NPR Health Blog - Fri, 10/02/2015 - 1:11pm
Mothers have been warned for years that sleeping with their newborn infant is a bad idea because it increases the risk the baby might die unexpectedly during the night. But now Israeli researchers are reporting that even sleeping in the same room can have negative consequences: not for the child, but for the mother.
Researchers at Ben-Gurion University of the Negev wanted to see whether sleeping in the same room as their newborn affected mothers' or babies' sleep. The short answer: It did, and the effect wasn't good for moms.
The researchers recruited 153 married couples expecting their first child to participate in the study. The new parents weren't told where or how to sleep. They were simply asked to record whether they slept in the same room as their newborn, the same bed and same room, or if the child slept in another room.
To measure sleep patterns, both mom and baby wore wristbands designed to measure movement during the night, a measurement that gives a pretty accurate indication of sleep patterns for both mother and child. The researchers measured sleep patterns before the babies were born, at 3 months and at 6 months.
Mothers who slept in the same room as their infants, whether in the same bed or just the same room, had poorer sleep than mothers whose babies slept elsewhere in the house: They woke up more frequently (approximately three times per night versus two), were awake approximately 20 minutes longer per night, and had shorter periods of uninterrupted sleep (approximately 136 minutes versus 166 minutes). These results held true even taking into account that many of the women in the study were breast-feeding their babies.
Infants, on the other hand, didn't appear to have worse sleep whether they slept in the same or different room from their mothers.
The researchers acknowledge that since the families they studied were all middle-class Israelis, it's possible the results would be different in different cultures. Lead author Liat Tikotzky told Shots in an email that the research team also didn't measure fathers' sleep, so it's possible that their sleep patterns could also be causing the sleep disruptions for moms.
Right now, to reduce the risk of sudden infant death syndrome, the American Academy of Pediatrics recommends that mothers not sleep in the same beds as their babies but sleep in the same room. The Israeli study suggests that doing so may be best for baby, but may take a toll on Mom.
The research appears in the journal Sleep Medicine.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Fri, 10/02/2015 - 10:45am
What do you see in your community that helps you be heart healthy, and what gets in your way? People who live in the "stroke belt," an area in the Southeast with high rates of heart disease and stroke, can show you.
"The idea was to have community residents take photos of their individual take on the topic of barriers to heart health," says Sarah Kowitt, a study author and graduate student in public health at the University of North Carolina, Chapel Hill.
The teen and adult volunteers took photos of what they think creates barriers to good heart health in Lenoir County, N.C., where they live. The study, published Thursday in Preventing Chronic Disease, is part of Heart Healthy Lenoir, a community-based project aimed at creating long-term strategies to reduce heart disease in a community at high risk.
Lenoir County is rural, low-income and mostly African-American. While cardiovascular disease is the leading cause of death in the U.S., there are "big disparities in income and disease among African-Americans" when compared with people of other races and ethnicities, Kowitt says.
This was a tiny study, just nine adolescents and six adults. But just look at some of these photos, and what people have to say about them.Barriers To Good Health
"He wasn't raised where health was an issue in the household. There was nobody talkin' about health, probably nobody talking about not smoking or drinking or unhealthy practices, what it could lead to. There was nobody talkin' about that."National Center for Chronic Disease Prevention and Health Promotion
No Safe Place To Play
"We live on a busy road ... but if you branch off there's little neighborhoods like this. There's a branch where you can go ride your bike. But where we live at, you walk out [laughter] you won't be walkin' no more."National Center for Chronic Disease Prevention and Health Promotion
Candy At The Front Of The Store
"Have you ever noticed, like when you walk in the store, like most of the time right upfront where the cash registers are it's candy, candy. All the healthy stuff is in the back, and right upfront is the candy, so it's the first thing you see 'cause everybody knows you're gonna buy it 'cause it's good. It's advertised good. People like it!"National Center for Chronic Disease Prevention and Health Promotion
"What I'm showing here is the amount of fast-food places on [omitted] Avenue within a mile. I would say less than a half a mile! Four pizza joints ... you got Moons, then you got a steakhouse right next to it. So you get your Chinese food and then your greasy sub sandwiches here; Burger King's ... you have Bojangles; the Mexican joint."National Center for Chronic Disease Prevention and Health Promotion
In discussion groups following the photo sessions, adults and teens dug into these and other stressors in the community. Adults often pointed to racial prejudice and the stress it causes, saying that "as a people, this whole stress thing is new; we just think this is how it is."
Bottom line, the photos and discussion sessions started a conversation about the importance of heart health and the difficulties many people face in maintaining it. According to co-investigator Alexandra Lightfoot, participants saw this as an opportunity to explore barriers to good health and rally the community to bring about needed changes.
Some great ideas emerged, says Lightfoot, including ways to "entice residents toward the healthy food" section in grocery stores and fast-food establishments, initiate nutrition education in the schools and even encourage rap stars to incorporate positive health messages in lyrics. All a great beginning, they say, in getting the community involved in helping make positive changes that are good for the heart.
What hurts or helps your health? Show us. Post your photos on Twitter or Instagram with the hashtag #NPRmyhealth.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Thu, 10/01/2015 - 1:51pm
Laticia Aossey was hospitalized while a student at the University of Northern Iowa when she realized she hadn't signed up for health insurance.Matthew Putney/Courtesy of Youth Today
Laticia Aossey was flat on her back in an Iowa hospital bed with a tube up her nose, a needle for a peripheral IV stuck in one arm and monitors pasted to her body. It was early June 2014, a week after her 18th birthday, when a friend brought Aossey's mail from home — including one ominous letter. Aossey's health insurance was about to be discontinued.
"My heart dropped. I just wondered to myself, 'Are they going to pull this tube out, unhook me from everything and roll me down to the street?' " Aossey said. "Could I get the medicine I needed?"
When children "age out" of foster care at age 18 in Iowa, they are eligible to receive Medicaid under the Affordable Care Act until they turn 26. But Aossey, a ward of the state as a foster child, had not filled out the necessary paperwork. Then she fell ill with stomach ulcers, acid reflux and cyclical vomiting.
She was in college at the University of Northern Iowa in Cedar Falls, and instead of using her dormitory address she had used a friend's home address. The state Medicaid office sent the paperwork to complete her health care enrollment to her friend's address in Iowa City, so she did not receive it right away.
"The first call I made from the hospital to get it straightened out, the woman said, 'Your parents need to call,' " Aossey said.
"My parents? I was in foster care. I had no parents. Then she said my caseworker, an adult, my boss, somebody ... [other than] me had to call. She wouldn't talk to me. I was 18."
Aossey's doctors finally calmed her fears, and a couple of days later, she said, a caseworker arrived to help her complete the paperwork. She realized she could have managed that before things became complicated in the hospital.
"Be an adult," Aossey advises other foster youth. "Find a way to do your paperwork. Do not rely on other people for something you should do."
Aossey is one of 400,000 foster youth in the nation, and one of approximately 23,000 per year who age out of foster care when they turn 18 (or 21 in some states). They are all eligible for Medicaid, regardless of income, under the Affordable Care Act until 26.
Federal law requires states to cover former foster youth, and the federal government provides Medicaid matching funds to pay for it. But 21 states chose not to expand their Medicaid programs under Obamacare. And some states make enrollment for former foster youth easier than others.
"In some states, where the state is not embracing ACA in general, there wouldn't be a particular incentive for them to inform young people of their eligibility," says Celeste Bodner, founder and executive director of Foster Club, a national advocacy organization for foster youth. "If you want to call that a hostile environment, I don't think that is a stretch."
In California and New York, youth who age out of foster care are automatically enrolled in Medicaid. But even then, social services providers say they often need help figuring out health care.
The Jewish Child Care Association, which serves 750 foster youth of all faiths and backgrounds in New York City, puts significant resources into getting teens in foster care ready to be independent. A state-funded program includes guidance on filling prescriptions and managing health care.
"Navigating anything as a 20-year-old under the best of circumstances is tough and anxiety-provoking," said Ronald E. Richter, CEO of the JCCA and a former commissioner of New York City's Administration for Children's Services. "Not all 20-year-olds come in for help with a smile on their face. Systems are not built for an anxious, stressed out 20-year-old."
California automatically enrolls foster youth in Medi-Cal, its Medicaid program, but even that seemingly foolproof method has its glitches.
The Covered til 26 campaign, run by the advocacy organization Children Now, has tried to canvass the foster youth population, yet some slip through the safety net because of coding issues or questions about eligibility, changing addresses, incarceration, health issues and the sheer complexity of the system.
And in states without automatic enrollment, "What tends to happen when kids age out of foster care is that nobody tracks them, nobody keeps in touch with them," said Bodner, of Foster Club. "It is extremely difficult to get word out to kids age 18 to 26 who are eligible. It can be an issue because that 18 to 26 population is really tough to find, there is no master list or a mailing list. This group is particularly transient."
Many former foster children also would qualify for Medicaid based on income, but they may not be aware that they are eligible because of their foster status.
"It's a complete maze," said Bodner. "They get tracked into an income-qualification category as opposed to the automatic eligibility."
Medicaid coverage for former foster children takes the place of insurance coverage that other young adults are eligible for through their parents, according to Jessica Haspel, a senior associate who handles welfare policy for Children Now in California.
"These are youth that have experienced abuse and neglect and the state has become their parent," Haspel said. "It is giving them an equal protection other youth have had. It is about equity."
Ray Glier writes from Atlanta. This story was produced by Youth Today, the national news source for youth-service professionals, including child welfare and juvenile justice, youth development and out-of-school-time programming.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Thu, 10/01/2015 - 11:35am
Is that struck by macaw, initial encounter, or struck by macaw, subsequent encounter?iStockphoto
If you're struck by a macaw, sucked into a jet engine or are having relationship problems with your in-laws, fear not: Your doctor now has a medical diagnosis code for that.
On Thursday, doctors, hospitals and health insurers must start using the ICD-10, a vast new set of alphanumeric codes for describing diseases and injuries in unprecedented detail.Additional Information: ICD-10 Medical Codes
Some of the ICD-10's more infamous medical diagnosis codes:
- W61.33 pecked by a chicken
- Y08.01 assault by hockey stick
- R46.1 bizarre personal appearance
- W22.02XD walked into a lamppost
- T71.224 asphyxiation due to being trapped in a car trunk
- Z63.1 problems in relationship with in-laws
- V95.42 forced landing of spacecraft injuring occupant
- W61.12xA struck by macaw, initial encounter
The transition, mandated by the federal government, has been called American health care's Y2K moment, because the codes haven't been updated in 36 years. Doctors and hospitals are on high alert since the arcane letters and digits are key to how health care providers get paid. If they don't use the right codes, down to the decimal, they may not be paid sufficiently — or at all.
