental Health Cops Help Reweave Social Safety Net In San Antonio
Officer Ted Simola and his colleagues in the unit work with county mental health workers to provide crisis intervention when people with mental illness come into contact with police.Shots - Health News Mental Health 101: Program Helps Police Intervene In Crises
On this day, Simola is working the triage desk on the sixth floor at LAPD headquarters. Triage duty involves helping cops on the scene evaluate and deal with people who may be experiencing a mental health crisis.
Today, he gets a call involving a 60-year-old man with paranoid schizophrenia. The call is typical of the more than 14,000 fielded by the unit's triage desk last year.
"The call came out as a male with mental illness," says the officer on the scene to Simola. "I guess he was inside of a bank. They said he was talking to himself. He urinated outside."
If it were another department, this man might be put into the back of a police car and driven to jail, so that the patrol officer could get back to work more quickly. But LAPD policy requires all officers who respond to a call in which mental illness may be a factor to phone the triage desk for assistance in evaluating the person's condition.
Officer Simola talks to the officer on the scene. "Paranoid? Disorganized? That type of thing?" The officer answers, "Yeah, he's talking a lot about Steven Seagal, something about Jackie Chan." Simola replies, "OK, does he know what kind of medication he's supposed to have?" They continue talking.
The triage officers are first and foremost a resource for street cops. Part of their job entails deciding which calls warrant an in-person visit from the unit's 18 cop-clinician teams. These teams, which operate as second responders to the scene, assisted patrol in more than 4,700 calls last year.
Sometimes their work involves high-profile interventions, like assisting SWAT teams with dangerous standoffs or talking a jumper off a ledge. But on most days it involves relieving patrol officers of time-consuming mental health calls like the one Simola is helping to assess.
The man involved in this call has three outstanding warrants for low-grade misdemeanors, including public drinking. Technically, any of them qualifies him for arrest. But Simola says today, he won't be carted off to jail.
"He'll have to appear on the warrants later," Simola says, "but immediately he'll get treated for his mental health."
That's the right approach, says Peter Eliasberg is legal director at the American Civil Liberties Union of Southern California. "The goal is to make sure that people who are mentally ill, who are not a danger to the community, are moved towards getting treatment and services as opposed to getting booked and taken into the jail."
Detective Charles Dempsey heads training for LAPD's mental evaluation unit. He says pairing a cop or detective with a county mental health worker means the two can discuss both the criminal justice records that the health worker isn't privy to and the medical records that a cop can't access because of privacy laws.
About two-thirds of the calls are resolved successfully, he says. "We engage them, they get help, they get services and we never hear from them again," he says.
But there are complicated cases, too. And these, Dempsey says, are assigned to the unit's detective-clinician teams. Dempsey says most of the 700 cases they handled last year involved both people whose mental illness leads them them to heavily use or abuse emergency services or who are at the greatest risk for violent encounters with police and others.
"It requires a lot more work," he says.
For nearly a decade, the LAPD has helped trained dozens of agencies both in and out of the U.S. in this type of specialized policing. Its emphasis is diversion over incarceration, for those who qualify.
Lt. Lionel Garcia commanded the unit for seven years until his retirement in April. "Low-grade misdemeanors we'll try to divert them to placement rather than an arrest," he says. But, he continues, "if it's a felony in this city, they're going to jail."
Last year, Garcia says, about 8.5 percent of the calls resulted in the person getting arrested and jailed. When that happens, he says the unit tracks the person through custody and then, upon their release, reaches out to them with links to services. "It's just common sense," he says.
Lt. Lionel Garcia was the lead officer of the LAPD's mental evaluation unit for seven years until his retirement in April.Maya Sugarman/KPCC
"Jails were not set up to be treatment facilities," says Mark Gale, who serves as criminal justice chairman for the LA County Council of the National Alliance On Mental Illness. "People get worse in jail."
Gale and other mental health advocates praise the LAPD unit's approach and call it a good first step. But for diversion to work well, they say, the city and county need to provide treatment programs at each point a mentally ill person comes into contact with the criminal justice system — from interactions with cops all the way through the courts.
This story is part of a reporting partnership with NPR, KPCC and Kaiser Health News.Copyright 2015 Southern California Public Radio. To see more, visit http://www.kpcc.org/.
Barracuda are one kind of fish that has been implicated in poisoning with ciguatera toxin.iStockphoto
Some tasty saltwater fish carry a toxin that you may never have heard of.
And a recent study found that more people in Florida may be getting sick from eating fish contaminated with the toxin than previously thought.
By comparing Florida public health records with survey results from thousands of fishermen, scientists from the University of Florida found that ciguatera fish poisoning, as the condition is called, is significantly underreported in the state.
Before the study was done, the prevailing estimate of ciguatera poisoning was 0.2 cases per 100,000 people per year. The latest work, led by epidemiologist Elizabeth Radke, suggests the cases may be more than 25 times higher.
Statewide, the case frequency may be as high as 5.6 cases per 100,000 people a year. In Miami-Dade County, the researchers put the number at 28 cases per 100,000, and in Monroe County it was 84 per 100,000.
"Doctors and labs are required to report [ciguatera cases] to the Florida Department of Health," Radke says, but it often doesn't happen. People might not go to the doctor, or the doctor might either get it wrong or just fail to send in the report.
The toxic culprit of ciguatera (say sig-WAH-terra) is made by microscopic algae called dinoflagellates. These tiny organisms cling to coral or algae in tropical and subtropical oceans. Small fish don't get sick when they eat the algae, but the toxin (called ciguatoxin) is stored in their bodies. When larger fish eat the small fish, the toxin accumulates. Humans who eat large fish full of ciguatoxin can be poisoned.
A case of ciguatera typically involves vomiting, diarrhea, nausea and cramps. At higher doses, the toxin triggers neurological symptoms, such as the reversal of the sensations of hot and cold. Some people report dizziness or hallucinations. The illness is rarely fatal, but symptoms can last for weeks or even years.
The results of the study were published Monday in The American Journal of Tropical Medicine and Hygiene.
Since ciguatoxin is most concentrated in large tropical fish, such as barracuda, grouper, amberjack and hogfish, the scientists emailed thousands of surveys to recreational saltwater fishermen asking about health issues related to the fish. Had the fishermen ever been diagnosed with ciguatera poisoning? Had they ever experienced its telltale symptoms after eating fish?
One advantage of the surveys, Radke says, is that fishermen are more likely to be able to identify a fish they ate, as well as know where it came from.
Wayne Litaker, an ecologist with the National Oceanic and Atmospheric Administration in North Carolina, says the survey approach makes sense. "There's really no optimal way to do it," he says. "They got the group that was most likely to be affected." Litaker says underreporting is common with ciguatera fish poisoning. "It's hard to diagnose," he says. "A lot of physicians don't know about it, or don't know it's a reportable disease."
Another source of confusion is that fish that may be contaminated are shipped all over the world. People who eat one containing ciguatoxin may not know what the fish was or where it came from. Even if they do develop the classic neurological symptoms, their doctors may have never seen ciguatera before. Litaker says the solution is "improved public outreach and better training of physicians."
