NPR Blogs

Is Your Heart Doctor In? If Not, You Might Not Be Any Worse Off

NPR Health Blog - 1 hour 15 min ago
Is Your Heart Doctor In? If Not, You Might Not Be Any Worse Off December 22, 2014 4:31 PM ET

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If your cardiologist is away at a conference when you're having a stabbing feeling in your chest, don't fret. You may be more likely to live.

A study published Monday in the journal JAMA Internal Medicine found frail patients admitted to teaching hospitals with two common types of heart problems were more likely to survive on days when national cardiology conferences were going on.

The researchers also discovered that heart attack patients who were at higher risk of dying were less likely to undergo angioplasties when conferences were occurring, yet their mortality rates were the same as similar patients admitted at other times. An angioplasty, in which a doctor unblocks an artery with an inflatable balloon inserted by a small tube, is one of the most common medical procedures for cardiac patients.

The conclusions about teaching hospitals surprised even the authors, who had begun their inquiry anticipating that death would be more common during cardiology meetings because hospital staffs were more short-handed than usual. Finding the opposite, the researchers speculated that for very weak patients, aggressive treatments may exceed the benefits.

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"There's something very specific about cardiology meetings and cardiology outcomes," said Dr. Anupam Jena, a professor at Harvard Medical School and the lead researcher of the study. "I can tell you with almost certainty that something different is happening in the hospital, but I can't tell you why this is happening."

The study looked at Medicare patients admitted to 263 major teaching hospitals between 2002 and 2011, during days that the American Heart Association or the American College of Cardiology held their annual meetings.

These conferences draw thousands of doctors, nurses, pharmacists and other medical professionals who come to hear of the latest research, therapies, drugs and technologies, as well as to network and socialize with colleagues.

Dr. Patrick O'Gara, president of the American College of Cardiology, said he was reassured by the finding that patient mortality didn't increase when those doctors were away. "People should take away from this particular paper that they should be confident of going to a teaching hospital at any time of the year," he said. He cautioned against drawing any conclusions from the paper's finding that mortality rates dropped for some people, noting that the data are "not granular enough to provide information about what types of patient therapies the patients received."

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For patients with heart failure, heart attacks or cardiac arrest, the researchers examined death rates — either in the hospital or within 30 days of leaving —and compared them with the rates for patients hospitalized on the same days of the week during the three weeks before the conferences started and the three weeks after.

The lower death rates during conferences were limited to high-risk patients in teaching hospitals. Researchers didn't see a change in mortality for high-risk patients in other hospitals. The study also found that the majority of patients with more robust health had no greater chance of expiring if their hospitalization overlapped with a conference.

The researchers found that 18 percent of high-risk patients with heart failure —where the heart muscle doesn't pump blood as well as it should — died on conference days, while 25 percent died on the non-meeting days. The difference was even greater for patients with cardiac arrest, when the heart isn't pumping blood. The study found 59 percent of cardiac arrest patients died when conferences were underway, while 69 percent died on other days.

The researchers suggested several possibilities, but also found reasons to doubt those explanations. It could be that cardiologists who attend conferences are more likely to do aggressive medical treatments such as complex angioplasties than are those doctors who skip conferences. While invasive treatments often save lives, they can also result in infections and other complications, some of which can be deadly.

The researchers also postulated that when a patient's primary cardiologist is out of town, a substituting doctor may be less likely to perform an aggressive intervention. However, the researchers were unable to find evidence of any procedures that were being performed less frequently for heart failure or cardiac arrest patients during conference dates. Jena said aggressive procedures, such as placing catheters into neck veins to measure the heart, can cause complications but aren't always easy to identify in the Medicare billing data used in the study.

The researchers hypothesized that during conferences, there might be fewer patients undergoing elective procedures, therefore giving the remaining doctors more time to focus on the urgent cases. However, they didn't find any decrease in the number of heart patient admissions during conference days. They also found no difference in the general health of patients hospitalized on meetings days and those admitted at other times.

One more possibility, Jena said, "is that the doctors who leave are primarily researchers and they don't take care of as many patients as other doctors, so they are worse doctors."

Heart attack patients were just as likely to die on conference dates as other dates. But 21 percent received angioplasties or stents when conferences were going on, less than the 28 percent who received these interventions other times. "Patients at the very least are no worst off and in fact they may be better off by having less stenting," Jena said.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

When Humans Quit Hunting And Gathering, Their Bones Got Wimpy

NPR Health Blog - 2 hours 43 min ago
When Humans Quit Hunting And Gathering, Their Bones Got Wimpy December 22, 2014 3:03 PM ET

Farming helped fuel the rise of civilizations, but it may also have given us less robust bones.

Leemage/UIG via Getty Images

Compared to other primates and our early human ancestors, we modern humans have skeletons that are relatively lightweight — and scientists say that basically may be because we got lazy.

Biological anthropologist Habiba Chirchir and her colleagues at the Smithsonian's National Museum of Natural History were studying the bones of different primates including humans. When they looked at the ends of bones near the joints, where the inside of the bone looks almost like a sponge, they were struck by how much less dense this spongy bone was in humans compared to chimpanzees or orangutans.

"So the next step was, what about the fossil record? When did this feature evolve?" Chirchir wondered.

Humans Our Skulls Might Have Evolved To Withstand Blows To The Face

Their guess was that the less dense bones showed up a couple million years ago, about when Homo erectus, a kind of proto-human, left Africa. Having lighter bones would have made it a lot easier to travel long distances, Chirchir speculated.

But after examining a bunch of early human fossils, she realized their guess was wrong. "This was absolutely surprising to us," she says. "The change is occurring much later in our history."

The lightweight bones don't appear until about 12,000 years ago. That's right when humans were becoming less physically active because they were leaving their nomadic hunter-gatherer life behind and settling down to pursue agriculture.

A report on the work appeared Monday in the Proceedings of the National Academy of Sciences, along with a study from a different research group that came to much the same conclusion.

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Those researchers looked at the bones of people in more recent history who lived in farming villages nearly a thousand years ago, and compared them to the bones of people who had lived nearby, earlier, as foragers.

The bones of people from the farming communities were less strong and less dense than those of the foragers, whose measured bone strength was comparable to similarly-sized nonhuman primates.

"We see a similar shift, and we attribute it to lack of mobility and more sedentary populations," says Timothy Ryan, an associate professor of anthropology at Penn State University. "Definitely physical activity and mobility is a critical component in building strong bones."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

A Family's Long Search For Fragile X Drug Finds Frustration, Hope

NPR Health Blog - 14 hours 4 min ago
A Family's Long Search For Fragile X Drug Finds Frustration, Hope December 22, 2014 3:42 AM ET Listen to the Story 6 min 51 sec  

Katie Clapp shares a laugh with her son Andy Tranfaglia, 25, at their home in West Newbury, Mass. Andy has a rare genetic condition called fragile X syndrome.

Ellen Webber for NPR

For a few weeks last year, Michael Tranfaglia and Katie Clapp saw a remarkable change in their son, Andy, who'd been left autistic and intellectually disabled by fragile X syndrome. Andy, who is 25, became more social, more talkative and happier. "He was just doing incredibly well," his father says.

The improvements came while Andy was taking an experimental drug — a drug made possible by the efforts of his parents. And at the time, it appeared this drug might become the first effective treatment for fragile X, a rare genetic syndrome that affects brain development and can lead to intellectual and social disabilities. The reality would turn out to be more complicated.

The story of this drug begins in 1994, when Clapp, a computer scientist, and Tranfaglia, a psychiatrist, helped launch the FRAXA Research Foundation. Their goal was simple: find a way to help Andy and other people with fragile X.

Andy in September 2010, before he began the new medication. He used to spend hours packing and unpacking videotapes and DVDs, especially when he was upset. His mother says he does that much less now.

Courtesy of Katie Clapp

The couple didn't know much about running a foundation. But they made some smart decisions. One of these was that FRAXA should support a researcher at MIT named Mark Bear, who made a big discovery. He found evidence that fragile X disrupts an important pathway in the brain called mGluR5.

Bear also realized that two big drug companies, Novartis and Roche, were already working on drugs for depression and addiction that might help repair this pathway. So Tranfaglia and Clapp began lobbying those companies to try the experimental drugs on people with fragile X.

Part of the sales pitch was that any drug that could reduce autism symptoms in people with fragile X might help millions of other people with autism. "And after a while, it worked," Tranfaglia says. "We finally got their attention, and they were convinced that a drug trial using some of these compounds was worth doing."

That was a huge step because drug trials typically cost millions of dollars. An even bigger step was getting Andy into one of these drug trials.

At first it wasn't possible because the trials were taking place in cities a long way from the family's home in West Newbury, Mass. But after several years, Novartis began testing its drug near Boston and Andy was included in the trial. "I do believe he was the last patient enrolled," Clapp says.

Andy began taking pills. At the time, no one knew whether they were sugar pills or the drug. But both parents saw a change in their son. He wasn't cured, but he was less rigid and more talkative.

For years, Clapp and her son had shared a joke. She would say, "I like that house." Then Andy would say, "Nah, I don't like it." One day during the drug trial, Clapp told Andy about a house she liked. "And this time, he says, 'Yes, I like it too. It has red shutters,' " she says. "He responded to me like any person would."

Mike Tranfaglia works on a puzzle with Katie and their son Andy. The parents started a foundation to fund research in treatments for fragile X.

Ellen Webber for NPR

The couple would find out later that Andy had been receiving the drug, not a placebo. It looked like their 20-year search for a treatment was over. Then Novartis held a meeting to announce the results of its drug trial.

