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After The Cranberries And Pie, Take Time To Talk About Death

NPR Health Blog - Fri, 11/27/2015 - 7:33am

What seemed like a burden can become a gift.


Two years ago my mom fell at home and ended up being admitted to the ICU with four broken ribs and internal injuries. She was lucky. After two weeks in the hospital and a few more in a rehab unit she was back home, using her new blue walker to get around.

I think of that each Thanksgiving as I make pies just the way she taught me, grateful that she's still with us and that she's told us how she wants to die

Before she was discharged, Mom signed a POLST form, short for a Physician Order for Life-Sustaining Treatment. I'd heard of advance directives, which spell out the kind of medical care a person would want if they become too ill to communicate those wishes. But I'd never heard of POLST.

In Oregon, where my mother lives, it's a one-page piece of pink paper that bluntly asks if you want to have CPR performed if your heart stops and you're not breathing. Three other check boxes ask how much medical intervention you want: going to the hospital and an intensive care unit; perhaps the hospital but no ICU; or skip the hospital altogether. A third question asks if you want to be fed through a tube. That's it.

Because it's signed by a doctor or other provider, a POLST has teeth. It overrides the legal obligation of an EMT or a hospital to provide CPR and other emergency care that for old and sick people can lead to a long, miserable hospital stay.

"It's not for healthy people," says Dr. Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health Science University. Instead, it's for someone who is aware that they may soon die.

"We would encourage doctors to reach out to patients if they would not be surprised if they died in the coming year," Tolle says, "or if they had advanced frailty. The little old lady hunched over their walker, that's the definition of frailty."

That's also the definition of my 92-year-old mom. She can still beat me handily at hearts, but she's physically weaker each time I see her. "Do everything" is the default mode for American medicine, but that all-out approach often doesn't serve the very old well.

CPR works only about 10 percent of the time in the general population, Tolle told me, and it's even less successful in a frail old lady.

First, if someone at that age collapses, it's usually because there's a serious medical problem like a heart attack or stroke. And performing CPR on someone with osteoporosis breaks ribs rather than circulating blood. "That isn't walking off the film set looking good with your hair nicely combed," Tolle says. "That's going to the ICU on a ventilator."

In studies, Tolle, who helped develop the POLST form, has found that just about 12 percent of permanent nursing home residents would want to go to an ICU. "Most say, 'I want to go to the hospital to get the easy things fixed, but I don't want the ICU. I don't want CPR.' "

POLST forms work well in nursing homes, where they're often taped on a resident's bathroom door. But they can be harder to put in force when people are still living in the community.

Oregon has an electronic POLST registry that EMTs and hospitals can check remotely. But only 18 states have POLST programs in place, though many more have them in the works. Most have no registry, meaning that someone intent on having the directions on their POLST form followed would need to wear a medical alert bracelet.

Some members of the disability community have questioned whether POLST is being too broadly applied. Rather than give people more control over end-of-life medical care, they say, it could mean interpreting "disabled" to mean "on death's door".

This video helps explain who's too healthy to sign a POLST form.

Oregon POLST YouTube

"Our concern is that it's being used with non-terminal people," says John Kelly, a 54-year-old quadriplegic who lives in Boston. He was taken aback when a nurse showed up with Massachusetts' version of the form, called a MOLST. "I joke that I've got my pink MOLST on the fridge, and I'm afraid that the firemen will come in and glance at the refrigerator and say, OK, he's got [a do-not-resuscitate order]. They interpret it as meaning no treatment at all."

POLST is almost certainly inappropriate for someone disabled but otherwise healthy, Tolle says. "People are handing out the form a little too early sometimes, and we want to push back on that," she says. "It's for people who we can say are in the winter of their lives. They have advanced illness and frailty. They have declining health."

Since her fall my mom has been quite clear about what treatments she doesn't want. I realize that her desires may change and that the POLST form should then change, too. And I know we'll be talking about this more, even though I have a hard time thinking about it without tearing up.

Family gatherings like Thanksgiving can be a good time for adult children to ask aging parents about their wishes for end-of-life care, and whether those wishes would be best expressed through an advance directive or a POLST. A number of groups offer crib sheets with questions that aren't entirely scary, like "Would you rather die at home or in a hospital?"

It's also a good time for parents to speak their minds if the kids don't ask.

"Lean into it, step up to the plate," Tolle says. "On Thanksgiving after dinner, tell your children what you want. You really will lift a burden."

An earlier version of this story ran on Nov. 28, 2013.

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Sweet Name Of Kids' Clinic Gives Some People Heartburn

NPR Health Blog - Fri, 11/27/2015 - 5:15am
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A view from the starting line of the sixth annual Krispy Kreme Challenge in Raleigh, N.C., in 2010. The local children's health clinic takes its name from this annual charity race, which draws about 8,000 participants each year.

Courtesy of Dustin Bates

The name that UNC Health Care is giving its children's clinic in North Carolina has been raising a lot of eyebrows. The facility is slated to be renamed the Krispy Kreme Challenge Children's Specialty Clinic. But criticism from the medical community at the University of North Carolina and elsewhere is making the health care system rethink that choice.

Since the announcement last month, Barry Popkin, a nutrition professor at UNC-Chapel Hill, says he's heard from a lot of colleagues wondering, "What the heck is going on at UNC?" The clinic in question is actually about 25 miles away, in Raleigh — home to North Carolina State University.

"For them to name it this way — to give advertisement to a very unhealthy food, high in added sugar and unhealthy fats and refined carbs with no nutritional value — was quite surprising to people around the nation," Popkin says.

The name seems particularly unfortunate, some critics say, because North Carolina ranks poorly in measures of childhood obesity.

In October the student group behind the Krispy Kreme Challenge, an annual charity race in Raleigh, N.C., pledged to raise a total of $2 million for the race's namesake clinic and UNC Children's Hospital.

Brian Strickland/UNC Health Care

For the Krispy Kreme company, the advertisement is both free and unintentional. Leslie Nelson, head of fundraising and communications at UNC Children's Hospital, says the clinic – and the race — are in no way sponsored by the doughnut maker, which is based in Winston-Salem.

"The corporation is definitely not part of the name," she says. "It's named for a race! The name of the doughnut happens to be in the name of the race. But at the heart of it, it's about the race and about these kids."

The Krispy Kreme Challenge is an annual, 5-mile charity race that student volunteers at NC State University created about a decade ago, initially just for fun, and then to raise money for the hospital. The event, always held in February, has grown in size over the years, and now includes about 8,000 runners.

Chris Cooper, a junior in chemical engineering and economics at NC State, is the current executive director of logistics for the race, which does involve eating doughnuts.

"You run 2.5 miles, starting at the NC State Belltower," Cooper explains, "and then the challengers eat a dozen doughnuts," which they pick up mid-way, at stations set up in front of the local Krispy Kreme shop.

But most of the runners raise money without scarfing down fried sweets.

"The casual runners normally just pick their doughnuts up and keep running," Cooper says. "And then you run 2.5 miles back to the Belltower." The students got permission from the pastry company to use the Krispy Kreme name — but they pay for the doughnuts.

If all that pastry pounding and distance running sounds kind of sickening, well, Cooper says it can be.

"After Krispy Kreme, when people are running back, there is normally a fair amount of throw-up that happens," he says. "We have a group of students whose job is to go around and clean up the streets."

Gross, sure. But the race has raised nearly $1 million for UNC Children's Hospital and clinics so far, and the student leaders have committed to raising another $1 million.

"Behind all of this is a group that's committed to making a difference for our patients and families," says Leslie Nelson.

UNC Health Care is now having conversations about whether to go through with the name change, Nelson says. An online petition to scrap it has gathered about 13,000 signatures so far.


twgr^author">Marion Nestle, a public health professor at New York University, and former adviser in nutrition policy for the federal government, says public fallout from awkward pairings of corporate brands with health causes has been increasing.

She points to Coca-Cola's corporate partnership with the American Academy of Family Physicians as another high-profile example.

"There was a big demonstration in front of a California hospital a few years ago," Nestle says, "in which physicians burned their membership cards to the academy in protest."

Last summer, the physician's group and the soft drink company announced they're ending their deal.

Nestle says that's certainly not apples to apples with what's happening at the UNC clinic. But she does think putting Krispy Kreme in the clinic's name — for whatever reason — sets a bad example for kids.

Race coordinator Chris Cooper says if UNC decides to back off the name change, he's OK with that.

"I don't think anyone in the organization was really excited about us having a name on the clinic," he says. "I think a lot more of it was, 'How are we going to use this name to help the children's hospital even more?"

But, if it isn't helpful in drawing more people to the race and in raising more money for the good cause, Cooper says, then he has no attachment to the name.

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

Copyright 2015 WFAE-FM. To see more, visit
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Inside Each Flu Shot, Months Of Virus Tracking And Predictions

NPR Health Blog - Fri, 11/27/2015 - 5:04am
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Every year, the flu almost goes extinct in temperate places like the United States. The key word is "almost." It stays afloat by constantly moving.

"It looks like it's hopping between different cities and different populations," says Sarah Cobey, a computational biologist at the University of Chicago.

The virus does an annual migration across the world, hitting the Southern Hemisphere during its winter, the Northern Hemisphere right about now, and hanging out in the tropics in between — especially in parts of Asia.

It's still unclear exactly why the flu ramps up when it does. What is clear is that the flu has been an annual bane of human existence for a long time.

Shots - Health News Many Americans Believe They Don't Need The Flu Vaccine

"Probably centuries," Cobey says, estimating that before densely populated cities and long-distance travel, the virus strains likely had a tougher time bouncing between host populations.

It's also clear that the strains evolve quickly.

"The turnover rate in the flu population is really high, so all of the flu viruses that are circulating on the globe right now are actually going to be extinct in a couple years," Cobey says. But new strains will take their place.

Cobey's ultimate goal is a big one. "I'm really interested in the question of whether we can drive flu extinct in humans," she says.

Step one in Cobey's game plan is understanding how human bodies change in response to the virus. She says high-speed Darwinian evolution goes on inside everyone in response to changes in the flu population that people are exposed to. It's a complicated back-and-forth, happening at breakneck speed. About every eight hours the immune system makes new generations of cells tweaked to better attack invaders like the flu.

"Influenza is covered with these spikes, basically, on its surface," Cobey says. Those are proteins usually referred to as "H" and "N." The spikes allow the virus to attach to the host's cells and infect them, commandeering the cells to replicate. In response, the immune system produces antibodies that attach to the spikes on the surface of the virus, blocking it from entering cells. But influenza mutates so often that the spikes frequently change shape, sometimes in ways that prevent antibodies from attaching to them.

"This is how flu is constantly outrunning the immune system," Cobey says.

That's one of the reasons why Cobey doesn't expect we'll get rid of the flu anytime soon.

A universal vaccine that would protect people from all influenza strains is in the works, though nowhere near production.

"I'd say that we're not going to be getting rid of [the flu] anytime soon," Cobey says. But in the meantime, our immune systems are doing a pretty good job of keeping up. And, of course, vaccination gives the body a better chance at fighting off the seasonal scourge.

Whether it's a shot in the arm or a spray up the nostril, the vaccine gives the immune system a preview of what strains to expect.

Derek Smith at the University of Cambridge is one of the people who figures out what goes in the vaccine each year. He's an evolutionary biologist, a virologist and a mapmaker. Smith's lab studies how the strains of flu virus evolve — specifically, how the outer coat of proteins changes.

Researchers like Smith look at about 20,000 strains of flu from throat swabs of sick people in about 100 countries across the globe. Then they map how far the viruses floating around in this year's coughs and sneezes have strayed from last year's versions. They put all that information into tables.

"These tables are a little bit like the mileage chart that says how many miles it is between different cities," Smith says. They show how the pattern of proteins coating each virus cell has changed from year to year.

Twice a year virus experts get together, usually in Geneva. In February, they decide what will go in the vaccine for the Southern Hemisphere. In September, they decide what will go in the vaccine for the Northern Hemisphere. To do so, they whip out tables and maps like the ones Smith makes. If a virus has evolved so that human antibodies won't recognize it as well, "that's the moment when the strain of flu that's in the vaccine needs to be updated," says Smith.

The committee then comes out with a list of the four strains most likely to make people sick, and vaccine manufacturers get moving. In the U.S., they make about 200 million doses in a matter of months.

"And it's rarely the case that more than one of those strains will change," Smith says.

Here's the snag: Sometimes they do, if there's a mismatch for one of the strains like there was last year. But a person will typically still be protected from the other strains in the shot, which means the best first line of defense against flu is still the seasonal vaccine.

This year's vaccine is intended to protect against strains similar to the H1N1 strain behind the 2009 swine flu pandemic, viruses like an H3N2 strain first identified in Switzerland in 2013, and two other strains that have been circulating in humans for much longer.

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Many Americans Believe They Don't Need The Flu Vaccine

NPR Health Blog - Fri, 11/27/2015 - 5:03am

Flu season is in swing and likely won't let up until April.

It seemed like high time to check in on how Americans feel about flu vaccination, so we asked more than 3,000 adults in the latest NPR-Truven Health Analytics Health Poll, conducted during the first half of October.