For months, health care insiders have been venting their frustrations with the changeover, posting Halloween-themed ICD-10 office decor on social media and mocking some of the wackier codes. Among the targets: W61.33 (pecked by a chicken), Y08.01 (assault by hockey stick) and R46.1 (bizarre personal appearance).
Not to mention W56.22xA — "struck by orca" — which became the title of an illustrated book of infamous ICD-10 codes that has sold nearly 10,000 copies, said its editor, Niko Skievaski of Madison, Wis.
"Basically everyone who works in health care interacts with this code system — it's really the language that's used to communicate from the clinical side to insurers," said Skievaski, whose experience at a health information technology company helped him and colleagues come up with the book idea. "These codes, they affect everybody."
Behind the gallows humor lies a major change in how health providers do business, albeit one that's nearly invisible to patients.
The codes doctors now must use to diagnose patients have multiplied from about 14,000 to nearly 70,000. Hospitals use a related set of medical procedure codes, which has grown even more — from 4,000 to about 72,000.
The reason for the change? The previous set of codes, ICD-9, which were in use since 1979, didn't reflect the complexity of modern medicine. And some of the information was wrong or obsolete.
The ICD-10 codes set a new bar for comprehensiveness. Did you break your shinbone? Your physician will need to figure out which among dozens of codes for a fractured tibia correctly identifies your injury. And if you've eaten toxic mushrooms, there are 18 potential codes to cover you.
Government and private insurers can reject claims that aren't specific enough, use the wrong codes or have a mismatch between a diagnosis and procedure code.
The ICD-10 changeover will be even more complicated in four states — California, Louisiana, Maryland and Montana — because of their antiquated billing systems. They have permission from the federal government to temporarily use the old codes, at least for their Medicaid billing, until their systems can be upgraded. California's upgrade is expected to be completed by 2017.
In Kaiser Permanente's 4 million-member health care region in Southern California, the transition involved revamping up to 30 computer systems and training about 10,000 employees, at an estimated cost of $15 million to $25 million.
"We're about as prepared as any region can be," says senior manager Larry Sharfstein, who has been leading the process.
A Pasadena "command center," a term generally applied in crisis situations, has been up and running since Monday.
So how does he feel now that the big day is here?
Sharfstein laughed. "I feel older," he said.
The ICD-10 codes used by doctors are based on the International Classification of Diseases, 10th edition, a list of medical classifications maintained by the World Health Organization. It contains codes for injuries and diseases and their causes and symptoms, along with patient complaints and socioeconomic circumstances.
While health organizations in the United States have long been preparing for the transition from ICD-9, the actual changeover date was delayed several times after some physicians and provider lobbying groups said they weren't ready.
Even with the additional time, some recent tests of the codes among early adopters nationwide resulted in about a fifth of the claims being denied because they weren't accurate or weren't correctly submitted, said Dr. Richard Thorp, the immediate past president of the California Medical Association.
In the small town of Paradise, Calif., 85 miles north of Sacramento, Thorp said his 18-person medical group is hoping for the best. It invested late last year in a new electronic health records system that should help with the transition. Even so, he remains skeptical that things will go smoothly.
"It's not going to be clear for three to six weeks whether there are going to be payment issues," he said.
If everything goes well, he said, "we'll just breathe a sigh of relief and go on doing what we really want to do — which is take care of patients."Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
NPR Health Blog - Wed, 09/30/2015 - 6:02pm
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The whole time, nurses will observe through large glass windows.
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None of the biocontainment treatment centers in U.S. hospitals were specifically designed for kids — until now. Texas Children's Hospital aims to fill that gap.Courtesy of Texas Children's Hospital
It's been exactly one year since the CDC confirmed that Thomas Eric Duncan had Ebola. He had flown from Liberia to Dallas to visit his fiancé, and became the first person diagnosed with the deadly virus on American soil.
During his stay at Texas Presbyterian Hospital in Dallas, two nurses also fell ill with Ebola. Duncan died, but the nurses survived, as did a handful of Americans who fell ill in West Africa but were transported back to the United States for care.
The Ebola outbreak in West Africa, and its spillover into the U.S., forced hospital officials to take a hard look at their readiness for a serious epidemic.
Within months the CDC designated 55 hospitals nationwide as future Ebola treatment centers, including two in Texas: the University of Texas Medical Branch, in Galveston, and Texas Children's Hospital in Houston.
For many of these hospitals, preparing to care for Ebola patients meant renovating rooms and increasing training and simulations for staff. But Texas Children's has built an entirely new unit for kids — a biocontainment wing with eight beds at its facility in suburban Houston.
"A year ago in the United States, there were only twelve beds for the entire country for patients that had a need to be isolated in a biocontainment unit," says Dr. Judith Campbell, medical director for infection control and prevention at Texas Children's. "And, not surprisingly, zero of those beds were designated for children."
The biocontainment unit is still under construction. Dr. Judith Campbell, a specialist in pediatric infectious disease, explains that a "pass-through window" will allow health workers to make some deliveries without having to don and doff the entire protective outfit.Carrie Feibel/Houston Public Media
Campbell helped design the special pediatric unit, which the hospital began planning after Duncan's death. The $16 million project, which includes a separate area with 10 regular pediatric beds, was paid for out of the hospital's capital funds and $1 million in donations.
Each of the eight patient rooms in the biocontainment unit has an antechamber, where doctors and nurses will put on protective gear, gloves and ventilated hoods. After treating the child inside the room, they will leave through a separate door and enter a third room, where they strip the equipment off.
The whole time, nurses will observe through large glass windows.
"So, if there's any question, they can say 'Wait, stop. You need to clean your hands again.' Or 'Wait, stop. Let's take this glove off more carefully,' " Campbell explains.
The unit has its own biosafety laboratory, so infected blood samples never have to be carried to other parts of the hospital. There's also a separate medical waste room, where carts full of used clothing and equipment can be wheeled inside 6-foot autoclaves. And, after every shift, medical workers will shower before leaving the unit.
Hospital officials say Ebola was the catalyst for the decision to build, but the unit is designed to handle any globe-trotting superbug.
"These rooms are equipped to take care of TB, MERS, pandemic influenza, bird flu and even a pathogen that we might not know what it is yet," Campbell says. "That's why we wanted to build something with the highest level of isolation ability." Before designing the unit, teams from Texas Children's visited adult biocontainment units at hospitals in Atlanta and Omaha.
The medical architecture in the new unit is impressive, says Dr. Amy Arrington, a pediatric intensive care specialist, but staff preparation is crucial, too. The initial training included 16 hours of learning how to maneuver in the awkward biocontainment suits – while still maintaining the emotional warmth and reassurance that's part of caring for a child.
Workers are still about a month from finishing up the 8-bed isolation unit at Texas Children's Hospital. The unit's goal is to provide for the special physical and emotional needs of kids with highly infectious diseases.Carrie Feibel/Houston Public Media
"I describe it as a space suit," Arrington says. The suit "has footies and arm holes and covers you up completely." Doctors and nurses who volunteered to work on the unit had to relearn skills — such as inserting IVs while wearing the suit.
"When you put three pairs of gloves on, you (can) lose sensation in your hands because they're so tight," says Arrington, "But you really lose that tactile feel that as physicians and nurses is really important in taking care of any patient, let alone a child."
As pediatricians and parents know, sick children not only need close monitoring, but also encouragement to eat and drink, and comfort when they are scared and confused. That can be harder in a pediatric biocontainment room — the parents of a very sick child will probably not be allowed inside.
But Campbell says Texas Children's Hospital is ready for that challenge, too. At least six doctors or nurses will be assigned to each child, and one of them will act as a family liaison. The kids will also be able to use tablet computers to talk with their families via video chat, and will be able to see them through the large windows.
The hospital is also developing a special doll that will wear a mini-version of the same biocontainment suit the doctors and nurses wear.
The goal there, Campbell says, is to soothe even the youngest kids, and help them understand, "Yes, we're dressed up a little differently, but ... their little doll has similar attire on."
The pediatric isolation unit is to be ready to accept patients in late October, with a formal ribbon-cutting expected in November.
This story is part of NPR's reporting partnership with Houston Public Media and Kaiser Health News.Copyright 2015 KUHF-FM. To see more, visit http://www.houstonpublicmedia.org.
NPR Health Blog - Wed, 09/30/2015 - 5:08pm
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The composition of the microbes living in babies' guts appears to play a role in whether the children develop asthma later on, researchers reported Wednesday.
The researchers sampled the microbes living in the digestive tracts of 319 babies, and followed up on the children to see if there was a relationship between their microbes and their risk for the breathing disorder.
In the journal Science Translational Medicine, the researchers report Wednesday that those who had low levels of four bacteria were more likely to develop asthma by the time they were 3 years old.
Specifically, the researchers focused on 22 children who showed early signs of asthma, such as wheezing, when they were 1-year-old. They were much more likely than the other children to have had low levels of the four bacteria when they were 3 months old. By the time they turned 3, most had developed full-blown asthma.
"The bottom line is that if you have these four microbes in high levels you have a very low risk of getting asthma," says Brett Finlay, a microbiologist at the University of British Columbia who helped conduct the research. "If you don't have these four microbes or low levels of these microbes you have a much greater chance of asthma."
Asthma is a common and growing problem among children. Evidence has been accumulating that one reason may be a disruption in the healthful microbes children get early in life, Finlay says.
"There's all these smoking guns like, for example, if you breast-feed versus bottle feed you have less asthma," he says. "If you're born by C-section instead of vaginal birth you have a 20 percent higher rate of asthma. If you get antibiotics in the first year of life you have more asthma."
The microbiomes of kids who aren't breast-fed and are born by cesarean section may miss out on getting helpful bugs. Antibiotics can kill off the good bacteria that seem important for the development of healthy immune systems.
"What's become clear recently is that microbes play a major role in shaping how the immune system develops. And asthma is really an immune allergic-type reaction in the lungs," Finlay says. "And so our best guess is the way these microbes are working is they are influencing how our immune system is shaped really early in life."
To further test their theory, the researchers gave laboratory mice bred to have a condition resembling asthma in humans the four missing microbes. The intervention reduced the signs of levels of inflammation in their lungs, which is a risk factor for developing asthma.