"We went into that meeting fully expecting great results because our son was just doing incredibly well," Tranfaglia says. "I thought, there's no way this doesn't work. This is amazing. And they presented these results, and the numbers were just unbelievably bad."

The drug may have been helping Andy. But overall, it didn't seem to work. "It was truly devastating," Clapp says. Then the couple learned that a second drug, the one from Roche, also failed in a large fragile X trial.

"The failures in these trials led us to question everything," Tranfaglia says. The couple wondered whether they had just seen what they wanted to see in their son's behavior. They even wondered whether it made sense for FRAXA to continue funding basic research in hopes of finding a drug for fragile X.

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In the end, the couple decided their approach was sound and that the drug really had helped their son. As a scientist, Tranfaglia knew that was possible. "Most clinical trials have some people who do really well even when the overall result is not necessarily great," he says.

But the drug Andy took is no longer available, even to researchers. And the future of the drug made by Roche is unclear.

The results were a huge disappointment, Clapp says, but not a failure. "To actually see an Andy I never, ever thought I would ever see, that was a success," she says.

Another success is FRAXA itself. The foundation now involves thousands of parents and hundreds of scientists. It has funded more than $24 million in research on fragile X.

And that research isn't going to stop, Clapp says. "We can't give up, because we have Andy."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Why Does It Take A Movie Robot To Show What Nurses Really Do?

NPR Health Blog - Sun, 12/21/2014 - 4:40am
Why Does It Take A Movie Robot To Show What Nurses Really Do? December 21, 2014 4:40 AM ET Kelli Dunham

I'm a proud nurse from a proud family of nurses, yet I would never claim that a layperson would enjoy watching mainstream medical dramas with us. We end up yelling at the screen: "There is nothing about that sexy get-up that remotely resembles a nursing uniform," and "Doctors don't fire nurses, nurse managers fire nurses," and "No emergency room nurse would ever have to be told by a doctor to start CPR!"

So when the Baymax, the nurse/robot in the hit Disney movie Big Hero Six turned out to be reasonable, competent and not dressed in fishnet stockings, I was thrilled.

“ "You know your profession has an image problem when you point to a balloonish animated robot doll and say 'Yes, that's good. That accurately reflects what I do on a daily basis. More representations like that, please.' "

You know your profession has an image problem when you point to a balloonish animated robot doll and say "Yes, that's good. That accurately reflects what I do on a daily basis. More representations like that, please."

Baymax might not look like any nurses you know, but unlike most nurse characters in the media he actually provides nursing care. He assesses the health condition of his charge, the boy-genius Hiro, makes recommendations related to his health and teaches him about his neurochemical processes.

Once Hiro reprograms Baymax with fighting capabilities, Baymax becomes Hiro's terrifying defender. If you've ever heard a nurse on the phone with an insurance company insisting that a patient get needed care paid for, you know this is not a misplaced metaphor.

Contrast this with the Nurse Dawn character in the HBO comedy Getting On. She has sex with a new nurse manager within hours of meeting him; doesn't seem to notice when a patient dies; cowers submissively in front of even the most incompetent doctors and never seems to provide any actual nursing care because she is too busy with self-created drama and paperwork.

Or the Nurse Beverly character in Fox's comedy The Mindy Project. She is fired from an office medical practice for incompetence, breaks a doctor's nose in angry response, and when she is rehired in a clerical position expresses relief that she finally has a job where she doesn't have to wash her hands.

Or the nurses in the Fox medical drama House. Rather than being sexually inappropriate or incompetent, these nurses all seem to be on a series-long coffee break. It is the doctors who are shown providing nursing care: starting IVs, doing patient teaching, negotiating complicated family dynamics at the bedside.

Additional Information:

Even when nurses are shown to be competent, compassionate patient-focused experts like Jackie Peyton, the main character in Showtime's Nurse Jackie, the creators aren't satisfied with the life-and-death drama of a high-level trauma center in a huge city. The nurse character has to be an unethical, lying, stealing, not quite-in-recovery drug addict as well.

The argument could be made that it's the job of Hollywood to create fiction of all the professions, and that popular culture gets everything about health care wrong.

Certainly examples of this exist: the new Fox teen drama Red Band Society is populated by exceedingly healthy looking, extremely attractive gravely ill teenagers who live for months in hospital rooms the size of two-bedroom apartments for no other apparent reason than to make it more convenient for them to kiss each other.

Any scenes in which the dying but randy teens are portrayed interacting with medical care (one patient is shown receiving dialysis for liver failure) are so ludicrous that it makes you wonder if the procedure for the show's writers is to ask their medical adviser how something might accurately be conveyed and then write the exact opposite.

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But even though this is just entertainment, the stakes for the future of nursing are high. Research has repeatedly demonstrated that Americans believe what TV shows say about medical care and health policy.

For 13 years the non-profit advocacy organization Truth About Nursing has been researching and documenting nurse representations in popular culture and has come to the conclusion that "the vast gap between what skilled nurses really do and what the public thinks they do is a fundamental factor underlying most of the more immediate apparent causes of the [nursing] shortage [including], understaffing, poor work conditions, [and] inadequate resources for nursing research and education."

This is bad news for nurses, but worse news for patients. Nurses make the difference in good health care; increased RN staffing decreases the overall patient death rate as well as the rate of hospital acquired pneumonia, falls, pressure ulcers and blood clots after surgery. When nurses show more signs of burnout related to understaffing, postsurgical infections increase.

“ Baymax's programming won't allow him to disengage until the patient has answered, "Are you satisfied with your care?" in the affirmative.

And there's the hard-to-quantify but essential benefit of being cared for. When I was in the hospital this past January after a life-threatening complication of knee-replacement surgery, I woke up one night in pain and unable to figure out how to move within the many drains, tubes and wires attached to, or inserted in, my body. I muttered an expletive and from around the corner a nurse appeared.

"I'm right here," she said. Even before she started to untangle my IV and troubleshoot better pain management, my panic was instantly calmed.

Baymax's programming won't allow him to disengage until the patient has answered, "Are you satisfied with your care?" in the affirmative. This is inconvenient for the characters in an action adventure movie, but it's a good question to ask in a hospital. If you're satisfied with your care, you may well have a nurse to thank.

Kelli Dunham is a nurse, stand-up comic, LGBT health advocate and author of five books, including the recent tragicomic collection Freak of Nurture (Topside Press, 2013).

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Why Does It Take A Movie Robot To Show What Nurses Really Do?

NPR Health Blog - Sun, 12/21/2014 - 4:40am
Why Does It Take A Movie Robot To Show What Nurses Really Do? December 21, 2014 4:40 AM ET Kelli Dunham

I'm a proud nurse from a proud family of nurses, yet I would never claim that a layperson would enjoy watching mainstream medical dramas with us. We end up yelling at the screen: "There is nothing about that sexy get-up that remotely resembles a nursing uniform," and "Doctors don't fire nurses, nurse managers fire nurses," and "No emergency room nurse would ever have to be told by a doctor to start CPR!"

So when the Baymax, the nurse/robot in the hit Disney movie Big Hero Six turned out to be reasonable, competent and not dressed in fishnet stockings, I was thrilled.

“ "You know your profession has an image problem when you point to a balloonish animated robot doll and say 'Yes, that's good. That accurately reflects what I do on a daily basis. More representations like that, please.' "

You know your profession has an image problem when you point to a balloonish animated robot doll and say, "Yes, that's good. That accurately reflects what I do on a daily basis. More representations like that, please."

Baymax might not look like any nurses you know, but unlike most nurse characters in the media he actually provides nursing care. He assesses the health condition of his charge, the boy-genius Hiro, makes recommendations related to his health and teaches him about his neurochemical processes.

Once Hiro reprograms Baymax with fighting capabilities, Baymax becomes Hiro's terrifying defender. If you've ever heard a nurse on the phone with an insurance company insisting that a patient get needed care paid for, you know this is not a misplaced metaphor.

Contrast this with the Nurse Dawn character in the HBO comedy Getting On. She has sex with a new nurse manager within hours of meeting him; doesn't seem to notice when a patient dies; cowers submissively in front of even the most incompetent doctors and never seems to provide any actual nursing care because she is too busy with self-created drama and paperwork.

Or the Nurse Beverly character in Fox's comedy The Mindy Project. She is fired from an office medical practice for incompetence, breaks a doctor's nose in angry response, and when she is rehired in a clerical position expresses relief that she finally has a job where she doesn't have to wash her hands.

Or the nurses in the Fox medical drama House. Rather than being sexually inappropriate or incompetent, these nurses all seem to be on a series-long coffee break. It is the doctors who are shown providing nursing care: starting IVs, doing patient teaching, negotiating complicated family dynamics at the bedside.

Additional Information:

Even when nurses are shown to be competent, compassionate patient-focused experts like Jackie Peyton, the main character in Showtime's Nurse Jackie, the creators aren't satisfied with the life-and-death drama of a high-level trauma center in a huge city. The nurse character has to be an unethical, lying, stealing, not quite-in-recovery drug addict as well.

The argument could be made that it's the job of Hollywood to create fiction of all the professions, and that popular culture gets everything about health care wrong.

Certainly examples of this exist: the new Fox teen drama Red Band Society is populated by exceedingly healthy looking, extremely attractive gravely ill teenagers who live for months in hospital rooms the size of two-bedroom apartments for no other apparent reason than to make it more convenient for them to kiss each other.