All told, 62 percent of people said they had been vaccinated or intended to get vaccinated against flu.

Those who hadn't been immunized and don't plan on it cited a variety of reasons. The top factors include a belief that a flu shot (or spray) is unnecessary for them (48 percent of the group), concerns about side effects or risks (16 percent) and worries that the vaccine could infect them with the flu (14 percent). About 8 percent of the people who plan to skip vaccination said it's because they believe it's ineffective.

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Cost didn't seem to be a significant barrier. More than three-quarters of those who had received the flu vaccine said it cost them nothing out of pocket.

"Education didn't make much of a difference. Income was not a big differentiator. Age was really the biggest differentiator," Dr. Michael Taylor, Truven's chief medical officer, tells Shots.

Those over 65 years of age were the most likely to have been vaccinated this year.

Shots - Health News Worried About The Flu Shot? Let's Separate Fact From Fiction

Data from the National Center for Health Statistics show the proportion of vaccinated Americans has increased since 1997, with dips in 2000 and 2004 because of vaccine shortages. But many adults choose not to get it, a phenomenon supported by this poll.

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Taylor says it was surprising that so many "people surveyed don't understand what they need to know about the vaccine. I thought that was kind of amazing, frankly."

Seasonal flu-related complications result in about 200,000 hospitalizations in the U.S. each year. On average, about 25,000 people in the United States die from influenza each year.

"That's a large number of people. The vaccine is really the best way to prevent those infections," says Ryan Malosh, an epidemiologist at the University of Michigan School of Public Health. In a study of about 550 people, Malosh found that adults who received the vaccine reported these as the most important factors in their decision: recommendation from a health care provider (47 percent), living or working with high-risk individuals (44 percent) and wanting to lower their own risk of disease (90 percent).

Vaccination reduces transmission, because even if the flu doesn't make one person particularly ill, it's possible for him or her to pass it to someone who could experience much more severe symptoms. Vaccination also helps limit transmission through something called herd immunity.

Since 2010, the Centers for Disease Control and Prevention has recommended vaccination for everyone except people who are allergic to the vaccine or who are younger than 6 months old.

Shannon Stockley, an epidemiologist with the immunization services division of the CDC, says last year, 47 percent of Americans 6 months and older received the flu vaccine. Two-thirds of adults over 65 received it. One-third of adults ages 18 to 49 did.

She thinks some misconceptions about flu cloud people's views of the benefits of vaccination. "People tend to minimize it," Stockley says. "They think, 'Oh, it's like a cold.' But it's actually much more serious than that, and they don't realize how important the vaccine is to protect against that disease."

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The language we use is part of the problem. "We say 'I have the flu,' or 'I have the stomach flu.' We use that word to represent any sort of illness. But flu is very specific — it's an infection caused by the influenza virus."

Stockley says she's familiar with the argument that people don't need it or that it will make them sick. "Yes, we do hear both of those reasons frequently," she says.

Stockley says side effects of the vaccine, like soreness at the injection site or a minor fever, can lead people to assume it made them ill.

"But those are normal reactions from the vaccine and they typically go away within a day or two," says Stockley. In fact, a small fever can be evidence that the vaccine is actually working — an indication that the body has built up antibodies so that if the actual flu virus comes around, the immune system is ready. "It's your body mounting the immune response," says Stockley.

"The virus that is included in the vaccine is either killed or weakened, so you just cannot get the flu from the flu vaccine," says Stockley. "I don't think they appreciate how serious influenza disease can be."

The Spanish flu of 1918 killed more people than World War I did, and the virus was most deadly for people ages 20 to 40.

But even with today's resources, the seasonal flu can be problematic. Stockley points to a study from 2012 showing that flu vaccination reduced children's risk of pediatric intensive care unit admission by 74 percent. Another study found that flu vaccination was associated with a 71 percent reduction in flu-related hospitalizations among adults of all ages.

Flu can exacerbate chronic conditions like asthma and heart disease. One of the strains last year was particularly virulent. Stockley says it led to the deaths of 145 children, "one of the highest levels we've seen in a long time," and caused hospitalizations for people 65 years and over to be the highest since 2005.

It takes about two weeks after vaccination for the protection to set in. This year's flu vaccine is expected to be more effective than last year's at fending off prevalent flu strains.

The NPR-Truven Health Analytics Health Poll was conducted in October with 3,008 participants. The margin for error is plus or minus 1.8 percentage points. You can find the questions and full results of the latest poll here. For previous polls, click here.

Copyright 2015 NPR. To see more, visit
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Your Adult Siblings May Hold The Secret To A Long, Happy Life

NPR Health Blog - Thu, 11/26/2015 - 8:19am
Katherine Streeter for NPR

Somehow we're squeezing 16 people into our apartment for Thanksgiving this year, with relatives ranging in age from my 30-year-old nephew to my 90-year-old mother. I love them all, but in a way the one I know best is the middle-aged man across the table whose blue eyes look just like mine: my younger brother Paul.

Paul and I kind of irritated each other when we were kids; I would take bites out of his precisely made sandwiches in just the spot I knew he didn't want me to, and he would hang around the living room telling jokes when he knew I wanted to be alone with the boy on the couch.

But as adults, we've always had each other's backs, especially when it comes to dealing with our mother's health crises, which have become more frequent in the past few years. Paul is the first person I want to talk to when there's something that worries me about Mom; I know he'll be worried, too.

There's probably a biological explanation for the intensity of the sibling bond. Siblings share half their genes, which evolutionary biologists say should be motivation enough for mutual devotion. ("I would lay down my life," British biologist J.B.S. Haldane once said, applying the arithmetic of kin selection, "for two brothers or eight cousins.") Siblings are a crucial part of a child's development, too, teaching one another socialization skills and the rules of dominance and hierarchy, all part of the eternal struggle for parental resources.

When psychologists study siblings, they usually study children, emphasizing sibling rivalry and the fact that brothers and sisters refine their social maneuvering skills on one another. The adult sibling relationship has only sporadically been the subject of attention. Yet we're tethered to our brothers and sisters as adults far longer than we are as children; our sibling relationships, in fact, are the longest-lasting family ties we have.

Most such relationships are close — two-thirds of people in one large study said a brother or sister was one of their best friends. One thing that can scuttle closeness in adulthood is a parent who played favorites in childhood; this sense of resentment can last a lifetime.

Jill Suitor, a sociologist at Purdue University, and her colleagues polled 274 families with 708 adult children (ages 23 to 68) in 2009 and found that the majority had good feelings toward their siblings. Most didn't remember much favoritism when they were kids, but those who did reported feeling less loved and cared for by their siblings. It didn't matter whether they felt themselves to be the favored or the unfavored child. The simple perception of parental favoritism was enough to undermine their relationship.

That's one thing Paul and I have going for us: We're pretty sure our parents treated us the same when we were growing up. Yet we're very different people. Paul is gregarious while I'm shy, funny while I'm not, a terrific amateur saxophonist while I can't read music or carry a tune. This isn't unusual. In families with more than one child, every sibling seems to get a label in contrast to every other sibling.

So if your kid sister is the queen bee in any social gathering, you might get labeled "the quiet one" even if you're not especially quiet, just quiet in comparison. And if you're a bright child who always gets good grades, you might not get much credit for that if your big brother is a brilliant child with straight A's. There's only room for one "smart one" per family — you'll have to come up with something else. (I was smart, but Paul was smarter; I ended up being the "good one.")

The very presence of siblings in the household can be an education. When a new baby is born, writes psychologist Victor Cicirelli in the 1995 book Sibling Relationships Across the Life Span, "the older sibling gains in social skills in interacting with the younger" and "the younger sibling gains cognitively by imitating the older."

They learn from the friction between them, too, as they fight for their parents' attention. Mild conflict between brothers and sisters teaches them how to interact with peers, co-workers and friends for the rest of their lives.

The benefits can carry into old age. The literature on sibling relationships shows that during middle age and old age, indicators of well-being — mood, health, morale, stress, depression, loneliness, life satisfaction — are tied to how you feel about your brothers and sisters.

In one Swedish study, satisfaction with sibling contact in one's 80s was closely correlated with health and positive mood — more so than was satisfaction with friendships or relationships with adult children. And loneliness was eased for older people in a supportive relationship with their siblings, no matter whether they gave or got support.

That's why it's so sad when things between siblings fall apart. This often happens when aging parents need care or die — old feelings of rivalry, jealousy and grief erupt all over again, masked as petty fights ostensibly over who takes Mom to the doctor or who calls the nursing home about Dad.

Many families get through their parents' illnesses just fine, establishing networks where the workload is divided pretty much equally. So far, Paul and I have done fine, too. But about 40 percent of the time, according to one study, there is a single primary caregiver who feels like she (and it's almost always a she) is not getting any help from her brothers and sisters, which can lead to serious conflict.

And because of the particular intensity of sibling relationships, such conflict cuts to the bone. People grieve for the frayed ties to their siblings as though they've lost a piece of themselves.

Throughout adulthood, the sibling relationship "is powerful and never static," said Jane Mersky Leder, author of the new e-book The Sibling Connection. Whether we are close to our siblings or distant, she writes, they remain our brothers and sisters — for better or for worse.

So let this all percolate as you sit down to turkey with your sometimes-complicated family. And remember the immortal words of folksinger Loudon Wainwright III, in a song called Thanksgiving. It's about spending the holiday with a brother and a sister he rarely sees but still has intense feelings about:

"On this auspicious occasion, this special family dinner/If I argue with a loved one, Lord, please make me the winner."

Science writer Robin Marantz Henig is a contributing writer for The New York Times Magazine and the author of nine books. A version of this article was published on Nov. 27, 2014.

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Many Health Co-Ops Fold, Others Survive Startup Struggles

NPR Health Blog - Thu, 11/26/2015 - 4:41am
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Rick and Letha Heitman, of Centennial, Colo., bought their health plan in 2015 through Colorado HealthOP, an insurance cooperative that will close at the end of the year. HealthOp's CEO says the co-op was "blindsided" when some promised federal subsidies failed to materialize.

John Daley/CPR News

Thousands of Americans are again searching for health insurance after losing it for 2016. That's partly because some large, low-cost insurers — health cooperatives, set up under the Affordable Care Act — are folding in a dozen states.

The startups were supposed to shake up the traditional marketplace by being member-owned and nonprofit. But it was tough to figure out how much to charge. Plans available through the co-ops tended to be priced low, and customers poured in.

Yet many of these new customers, it turned out, had costly medical conditions, so when co-ops had to start paying their bills, the math didn't add up.

Shots - Health News Small Health Insurance Co-Ops Seeing Early Success

On top of that, co-ops were counting on a variety of funding streams from the federal government, and some of that money never materialized. Of the 23 health co-ops that opened in 22 states with the advent of Obamacare, just 11 are still in business.

The failure of one of these insurers, Colorado HealthOp, has hit Rick and Letha Heitman hard. The couple says that Colorado HealthOp, which is due to close at the end of the year, saved Rick's life when he was diagnosed with an aggressive prostate cancer last spring.

"I owe them for taking care of me," says Rick, who owns a construction business with his wife. "They helped me at a time when I needed it a lot."

Now, about 80,000 people, including the Heitmans, are suddenly on the hunt for new insurance plans on Colorado's exchange.

Co-ops Left Holding The Bag

Julia Hutchins, HealthOP's CEO, says the co-op got walloped by the equivalent of a fast-moving tornado after the federal government said it wouldn't be paying co-ops millions in subsidies that she and others expected.

"We were really blindsided by that," Hutchins says. "We felt like we'd done our part in helping serve individuals who really need insurance, and now we're the one left holding the bag." HealthOp was on track to becoming profitable, she insists.

Linda Gorman, director of the Independence Institute, an advocacy group and think tank in Colorado, says the new co-ops were in over their heads.

"You shouldn't go into business counting on federal subsidies," Gorman says. "The notion that you should beat up on for-profit entities and then form these nonprofits and everything will be magically OK is unfortunate to begin with, and we've wasted a lot of taxpayer money on that. We've wasted two to three billion dollars on subsidies for these co-ops."

But the HealthOP's senior IT manager Helen Hadji, a Republican, says she blames conservatives in Congress for not authorizing the money needed to keep the cooperatives afloat.

"This is a federal failure," Hadji says. "This is all a political battle to dismantle Obamacare."

Colorado's co-op captured 40 percent of the individual market on the state's exchange. Now, as customers like Rick and Letha Heitman hunt for new insurance for 2016, they are facing higher prices.

The Heitmans paid about $500 a month last year for their co-op plan. For 2016 they'll likely have to pay double or triple that to get health insurance that includes the doctors who are treating Rick's cancer.

Slower Growth Was Key To A Connecticut Co-Op's Success

In Connecticut, a different story is playing out. If Colorado saw an early surge in membership because of low prices, Connecticut's co-op nearly priced itself out of the market in its first year, charging rates that were much higher than its competitors. For 2015, HealthyCT only got 3 percent of the state's business under the Affordable Care Act.

"In that first year, the reason we had such low market share was that consumers — new to the industry, new to insurance — most of those individuals bought on price," says Ken Lalime, who runs the co-op.