The bacteria are from four genuses: Lachnospira, Veillonella, Faecalibacterium and Rothia. The researchers aren't exactly sure how the microbes may protect against asthma. But babies with few or none of them had low levels of a substance known as acetate, which is believed to be involved with regulating the immune system.
Other scientists praised the work and said it provided additional evidence about how important it is for kids to get the right microbes in the first few months after birth.
"The microbes that babies have early in life are not accidental. They got a lot of them from their mothers. It's been going on since time immemorial," says Martin Blaser, who studies the human microbiome at New York University co-wrote a commentary about the research. The microbes help "choreograph early immune development," he says. "And if you mess with that, then the choreography is different. There could be disease consequences like asthma."
If the results are confirmed by additional studies, Finlay and Blaser say doctors could one day test babies to see if they're missing key microbes and replenish them, if so.
But a scenario like that is years away. In the meantime, Finlay and Blaser say more breast feeding, fewer C-sections and more careful use of antibiotics could go a long way toward nurturing the microbes babies need to avoid asthma and other diseases.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Wed, 09/30/2015 - 4:22pm
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The benefits of talk therapy for depression have been overstated in the scientific literature, according to a study in the journal PLOS ONE.
The finding comes several years after a similar study reached the same conclusion about antidepressant drugs.
Both talk therapy and antidepressant drugs "are efficacious," says Steven Hollon, a professor of psychology at Vanderbilt University and an author of the study, which was published Wednesday. "They're just not as efficacious as we think they are."
For each treatment, researchers found that the apparent effectiveness was inflated by publication bias. This sort of bias occurs when studies finding that a treatment works are more likely to be published than those with a negative finding.
"It's like flipping a bunch of coins and only keeping the ones that come up heads," Hollon says. The result is that anyone who reviews the published literature on a particular treatment will see a distorted picture.
The study of talk therapy involved a review of 55 National Institutes of Health grants awarded between 1972 and 2008. The grants paid for clinical trials of psychotherapy for depression.
But results from nearly a quarter of these trials were never published, says Erick Turner, a psychiatrist and researcher at Oregon Health and Science University and an author of both the 2008 study on depression drugs and the new one on talk therapy.
Turner and his colleagues were able to obtain the unpublished results from the researchers who did the trials. "And when you bring in the unpublished data it brings down the apparent efficacy of psychotherapy for depression" by about 25 percent, he says.
The new finding could help reverse an unfortunate side effect of the 2008 analysis of depression drugs, Turner says. After the study came out, it was used by critics of antidepressants to suggest that people with depression should avoid drug treatment.
"There was a wave of just simple antidepressant bashing that went on and has continued," Turner says. And the results were used to suggest that people with depression should choose talk therapy over drugs.
That made no sense to Turner. "Why should we be recommending this other treatment when it might be just as fraught with publication bias as the drug literature is?"
So Turner was happy to join Hollon and other researchers interested in finding out whether the psychotherapy research had the same bias as drug research.
The result of that effort should reduce unjustified criticisms of drug treatment, Hollon says. "This article if anything kind of evens up the playing field," he says.
Publication bias may have led psychiatrists and psychologists to be too optimistic about both talk therapy and drug treatment, Hollon says. But he says that's less likely to be a problem for patients.
"When people are depressed they are usually unduly pessimistic [about treatment]," he says. "The biggest problem we have in depression is getting people to avail themselves of treatment, whatever it is."
And the act of starting treatment produces a powerful placebo effect, which can make a big difference even if the treatment itself produces only a small benefit, Hollon says.
Of course, publication bias isn't limited to depression treatments. It's a widespread problem throughout the research world, says Kay Dickersin, a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health.
"We're rewarded for getting papers out, for finding results that will bring attention to our universities and to ourselves," she says. "We aren't rewarded for being honest; we're rewarded for making a splash."
And that presents a challenge both to doctors and to their patients, Dickersin says. "I think the question that's really arisen is, how much of what's out there should we really believe."
One solution, Dickersin says, is to have research grants include a requirement that all study results be made public, even if they're never published.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Wed, 09/30/2015 - 3:01pm
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A surgical team at Sooam Biotech in Seoul, South Korea, injects cloned embryos into the uterus of an anesthetized dog.Rob Stein/NPR
The Sooam Biotech Research Foundation's sleek marble building is on the outskirts of Seoul, South Korea. After passing through a guarded gate, visitors climb the steps to the entrance and a big door with tinted glass slides open.
"Hello, sir. Nice to meet you, sir," says David Kim, a researcher at the laboratory. "You can follow me. We can go into the clean room. It's the laboratory where we do the procedures — the cloning."
Sooam Biotech is the only lab in the world that makes genetically identical copies — clones — of dogs for pet owners. Nearly 20 years ago, when Dolly the sheep became the first mammal ever cloned from a mature cell taken from an adult animal, many people feared the advance would lead to human cloning.
That hasn't happened. But scientists have cloned several other species since, including cattle, rabbits, mules and cats. The success rates and health of the cloned animals has varied from species to species; Sooam's scientists seem to be the only ones to figure out how to clone dogs.
For $100,000, anyone who has a cell from any dog can attempt to get a clone. The lab says it has cloned more than 600 dogs so far. Many of these clones are created for grieving pet owners, but some are being used by police agencies, including the South Korean National Police Agency.
Dr. Hwang Woo Suk founded Sooam's dog cloning service. But he is better known for announcing in 2004 that his research team had cloned the first human embryos. Other scientists found that claim to be fraudulent.Rob Stein/NPR
Sooam's dog-cloning service is controversial. It was started by Hwang Woo Suk, who became a scientific pariah in 2006, when his claim that he had created the first cloned human embryos in 2004 to produce human embryonic stem cells was discovered to be fraudulent.
But no one doubts that Hwang is cloning dogs. The big question is: Why? For the money? To fund other research? To reclaim the spotlight? Hwang refused several requests by NPR for an interview, but he agreed to let me tour the facility with Kim, to see how the process is done.
After we change into rubber slippers and blue jumpsuits, Kim leads me into a darkened room that's crowded with technicians peering into microscopes. Kim points to a flat screen on the wall that shows a live feed of what's happening in a petri dish under one microscope. There's a big blob near the center of the dish.
"What you see here on the screen is the egg," Kim says, explaining that to clone one dog, scientists start with an egg from another dog. "The small, blue shining dot that you see is the genetic material, which we will take out now."
A technician gently pierces the egg's outer membrane with a tiny glass tube and withdraws the genetic material.
A Sooam Biotech technician prepares to zap an egg that's been re-injected with a skin cell from a donor dog. The tiny shock can be enough to prompt the egg to start dividing and developing into a viable dog embryo.Rob Stein/NPR
"We can see how the DNA is being extracted," Kim says. "So now, what we are left with is a blank egg, in a sense."
Next, the technician injects another tiny blob into the blank egg. It's a skin cell from the animal that's being cloned. A single skin cell contains all the DNA needed to create a genetically identical clone.
"We will insert one cell per egg," Kim says. "With this, the procedure is done."
Well, almost. After that another technician zaps the egg with a tiny bit of electricity.
"After you zap it, it will start developing — dividing and developing — into an early embryo," Kim says. "It's at the stage of early embryonic development."
Within days, if all goes well, the embryos will be ready for transfer into the uterus of another female dog — a surrogate mother.
Kim heads to another part of the lab, stopping on a platform in front of a huge window that overlooks an operating room. Two big brown dogs lie unconscious on tables, each mostly covered by a green tarp. The dogs have tubes down their throats, and their long, pink tongues dangle to the side.
A half-dozen people in blue scrubs and surgical masks scurry around; bits of conversation are audible through a monitor on the wall.
"Are you ready?" one of the surgeons asks the team. He leans over a small opening in the tarp and makes an incision that will give him access to the dog's ovaries.
"We are going to flush out the eggs," Kim explains.
After a few minutes, when the surgeon steps away from the operating table and pulls down his mask, I can see that it's Hwang Woo Suk — the scientist who runs the lab.
"We got 15 eggs from both sides of the ovaries," Hwang says.
They'll take those eggs back to the microscope room, in hopes of turning them into cloned dog embryos.
Hwang moves over to the second dog and starts cutting. She's there to become the surrogate mother for a cloned puppy.
"This is our final process of embryo transfer — using an embryo-loaded catheter," Hwang explains.
After just a few seconds he's injected several previously created embryos into the dog's uterus and steps away from the table.
A litter of puppies created at Sooam Biotech. Though clones share the same genes, they aren't exact replicas; developmental changes have an effect on markings, for example.Ron Stein/NPR
"Hopefully we can get cloned puppies after 61 days," he says. That's how long a dog pregnancy usually lasts.
The next stop on the tour is a long, bright kennel room. Puppies paw at the glass doors of each stall — a Boston terrier bound for the United States, a black female pug, a couple of male Pomeranians and a pair of Yorkshire terriers headed for Ireland.
Some newborn cloned puppies are still with their surrogate mothers in another kennel downstairs, in the process of being weaned. Others are outside getting some exercise. All the animals look healthy and happy. But critics have some big concerns about this procedure.
For one thing, this cloning process works only about a third of the time. So, getting a cloned puppy entails a lot of attempts and a lot of miscarriages. And the process requires many dogs — some to provide the eggs, and others to serve as surrogates.
"I think you really need to think twice about it in terms of animal welfare," says Insoo Hyun, a bioethicist at Case Western Reserve University. "Dog owners should really be aware of the potential harm to dogs that could be produced during this process."
What's more, most cloned animals end up pretty sickly — which raises further questions about the cloning process.Shots - Health News Cloning Your Dog, For A Mere $100,000
"The cloning process is imperfect. It doesn't completely reset the DNA to an embryonic state," Huyn says. "So depending on how imperfect that process is, you have different ailments that will befall the dog — many of them might die at an early age."
And even when the process works perfectly, the cloned animals aren't exact replicas of the originals. Environmental influences, including some that help determine when particular genes are turned on and off during development, play a role in how closely the resulting clone mimics the the original dog.
"They may not even look like your beloved pet," Hyun says.
Hyun also worries that Hwang is using his dog-cloning services as a way to try to rehabilitate his career and eventually be allowed to return to doing research involving human cells.
"I'm a little bit wary of the idea that he's still trying to do research and publish in scientific journals," Hyun says. "And some have even suggested that over time, he may make a comeback in the human research arena. I just don't think someone like him can be trusted to follow the rules appropriately."
Although reputable scientists say Hwang committed fraud, he has always maintained that he did clone stem cells; during the tour Kim shows off what he claims is the original line of these cells.