Any scenes in which the dying but randy teens are portrayed interacting with medical care (one patient is shown receiving dialysis for liver failure) are so ludicrous that it makes you wonder if the procedure for the show's writers is to ask their medical adviser how something might accurately be conveyed and then write the exact opposite.

Shots - Health News Nurses Want To Know How Safe Is Safe Enough With Ebola

But even though this is just entertainment, the stakes for the future of nursing are high. Research has repeatedly demonstrated that Americans believe what TV shows say about medical care and health policy.

For 13 years the non-profit advocacy organization Truth About Nursing has been researching and documenting nurse representations in popular culture and has come to the conclusion that "the vast gap between what skilled nurses really do and what the public thinks they do is a fundamental factor underlying most of the more immediate apparent causes of the [nursing] shortage [including], understaffing, poor work conditions, [and] inadequate resources for nursing research and education."

This is bad news for nurses, but worse news for patients. Nurses make the difference in good health care; increased RN staffing decreases the overall patient death rate as well as the rate of hospital acquired pneumonia, falls, pressure ulcers and blood clots after surgery. When nurses show more signs of burnout related to understaffing, postsurgical infections increase.

“ Baymax's programming won't allow him to disengage until the patient has answered, "Are you satisfied with your care?" in the affirmative.

And there's the hard-to-quantify but essential benefit of being cared for. When I was in the hospital this past January after a life-threatening complication of knee-replacement surgery, I woke up one night in pain and unable to figure out how to move within the many drains, tubes and wires attached to, or inserted in, my body. I muttered an expletive and from around the corner a nurse appeared.

"I'm right here," she said. Even before she started to untangle my IV and troubleshoot better pain management, my panic was instantly calmed.

Baymax's programming won't allow him to disengage until the patient has answered, "Are you satisfied with your care?" in the affirmative. This is inconvenient for the characters in an action adventure movie, but it's a good question to ask in a hospital. If you're satisfied with your care, you may well have a nurse to thank.

Kelli Dunham is a nurse, stand-up comic, LGBT health advocate and author of five books, including the recent tragicomic collection Freak of Nurture (Topside Press, 2013).

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

At Last, I Meet My Microbes

NPR Health Blog - Fri, 12/19/2014 - 2:00pm
At Last, I Meet My Microbes December 19, 2014 2:00 PM ET Katherine Harmon Courage

Lactobacillus acidophilus, which is one variety of the genus Lactobacillus is one of the common active cultures found in yogurt and in the human gut.

Scimat Scimat/Getty Images/Photo Researchers

A veritable jungle of organisms is helping keep each of us alive. But we've been rather negligent hosts. For starters, we don't even know who has shown up for the party.

When I signed myself, my husband, our dog and my mother up for the American Gut Project to have our gut microbes analyzed last year, I had no idea what the results would turn up. And based on current research even Rob Knight, who helps run the project, couldn't predict whether I would share more microbes with my mom or with my husband.

So we waited for results. And waited. And waited. It turns out that being part of new research — no matter how well-planned — is an experience that requires a lot of patience.

Months after dropping off our samples at the post office, I got an email with a colorful, graphic display of my very own gut microbial communities. There were bar graphs, scatter plots and lots of unfamiliar names.

Katherine Harmon Courage's microbiome results. The distribution of major groups can be compared with others, including author Michael Pollan, in the top left graph. The chart on the top right lists some of the most common and the most unusual microbes found in her gut. The scatter plots below locate her particular sample against other populations.

Katherine Harmon Courage for NPR

So, after 31 years — and a few extra months of waiting — it was finally time to meet my microbes.

My gut is full of different species of Firmicutes, a whole phylum of bacteria. These can be incredibly diverse and include those in the order Lactobacillales (familiar to many from its member Lactobacillus, one kind of the bacteria that's active in some yogurts). I had many more of these bacteria than the average person, which was surprising. They've been linked to obesity, and I've always been lean.

The second most common were Bacteroidetes species (primarily in the Bacteroides genus), which help us mammals digest food. These guys indicate, according to a 2011 study in Science that Knight co-authored, that my diet is heavier on animal proteins and fats than on carbohydrates.

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I didn't expect that because at the time I, um, collected the samples I was eating a mostly plant-based diet. But perhaps the occasional pulled-pork sandwich or milkshake was enough to sway my bacterial profile. Although a different diet could change a person's microbe makeup within 24 hours, even a week on a different diet didn't entirely alter the profiles from long-term dietary patterns, the same study said.

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So maybe my relative levels were due to my generally meat-and-potatoes upbringing — or my birth by cesarean section. Research published last year found that infants born by C-section had lower levels of Bacteroides (as I had) than did babies born vaginally.

Even the researchers who have been practically swimming in gut samples couldn't yet tell me exactly what my sample said about me — or about my health.

"We don't have a good handle on the bounds for what a healthy gut looks like in the larger population, or how lifestyle and diet drive the gut," says Daniel McDonald, a graduate student working on the project and studying quantitative biology and computer science.

And what about the other guts in our family? The sample from our pooch, Raz, is still (yes, still) awaiting enough fellow pet entrants to be analyzed.

As for the humans, the beasties living in my gut were not much of a match to those in my mother's — despite quite a bit of research hinting at mothers' microbial influence.

She had about similar abundances of Bacteroides and Firmicutes, as well as 13 rare species that didn't even register on my chart.

Even though my diet mirrored hers for the majority of my life, in recent years it has shifted to a more vegetarian mix, away from meat and dairy.

Maybe 20 years ago, there would have been a more obvious overlap between Mom's microbiome and mine. And perhaps having been born via C-section sent my microbiome on its own trajectory.

Still, when compared with the rest of the study population, we clustered closer together than an average stranger, most of whom had a majority of Firmicutes.

My gut microbes were much more similar to my husband's. He and I both had higher Bacteroides and lower Firmicutes and four times the average of some genus called Lachnospira.

As McDonald notes, "cohabitating is the likely driver of similarity." But, he cautions, "there is a large amount of day-to-day variation within an individual." And that means "multiple samples are necessary to begin to assess if there is a significant similarity." That's probably not what my husband wanted to hear.

Once there are more samples gathered consecutively from the same people, Knight says, he and his team might be able to make predictions about how specific changes in the gut, say an overabundance of Bacteroidetes or the presence of a little known species, might affect health.

But, as in the early days of the human genome, we are still very much in the process of mapping this uncharted intestinal territory. Researchers are just starting to gather enough points of microbial and human data to decide what a sea of Firmicutes, for example, might mean for health and whether or not people with particular disorders have similar microbial maps.

Some of these designations, such as Firmicutes, are as broad as an entire phylum, which can contain organisms as far apart on the tree of life as humans and conger eels. So to truly start to get an estimate on the closeness of two people's microbes, researchers must calculate the evolutionary distance between different samples, adding yet another time-consuming step.

And we also still don't have the concrete knowledge to translate microbiome analyses into advice for people to get healthier. "That's why we started the study — to be able to make these recommendations," Knight tells me. For now, however, they're just trying to find a few meaningful patterns in the vast microbial ocean of thousands of fecal samples.

The gut is just part of the picture. Microbes live all over our skin, in our nose and mouth, on our pets, in the soil and even in the air.

And until we know more about these mysterious microbes, perhaps we should sit back and marvel at the jungles of life that we really are. And do our best to keep our beneficial beasties happy.

This is the final story in a four-part series.

Katherine Harmon Courage is a freelance health and science writer in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Some Early Childhood Experiences Shape Adult Life, But Which Ones?

NPR Health Blog - Fri, 12/19/2014 - 10:47am
Some Early Childhood Experiences Shape Adult Life, But Which Ones? December 19, 201410:47 AM ET

Having warm, supportive parents early on correlates with success in adulthood.

Agent Illustrateur/Ikon Images

Most of us don't remember our first two or three years of life — but our earliest experiences may stick with us for years and continue to influence us well into adulthood.

Just how they influence us and how much is a question that researchers are still trying to answer. Two studies look at how parents' behavior in those first years affects life decades later, and how differences in children's temperament play a role.

The first study, published Thursday in Child Development, found that the type of emotional support that a child receives during the first three and a half years has an effect on education, social life and romantic relationships even 20 or 30 years later.

Babies and toddlers raised in supportive and caring home environments tended to do better on standardized tests later on, and they were more likely to attain higher degrees as adults. They were also more likely to get along with their peers and feel satisfied in their romantic relationships.

13.7: Cosmos And Culture Why We Aren't The Parents We Know We Could Be

"It seems like, at least in these early years, the parents' role is to communicate with the child and let them know, 'I'm here for you when you're upset, when you need me. And when you don't need me, I'm your cheerleader,' " says Lee Raby, a psychologist and postdoctoral researcher at the University of Delaware who led the study.

Raby used data collected from 243 people who participated in the Minnesota Longitudinal Study of Risk. All the participants were followed from birth until they turned 32. "Researchers went into these kids' home at times. Other times they brought the children and their parents to the university and observed how they interacted with each other," Raby tells Shots.

Of course, parental behavior in the early years is just one of many influences, and it's not necessarily causing the benefits seen in the study. While tallying up the results, the researchers accounted for the participants' socioeconomic status and the environment in which they grew up.

Ultimately, they found that about 10 percent of someone's academic achievement was correlated with the quality of their home life at age three. Later experiences, genetic factors and even chance explain the other 90 percent, Raby says.

And a child's psychological makeup is a factor as well.

Shots - Health News Anxious Parents Can Learn How To Reduce Anxiety In Their Kids

The second study, also published in Child Development, found that children's early experiences help predict whether or not they end up developing social anxiety disorder as teenagers — but only for those who were especially sensitive and distrustful as babies.