Radke agrees. "There are fish, like barracuda, that people shouldn't be eating at all," she says. Barracuda may be the worst offenders, but people need to be aware of other potentially toxic fish, and go to a doctor if they start to feel sick.
Climate change is expected to expand the range of the toxic dinoflagellates, which thrive in warm waters. Ciguatera poisoning might show up in places that have never had it before.
Since Florida is the most northern limit of ciguatera in the U.S., it's important to keep an eye on the illness there. "It can really be a bellwether for the rest of the world," Radke says.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
You can now order genetic tests off the Internet and get your child's genome sequenced for less than the cost of a new car. The question is, should you?
Almost certainly not, according to the American Society for Human Genetics, which released a position paper Thursday intended to give parents some help navigating the dizzying world of genetic tests.
"This is something that we don't think is ready for prime time for kids," says Dr. Jeffrey Botkin, a professor of pediatrics at the University of Utah and lead author of the paper.
Back in 1995, the last time the society, which includes genetic researchers and clinicians, offered recommendations on genetic tests for children, they were weighing the risks and benefits of testing for diseases caused by a single gene. They discouraged getting children and teenagers tested for mutations that increased the risk of disease in adulthood, like the newly discovered BRCA mutations that cause breast cancer.
"Families and kids end up dealing fairly well with that kind of predictive information," Botkin says. So the organization now says families should be given more leeway in making that own decision.
Genetic testing has changed drastically since 1995. It's now possible not only to check for hundreds mutations that cause disease, but to scan and catalogue all of a child's DNA for a few thousand dollars.
That's a lot of data. The problem, as this report points out, is that it's hard to know what's a harmless genetic blip and what could be life-threatening. That includes what scientists call "incidental findings" – we weren't looking for it, but here it is, and we have no idea what it means.
"At the present time," the report notes, "the contrast between our ability to identify genetic variants and our ability to fully interpret the information gives rise to the many ethical issues in this domain."
Because of that, the society recommends that rather than scan all genes and then try to figure it out, in most cases testing and analysis should focus on a single gene or a small number of genes that are likely culprits, based on a child's symptoms.
"People have been attracted to this idea of well, let's just do the whole genome," Botkin says. "When you may be raising a lot more problems than you're solving. The more specific the test you can use, the better."Shots - Health News Screening Newborns For Disease Can Leave Families In Limbo
Hold off on genome-wide sequencing on healthy children, the report says, including genome-wide newborn screening for genetic disorders.(Most newborns are tested for rare disorders shortly after birth, but those tests look only for specific mutations mandated by state law.)
Of course, you can now pay online to get direct-to-consumer genetic tests for cancer risks and all sorts of things. Other firms have offered chunks of your genome scanned by companies like 23andme, which offered health risk predictions before the Food and Drug Administration forced it to back off in 2013. Best to avoid direct-to-consumer genetic testing until companies can prove it's accurate and they provide reliable counseling, the society says.
An increase in genetic testing is "inevitable," the report states, so doctors, nurses, physician assistants and counselors need to up their game and learn how to explain the complexities of genomic medicine.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Skydiving and vacuuming burn the same number of calories. So what'll it be, thrills or a clean carpet?Mary McLain/NPR
Sure, playing in the women's World Cup burns a lot more energy than watching the women's World Cup. But the number of calories expended in sports and daily activities isn't always so obvious.
To figure it out, we dove into this database compiled by Arizona State University. It charts the energy expenditure for hundreds of activities, from mainstream ("bicycling, leisure, 5.5 mph") to obscure ("caulking, chinking log cabin").
Calories burned by a 200-pound person in 30 minutes:Copyright 2015 NPR. To see more, visit http://www.npr.org/.
With summer vacations coming up, one reader this week asked about travel insurance, while others had questions about coverage of preventive services, including costs related to colonoscopies.
We know now that anesthesia for a screening colonoscopy is covered with no cost sharing as a preventive service under the health law. As a plan administrator, I am also struggling to find guidance on how to handle bowel prep kits for colonoscopies. Can you help?
Without some sort of bowel cleansing preparation — often a powerful laxative that scours out the colon — the exam, which involves inserting a flexible tube with a camera on the end into the rectum and snaking it through the large intestine to look for polyps and other abnormalities, couldn't be done.Shots - Health News Feds Tell Insurers To Pay For Anesthesia During Screening Colonoscopies
When the federal government clarified in May that under the Affordable Care Act's preventive services provisions consumers can't be charged for anesthesia they receive as part of a screening colonoscopy, it didn't address other services that are generally part of the exam, including bowel prep kits.
"The federal coverage mandate doesn't include any ancillary services," including bowel prep kits or even the pre-screen consults that can cost as much as $250, says Citseko Staples-Miller, senior specialist for state and local campaigns for the American Cancer Society Cancer Action Network. Some states may impose additional coverage requirements on insured plans. But aside from anesthesia, plans can generally decide for themselves under federal law whether to cover such services without cost sharing.
Why should I buy travel insurance if it won't cover pre-existing medical conditions? That's exactly what I'd probably need it for.
It's often easy to get that coverage if you need it. Most comprehensive travel insurance policies cover pre-existing conditions if you buy coverage within 14 to 21 days of making your first trip payment, says Lynne Peters, insurance product manager at insuremytrip.com, a website that offers plans from 25 companies.
Even if you miss that window, as long as you haven't recently needed medical attention for your diabetes or bad back, for example, you may not run into trouble.
"Most policies have relatively short 'lookback' periods," Peters says. That means that if you file a claim, the insurer will only review your medical records for pre-existing conditions for a specified period before your policy's effective date, typically 60 to 180 days. As long as you haven't received any medical treatment, testing, medication changes or recommendations from a physician related to your pre-existing condition during that timeframe, the claim wouldn't be denied on that basis, Peters says.
With too many children affected by prenatal exposure to illicit drugs, alcohol or tobacco, why doesn't the federal government include prenatal screening in its list of preventive services that must be covered without cost sharing?
It's standard practice to screen pregnant women for alcohol, tobacco and illicit drug use and intimate partner violence during their initial visit with an OB-GYN, says Dr. Lisa Hollier, of the Center for Children and Women in Houston who is assistant secretary of the executive board of the American Congress Of Obstetricians And Gynecologists.Shots - Health News Addicted And Pregnant: 'The Most Heart-Wrenching Experience Of My Life'
Screening involves asking a series of questions about substance use. It doesn't involve urine or other tests that might discourage women from getting appropriate prenatal care because they fear running into legal problems, according to ACOG.
In addition, the health law requires most plans to cover preventive services recommended by the U.S. Preventive Services Task Force without requiring consumers to pay anything out of pocket. The task force recommends that tobacco and alcohol screening be performed and counseling provided if necessary for pregnant women. It concludes that there's not enough evidence to assess whether screening pregnant women for illicit drug use is clinically useful. As a practical matter, the task force's lack of endorsement for drug screening for pregnant women doesn't mean plans won't cover it.
While screening isn't generally a concern, treatment can be.
"There are not many professionals who have specific expertise in managing these problems with pregnant patients," Hollier says.Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Few days went by last year when New Hampshire nephrologist Ana Stankovic didn't receive a payment from a drug company.