And starting the business was hard, Lalime says.

"Nobody's built a new insurance company in the state of Connecticut in 30 years," he says. "There's no book that you pull off the shelf and say, 'Let's go do this.' "

Lalime faced the same problem other co-ops faced nationally. He didn't know who his customers would be, didn't know whether they'd be sick or healthy and didn't know how much to charge. In the end, his co-op charged too much.

However, even though that meant relatively few sign-ups in year one, the slow start actually helped. The co-op didn't have a huge number of claims to pay immediately, and those that it did pay didn't break the bank.

"Hindsight, yes, that didn't hurt us — to be able to take it slowly," Lalime says.

In year two, HealthyCT's average premiums were more competitive — and the co-op went from a 3 percent share of the market to 18 percent. For 2016, its initial premium request came in high; it subsequently revised that number to be much lower, and the state overseers eventually announced that HealthyCT's premiums will go up 7 percent.

Paul Lombardo, an actuary for the state of Connecticut, says the back-and-forth is an indicator that setting the price of premiums is still a bit of a gamble under the Affordable Care Act. These are still early days, he says. So few people signed up with HealthyCT in the beginning that the health co-op didn't have enough information to guide its decisions about 2016 premiums.

"There wasn't a lot of data to say, OK, we can use 2014 experience to project forward," Lombardo explains.

For now, HealthyCT is holding its own.

"They're in good standing," Lombardo says. "The premium we think that we're setting for 2016 — albeit a little bit higher than they wanted it to be on the revision — is appropriate. And we look to have them go through the full year — as any of our other health plans do in 2016."

Enrollment for 2016 health insurance on the Affordable Care Act's exchanges will continue until Jan. 31.

This story is part of NPR's reporting partnership with Colorado Public Radio, WNPR and Kaiser Health News.

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Deaths Persist In Youth And Student Football Despite Safety Efforts

NPR Health Blog - Wed, 11/25/2015 - 4:10pm
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We know more than ever about concussions, the permanent brain damage of chronic traumatic encephalopathy and the other physical risks of football.

Yet so far this year, at least 19 students have died playing football, according to the University of North Carolina's National Center for Catastrophic Sport Injury Research.

Cam'ron Matthews played safety on the Alto, Texas, varsity football team. The 16-year-old died after a game in October.

Laurie Gould Photography

Though participation is slowly declining, football is still the country's most popular high school sport. Over a million high schoolers played last season.

Researchers at UNC have been tracking football-related deaths since the 1960s. Director Kristen Kucera describes two main tallies: deaths caused directly by football, like a broken spine or brain trauma, and those that are indirect like heat stroke or sudden cardiac arrest that occurred during a game or practice.

The good news is that there are fewer fatalities than there used to be. Back in the 1960s, around 30 or 40 players died each year. Then came a steep decline thanks to new safety measures: a standardized helmet that must be certified for use in a game; a rule banning headfirst tackling; and improvements in athletic medical care.

But instead of dropping to nil, the number of football-related fatalities leveled off in the 1990s. Since then, a persistent average of about four or five football players have died each year as a direct result of playing their sport, along with an average of 10 or so indirect fatalities.

When asked why the numbers have leveled off instead of reaching zero, Kucera hesitates. "That's a great question," she says. "That's what we're working really hard to figure out."

One player who died this year was Cam'ron Matthews, a 16-year-old from Alto, Texas.

On a Friday night in November, one month after Matthews died, the Alto Yellowjackets bounded out of their black-and-yellow inflated tent through an artificial cloud of mist and onto the field. There was no trace of sadness. They were focused on winning.

Alto is a small town of about 1,200, and on Friday nights it feels like everyone comes to watch the boys play. Some parents like Misty Collins get there early to stake out a spot on the metal bleachers. Collins was there Oct. 16, when Matthews told the coach he felt dizzy, then collapsed on the sideline.

"We just all prayed," she remembered. "We prayed that he was going to be OK, but the good Lord took an angel that was down here on Earth."

That's how people who knew Matthews talk about him. The 6-foot safety was one of the team's captains. He was the only junior elected.

"He's our number one, that was his jersey number," Collins said. "He was an awesome student, and very polite, and anything that came out of his mouth was 'Yes, ma'am' and 'No, ma'am.' He was an awesome guy."

After he collapsed, medics took Matthews to a hospital in East Texas, where he died the next day.

Doctors told the family he likely died from a burst brain aneurysm, though they're still waiting for an autopsy to confirm that.

A fatal aneurysm could be related to football or other vigorous activity, according to Robert Cantu, a neurosurgeon in Concord, Mass., who specializes in football injuries. That activity could cause an aneurysm, which is a weak area in the wall of an artery, to burst, which in turn could cause dizziness, collapse and death. Aneurysms can run in families, but are "very uncommon" in 16-year-olds, Cantu says.

Matthews' friend and teammate Keenan Johnson said it's been hard to get back in the groove. But instead of falling apart, he says, the team has pulled together.

The Alto Yellowjackets take the field on Nov. 13, a month after Matthews died.

Lauren Silverman/NPR

"It hurts that he's not here," Johnson says. "He's one of my closest friends, and we worked out all summer. But we dedicate it to him. We're trying to win the state championship for him, be number one for him."

In the playoff game in November, the Yellowjackets faced a longtime rival – the Groveton Indians. And Matthews was on the sidelines, in a way. His number 1 jersey was perched on a wooden hanger. His sister Paige sat in the bleachers at the 50-yard line. The team won 63 to 14.

Parents rushed onto the field to thank head coach Paul Gould. Gould says he's proud of how the players are handling their teammate's death.

"I think they're doing probably about as good as possible, but this is something they're going to deal with for the rest of their lives," he says.

Gould knows parents are concerned about injuries associated with football, especially concussions. This year the governing body for high school sports in Texas says it will start counting concussions for the first time.

This month, the American Academy of Pediatrics made new recommendations about safety and urged players to consider "whether the benefits of playing outweigh the risks of possible injury." The AAP is urging the expansion of non-tackle leagues like flag football and calling for athletic trainers to be present during practices and games. Only 37 percent of high school nationwide have a full time athletic trainer on staff.

Two University of Minnesota professors have gone even further, calling for the elimination of tackle football programs from public schools altogether.

"Everybody wants their kids to be safe. Everybody wants their kids to be OK, and I understand that," Gould says. "We try to make sure we coach kids to hit the correct way. You try to make your kids as safe as possible, because that's our job."

After Matthews died, Gould says not a single parent pulled their kid from the team. He hopes what happened doesn't fuel negative ideas about the game.

"I can say this: What football teaches kids for the rest of their life, in my opinion, is priceless," Gould says. "I mean, it teaches you to deal with things. This situation is definitely teaching our kids to deal with things as they move forward."

Mississippi defensive back Roy Lee "Chucky" Mullins tackled Vanderbilt fullback Brad Gaines on Oct. 28, 1989. The tackle paralyzed Mullins from the neck down. He died two years later.

Bruce Newman/AP

But players who have been involved in a fatal play say the experience will haunt them forever.

Back in 1989, Brad Gaines was a star running back at Vanderbilt University. Then came October 28, a date Gaines will never forget. It was a must-win game at Ole Miss in Oxford.

Vanderbilt received the opening kickoff and drove down the field. On third and goal at the 12-yard line, Gaines and the Commodores lined up for a play designed to pass the ball to Gaines.

The ball snapped and his quarterback threw the pass. An Ole Miss linebacker was close on Gaines's tail.

"As soon as the ball reaches me, reaches my hands ... bang!" Gaines remembers. "Just a fantastic hit from the back, and breaks up the pass, and [the linebacker] just makes a great play."

Gaines headed back to the sideline, then noticed the linebacker hadn't yet gotten back up. At first, Gaines thought this was another of football's routine injuries. A sprained ankle, maybe. But five minutes went by. Ten minutes. The linebacker was still lying on the field, surrounded by trainers and medical staff. Maybe a broken arm, Gaines thought.

Finally Gaines realized it was something more serious when a helicopter ambulance arrived to take the linebacker to Memphis, about 70 miles away.

Later he learned the linebacker's name — Chucky Mullins — and his injury: Mullins had broken his spine and could not move any of his limbs.

"I had the doctor tell me sometime later that when they got him stabilized, when they got him into surgery... his neck looked as if you dropped a grenade down his shirt."

Gaines was horrified.

"The only thing I knew was you strapped up your cleats before practice, you went out and played and it was fun. I didn't know that there was this other part to this game," says Gaines, now 48 and living in Nashville, where he works in health care.

"In an instant, he goes from being a world-class athlete in the best conference in America, and now he's laying on his back, and he'll never move again. He will not be able to brush his teeth. He will not be able to wash his hair. He will never be able to feed himself. And I just felt like I was the cause of that."

Against the advice of his coach and a psychologist, Gaines decided to visit Mullins in the hospital. He was scared to death, petrified, he says, and not prepared for what he saw when he walked in: a much skinnier Mullins, with "cords, tubes, things hanging out of him."

Mullins's guardian was there, and told Gaines that Mullins had something he wanted to tell him.

Gaines leaned over to hear Mullins whisper through his tracheal tube: "It's not your fault."

"And oh my goodness," Gaines remembers. "It's tough saying it now, but I tell you, it was a total selfless act on his part. I don't know if I could have done that."

Gaines and Mullins remained friends for the following year and half, until Mullins died of complications in 1991. Every year still, he drives to Mullins's grave on October 28, the anniversary of the game, and on Christmas.

Today, Gaines regularly receives phone calls from players like him — players, often teenagers, who make a routine play or tackle that ends with an opponent's death. Gaines is one of few people they can turn to who actually understands what they're going through, and he's happy to help.

"What I learned from Chucky Mullins was that selfless nature. It's not about me. It's not about Brad Gaines. I can help people. So if somebody calls me and asks me that's going through something like this, or needs some advice, or counsel, then that's my duty."

Gaines thinks the game is safer today, thanks to things like better concussion protocol and the new kickoff positions that mean fewer kickoff returns. But he still calls himself a football purist. He says he couldn't tell his 11-year-old son not to play football.

"I know that it's not the game's fault. I know that. And I know that there are going to be injuries," Gaines says. "But when you love the game, you accept that. You accept that there could be consequences like this."

Lauren Silverman reports for NPR member station KERA in Dallas.

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To Reduce Infant Deaths, Doctors Call For A Ban Of Crib Bumpers

NPR Health Blog - Wed, 11/25/2015 - 12:37pm

Babies have suffocated after being trapped in padded crib bumpers, according to the Consumer Product Safety Commission.


Flip through a popular children's furniture catalog and you'll find baby cribs with bumpers — a padded piece of fabric that ties around the wooden slats, making the crib look cozy and cute. The problem, researchers say, is these bumpers can be deadly, because babies can get caught in the fabric and suffocate.

"They are dangerous; don't use them," says Dr. Bradley Thach, a professor emeritus of pediatrics at the Washington University School of Medicine. Thach was the author of a landmark study in 2007 that first documented crib bumper deaths. He says things have gotten worse since then.

Thach is one of the authors of a study, published Wednesday in The Journal of Pediatrics, that shows the number of deaths attributed to crib bumpers has increased significantly in recent years.

Using data reported to the Consumer Product Safety Commission, an independent federal regulatory agency that oversees consumer products, the study found that 23 babies died over a seven-year span between 2006 and 2012 from suffocation attributed to a crib bumper. That's three times higher than the average number of deaths in the three previous seven-year time spans. In total 48 babies' deaths were attributed to crib bumpers between 1985 and 2012. An additional 146 infants sustained injuries from the bumpers, including choking on the bumper ties or nearly suffocating.

"These deaths are entirely preventable," says N.J. Scheers, the study's lead author and former manager of the CPSC's infant suffocation project. Babies either got their face caught in the bumper and couldn't breathe or they got wedged between the bumper and something else in the crib. In all of these instances, Scheers says, "If there were no bumper, the baby would not have died."

Bumpers were originally intended to stop babies from falling out of the crib; regulations now require the wooden slats to be narrower. Bumpers were also designed to prevent babies from bumping their heads or getting their arms and legs caught in the rails. But Scheers says a sleeping sack is a safer way to keep arms and legs safe, and a little bump on the head is not worth the risk of suffocation.

The American Academy of Pediatrics and the American SIDS Institute have both issued warnings about crib bumpers; they advise parents not to use them. But Scheers says when parents go to buy a crib, they see them decorated with bumpers and say, "if they are dangerous, why would the stores be selling them?"

The safest choice is a crib with no bumpers, pillows or quilts, according to the CPSC.


In 2012, a voluntary industry standard was revised to decrease the thickness of the bumpers to 2 inches or less, with the hope that thinner bumpers would be less likely to cause suffocation. But this most recent study found that three deaths occurred with the thinner bumpers.

In 2011, Chicago became the first city in the country to ban the sale of crib bumpers. And in 2013, Maryland also banned the sale of crib bumpers with two exceptions: mesh or breathable bumpers made of thin fabric that allow air to pass through, and vertical bumpers that wrap around each individual crib rail. Scheers wants a similar ban nationwide, with the caution that mesh and vertical bumpers still need to be studied because there's no data available to prove they are safe.