For this study, researchers from the University of Maryland observed how 165 babies interacted with their parents. When separated from their parents, some got upset but quickly recovered when they were reunited. Other babies had a harder time trusting their parents after a brief separation, and they weren't able to calm down after being reunited.

Those extra-sensitive babies were more likely to report feeling anxious socializing and attending parties as teenagers.

So what does this all mean? For one, it means that human development is complicated, according to Jay Belsky, a professor of human development at the University of California, Davis who was not involved in either study.

We know that our early experiences likely affect all of us to a certain extent, Belsky says. And we know that due to variations in psychological makeup, some people are more sensitive to environmental factors than others.

But that doesn't mean people can't recover from bad childhood experiences. "For some, therapy or medication may help," Belsky says. "And it's interesting, because there's now other evidence suggesting that the very kids who succumb under bad conditions are the ones who really flourish under good ones."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Teaching Hospitals Hit Hardest By Medicare Fines For Patient Safety

NPR Health Blog - Fri, 12/19/2014 - 9:50am
Teaching Hospitals Hit Hardest By Medicare Fines For Patient Safety December 19, 2014 9:50 AM ET

Partner content from

Jordan Rau

NYU Langone Medical Center is one of the teaching hospitals being penalized by Medicare for its rate of medical errors.

Joshua Bright/AP

Medicare has begun punishing 721 hospitals with high rates of infections and other medical errors, cutting payments to half of the nation's major teaching hospitals and many institutions that are marquee names.

Intermountain Medical Center in Utah, Ronald Reagan UCLA Medical Center in Los Angeles, the Cleveland Clinic, Geisinger Medical Center in Pennsylvania, Brigham and Women's Hospital in Boston, NYU Langone Medical Center and Northwestern Memorial Hospital in Chicago are all being docked 1 percent of their Medicare payments through next September, federal records show.

In total, hospitals will forfeit $373 million, Medicare estimates.

The federal health law required Medicare to lower payments for the quarter of hospitals with the highest rates of hospital-acquired conditions, or HACs.

These avoidable complications include infections from central-line catheters, blood clots and bedsores.

The penalties come as hospitals are showing some success in reducing harmful errors. A recent federal report found that the frequency of mistakes dropped by 17 percent between 2010 and 2013, an improvement that Health and Human Services Secretary Sylvia Burwell called "a big deal, but it's only a start." Even with the reduction, 1 in 8 hospital admissions in 2013 included a patient injury.

Dr. Eric Schneider, a Boston health researcher, said studies have shown that medical errors can be reduced through a number of techniques, such as entering physician orders into computers rather than scrawling them on paper, better hand-washing, and checklists on procedures to follow during surgeries. "Too many clinicians fail to use those techniques consistently," he said.

The quality penalties have "put attention to the issue of complications, and that attention wasn't everywhere," said Dr. John Bulger, chief quality officer at Geisinger Health System, based in Danville, Pa. However, he said hospitals like Geisinger's now must spend more time reviewing their Medicare billing records as the government uses those to evaluate patient safety. The penalty program, he said, "has the potential to take the time that could be spent on improvement and [spend it instead] making sure the coding is accurate."

Hospitals complain there may be almost no difference between hospitals that are penalized and those that narrowly escape fines. "Hospitals may be penalized on things they are getting safer on, and that sends a fairly mixed message," said Nancy Foster, a quality expert at the American Hospital Association.

The penalties come on top of other fines Medicare has been levying. With the HAC penalties now in place, the worst-performing hospitals this year risk losing more than 5 percent of their regular Medicare reimbursements.

About 1,400 hospitals are exempt from penalties because they provide specialized treatments such as psychiatry and rehabilitation or because they cater to a particular type of patient such as children and veterans. Small "critical access hospitals" that are mostly located in rural areas are also exempt, as are hospitals in Maryland, which have a special payment arrangement with the federal government.

In evaluating hospitals for the HAC penalties, the government adjusted infection rates by the type of hospital. When judging complications, it took into account the differing levels of sickness of each hospital's patients, their ages and other factors that might make the patients more fragile. Still, academic medical centers have been complaining that those adjustments are insufficient given the especially complicated cases they handle, such as organ transplants.

"To lump in all of those things that are very complex procedures with simple things like pneumonia or hip replacements may not be giving an accurate result," said Dr. Atul Grover, the chief public policy officer of the Association of American Medical Colleges.

Medicare levied penalties against a third or more of the hospitals it assessed in Colorado, Connecticut, Delaware, Nevada, New Jersey, New Mexico, Rhode Island, Utah, Washington and the District of Columbia, a Kaiser Health News analysis found.

A separate analysis of the penalties that Dr. Ashish Jha, a professor at the Harvard School of Public Health, conducted for Kaiser Health News found that penalties were assessed against 32 percent of the hospitals with the sickest patients. Only 12 percent of hospitals with the least complex cases were punished.

Hospitals with the poorest patients were also more likely to be penalized, Jha found. A fourth of the nation's publicly owned hospitals, which often are the safety net for poor, sick people, are being punished.

"I've worked in community hospitals. I've worked in teaching hospitals. My personal experience is teaching hospitals are at least as safe if not safer," Jha said. "But they take care of sicker populations and more complex cases that are going to have more complications. The HAC penalty program is really a teaching-hospital penalty program."

You can download the full list of hospital penalties here.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

NIH Allows Restart Of MERS Research That Had Been Questioned

NPR Health Blog - Thu, 12/18/2014 - 2:20pm
NIH Allows Restart Of MERS Research That Had Been Questioned December 18, 2014 2:20 PM ET

A transmission electron micrograph shows Middle East respiratory syndrome coronavirus particles (colorized yellow).

NIAID

Some researchers who study the virus that causes Middle East respiratory syndrome got an early Christmas present: permission to resume experiments that the federal government abruptly halted in October.

The scientists were trying to modify the MERS virus so that it's better able to sicken mice. Their goal is to make a lab model that would let them test vaccines and drugs against this disease. MERS, which seems to normally infect camels, has sickened hundreds of people in the Middle East in recent years. Many have died.

Shots - Health News Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab Shots - Health News How A Tilt Toward Safety Stopped A Scientist's Virus Research

Some experts worry that the virus could mutate, start spreading easily in people, and cause a pandemic. They say it's vital to get prepared.

But the U. S. government stopped those mouse experiments as part of a temporary moratorium on government-funded research that might make three viruses — influenza, MERS, and SARS (which causes a severe acute respiratory syndrome) — more contagious or deadly.

Officials said they wanted to reconsider the risks and benefits of the experiments in the wake of some high profile lab mishaps involving agents like anthrax and smallpox. The review process is expected to take about a year, and includes public meetings like one held at the National Academy of Sciences this week.

At the meeting, scientists who study coronaviruses like MERS defended their work. The modifications they're making to the virus aren't likely to make it worse for humans — just worse for mice, they said.

That argument convinced Thomas Inglesby of the UPMC Center for Health Security. He's been a prominent critic of past experiments that modified a dangerous bird flu virus in ways that might make it transmissible in people. But since no MERS or SARS scientists are trying to modify these viruses in ways that would make them more contagious in humans, Inglesby says "it seems reasonable and prudent to end the moratorium on coronavirus related work."

The day after the meeting, scientists including Matthew Frieman of the University of Maryland School of Medicine got word from the National Institutes of Health that their requests for waivers from the moratorium have been approved and that their mouse experiments with MERS could continue.

Other experiments, however, remain off-limits for federal funding. Virologist Ron Fouchier of Erasmus Medical Center in the Netherlands, whose lab did the controversial bird flu experiments with U.S. funding, told NPR in an email that he received stop-work orders from the NIH in October.

The point of his research is to understand how bird flu viruses might mutate in ways that would let them sicken people and start spreading like seasonal flu—information that could help public health workers prepare for the threat of a naturally occurring flu pandemic. Fouchier says he didn't apply for a waiver but has asked the government to better define the experiments of concern so that he can continue the non-concerning work.

Fouchier questioned whether the government's current effort to weight the benefits and risks of this kind of research is going to provide any new insights that haven't already been discussed over the last three years since the debate over his experiments first began. "I think that the quantitative risk and benefit analysis is going to be close to impossible," Fouchier told NPR. "Whatever the numbers are they come up with, in the end it will still be a judgment call by someone, somewhere."

Updated 3:23 p.m.: The National Institutes of Health confirmed the changes in an email. "All studies using a mouse model for MERS (five) have been excepted from the pause," a spokeswoman wrote. "In addition, exceptions were granted for two flu studies. Investigators have been (or will be shortly) informed and an official letter will be sent."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

California Whooping Cough Infections Run High Among Latino Babies

NPR Health Blog - Thu, 12/18/2014 - 11:49am
California Whooping Cough Infections Run High Among Latino Babies December 18, 201411:49 AM ET

fromKQED

April Dembosky

Nurse Julietta Losoyo gives Derek Lucero a whooping cough vaccination at the San Diego Public Health Center on Dec. 10.

Chris Carlson/AP

California is battling the worst whooping cough epidemic in 70 years.

Nearly 10,000 cases have been reported in the state so far this year, and babies are especially prone to hospitalization or even death.

California's Whooping Cough Epidemic 5 min 34 sec   Shots - Health News Calif. Vaccination Gap And Whooping Cough

Six of 10 infants who have become ill during the current outbreak are Latino. There's no conclusive explanation, but there are a few theories that range from Latino cultural factors to a lack of health insurance.

"Hispanics have larger household sizes, and there may be cultural practices around visiting new infants that increase the number of contacts," says Dr. Gil Chavez, deputy director of California's department of public health.

