NPR Health Blog - Fri, 10/14/2016 - 7:00am
Organ Donations Spike In The Wake Of The Opioid Epidemic Listen · 2:47 2:47 Toggle more options
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At his home in Haverhill, Mass., Colin LePage leafs through newspapers he shows to middle-schoolers to educate them about the dangers of drugs.Martha Bebinger/WBUR
On the final day of June 2015, Colin LePage rode waves of hope and despair. It started when LePage found his 30-year-old son, Chris, at home after an apparent overdose. Paramedics rushed Chris by helicopter to one of Boston's flagship medical centers.
Doctors revived Chris' heart, but struggled to stabilize his temperature and blood pressure. At some point, a doctor or nurse mentioned to LePage that his son had agreed to be an organ donor.
"There was no urgency or, 'Hey, you need to do this.' I could see genuine concern and sadness." LePage says, his voice quavering.
The next morning, after another round of tests showed no signs of brain activity, LePage said goodbye to the son who'd been revived but wasn't fully alive.
"I sat in a chair with him and held his hand," LePage says. "It wasn't clinical. It didn't feel like someone's gaining something here. I knew that someone was, and that's comforting that someone else has been able to have a little piece of my son and some of their pain is not what it used to be."
Chris' liver is now working in the body of a 62-year-old pastor. His case is one among the nearly 900 percent increase so far in donations across New England since 2010. So far this year, more than 1 in 4, or 27 percent, of donations in New England are from people who died after a drug overdose. Nationally, that rate dips to 12 percent for the same time period.Shots - Health News As Opioid Epidemic Surges, Medical Schools Try To Keep Pace
"It's remarkable and it's also tragic," says Alexandra Glazier, president and CEO of the New England Organ Bank. "We see this tragedy of the opioid epidemic as having an unexpected life-saving legacy."
That legacy is much more dramatic in New England than across the U.S. as a whole, where organ donations from drug users are up from 341 in 2010 to 790 through Aug. 31 of this year.Additional Information: Spike In Organs Donated From Overdose Patients Source: The New England Organ Bank
It's not clear why. Overdose death rates are high in New England, but not the highest in the country. Glazier says the 12 transplant centers in that region may be more aggressive about finding a match for patients with failing hearts, livers or kidneys. And she says New Englanders tend to be pragmatic about end-of-life decisions.
Some hospitals in Massachusetts report that they are performing a record number of transplants. At Lahey Hospital and Medical Center in Burlington, the number of patients receiving a liver transplant has roughly doubled in the past three to four years.
Hospitals are required to test organs and warn patients if there is a risk of contracting HIV or hepatitis B or C, which are more common in IV drug users. That risk may be less troubling for patients these days because there are drugs to treat these viruses if patients become infected.
Some patients in need of organs still hesitate at the idea of accepting a liver or kidney donated by a drug user. But not at Lahey, where Dr. Mohamed Akoad chairs the department of transplantation.
"Most of these patients trust the fact that these donors are tested and they understand that their chance of dying while waiting for an organ is high," he says.
Akoad says Lahey has not had any cases of HIV or hepatitis B or C transmission in recent years.
That's the case at Mass General in Boston as well. Dr. Jay Fishman, associate director of the hospital's transplant center, says an organ from someone who used drugs is not necessarily risky and may even be healthier than other options.Shots - Health News New Source Of Transplant Organs For Patients With HIV: Others With HIV
"You have to remember that as awful as this outbreak is, these are younger people who are dying, often with needles in their arms, and many of them were first-time drug users," Fishman says. "They weren't all addicts."
Despite the increase in available organs, there's no sign that the supply is keeping up with the demand from aging Americans and those with chronic diseases.
"The number of people on the waiting list is increasing faster than the number of donors, even with the increases related to overdoses," says Dr. David Klassen, chief medical officer at the United Network for Organ Sharing, which tracks and manages organ donations in the U.S.
There are likely many more organs available from the victims of drug overdoses than those collected. Some patients addicted to heroin or other opioids don't carry a driver's license, haven't spoken to a family member about their end-of-life wishes, or aren't in touch with family members who could give consent to donate an organ.
"I've never heard anyone talk about organ donation as a possibility. I'm not sure it's on their radar screen," says Dr. Jessie Gaeta, chief medical officer at the Boston Health Care for the Homeless Program.
Gaeta says she isn't sure how she would suggest organ donation, even to her high-risk patients.
"It's really nihilistic to say that to someone in their early 20s," Gaeta says. "I have so much hope for my patients, yet if someone does die and there's a chance for their organs to be helpful, that's one good thing to come of a death like that."
Debbie Deagle holds a photo of her son Stephen and herself.Martha Bebinger/WBUR
For many mothers and fathers, sisters and brothers who've lost someone to an overdose, organ donation is a nearly taboo topic. It can trigger feelings of guilt, anger and despair, even among people who participate.
Debbie Deagle sat next to her son Stephen's unresponsive body for six days before agreeing to turn off his respirator.
"Before they took him," Deagle says, weeping, "I had my head on his heart, just so I could hear that beat, and they had to peel me off."
More than a year later, Deagle is still haunted by questions: Should she have asked for another opinion about the scans of Stephen's brain?
"Never in a million years do you ever visualize kissing your child whose heart's beating and having to watch them wheel that stretcher away and know they're going to cut him open and take out a beating heart," Deagle says.
The transplant patient who received Stephen's heart did not make it, leaving Deagle with the feeling her son had died again. She has written to the patients who received Stephen's liver and kidneys, but has not heard back.
This story is part of NPR's reporting partnership with WBUR and Kaiser Health News.Copyright 2016 WBUR. To see more, visit WBUR.
NPR Health Blog - Thu, 10/13/2016 - 1:57pm
Lack of access to quality medical care remains a major factor in higher breast cancer death rates among African-Americans.Deborah Jaffe/Getty Images
Women are less likely to die of breast cancer than they were a decade ago, but not all women are benefiting from that trend.
White women saw more of a drop in death rates than black women — 1.9 percent a year from 2010 to 2014, compared to a 1.5 percent decrease for black women, according to a report published Thursday by the Centers for Disease Control and Prevention.
And while the death rates for women under 50 declined regardless of race, older black women are more likely to die of breast cancer than are white women.
That's especially troubling because 40 years ago, black women were less likely to get breast cancer. That's changed. Black women's breast cancer risk is now the same as that of white women's, and black women are 41 percent more likely to die of the disease.
There can be some good reasons for the rise in the number of black women being diagnosed with breast cancer, like more women getting screening mammograms. But there are bad reasons, too.
The CDC report cites calorie-dense foods, lack of exercise and increasing rates of obesity as potential reasons.
And while this report found similar reductions in deaths among younger black and white women, older white women saw their death rates drop by 2 percent a year, compared to 1 percent in black women.Shots - Health News Black Women's Breast Cancer Risk Rises To Equal White Women's
Access to care is one big reason why, according to Otis Brawley, chief medical and scientific officer for the American Cancer Society.