Kim also says all cloned dogs born so far have been perfectly healthy — and almost always look and act a lot like the dogs they were cloned from. Kim also says Sooam Biotech takes good care of the donor and surrogate dogs, though he wouldn't say where the lab gets these animals or what happens to them after they are no longer needed.
Kim tells me the lab is using the cloning techniques its staff developed to clone dogs for other research — including creating animal models of Alzheimer's disease and diabetes, in hopes of finding treatments for the human illnesses.
Scientists at Sooam are also trying to save endangered species, Kim says, and even hope to one day re-create extinct ones — like the woolly mammoth.
In response to those who question the dog research, Kim says Sooam is just offering something that people want.
"Among the domestic animals that share a deep relationship with humans, you know, they say that dogs are a man's best friend," he says. "So there is a demand for it."Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Wed, 09/30/2015 - 11:08am
Correctional facilities have to provide health services to people who are incarcerated, but that doesn't mean the care is free of charge. In most states, inmates may be on the hook for copayments ranging from a few dollars to as much as $100 for medical care, a recent study finds.
At least 35 states authorize copayments and other fees for medical services at state prisons or county jails, according to the analysis by the Brennan Center for Criminal Justice at New York University School of Law.
The Federal Bureau of Prisons also permits inmates to be charged copayments for medical services. Some states and local governments require copayments for emergency treatment and hospitalizations in addition to routine care, says Lauren-Brooke Eisen, senior counsel at the Brennan Center's justice program who authored the study.
"It's understandable why jurisdictions need to increase their revenue," says Eisen. "From a public policy standpoint, however, the fees can serve as a deterrent to getting care."
The practice is part of a larger trend of charging inmates for prison services, says Eisen. In addition to medical copayments, more than half of states allow prisoners to be charged room and board while incarcerated. They generally also charge for incidentals like phone calls and Internet use.
In addition to raising money, prison officials hope that by imposing fees they'll reduce demand for services, says Dr. Robert Greifinger, a former chief medical officer of the New York Department of Corrections who works as a correctional consultant.
But fees, even small ones, may not only deter prisoners from making requests for care that prison officials consider frivolous, they may also deter necessary care to keep chronic conditions in check or treat communicable diseases that could easily spread through crowded prisons.
An estimated 80 percent of prisoners are poor. Medical copayments typically come out of their commissary accounts, which are often funded by money provided by their families and earnings from prison jobs.
"Prisoners don't have money; they're getting $20 a month from their family," says Greifinger. "If they deplete that for medical care, they don't have money for underwear, soap or food."
In a landmark 1976 case, Estelle v. Gamble, the Supreme Court held that not providing adequate medical care to prisoners was a violation of the Constitution's Eighth Amendment against cruel and unusual punishment. But courts have generally allowed prisons to attempt to recoup some of the costs of treating inmates by charging them for their care.
At the Bernalillo County Metropolitan Detention Center in Albuquerque, inmates can see a nurse on a walk-in basis rather than having to put in a written request first. The process, implemented two years ago, is intended to give inmates better access to health care services, says Phillip Greer, chief of corrections at the center. Still, sometimes inmates misuse the system and copayments are one way to discourage that, Greer says. Prisoners generally pay $3 to see a nurse and $5 for a doctor visit. If they can't afford to pay, they're not charged, he said.
State spending on prison health care grew to $7.7 billion by 2011, with increases of more than 13 percent in half of states, according to an analysis by the Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation.
But inmates, many of whom are uninsured when they enter prison, often don't get the care they need. Among inmates with chronic medical problems, many didn't receive a medical exam while incarcerated, including 68 percent of local jail inmates, 20 percent of state prison inmates and 14 percent of federal prison inmates, a 2009 study published in the American Journal of Public Health found.
Dr. Josiah Rich, professor of medicine and epidemiology at Brown University, conducts a weekly clinic at the Rhode Island Department of Corrections in Cranston. Prisoners pay a few dollars if they make an appointment to see him. But if the doctor initiates the appointment rather than the prisoner, it's free of charge, says Rich, who is also co-director of the Center for Prisoner Health and Human Rights.
Recently the prison announced that if a doctor orders Tylenol, a topical cream or other over-the-counter treatment, those items will have to be purchased by the prisoner with commissary funds rather than provided through the prison's medical service at no charge, Rich says.
"Charging prisoners for health care is yet another way of kicking them when they're down," Rich says.Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
NPR Health Blog - Wed, 09/30/2015 - 6:33am
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Ken (left) and Henry were created using DNA plucked from a skin cell of Melvin, the beloved pet of Paula and Phillip Dupont of Lafayette, La.Edmund D. Fountain for NPR
It's a typical morning at the Dupont Veterinary Clinic in Lafayette, La. Dr. Phillip Dupont is caring for cats and dogs in the examining room while his wife, Paula, answers the phone and pet owners' questions. Their two dogs are sleeping on the floor behind her desk.
"That's Ken and Henry," Paula says, pointing to the slim, midsize dogs with floppy ears and long snouts. Both dogs are tan, gray and white, with similar markings. "I put a red collar on Ken and a black collar on Henry so I can tell who's who."
Ken and Henry are genetically identical, though not exact replicas. They're clones of the Duponts' last dog, Melvin — created when scientists injected one of Melvin's skin cells, which contained all of his DNA, into a donor egg that had been emptied of its original DNA.
Ken and Henry are two of only about 600 dogs that have been cloned since scientists at Sooam Biotech, a suburban company near Seoul, South Korea, developed the technology to create cloned canines.
The Duponts sat down with Shots to explain why they decided to clone Melvin.
Two years ago, Paula and Phillip Dupont paid $100,000 to have their mutt Melvin cloned by a laboratory in South Korea. They are so pleased with the results they may do it again.Edmund D. Fountain for NPR
"He was different," says Phillip Dupont. "Of all the dogs I had, he was completely different."
Melvin was supposed to be a Catahoula leopard dog, Louisiana's state dog (sometimes called a Catahoula hound). Turned out, Melvin was a mutt, probably part Catahoula and part Doberman.
"I paid $50 for him," says Phillip. "But I wasn't going to return it. I thought for a while I was going to put him to sleep." Then he changed his mind. "Turned out to be the best dog I ever owned."
Phillip Dupont says losing his original dog Melvin (far right) was very hard, but Ken (far left) and Henry — two clones made from Melvin's skin cells — have helped a lot with the grief. The dogs' slightly different markings reflect differing environmental influences.Courtesy of Paula Dupont
The Duponts have lots of stories about what made Melvin the best dog they ever owned, including the time Melvin found car keys Phillip had lost in the tall grass. The couple trusted the dog so much they let him babysit their grandson in the backyard all by himself.
"He listened," says Phillip. "You could talk to him and you swore he understood what you were talking about. It was weird."
So a couple of years ago, when Melvin was about 9 and starting to show his age, the Duponts turned to a lab in South Korea. Even though the process would cost them $100,000, the couple decided to do it. They'd already spent that much on a Humvee, Phillip notes. "So, what the heck?"
He sent some of Melvin's skin cells off to the lab — the only place in the world that is cloning dogs for pet owners. The first cloned puppy soon died from distemper. The lab tried again, this time producing two healthy clones.
Subtle differences notwithstanding, Ken and Henry "are so much like Melvin, it's unreal," says Phillip Dupont.Edmund D. Fountain for NPR
For a while it was like having three Melvins. The personalities of the dogs, the Duponts say, are very similar. But less than two years later, Melvin's time came.
"It was hard," says Phillip, choking back tears.
Having the clones — Ken and Henry — helped the couple cope with the loss.
"They come running through the house and jump in your lap — a 75-pound dog sitting in your lap, watching TV." They still miss Melvin, they say, but having two more dogs so similar to him has helped "quite a bit."
Most of the dogs cloned so far have been for grieving pet owners. Some have been for police agencies looking for special skills — bomb-sniffing, for example.
Cloning a canine requires that other dogs — donors and surrogates — undergo surgery. But the results are worth it, say the Duponts, playing here with Ken and Henry outside the couple's veterinary clinic in Louisiana.Edmund D. Fountain for NPR
But not everyone thinks this idea is so great.
"If you love dogs and you really want to have your companion animal cloned, you really do need to take very seriously the health and well-being of all the dogs that would be involved in this process," says Insoo Hyun, a bioethicist at Case Western Reserve University.
To clone a dog you need to use a lot of other dogs to serve as egg donors and surrogates, Hyun explains, and that means many dogs are undergoing surgical procedures. Most of the time the process doesn't work; many attempts are required to produce a single clone.
"I think there are probably better ways to spend $100,000 if you really care about animals," Hyun says.
The Duponts expected only one puppy, but the lab in South Korea eventually got three viable embryos from the cloning process. The first puppy died right away from distemper, but Ken and Henry both seem healthy.Edmund D. Fountain for NPR
He also wonders about the health of Sooam's cloned puppies. Most cloned animals end up pretty sickly — all that for a dog that isn't even an exact replica of the original.
"All cloning does is reproduce the genome of your original pet," Hyun explains.
"But maybe the way your dog interacted with you — and even the way it looks — was also strongly environmentally influenced." You can never duplicate that kind of influence, Hyun says.
When pressed about how much the clones are really alike, the Duponts admit there are little differences, much as differences show up among identical twins. The white stripe on Henry's nose is a lot wider than Ken's, and Henry weighs a bit less. Ken is more of a loner. But that's about it for differences, the couple insists.
"They're so much like Melvin it's unreal," Phillip Dupont says. So far, he adds, both clones seem perfectly healthy.
As far as whether other dogs suffered in creating theirs — the Duponts dismiss that notion, based on what they saw at the lab when they visited twice to pick up their clones.
"Even though South Koreans eat dogs, they love their pets," Phillip says. "They've got rooms for these dogs to sleep in, with beds. They've got technicians who sleep with the dogs. And [the dogs] are all well cared for."
He says the lab staff told him that after dogs have served as donors or surrogates, "they're fixed up and go to new homes." (Sooam Biotech did not confirm or deny that assertion when NPR asked what happens to the dogs the company uses as donors and surrogates).
The Duponts also say they don't feel bad about spending so much money to create cloned dogs, when so many other dogs need homes.
There will always be strays on the road and too many dogs at the animal shelter, because irresponsible owners don't spay or neuter their pets, Paula says. In contrast, she says, families that clone their pets don't do it "with the idea of producing 10 more. We're looking at having the one special dog again."