The CPSC is currently in the process of putting forward a recommendation on how crib bumpers should be regulated. In the meantime, it recommends that "Bare is Best" — the safest way for a baby to sleep is in a crib with nothing but a tightly fitted sheet.

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Premiums Rise Faster For Flexible Health Plans Than For HMOs

NPR Health Blog - Wed, 11/25/2015 - 9:48am
Karen Stolper/Photolibrary RM/Getty Images

Consumers seeking health policies with the most freedom in choosing doctors and hospitals are finding far fewer of those plans on the insurance marketplaces. And the premiums are rising faster than for other types of coverage.

The plans, usually known as preferred provider organizations or PPOs, pay for a portion of the costs of out-of-network hospitals and physicians. They are the most common type offered by employers, and some consumers in the individual marketplaces find them more appealing than health maintenance organizations and other policies that pay only for medical facilities and doctors with whom they have contracts.

In Kelly Filson's Indiana hometown of Plymouth, all but two of the 75 insurance policies available on the health marketplace for 2016 are the restrictive type. Only one of those would provide substantial coverage to the two hospitals her family wants access to next year, a local community facility and a children's hospital where her 12-year-old will need special surgery. But at $1,109 a month, the policy is twice as costly as the cheapest plans in the area.

"I'm just trying to figure out what we can feasibly afford. That's the bottom line," said Filson, a music teacher.

A Kaiser Health News analysis of costs in the three-dozen states selling policies through the federal website found a sharp difference in premium prices between plans that offer out-of-network care and those that don't.

The analysis compared the monthly premiums for the least expensive silver-level plans — the category that are the most popular purchases — for a 40-year-old in each county.

While the average premium for the least expensive closed-network silver plan — principally HMOs — rose from $274 to $299, a 9 percent increase, while the average premium for the least expensive PPO or other silver-level open access plan grew from $291 to $339, a 17 percent jump, KHN found. The cost variations hold true for any age.

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Katherine Hempstead, who studies health insurance for the Robert Wood Johnson Foundation, said there are fewer PPOs because insurers found them more expensive to offer: Out-of-network doctors generally charge more than the contracted rates paid to in-network providers by insurers. And, even though insurers pay only a portion of an out-of-network bill, the costs add up.

"Out-of-network providers were causing carriers to lose a lot of money, and they really needed to put their thumbs down on that," Hempstead said.

Hempstead found that there will be fewer or no silver-level PPOs in 22 states next year. Federal records show there will be none in Miami and most Florida counties, much of Texas, New Mexico, New York and many counties in Mississippi and South Carolina.

The price gap between PPOs and HMOs is growing in many places where both are offered. In Chicago, the least expensive silver PPO next year will cost $270 a month, $75 more than the least expensive silver HMO, and 27 percent more than the cheapest silver plan costs now. Meanwhile, the price of the least expensive silver HMO in Chicago is dropping by 12 percent.

In Salt Lake City, the premium for the only silver PPO is rising by 30 percent, nearly four times the increase for the least expensive HMO.

In Philadelphia, the cheapest silver PPO will be $389, $113 more than the cheapest HMO. This year, Philadelphians wanting a silver open-access plan had to pay just $66 more. As in many places, insurers also are selling different bronze, gold and platinum PPOs (the metals indicate how the insurer and patient divide the cost of care), but the cheapest plan in each tier in Philadelphia is an HMO.

In Houston, the only plans available through the federal exchange have closed networks. Blue Cross Blue Shield of Texas, which offered a PPO plan in Houston for 2015, cited rising costs as a reason it will not offer any open-access plans next year. There is at least one PPO that consumers can purchase directly or through a broker, offered by the Memorial Hermann Health System. But it isn't listed in the federal marketplace offerings, so premium subsidies aren't available.

"Everyone is up in arms," said Jo Middleton, a Houston insurance broker. "I do not have a single client who is happy. They want PPOs and can't get them. They want the flexibility."

The biggest complaint, she said, is not that the HMOs don't allow out-of-network coverage, but that their networks are too small.

"If you are someone who needs several doctors and several specialists, it's difficult to find a network they are all in," Middleton said. "In many cases, the doctors may be in a network but only have admitting privileges at a non-network hospital. In the 11 years I've been in the business, this is unprecedented."

None of the plans available through the federal exchange in Houston include the city's well-known MD Anderson Cancer Center in their networks. "It's a huge problem," said insurance broker J. Casey Lowery. "If you're a cancer patient, think about it. All of a sudden you have to switch doctors. Or, if you want to stay with a doctor because he saved your life, and now you're in an HMO, you have no coverage."

Dan Fontaine, an administrator at MD Anderson, said some insurers didn't invite the cancer center into their networks. Others offered payment rates that, he said, "we don't consider serious" because they were too low "and oftentimes less than what Medicare or Medicaid pay us." He said the center was trying to make arrangements with insurers for patients who are in treatment now.

Plans with out-of-network benefits are not disappearing everywhere. Alaska, Arkansas and Wyoming are bucking the trend by only offering PPOs. Out-of-network costs even with PPOs can be prohibitively expensive because many PPOs will cover only a minority of costs, diminishing the difference from HMOs. Also, people who qualify for government premium subsidies can be insulated from the full cost of a PPO.

Allen Gjersvig, an executive at the Arizona Alliance for Community Health Centers, says one PPO in the state requires approval before seeing a specialist — a restriction often associated with HMOs — while there are HMOs that don't mandate pre-approval of specialist visits. "The meaningfulness of HMO and PPO is starting to really blur," he said.

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente.

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A Controversial Rewrite For Rules To Protect Humans In Experiments

NPR Health Blog - Wed, 11/25/2015 - 4:08am
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Throughout history, atrocities have been committed in the name of medical research.

Nazi doctors experimented on concentration camp prisoners. American doctors let poor black men with syphilis go untreated in the Tuskegee study. The list goes on.

To protect people participating in medical research, the federal government decades ago put in place strict rules on the conduct of human experiments.

Now the Department of Health and Human Services is proposing a major revision of these regulations, known collectively as the Common Rule. It's the first change proposed in nearly a quarter-century.

"We're in a very, very different world than when these regulations were first written," says Dr. Jerry Menikoff, who heads the HHS Office of Human Research Protections. "The goal is to modernize the rules to make sure terrible things don't happen."

Many of the revisions are long overdue and would significantly improve oversight of scientific research, say researchers, bioethicists and officials who oversee human research studies.

But many of the updates are also triggering intense debate and criticism.

The new rules are too complex and too vaguely written in many places, says Elisa Hurley, executive director of Public Responsibility in Medicine and Research, a nonprofit organization in Boston. As such, she says, they could cause confusion for volunteers and researchers. It's a "flawed attempt" to improve things, Hurley says.

After hearing such criticism and receiving numerous requests to give the public more time to study the proposed revisions, the HHS office announced Tuesday that it was extending the public comment period by 30 days — to Jan. 6.

One change that some object to would require scientists to obtain explicit consent from patients before using their blood or tissue for research. The requirement aims to prevent a repeat of what happened to Henrietta Lacks. She was an African-American woman who died of cervical cancer in 1951. Cells taken from her cervix were used without her consent to produce a research cell line that has been kept alive in labs around the world ever since.

A color-enhanced scanning electron micrograph shows HeLa cells, which are commonly used in biomedical experiments. The research cell line was derived from cervical cancer cells taken from Henrietta Lacks in 1951.

Science Source

Researchers and companies use these cells in a wide range of research, including the development of new drugs. Neither Lacks nor her family consented to this use.

Under the new rules, scientists would only be able to do research on biological specimens from people who explicitly agree to it: " 'I'm OK with that. I'm OK with future research studies taking place using the leftover portions of my tumor or blood,' " Menikoff says.

But some scientists argue that in most cases the new requirement would create unnecessary red tape that would significantly impede important research.

"It's now going to be much more onerous to get this tissue that otherwise would just go in the trash," says Dr. Luis Garza, a Johns Hopkins University dermatologist who uses foreskin from circumcisions for a variety of experiments. "It's creating barriers for working on human tissue, which is what we need to do to solve human disease."

Another revision would expand the number of studies that would have to follow the rules. All scientists who get federal funding would be required to adhere to the rules for every experiment they conduct, even those that aren't funded directly by the government.

Other changes are designed to make some research easier, such as conducting large studies involving multiple institutions. Right now, independent panels known as institutional review boards, or IRBs, oversee studies in each location where people volunteer. Under the proposed rules, one centralized IRB could run an entire multicenter study.

"It is all one study," HHS' Menikoff says. "So basically the same ethical rules apply to all of the subjects in the study."

He says the issues raised by any given study are pretty much the same at one study site compared to another site, so that duplicate ethical reviews can be eliminated. He and other researchers say the proposed change would help get new cures to patients more quickly.

But some advocates and bioethicists worry that streamlining study reviews in this way would undermine protections for volunteers, especially studies involving many sites, says Dr. Michael Carome, who heads Public Citizen's Health Research Group, a Washington, D.C.-based advocacy group.

It's unlikely one IRB can "adequately understand the local context, local ethical issues, the quality of the facilities and the credentials of the practitioners," he says. "That one IRB is unlikely to have sufficient knowledge of all those sites."

The proposal would also exempt many studies that don't pose physical risks. Examples include projects that only involve asking subjects questions and answers — things like surveys and in-depth interviews. The idea is to get rid of unnecessary bureaucratic hoops for harmless research, Menikoff says.

But this change is raising fears, too.

"I think that's a major step backwards that, as far as I'm concerned, takes us back into the dark ages," says Ruth Macklin, a bioethicist at the Albert Einstein College of Medicine in New York.

Those kinds of studies "are not physically invasive, but they may be intrusive," Macklin says. "There are forms of harm that are not just physical harm."

Probing people about sensitive subjects, such as whether they've had an abortion or have been physically or sexually abused as children, can trigger strong emotional reactions, potentially causing psychological distress, Macklin says.

Menikoff disputes whether the changes would put anyone at risk. But he says the government will consider all the feedback it gets before changing the rules.

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Worried About The Flu Shot? Let's Separate Fact From Fiction

NPR Health Blog - Tue, 11/24/2015 - 1:57pm

A nurse prepares an injection of the influenza vaccine at Massachusetts General Hospital in Boston in 2013.

Brian Snyder/Reuters/Landov

Every year before influenza itself arrives to circulate, misinformation and misconceptions about the flu vaccine begin circulating. Some of these contain a grain of truth but end up distorted, like a whispered secret in the Telephone game.

But if you're looking for an excuse not to get the flu vaccine, last year's numbers of its effectiveness would seem a convincing argument on their own. By all measures, last season's flu vaccine flopped, clocking in at about 23 percent effectiveness in preventing lab-confirmed influenza infections.

But that's not the whole story, said Lisa Grohskopf, a medical officer in the influenza division of the Centers for Disease Control and Prevention.

"Twenty-three is better than zero, but the 23 percent was overall. If you were one of the people who got an influenza B strain, it was closer to 60 percent," she said. "Even if it's not going to work against one virus very well, there are other viruses circulating."

Each year's flu vaccine contains three (trivalent) or four (quadrivalent) strains of the flu, selected in February by the World Health Organization and then endorsed by the Food and Drug Administration, as the ones experts expect will circulate in the coming flu season. They choose one H1N1 strain, one H3N2 strain and one B virus strain, either from the Yamagata lineage or the Victoria lineage. Quadrivalent vaccines contain a B strain from each lineage.

"Viruses in the Yamagata lineage or in the Victoria lineage are different enough that there's not a lot of cross-protection," Grohskopf said. "So if, say, we have a vaccine that contains a Yamagata family virus one season and it ends up being a predominantly Victoria season, we might not get very good protection against B strains."

But sometimes the experts' predictions are off the mark, and sometimes a strain they select mutates before the season arrives. Last year, the H3N2 strain they chose was a poor match, and that strain dominated the season, though B viruses became more common toward the end, Grohskopf said. Adjustments were made in the vaccine for the H3N2 virus this year.

"There's definitely reason to be hopeful that it's going to be better this year, but it's a little too early to tell," Grohskopf said. "Flu seasons can be very variable in terms of how fast they take off, but right now activity is still fairly light."

The flu vaccine options this year haven't changed much from last year, with two exceptions. The recombinant flu vaccine, made without the virus and without eggs, is now approved for all adults age 18 and older (instead of just those ages 18 to 49). And the intradermal vaccine, a low-dose vaccine that uses a shorter needle and injects only into the skin, is now available as a quadrivalent vaccine instead of just trivalent.

The CDC does not recommend any one vaccine over another. "We really just think it's important that people get vaccinated, and depending on where you are, you may not be able to get a particular product," Grohskopf said. "We don't want to hunt for one thing and then not get vaccinated until it's too late and flu is already peaking for the season."

Getting vaccinated against flu is particularly important for several at-risk groups and people in frequent, close contact with those at-risk groups, Grohskopf said. The populations at the highest risk of serious complications from the flu include pregnant women, people age 50 and older and children under age 5, particularly under age 2, she said.