"Forty to 50 percent of black women get less than optimal care for breast cancer, whether it's mammography or treatment," Brawley says.
They're not alone in that; poor white women are also much less likely to get adequate care, and more likely to die as a result.
"We need to focus on getting good care, high-quality care to everybody," Brawley adds. "We need to realize that in the United States of America in 2016 a substantial proportion of Americans with cancer get absolutely atrocious care."Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Thu, 10/13/2016 - 1:19pm
Brain Implant Restores Sense Of Touch To Paralyzed Man Listen · 3:12 3:12 Toggle more options
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Robert Gaunt tests Nathan Copeland's ability to detect touch by tapping fingers on a robotic hand.UPMC/Pitt Health Sciences
Twelve years ago, a car wreck took away Nathan Copeland's ability to control his hands or sense what his fingers were touching.
A few months ago, researchers at the University of Pittsburgh and the University of Pittsburgh Medical Center gave Copeland a new way to reach out and feel the world around him. It's a mind-controlled robotic arm that has pressure sensors in each fingertip that send signals directly to Copeland's brain.
The scientists published details of their work online Thursday in the journal Science Translational Medicine.
"It's a really weird sensation," Copeland, now 30, says in a video made shortly after he first tried the system. "Sometimes it feels, kind of, like electrical and sometimes it's more of a pressure." But he also describes many of the sensations coming from his robotic hand as "natural."
When Copeland touches an object with the robotic hand, he can tell which finger the sensation is coming from and whether an object feels hard or soft, says Robert Gaunt, a bioengineer and assistant professor in the Department of Physical Medicine & Rehabilitation at the University of Pittsburgh.
"But we're really not at the point where we could, say, get him to feel the difference between silk and burlap," Gaunt says.
The success represents an advance that is "absolutely critical in terms of making prosthetics useful," says Mike McLoughlin, an engineer at the Johns Hopkins University Applied Physics Laboratory.
McLoughlin is part of a team at Hopkins that developed the Modular Prosthetic Limb that Copeland is using. The research at both Hopkins and in Pittsburgh is supported by the government's Defense Advanced Research Projects Agency.
For several years now, people have been able to control robotic arms using thoughts alone. But they have relied entirely on vision to know whether the arm is going in the right direction or grasping an object with the proper amount of force.
That makes it very challenging to perform simple tasks like grasping a foam coffee cup without crushing it, McLoughlin says.Additional Information: Sensing Touch
Watch a blindfolded Nathan Copeland accurately sense which finger's being touched.
It was several weeks before the team was able to send the first tiny pulse of electricity to Copeland's brain. In this video, Gaunt tests Copeland's ability to perceive touch through the robotic arm.
Credit: UPMC/Pitt Health Sciences
"Without sensory feedback, somebody would have to actually have to look at the prosthetic, look at the cup, start to close the hand, (and) visually see the cup is starting to deform," he says.
Restoring Copeland's sense of touch was a painstaking process, but the Pittsburgh team knew it was possible.
"His hand has been disconnected from his brain because of his spinal cord injury," Gaunt says. "But the brain hasn't lost its ability to feel."
So the team began looking for a way to send touch sensations directly to Copeland's brain. The first step was to monitor his brain activity using a technique called magnetoencephalography.
"We were able to see the parts of his brain that became active when he was watching videos of a hand being touched," Gaunt says.
Next, the researchers placed tiny electrodes in Copeland's brain that could stimulate the areas corresponding to each finger. Then they waited for the brain to heal, as it adjusted to the presence of the electrodes.
It was several weeks before the team was able to send the first tiny pulse of electricity to Copeland's brain. "When it finally happened, he just very calmly said, 'Yep, I felt it on my index finger,' " Gaunt recalls. "But in the background I was breathing a sigh of relief and other people were cheering."
Of course, mind-controlled robots are still years away from consumer applications, McLoughlin says. At the moment, they are still too expensive, too bulky and too finicky to be used outside a laboratory setting. And there's no good way to control them without implanting electrodes in the brain.
Still, the ability to receive touch sensation from a robotic arm has the potential to help not only thousands of people who are paralyzed, but also people with a wide range of physical disabilities, McLoughlin says. For example, robots that provide sensory feedback could eventually help a disabled person cook a meal or clean up things at home.
"We're on the verge of something here that's going to transform lives," he says.Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Wed, 10/12/2016 - 4:02pm
Kratom, seen in capsule form here, has been under review by the Drug Enforcement Administration for possible restriction.Photo illustration by Joe Raedle/Getty Images
It's been a wild ride for kratom lately.
Since Aug. 31, when the Drug Enforcement Administration announced its intention to classify the plant as a Schedule I substance, a group of kratom vendors filed a lawsuit against the government to block the move, angry advocates took to social media in protest and scientists questioned whether they would be able to continue kratom research.
Now, the DEA is withdrawing its notice of intent to put kratom in the most restrictive category of controlled substances, with drugs like LSD and heroin. The DEA says it will instead open an official public comment period — to last until Dec. 1, 2016 — for people to share their experiences using kratom as a medical treatment. It has also requested that the Food and Drug Administration expedite scientific research.
DEA spokesman Russ Baer says the DEA received more than 2,000 phone calls since August, mostly in opposition to the plan to classify kratom as Schedule I.
"So in a spirit of transparency, and to open this up to public dialogue, we withdrew our notice to temporarily schedule kratom," Baer says. "We will then give full consideration to those comments before we move forward with any action."
Kratom is derived from the leaves of a tree native to Southeast Asia. It is a relative of the coffee plant. According to David Kroll, a pharmacologist and medical writer, farmers and indigenous people have used it for hundreds of years as both a stimulant to increase work output and also as a way to relax.
In the U.S., kratom has become popular among people coping with chronic pain and others trying to wean themselves off opioids or alcohol.
The main active ingredients in kratom are mitragynine and a related chemical that bind to some of the same receptors as opioids, providing some pain relief and feelings of euphoria. But, Kroll says, not the same high. And the chemical isn't known to cause the same, sometimes deadly, side effects as opioids, such as respiratory depression.
Still, the DEA attributed 15 deaths to kratom between 2014 and 2016. Fourteen of the 15 people who died also had other drugs or illegal substances in their systems.Shots - Health News Kratom Advocates Speak Out Against Proposed Government Ban
Kratom advocates, like Karisa Rowland of Cleburne, Texas, point out that opioid abuse kills tens of thousands of people every year. She's thrilled that the DEA will now take time to gather public comments and more scientific research.
"Now that the DEA is officially withdrawing the proposal, I can continue the crusade for the rights of chronic pain sufferers like myself," Rowland says.
She attributes the change in position to work by activists and to lawmakers who urged the DEA to reconsider its "hasty" ban.