Or, in their case, two special dogs again, and maybe one more. The Duponts are already talking about cloning Melvin again — for their grandson.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Wed, 09/30/2015 - 5:02am
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Nurses Patricia Wegener (left) and Susan Davis at Mercy Hospital can monitor the condition of a patient who is miles away via the hospital's technology. But some health insurers and analysts remain skeptical that telemedicine saves money.Alex Smith/KCUR
Say you're a Midwestern farmer in a hospital bed, recovering from surgery or a major illness. It's time for the nurse's check-in, but there's no knock on the door.
At Mercy Hospital in St. Louis, a camera attached to the wall over the foot of the bed whirls around, as a video monitor next to the camera lights up to show a smiling face with a headset on.
"Good afternoon, this is Jeff with SafeWatch," the smiling face says. "Just doing my afternoon rounds."
It's a little hard to shake the Jetsons vibe in this telemedicine training exercise, but this kind of health care isn't just futuristic; it's happening now and expanding. On Oct. 6, Mercy Hospital will open its new telemedicine mothership. The idea isn't so much to keep closer track of patients at the St. Louis hospital, as to treat thousands of patients spread across five states.
The new facility will offer an increasing number of patients in remote parts of the rural Midwest and South the sort of detailed health monitoring offered at large, well-staffed hospitals in cities and suburbs, says Tom Hale, the executive medical director of Mercy Virtual.
"You can monitor their heart, their blood pressure, their respiratory rate, their temperature on a 24/7 basis," he says. "You can monitor their position — so you can tell if they've been out of bed. You can tell if they've turned in bed."
He says the quality of telemedicine can be high, and it's cheaper than in-person care. Hale and his team now largely provide care for patients in rural areas, but the use of their system may soon extend quickly to a different group of patients: baby boomers anywhere who want to stay in their homes instead of moving to a nursing facility when their need for health care increases.
Industry analyst Sarah Turk of IBISWorld says that expanding population could propel telemedicine to a $3.5 billion industry by 2020.
"Coverage will be expanded to include more physicians and more specialties and also a range of communications," Turk says. "So instead of it being only interactive video consultation, it could be text messaging as well."
Still, the telemedicine boom faces some big challenges, she says. Many insurance companies have been slow to pay for these services. Medicare, the largest health insurer for Americans over 65, is a financial powerhouse; insurance companies often follow Medicare's lead in determining which treatments and procedures they'll cover.
Right now, Medicare only covers the use of telemedicine in rural or medically underserved areas, and only when video conferencing is used. But telemedicine has broadened as the technology has developed. Now that doctors and nurses could use a smartphone app to, say, monitor their patient's falls in the home, insurance companies and Medicare need to rethink their payment criteria, proponents say.
But Dr. Ashish Jha, a health policy analyst and professor at the Harvard T.H. Chan School of Public Health, says insurance companies have good reason to hesitate and be skeptical.
"If telemedicine really saved money, payers would be falling over themselves paying for this stuff, right?" Jha points out. "Because it would actually benefit their bottom line."
Telemedicine does seem to provide good access to quality medical care, he says. But even though it could save money, that's not what's happening.
"It tends to be an addition," he explains. "You do the telemedicine; it leads to more tests. It leads to more follow-up visits. And, over time, when you look at the data, it turns out that telemedicine overall is not necessarily a big cost saver."
Nonetheless, executives at Mercy Hospital are betting that expanding their use of telemedicine will be a good deal. With its new facility, the hospital can monitor nearly 7,500 acute-care beds in five states, and the plan is to keep expanding.
This story is part of NPR's reporting partnership with KCUR and Kaiser Health News.Copyright 2015 KCUR-FM. To see more, visit http://www.kcur.org/.
NPR Health Blog - Tue, 09/29/2015 - 7:03pm
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But here's the surprise: Even the adults who had lower distress levels were at higher risk of chronic illness if they had experienced higher levels of distress during childhood.
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The large British study, begun in 1958, tracked the diet, habits and emotional and physical health of thousands of people from childhood through midlife.iStockphoto
We might not be able to remember every stressful episode of our childhood.
But the emotional upheaval we experience as kids — whether it's the loss of a loved one, the chronic stress of economic insecurity, or social interactions that leave us tearful or anxious — may have a lifelong impact on our health.
In fact, a study published this week in the Journal of the American College of Cardiology indicates that emotional distress during childhood — even in the absence of high stress during adult years — can increase the risk of developing heart disease and metabolic disorders such as diabetes in adulthood.Shots - Health News Take The ACE Quiz — And Learn What It Does And Doesn't Mean
"We know that the childhood period is really important for setting up trajectories of health and well-being," explains Ashley Winning, an author of the study and postdoctoral research fellow in social and behavioral sciences at the Harvard T.H. Chan School of Public Health.
To assess the connection between childhood stress and the risk of disease, Winning and her colleagues analyzed data from the 1958 British Birth Cohort Study, a long-running study that documented the diets, habits and emotional health of thousands of British children born during the same week that year.
As the children entered school, the classroom became the laboratory for observation.
"Teachers collected a lot of information — assessing signs and symptoms of distress," Winning explains. "The teachers were checking off [answers to questions such as]: 'Was this child tearful or sad?' " Teachers completed a 146-item assessment.
Teachers evaluated each child at ages 7, 11 and again at 16. After that, as the participants grew older they completed their own assessments of the stress in their lives at ages 23, 33, and 42.
When the participants turned 45, they underwent a biomedical assessment to measure markers of metabolic and cardiovascular health — as well as immune function.
Using these data from 6,714 participants, Winning and her colleagues analyzed the relationship between stress and the risk of various chronic diseases.
"Not surprisingly, those with persistent distress — so, both in childhood and adulthood — had the highest risk," Winning says.Shots - Health News 10 Questions Some Doctors Are Afraid To Ask
But here's the surprise: Even the adults who had lower distress levels were at higher risk of chronic illness if they had experienced higher levels of distress during childhood.
"It's very interesting that early-life experiences seemed to be such an important predictor [of disease risk]," says Aric Prather, a research psychologist in the department of psychiatry at the University of California, San Francisco. Though the study can measure only correlation, not causation, it dovetails with other findings. And the large number of people it tracked for many decades make its findings worth paying attention to, scientists say — and worth following up on with other kinds of research.
Prather, who also studies the links between psychology and immunity, says the mechanisms by which early-life experiences influence health are complicated and not yet completely understood.
"There's certainly growing evidence that there may be some biological embedding that takes place," Prather says.
In other words, it's possible, he says, that when people experience early-life stress "it actually changes something about them biologically." Stress may influence how genes get switched on or off, for instance, or may initiate some other physiological effects.
There's still a lot to learn, but this much is clear, Prather says: "The mind and the body are much more tightly related than we used to believe."Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Tue, 09/29/2015 - 2:35pm
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Reflections of a Street Doctor
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As a doctor who provides medical care to Boston's homeless population, James O'Connell and his colleagues are used to working in unusual locations. "We are basically visiting them in their homes, which are often under bridges, down back alleyways [and] on park benches," O'Connell tells Fresh Air's Terry Gross. "It's been an education for us over these years."
O'Connell is president of the Boston Health Care for the Homeless Program, which provides health care services at over 65 sites, including adult and family soup kitchens, detoxification units and corrections facilities. He writes about his practice in a new memoir, Stories from the Shadows: Reflections of a Street Doctor.
O'Connell has been caring for Boston's "rough sleepers," or homeless, since 1985. He says that homeless patients suffer from the same chronic and acute illnesses as the general population — with one crucial difference. "What we see ... frequently, are regular issues that have been neglected for years and years," he says. "So we see the natural history of illness that is usually interrupted by good preventive care."
Over the years, O'Connell has seen the ravages of untreated frostbite, AIDS and diabetes, as well as the effects of profound isolation and extreme loneliness. But he has also witnessed a courage and resourcefulness in his patients.
"These are people who are nameless and faceless when they are sitting out in the street," he says. "But when you get to know them, they are stories of great courage, of struggles against unbelievable adversity. ... I think I probably would've been a broken person had I lived through what they lived through."Interview Highlights
James O'Connell is the president of the Boston Health Care for the Homeless Program. He is also an assistant professor of medicine at Harvard Medical School.Roger Farrington/BHCHP
On suspending judgment
I remember what came across is that whatever I thought of someone, when I first met them or first walked by them, it rarely panned out once I got to know them, and the stories that emerged from these people, what they have lived through and as you learn, each one is very different from another, but each one has a remarkable story. ... I hope in these stories what emerges is the real resilient spirit of people who have really, really been dealt a bad hand in life and suffer from all those social determinants of poverty.
On the result of homeless people not receiving good preventive health care
We ... see the end stage of many things. We often see pneumococcal pneumonia, for example, which probably should've been treated on Day 1 or Day 2; by Day 7 or Day 8 it can be very, very devastating. ...
As we learned the hard way ... these are people who were struggling to survive outside on the streets. They're interested in just being safe today or just getting the next meal or just getting a bed for the night. Taking care of an infection in their foot or diabetes or their hypertension is way down the list of priorities, which, of course, is really difficult for us doctors who think that should be the top of the list.
On the extreme illnesses he's seen
We see dramatic things that I never saw in medical school or often even in the textbooks. During this past year [we] have watched a man who had been outside for a very long time who has a pretty difficult psychotic disorder who got frostbite on both feet, really severely, came into our respite facility where we cared for him and he elected to not do surgery, and we spent the past year watching his feet fall off from auto-amputation, which is what happens at the end stages of frostbite. Most of our staff, including our nurses, had never seen anything as dramatic as that.
We will also see tuberculosis, things that you would be used to seeing in a Third World country much more than an inner city of a very medically rich world. We see all of the end stages of AIDS neglected because people were not able to get to treatment. ... If you are caring for a homeless population, you are really seeing the really both exotic illnesses as well as the end stages of chronic, common illnesses.
On hidden homeless communities
Even after I had been doing this job for almost 15 years thinking I knew every nook and cranny of the city of Boston, somebody pointed out to me that there were 20 people living in a tunnel under Copley Square. ...They came out only at nighttime; they spent their days down in the tunnels. And I remember going down there and meeting all these people for the first time and being stunned that most of them had been there the whole 20 years that I had been out. We always think we know a lot, but we keep our minds open to finding there's always a new place where someone can be.
On trauma homeless women face
For women to get to the streets we know that the journey is one that is very complex and almost always full of unspeakable trauma — sexual, physical and emotional trauma — and, so, by the time women are on the streets, they are really suffering, and those who become pregnant often feel despair, discouraged, feel they have no place to go, and feel very attached to having the baby safely and in a good way.