Babies can't get their first dose of the vaccine until they are two months old. Some adults may be infected and not know it. The more siblings and extended family members that babies live or visit with, the more exposure they may have to whooping cough.

"Aunts, uncles, grandparents who may not have had a booster shot, they may be passing it on that way," says Michael Rodriguez, a family physician at UCLA.

However, he points out that several other ethnic groups have large family sizes or live together because financial resources are limited. These factors alone can't explain why Latino babies are disproportionately affected, he says.

"It really speaks to the lack of access to health insurance that's particularly predominant within the Latino community," says Sarah de Guia, executive director of the California Pan-Ethnic Health Network, an advocacy group.

Latinos make up 62 percent of the uninsured, she says, either because they can't afford to pay for health insurance, or because they're afraid that signing up for coverage will expose family members who aren't lawfully present in the U.S.

Many parents who entered the country illegally are afraid they will be discovered and deported if they enroll their children, who are legal immigrants or citizens, into government coverage, such as Medicaid.

"That's the primary reason why people are not getting the preventive care that they need," she says. "And then that impacts everyone."

Public health officials attribute the ongoing epidemic to several factors.

Whooping cough is cyclical in nature and tends to peak every three to five years. The last outbreak of the disease in California was in 2010.

But doctors are discovering that immunity from the current vaccine may be wearing off on a similar timeline. Medical recommendations suggest booster shots after eight years, but doctors are seeing kids who received a booster three years ago getting sick. Public health officials are considering an update to the recommendations to account for the dip in immunity seen after three years.

Plus, many kids in some areas aren't getting vaccinated at all. The highest rates of whooping cough are found in the Bay Area counties of Sonoma, Napa and Marin, which also have some of the highest rates of parents who opt out of vaccinating their children.

Doctors believe these kids are the root of the current and recent epidemics.

"We had a lot of unvaccinated children that acted as the kindling to start an outbreak," said Dr. Paul Katz, a pediatrician at Kaiser Permanente in San Rafael. "Those children were able to infect all the other children who were vaccinated but were too early for a booster –- they became the rest of the wood to start the fire."

All of these factors combine to put babies at risk, especially babies who are not old enough to be vaccinated.

And if Latino children and adults don't have health coverage, they are less likely to be visiting the doctor regularly and getting their booster shots, says Rodriguez.

California's public health department has done some outreach to encourage pregnant women to get vaccinated in the third trimester, in order to pass immunity on to the fetus. But little outreach has been done in Spanish, and most materials are distributed directly to doctors' offices. Latinos aren't likely to see that information if they don't have insurance and aren't going to the doctor.

Advocate Sarah de Guia says more work needs to be done so pregnant women –- and adults -– in Latino communities know they need to update their vaccinations.

"It's important for public officials to provide culturally and linguistically appropriate outreach to make sure people are getting the message in their language, and in a way they will understand," she says.

Copyright 2014 KQED Public Media. To see more, visit http://www.kqed.org.
Categories: NPR Blogs

Is Your State Ready For The Next Infectious Outbreak? Probably Not

NPR Health Blog - Thu, 12/18/2014 - 10:30am
Is Your State Ready For The Next Infectious Outbreak? Probably Not December 18, 201410:30 AM ET $(function() { var pymParent = new pym.Parent( 'responsive-embed-state-outbreak-preparedness', 'http://apps.npr.org/dailygraphics/graphics/state-outbreak-preparedness/child.html', {} ); });

Ebola may have slid off the nation's worry list, but that doesn't mean the United States is ready to handle an outbreak of Ebola or another infectious disease, an analysis says. That includes naturally occurring outbreaks like dengue fever, tuberculosis and measles, as well as the use of bioterrorism agents like anthrax.

Goats and Soda Endless Ebola Epidemic? That's The 'Risk We Face Now,' CDC Says

The report issued Thursday gives half of the states and the District of Columbia failing grades on 10 measures of preparedness, which include maintaining funding for public health services from 2012; getting half the population vaccinated for flu; reducing the number of bloodstream infections caused by central lines for people in the hospital; testing the response time for emergency laboratory tests; and testing 90 percent of suspected E. coli 0157 infections within four days.

Maryland, Massachusetts, Tennessee, Vermont and Virginia did the best, scoring eight out of 10, while Arkansas, Idaho, Kansas, Kentucky, Louisiana, New Jersey, Ohio and Wyoming scored at or near the bottom.

That's not so good, considering that infectious diseases are the leading cause of death in people under age 60 worldwide, and cost the United States more than $120 billion a year. The list of diseases is long and growing, with old foes like tuberculosis and influenza, and newer threats like West Nile virus and Middle East Respiratory Syndrome.

Shots - Health News Is Enterovirus D68 Behind The Mysterious Paralysis In Children?

It doesn't take rocket science to combat infectious disease; the public health strategies required have been used successfully for decades. But public health preparedness often loses out in state and federal budgets, unless there's been a recent Ebola outbreak or anthrax attack.

An up-to-speed public health system will be able to manage these challenges:

  • Quickly diagnosing outbreaks with laboratory testing and investigators who can trace contacts. Testing and contract tracing were used to contain the Ebola cases in Texas, and are used routinely by state and local health departments to combat outbreaks of foodborne illness.
  • Containing outbreaks with vaccines, medications and other countermeasures, including quarantine.
  • Train hospitals so they can respond quickly and safely when a novel infection presents itself, whether it's Ebola or the mysterious enterovirus D68, which sickened hundreds of children this fall.
  • Reporting systems that can help investigators quickly recognize an outbreak in the making, whether with everyday infections like flu and West Nile virus or rarer pathogens like Ebola and chikungunya.
  • Communicate swiftly and clearly among health workers, government agencies and the public.
  • Rapidly develop new vaccines or medical treatments, which multiple companies and countries are attempting now with Ebola.

The report was issued by the Trust for America's Health and the Robert Wood Johnson Foundation (which also provides funding to NPR.)

Goats and Soda Experimental Vaccine For Chikungunya Passes First Test

"Infectious disease control requires constant vigilance," the report concludes. "This requires having systems in place and conducting continuous training and practice exercises. The Ebola outbreak is a reminder that we cannot afford to let our guard down or grow complacent when it comes to infectious disease threats."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Worries About Unusual Botulinum Toxin Prove Unfounded

NPR Health Blog - Thu, 12/18/2014 - 9:47am
Worries About Unusual Botulinum Toxin Prove Unfounded December 18, 2014 9:47 AM ET

A culture of Clostridium botulinum, stained with gentian violet.

CDC

Remember that worrisome new form of botulinum toxin we told you about in late 2013, the one that supposedly had to be kept secret out of fear it could be used as a bioweapon that would evade all of our medical defenses?

Well, as it turns out, it's not that scary after all. The antitoxin stored in the government's emergency stockpile works and would neutralize the toxin just fine.

That's the conclusion of some recent studies done by folks at the Centers for Disease Control and Prevention, which after two years of waiting finally received the strain of Clostridium botulinum bacteria from the public health department that identified it.

Shots - Health News Who's Protecting Whom From Deadly Toxin? Shots - Health News Why Scientists Held Back Details On A Unique Botulinum Toxin

Botulinum toxin is one of the most poisonous substances known, and for a long time scientists knew of seven different types. Then researchers at the California Department of Public Health announced that they'd discovered the first new form of the toxin to turn up in over 40 years.

They called it "type H" and described their find in a medical journal. But here's the unusual and worrying part: The editors of the journal allowed the researchers to withhold key genetic details that would allow others to make or study this toxin. The reason given was that "no antitoxins as yet have been developed to counteract the novel C. botulinum toxin."

As NPR reported, however, other botulism researchers soon raised serious concerns. They said the California lab wasn't sharing the genetic information, and was also keeping the novel strain under lock and key. No one could independently confirm the claims that this was a new and potentially lethal toxin — or consider how to protect the public, if the concerns were valid.

When other scientists finally got the strain, they were relieved. "We don't think it poses a new, novel threat," says Robert Tauxe of the CDC's division of foodborne, waterborne and environmental diseases. "It appears to be a hybrid, that is a naturally occurring combination of two other existing toxins."

Tauxe explains that the botulinum toxin is a protein with two different parts. "I think of it as being like the scissors on a Swiss Army knife," he says. "There is the scissors part that actually does cut a piece of protein on a nerve cell. And that is held in a larger handle. And the larger handle is really how the immune system recognizes the toxin and reacts to it."

He says the newly discovered hybrid toxin has a "scissors" part that cuts like a type F toxin, but the "handle" is very similar to a type A toxin.

"What this means is that our medical countermeasures, our antisera that we have produced in quantity and have stocked in the national stockpile and that we use to treat botulism routinely, contain antibodies that protect against this novel toxin," says Tauxe.

At the CDC, scientists did experiments with mice showing that the current antitoxin offers protection. Other studies using cultures of nerve cells came to the same conclusion.

NPR asked the California Department of Public Health how it responds to criticism over the decision not to make the genetic sequence and strain available to others earlier, given that other labs were able to quickly ascertain that the current defenses would work. In reply, a spokeswoman sent a statement from James Watt, chief of its division of communicable disease control.

He said that discovery of the new strain was unusual for the department:

"The department does not typically identify agents that are potentially novel and/or of national security significance. Since there was no immediate threat, we chose to proceed carefully and deliberately to prevent any possible threat to public health and security."