Kendra Jowers, an attorney who works in the substance abuse treatment industry in Florida, says in an email she is heartened that the DEA has reconsidered what she calls a "misguided and improper attempt to schedule kratom without the input of relevant stakeholders."
"This represents a huge sigh of relief for individuals who have come to rely on kratom to overcome addiction or maintain their sobriety," Jowers says. "At least for the time being, it relieves some [of] the terror people felt at once again facing a life of intractable pain or depression. It has been a lot of work to get to this point, and now I encourage people to fully engage in this hard-fought comment period."
Kratom user Seth Long of Kearney, Neb., is also pleased the DEA is listening to the public. "The DEA spokespeople have emphasized their reliance on science rather than anecdote in making scheduling decisions, so given the response not just from the public but from research scientists at Columbia University, among other institutions, they seem willing to admit their mistake in lumping together a coffee plant with synthetic 'designer' drugs," he writes in an email. "I hope the decision signals the DEA's willingness to become a more responsive institution and isn't just squid ink covering the same old drug war policies."
Instructions for submitting a comment by mail or electronically can be found in the DEA's Oct. 12 announcement. After the public comment period ends Dec. 1, the DEA could still decide to temporarily ban kratom, or permanently place the plant in a scheduled category defined by the Controlled Substances Act. The agency could also decide to leave kratom unregulated.
This story is part of a reporting partnership with NPR, KERA and Kaiser Health News.Copyright 2016 KERA. To see more, visit KERA.
NPR Health Blog - Wed, 10/12/2016 - 12:16pm
Reviews Of Medical Studies May Be Tainted By Funders' Influence Listen · 4:26 4:26 Toggle more options
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When doctors want to help untangle confusing and sometimes contradictory findings in the scientific literature, they often turn to specially crafted summary studies. These are considered the gold standard for evidence. But one of the leading advocates for this practice is now raising alarm about them, because they are increasingly being tainted by commercial interests.
For many years, these studies — called meta-analyses and systematic reviews — seemed to solve a big problem. Doctors who had once relied on each other's expert opinions to select the best treatments gradually turned to careful scientific studies instead.
But the number of studies mushroomed and often came to different conclusions. So in the 1990s, doctors and medical advisory committees started relying on studies that combined results from many different research projects to streamline the search for answers.
These kinds of studies are "extremely important," says Dr. John Ioannidis, a professor of medicine health research and policy at Stanford University. He has conducted many of these types of studies over the course of his career. "They're trying to make some sense out of a very convoluted scientific and medical literature."
But Ioannidis says unfortunately things have gotten out of hand. First, "the problem is that there are just too many meta-analyses," Ioannidis says.
In a recent study on the subject, titled "The Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-Analyses," he chose as an example studies involving antidepressant drugs. "There are 185 of them published in the literature within seven years, which means about 25 of them published every year for the very same drugs and the very same indication, major depression," Ioannidis said.
What's worse, they're increasingly being generated by scientists who have financial interests in the outcome, Ioannidis found.
"About 80 percent of them have been funded or have some other conflicts of interest with manufacturers of these drugs," he says. "If you look at what their conclusions are, those that have been authored by industry employees, practically all of them, with one exception, have claimed that there are no caveats about antidepressants."
You have to read deep into the studies to find warnings about potential suicide risks, for example — if downsides are mentioned at all.
That's potentially misleading to doctors who turn to this kind of analysis to get a quick take on what works and what doesn't. Ioannidis says the drug industry has started using meta-analysis for commercial purposes, rather than as a disinterested look at the evidence.
"They can get the results or at least the interpretation that fits their needs. So you have the most powerful and most prestigious design in current medical evidence, and it can be easily manipulated as an advertisement, as a marketing tool."
And that defeats one of the main purposes of these studies, which is to make an overflowing scientific literature more manageable.
Peter Kramer, a clinical professor emeritus at Brown University and author of Listening to Prozac, took a deep dive into meta-analyses when he was writing his latest book, Ordinarily Well. He found the situation even worse than Ioannidis suggests.
"In some ways my doubts are stronger than his," Kramer told Shots.
Some analyses he looked at were trying to parse very subtle differences — for example, comparing two very similar antidepressants. You could get any answer you want, depending on how you set up the study, Kramer says.
And the problems he found aren't simply commercial conflicts of interest. For example, he saw biases among academics who were wedded to the notion that placebos are just as good as actual drugs for depression.
"Even on that side of the equation, where there's no adverse sponsorship but just an allegiance to an idea, I thought it wasn't always the case that everybody's hands were on the table," Kramer said.
But financial conflicts are easier to identify. Five years ago, the National Academy's Institute of Medicine (now called the National Academy of Medicine) suggested dozens of standards that should apply to systematic reviews of the research literature.
The influence of funders is a concern, says Dr. Alfred Berg, a professor emeritus of family medicine at the University of Washington who chaired one of the committees.
"If there's obvious sponsorship from an organization that might have a conflict of interest, that's probably not a good idea," he says. It's reasonable to suggest that scientists with clear financial conflicts of interest should not be producing these studies. "Is it going to happen in my lifetime?" Berg says. "Probably not!"
Pfizer, one of the many drug companies that fund meta-analyses involving their own products, declined an interview request. But the company noted in an emailed statement that the drug company "shares data from its clinical trials with outside members of the research community for them to conduct their own independent meta-analyses."
Fortunately, scientific journals are starting to do a better job of making sure researchers disclose their financial interests. It's up to readers now to take heed.
Email Richard Harris at email@example.com.Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Wed, 10/12/2016 - 7:00am
I was 8 or 9 years old when I moved from a rural town in Oregon to the San Francisco Bay Area. It was one of seven moves my family made during my elementary years. The culture shock of moving from country to city hit me hard. I stuck out at my new school. It was hard to make friends with my new classmates. My parents argued often. So I spent a lot of time doing my own thing, trying not to think too hard about the rapid changes happening to my life.
This is when I started drawing.Desmond Meagley/Youth Radio
My interest in drawing started as a way to deal with my feelings. To the rest of the world, I was a girl. But even then I knew that didn't quite fit.
I was a young kid with a changing family, moving from city to city, and drawing gave me a distraction. When I felt lonely, homesick or just bored, I drew my imaginary friends and characters from my favorite games. It was hard to make friends when my family moved so much. So I took characters out of computer games, books and movies, and imagined them like they were there hanging out with me.
Even when I did spend time with other kids, I felt out of place. In middle school, it became increasingly difficult to relate to girls from my class. So I mostly hung out with a group of guys who shared my interests in drawing, Internet culture and video games. I thought I fit in with them. But then, one day, I was talking to one of them over lunch and he said, "You know, it's weird that you're a girl and you hang out with us."Desmond Meagley/Youth Radio
I was surprised. Then confused. Then hurt.