All told, 29 different pharmaceutical companies paid her $594,363 in 2014, mostly for promotional speaking and consulting, but also for travel expenses and meals, according to data released Tuesday detailing payments by drug and device companies to U.S. doctors and teaching hospitals. (You can search for your doctor on ProPublica's updated Dollars for Docs interactive database.)
Stankovic's earnings were certainly high, ranking her about 250th among 606,000 doctors who received payments nationwide last year. What was more remarkable, though, was that she received payments on 242 different days —nearly every workday of last year.Additional Information: Web Resources Check Dollars For Docs to see if you doctor received money.
Reached by telephone Tuesday, Stankovic declined to comment. On her LinkedIn page, Stankovic lists herself as vice chief of staff at Parkland Medical Center HCA Inc. in Derry, N.H., and as medical director of peritoneal dialysis at DaVita Inc., also in Derry.
That doctors receive big money from the pharmaceutical industry is no surprise. The latest data released by the Centers for Medicare and Medicaid Services shows that such interactions are widespread, with not only doctors, but thousands of dentists, optometrists, podiatrists and chiropractors receiving at least one industry payment from August 2013 to December 2014.
What is being seen for the first time now is how ingrained pharmaceutical companies and their sales reps are in the lives of those who write prescriptions for their products. A ProPublica analysis found that 768 doctors received payments on more than half of the days in 2014. More than 14,600 doctors received payments on at least 100 days in 2014.
Take Juichih Hsu, a Maryland doctor whose specialty is family medicine. She received payments on 286 days of 365, more than anyone else. Sometimes, she received meals from several drug companies on the same day. Hsu's payments totaled $5,959. She declined to comment when reached on Tuesday.
"There are physician practices which have very deep relationships with pharmaceutical representatives, where they are a very integral part of the practice," said Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School who has written about industry relationships with doctors. "Every day it's another drug company coming in for a lunch. Sometimes it may be some drug companies are bringing breakfast and some are bringing lunch and it's just part of the culture of the practice."
Sometimes there may be more at work than that.
The doctor with the second-highest number of interactions with drug and device reps, John Fritz, of Jersey City, N.J., logged payments on 256 days last year. His payments totaled $232,003. Fritz was indicted in June for referring patients to a medical imaging company from 2006 to 2013 in exchange for about $500,000 in kickbacks.
The drugs for which Stankovic received the most money to promote are costly. One, H.P. Acthar Gel, cost an average of nearly $39,000 a prescription, Medicare data from 2013 shows, and experts say there's little evidence it works better than less expensive drugs. Another drug, Soliris, for which Stankovic received promotional payments is among the most expensive drugs in the world but is considered highly effective in treating serious kidney disease.
ProPublica's analysis turned up big differences in the number of industry interactions among physicians in different specialties. On average, doctors who received payments interacted with drug and device companies on 14 days last year, receiving an average of $3,325 in total.
The nation's 3,900 rheumatologists in the data averaged 40 days of interactions with drug and device companies, more than doctors in any other large specialty. They were followed closely by endocrinologists, electrophysiologists and interventional cardiologists. On the other end of the spectrum, dentists, chiropractors, neonatologists and pathologists had among the fewest interactions with drug and device makers.
A spokeswoman for the pharmaceutical industry said in a statement that company interactions with doctors are important. "Collaboration between physicians and biopharmaceutical professionals is critical to improving the health and quality of life of patients," the statement from the Pharmaceutical Research and Manufacturers of America said.
ProPublica has been tracking industry payments to doctors since 2010. Our Dollars for Docs interactive database allowed people to search payments made by 17 companies between 2009 and 2013. Most of those companies were required to report their payments as a condition of legal settlements with the federal government.
The data released Tuesday radically expands the amount of data available to patients. ProPublica has overhauled Dollars for Docs to include these payments. The Physician Payment Sunshine Act, a part of the 2010 Affordable Care Act, mandated that all drug and device companies publicly report payments to doctors. The transparency effort is called Open Payments.
The government initially released some data last fall, covering the period of August to December 2013, but it was significantly redacted because of data inconsistencies. The data released Tuesday covers the period of August 2013 to December 2014. The data inconsistencies have been resolved.
All told, 1,617 companies reported 15.7 million payments valued at $9.9 billion. Nearly all of those payments — 14.9 million — were classified as "general payments," covering promotional speaking, consulting, meals, travel and royalties. They totaled $3.5 billion over the 17-month period.
There were far fewer research payments, 826,000, but they were valued at $4.8 billion. The remaining payments related to ownership or investment interests that doctors had in companies. Research and ownership payments are currently not shown in Dollars for Docs.
Open Payments does not include money spent on drug samples left at doctors' offices and doesn't include the bulk of the money companies spend on independently administered continuing medical education, which they support with unrestricted grants. The government has tightened the rules for reporting such continuing education in the future.
ProPublica news application developers Mike Tigas and Lena Groeger and senior reporting fellow Annie Waldman contributed to this report..
If you run into an old friend at the train station, your brain will probably form a memory of the experience. And that memory will forever link the person you saw with the place where you saw him.
For the first time, researchers have been able to see that sort of link being created in people's brains, according to a study published Wednesday in the journal Neuron. The process involves neurons in one area of the brain that change their behavior as soon as someone associates a particular person with a specific place.
"This type of study helps us understand the neural code that serves memory," says Itzhak Fried, an author of the paper and head of the Cognitive Neurophysiology Laboratory at UCLA. It also could help explain how diseases like Alzheimer's make it harder for people to form new memories, Fried says.
The research is an extension of work that began more than a decade ago. That's when scientists discovered special neurons in the medial temporal lobe that respond only to a specific place, or a particular person, like the actress Jennifer Aniston.
The experiment used a fake photo of actor Clint Eastwood and Pisa's leaning tower to test how the brain links person and place.Courtesy of Matias Ison/Neuron
More recently, researchers realized that some of these special neurons would respond to two people, but only if the people were connected somehow. For example, "a neuron that was responding to Jennifer Aniston was also responding to pictures of Lisa Kudrow," [another actress on the TV series Friends], says Matias Ison of the University of Leicester in the U.K.
The two actresses were often on screen together. So it made sense that the brain would create a link between them. And Ison thought those special neurons in the medial temporal lobe might be that link.
To find out, he and a team of researchers did an experiment involving 14 epilepsy patients who had electrodes temporarily implanted in their brains to identify the source of their seizures. The patients agreed to let researchers use the electrodes to monitor individual brain cells in the medial temporal lobe of their brains.
First, the team identified neurons that responded to pictures of a specific person, like Jennifer Aniston or Clint Eastwood. Then they identified different neurons that responded to pictures of a particular place, like the Eiffel Tower or the Leaning Tower of Pisa.
The next step was to get the patients' brains to form a new association between a person and a place. The team did that by showing them fake images of Jennifer Aniston at the Eiffel Tower or Clint Eastwood at the Leaning Tower of Pisa.
When people saw these fake images, it was like running into an old friend at the train station. The experience created a new memory linking the person and the place.
And that caused neurons in the medial temporal lobe to change their behavior, Fried says.
"When the association is created, suddenly the cell very rapidly changes its firing properties," he says. For example, a cell that had responded only to pictures of Clint Eastwood would start responding in a similar way to pictures of the Leaning Tower of Pisa.