The department has transferred governance over the new strain to the feds, he said, adding, "any decision regarding both releasing the sequence and the strain will be made by them now."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

What Happens After You Get That Mammogram

NPR Health Blog - Wed, 12/17/2014 - 3:47pm
What Happens After You Get That Mammogram December 17, 2014 3:47 PM ET

This graphic lays out the possible outcomes for 10,000 women if they start getting annual screening mammograms at age 50 and continue that for 10 years.

Courtesy of JAMA

Women and their doctors have a hard time figuring out the pluses and minuses of screening mammograms for breast cancer. It doesn't help that there's been fierce dissent over the benefits of screening mammography for women under 50 and for older women.

To make it easier to grasp the big picture, Dr. Jill Jin, an associate editor of JAMA, the journal of the American Medical Association, put together this graphic on the odds of various outcomes from screening mammography. It's based on a review of studies on the risks and benefits of mammography earlier this year and was published Wednesday in JAMA.

Because mammograms aren't perfect screening tests, they can miss some cancers and falsely diagnose cancer that's not there. Those false positives can lead to more testing, including biopsies, and needless anxiety.

Mammograms can also lead to overdiagnosis, when a scan finds something that would never become life-threatening but can lead to surgery, radiation and chemotherapy. Some studies estimate that 20 percent of cancers found on mammograms are overdiagnosed and lead to unnecessary treatment, according to Jin.

The graphic looks at the odds of false positives, overdiagnoses and breast cancer diagnosis for 10,000 women over 10 years, if each started getting annual mammograms at age 50, the age recommended by the U.S. Preventive Services Task Force. About 3,568 women will have normal exams, while 6,130 will have at least one false positive result. About 302 will be diagnosed with cancer, and 10 deaths will be averted because of screening.

Bottom line: Mammograms are the best tool we have for early detection of breast cancer, but they're not perfect. It's best to know the likelihood of possible harms, as well as the benefits.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Managed Care Plans Make Progress In Erasing Racial Disparities

NPR Health Blog - Wed, 12/17/2014 - 1:30pm
Managed Care Plans Make Progress In Erasing Racial Disparities December 17, 2014 1:30 PM ET

fromKQED

Lisa Aliferis

A nurse checks a man's blood pressure during a health clinic In Los Angeles.

Patrick Fallon/Bloomberg via Getty Images

Years of efforts to reduce the racial disparities in health care have so far failed to eliminate them. But progress is being made in the western United States, due largely to efforts by managed care plans to identify patients who were missing out on management of chronic diseases like diabetes and heart disease.

While management of blood pressure, cholesterol and blood sugar improved nationwide, African-Americans still "substantially" trailed whites everywhere except the western U.S., an area from the Rocky Mountains to the Pacific as well as Alaska and Hawaii.

"We were certainly hoping we would see indications of progress in eliminating disparities in the country as a whole," said Dr. John Ayanian, who heads the Institute for Healthcare Policy and Innovation at the University of Michigan and was lead author of the study. While it was "disappointing" that disparities persisted, he said, "it's also heartening to see that ... in the West, the disparities had been eliminated, and that was both surprising and encouraging."

To find that out, Ayanian and his colleagues looked at 100,000 Medicare patients who were enrolled in HMOs, called "Medicare Advantage" plans, from 2006 to 2011. The study was published last week in the New England Journal of Medicine.

Shots - Health News African-Americans Remain Hardest Hit By Medical Bills

Disparities in health care have long been noted in American health care. The researchers wrote that, in 2008, "life expectancy was 5.4 years shorter for black men and 3.7 years shorter for black women than for white men and white women." Heart disease and diabetes — diseases that can be better managed by controlling blood pressure, cholesterol and blood sugar, the risk factors measured in the study — accounted for 38 percent of the gap in mortality between black and white men, and 54 percent of the gap among women, the researchers said. That's why closing the racial gap on these measures is so critical.

"It's one of the first large studies to show that it's possible to eliminate deeply ingrained racial disparities in important risk factors," Ayanian said. He said that outcomes for Hispanics, and Asians and Pacific Islanders were "also encouraging."

Nationwide, black enrollees in the study were substantially less likely than white enrollees to have adequate control of blood pressure, cholesterol and blood sugar, trailing whites by about 10 percent.

Hispanics were 1 to 3 percent less likely than whites to have blood pressure, cholesterol or blood sugar under control. Asians and Pacific Islanders were more likely than whites to have good control of blood pressure and cholesterol. Blood sugar control was about the same.

Specifically, the researchers pointed to Kaiser Permanente health plans as being successful in eliminating disparities. Kaiser includes "nearly half" of Medicare HMO enrollees in the western region of the U.S., Ayanian said.

"Our findings in the West of nearly identical control of three major risk factors among black Medicare enrollees and white Medicare enrollees in Kaiser health plans and control of (blood sugar) in other health plans show the potential to achieve equity in these key health outcomes," the researchers wrote.

Kaiser representatives said they did not have any advance knowledge of the publication of the study.

Dr. Joseph Young, who leads Northern California Kaiser's clinical hypertension program, said that Kaiser adopted a population management approach to managing chronic conditions in 2006. Kaiser has created registries for people with various kinds of conditions, so that patients who might be missing preventive care or better management of disease can be easily identified.

In the area of blood pressure control, Kaiser changed its drug formulary to allow a "combined pill — a single pill that includes two drugs, to make it easier for patients to take their medication.

These population-based strategies resulted in big improvements in overall outcome for Kaiser patients. Young said that during the 2000s, very serious heart attacks ... fell by 62 percent, and our stroke mortality fell by 42 percent.

Kaiser does have some remaining racial disparities in its non-Medicare population, and Young said they are "actively focusing" on closing those remaining gaps.

"We want clinicians to do what Kaiser is doing and take seriously to provide high quality race-blind clinical care," says Dr. Anthony Iton, who leads the Healthy Communities initiative at the California Endowment. "Kaiser is showing it can be done." He called the study "very hopeful" and believes that Kaiser's approaches are replicable elsewhere.

"Any other system that says it's not doable has to explain how they can justify not providing the same high-quality care to everyone that comes in the door," Iton said.

California probably has "less of a socioeconomic spread between whites and blacks than you do in the southeastern United States," Iton noted. "It's a heavier lift in the Southeast than in the West. But despite that, it's clearly doable."

This story is part of partnership that includes NPR, KQED, and the Kaiser Family Foundation.

Copyright 2014 KQED Public Media. To see more, visit http://www.kqed.org.
Categories: NPR Blogs

Behind The Scenes At The Lab That Fingerprints Microbiomes

NPR Health Blog - Wed, 12/17/2014 - 12:06pm
Behind The Scenes At The Lab That Fingerprints Microbiomes December 17, 201412:06 PM ET Katherine Harmon Courage

Rob Knight, co-founder of the American Gut Project at the University of Colorado in Boulder, works in the lab where the samples are processed.

The American Gut Project

The gut microbiome may soon reveal important answers to questions about our health. But those answers aren't yet easy to spot or quick to obtain.

The week after I mailed off my family's microbial samples to be analyzed for the American Gut Project, I followed them down the road from my home to the University of Colorado, Boulder. They — and I — came to a massive, futuristic science complex there. Daniel McDonald, a doctoral student studying quantitative biology and computer science, greeted me and brought me up to the workspace, where rows of researchers worked on computers outside of a small lab room.

Shots - Health News Poo And You: A Journey Into The Guts Of A Microbiome Shots - Health News To Get To The Bottom Of Your Microbiome, Start With A Swab Of Poo

Inside the lab, where the sealed samples were received, a lone technician sorted through new arrivals, snipping off intentionally fouled swab heads. Each sample kit contains two cotton swabs. One swab head goes directly to the freezers for safe keeping (in case the first sample doesn't provide clear results or for the near future, when sequencing technology is better). The other gets dissolved in a solution so its contents can be carefully analyzed for genetic traces of microbes.

Just down the hall is one of the lab's boxed-in robots, charged with loading samples into individual wells on a tray that will later get fed through the sequencers. The task might seem mundane for such a high-tech tool, but the bot works much faster and more accurately than a human lab helper can.

Still, this is where some of the work can be slow going. The team must wait for hundreds of fecal, oral or skin samples to process together. A single sample could go through the full analysis process in a week, but it would cost thousands of dollars, Rob Knight, a co-founder of the project, estimates, rather than the $99 members of the study pay. For the project to be cost-effective for participants, the research team must wait to collect large groups of samples and analyze them together. (Little did I know then just how long I would be waiting for my family's samples to be processed.)

This robot in the Knight lab can handle many samples simultaneously. To avoid contamination, the lab only processes the same kind of samples at the same time together (fecal with fecal, skin with skin and pet with pet).

Katherine Harmon Courage for NPR

Most of the human microbiome is uncharted territory because many of the microbes that live in our guts can't be grown easily in the lab. Oxygen is toxic to them. Using the tools of genetics to probe the human microbiome has already uncovered many new species, each of which has a full genome of its own.

We're still far from getting quick full genomes from each of the inhabitants. Instead, scientists rely on microbes' telltale 16S gene, a marker that helps identify bacteria from one another. Finding the base pairs —the As, Cs, Ts and Gs — for this gene can help scientists sort out which species are present.

This is where a nifty machine that performs PCR (polymerase chain reaction) comes in. It makes thousands of copies of the genetic material so that the pattern in the genetic code is easier for the sequencers to find.

These sequencers are located on a lower floor of the building in a room that smells a bit like a photography darkroom. Here, each tray of samples takes about 20 hours to process. On a nearby screen, I see a readout of bright genetic points against a dark background, which looks more like a telescopic image of a night sky than the code to microbial life from someone's stomach.