Anyone with a chronic medical condition, such as lung disease, heart disease, kidney disease, liver disease or a neurological condition also has a higher risk of serious complications with an influenza infection. Those at risk of infecting more vulnerable people include parents of young children, day care workers, teachers, caretakers of elderly individuals and anyone working in health care.

But the problem with limiting flu immunization to these groups, she said, is that the flu is a tricky bug — and unpredictable.

"While some people are definitely at higher risk for severe disease if they get the flu, sometimes even generally healthy, young people — older children, younger adults who are the most hardy folks if they don't have any other chronic illnesses — can get really sick, hospitalized and even die, and we can't really predict who those folks are going to be," Grohskopf said. "The majority of people who get the flu are going to feel really crummy for a time and then recover without any problems." But even those folks lose work time and risk spreading the disease to family members and others, she said.

Another monkey wrench this year is additional evidence, reported at Stat, that getting a flu shot every year might reduce its effectiveness in warding off the flu. This evidence isn't entirely new, and scientists still don't entirely understand it, but it also doesn't mean that skipping the flu shot this year is wise if you got it last year.

In the meantime, for those who still haven't gotten the vaccine this year, make sure it's not because of one of the concerns below. As described in the links, each of these misconceptions is based on inaccurate information, a misunderstanding or an exaggeration.

Concern No. 1: Can getting the flu vaccine give you the flu or make you sick?

Fact: The flu shot can't give you the flu

Concern No. 2: Do I really need to get the flu vaccine this year if I got it last year?

Fact: For now, a new flu shot each year is still recommended

Concern No. 3: Could getting the flu vaccine make it easier for me to catch viruses, pneumonia or other infectious diseases?

Fact: Flu vaccines reduce the risk of pneumonia and other illnesses

Concern No. 4: Isn't the flu shot just a "one size fits all" approach that doesn't make sense for everyone?

Fact: You have many flu vaccine options, including egg-free, virus-free, preservative-free, low-dose, high-dose and no-needle choices

Concern No. 5: Can the flu shot cause death?

Fact: There have been no confirmed deaths from the flu shot

Concern No. 6: Aren't deaths from the flu exaggerated?

Fact: Deaths from influenza range from the lower thousands to tens of thousands each U.S. flu season

Concern No. 7: Aren't the side effects of the flu shot worse than the flu?

Fact: Influenza is nearly always far worse than flu vaccine side effects

Concern No. 8: Don't flu vaccines contain dangerous ingredients such as mercury, formaldehyde and antifreeze?

Fact: Flu shot ingredients do not pose a risk to most people

Concern No. 9: Shouldn't pregnant women avoid the flu shot or only get the preservative-free shot? Could the flu vaccine cause miscarriages?

Fact: Pregnant women are a high-risk group particularly recommended to get the flu shot. Fact: The flu shot reduces miscarriage risk. Fact: Pregnant women can get any inactivated flu vaccine

Concern No. 10: Can flu vaccines cause Alzheimer's disease?

Fact: There is no link between Alzheimer's disease and the flu vaccine; flu vaccines protect older adults

Concern No. 11: Don't pharmaceutical companies make a massive profit on flu vaccines?

Fact: Vaccines make up a tiny proportion of pharma profits. That makes it possible for them to continue making them in the event of a pandemic

Concern No. 12: Flu vaccines don't really work, do they?

Fact: Flu vaccines reduce the risk of flu

Concern No. 13: But flu shots don't work in children, do they?

Fact: Flu vaccines reduce children's risk of flu

Concern No. 14: Can flu vaccines cause vascular or cardiovascular disorders?

Fact: Flu shots reduce the risk of heart attacks and stroke

Concern No. 15: Can vaccines can break through the blood-brain barrier of young children and hinder their development?

Fact: Flu vaccines have been found safe for children 6 months and older

Concern No. 16: Will the flu vaccine cause narcolepsy?

Fact: The U.S. seasonal flu vaccine does not cause narcolepsy.

Concern No. 17: Can the flu vaccine weaken your body's immune response?

Fact: The flu vaccine prepares your immune system to fight influenza.

Concern No. 18: Can't the flu vaccine cause nerve disorders such as Guillain-Barré syndrome?

Fact: Influenza is more likely than the flu shot to cause Guillain-Barré syndrome.

Concern No. 19: Can the flu vaccine make you walk backward or cause other neurological disorders like Bell's palsy?

Fact: Neurological side effects linked to flu vaccination are extremely rare (see Concern No. 18), but influenza can cause neurological complications. Fact: The flu shot has not been shown to cause Bell's palsy.

Concern No. 20: Don't people recover quickly from flu since it's not really that bad?

Fact: Influenza knocks most people down *hard*

Concern No. 21: Can people die from the flu even if they don't have another underlying condition?

Fact: Otherwise healthy people DO die from the flu

Concern No. 22: Can people with egg allergies get the flu shot?

Fact: People with egg allergies can get a flu shot

Concern No. 23: Can't I just take antibiotics if I get the flu?

Fact: Antibiotics can't treat a viral infection

Concern No. 24: Since I got the flu last time I got a flu shot, that means it doesn't really work for me personally, right?

Fact: The flu shot cannot guarantee you won't get the flu, but it reduces the risk of catching it

Concern No. 25: But I don't need the shot since I never get the flu, right?

Fact: You can't predict whether you'll get the flu

Concern No. 26: Can't I protect myself from the flu by simply eating right and washing my hands regularly?

Fact: A good diet and good hygiene alone cannot prevent the flu

Concern No. 27: Won't getting the flu simply make my immune system stronger?

Fact: The flu weakens your immune system while your body is fighting it and puts others at risk

Concern No. 28: If I get the flu, why won't just staying home prevent me from infecting others?

Fact: You can transmit the flu without showing symptoms

Concern No. 29: Can having a new vaccine each year make influenza strains stronger?

Fact: There's no evidence flu vaccines have a major effect on virus mutations

Concern No. 30: Isn't the "stomach flu" the same thing as the flu?
Fact: The "stomach flu" is a generic term for gastrointestinal illnesses unrelated to influenza

Concern No. 31: Is there any point in getting a flu shot if I haven't gotten one by now?

Fact: Getting the flu shot at any time during flu season will reduce your risk of getting the flu

Tara Haelle is a freelance health and science writer based in Peoria, Ill. She's on Twitter: @tarahaelle

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Common ADHD Medications Do Indeed Disturb Children's Sleep

NPR Health Blog - Tue, 11/24/2015 - 12:05pm

Boy sleeping in bed


For a child with attention deficit hyperactivity disorder, meeting the daily expectations of home and school life can be a struggle that extends to bedtime. The stimulant medications commonly used to treat ADHD can cause difficulty falling and staying asleep, a study finds. And that can make the next day that much harder.

As parents are well aware, sleep affects a child's emotional and physical well-being, and it is no different for those with ADHD. "Poor sleep makes ADHD symptoms worse," says Katherine M. Kidwell, a doctoral student in clinical psychology at the University of Nebraska, Lincoln, who led the study. "When children with ADHD don't sleep well, they have problems paying attention the next day, and they are more impulsive and emotionally reactive."

Stimulant medications boost alertness, and some studies have found a detrimental effect on children's sleep. However, other studies have concluded that the stimulants' ameliorating effects improve sleep. The drugs include amphetamines such as Adderall and methylphenidate such as Ritalin.

To reconcile the mixed results on stimulants and children's sleep, Kidwell and her colleagues undertook a meta-analysis, a type of study that summarizes the results of existing research. The team found nine studies that met their criteria. These studies compared children who were taking stimulant medication with those who weren't. The studies also randomly assigned children to the experimental group or the control group and used objective measures of sleep quality and quantity, such as assessing sleep in a lab setting or with a wristwatch-like monitor at home rather than a parent's report.

Taking a stimulant medication leads to poor sleep overall for children, the researchers reported online Monday in Pediatrics. They found that the more doses of medication a child took per day, the longer it took for that child to fall asleep at night. The study suggests that extended-release versions of stimulants, which are taken once a day, have less of an impact on how long it takes to fall asleep than immediate-release formulas, which are sometimes taken three times a day, with the last dose close to bedtime.

Furthermore, the quality of sleep, or sleep efficiency — the percentage of time one is asleep while in bed — was worse for those on stimulant medications, although those kids who had been on the drugs longer fared better than those who had just begun taking the medication. There was also a gender difference, with boys on stimulant medication getting poorer-quality sleep than girls.

Finally, stimulants reduced the total amount of sleep children got at night. "Families and pediatricians need to be aware that sleep problems are a real effect of stimulant medication," says Kidwell.

"It's really good to see this," says William E. Pelham, a clinical psychologist and director of the Center for Children and Families at Florida International University, who studies ADHD in children and adolescents. Pediatricians are often quick to prescribe a medication without adequate follow-up, he says, and "assessing sleep side effects is important — it needs to be something that pediatricians routinely do."

For families, Kidwell says that the bedtime routines all parents use — reading stories, sharing news about the day, quiet activities like coloring — are very helpful for kids with ADHD too. "But parents may need to provide more structure, support, and simpler reminders for children with ADHD."

Aimee Cunningham is a freelance science journalist based in the Washington, D.C., area.

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Answering Your Questions: Health 101 For Grown Women

NPR Health Blog - Tue, 11/24/2015 - 5:08am
Katherine Streeter for NPR

Remember that health class you had in middle school? Where you found out all that stuff about your body? We wondered why there wasn't a class like that for middle age. Could someone tell us what happens to us as we move through the decades?

Morning Edition asked listeners to send their questions about women's bodies and aging as part of our ongoing series Changing Lives of Women. We heard from hundreds of you asking about everything from sleeplessness to STDs to sex in old age.

We put your questions to two physicians: Dr. Nanette Santoro, a professor and E. Stewart Taylor chair of obstetrics and gynecology at the University of Colorado School of Medicine, and Dr. Cheryl Iglesia, a professor of obstetrics and gynecology at Georgetown University School of Medicine. Here are their answers, edited for length and clarity.

In my 20s I began getting one or two coarse black hairs on my chin. I jokingly referred to them as "stray eyebrow hairs." But as I've gotten older these hairs have increased and they grow back much more quickly. I'm tweezing at least once a week. Is this normal? — Amanda, 39, Texas

Yes, it is normal and not very well explained. The best explanation is that with aging, we become more insulin resistant. This leads to a decrease in a protein produced by the liver called "sex hormone-binding globulin" or SHBG. SHBG does what it says: it binds up the estradiol and testosterone that women make, and makes them less available to local tissues to do their job.

When SHBG drops, the "free" hormone in your bloodstream goes up in a sense, because it becomes more bio-available to your tissues. This is not a big deal in terms of estradiol, because estrogen is going down with menopause anyway, but testosterone can become more available to your tissues and skin, and is the likely culprit for your increased hair growth. — N.S.

Can you help me understand the roles of hormones and the appropriate levels for my body, age, etc.? I know about estrogen and progesterone. What else? — Denise, 49, South Carolina

Women have three types of reproductive hormones: estrogens (estradiol and its less potent cousins estrone and estriol), progestins and testosterone.

Estradiol is almost exclusively produced by the ovary. After menopause, estradiol levels can become so low that by age 70 or so, a woman is likely to have less estradiol circulating in her body than her same-age husband would have.

Progesterone, a naturally produced progestin, is made all the time in tiny quantities by the adrenal gland. But the ovary makes enormous amounts of it after ovulation, and women are exposed to it during their reproductive years every two weeks. There is no known appropriate level for progesterone in women, as no one knows exactly how much is needed after ovulation. If a woman is getting regular menstrual periods, she is very likely to be making adequate quantities of both estradiol and progesterone.

Testosterone's role is less well-defined in women. Women need some circulating testosterone to have normal ovulation, as the ovary takes up the testosterone and "feeds" it to the growing follicles, so they can produce estrogen. Beyond that, testosterone is believed to possibly drive libido in women, but this is not a very powerful effect for most women. (Sometimes testosterone is used as a treatment for low libido in women.)

As women age, their overall production of testosterone drops. The most dramatic drop is 10 to 15 years before menopause. There are some conditions in which women make too much testosterone. The common disorder of polycystic ovary syndrome, which affects about 5 to 7 percent of adult women, is such an example. In this case, the testosterone may disrupt the menstrual cycle and interfere with a woman's ability to ovulate, not to mention cause other problems like acne and excessive body hair. — N.S.

Does the decision not to have children affect my reproductive health and is there anything I can do to keep it in tip-top shape through the years? — Carolanne, 28, Oregon

Yes, there are things you can do. Not getting pregnant before age 30 can increase your risk of breast cancer, and nulliparity (no pregnancies) increases your risk of ovarian cancer. Tip-top shape requires a proactive approach. Maintain a healthy lifestyle and weight with healthy eating, adequate exercise and sleep. Oral contraceptives can protect against breast cysts and actually lead to decreased ovarian cancer, if taken for 10 years or more. Also, breast self-awareness and screening mammograms should be conducted at intervals based on your age and individual risk factors. — C.I.