I felt bad in a way I couldn't describe yet. It wasn't fair. It didn't make sense. And it was one of the first moments I realized that my gender mattered to other people — that the way I experienced gender, as something more nuanced than just male or female, masculine or feminine, was not the way that other people thought about it.Desmond Meagley/Youth Radio
During this time, my drawings were also changing. I found myself drawing a lot of androgynous dudes. I related strongly to one character in particular: He was an artist; short, with long, silver-dyed hair and shaved patches on the sides of his head. He wore nail polish, piercings and black clothing.
Drawing him was like escaping myself for a moment: I could be where he was, do what he was doing, and think his thoughts. I never felt like I was living in the wrong body. But some of the bodies I drew definitely felt "right." My characters were half friends, half alter egos.Desmond Meagley/Youth Radio
Meanwhile, in real life, I tried to dress the way the girls in my class did, to look more feminine than I felt. I masked myself with smeary lip gloss and eye shadow. It was bittersweet to get compliments on my more feminized appearance. On the one hand, I liked the positive attention. But it felt hollow.
I figured being a girl was an acquired taste: unpleasant at first, but you eventually get used to it and begin to enjoy it.
Only I didn't. Going to school caused me so much anxiety and dysphoria that I'd fake being sick to stay home. And when I did make it to class, putting my head down to sketch was much more attractive than trying to socialize or focus on schoolwork. I could turn off my thoughts and let the pen take over until the day was over — and then I could disappear.
My drawings provided a raft of confidence that let me drift slowly through the turbulent waters of my early teens. I thought that if I couldn't be normal, then I could at least be accepted on the outside. But that phase of denial wasn't meant to last past the last weeks of middle school, when I came out as transgender.
Source: Youth Radio
Credit: Desmond Meagley
At the time, I didn't ascribe much significance to the role drawing has played in my life. But recently I found a box of my old drawings. Lots of them made me cringe, but when I looked at some of my old characters, I noticed familiar features.
Today, I'm 19 and have long hair that's cut short on the sides. I have a few piercings. I wear black, and I like bleaching and dying my hair and occasionally applying nail polish. The person I am today could have walked out of a drawing I did eight years ago.
Drawing isn't just a hobby for me: It's how I process my thoughts and experiences. It's my way of preserving the past, coping with the present and visualizing the future.
But now, I don't need to escape to feel comfortable with myself. When I look at my art, and how much it's evolved, I appreciate how much my struggles, and the skills I've developed, have shaped me.
This story was produced by Youth Radio's outLoud, with illustrations & story by reporter Desmond Meagley. Teresa Chin was lead designer and producer, and Storm White the design associate. Visit them on the Web at www.youthradio.org. Copyright ©Youth Radio, 2016.Copyright 2016 Youth Radio. To see more, visit Youth Radio.
NPR Health Blog - Wed, 10/12/2016 - 5:00am
Mammograms are said to cut the risk of dying from breast cancer by as much as 20 percent, which sounds like an invincible argument for regular screening.
But two Maryland researchers want people to question that kind of thinking. They want patients to re-examine the usefulness of cancer exams, cholesterol tests, osteoporosis pills, MRI scans and many other routinely prescribed procedures and medicines.
And they want to convince them with statistics — but don't worry! They promise not to use algebra or spreadsheets. Or even numbers.
Health costs continue to grow much faster than the economy's ability to pay them. Partly as a result, scrutiny of potentially unneeded and harmful treatment has never been more intense.
Nearly 3 in 4 physicians surveyed by the American Board of Internal Medicine said unnecessary tests and procedures are a serious problem. The authoritative National Academy of Medicine estimated that 30 percent of all health spending — $750 billion — is wasted on fraud, administration and needless procedures.
But even doctors often don't understand the trade-offs involved in many tests and medicines, says Dr. Andrew Lazris, a Maryland internist. When they do, they have trouble explaining them to patients.
To change that, Lazris and environmental scientist Erik Rifkin are trying to popularize an intuitive, pictorial way of showing just how few people are helped — and how many are even harmed — by many common procedures.
Health is best discussed in the language of risk and probability, but the $70 billion spent on long-shot government lotteries every year suggests that Americans are a bit challenged in that regard. Behavioral psychologists have confirmed what a French writer observed in the 1600s: "Each believes easily what he fears and what he desires."
Especially about health. Lazris and Rifkin want to give people a more realistic way of evaluating medical hopes and worries.
They ask patients to picture a hall of people getting a test, operation or prescription. Patients might be shocked at how few in the crowded room get any benefit from the expensive care.
Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. There's a sold-out house of 1,000 playgoers or concertgoers, all getting a particular kind of exam, screen or pill.
Then the curtain falls. Everybody helped by the procedure or prescription gets up and leaves. Often it's only a few people. Sometimes very few. Or nobody.
As NPR has reported, Lazris has used this approach to help patients in his practice — some of whom are older smokers — to weigh risks and benefits of using CT scans to look for lung cancer.
The theater approach also works when it comes to breast exams. Only one woman in the thousand-person theater receiving mammograms over a lifetime is saved from dying by detecting a cancer before it spreads, according to Rifkin and Lazris' summary of the research.
At the same time, hundreds of women in that audience will receive test results suggesting they have cancer when they don't, so-called false positives. Sixty-four get biopsies, which generally involve cells withdrawn through a needle, for nonthreatening lumps.
Ten receive unnecessary treatment including radiation and surgery for lumps that never would have caused a problem.
The theater images show all of that as well, presenting visual demonstrations that the odds of harm, worry or inconvenience caused by the tests are often much higher than the likelihood of benefit.Shots - Health News Women In Their 40s Get Some Help With The Mammogram Decision
Drawing conclusions from mammogram studies is contentious. Some reports show greater benefits — as many as five fewer deaths for 1,000 women. Benefits also vary by age. For women with a family history of breast cancer, dense breasts and others with higher risks, benefit from screening — perhaps beyond mammograms — is higher than for those with normal risk, researchers say.
Showing all this with theaters "seems like a great idea," said Dr. Zackary Berger, an assistant professor at the Johns Hopkins School of Medicine who studies patient communication. "It seems pretty intuitive, and that's the trick. You want to deliver this information in a way that people can really take in."
Aids for medical decision-making are available online. But doctors may not know about them, Berger said. Even if they do, showing patients requires a computer and a bunch of keystrokes. The theaters are pictures on paper.
What Lazris and Rifkin especially want to combat is the practice of discussing only relative benefits of medical procedures.
Stating that a mammogram lowers mortality risk from breast cancer by 20 percent says nothing about how likely a person is to die of that disease in the first place. Not to mention what the test might cost in pain, harm or hassle.
Cutting womens' risk by 20 percent sounds impressive — until one realizes it might be the difference between 5 in 1,000 who don't get mammograms and die of breast cancer and 4 in 1,000 who do get mammograms and die of breast cancer anyway. (Mammograms miss lots of deadly cancers, and some tumors prove fatal even with early detection.)