So we found that pregnancy often is not only alarming for the women, but it's a place where they can actually take stock of their lives and try to come in, so we always try to provide as much service ... gentle service as we can to anyone who is pregnant on the street, so they can deliver a good baby and hopefully hang on to that baby.
Unfortunately, many of the women, if you speak to them on the street, have had many children, all of whom they've lost to social services, because they were unable to stop using or they had no place to bring the baby once the baby was born. There's an awful lot of trauma among the women on the streets about the children they have lost and mourn.Copyright 2015 Fresh Air. To see more, visit http://www.npr.org/programs/fresh-air/.
NPR Health Blog - Tue, 09/29/2015 - 1:35pm
Before they were removed following an outcry over privacy, backscatter X-ray security scanners at airports also raised worries among some travelers and scientists about exposure to potentially harmful radiation.
After all, the machines use ionizing radiation to produce those very graphic body images. Now, with the Transportation Security Administration considering redeploying a second generation of such scanners, a report released Tuesday allays some concerns while leaving other questions unanswered.
The machines, pulled in 2013, expose travelers and airport workers to a dose of radiation well within acceptable limits — a factor of 10 below recommended safety standards — concludes the National Academies of Sciences, Engineering and Medicine, a private nonprofit organization chartered by Congress to provide expert technical advice.
Even in a worst-case scenario, the report says, if the device malfunctioned and focused the beam on one part of the body, it would not cause tissue damage or result in overexposure.
The scanners were installed in airports in 2008 as secondary screening devices but were stepped up to the primary method after a passenger tried to set off a bomb in his underwear on a 2009 Christmas Day Northwest Airlines flight.
One at a time, passengers step inside the scanners, plant their feet hip width apart, and raise their arms, as if surrendering. A panel slides back and forth and, seconds later, the scan is completed. The committee studied two devices, a Rapiscan Secure 1000 and an AS&E SmartCheck scanner, that are now in storage.
The airport scanners currently in use rely on radio waves — rather than ionizing radiation — to produce images, which are displayed on standard outlines of human bodies, instead of depictions of a person's actual physique, as was the case with backscatters.
The study, called for by the Department of Homeland Security, followed legislation introduced on Capitol Hill in 2012 seeking additional review, as well as concerns by some scientists that the devices — whose radiation doesn't penetrate the skin as deeply as medical X-rays — could nonetheless pose a skin cancer risk or other problems.
Four experts from the University of California, San Francisco wrote the assistant to the president for science and technology in 2010, saying existing research wasn't adequate and that the devices might pose a skin cancer risk.
While it found the dose to the skin is not elevated, the report may not end the debate.
"I don't know if anything could," said Harry Martz Jr., director of the Nondestructive Characterization Center at the Lawrence Livermore National Laboratory in California. Martz was chairman of the committee of scientists, physicists, statisticians and other experts who wrote the report.
That's partly because the NAS committee was specifically directed not to analyze whether the safety standard — set by the American National Standards Institute/Health Physics Society — is adequate.
So are the machines safe?
"We were not asked if they were safe or not, just whether they meet the standard," said Martz.
The committee was also specifically barred from commenting on whether the TSA should use the machines even though the radio wave alternative exists, which doesn't use ionizing radiation.
That the dose of radiation falls well below safety thresholds — and is less than what a body absorbs from cosmic radiation while flying across the country — is not surprising but is only one part of the equation, said David J. Brenner, director of the Center for Radiological Research at Columbia University Medical Center. He didn't work on the report but has seen a copy.
"If you're going to travel in an airplane, you can't really avoid the radiation from cosmic rays. But there is an alternative to this radiation exposure [from X-ray scanners]," Brenner said. "The fact that we have other risks in our lives doesn't mean we shouldn't try to minimize those that we can."
Earlier studies generally found the devices provide a level of radiation well below health and safety standards, the report noted. After conducting its own tests using additional research methods on the two scanners, the committee concluded that the dose absorbed even by small children or developing fetuses would not exceed the standard.
It cautioned that any second-generation machines should have a way to ensure that they do not screen a traveler longer than the short time needed to get an image — and that daily tests on the scanners are used to check that they are operating within limits.http://www.kaiserhealthnews.org/.
NPR Health Blog - Tue, 09/29/2015 - 12:01pm
When Angelina Diaz-Ramirez, an immigrant farmworker from Mexico, suffered a heart attack, no one at the hospital could explain what was happening to her. She speaks Triqui, an indigenous language in southern Mexico.Jeremy Raff/KQED
Angelina Diaz-Ramirez had no idea a surgeon was about to cut open her chest. The 50-year-old had been rushed to the hospital from the California field where she worked picking green beans. Doctors said she had a heart attack and that they would do surgery to install a pacemaker.
But Diaz-Ramirez, an immigrant from Mexico, doesn't speak Spanish or English. She speaks Triqui, an indigenous language. And the hospital had no one who could translate the doctors' words for her.
"None explained anything to me," said Diaz-Ramirez. "I was scared, but I didn't have a choice."
She's not alone. One-third of farmworkers in California speak indigenous languages from southern Mexico, including Triqui and Mixteco. Many don't speak Spanish or English.
Interpreters are "absolutely necessary," said Alicia Fernandez, a medical interpretation expert at the University of California, San Francisco. Quality health care and basic informed consent can be nearly impossible without them.
That's why using improvised sign language, or asking a child to interpret — just getting by — is simply not good enough, said Fernandez. "Getting by leads to mistakes," she said. "And mistakes can be tragic, for both the patient and the physician."
Erica Gastelum, a pediatrician in Fresno, Calif., regrets that she rarely has access to an interpreter for her Mixteco-speaking patients. She says without one, "You're not able to provide equal care to all comers."
She remembers a 1-year-old boy with fatal congenital heart disease. Doctors had exhausted every option, and the family was gathered in the intensive care unit.
"This is it, this is the moment where we're going to disconnect the tubes," said Gastelum. "It seemed like they understood. But in such a crucial moment like that, it would have been so much better to have a culturally sensitive, in-person interpreter."
Most hospitals, including Gastelum's, have telephone services designed to let doctors call an interpreter for any language. But the system doesn't always work for more unusual languages.
This map shows where Mexican indigenous languages originate. Triqui and Mixteco belong to the Oto-Mangue family, in the southwest of the country.Jeremy Raff/KQED
"When you try to use the phone interpreter line to get the indigenous speaker, you'll be on hold for like two hours," said Jasmine Walker, also a pediatrician in Fresno. "Then when you get them, they don't actually speak the language that you need."
Seth Holmes is a physician who lived and worked alongside Triqui migrant farmworkers for 10 years and wrote about his experiences in the book Fresh Fruit, Broken Bodies. As the migrants followed crops up and down the West Coast, they often asked Holmes to accompany them to health clinics.
In dozens of clinics throughout California, Washington and Oregon, he said, "I have never seen any Triqui person get a medical interpreter."
Hospitals may underestimate how many indigenous patients they have and how many interpreters they need because many providers assume all Mexicans speak Spanish. Some indigenous people may be afraid to call attention to themselves by asking for an interpreter because they are undocumented.
"They don't know that they're entitled to someone who speaks their language," said Leoncio Vasquez, director of the Binational Center for the Development of Oaxacan Indigenous Communities in Fresno. He has been training interpreters for 15 years.
Any health care facility receiving public money has a legal obligation under both state and federal law to provide an interpreter to every patient who needs one. But only a few health care providers have made California's 120,000 indigenous farmworkers an explicit priority.
Before becoming an interpreter at Natividad Medical Center in Salinas, Calif., Brigida Gonzalez (right) worked in the strawberry fields.Jeremy Raff/KQED
Brigida Gonzalez, wearing a big "Qualified Interpreter" badge, hustles around Natividad Medical Center in Salinas, Calif. It's a big building and she's needed all over.
Today she's a professional employee at a big hospital. A year ago, she was picking strawberries nearby.
In the fields one day, another picker noticed that Gonzalez spoke English, a rarity in agriculture. She suggested she look into Natividad's training program.
People at Natividad were thrilled to hear from Gonzalez, "because it was so hard to find someone who spoke English, Spanish and an indigenous language like Mixteco and Triqui," she said.
Gonzalez completed Natividad's six-month training program for indigenous interpreters, the first of its kind in the United States, and now works there part time.
The need for trilingual interpreters like Gonzalez is growing, and it's not just hospitals.
Four hours down the coast in Oxnard, all three school districts have hired Mixteco interpreters, and the police have one on contract.
Altogether, there are about 20 Mixteco speakers making a good living with their language skills in Ventura County.
These opportunities are one reason why Argelia Zarate, the Oxnard School District's first full-time Mixteco interpreter, encourages students to practice their Mixteco so they don't lose it.
"I didn't go to college, yet I have this job," said Zarate, "because the community is growing so big that they don't need bilinguals — they need trilinguals."
Argelia Zarate, a Mixteco interpreter at the Oxnard School District, encourages students to practice their native languages.Jeremy Raff/KQED
The U.S. Bureau of Labor Statistics expects employment of interpreters and translators to grow by 46 percent between 2012 and 2022. Driving that demand is the 158 percent increase since 1980 in the number of people who speak a language other than English at home.
Nationally, the median hourly wage for interpreters is $25, compared with $9.09 for farm work.
Zarate says the better pay, stable hours and a chance to serve her community all make interpreting a big step up from fieldwork.
"Here everybody is nice to you. They talk to you, appreciate what you do," Zarate said at the elementary school where she works. "In the fields, they treat you like you're nothing, a slave working for a little bit of money."
The Mixteco/Indigena Community Organizing Project has trained dozens of interpreters in Ventura County and has pressured public agencies to make use of them.
"Ventura County has invested in having better language access than most parts of California, and honestly most parts of Oaxaca," said Margaret Sawyer, the group's development director, referring to the Mexican state that many Mixteco migrants are from.
But most hospitals rely on freelance part-time interpreters, who have a hard time making a living.
"They will have you for two or three hours, then you're done for the whole day," said Israel Vasquez, a trilingual interpreter in Ventura County, Calif. He worked in hospitals, clinics, social service agencies, school and courts in Ventura County but eventually quit because he couldn't get enough hours. He says, "You can't really live off that."
"Making a living specifically in health care interpreting right now is not really going to happen," said Don Schinske, executive director of the California Healthcare Interpreting Association.