This sort of change to individual cells could help explain how the brain creates memories of experiences, which may involve not only people and places, but emotions and sensations and lots of other information, Fried says. And when we recall an experience, these special neurons may help us re-assemble all the relevant information, he says.Shots - Health News Bursts Of Light Create Memories, Then Take Them Away
The study may also help explain what's going wrong in the medial temporal lobe of people who have trouble forming new memories, Fried says. "We know in situations like Alzheimer's, one of the very first changes you see is in this very area," he says.
And if Alzheimer's affects the same neurons that make associations, it would explain why people with Alzheimer's can't remember things like where they parked their car, Fried says.
"I have to create an association between my car and the particular place," he says. "If an association is not created, then I will not be able to find my car."
The study also backs the idea that memories can be formed very quickly, says Michael J. Kahana, a professor of psychology at the University of Pennsylvania who was not involved in the research.
"Even a single brief exposure to any information changes the human brain," he says.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Powerful antipsychotic medications are being used to treat children and teenagers with ADHD, aggression and behavior problems, a study finds, even though safer treatments are available and should be used first.
"There's been concern that these medications have been overused, particularly in young children," says Mark Olfson, a professor of psychiatry at Columbia University who led the study. It was published Wednesday in JAMA Psychiatry. "Guidelines and clinical wisdom suggest that you really should be using a high degree of caution and only using them when other treatments have failed, as a last resort."
Olfson and his colleagues looked at prescription data from about 60 percent of the retail pharmacies in the United States in 2006, 2008 and 2010. That included almost 852,000 children, teenagers and young adults. Teens were most likely to be prescribed antipsychotics, with 1.19 percent getting the drugs in 2010, compared to 0.11 percent in younger children. Boys were more likely to be given the medications.
Antipsychotic medications like clozapine and olanzapine are used to treat schizophrenia, bipolar disorder and some symptoms of autism. They have not been approved by the Food and Drug Administration to treat aggression and ADHD, but are prescribed off label to reduce disruptive behavior.FDA Debates Safety Of Antipsychotic Drugs In Kids
Use of antipsychotics in children has been questioned because the drugs can have serious side effects, including tremors, weight gain, increased diabetes risk and elevated cholesterol.
This study, which may be the broadest look yet at use of antipsychotics in children, found that most children had not been diagnosed with a mental disorder before being given antipsychotics.
ADHD was the most common diagnosis, applied to 52.5 percent of young children, 60 percent of older children, and 34.9 percent of teenagers diagnosed with ADHD. Depression was the most common diagnosis in young adults, with 34.5 percent. The researchers determined that by looking at inpatient and outpatient claims for a smaller subset of patients in 2009.
"About half of the kids with ADHD have aggression and have disruptive behaviors," Olfson says. "They can be difficult to control." The medications do reduce aggression, Olfson says, but that can also be achieved with behavioral programs such as teaching problem solving skills.
"Behavior modification and family treatment is something that should always some first, but less than one quarter of children and teens are getting that," says Christof Correll, a professor of psychiatry at Hofstra North Shore-Long Island Jewish School of Medicine. He wrote an editorial accompanying the study.Shots - Health News Risks Run High When Antipsychotics Are Prescribed For Dementia
"Physicians use these medications too fast," Correll says. There are a lot of reasons for that, he says, including a shortage of psychotherapists, the amount of time required for family therapy and lack of insurance coverage. As a result, many parents don't seek help until a child is in serious trouble, perhaps about to be expelled or land in juvenile detention.
Only a minority of children had seen a child or adolescent psychiatrist before being treated, the study found.
Earlier studies have found that giving families training on how to deal with aggression can reduce disruptive behavior. Appropriate dosing with stimulant medications like Ritalin also can help.
"It is complicated, and that's why it's hard to fault families or clinicians," Correll adds. Behavior problems can have interfere with a child's education, social interactions and development, he notes, so parents shouldn't delay seeking help. "They should try to get guidance counselor involvement at school, and not dismiss it until it's too late."
Seeking out a psychiatrist or other specialist can not only help find appropriate treatments, but can speed up referrals to therapists, Correll says.
The study, which was funded by the National Institute of Mental Health, involved researchers at Columbia University, Yale and NIMH.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Donetta Held unloads needles and pipes confiscated from a contaminated meth home. She owns an environmental decontamination company and says meth tests are their most demanded service.Barbara Brosher/WFIU
Jennifer Nugent and her three kids are throwing a big, blue ball around in the small living room of their rental home.
The kids are happy, but Nugent isn't. She planned to raise them in a place with much more room to play.
And she was. That is, until she learned that home was uninhabitable.
Two years ago, she and her husband bought a country home in the small central Indiana town of Mooresville.
"It was blue and it had a lot of potential for us to add on," she says. "We really, really wanted that house."
But shortly after the Nugent family moved in, their dream home became a nightmare.
Jennifer Nugent, who discovered the house she bought in Mooresville, Ind., had been used as a meth lab, wants the state to require methamphetamine tests on all houses for sale.Barbara Brosher/WFIU
The kids were constantly sick and struggling to sleep. The Nugents puzzled over their children's health problems until a neighbor mentioned that the previous homeowner referred to the bathroom as his "smoke shop."
That's when Nugent paid $50 for a methamphetamine test. The first test revealed meth levels three times the legal limit. When meth is smoked, dangerous chemicals are released into the air that can cling to clothing, carpets and walls.
State police here have busted more than 11,000 meth labs since 2007. Indiana leads the nation in the number of meth lab seizures, causing hundreds of homes to be contaminated with dangerous chemicals each year.
Contaminated houses are listed on the state's public online database and properties are removed from the list only after they've been cleaned by a qualified inspector. The Drug Enforcement Administration keeps a national registry that logs the locations of known contaminated homes as reported by law enforcement.
Lori Endris, who heads a drug testing lab for the state of Indiana, says that doesn't mean people can still end up living in a contaminated house without realizing it.
"If you look at the numbers of properties versus the numbers that have been properly cleared by a qualified inspector, you're talking an [8,000-] to 9,000-house difference and I don't believe that all of those are sitting empty," she says.
A recently passed state law aims to protect homebuyers from unknowingly buying homes contaminated by meth.
Just like checking a box to indicate if there's lead or asbestos on a property, homeowners must disclose whether meth was manufactured there. Just over half of states have similar disclosure laws.
But, of course, they depend on the seller's honesty.
"I field a lot of calls from Realtors wanting to know if a property has been cleaned or cleared because people aren't wanting to tell the truth," Endris adds.
Indiana-based Crisis Cleaning has a special team that works solely on decontaminating meth homes.
Meth tests are the company's most in-demand service, according to Donetta Held, the firm's owner.Additional Information: Shots - Health News Indiana's HIV Outbreak Leads To Reversal On Needle Exchanges Around the Nation Drug-Sniffing Dogs Ease Parents' Minds — Or Confirm Their Fears
"We'll do a floor, a ceiling and two walls. And we'll take a pre-wetted alcohol wipe and we'll wipe within that square, put that in the jar. We label that 'came from the kitchen' and we do that in each room and we overnight that to the lab," she says. "They analyze how much meth, if any, is in that."