This supercomputer, affectionately known as "Compy," crunches massive amounts of microbiome data at the University of Colorado, Boulder.

Katherine Harmon Courage for NPR

Deciphering this code is just the first step in understanding what is going on in the jungle of your gut. Like many things in biology, it is not just the organisms present — plants, animals or bacteria — but how these organisms interact that is important.

The dynamics among the characters make a play — not just the cast.

For instance, research has shown that many of us are walking around with E. coli in our guts but show no ill effects. In much the same way that weeds or hungry insects might not harm a thriving field or forest but could wreak havoc on an unbalanced ecosystem, we depend on a healthful mix of good microbes to keep the bad ones from taking over.

And to see what our intestinal forests are composed of, we need more than just a few points of genetic data. So after the sequencer spits out the genetic code it has assembled, the data needs to get turned back into intelligible (or at least semi-intelligible) patterns.

To do this, our microbial code gets run through a supercomputer nicknamed Compy, which hums safely in the building's basement beyond two sets of doors and a sticky, dust-collecting floor mat. When I meet her, Compy is busy crunching away on base pairs with her 1,000 processors.

From there, the microbe sequences get reunited with their human host's information from the questionnaires. But figuring out the best way to do this is still a work in progress.

The research group is testing using new software to analyze and display these many layers of information. One colorful display that we examine back up in McDonald's fourth-floor office shows a 3-D plot of microbe species and their sites on the human body. It looks a little like an explosion of Dippin' Dots caught in midair — only the brown blobs don't indicate chocolate.

But these dots aren't our microbes. Our samples are still standing by in a freezer for their turn with the robots and whirring sequencing machines. With our samples in the hopper and the process of turning a messy, poop-swab into a sterile, color-coded microbiome chart a bit demystified, it was now time to wait to see what our swipes would turn up.

This is the third story in a four-part series.

Katherine Harmon Courage is a freelance health and science writer in Colorado. She is the author of Octopus! The Most Mysterious Creature In the Sea, now available in paperback.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Too Little, Too Late For Many New Yorkers Seeking Hospice

NPR Health Blog - Wed, 12/17/2014 - 5:04am
Too Little, Too Late For Many New Yorkers Seeking Hospice December 17, 2014 5:04 AM ET

fromWNYC

Fred Mogul Listen to the Story 6 min 2 sec  

Sandra Lopez (left) and her dog, Coco, greet hospice nurse Heather Meyerend last fall. In the weeks before Lopez died, Meyerend stopped by weekly to check her physical health, pain levels and medications.

Amy Pearl/WNYC

Sandra Lopez and her Chihuahua, Coco, were inseparable. He followed her everywhere, and kept Lopez's mood up when she was in pain — which was often.

On Oct. 15, 2014, Lopez died at age 49 of melanoma that had slowly spread throughout her body over the course of two years.

“ If you're referred to hospice, it means no one expects you to get better. And that is, in my mind, a threshold that's difficult for people to step over.

Lopez was in and out of the hospital in 2014, but during the months she was home, a hospice nurse from the Metropolitan Jewish Health System visited once a week to help manage the pain, backed up by a 24-hour, nurse-staffed phone line that Lopez called often.

"Some days the pain is so excruciating," Lopez told me in August from the couch in her Brooklyn apartment, "that the pain overrides the medication."

But despite evidence that hospices can greatly relieve discomfort, extend life and save money, and despite a generous hospice benefit available through both Medicare and Medicaid, relatively few people in New York take advantage of it, compared with elsewhere in the country.

The reasons for this local gap are complicated, but Jeanne Dennis, senior vice president of hospice and palliative care at the Visiting Nurse Service of New York, says one place to start is with patients' fears. "If you're referred to hospice, it means no one expects you to get better," Dennis says. "And that is, in my mind, a threshold that's difficult for people to step over."

Experts also focus on what they call medical culture, which can vary dramatically from region to region. According to this theory, physicians in the metropolitan area are specialists and sub-specialists, and institutions put a premium on treatments and tests. Even more than in other places, the goal in New York City is to cure patients rather than simply care for them. Treating and testing is just what they do — letting go isn't, says Dennis.

Physicians put off the conversation, she says, with rationalizations like, " 'It's a little too soon'; 'It's a little too early'; 'I don't have enough time today'; 'I'm not sure they're ready for it.' "

New York has 7 out of the 10 hospitals in the country with the fewest hospice referrals. Local academic medical centers — national leaders in research — do better, but still lag behind the rest of the country in their referral rates. It's a big contrast to some hospitals around the country, particularly several in Arizona, Utah and Florida, where more than 75 percent of dying patients take advantage of Medicare's hospice benefit.

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Further, most hospice referrals in New York are for brief stays — a week or less — 2.5 times shorter than the national average. Szoa Geng, a health care consultant from the firm Strategy&, says when hospitals move people to hospice with just a few days left to live, the patients don't get the full hospice experience.

"They're not getting the psychosocial support, and their families are not," Geng says. "It can be a time of closure, and coming to peace with a lot of things in your life, and none of that can happen if you come onto hospice with a day left."

Hospice care mostly takes place at home, but it can also occur in freestanding hospices, nursing homes or designated areas of hospitals. To receive the care, a doctor must predict a patient is in the last six months of life without hope of improving. There's no penalty for outliving that prediction; some patients stabilize and go off hospice care, then return later when they start declining again.

About 25 percent of people in the New York metropolitan area use hospice care in their last six months of life, compared with close to 50 percent nationally. Statewide, the rate is closer to 30 percent. But that still makes New York 49th out of 50 states and the District of Columbia, according to the 2012 Dartmouth Health Atlas, the most recent statistics available.

Sandra Lopez said that before her oncologist told her about hospice care, she frequently called 911 to request an ambulance to take her to the hospital, where she would be admitted and spend days at a time. That happened "dozens and dozens of times" in a year, Lopez said.

At around $210 a day, Lopez's hospice care cost Medicaid tens of thousands of dollars — probably less than her revolving-door trips to the hospital (with all their multinight stays), but still a lot of money.

For Lopez, hospice helped her get ready to walk down the final road.

"I stopped worrying — like the worry box I used to be," she told me in August. "I just live my life normally, like everybody else, because worrying will just probably get me more sick."

Lopez knew that at some point her body would start shutting down, but she would never say how much time her doctors estimated she had remaining, because she didn't dwell on that, she said. She was at peace as she faced death and knew she could stay that way — as long as someone was with her at home, at her bedside, helping to subdue her pain.

This story is part of an NPR reporting partnership with WNYC and Kaiser Health News. Special thanks to WYNC's Data Team.

Copyright 2014 WNYC Radio. To see more, visit http://www.wnyc.org/.
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When You Burn Off That Fat, Where Does It Go?

NPR Health Blog - Tue, 12/16/2014 - 3:58pm
When You Burn Off That Fat, Where Does It Go? December 16, 2014 3:58 PM ET

Lose weight and those pounds shuffle off, unmourned. Good riddance. Please don't come back soon.

But where does weight go when we lose it?

We talk about burning off fat, and it does burn in a way, going through a complex biochemical process. But mass can't be created or destroyed, so the atoms that made the triglycerides that plumped up the love handles have got to be somewhere.

The Salt Cutting Back On Carbs, Not Fat, May Lead To More Weight Loss

That mystery was bedeviling Ruben Meerman, an Australian and former physicist turned TV personality and science educator. Meerman had recently lost 15 kilos (33 pounds), and he was wondering where the fat went.

So he teamed up with Andrew Brown, a lipid researcher at the University of New South Wales, to figure it out. Their results were published Tuesday in the lighthearted Christmas edition of The BMJ, formerly the British Medical Journal.

The adipose sleuths started with this chemical formula, which describes what happens when you burn a molecule of triglyceride, the predominant fat in a human body:

C55H104O6+78O2 —> 55CO2+52H2O+energy.

If you remember your high school chemistry, you've already figured out that when you metabolize fat you end up with carbon dioxide, water and energy.

Oxidizing 10 kilos of human fat requires inhaling 29 kilos of oxygen to produce 28 kilos of carbon dioxide and 11 kilos of water, the authors figure.

The Salt Rethinking Fat: The Case For Adding Some Into Your Diet

That's based on the work of other scientists. Meerman and Brown then fired up their calculators to figure out the proportion of mass that ends up as CO2 versus H2O — 84 percent compared to 16 percent.

Carbon dioxide is a common gas in the atmosphere, so it's pretty obvious where it would go.

Yes, we exhale lost fat. There it helps plants photosynthesize (if you're feeling noble) and contributes to global warming (if you're feeling guilty).

Exhale more CO2, and you'll lose more weight — especially if you're exhaling more frequently because you're running.

The relatively small amount of water produced by fat metabolism could be disposed of through urine, sweat or other bodily fluids, the authors note.

Many people think that fat metabolites are disposed of in feces or converted to muscle, Meerman and Brown write, but that's not correct. "We recommend these concepts be included in secondary school science curriculums and university biochemistry courses to correct widespread misconceptions about weight loss."

And let your fat drift away on the breeze.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab

NPR Health Blog - Tue, 12/16/2014 - 1:19pm
Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab December 16, 2014 1:19 PM ET

The coronavirus responsible for Middle East respiratory syndrome (green particles) seen on camel cells in a scanning electron micrograph.

NIAID/Colorado State University

Imagine that scientists wanted to take Ebola virus and see if it could ever become airborne by deliberately causing mutations in the lab and then searching through those new viruses to see if any spread easily through the air.

Would that be OK?