Part of the problem, Schinske said, is that even though federal law requires hospitals to provide interpreters, there is not a direct federal funding stream to pay for those services.
"You get a lot of this sentiment from hospitals: 'Look, we're trying to get people services in their language, but it is a nicety, not a necessity,' " said Schinske.
The indigenous interpretation programs at Natividad Medical Center are funded by private donations from agricultural businesses in the area, who have contributed $1.7 million since 2010.
Meanwhile, a bill that would make it easier for hospitals to get federal money for medical interpreters has stalled in the California Legislature.
Farmworker Angelina Diaz-Ramirez returned home after her surgery with a new pacemaker ticking in her chest and a stack of printed instructions that she couldn't read.
"I didn't know what to do," she said through an interpreter. "I had strong pain. Should I call them back?"
Diaz-Ramirez didn't know who her cardiologist was, how to get an appointment or which medications to take. "I just felt very sad," she said.
Every week, indigenous people with these same questions visit Leoncio Vasquez at his storefront office in Fresno.
He looks through their paperwork, pieces together a backstory and helps them figure out what to do next — something that should have happened at the hospital or clinic, with one of the dozens of interpreters Vasquez has already trained.
But those interpreters "can't find jobs related to interpreting," said Vasquez. "Some go back to the fields to do farm work."
This piece was produced with support from the Institute for Justice and Journalism. It was first published in KQED's State of Health blog.Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
NPR Health Blog - Tue, 09/29/2015 - 10:18am
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In 1954, Dr. Frederick C. Robbins, then chief of pediatrics and contagious diseases at Cleveland Metropolitan General Hospital, was one of three winners of that year's Nobel Prize in medicine. The scientists' work, which led to a vaccine against polio, was performed in human fetal cells.AP
Larry Goldstein is trying to find drugs to treat Alzheimer's disease. A biologist in cellular and molecular medicine at the University of California, San Diego, Goldstein also just started testing something he hopes will enable paralyzed people to walk again.
For both lines of research, he's using cells from aborted fetuses.
"The fetal cells are vital at this time because, to our knowledge, they have the best properties for the kinds of experiments that we need to do," Goldstein says.
Research involving fetal tissue has come under renewed public scrutiny recently because of a series of videos involving the Planned Parenthood Federation of America. The president of the organization, Cecile Richards, is slated to testify before a House committee Tuesday, even as some members of Congress try to cut off funding for Planned Parenthood, and some states try to restrict research involving fetal tissue.
Goldstein insists such research is invaluable. For his Alzheimer's experiments, for example, he's using cells from the brains of fetuses to look for drugs that could protect neurons from that devastating disease.
"To be honest, we don't know all the things the fetal-derived cells do, but understanding what they do is an important part of the research," he says.
Goldstein also just started transplanting fetal nerve cells into the spines of some people who are paralyzed, to try to repair their damaged spinal cords.
"We're using fetal stem cells in a clinical trial to test whether they can help paralyzed people walk, as we've seen in rat versions of spinal cord injury," he says.
Goldstein is far from alone in his reliance on fetal cells. The National Institutes of Health alone funds about $76 million in fetal cell research each year. This type of scientific study has gone on for decades.
"Fetal tissue is involved in research across a host of different diseases and conditions," says Carrie Wolinetz, the NIH's associate director for science policy. The cells have long been used to make some vaccines. And these days scientists are also using the cells to try to cure AIDS, fight blindness, prevent miscarriages and birth defects, and to find new ways to treat diabetes, cancer, Parkinson's disease and other disorders.
"Fetal tissue is used to study early brain development, which has great relevance to our understanding of the development of diseases such as autism and schizophrenia," Wolinetz adds.
Fetal tissue is vitally useful, she says, because it's unique in several ways. It grows fast, lives a long time and is incredibly versatile.
"It allows us to answer specific questions that can't be answered by adult tissue, which is far more specialized," Wolinetz explains. "Fetal tissue can contain information — about structural features, or the architecture of organs — that cells in a dish alone can't provide. And this is sometimes very important to our understanding of disease."
But critics question all that.
"It's a bit antiquated in terms of its scientific use," says David Prentice, vice president and research director at the Charlotte Lozier Institute, an organization that is opposed to abortion. He dismisses the idea that fetal tissue is scientifically indispensable.
"This is no longer any type of cutting-edge research," he says. "It might have been the gold standard back in the 1950s and the 1960s. But we're long past that."
Prentice and some others say that cells from animals, or from human umbilical cords, or cells known as induced pluripotent stem cells — created by genetically engineering cells from adults to revert to an earlier, embryonic-like state — are much more useful.
"The induced pluripotent stem cells are a much better model, because you can take those directly from patients to even study a disease in the dish," Prentice says.
Goldstein says that the research in fetal-derived tissue is much farther along — and that no one can be sure yet that any of the alternatives will work as well. Still, Prentice isn't alone in his criticism.
"We believe it is neither necessary for the advancement of science and the discovery of new cures, nor is it ethical," says Kathleen Schmainda. She's a professor of radiology and biophysics at the Medical College of Wisconsin, and among a group of scientists there who oppose the use of aborted fetal tissue in research. They wrote an editorial earlier this month in the Milwaukee Journal Sentinel to explain their reasoning.
"You're basically taking the life of one member of human society to use for the life of another," Schmainda says. Using aborted tissue drives away scientists who have moral qualms about using fetal tissue, she asserts.
"This practice of basically linking up science with the abortion industry corrupts what we do," she says. "And, I would argue, it corrupts the science and the discovery that can take place."
Other researchers dispute Schmainda's assertion. Fetal cells remain crucial for many lines of research, they say, and the work can be done ethically.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Mon, 09/28/2015 - 4:32pm
Michael Jarrett/Genomic Health
For the past 10 years, doctors have used a genetic test to decide which patients may be able to skip chemotherapy after surgery for breast cancer.
Now a study confirms that this test, called Oncotype DX, works well for a small group of patients. But a longer, follow-up study is needed to draw conclusions for a fuller range of patients with riskier tumors.
Oncotype DX analyzes 21 genes in the tumor to estimate a woman's risk of the cancer coming back after surgery.
For patients who fell into the test's low-risk category, 99 percent didn't develop metastatic breast cancer five years after surgery, even though they didn't have chemotherapy. The overall survival rate among this group was 98 percent, doctors reported Monday in the New England Journal of Medicine
"This is really great news for the patients we're treating" says Dr. Sharon Giordano, an oncologist at MD Anderson Cancer Center in Houston, who wasn't involved in the study.
Oncotype DX is recommended by the American Society of Clinical Oncology and is considered the standard of care for a particular type of breast cancer, Giordano says.
Each year, about 230,000 Americans are diagnosed with breast cancer. About 100,000 qualify for the Oncotype DX, and 16,000 fall into the low-risk category. The test costs about $4,000 and is covered by most insurers.
"It's important that the test was validated, but also how low the risk of recurrence actually was for this subset of patients," she says. "Chemotherapy is more likely to harm these patients than to help them."
In the study, doctors around the country, gave the Oncotype DX test to more than 10,000 women diagnosed with a common form of breast cancer that responds to anti-hormone treatments. About 16 percent of the women scored low on the test and thus, received only anti-hormone therapy, no chemotherapy.
Five years later, this group of women were more likely to develop another type of cancer — or die of something other than cancer — than they were to have their first tumors return somewhere else in their bodies.
"This is very reassuring that the guidelines we've been following are right," says Dr. Daniel Hayes, who co-directs the Breast Oncology Program at the University of Michigan and contributed to the current study. "It's one more step forward to personalizing how we treat patients."
But, for a large percentage of patients, the Oncotype DX test is still ambiguous, Hayes says. Nearly 70 percent of the patients in the study scored in the mid-range of the test and were considered a moderate risk for a relapse.
Hayes and his colleagues are now testing to see which of these patients benefit from chemotherapy. The results of that trial are due out in a few years.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Mon, 09/28/2015 - 1:22pm
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As life draws to an end, compassion is more important than food.Kacso Sandor/iStockphoto Additional Information: The Shift
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Palliative care nurse Theresa Brown is healthy, and so are her loved ones, and yet, she feels keenly connected to death. "I have a deep awareness after working in oncology that fortunes can change on a dime," she tells Fresh Air's Terry Gross. "Enjoy the good when you have it, because that really is a blessing."
Brown is the author of The Shift, which follows four patients during the course of a 12-hour shift in a hospital cancer ward. A former oncology nurse, Brown now provides patients with in-home, end-of-life care.
Talking — and listening — are both important parts of her job as a palliative care nurse. This is especially true on the night shift. "Night and waking up in the night can bring a clarity," she says. "It can be a clarity of being able to face your fears, it can be a clarity of being overwhelmed by your fears, and either way, I feel like it's really a privilege to be there for people."
Sometimes Brown finds herself bridging the gap between patients who know they are dying and family members who are still expecting a cure. "There can be a lot of secrets kept and silences. ... One thing that palliative care can be really good at is trying to sit with families and have those conversations," she says.
While some might see her job as depressing, Brown says that being with people who are dying is a profound experience. "When you're with people who die ... and being in their homes and seeing their families, it's incredible the love that people evoke. And it makes me realize this is why we're here; this is what we do; this is what we give to each other."Interview Highlights
On cutting costs and stretching nurses too thin
There's a sense that you can stretch a nurse just like an elastic band and sort of, "Well, someone called off today." That means a nurse calls in and says that she's sick or her car broke down or he won't be there, and sometimes we're able to get someone onto the floor to take that person's place, but often we're not. Or an aide might not be able to show up for whatever reason, and then the assumption is just, "Well, the nurses will just do all the work that the aide would've done," and the problem is that people do not stretch like rubber bands, and even rubber bands will break if you stretch them too far.
On loved ones wanting to feed their dying family members
Theresa Brown is a critical care nurse in Pittsburgh. Her previous book is Critical Care: A New Nurse Faces Death, Life, and Everything in Between.C. Ken Weingart/Algonquin Books
Food is so fundamental, and their feeling is "I'm letting my husband starve to death and that's wrong." So I have to talk them through the process of the body slowly going in reverse. All the processes we think of as normal and that are integral to life, they're all slowing down. And so the body just doesn't need food when someone gets very close to the end of their life and, in fact, they found that forcing someone to eat can mean that they just have this food sitting in their stomach, they're not able to digest it, can actually make them more uncomfortable. So I talked to [one family member] about that, but tried to do it as gently as possible, while also acknowledging the incredible love that was motivating her and trying to honor that, but make it clear that she needed to show her love by being close with her husband, by holding his hand, by talking to him, but not by feeding him.