It can cost tens of thousands of dollars to decontaminate a property.
That means some people just don't bother, leaving behind dozens of toxic chemicals that can contribute to lasting health problems.
Short term health risks include headache, nausea, and eye irritation. Long-term effects are unclear, but children are particularly vulnerable. That's why Nugent wants Indiana to strengthen its laws.
In her case, she says the previous homeowner didn't disclose that meth was in the home.
"You're relying on a criminal to disclose his criminal acts to a buyer and lose the sale," she says. "So I don't think that's enough."
Nugent wants the state to require homeowners or real estate agents to have methamphetamine tests performed on all listed properties.
Even after having it decontaminated, the Nugent family decided to sell their dream house. As a result, they took a significant financial loss.Copyright 2015 WFIU-FM. To see more, visit http://wfiu.org.
Ten-year-old Jake Herrera and his Los Angeles team run around the diamond as a warmup for baseball practice.Benjamin B. Morris for NPR
Amy Roegler and her husband, Octavio Herrera, live with their young kids, Jake and Alyssa, in Los Angeles. When it comes to pro baseball, they're all Dodgers fans. And Jake loved balls even as a baby, Octavio says.
"We have a picture of him as a 3-month-old with a little Dodger jersey and a glove," Octavio says. "So he was definitely going to be introduced to sports early, and he took to it right away." Today 10-year-old Jake is on his baseball league's All-Star team.
Meanwhile his sister, 8-year-old Alyssa, has a passion for gymnastics. She, too, was a natural, her parents say — swinging on the monkey bars at age 2 and practicing splits on a balance beam today.
The parents know that the physical exercise their kids are getting is good for their health. But that's not their only motivation for encouraging the children to participate in organized athletics.
"When you do sports as a kid," Roegler says, "you learn how to win and how to lose. You learn what it's like to put in lots of work and have things not turn out terrifically. And you learn what it feels like to put in a lot of work — and then win.
Jake Herrera says he likes to get to the field early to help with the equipment and get in a little extra batting practice.Benjamin B. Morris for NPR
"I think you can't teach those lessons," she says. "You have to experience them."
The majority of parents in NPR's recent poll on the role of sports and health in America seem to agree. The poll, done in conjunction with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, finds that the majority of adults say they played sports when they were younger.
Moreover, 76 percent of adults who have children in high school or middle school today say they encourage their children to play sports. Engaging in sports isn't just an important physical and social activity, these parents say. It also builds skills that can make a difference later.
Eight-year-old Alyssa Herrera competes in gymnastics.Courtesy of Greeno Photography
"Parents think that the organized way you participate in sports — the leadership and fellowship — is actually preparing people not only for the next game but for much broader roles in life," says Harvard professor and health policy analyst Robert Blendon, who co-directed our poll.
Like the Herreras, the parents in our poll talk about sports teaching their children about discipline, dedication and how to get along with others — all skills to help in future schooling and beyond.
Octavio Herrera also played baseball when he was Jake's age, and well remembers how it felt.
"Nerves in your stomach, right?" he says. "Butterflies. I remember that as a kid, pitching in a game — 10 years old — so nervous and so scared."
It may be uncomfortable at the time, he says, but "that's great to have in a situation where the stakes are really low — where, if you fail you're still going to get pizza and ice cream, and your parents are still going to tell you they love you."
If kids can learn to fight their fear and work through it, he says, that steadiness comes in handy later in life — when the stakes are much higher. It's an ability Octavio says he relies on routinely, as a software entrepreneur who has created, bought and sold a number of companies.Shots - Health News Take A Swing At This: Golf Is Exercise, Cart Or No Cart
Octavio also stresses the value of learning to be part of a team — both in childhood and now, at the office.
"It's just like that baseball team when we were little kids," he says. "Not all the kids were great hitters, or could pitch. But everyone could contribute." His business works the same way, he says.
"I can't do everything. My partner can't do everything. We hire people who are good at what they do — we put together a team, come up with an idea, execute. It takes teamwork — just as winning a baseball game does."
Amy Roegler played soccer in high school and college and says team sports aren't just about winning, but also about developing a solid work ethic, and learning why that's important.
"I was the captain in high school," she explains, "and then my first year playing college soccer, I was on the bench."
No problem," she says. "I belonged on the bench — many teammates were incredible." It motivated her to want to earn a starting position, she says.
Jake's very proud of his All-Star jacket, says his mom, Amy Roegler. She played soccer in high school and college, and says team sports aren't just about winning. Players also develop a strong work ethic, she says, and learn why that's important.Benjamin B. Morris for NPR
Andy Driska is a Michigan State University researcher with the Institute for the Study of Youth Sports. He says parents are right when they cite life skills — like discipline, commitment and physical confidence — that can develop naturally when kids play sports.
In a recent study that's not yet published, Driska and his colleagues looked at an intense two-week wrestling camp, measuring feelings and attitudes of 89 teens before the camp experience and after.
As expected, the players' confidence increased — it was a tough camp to get through, Driska says. But what surprised him, he says, was how much feelings of hopefulness among the young people also increased.
Profoundly so, he says. One teenage boy, for example, told Driska the camp changed the way he interacted with his mom, helping to quell the bitter arguments they always seemed to fall into.
"He said that he sat down — talked it out, resolved the situation," Driska says. The teen told Driska that "before camp he would not have done that — been pro-active in seeking a solution. He simply would have walked away and just been bitter or complained about it."
Playing catcher, Jake makes a play at home base during a practice at the Bad News Bears Field in Los Angeles.Benjamin B. Morris for NPR
In just a brief sports experience at camp, that teen and many of the others developed a "can do" life strategy that seemed to translate to other aspects of their lives, Driska says.
And that change persisted. Nine months after the camp ended, Driska notes, the teens in his study maintained their bolstered sense of confidence — and hope.http://www.npr.org/.
What's the best way to connect patients to dialysis machines?iStockphoto
When it comes to dialysis, one method of accessing the blood to clean it gets championed above the rest. But quite a few specialists say there's not enough evidence to universally support the treatment's superiority or to run down the other options.
"When we talk to [dialysis] patients in the clinic, we cannot address their profound question: 'Which access is better for me?' " says Dr. Pietro Ravani, an epidemiologist at the University of Calgary in Canada. "We just don't know, yet we are selling patients on a certain one."
Ravani is talking about guidelines that encourage doctors to pursue connections for dialysis known as arteriovenous fistulas. Research says hemodialysis patients with fistulas have a reduced risk of death, blood clots and infections compared with other access methods.Shots - Health News Most Dialysis Patients Aren't Receiving The Best Treatment
The connections require surgeons to stitch together an artery and vein, usually in the arm, to create a sturdier vein with greater blood flow. Patients are then pricked at the site of the fistula during each visit to connect to the blood-cleaning hemodialysis machine.
About 450,000 people in the U.S. are on dialysis.
Studies, like this one that was published in May, have shown patients with the fistulas had a lower risk of death (about a third less) when they start dialysis with fistulas rather than catheter connections.
But Ravani says not so fast. "The literature that is available and used to promote fistulas is biased," he says, adding there is no way catheters, an alternative to fistulas, are as deadly as some others have concluded.