That's not much change in absolute risk. The theater images capture that subtlety.
Other procedures and prescriptions show similarly small benefits.
Hip fractures prevented by osteoporosis pills such as Fosamax, according to Lazris and Rifkin? Roughly 5 in 1,000 taking the medicine.
Strokes prevented by blood thinner warfarin among patients with atrial fibrillation, a type of irregular heartbeat? Six out of 1,000 — but 12 people out of those 1,000 will suffer major bleeding episodes.
Lives saved per 1,000 men screened for prostate cancer? Zero. Nobody leaves the theater. (It's unclear whether screening and detection change the course of the disease.) Risks of impotence from surgery or radiation for prostate abnormalities detected by screening that may be nonfatal? Six-hundred men get up and walk out.
Lazris and Rifkin say they aren't pressuring people to avoid tests.
Under the growing philosophy of shared decision-making, they just want patients to have a good conversation about what procedures can and can't do. Then patients decide.
"Whenever I use this, the patients tend to not favor taking the treatment," Lazris said. However, "there are people who look at the one out of a thousand and say, 'That looks pretty good. That's me sitting there. I'll take it.' "
The researchers published a book in late 2014 on their theater visuals and have tried the images in focus groups. They're trying to interest insurance companies and health systems.
"When we showed people the theaters and they didn't have to deal with numbers at all," Rifkin said, "they all responded positively."
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Neither of them is affiliated with health insurer Kaiser Permanente. You can follow Jay Hancock on Twitter:@jayhancock1.Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
NPR Health Blog - Tue, 10/11/2016 - 3:59pm
Matt Larson, shortly after his brain surgery, with his wife, Kelly. Larson says he would like the option to end his life rather than face a painful death.Courtesy of Matt Larson
Last spring everything changed for Denver resident Matt Larson.
"One day I was fine," says Larson. "The next I was being rushed by ambulance to Denver Health following two very massive and violent seizures."
The force of the seizures, from the sheer shaking, fractured and dislocated his shoulders and snapped two bones in his back. Soon his providers had life-altering test results.
"They came back and shut the door and said 'you have mass on your brain,' which was tough to hear," says Larson.
The diagnosis, a malignant brain tumor called an anaplastic oligodendroglioma, rocked his world. Larson, 36, and his girlfriend, Kelly, decided to get married. He says a couple of days later, surgeons cracked open his skull and scooped out part of his brain. Since then he's endured the tough road of radiation and chemo, with a sobering outlook.
"I have a 50/50 probability that I'm going to live," says Larson. "I hope to beat the odds. I desperately want to live."
But Larson has decided that if the brain cancer returns and is incurable, he'd like the option to end his life rather than face the possibility of an agonizing and painful death.
"It would just bring me a ton of peace and comfort now to know that I have this option," Larson says.
He's become an advocate for Colorado's Proposition 106. It would give mentally competent adults the ability to end their lives with a doctor-prescribed drug, generally a sleeping medication called secobarbital.
"We need to help people diminish and assuage their suffering any way we can," says Dr. David Grube, a family doctor in Oregon, one of five states to allow the practice.Shots - Health News Despite Sweeping Aid-In-Dying Law, Few Will Have That Option
Grube, who retired after practicing for 38 years, is also the national medical director for the group Compassion & Choices. He became a proponent of what he calls "death with dignity" shortly before the law passed in Oregon in 1994. He was moved to the position after one of his patients, who was dying from bladder cancer, shot himself to death.
"If I can ever prevent such a violent and tragic end to a person's life, I should be open to helping people," Grube says.
Five states currently allow the practice: Washington, Oregon, California and Vermont; and Montana has effectively legalized it, due to a court ruling that protects doctors who help dying patients from prosecution.
Colorado's proposal is modeled after Oregon's law. In both, two doctors must determine a patient is mentally capable of making the choice and isn't under undue influence or coercion. Grube says he has helped about 30 people end their lives, with about a third of those who requested medications deciding not to take them.
"Many more people just want to talk about it, just want to know if it's a possible option," says Grube. "Still, in all, it's quite uncommon."
According to the Oregon Public Health Division, during 2015, 218 people received prescriptions for lethal medications under the provisions of the state's Death with Dignity Act. That was up from 155 the prior year. The division has received reports of 132 people who died in 2015 from taking the medications prescribed under the act, a rate of 38.6 per 10,000 patients.
More than 90 percent of those patients died at home and were enrolled in hospice care. Since the Oregon law was passed, 1,545 people have received legal prescriptions; 991 patients died after ingesting the medications.
When patients were asked why they decided to consider ending their lives, the most common concerns were that they were less able to engage in activities that make life enjoyable, and that they were losing both autonomy and dignity. Further down the list were inadequate pain control and the financial impact of the treatment.
Doctors as healers
But Denver physician Alan Rastrelli opposes the proposal. He worries it will erode the public's trust in doctors as healers.
"Physicians will go towards this philosophy of assisting a patient in their death," he says. "That will destroy, I think, the patient and physician relationship."
Dr. Alan Rastrelli, a hospice and palliative care physician, says Proposition 106 will erode the doctor-patient relationship.John Daley/CPR
Rastrelli, who practiced anesthesiology for 28 years, transitioned into hospice and palliative medicine 15 years ago. He says when doctors help patients end their lives, it creates a societal and bioethical calamity.
Rastrelli worries about what the initiative doesn't do, such as require a physician to be present when the person dies. He also said it's difficult to know about common problems or mistakes because reporting requirements in Oregon, and in Colorado's proposal, are weak.
He advocates helping dying patients to use pain relievers and receive spiritual and psychological support to ease suffering.
"Woody Allen said, 'I'm not afraid of dying, I just don't want to be there when it happens,' " Rastrelli says. "We can help people be OK all the way through to the end."
That makes a lot of sense to advocates with Not Dead Yet, a national group run by people with disabilities that opposes the proposal.
Anita Cameron, one of the group's board members, says doctors "are humans and they make mistakes."
Anita Cameron, a board member of the group "Not Dead Yet," opposes Proposition 106.John Daley/CPR
Cameron's mother, Alice, was diagnosed with end-stage chronic lung disease seven years ago. She was given less than six months to live. Today, Cameron's mother is still alive.
"Had the law been in place, I'm pretty sure those doctors would have convinced my mom to take the pills," Cameron said. "And she'd be dead."
Cameron has several disabilities, including multiple sclerosis. She worries that the ballot proposal will encourage people with disabilities to kill themselves. She also thinks that in some cases, insurers will agree to pay for end-of-life medications, but not for measures to keep someone alive.
"When is it going to be a duty to die?" asks Cameron. "That's what euthanasia is, and when is it going to stop being a choice?"
Battle draws big bucks
The ballot initiative is drawing passion — and plenty of money.