On whether patients ask if they're dying
No, they don't. ... I think it's because they're afraid. They want to just take things day by day. I did have a wife once ask me. She said, "You know, I'm not new to this, and I want you to just tell me. Is he dying?" And at that point I was a pretty new nurse and I didn't have the experience to know to say, "Yes." Now I would know to say that. ... I got a sense that she really wanted to know and no one else was telling her. ...
Physicians can have a mindset of "we're thinking positively, we're focusing on the good that can come, and we're not going to talk about 'what if it doesn't work out.' " And they will sometimes pull the nurse aside and say, "What's going on?"
On leaving the hospital setting for palliative care
I love the hospital. I never thought I would leave the hospital, but I left to see patients outside the hospital because in the hospital I feel like we never see people at their best. They feel lousy. We wake them up at night. We give them no privacy. We give them, really, almost no dignity. We tell them what they're going to do when, what they're going to eat when, what pill they're going to take when and no one likes living like that. ... So I wanted to see people in their homes because I thought there's got to be a way we could make the hospital better. Seeing what it's like for patients in their homes I thought would show me that. And I would say overwhelmingly what I've seen is control: People have so much more control when they're in their homes and it should not be that hard to give them back a little bit more control in the hospital.Additional Information: Related NPR Stories Shots - Health News Nurses Have To Translate When Medical Devices Fail To Communicate Shots - Health News Getting Hospice Care Shouldn't Have To Mean Giving Up
On traveling to a patient's home
When I started, I thought, "I can't believe I'm doing this. I can't believe I just drive up to these houses and go inside them." I live in Pittsburgh, but it can get very rural feeling actually pretty quickly, and I remember ... going to [a house] that was already through back-country roads and then down a gravel driveway, and I thought: "What am I doing? Am I insane?" And then I went into this house, and this family was so loving and amazing and wonderful, so it was a great education for me not to judge. And I know that my workplace checks out and makes sure that the places we're going are real, so that's comforting, but it's definitely a giant leap of faith, and you just have to make that leap.
On home care versus hospital care
Often in the hospital they can be more comfortable in terms of we're relieving their pain, we're getting them anti-nausea medications very quickly, but ... they're not as comfortable with themselves, and in their homes they seem much more comfortable with themselves and with the people around them, and I had never thought about those two things as being so distinct, but they are. So the question then is how do we give people care that marries those two things, because they're both so important.
On how patients express appreciation to nurses
A very popular gift in my hospital was Starbucks [gift] cards. ... Often people bring in cookies and chocolate and that's wonderful, but I remember one nurse saying, "You know, I wish someone would just bring in a lasagna." ... Because we never have time to eat and then you go into the break room and you're hypoglycemic and you see all this chocolate, and so you eat all this chocolate, which doesn't really help you feel that much better in the long run. So to actually drop off a meal is wonderful.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Mon, 09/28/2015 - 10:52am
Children in foster care typically haven't been to the doctor or dentist regularly.iStockphoto
On any given day, about half a million children are living in foster care. They've been removed from violent or abusive households; many suffer physical and mental health problems that have gone untreated.
Their need is acute but the response is often dangerously slow, according to a policy statement from the American Academy of Pediatrics. The recommendations, published Monday in the journal Pediatrics, are intended as a wake-up call for pediatricians who care for foster kids.
According to the report, more than 70 percent of these children have a documented history of child abuse or neglect, and 80 percent have been exposed to significant violence, including domestic violence. Almost all are further traumatized by being removed from their families, says author Moira Szilagyi, a professor of pediatrics at the David Geffen School of Medicine at UCLA.
Foster care becomes a "window of opportunity for healing," Szilagyi says, often the first chance these children have to get the help they need.
And the need is great. Thirty to 80 percent of these children have an untreated medical condition. That can be as simple as eczema or asthma or far more severe and complicated, such as cerebral palsy or neurological damage from shaken impact injuries.
"We see the spectrum," Szilagyi says, including teenagers who have multiple mental health conditions such as conduct disorder, bipolar disorder, depression, ADHD — "a laundry list of diagnoses."
The problem is that many of these children face barriers to care, starting with the permission to treat them in the first place. The process for foster parents to get consent from a family member or guardian can be cumbersome and often stops before it even begins.
And if foster parents do obtain consent, medical providers typically face an incomplete if not invisible medical history.
"Often these children have gone from one relative to another," says Szilagyi, adding it's often not clear how many caregivers the child had prior to foster care. There's no record of treatment, no history of vaccinations, no information about psychosocial development, behavior or mental health problems. The children have a very high prevalence of dental problems.
While the report finds that the number of children in foster care has decreased over the past few decades, the number labeled as "emotionally disturbed" has increased. Szilagyi says these findings should serve as a heads-up for health care providers to refer children to get the care they need, be it from dentists and pediatric mental health providers.Copyright 2015 NPR. To see more, visit http://www.npr.org/.
NPR Health Blog - Mon, 09/28/2015 - 5:20am
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A mind-altering drug called ketamine is changing the way some doctors treat depression.
Encouraged by research showing that ketamine can relieve even the worst depression in a matter of hours, these doctors are giving the drug to some of their toughest patients. And they're doing this even though ketamine lacks approval from the Food and Drug Administration for treating depression.
"It became clear to me that the future of psychiatry was going to include ketamine or derivatives of ketamine," says David Feifel, a professor of psychiatry at the University of California, San Diego, who began administering the drug to patients in 2010.
Ketamine was developed as an anesthetic and received FDA approval for this use in 1970. Decades later, it became popular as a psychedelic club drug. And in 2006, a team from the National Institute of Mental Health published a landmark study showing that a single intravenous dose of ketamine produced "robust and rapid antidepressant effects" within a couple of hours.
Since then, thousands of depressed patients have received "off-label" treatment with ketamine.
One of those patients is Paul, 36, who lives in San Diego and is a patient of Dr. Feifel. We're not using his last name to protect his medical privacy.
Paul's depression began with anxiety. "I was an extremely anxious child," he says. "I would always make choices based on fear. My life was really directed by what was the least fearful thing that I could do."
As Paul grew up, his extreme anxiety led to major depression, which could leave him unable to get out of bed for days. "I lived in pain," he says.
Paul managed to get through college and a stint in the Peace Corps. But most days were a struggle. And Paul has spent much of his adult life searching for a treatment that would give him some relief.
He tried just about every drug used for depression, as well as cognitive behavioral therapy, acupuncture, and even electroconvulsive therapy, which induces a brief seizure. But nothing worked — at least not for very long.
Paul says he was increasingly haunted by "this comforting thought of pressing a cold gun against my forehead where I felt the pain the most."
Then one day, while investigating depression on the Internet, Paul discovered the research on ketamine. "It was clear to me that this was real," he says.
Ordinarily, there would have been no legal way for Paul to get ketamine. He didn't qualify for most research studies because of his suicidal thoughts. And doctors usually won't prescribe a mind-altering club drug to someone with a mental illness.
But the studies of ketamine have produced results so dramatic that some doctors, including Feifel, are bypassing the usual protocols.
By the time Feifel began hearing about ketamine, he had become frustrated with existing depression drugs. Too often, he says, they just weren't helping his patients.
David Feifel, a psychiatrist at the University of California, San Diego, has treated about 100 people with ketamine.Courtesy of David Feifel
A major study on antidepressant medication published in 2008 seemed to confirm his suspicions. It found that current antidepressants really aren't much better than a placebo.
Many psychiatrists criticized that study. But not Feifel. "I was kind of like, I'm not surprised," he says. "These really don't seem like powerful tools."
Feifel remembers feeling "professionally embarrassed" that psychiatrists didn't have something better to offer their depressed patients. Something like ketamine.
He knew the drug had risks. It could be abused. It could produce hallucinations. And it didn't have the FDA's OK for treating depression.
But he also knew that doctors had a lot of experience with ketamine. It's been used for decades as an anesthetic that can rapidly stop pain without affecting vital functions like breathing. And ketamine's safety record is so good that it's often the painkiller of choice for children who arrive in the emergency room with a broken bone.
So in 2010, Feifel decided he wanted to offer low doses of the drug to some patients. The decision put him at odds with some prominent psychiatrists, including Tom Insel, director of the National Institute of Mental Health. "While the science is promising, ketamine is not ready for broad use in the clinic," Insel wrote in his blog a few months ago.
"There are a lot of pundits who remain skeptical or feel we need to research this ad infinitum before it's ready, which doesn't make sense to me," Feifel says. It's hard to take the wait-and-see approach when you're treating patients who are desperate for help, he adds.
Paul was one of those desperate patients when he was referred to Feifel in March of 2014. The referral was from a local psychiatrist who had run out of ideas, Feifel says.
And Paul jumped at the chance to try ketamine. "If there was even a 1 percent chance that this worked, it would have been worth it to me," he says. "My life was hanging in the balance."
And for Paul, the benefits of ketamine became obvious soon after one of his early injections.
"I remember I was in my bathroom and I literally fell to my knees crying because I had no anxiety, I had no depression," he says
For the past year, Paul has been getting ketamine every four to six weeks. He feels an altered sense of reality for an hour or two after getting the drug. The effect on depression and anxiety, though, lasts more than a month.
Ketamine doesn't always work that well, Feifel says. After treating more than 100 patients, he's beginning to understand the drug's limitations.
One is that its ability to keep depression at bay can fade pretty quickly. Feifel recalls one patient whose depression would disappear like magic after a dose of ketamine. But "we could never get it to sustain beyond maybe a day," he says.Shots - Health News Depression Treatments Inspired By Club Drug Move Ahead In Tests
Also, ketamine treatment is expensive because patients need to be monitored so closely. Feifel charges about $500 for each injection and $1,000 for an intravenous infusion, which takes effect more quickly. Insurers don't cover the cost because the treatment is still considered experimental.
Even so, ketamine clinics are popping up around the country and they have already treated thousands of patients willing and able to pay out of pocket. Some of the clinics are run by psychiatrists. Others have been started by entrepreneurial anesthesiologists and emergency room doctors, who are familiar with ketamine but may not know much about depression.
"We've seen ketamine clinics open up as pure business models," Feifel says. "I'm a little bit concerned about that."
Feifel fears something bad will happen to a depressed patient at one of these clinics. And that could set back efforts to make the drug more widely available.Copyright 2015 NPR. To see more, visit http://www.npr.org/.