Catheters are small plastic tubes, usually placed in a vein along the neck, chest, leg or groin, that can also be conduits for infection. Catheters are the go-to method for access to the blood when the kidneys suddenly fail and patients crash into dialysis, requiring emergency hospitalization and treatment. Fistulas can't be used for one to three months after an operation. Catheters can be used immediately.
Studies comparing these two access types and their mortality rates have only been observational, Ravani argues. That means researchers have looked at what happens to patients after doctors decided on their own how to treat patients. A randomized controlled trial that assigns patients to one treatment or the other and then collects information on what happens to them is necessary to ultimately prove the superiority of one method over another, Ravani says.
Patients with catheters, he explains, are usually pretty sick. But because it takes fistulas several months to develop before use, they are typically given to healthier patients who aren't in immediate need of dialysis.
"The very strong association between catheters and mortality could be related to how sick the patients were, not to the access type," Ravani says. "When you need to start dialysis urgently, it's because you're very sick so you use catheters, not fistulas. This makes it hard to determine if the poorer outcomes observed in patients with catheters are because of catheter or because they are already very sick."
For this same reason — serious illness — Ravani argues that patients with catheters succumb to infection more often than healthy patients with fistulas. If a healthy patient used a catheter, they wouldn't be as likely to contract an infection.
Nephrologist Swapnil Hiremath, at Ottawa Hospital in Canada, agrees that more research is needed to fully assess the value of fistulas. "The portrayal that fistulas are the ultimate access [for dialysis] and that if everyone has one, mortality rates will go down, is an exaggeration," Hiremath says. "You cannot go around blaming catheters; it's the nature of things that these patients are sicker and have a higher risk of death."
Hiremath adds that despite initiatives to increase the number of dialysis patients with fistulas, the treatment method is extremely difficult to provide to patients in the first place.
Roughly half of fistulas fail to mature, particularly in older individuals, and don't end up being used to access the blood, he says. Doctors then resort to catheters or another method to connect patients to dialysis machines. What's more, some 30 percent of patients completely reject the proposal of a fistula, despite explanations of their benefits.
And patients with fistulas can develop complications, such as heart failure, blood clots and swelling.
"To say that everyone who has a catheter should have a fistula, that's not easy," Hiremath says. "Doctors need to have an open mind, but unfortunately many people have already decided that fistulas are the best option."
Johns Hopkins University surgeon Dr. Mahmoud Malas, lead author of the recent paper on the advantages of fistulas, says Ravani's and Hiremath's criticism doesn't make sense to him.
Malas and his colleagues were behind an observational study showing patients starting dialysis with fistulas had lower risks of death. Despite the fact that he and his colleagues only reviewed existing numbers in the U.S. Renal Data System, Malas says they were able to minimize bias by matching the characteristics of patients with fistulas and catheters.
"If we saw a male patient with a catheter that was 40 years old who had diabetes and hypertension, we would find his exact match in a patient using a fistula," Malas explains. "Even with this matching analysis, you still see a much higher mortality rate for those on catheters."
"And our finding is not new, hundreds of prior studies have shown this difference," he adds.
Either way, Malas doubts a randomized trial could ever be carried out to truly compare those on fistulas and catheters. "Nobody would approve that trial," he says. "People will think it's unethical."
Ravani and Hiremath think differently. They are currently pursuing a randomized trial in Canada to tease out the differences between the two methods once and for all.
"For 40 years we have ignored this question with a randomized trial," Ravani says. "And until we have this answer, we cannot say fistulas are better."Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Marking novice drivers' cars doesn't help reduce crash rates when it comes to learner's permit holders, study finds.iStockphoto
Nothing says "I'm a new driver" more than a fire-red label stuck to your license plate for all to see. That's what happens in New Jersey to anyone with a learner's permit under age 21. But identifying these newest drivers doesn't necessarily help reduce crash rates, research finds.
For young drivers holding a learner's permit, putting up the decal has no significant effect, a study published this week in the journal Injury Prevention suggests. On the other hand, the same researchers have found a substantial reduction in crashes when warning labels are required in the first months after a young person exchanges that beginner's permit for an actual driver's license.Shots - Health News Teens Say They Change Clothes And Do Homework While Driving
New Jersey rolled out its decal mandate in May 2010 as part of the state's graduated driver licensing laws. These GDL laws, which are now in use in various ways in all 50 states and the District of Columbia, are designed to only gradually ramp up the rights and independence of teen drivers.
Here's how they work: New drivers have to be at least 16 to get a driving permit. Then they can only drive under adult supervision, typically for at least 50 hours. After earning an intermediate license when they can drive alone, teens face restrictions on nighttime driving, cellphone use and the number of peer passengers allowed in the car. These restrictions disappear with full-fledged licensure, usually 12 months after the intermediate stage or when the driver reaches the age of 18. And they are still required to follow state laws.
"GDL has been the cornerstone of public policy in reducing crashes [involving teen drivers]," Allison Curry, main author of the study, says. "One of the challenges with GDL is it's difficult for the police to identify learner drivers and intermediate drivers," Curry says.
New Jersey's decal mandate is the first of its kind in the nation. The reasoning behind it is simple: The police can now easily identify teen drivers who are violating GDL restrictions, such as driving at night. And the hope is that the chance of being caught will make teens less likely to engage in wrongdoing.Shots - Health News When Teen Drivers Multitask, They're Even Worse Than Adults
Curry, director of epidemiology and biostatistics at the Center for Injury Research and Prevention, Children's Hospital of Philadelphia, and her team looked at New Jersey's crash rates and GDL citations among drivers younger than 21 in the four years pre-decal and two years post-decal.
For drivers still in the baby stage of holding a learner's permit, the study showed decals didn't seem to be of much use. Curry attributes this lack of impact to parents and supervisors sitting in the car. Studies that observed what drivers were doing in their cars found that virtually all of the time, an adult sat next to the new driver, as they're supposed to. This is probably why the crash rate for newbie drivers is already very low, Curry says, and it leaves little room for the decals to make an impact.
But that's not the case for intermediate drivers on the road. For them, decals are saving lives. In a study published earlier this year, Curry's team found a significant 9.5 percent decrease in crash rates for that group two years after the mandate was enforced. That's an estimated 3,197 intermediate drivers prevented from crashing in two years, she says.
This all sounds promising, but could singling out teen drivers to all drivers sharing the road make them more rebellious and rash behind the wheels?Shots - Health News Teens Say They Don't Text Or Drink While Driving
"Fortunately, the research did not reveal an increase in citations, which is a potential side effect of concern from the perspective that teenage drivers should not necessarily be singled out," Bruce Simons-Morton, a behavioral scientist with the National Institutes of Health who researches adolescent driving, wrote to Shots in an email. He did not participate in the study.
One of the notions underlying GDL rules, Simons-Morton says, is that teens are best managed by their parents rather than police. Novice drivers are seldom stopped or cited for violation of GDL rules, he says, and decals appear not to increase citations.
No word yet whether other states are thinking of deploying this sort of decal system with learners' permits, but Curry notes there may be long-range benefits that didn't show up in their data.
Remember that the goal is to establish good driving habits early on, she says. "Today's learner drivers are tomorrow's intermediate drivers."Copyright 2015 NPR. To see more, visit http://www.npr.org/.