According to the latest filings with the Colorado Secretary of State's office, backers have raised about $5.3 million, mostly from Compassion & Choices Action Network.
The "No Assisted Suicide Colorado" campaign has raised $1.8 million. That money is primarily coming from the Roman Catholic Archdiocese of Denver, which has donated $1.1 million, as well as other archdioceses around the country.
Both groups have also received numerous smaller donations.
The board of the Colorado Medical Society, the state's largest physician group, voted to take a neutral position on the measure. President-elect Dr. Katie Lozano calls the proposal "the most personal of decisions that must be left to our patients" to decide.Shots - Health News Increasing The Odds That End-Of-Life Wishes Are Honored
A February poll of 618 Colorado physicians before the ballot measure was proposed found support within the group for physician-assisted death in general. Fifty-six percent of medical society members favored it; 35 percent opposed.
Among those who frequently treat patients in later stages of a terminal illness, the gap was smaller, with 50 percent backing physician-assisted death and 41 percent opposing it.
The medical society said there was a consensus that if the law were to pass, the medical society should focus on protecting patients and doctors, and increase awareness of end-of-life choices, emphasizing the importance of palliative and hospice care.
Election ballots will start being mailed next week.
This story is part of a reporting partnership with NPR, Colorado Public Radio and Kaiser Health News.Copyright 2016 Colorado Public Radio. To see more, visit Colorado Public Radio.
NPR Health Blog - Tue, 10/11/2016 - 11:58am
Skopein/Ikon Images/Getty Images
Aiming to attract and keep top-notch talent, a growing number of companies are dangling family-friendly perks such as lengthy paid leave for new moms and dads, back-up child care and onsite infant vaccines. But the attention-grabbing headlines — such as "IBM plans to ship employees' breast milk home" — obscure the reality that for many workers, basic benefits such as guaranteed parental leave, even unpaid, are unavailable.
In California, long a trailblazer on paid leave, work-life advocates suffered a setback recently when the governor vetoed a bill that would have required small businesses to guarantee employees' jobs after they take a parental leave.
Workers at larger employers already have that protection under federal law. The Family and Medical Leave Act allows workers at companies with 50 or more employees to take up to 12 weeks off without pay following the birth or adoption of a child without jeopardizing their jobs. It also applies for care for themselves or a family member with a serious health condition.
California takes it a step further, however. It's one of just four states that replaces a portion of workers' wages while they're on unpaid family leave. New Jersey, Rhode Island and, beginning in 2018, New York, are the others. Washington state also has passed a law but never funded it.Shots - Health News A Pediatrician's View Of Paid Parental Leave
Though other states have expressed interest in this type of coverage, "change is glacial, and most people still don't have access" to paid family leave, said Vicki Shabo, vice president at the National Partnership for Women and Families, an advocacy group based in Washington, D.C.
In California, workers at companies of all sizes who take family leave can receive up to 55 percent of their wages, going up to a maximum 70 percent in 2018, for up to six weeks to care for a newborn, newly adopted or foster child or ill family member. The leave is financed by a payroll tax on employees that was added to the state's existing temporary disability program.
But even though workers pay into the fund and are entitled to the state payments during a family leave, people who use the benefit can find themselves out of work at smaller companies. In some cases, workers reluctantly use their more limited paid vacation instead, or they may skip parental leave entirely.
When Charles and Angelique Anderson's daughter was born in July, Charles asked his company for a month off to bond with the baby. The debt collection company he works for turned down his request because, he said, it told him his office of roughly 30 workers isn't bound by the family leave law. When the baby was born, Anderson, 32, took just a week of vacation before returning to his Sacramento job.
"I was angry," said Anderson, who has worked at the company since 2007. "Now I have my first baby and they deny me leave because it would have hurt their money."
The bill vetoed by Gov. Jerry Brown on Sept. 30 would have allowed workers at small businesses with between 20 and 49 employees to take up to six weeks off after the birth or adoption of a child without losing their jobs.
In his veto message, Brown said he was worried about the effect on small businesses. The California Chamber of Commerce opposed the bill, calling it a "job killer" because it would impose another protected leave of absence on small businesses. The chamber didn't respond to a request for comment.
Small businesses, however, didn't necessarily agree with that assessment.
"Small employers need to compete for talent and they want to be able to offer their employees the whole suite of benefits," said Mark Herbert, California director of the Small Business Majority, an advocacy group.
Although the organization didn't take a position on the bill, Herbert said the financial consequences of such a law might be positive for small businesses. That's because employers don't pay workers' wages while they're on family leave.
A survey of 250 California employers in 2010 found that roughly 90 percent reported no problems with morale, productivity, profit or costs because of the family leaves. That's generally consistent with national employer surveys about family leave laws.
Nationally, just 13 percent of private sector workers have access to paid family leave, while 87 percent have access to unpaid family leave, according to the U.S. Department of Labor's annual national compensation survey of employee benefits.
Sixteen percent of workers who were eligible for leave under the federal Family and Medical Leave Act in 2012 took it, usually because of their own illness. Of those, about one in five took leave because of pregnancy or a new child, according to a report prepared by Abt Associates for the Department of Labor.
Although big-name companies offer generous paid family benefits — sometimes months of leave for both parents — many workers can't take more than a few days off, even without pay. But work-life advocates say they're encouraged by generous corporate perks.
"It's a cultural shift," said Maya Raghu, director of workplace equality at the National Women's Law Center. "Some employees don't see this as a benefit but as a necessity."
For their part, California advocates aren't giving up on small business protections. "Instead of being sad, people feel really energized," said Jenya Cassidy, director of the California Work and Family Coalition, which advocated for the bill. "We're still not done."
Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter: @mandrews110.Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
NPR Health Blog - Mon, 10/10/2016 - 5:01pm
Rethinking Automatic Insurance Coverage For Preventive Health Care Listen · 3:33 3:33 Toggle more options
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Mylan CEO Heather Bresch holds up an EpiPen two-pack while testifying about price increases to the House Oversight and Government Reform Committee on Sept. 21.Pablo Martinez Monsivais/AP
Three doctors who have led a task force that evaluates preventive medical services say the group's recommendations shouldn't be tied by law to insurance coverage.
The former chairmen of the U.S. Preventive Services Task Force say the link between medical recommendations and insurance coverage leads to financial incentives that can corrupt the process and distort people's health care decisions.
Under the Affordable Care Act, any preventive service that receives one of the USPSTF's top two ratings must be covered by insurance without any out-of-pocket cost for the patient. The doctors advice to decouple the task force ratings from insurance coverage would require a change in the health law.
The authors of the commentary, which appears Monday in the Annals of Internal Medicine, point to heavy lobbying by the pharmaceutical company Mylan N.V. to get its anti-allergy device EpiPen deemed a preventive service. They say such lobbying can interfere with the task force's mission to evaluate medical services to improve the health of the overall population.