So, kegels — you know, the things I should have been doing forever but didn't? Now I know why I should have done them. Can I make up for lost time or is it a lost cause? — Amelia, 48, Colorado

Kegels (pelvic floor muscle exercises) are important in maintaining bowel and bladder function and sexual satisfaction. Here is how they are done. A health care provider or physical therapist can help if you think you are not doing the exercises correctly. — C.I.

There is so much so much conflicting information about fat loss, specifically on women's hips. Could someone answer, once and for all, how to get rid of that stubborn fat that Mother Nature "gifted us"? Some of us want a gift receipt. — Cassidy, 25, Kentucky

Alas, there is no formula that will eliminate the accumulation of midbody fat with aging. As we age, we all become more insulin resistant and tend to accrue fat in the hips and waist. To boot, menopause is associated with a small increase in waist girth in most women. The best way to combat this increase is exercise, and women have to up their game in midlife to stay in the same place. When all else fails, there's always liposuction! — N.S.

I have started to skip periods. Does that mean I'll go into full menopause within the next few years? Or will I keep having periods for 10 more years? What are the real signs that you're almost done? — Jerrilyn, 44, Oregon

The menopause transition is divided into two stages — early and late. The early transition is marked by relatively isolated skipped periods, such that a woman does not go more than 60 days without a bleed. This stage can be very variable. If that is where you are at age 44, it's quite possible that you won't be fully menopausal (one whole year without a period) until you are 50 or so.

The median age at menopause is 51.4 years. However, if you enter the late transition stage and are more than 60 days without a bleed, that usually means you are going to be fully menopausal within 4 years. — N.S.

Does menopause end? When and why do the hot flashes and mental fog go away? — Anonymous, 52, Washington, D.C.

While the onset of menopause is easy to define, the end is far more squishy.

For most women, the first five years are the most symptomatic, but for up to 20 to 40 percent of women, depending on their particular physiology, hot flashes can last for 10 years. And for about 10 percent of women, they just keep going on and on.

The most characteristic mental symptom that women experience is short-term recall loss, which partially comes back (but doesn't go back to what it was before the transition started). Some women experience a loss in "executive function" and have difficulty with organizational tasks, and there is some evidence that this may be treatable with medication used for adult ADHD.

Poor sleep and depression can also co-exist with menopausal symptoms, and these problems will also contribute to mental fog-type symptoms. Treating the primary problem can help. — N.S.

I'm taking antidepressants and have little sex drive. How do I strengthen it? — Regina, 49, Illinois

Decreased libido is common during perimenopause, the transitional period before menopause. Flibanserin (Addyi) is the new FDA-approved drug for hypoactive sexual desire disorder in premenopausal women. Some antidepressants like SSRIs (including Prozac, Zoloft and Lexapro) are associated with decreased libido. Ask your doctor if you can switch to a different medication (like bupropion — Welbutrin). Strengthening the relationship with your partner to improve communication can often be very helpful in midlife. — C.I.

What can young women do to deter osteoporosis and improve joint health for later in life? When should women start working to preserve bone health? — Britt, 31, Texas

You can't start early enough. Women should pay attention to their calcium intake and ideally take in about 1,000 mg a day from dietary sources when they are premenopausal. After menopause, unless a woman is taking estrogen, her calcium needs go up to 1,200 mg a day. Vitamin D is also important to maintain. It's fairly easy to find the calcium content of commonly eaten foods on the Web; I like to refer my patients to the National Osteoporosis Foundation website, which links to several sources.

Taking a calcium supplement is reasonable if calcium intake is very low due to dairy intolerance or other reasons, but it's important not to overdo it. Too much calcium supplementation has been linked to a small but increased risk of heart disease. — N.S.

I have endometriosis and I'd like to know what I can expect as I age. Will going into menopause essentially "cure" the endometriosis? — Holly, 41, Massachusetts

Endometriosis affects about 3 to 5 percent of women and happens when the inner lining of the uterus, the endometrium, starts to grow within the pelvis. It tends to "burn out" and improve with menopause. If a woman has had multiple surgeries and has less ovarian tissue remaining, she may go through menopause earlier than normal. Many women with endometriosis tend to have menopause slightly earlier. Women with endometriosis can take hormones after menopause if their disease is not active, but it is recommended that they take estrogen with progesterone to prevent endometriosis growth, even if they have had a hysterectomy. — N.S.

What is the current practice on taking hormones for transgender women as they enter what would be the menopause years? Keep taking estrogen? Gradually decrease? — Alison, 42, Minnesota

Theoretically, a trans woman will have been exposed to estrogen for fewer years in her life, and might be able to extend the time during which she takes hormones. But there is not a lot of knowledge about how the long-term risks may play out in trans women. Therefore, current guidelines for trans women are similar to women who have been exposed to estrogen for their entire lives. In general, there is no reason to take hormones after the age of about 50 unless menopausal symptoms are present. — N.S.

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More Women Are Freezing Their Eggs, But Will They Ever Use Them?

NPR Health Blog - Tue, 11/24/2015 - 5:04am
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If egg freezing once sounded like science fiction, those days are over. Women now hear about it from their friends, their doctors and informational events like Wine and Freeze.

Shady Grove Fertility Center in the Washington, D.C., area hosts Wine and Freeze nights for prospective patients every few months. Fifteen or so women in their 30s gathered at one recently over wine, brownies and sticky buns. A doctor explained the procedure, the costs and the odds of frozen eggs resulting in a baby — which decline as a woman ages.

Egg freezing for medical reasons — often women undergoing chemotherapy — has been possible for decades. Some 5,000 babies have been born from eggs that were frozen, thawed and fertilized.

In 2012, the American Society for Reproductive Medicine decided egg freezing was no longer an experimental procedure. That opened the door for clinics like Shady Grove to market it to women who don't have a medical reason to do it but are simply worried about their declining fertility — what's being dubbed as "social" egg freezing.

The "social" egg freezing business these days is good, says Shady Grove medical director Dr. Eric Widra. "This is clearly a time where the technological ability to do this is converging with the demographics," he says. "There are more and more women who find themselves in a situation where they may potentially benefit from having their eggs frozen."

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The majority of women currently freezing their eggs live in cities like New York, San Francisco and Los Angeles, according to Jake Anderson-Bialis, who's building a company called FertilityIQ with his wife, Deborah. "Marketing is aggressively happening, and these are the hubs where fertility clinics will prove out the concept," he says.

Anderson-Bialis says he's hoping to serve women freezing their eggs, as well as couples doing in vitro fertilization, with a database of fertility doctors and reviews from patients. FertilityIQ has so far gotten about 200 women who have frozen their eggs to write reviews of their experience.

The fact that wine is served at egg-freezing info sessions around the country might imply that this is no big deal, even fun. In fact, it's a complicated and physically demanding process.

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Women inject themselves with hormones for up to two weeks to stimulate their ovaries to get as many mature eggs as possible. There's a surgical procedure to retrieve them. And there can be side effects along the way.

It also isn't cheap. One round averages about $12,000, and multiple rounds may be needed. No insurance companies cover egg freezing, but in October, a third tech company, Intel, joined Apple and Facebook in offering to pay the costs of egg freezing for employees. Financing may be available from a company called EggBanxx as well as some fertility clinics.

Stacey Samuel is a producer with CBS in Washington, D.C., (formerly with CNN). She thought about freezing her eggs earlier, but couldn't afford it until this year. "Before you know it, I'm 40, and I thought, oh, my goodness, this is very real for me," Samuel says.

Doctors prefer that women freeze their eggs before their mid-30s. But Samuel thought that advice might not apply to her. "I'm a black, South Asian female. Fertility in my culture and family extends for many years," she says. "So I'm thinking 40 is nothing but a number — I still get carded."

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She assumed she'd get the 15 to 20 eggs that doctors recommend women freeze. But in the middle of her cycle, while she was injecting hormones, there were complications. She ended up with just 10.

"Even when I choose to go use those eggs, I could lose them again," Samuel says. "So that feeling of reassurance that I thought I was buying with my near $20,000 on the table — I'm still unable to control the outcome."

Preserved eggs offer women like Samuel hope for beating the biological clock. But you can't escape the fact that your body will continue to age. The older a woman is when she freezes her eggs and when she uses them with in vitro fertilization, the lower her chances of success.

"There was a lot of encouragement to go forth even if it looks like you're kind of a risky case, because I think these dedicated doctors really want to know where they can take this," Samuel says. "And they need the numbers, and they need those of us who are willing to go through with it."

That concerns John Robertson, a professor of law and bioethics at the University of Texas Law School. He wrote a paper published in 2014 in the Journal of Law and the Biosciences on how women freezing their eggs can be both empowered and alienated by the procedure.

"The problem is it may be marketed to women who are in the older age group who may have very little chance of obtaining viable eggs," Robertson says. "So it's extremely important that there be full disclosure at every step of the process."

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Dr. Kevin Doody agrees. He codirects the Center for Assisted Reproduction in Dallas, and is president-elect of the Society for Assisted Reproductive Technology, or SART.

"I do not think that this should be highly promoted for the older-age woman," Doody says. "I'm not saying one should refuse or deny services if a 40- or 42-year-old woman wanted to have her eggs frozen. But I think it would warrant a substantial counseling session with that patient."

SART collects data on egg freezing in the U.S. And Doody says in 2013, about 4,000 women froze their eggs, up from about 2,500 the year before. And he predicts the number this year will be much higher.

But so far very few women who've frozen their eggs since the experimental label was lifted in 2012 have gone back to try to use them. SART found that of the 353 egg-thaw cycles in 2012, only 83 resulted in live births. In 2013, there were 414 thaw cycles and 99 live births. "Live birth" is not babies born — it means delivery of one or more infants, so it can include twins.

Overall, the success rate of live births from frozen eggs has remained consistently pretty low, at about 20 to 24 percent since 2009. And, Doody adds, "Even if the success rates were significantly higher, there's never going to be a guarantee for an individual patient that the eggs she would bank would ultimately result in a baby for her."

Medical anthropologist Marcia Inhorn at Yale University is conducting a study of the women who have frozen their eggs.

"The vast majority say, 'Well, it's given me peace of mind, I feel a sense of relief, it's taken the pressure off of me to rush into a relationship with someone who isn't right,' " she says.

Inhorn has interviewed about 100 women so far for her study.

"Most of these women are amazing professional women, I have to say," says Inhorn. "But the major reason over and over is not being able to find the right person to embark on a partnership and parenthood with."

Finding the right person is likely to be just as big a challenge for women in the future, Inhorn says. Which is why she believes this technology will become normalized, like in vitro fertilization.

And maybe it's already happening if people like Mindy Kaling are talking about it. The actress, producer and writer hit on this in an episode of her Hulu show The Mindy Project. Her character, a fertility doctor, goes to a college campus to peddle her newest service for women.

Here's what she tells them:

"When I was your age, I thought that I was going to be married by the time I was 25. But it took a lot longer than that. And unfortunately your body does not care if you are dating the wrong guy. ... Your body and your eggs just keep getting older, which is why freezing them is a pretty smart idea, 'cause it gives you a little bit more time."

But it will be years before there's enough data showing us whether egg freezing actually helps most of the women doing it fulfill their dreams of motherhood.

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Treating Prisoners With Hepatitis C May Be Worth The Hefty Price

NPR Health Blog - Mon, 11/23/2015 - 5:04pm

Harvoni is one of the new medications for hepatitis C that can cure almost all infections.

Lloyd Fox/TNS/Landov

Doctors, patients and insurers have been struggling with how to determine who should be treated for hepatitis C now that effective but wildly expensive drugs can all but cure the disease. Treating prison inmates is a good investment that would save money in the long run, a study finds.

The drugs, Harvoni and Sovaldi, cure about 90 percent of patients, but at a hefty price, about $90,000 per patient. The drugs are made by Gilead Sciences and were approved by the Food and Drug Administration in the last two years.

More than 15 percent of U.S. prison inmates are infected with Hepatitis C. The study, published Monday in Annals of Internal Medicine, shows that as many as 12,000 lives would be saved if inmates were screened and treated.

And while it would cost a lot of money up front, over time the savings to society at large would be huge.

"We have to invest money either now or we invest later," says Jagpreet Chhatwal, an assistant professor at Harvard Medical School and senior author of the study. "If we invest now, it would gain us additional lives, it would prevent liver transplants, and it would prevent several thousands of advanced stage liver diseases."

Treating just those in prison would save $750 million over 30 years, the study finds, even including the cost of screening and medication.

Chhatwal acknowledges it's a tall order.

The first year cost of a widespread screening and treatment program in state prisons across the country would cost as much as $1.15 billion. That would require corrections systems to boost their health care budgets by 12.4 percent. The price would plummet over time, however.

The benefits would accrue mostly to people not in prison, the researchers found. That's because inmates would not infect people in the community after they are released.

"It's going to be very cost effective to provide screening and treatment because this would avoid new infections from occurring," Chhatwal added. "The majority of these new infections would occur outside the prison."

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A Peek At Brain Connections May Reveal Attention Deficits

NPR Health Blog - Mon, 11/23/2015 - 4:22pm
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Brain imaging experiments found patterns associated with attention span.


A look at the brain's wiring can often reveal whether a person has trouble staying focused, and even whether he or she has attention deficit hyperactivity disorder, known as ADHD.