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The question was posed by David Relman, a microbiologist at Stanford University, at a two-day meeting being held at the National Academy of Sciences in Washington, D.C., to discuss whether some experiments with germs are so risky that the dangers aren't worth the potential benefits.

Researchers call these "gain-of-function" experiments. Take a bug that's bad and give it some genes that just might give the microbes new abilities.

The work has split the scientific community. Some of the most prominent figures in this saga showed up at the historic National Academy of Sciences building this week to have another go at it.

The controversy started a few years ago, with some experiments that took a bird flu virus and altered it so that it spread easily between ferrets, the lab stand-in for people. Critics said the scientists had created a superflu that could cause a pandemic in people if it ever got out of the lab, but the researchers said their work was essential to understanding how flu viruses can jump from animals into people and start devastating flu pandemics.

This disagreement rumbled along until this summer, when some high-profile lab mishaps with other infectious agents prompted the government to temporarily halt certain federally funded research projects that might make three viruses — influenza, SARS and MERS — more pathogenic or contagious.

Officials said they wanted to reassess the risks and benefits, and the meeting that started Monday is part of that effort. "We want to provide a neutral venue for open discussion," said Victor Dzau, president of the Institute of Medicine of the National Academy of Sciences.

The one thing that almost everyone seemed to agree on is that they hate the term "gain-of-function," saying that it doesn't meaningfully describe the kinds of experiments that have some people worried.

"I think the term 'gain-of-function' is being misused more than the viruses," said Michael Imperiale, a microbiologist with the University of Michigan Medical School. "I'd rather that we just take each individual case and call it what it is." Kanta Subbarao of the National Institutes of Health, whose lab works on all three pathogens, said the term is "vague and unsatisfactory."

Virologist Yoshihiro Kawaoka of the University of Wisconsin, Madison, whose lab did one of the flu experiments that caused such controversy, said his work convinced government agencies that they needed to spend the money to replenish the emergency vaccines that have been stockpiled for this particular bird flu virus, because it does indeed seem capable of mutating in ways that could start a pandemic. "This information is important for policymakers," he said, adding that such experiments allow scientists "to obtain information that we could not obtain by other methods unless it actually occurred in nature."

Relman, in response, said that "we already knew enough to be very concerned and motivated to do something" and suggested that if additional motivation was needed, it could have been achieved through experimental approaches that carried less risk.

Meanwhile, scientists who study MERS and SARS, like the University of North Carolina's Ralph Baric, came to the meeting and argued that they weren't doing anything worrisome with these viruses. But they had been dragged into the discussion and had their work halted only because they study respiratory viruses that can be highly pathogenic in people.

The government's review process is expected to last about a year, with another conference planned at the National Academies to discuss draft recommendations on how the government should weigh the risks and benefits of this type of work. Those recommendations will be developed by an advisory committee called the National Science Advisory Board for Biosecurity, which will also be holding public meetings.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Few Employers Cover Egg Freezing For Women With Cancer

NPR Health Blog - Tue, 12/16/2014 - 8:22am
Few Employers Cover Egg Freezing For Women With Cancer December 16, 2014 8:22 AM ET

Partner content from

Michelle Andrews

As some companies add egg freezing to their list of fertility benefits, they're touting the coverage as a family-friendly perk.

Women's health advocates say they welcome any expansion of fertility coverage. But they say that the much-publicized changes at a few high-profile companies such as Facebook and Apple are still relatively rare, even for women with serious illnesses like cancer who want to preserve their fertility.

Shots - Health News Women Can Freeze Their Eggs For The Future, But At A Cost

News stories about company-paid egg freezing for female employees have focused on whether the benefit truly gives women and men more options for balancing work and family life or instead sends a message that they're expected to put off having a family if they want to get ahead on the job.

But career advancement isn't the main concern for some women who, because of illness or age, are worried that time is running out for them to have children. After their mid-30s, women can still carry a pregnancy, but their eggs are less viable. Egg freezing allows women to extend their fertile years.

Brigitte Adams, 42, became the face of oocyte cryopreservation, as egg freezing is called technically, when Bloomberg BusinessWeek put her on its cover for a story on the subject last spring.

Divorced in her mid-30s, she froze her eggs three years ago, paying for the $12,000 egg retrieval procedure with personal savings and help from her parents. Adams pays $300 annually to store her eggs, and she's pondering becoming a single mother. Her marketing job at a tech startup in Los Angeles doesn't provide any coverage for egg freezing and storage or the in vitro fertilization that will be required if she decides to go ahead.

Adams is keenly aware that there is no guarantee that the 11 eggs she's storing will result in a pregnancy. "It's not a silver bullet," Adams says, "but it gave me the sense I'd done everything I could, and that has helped me tremendously to just move on."

Two years ago, the American Society for Reproductive Medicine declared that it no longer considered egg freezing to be experimental. Research shows that fertilization and pregnancy rates using frozen eggs are similar to those using fresh eggs, and children born using frozen eggs don't have higher levels of chromosomal abnormalities or birth defects, the ASRM said in its revised practice guideline.

Yet insurance coverage for egg freezing and other infertility treatments remains spotty, says Richard Reindollar, executive director at the ASRM. "Of all the disease processes, insurance coverage is available for essentially all of them, but not for infertility," he says.

America's Health Insurance Plans hasn't surveyed insurers specifically about egg-freezing coverage, says Susan Pisano, a spokesperson for the trade group. However, she said her understanding is that many plans cover egg freezing when there's a diagnosed fertility problem or when an individual is at risk for infertility because of treatments like radiation therapy or chemotherapy. Coverage for nonmedical reasons is much less common, Pisano says.

Roughly a third of companies with 500 or more workers provide no coverage for infertility services, according to benefits consultant Mercer's annual survey of employer health benefits.

High-tech companies are more likely to cover fertility services than other firms, according to Mercer. Forty-five percent of high-tech companies cover in vitro fertilization, and 27 percent cover other advanced reproductive procedures, such as egg freezing, for example. The comparable figures for companies not in the technology sector were 26 percent and 14 percent, respectively.

Infertility advocates would like to see more companies adopt egg freezing policies, especially for women who have cancer, for example, and are likely to become infertile as a result of chemotherapy.

"I think it's amazing for people at these companies, but can we also get this covered for women with cancer?" says Barbara Collura, president and CEO of Resolve, an infertility advocacy group.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Alaska's Governor Eager To Expand Medicaid

NPR Health Blog - Tue, 12/16/2014 - 3:28am
Alaska's Governor Eager To Expand Medicaid December 16, 2014 3:28 AM ET

fromAPTI

Annie Feidt Listen to the Story 2 min 54 sec  

Valerie Davidson was appointed health commissioner by Alaska's Gov. Bill Walker to help him expand Medicaid in the state. She'll look for middle ground with Republicans to get it done, she says.

Lori Townsend/Alaska Public Media

Alaska's new governor won his election in one of the tightest races in the country, a race that was too close to call even a week after election night. Bill Walker, who ran as an independent (unaffiliated with the Republicans or Democrats), took office on Dec. 1, after campaigning on the promise that he would expand Medicaid as one of his first orders of business.

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To make good on that, he'll have to face a Republican-controlled legislature that hasn't been willing to even consider the idea.

But for Walker, it's a no-brainer: Around 40,000 low-income Alaskans would receive health benefits under Medicaid expansion; most of those affected would be childless adults. The federal government would pay 100 percent of the costs until the end of 2016, and after that the state's share would only slowly increase to 10 percent by 2020.

Plus, Walker points out, Alaskans already pay taxes that fund the expansion.

"I always will default back to what is best for Alaskans," he says, "and it's best for Alaskans to have the health care coverage we've already paid for."

The Alaska Chamber of Commerce, the Alaska State Hospital and Nursing Home Association and the Alaska Native Tribal Health Consortium, all support the Medicaid expansion. So far 28 states have expanded their coverage, and most of those governors have had legislative support says Laura Snyder, a policy analyst with the Kaiser Family Foundation.

“ I always will default back to what is best for Alaskans, and it's best for Alaskans to have the health care coverage we've already paid for.

"There have been a few states where the governor has acted on his own through executive authority," she says, "but most states have generally incorporated it into state budgets which usually require legislative signoff."

In the case of Alaska, Gov. Walker will probably need the legislature because the state has to pay some administrative costs that would add up to as much as $10 million per year. Those millions could be a tough sell for the Republican legislature. Republican Sen. Anna MacKinnon says Walker will have to make a strong case.

"It will be a lively debate," MacKinnon says, "but I look forward to working with him to the best of my abilities within the financial constraints that this state is currently facing."

To help his case, Walker has appointed Valerie Davidson as Health Commissioner. She's been a leader in the Alaska Native health care system and a determined advocate for Medicaid expansion since the health law passed. She says she'll rely on a cooperative work ethic as she negotiates with lawmakers over expansion. Davidson's confident Alaska can get it done.

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"It may not be something everyone's 100 percent happy with," she says, "but we may be able to find middle ground that we can all live with.

"I think that's what makes Alaska so great," Davidson adds. "We don't back down just because things get difficult. If it's 40 below we go about our day and get things done. That's just what we do. And we do that with policy issues as well."

Beyond any opposition by the legislature, Alaska faces big technical hurdles before Medicaid expansion can work. The state's payment and enrollment systems aren't functioning properly right now, and Davidson wants to address those issues before any expansion.

This story is part of NPR's reporting partnership with Alaska Public Media and Kaiser Health News.

Copyright 2014 Alaska Public Telecommunications Inc.. To see more, visit http://www.alaskapublic.org.
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