"When people try to twist that mission for their own purposes, essentially what they're doing is violating the integrity of the task force process, and it's distracting from the mission," says Dr. Virginia Moyer, the lead author of the commentary. Moyer, a former chairman of the task force, is now a vice president of the American Board of Pediatrics.
The USPSTF is an independent group of volunteer physicians who review the research on preventive medical services, such as vaccines and screenings tests, and recommend who should get them and how often.Shots - Health News EpiPen's Dominance Driven By Competitors' Stumbles And Tragic Deaths
Mylan has been lobbying the task force to have the EpiPen listed as a preventive device, even though it is used by people with diagnosed allergies. The EpiPen is an automatic injector that delivers a dose of epinephrine to stop dangerous allergic reactions. A two-pack costs more than $633, according to GoodRx.
The company has been under fire in recent months because it has raised the price of the device more than fivefold since 2007, even though the product has been on the market for decades. Mylan CEO Heather Bresch has blamed the uproar on trends in insurance coverage that leave patients responsible for a larger share of their medical costs.
If EpiPens were covered as preventive medications, patients could get them at no cost. The price increases Mylan has put in place would be invisible to consumers but would have to be borne by insurers.
"What Mylan has done, or what they're attempting to do with this effort, is use a provision in law, which is intended to give people access to preventive services, and use it to their advantage for something that just plain is not a preventive service," Moyer says.
That effort by Mylan, which was detailed in a story by The New York Times, spurred Moyer and her two colleagues, Dr. Michael LeFevre and Dr. Ned Calonge, who were also task force leaders, to write the opinion piece that questions the overall idea that insurance coverage should be tied by statute to the recommendations of the volunteer medical group.
The authors say the issues with the link go beyond the problem of lobbying. By putting prevention ahead of treatment of illness by making it free of cost, the system created by the ACA may be making treatment of illness more expensive and putting it out of reach of some patients.
"If such financial access comes at the cost of increased deductibles or copays for equally important services that are not preventive, then we must question whether the link inadvertently discourages other important care," they write.
"Perhaps it is time for the USPSTF to inform, but not determine, coverage," they conclude.
A recent survey by the Kaiser Family Foundation shows that more than half of people with insurance through their employer have policies with deductibles of more than $1,000.
Many advocates and economists agree that preventive services can cost more but also can improve the quality of health care. When the Affordable Care Act was being debated, advocates on both sides argued whether or not preventive services would save money in the long run.
"Preventive health services have become quite expensive over time," says Joe Antos, a resident scholar at the American Enterprise Institute.
He says some preventive services such as vaccines are inexpensive and undoubtedly valuable. Others, such as mammograms, are also medically important but don't necessarily save money.
When those services are provided free, the costs are spread across all policy holders through premiums and deductibles.
But Antos cautions against blaming rising deductibles and premiums only on preventive care.
"To what extent have preventive services been responsible for the big increase in deductibles and co-payments over the last decade or so?" he asks. "I would argue that they've contributed. But we're really talking about rising health care costs, not just preventive services."Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Mon, 10/10/2016 - 2:55pm
A Pediatrician's View Of Paid Parental Leave Listen · 3:49 3:49 Toggle more options
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NPR StaffCargo/imagezoo/Getty Images
Paternity leave can make a big difference in a dad's long-term engagement with the child, doctors find. Paid family leave also fosters breastfeeding and reduces the incidence of maternal depression.
As part of All Things Considered's series Stretched: Working Parents' Juggling Act, NPR talked with Dr. Benard Dreyer, a developmental and behavioral pediatrician at the New York University School of Medicine and president of the American Academy of Pediatrics, to get a better sense of what the scientific evidence says about the health benefits of paid family leave.
The AAP is the leading U.S. pediatricians' organization, with approximately 66,000 members, including pediatricians and other pediatric care providers. It's one of several medical groups calling on Congress to pass the Family and Medical Leave Insurance Act, which would create a nationwide social insurance program that enables eligible workers to take up to 12 weeks of paid leave to care for themselves or a family member.
Here are a few highlights from our interview, edited for length and clarity.Interview Highlights
On the optimal length of family leave
We know that at least 12 weeks of parental leave does make a significant difference. Paid maternity leave of at least 12 weeks increases early childhood checkups and immunizations.
But there is research that shows parental leave is better the longer it is. There's no cutoff for the increased benefits of longer leave. Frankly, if I were to suggest it, I'd say six to nine months should be the minimum. I know we're so far away from that, that it's hard to even speak about, but by six months the parent is really in a different place with their child. Leaving them part of the day and finding child care is also easier at that point.
When it comes to family leave, America's an outlier among high-income countries. In most of Europe and Canada, there's paid maternity leave of six to 12 months, and paid paternity leave.
We've focused primarily on the needs of newborn children and their parents, but paid family leave for a child's illness is also very important. It's especially critical for parents of children with chronic or complex diseases who need their parents' care. Parents often lose their jobs because they have to stay home with their kids. Or, if they know they can't afford to lose their jobs, they can't stay home with their kids and provide them with the care a child needs when sick.
On the ways paid leave benefits the whole family
There's very strong evidence that family leave decreases maternal depression. This is key, because maternal depression prevents mother-infant bonding and has negative effects on a child's cognitive, social and emotional development.
This is true for fathers, too. When fathers take some time from work around the time the child is born they're more likely to spend time with their children in the months following. This decreases stress on the family and contributes to father-infant bonding. Just two weeks or so of paternity leave can make a big difference in fathers' long-term engagement with their children.
How family leave increases breastfeeding and the child's health
Studies from California and Canada show that family leave increases breastfeeding. Breastfeeding has many known positive effects, including bonding between the mother and child. It stimulates positive neurological and psychosocial development. It strengthens the baby's immune system. It also decreases the risk of many health problems such as acute diarrhea, respiratory illness, asthma, sudden infant death syndrome and obesity.
Why the early months matter most
Research tells us that infancy is a critical period for health and child development. In the first year or two of life, 700 new synapses are forming every second in the child's brain. As a developmental and behavioral pediatrician I know firsthand that the first six to nine months of life is a critical bonding time for the parents and the child, and bonding is the basis of the parent responding to the child's needs.
Without paid and job-protected family leave, most parents — especially low-income, working parents — will not take time off. They just can't afford it. But I don't think we, as a society, can afford to not have them nurture their child during this critical period.Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Mon, 10/10/2016 - 4:42am
With No Sense Of Smell, The World Can Be A Grayer, Scarier Place Listen · 4:36 4:36 Toggle more options
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Annette HeistCornelia Li for NPR
Nisha Pradhan is worried. The recent college graduate just turned 21 and plans to live on her own. But she's afraid she won't be able to stay safe.
That's because Pradhan is anosmic — she isn't able to smell. She can't tell if milk is sour, or if she's burning something on the stove, or if there's a gas leak, and that worries her.