The U.S. Supreme Court gave a reprieve to Texas clinics that provide abortion services.Mark Wilson/Getty Images
Tuesday would have been the last day of operation for 10 clinics in Texas that provide abortion services. But on Monday the U.S. Supreme Court, in one of its final actions of this session, said the clinics can remain open while clinic lawyers ask the court for a full review of a strict abortion law.
Two dozen states have passed regulations similar to the ones being fought over in Texas.Shots - Health News Texas Abortion Case May Hinge On Definition Of 'Undue Burden'
Two years ago, when Texas passed one of the toughest laws in the country regarding abortion services, the number of clinics offering the procedure dropped from 41 to 19.
Amy Hagstrom Miller, chief executive of Whole Woman's Health, already had to close two clinics in Texas because of the law and was about to close two more. "Honestly, I just can't stop smiling," Hagstrom Miller says. "It's been so much up and down, so much uncertainty for my team and the women that we serve."
The Texas law says doctors who perform abortions must have admitting privileges at a nearby hospital. But some hospitals are reluctant to grant them because of religious reasons, or because abortion is so controversial.
The law also requires the clinics to meet the same standards as outpatient surgery centers. Those upgrades can cost $1 million or more.
"It's an example of the rash of laws that have passed throughout the country the past couple of years that have taken a sneaky approach by enacting regulations that pretend to be about health and safety but are actually designed to close down clinics," says Nancy Northrup, chief executive of the Center for Reproductive Rights, which is representing clinics in their fight to overturn the Texas law.
Supporters of the law say every woman deserves good medical care whatever the procedure.Shots - Health News Court Decision On Texas Abortion Law Could Hasten Clinic Closures
"While we hope that she would not be compelled to choose abortion we hope that her life would of course not be at risk should she choose to do that," says Emily Horne of Texas Right to Life. "Pro-life does not just mean care for the life of the unborn child, it's care for the life of the woman undergoing the abortion as well."
The law has had a drastic effect in Texas, the country's second most populous state, leaving most of the remaining clinics in major cities.
There's just one clinic left along the Mexican border and one in far west El Paso. There were among the nine expected to shut down.
If they had closed, the women there faced round trips of 300 miles or more within Texas to get an abortion.
Hagstrom Miller says all these clinic rules and the doctor restrictions are a deliberate strategy waged by anti-abortion groups. "They're going state by state by state by state," she says. "They can't make it illegal so they're basically making it completely inaccessible."
Other states that have passed similar laws are also facing legal challenges.
Emily Horne, of Texas Right to Life, says her group would welcome a legal review by the Supreme Court. "With this case, issuing some more guidance on that could be very helpful for the pro-life movement in determining what courses to pursue, which laws they might pass in other states in the future," she says.
The clinics in Texas can stay open at least until the fall. If the court decides to take the case, it would hear arguments in its next term that starts in October.
This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.Copyright 2015 KUHF-FM. To see more, visit http://www.houstonpublicmedia.org.
Travis Driscoll, a medical school applicant from Berkeley, Calif., studies for the revamped MCAT.April Dembosky/KQED
It's T minus four days until exam day, and Travis Driscoll is practically living at his desk.
"Each day, I'm easily here for five hours," he says. "I haven't done much of anything else but studying for the last two months."
Driscoll is one of 13,000 medical school applicants across the U.S. taking the new Medical College Admissions Test, or MCAT. He's got stacks of science books on his desk to help him prepare and a rainbow of biochemistry charts pasted to the walls: glycolysis, citric acid cycle, electron transport chain, mitosis, meiosis and DNA replication.
He also has a thick prep book on psychology and sociology — new ground for this year's MCAT takers.
The test has been thoroughly revamped and is now three hours longer. It takes 7 1/2 hours to complete, including breaks, and covers four new subjects, including a combined section on psychology and sociology that account for a quarter of the overall score.Shots - Health News A Top Medical School Revamps Requirements To Lure English Majors
Driscoll, who works in a San Francisco theater, focused on biomedical engineering in college. So for him, the new psychology/sociology section is the one he's most nervous about.
"It's at the end of the test, which makes it more difficult because you're pretty tired by then," he says. "And it's the thing I had the least experience with."
Bringing Test Up To Date
The Association of American Medical Colleges, which administers the MCAT, wants to make sure the doctors of tomorrow are better prepared to care for an increasingly diverse patient population in a rapidly changing health care system. Administrators say the exam changes are necessary to bring it up to date with how medicine is practiced, and with all the scientific discoveries that have been made since the test was last revised, more than 20 years ago.
Research on genetics and the social factors that affect health, in particular, have advanced significantly.
"Whether or not someone becomes ill has a lot to do with the society in which they live," says Catherine Lucey, vice dean of education at University of California, San Francisco School of Medicine and a member of the committee that will assess the new MCAT.
For example, she says, we now know a lot more about what happens to children who are exposed to violence before they turn 5.
"If they live in a violent neighborhood, if they hear gunshots all the time, if they themselves are the victims of interpersonal violence or child abuse," Lucey says, "they are much more likely to develop diabetes, high blood pressure, obesity, and many other chronic conditions, because of their social environment."
How those conditions are treated has also evolved. Doctors know how to treat acute infection now. But managing chronic disease has become a much bigger part of medical care, and doctors need to develop different skills and a different kind of relationship with the patient. Doctors need to build trust, Lucey says, to understand how patients think and make decisions, in order to convince them to exercise more and change their diet.
"My ability as a physician to affect that patient's health is not only dependent on medical knowledge, in terms of what drug should I give this individual, but on my ability to support this patient in the decisions they're making on a daily basis," she says.
Attracting A New Type Of Students
While the test prep industry adapted quickly to the new MCAT, enrollment in prep courses at the Princeton Review and Kaplan is only starting to pick up.
The real rush was last fall, when students flocked to take the old test, says Krissi Taylor Leslie, tutoring director at the Princeton Review in Northern California.
There was a recognition among students "that was my chance at the 'easier' test and now I'm up against this beast," Leslie says.
She says the new social sciences section is already attracting a different kind of student to consider med school.
"It entices certain students to come in and consider this test when they might not have otherwise," she says. "For instance, an increase in the number of English majors, of psychology majors."
And philosophy majors, like Ari Fischer. He started thinking about a career in medicine the summer after his junior year, when his grandfather was diagnosed with cancer.
"And that's when I was first shown, hands on, what physicians do every day," he says.
He started taking medical ethics classes — one was called "Life and Death" — where he read works about immortality, the meaning of death and the meaning of life in the face of death.
Fischer says he can imagine drawing on this knowledge one day if he has a patient facing tough end-of-life decisions.
"There's always a scientific view, then there's the theological views, or philosophical views. Knowing what other disciplines believe is going on at the same time, I think that could really help me in a daily practice of medicine," Fischer says. "What a cool way to take my degree in philosophy and turn it into a helpful, practical skill."
Fischer took the MCAT on the first testing date for the new exam in April, and just got his full score back on Tuesday. He did best on the social sciences section and the verbal, analytic reasoning. Overall, he landed in the 87th percentile.