A team led by researchers at Yale University reports that they were able to identify many children and adolescents with ADHD by studying data on the strength of certain connections in their brains.

"There's an intrinsic signature," says Monica Rosenberg, a graduate student and lead author of the study in Nature Neuroscience. But the approach isn't ready for use as a diagnostic tool yet, she says.

The finding adds to the evidence that people with ADHD have a true brain disorder, not just a behavioral problem, says Mark Mahone, director of neuropsychology at the Kennedy Krieger Institute in Baltimore. "There are measurable ways that their brains are different," he says.

The latest finding came from an effort to learn more about brain connections associated with attention.

Initially, the Yale team used functional MRI, a form of magnetic resonance imaging, to monitor the brains of 25 typical people while they did something really boring. Their task was to watch a screen that showed black-and-white images of cities or mountains and press a button only when they saw a city.

"It gets really dull after a while," Rosenberg says, "so it's really hard to pay attention to over a long period of time."

During the test, the team measured the strength of thousands of connections throughout the participants' brains. And they were able to identify certain patterns that predicted a person's ability to stay focused.

What's more, these connection patterns were present even when the person wasn't trying to keep track of cities and mountains, or anything else, Rosenberg says. "We could actually look at that signature while they were resting and we could still predict their attention," she says.

The team wanted to know whether this signature could be used to assess younger people, especially those with ADHD. So they reviewed data on 113 children and adolescents whose brains had been scanned by scientists in China as part of an unrelated study. The children had also been assessed for ADHD.

The team used the information about brain connections to predict how well each child would do on the attention task with cities and mountains.

"And what we found was really surprising, and I think really cool," Rosenberg says. "When we predicted that a child would do really well on the task, they had a low ADHD score. And when we predicted they would do really poorly on the task, they had a high ADHD score, indicating that they had a severe attention deficit."

For many of the children, the researchers were able to predict not only whether they had ADHD, but how severe the problem was.

The test isn't perfect but does provide useful information, Rosenberg says. Eventually, she says, it might help psychologists and psychiatrists assess children with attention problems.

One potential limitation of the approach is that attention deficits aren't found only in people with ADHD, says Mahone. Individuals with anxiety, depression, learning disabilities and autism also have trouble staying focused, he says.

Regardless of the diagnosis, though, Mahone says, "knowing how the brain is different in a disorder, we can look at ways to help 'normalize' the brain."

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Mendocino Coast Fights To Keep Its Lone Hospital Afloat

NPR Health Blog - Mon, 11/23/2015 - 3:30pm
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Mendocino, Calif., lures vacationing tourists and retirees. But the lone hospital on this remote stretch of coast, in nearby Fort Bragg, is struggling financially.

David McSpadden/Wikimedia

Board meetings for the Mendocino Coast District Hospital are usually pretty dismal affairs. The facility in remote Fort Bragg, Calif., has been running at a deficit for a decade and barely survived a recent bankruptcy.

But finally, in September, the report from the finance committee wasn't terrible. "This is probably the first good news that I've experienced since I've been here," said Dr. Bill Rohr, an orthopedic surgeon at the hospital for 11 years. "This is the first black ink that I've seen."

The committee erupted in applause, even a few cheers. But the joy was short-lived. By the next month, the hospital was back in the red.

Things first started going badly for the hospital in 2002, when the lumber mill in Fort Bragg closed down. Many people lost their jobs — and their health insurance, which had paid good rates to the hospital. Today, about 7,000 people are left in the blue-collar town, and the economy is propped up by tourists who come to the rugged Mendocino coastline to hike or fish. Visiting the hospital does not usually make it onto their itinerary.

By 2012, the hospital had declared bankruptcy. Now it's barely hanging on. And some locals are worried that the only hospital in the area might close for good.

If The Hospital Fails, So Goes The Community

"Nobody can live here without that hospital," says Sue Gibson, 78, a Mendocino resident. "I mean, the nearest hospital is an hour and a half away on treacherous mountain roads."

It's not only her family's health and the community's that Gibson is concerned about. She's afraid the local economy would be wrecked. The hospital is the largest employer.

"It has probably the best-paying jobs, and if they close that, all of that income would go away," she says.

That means less money spread around to the local bait shops and seafood restaurants. Also, Gibson says, the property values of businesses and homeowners would plummet.

Shots - Health News Help Wanted: Last Pediatrician On Mendocino Coast Retires

Across the country, rural communities share similar fears. Small rural hospitals everywhere have been struggling to survive. Many people who live in these areas are older or low income — not a great customer base for a hospital that needs to make money.

The government used to pay these small critical access hospitals extra to account for that. Medicare reimbursed them 101 percent of their reasonable costs. But after the recession, the government trimmed payments to 99 percent of costs. Medicaid pays much less, sometimes just half the cost of providing the care.

At the Mendocino Coast Hospital, more than 80 percent of patients are covered by Medicare or Medicaid.

"The general health care reimbursement environment is to do more with less," says Bob Edwards, the hospital's CEO. "And I would even go so far as to say, it's a starvation model."

Plus, the government excludes a lot of expenses from its cost calculation, like doctors' fees or janitorial services, says Wade Sturgeon, the hospital's chief financial officer. Medicare basically tells the hospital what it will pay.

"So it'd be like going in to Safeway and saying, 'Hey, there's a jug of milk. I really want that jug of milk; I'll give you $2,' " Sturgeon explains. "But the price says $3.50. 'You're only going to get $2.' Often times, that's what happens to us."

The upshot: Many hospitals that never had to worry about controlling costs now do. They have to learn to compete in an open market, just like other hospitals, just like many other profit-driven businesses.

Some hospitals have planned ahead and adapted. Down the long, winding road from Fort Bragg, the Frank R. Howard Memorial Hospital in Willits just finished a $64 million renovation, complete with modern technology and a full organic garden that supplies the hospital cafeteria.

But some hospitals haven't adapted. In the past five years, 57 rural hospitals in the United States have closed, according to data from the Rural Health Research Program at the University of North Carolina. Others have declared bankruptcy, like the Mendocino Coast District Hospital.

Battles Over How To Keep Hospital Afloat

The financial failure led to a lot of finger-pointing in this small town. Administrators blame the policy changes and payment reforms. Some doctors blame the administrators.

"It was economic mismanagement, to put a single label over all these things," says Dr. Peter Glusker, a neurologist based in Fort Bragg for 37 years. "Because of people who just didn't know any better."

The public hospital is governed by a five-member board of directors, elected from and by the community. Glusker says some past directors knew nothing about finance or nothing about health care. Some just stopped caring.

So he and another doctor ran their own campaign, promising to shake things up on the board and change things. They were elected last year.

"There's a segment of the population that says, 'Oh good, it's about bloody time,' " Glusker says. "But there's another segment of the population, in the institution, that says, 'Hey, you're rocking the boat and this is bad.' "

Glusker's running mate and ally on the board is Rohr, the steely orthopedist, who wears his gray hair long, tied back in a tight ponytail. He spent many years in the corporate world and vowed to bring the kind of financial discipline he learned there to the tiny public hospital in Fort Bragg. A lot of people are afraid of him.

"Look, this is not about being ruthless," Rohr says. "It's about keeping this business alive, and it's only alive if it makes money, OK."

A lot of his sentences are punctuated like this, with a sometimes impatient "OK," which seems aimed at making sure you don't miss his point. Like when he's giving a presentation at a finance committee meeting, staring daggers at the CEO.

"We keep saying $870,000 loss," Rohr says. "Not acceptable, OK."

Edwards, the current CEO, has been on the job six months. He's the hospital's fourth chief executive in a year. His right-hand man is Sturgeon, the brand-new CFO, who started in September.

On days the financial committee meets, Sturgeon wears a mint-green shirt and a tie with a $100 bill on it. He says things like, "Do the math."

Right now, the hospital administrators and the doctors on the board are pitted against each other in a battle over how to keep the hospital doors open — a battle that is echoed at small hospitals across the nation.

Cut costs or raise prices? Board members disagree on best approach

CFO Sturgeon and CEO Edwards say the hospital should focus on increasing revenues. It should find more patients to come to the hospital, maybe develop new services to attract then.

"If you're not growing, you're dying," Sturgeon says.

He says the hospital should also charge more money for services provided to patients who have private insurance — currently about 15 percent of the hospital's patients.

"Anytime we don't raise prices, we're leaving money on the table," he says.

But Rohr says that would put an unfair burden on the small-business owners in town, the ones who typically buy their own private insurance.

He and Glusker say the hospital should be focused on controlling costs.

"It's obviously an expense problem," Rohr says. "And you can come to that conclusion very quickly, just by looking at the data."

The hospital is going to have to make some very difficult decisions to balance its budget, Rohr says. He offers this analogy: "There's 20 people in the water about to drown. And there's a rowboat there, but the rowboat can only hold 10," he says. "If 11 people get in that rowboat, it sinks and all die, OK."

At the hospital, this means choosing between a cardiologist and an ophthalmologist, a cafeteria and a new X-ray machine.

"It's horrible to make the decision that 10 are going to drown," he says. "But I've got to pick the 10. OK."

One area Rohr thinks could be ripe for trimming? Administrative positions.

"I walk into the hospital to do rounds in the morning, and there are more people standing around with clipboards than with stethoscopes," he says, "and that doesn't feel like the right formula to me."

But CFO Sturgeon says there's not enough management. "Physicians always think there's too much management," he says. "You have some people with 50 direct reports. Does that make sense?"

There are some cuts both sides agree on. All say there needs to be some serious culling of the health benefits for hospital staff. Years ago, the nurses union negotiated to have the hospital pay full health benefits for any full-time or part-time nurse and their entire families. Nurses pay nothing toward their monthly premiums.

"Do the math. How many people are we paying for to have full family coverage?" Sturgeon says. "I've never worked in a hospital that provided the type of health insurance benefits that we have at this facility."

Meanwhile, Need For New Hospital

To understand exactly how dire the financial situation is, one need only walk into the lobby of the hospital itself. It's like stepping back into 1971. The main patient floor is lined with drab brown carpets. The smell of Salisbury steak spills out of patient rooms.

"I've been in Third World countries. This is pretty basic, OK," Rohr says, walking by the operating suite.

Through the maternity ward and the emergency room, Rohr says the flooring is layered with asbestos. The concrete isn't strong enough to hold the weight of modern CT scanners and MRI machines. On top of all that, in 2030 new state requirements kick in for earthquake readiness.

It all points to one conclusion. "We're going to have to build a new hospital," Rohr says.

So, not only is the hospital struggling to maintain a balanced budget through normal hospital operations but it also has to come up with tens of millions of dollars to replace itself in 15 years.

It's an especially tall order for a hospital that just posted its first monthly profit in a decade, then slipped into the red again right away.

If you ask the Washington policymakers in charge of payment reform, some will say it's just a harsh reality that some hospitals will have to close. Some previous local administrators have predicted that the Fort Bragg hospital will one day be replaced by a helicopter landing pad. People will be airlifted out for heart attacks and other emergencies. For other planned surgeries, like hip replacements, people will have to drive "over the hill" to another hospital.

But the people who live in Fort Bragg and Mendocino don't like that scenario. Gibson has been hosting community meetings in her living room, where people spread out on the pink Victorian sofas to talk about how to save the hospital.

She's rallying support for a possible solution, and it's one the administrators and doctors are united around: a new tax on homeowners. Local residents will very likely vote on that in November 2016.

"The only way we're going to be able to save this place, really, is with a parcel tax," she says. "But they can't even think about that until they clean up their act."

After the Wall Street meltdown, banks were too big to fail. The feeling here is that the local hospital is too important to fail. And the residents will be tapped to fund the bailout.

This story comes from a reporting partnership of NPR, KQED and Kaiser Health News.

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Gratitude Is Good For The Soul And Helps The Heart, Too

NPR Health Blog - Mon, 11/23/2015 - 3:54am
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As we launch into Thanksgiving week, consider this: Research shows that feeling grateful doesn't just make you feel good. It also helps — literally helps — the heart.

A positive mental attitude is good for your heart. It fends off depression, stress and anxiety, which can increase the risk of heart disease, says Paul Mills, a professor of family medicine and public health at the University of California San Diego School of Medicine. Mills specializes in disease processes and has been researching behavior and heart health for decades. He wondered if the very specific feeling of gratitude made a difference, too.

So he did a study. He recruited 186 men and women, average age 66, who already had some damage to their heart, either through years of sustained high blood pressure or as a result of heart attack or even an infection of the heart itself. They each filled out a standard questionnaire to rate how grateful they felt for the people, places or things in their lives.

It turned out the more grateful people were, the healthier they were. "They had less depressed mood, slept better and had more energy," says Mills.

And when Mills did blood tests to measure inflammation, the body's natural response to injury, or plaque buildup in the arteries, he found lower levels among those who were grateful — an indication of better heart health.

So Mills did a small follow-up study to look even more closely at gratitude. He tested 40 patients for heart disease and noted biological indications of heart disease such as inflammation and heart rhythm. Then he asked half of the patients to keep a journal most days of the week, and write about two or three things they were grateful for. People wrote about everything, from appreciating children to being grateful for spouses, friends, pets, travel, jobs and even good food.