"Perhaps Harvard will think I'm lacking in my MCAT score," he says. "For myself, I did well enough."
Altogether, he's applying to 38 schools. He says he's willing to go anywhere that will take a humanities major like him.
"All I've ever wanted out of the MCAT really is a score that's good enough to not get me kicked out of the pile when it comes to admissions decisions," he says. "Any school that gives me a shot, I'm going to be thrilled."Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
The crowd reacts as the ruling on same-sex marriage was announced outside of the Supreme Court in Washington, D.C., Friday.Jacquelyn Martin/AP
The right to marry in any state won't be the only gain for gay couples from last week's Supreme Court ruling. The decision will likely boost health insurance among gay couples as same-sex spouses get access to employer plans.
The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren't married. Virtually all of them offer coverage to spouses.
By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now, as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week's ruling, up from nine in 2012.
New York legalized gay marriage in 2011. The next year, there was a big increase in same-sex couples covered by employer-sponsored health insurance, according to a study published Friday by JAMA, a journal of the American Medical Association.
Although the court found a constitutional right to same-sex marriage, lawyers gave mixed messages on whether employers must now offer health insurance to same-sex spouses if they offer it to opposite-sex spouses.
Edward Fensholt, a benefits lawyer with brokers Lockton Companies, expects most companies to cover same-sex spouses if they already offer benefits to opposite-sex spouses. But the decision doesn't require them to, he said.
"Employers get confused about this," he said. "They'll see that ruling and they'll start to think they have to offer coverage to same-sex spouses."
But Lambda Legal, which advocates for gay rights, said employers refusing to offer health insurance to all married couples would violate federal law prohibiting sex discrimination.
"You should be able to add your [same-sex] spouse to your health insurance," Lamba Legal and other civil rights groups wrote in an online FAQ.
Also, state laws may require equal benefits for same-sex spouses.
Big companies also like the simplification the ruling brings to their human resources departments.
"We're relieved because this basically means you won't have to do a state-by-state analysis" of how the law applies to same-sex couples, said Gretchen Young, senior vice president of health policy at the ERISA Industry Committee, which represents very large employers. "We always want uniform treatment."
Weirdly, a constitutional right to same-sex marriage may harm some same-sex couples: those with domestic-partner benefits who don't want to get married.
Last year Verizon told same-sex partners in states where gay marriage is legal they had to wed if they wanted to qualify for benefits. Now that the high court has placed same-sex and opposite-sex marriage on the same level, other companies are likely to follow, say benefits specialists.
"We would certainly expect to see a falloff in domestic partner benefits," said J.D. Piro, a health benefits lawyer with Aon Hewitt, a consulting firm. "Given the decision, employers might want to be asking, do we still need to do that?"Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Arturo Martinez watches his wife, Aurora Martinez, put on makeup in their San Rafael, Calif., home. She has Alzheimer's.Lynne Shallcross for NPR
A doctor I interviewed for this story told me something that stuck with me. He said for every person with dementia he treats, he finds himself caring for two patients. That's how hard it can be to be a caregiver for someone with dementia.
The doctor is Bruce Miller. He directs the Memory and Aging Center at the University of California, San Francisco. According to Miller, 50 percent of caregivers develop a major depressive illness because of the caregiving. "The caregiver is so overburdened that they don't know what to do next," he says. "This adds a huge burden to the medical system."
This burden is going increase dramatically in the coming decade. By 2025, 7 million Americans will have Alzheimer's disease, according to one recent estimate. Millions more will suffer from other types of dementia.
Together these diseases may become the most expensive segment of the so-called "silver tsunami" — 80 million baby boomers who are getting older and needing more medical care. The cost of caring for Alzheimer's patients alone is expected to triple by 2050, to more than $1 trillion a year.
So UCSF, along with the University of Nebraska Medical Center, is beginning a $10 million study funded by the federal Centers for Medicare & Medicaid Innovation. Researchers plan to develop a dementia "ecosystem," which aims to reduce the cost of caring for the growing number of dementia patients and to ease the strain on caregivers.
That includes caregivers like Maria Martinez, 42, who visits her parents' small apartment in San Rafael, Calif., almost daily to help care for her mom, Aurora Martinez, who has Alzheimer's.
Maria Martinez is an only child with a partner and a full-time job as an occupational therapist. But nearly every day she spends at least a couple of hours with her parents, managing a long list of responsibilities that are critical to their ability to live independently.
"Does she have a doctor's appointment?" Martinez says. "Are there enough diapers? Clothing? Laundry. Financial stuff, I manage that too."
She bathes her mother, who is 78, manages upkeep on the apartment, does much of the shopping and fills prescriptions for both of her parents.
Especially in the early stages of Aurora's illness, practical concerns loomed large. Sometimes she would wander in the middle of night. Her husband, Arturo Martinez, 75, took to sleeping on the floor in front of the door, worried Aurora might end up falling in the street and being hit by a car.
Eventually, Martinez installed a lock at the top of the door where Aurora couldn't reach it, and a wind chime to serve as an alarm.
Though the Martinezes are not part of the study, they are the kind of family that the dementia ecosystem study is designed to help.
The study will enroll 2,100 patients at the two sites. Each patient will have a navigator, a nonmedical staff person who will coordinate care and triage calls, so minor issues don't land patients in the ER.
Some patients will also receive activity trackers and sensors, which will be placed around the house or worn on the patient's wrist. Much like Martinez's wind chimes, the idea is to see whether sensors can detect when a patient is wandering off or if they've been inactive for too long.
A few weeks ago, in a sunny conference room at UCSF, techies and doctors, almost all of whom have had family members with dementia, sat around a table, brainstorming other ways technology might be applied to dementia care.
"There are safety issues like leaving the stove on," suggests Katrin Schenk, who teaches physics at Randolph College in Virginia.
"You could easily put in a temperature sensor that knows they went in there and turned on that burner," Schenk says. "It's been on for two hours — someone needs to do something."
Or, she continues, what about the roughly one third of dementia patients who also have diabetes? Could Bluetooth-enabled blood-sugar monitors allow family members and medical staff to check up on them remotely?
If this all sounds intrusive, says Kate Possin, a neuropsychologist at UCSF, consider the alternative: anxious adult children, and parents who end up in nursing homes sooner than they want to.
"This may be a compromise for them," Possin says. "'If I use this system, then my son who lives three hours away feels comfortable and safe with me living at home a little bit longer.'"Shots - Health News Will This Tech Tool Help Manage Older People's Health? Ask Dad
A handful of tech start-ups are making the same case. In San Francisco, Lively markets a system of networked sensors and a watch that can pick up on activity around the house and let family members or care providers know if there's a worrisome change.
These kinds of products, which let doctors and caregivers check up on patients remotely, make sense for some cases, Schenk says.
But do they help in the long run?
That's one question researchers want to answer.
"I know for sure no one's gotten the data and proven that [this technology] works," Schenk says. "Proven that it improves peoples' health, improves caregiver burden."
"Reduces hospitalizations," adds Possin.
"Delays the entrance into a nursing home," finishes Schenk.
Researchers will also want to see whether sensors and other technologies are helpful for people in later stages of dementia like Aurora Martinez or whether they just create more hassle.
Possin says they hope to have some preliminary results next January.Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.