After two months, Mills retested all 40 patients and found health benefits for the patients who wrote in their journals. Inflammation levels were reduced, and heart rhythm improved. And when he compared their heart disease risk before and after journal writing, there was a decrease in risk after two months of writing in their journals. Those results have been submitted to a journal, but aren't yet published.

Mills isn't sure exactly how gratitude helps the heart, but he thinks it's because it reduces stress, a huge factor in heart disease.

"Taking the time to focus on what you are thankful for," he says, "letting that sense of gratitude wash over you — this helps us manage and cope."

And helps keep our hearts healthy.

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When A Stranger Leaves You $125 Million

NPR Health Blog - Sat, 11/21/2015 - 8:01am
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Bryan Bashin, CEO of the LightHouse for the Blind and Visually Impaired, in San Francisco, started losing his sight in his teens. "Don't just hide," he advises others. "This is not some kind of deep loss. This is just another side of being human."

Jeremy Raff/KQED

One morning last year, when Bryan Bashin sat down to check his email, a peculiarly short note caught his attention.

"A businessman has passed away. I think you might want to talk to us," it read.

Bashin directs a nonprofit in San Francisco called the LightHouse for the Blind and Visually Impaired, so he gets a lot of email about donations. But this one felt different. It came from a group of lawyers handling the estate of a Seattle businessman who had died, Donald Sirkin.

When Bashin and the LightHouse's Director of Development, Jennifer Sachs, checked the LightHouse's donor database, they found no record of him. Sirkin had never donated to the LightHouse for the Blind and Visually Impaired before, or used its services.

And yet, in his will, Sirkin had left almost his entire estate to the LightHouse, with no explanation.

In the end, the gift totaled over $125 million, more than 15 times the LightHouse's annual budget. Bashin believes it's the largest single gift ever given to a blindness organization.

"It's one of those experiences where time stands still, where you know that every little bit of what you're experiencing will be engraved in your memory," Bashin says. "This is the moment that everything is going to change."

He's 60 years old, tall and almost always smiling. His eyes are cloudy; he walks with a cane. He gives off the impression of being an entirely functional, confident blind person.

But this Bryan Bashin is a relatively recent incarnation, because for a long time, Bashin didn't identify as blind at all.

"I didn't say the "B" word," Bashin says. "Instead I used euphemisms if I had to. I used the lingo of the day: 'visual impairment,' 'low vision,' 'visual challenge,' that kind of thing."

Bashin's vision began to falter when he was in his teens, and gradually got worse. By his 20s, he was legally blind. Today, he says, he sees the world "as if through wax paper." He can make out some light and color, but not faces or words.

Yet through his 20s and most of his 30s, Bashin squeezed by on the little vision he had, relying on magnifiers and special lamps to read what he could. He memorized the map of his daily route so as to not get lost. He only went out during daylight, to avoid the confusion of navigating in complete darkness.

Bashin says that a lot of blind Americans use work-arounds like these.

"Most never use a cane, or a dog, or Braille or any of the things that are identifiably blind," he says. "In the blind community we say we're in the closet, and it is just like being in the closet in the gay community. You try to pass and you try to be somebody that you're not."

But as Bashin's vision declined, these work-arounds became harder to pull off. They were time-consuming and exhausting. Finally, when Bashin was 38, with his vision at about 10 percent of normal, he realized he couldn't hide anymore. He decided to learn to be a blind person in public.

A friend took Bashin to a local blindness agency that Bashin found dishearteningly shabby. Stuffing was coming out of the chairs. The air conditioners buzzed. The office hadn't been painted in decades.

For Bashin all of this was symbolic. The place lacked dignity. "None of that period made me feel like I could be a cool blind person and do stuff in the future," Bashin said. "I felt ashamed. I felt confirmed in my suspicion that blindness would be a diminishment of my potential."

But he did get something out of it. He learned how to navigate with a cane. He started learning the technologies that make life vastly simpler for blind people than it was a generation ago: the smart phone, text readers and pocket recorders.

And suddenly, everything got easier. For example, using text-to-speech was "vastly quicker" than trying to make out giant letters on a screen.

Since then, Bashin has made it his life's mission to help other blind people make the leap he did. He got a job at the agency with the ripped up couches. And in 2010, he became the Executive Director of the LightHouse for the Blind and Visually Impaired in San Francisco.

Bashin says that with the right tools and training, blindness can be reduced to the level of inconvenience. "Don't just hide," Bashin said. "This is not a tragedy or shame. This is not some kind of deep loss. This is just another side of being human."

Despite enormous technological gains that have made life vastly easier for blind people in the last decade, there are still significant obstacles to independence. The unemployment rate among working-age blind people is 50 percent — ten times the national average. Job training is expensive, and learning to live independently as a blind person takes time and resources. It's often easier to get disability checks than to find and pay for necessary training.

Bryan Bashin says Donald Sirkin's bequest can help change the way blindness is perceived, by providing more people who have diminished vision with training and skills to achieve self-reliance at work and at home. The money, Bashin says, " is about ... feeling like we can dream and have options and be proud of who we are."

Jeremy Raff/KQED

To really master walking around using a white cane, Bashin says, requires 200 to 400 hours of training with somebody who is being paid to work with you. Learning to use a computer requires that same kind of training.

Through constant fundraising, Bashin's organization has the resources to provide basic services to their clients.

But what Bashin wants is bigger than that: a change in how blindness is perceived. He wants to to encourage more blind people to come "out of the closet," to embrace and celebrate blindness as a difference, and get the skills they need to pursue their ambitions.

Now, suddenly, thanks to this mysterious businessman in Seattle, Bashin and the LightHouse are looking at a different scale of ambition.

"When you get right down to it, the Sirkin bequest is about ... feeling like we can dream and have options and be proud of who we are," Bashin says.

LightHouse for the Blind and Visually Impaired is just beginning its strategic planning process, to decide how to spend the Sirkin money, but Bashin has some ideas.

One major project — which had begun well before the Sirkin grant – is a new headquarters in San Francisco. The building will have expanded facilities, including a dormitory where blind people can stay while they receive training in blind tech, cane navigation, and other necessary skills.

There's also the idea of an award for blind people who do extraordinary things — say, travel around the world independently, or invent some kind of game-changing tool for blind accessibility.

For now, Bashin wants to understand the man behind the donation: This mysterious Seattle businessman, Donald Sirkin, left $125 million to an organization that had never heard of him, with no explanation — just a few legal sentences in a three-page will.

Last year, to try to reconstruct this man from the dead, Bashin made a trip to Seattle, where Don Sirkin had lived. He took a tape recorder and interviewed everyone he could find who had known Sirkin, including Sirkin's ex-girlfriend, a half dozen of his colleagues and good friends.

The interviews reveal a charismatic, idiosyncratic businessman. Sirkin built a hugely successful insurance company from the ground up. He was on a caloric-restriction diet that consisted of large quantities of pomegranate juice and seaweed. He refused to eat in public. His ex-girlfriend Sue Tripp remembers going on a trip to New York with him. But while Sue went to see the Statue of Liberty, Sirkin stayed in the hotel and exercised for hours.

Don Sirkin commanded attention. If left too long in a waiting room, he would walk around on his hands to catch the eye of the receptionist, as change and keys flew out of his pockets. He loved a big gesture, handing out $100-bills to his staff after closing on a big client.

The interviews also reveal a man estranged from his family. Missing from Bashin's tapes are Don Sirkin's children. He had two – a daughter and son. Neither of them wanted to be interviewed. The kids received relatively little from his will: $250,000 apiece, compared to the LightHouse's $125 million.

In May, Sirkin's daughter Anna sued her father's estate. Her complaint says that her father hit her and touched her sexually. She says this happened dozens of times. If she wins, she could get a small percentage of what would otherwise go to the LightHouse. Anna Sirkin told us through her lawyer that she didn't want to talk to us for this story.

As part of the Sirkin bequest, the LightHouse inherited Sirkin's private residence on the edge of the Puget Sound. Last year Bashin and Jennifer Sachs, the LightHouse's Director of Development, went to see it.

Sachs recalls that the house was in disrepair. Crows had pecked away at the shingles. The roof was crumbling. And inside, it was packed with stuff: thousands of books suggesting a vast range of interests; piles of old papers; paintings; plastic clocks stacked on top of each other.

What Bashin wanted, of course, were clues. And pretty quickly, he found them.

"As we wandered through [Sirkin's] house," Bashin said, "we saw all these gadgets: giant light boxes, magnifiers, enormous plasma TVs in his kitchen and throughout his house." Bashin recognized these clues because he'd used them himself, back when he was trying to hide his blindness.

It appeared that Sirkin, too, had lost his sight. He kept it a secret from almost everyone he knew.

Instead of getting help, or learning to use a cane, it seems he'd tried to bring his eyes back with special diets, the pomegranate juice and the caloric restriction.

Sirkin's colleagues said that in his final years, he became more reclusive than ever. He holed up in his house — in a little room off the side of his kitchen.

In that room, Sirkin's heart gave out on him. His body wasn't discovered for days.

To Bryan Bashin, Sirkin is a black box, a mystery. Estranged from his family, reclusive, even to those who worked with him. A guy who also made this dramatic, final gesture – this extravagant gift – to people he had never met.

What Bashin found in Sirkin's home reminded him of his own difficulty in "coming out" as blind. Sirkin couldn't make the leap Bashin did. Instead, he hid. But he also did something else. He left his entire inheritance to a group of people who could have helped him, but didn't get the chance.

This story was produced for KQED's new podcast The Leap, co-hosted by Amy Standen and Judy Campbell. You can subscribe to the podcast through iTunes or Stitcher.

Copyright 2015 KQED Public Media. To see more, visit
Categories: NPR Blogs

A Doctor Wrestles With Whether To Keep Wearing His White Coat

NPR Health Blog - Sat, 11/21/2015 - 7:03am
Lorenzo Gritti for NPR

I remember being handed a white coat during my first year of medical school. It came crisply folded in a cellophane bag. I was told to wear it anytime we were in the hospital or with patients as a sign of respect.

There was no pomp about it. I took it home and tried it on. It was like putting on a costume and pretending to play doctor. The white coat continued to feel that way to me for a long time.

Over the years, the costume has become second nature and part of my clinical identity. I slip it on when I'm seeing patients, because when I've asked, most of them tell me they prefer it. The coat provides a mutual comfort to us both.

My, how times have changed. Now the vast majority of the nation's medical schools (along with more than 700 nursing schools and physician assistant programs) host special white coat ceremonies, in which new students are welcomed into their profession with a solemn ceremony invoking commitment to the healing arts. White coats are formally offered to students, and put on them by their school's leadership.

These ceremonies present an opportunity for the students and their families to mark the beginning of health careers in an educational and professional crucible that will challenge their ideals, empathy and compassion. "The iconography, the ritual of holding up members of the profession in this time of change must be maintained," says Dr. Richard Levin, president and CEO of the Arnold P. Gold Foundation, whose mission is to promote and maintain humanism in health care.

Now in the role of medical educator myself, I find anything that helps students stay connected with their highest ideals valuable in imparting a sense of professionalism. That's why it's disconcerting to think that our white coats are being challenged as possible vectors of infection.

A group of doctors in the field of infectious diseases has begun to rally around a mantra of "bare below the elbows," suggesting that health professionals avoid wearing white coats altogether, as is the custom in the U.K.

It turns out we don't wash the things nearly enough.

In a piece titled "It's Time for Doctors to Hang up their White Coats for Good," Boston-based infectious diseases specialist Philip Lederer argues that white coats have outlived their usefulness, both as guardians of cleanliness and as symbols of the profession.

Studies demonstrate the presence of harmful bacteria on our white coats, though evidence of direct harm to patients is lacking.

"We don't need a randomized trial to prove that parachutes save lives," Lederer told me. He prefers wearing khakis and dress shirts with the sleeves rolled up; no tie. He mentioned other docs who favor vests for their pockets and warmth, a trend some hope will catch on. And while Lederer supports the idea of a humanism-themed ceremony to welcome students into the profession, he and others suggest that even as a symbol white coats are more of a barrier than a conduit to strong doctor-patient relationships.

Levin counters that with all of the changes in health care, people in the field feel a tremendous sense of dislocation. "The idea of taking away [professional status] rather than elevating it is a problem for health care," he said. But taking away the coats wouldn't necessarily be a blow, he said, pointing to a study that challenges the notion that white coats are fundamentally elitist.

The debate over white coats has forced me to consider my own practice. In the end, I think the issue is as much about generational change as it is about infection control. I'd give up my white coat instantly if I knew it was spreading harmful bacteria. But colonization with bacteria is different from transmitting them to another person.

Bacteria live on all of us, so are white coats necessarily worse than our other garments or even our own skin?

It's likely that this debate will continue, unless patients were to somehow come to consensus on what they want doctors to wear. And that's not likely to happen anytime soon.

Until then, I vow to wash my white coat more frequently.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa's Medical Matters. He's on Twitter: @GlassHospital

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Categories: NPR Blogs
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