"It actually didn't even strike me as being a big deal until I got to college," Pradhan says. Back home in Pennington, N.J., her family did her smelling for her, she says. She's moved in with them for now, but she's looking for a place of her own.
"Now that I'm searching for ways or places to live as an independent person, I find more and more that the sense of smell is crucial to how we live our lives," Pradhan says.
There's no good estimate for how many people live with smell loss. Congenital anosmia, being born without a sense of smell, is a rare condition. Acquired smell loss is more common. That loss can be total, or what's known as hyposmia, a diminished sense of smell.
Pradhan doesn't know how she lost her sense of smell. She thinks she was born with it because as a child, she says she liked to eat and ate a lot. But there came a point where she lost interest in food.
"That's actually one of the first things that people notice whenever they have a smell problem, is food doesn't taste right anymore," says Beverly Cowart, a researcher at the Monell Chemical Senses Center in Philadelphia.
That's because eating and smell go hand in hand. How food tastes often relies on what we smell.
"When you lose your sense of smell, your whole sense of food flavor is distorted and diminished," Cowart says. "You can still taste the basic tastes which are sweet, salty, sour, bitter, and umami or savory. What you're missing are the sort of subtle distinctions, the difference between strawberry and banana; between chocolate and vanilla."
And that can make eating a dull experience for anosmics.
"When I go out to eat — it might be Mexican, Chinese, Italian — I have often found that that food is very bland to me. I never feel full. I never feel a sense of contentment," Pradhan says.
When socializing centers around eating, Pradhan says she sometimes feels left out. "I think a lot of us today like to pretend or be foodies and we all like to talk about 'Oh, I think this could use a little bit more lemongrass,' or 'I think this has a hint of cinnamon.' I can't really participate in those conversations," she says.
People need olfactory receptor neurons to smell. These nerve cells come into direct contact with the air we breathe. They then pass from the upper part of the nose to the brain through a honeycomb-like structure called the cribriform plate.
"These neurons are going from the nose directly to the brain and connecting to the olfactory bulb. They're really the only nerves in the body that interact directly with the environment that way," Cowart says.
Because of that, the neurons are vulnerable. Damage to the cribriform plate, say from a head injury, can crush or sever them. Things we inhale can also harm them.
"Their function is to detect chemicals, and chemicals can sometimes be toxic," Cowart says. "They can also be damaged by viruses. Simple cold viruses will sometimes seem to attack those receptor neurons and cause a longer-term loss of smell due to damage to those neurons."
Aging also plays a role, as the neurons dwindle over time. The replacement process isn't perfect, and it may also tend to slow down with age. "So a very large proportion of the population has some degree of smell loss in their 60s, 70s and 80s," Cowart says.
Smell loss might cause some older people to over-season food or lose interest in eating. There's also evidence that smell loss may be an early indicator of Alzheimer's and other neurodegenerative diseases.
In spite of her smell loss, Pradhan still loves to cook. She even ran a food blog called "Anosmic Chef." She favors foods that are spicy, a quality she can still detect. What we think of as food "flavor" is actually a combination of things: odor; taste (sweet, sour, salty, bitter, umami); and chemosensory irritation.
Chemosensory irritation includes sensations like warmth, cooling and pungency. Those signals are carried to the brain via the trigeminal nerve, which is separate from the olfactory system and unaffected by Pradhan's anosmia.
"So the kinds of sensations you get from that are like the coolness of menthol, the spiciness of hot peppers or mustard," Cowart says.
Pradhan wonders whether her anosmia has affected more than her appetite. She thinks it also may have affected her memory.
Remember the smell of your elementary school cafeteria or the perfume of your first crush? That feeling — where a certain smell instantly takes you back — doesn't happen for Pradhan. And she's afraid it means parts of the past are missing.
"When I ask my sister about this, and she and I are not very far apart in age, she remembers people and places and things we've done more vividly than I do," Pradhan says.
Pradhan may be on to something, according to biologist Paul Moore, author of The Hidden Power of Smell: How Chemicals Influence Our Lives and Behavior.
That's because smell memories are created in a different way than other memories. When you smell something, he says, it triggers a response in the limbic system – what he calls the emotional part of the brain.
"When olfactory signals come in, you feel about them first. And then you think about it and then the memory is laid down," Moore says.
So without the feeling part, the thinking about it part doesn't come. And that means no new smell memory gets created, according to Moore.
There's no cure for congenital anosmia. Doctors can treat the inflammation or nasal blockage that may be causing acquired smell loss. If the damage isn't too great, sometimes a sense of smell returns. But it could take years.
Some people have found hope in "smell training" — a sort of brain retraining program for anosmics who have regained at least a bit of their ability to smell.
Researchers are also studying stem cells, to see if they can coax them into becoming new olfactory neurons. But human trials are years away, Cowart says.
Smell has been shorted when it comes to research, says Moore. "We undervalue smell so much that there is very little research into curing anosmia," he says.
Pradhan, who studied biology and hopes to go to medical school, thinks there probably won't be a cure for her anosmia anytime soon.
"I know a little bit about how research works and how long trials take to get medications or therapies out," Pradhan says.
Her biggest concern right now is: "Can I really trust myself to live on my own?" At home in New Jersey, she's reinforcing her strategies for staying safe –double checking the stove and making sure the smoke alarms are working. And she hasn't ruled out a roommate.NPR.
NPR Health Blog - Sun, 10/09/2016 - 2:40pm
The study looked at the relationship between women who used hormonal birth control, and antidepressant use, and diagnoses of serious depression.AJPhoto/Science Source
When the birth control pill debuted more than 50 years ago, women wanted to know: Is it safe? There wasn't much evidence to answer that question, but women embraced the Pill as a revolutionary improvement in contraception.
Today, millions of women around the world use hormonal contraceptives that have expanded beyond the Pill to patches, implants, injections and uterine devices. Decades of research support their safety, and serious but very rare side effects such as blood clots are finally much better understood. But other areas of research lag, and we still don't know as much as we'd like about how these medications affect women's mental health.
So when a study came out linking hormonal birth control and depression, the headlines went wild. The stories made for good clicks, but not so great science reporting. Insufficient skepticism about a single study makes it easy to imply birth control definitely causes depression when the study shows nothing of the sort.
The study, which was conducted in Denmark and published in JAMA Psychiatry, analyzed 14 years' worth of health data for more than 1 million women from national healthcare systems and databases not available in most other countries. It also measured depression two ways: diagnosis at a psychiatric hospital, which would be quite severe depression, or filling a prescription for antidepressants. Across the whole study, 2 percent of all women ages 15 to 34, were diagnosed with depression at a hospital and 13 percent began taking antidepressants.
Several news stories reported an 80 percent increase in risk of depression in some groups of women, but few noted that was relative risk, which is an expression of proportional increase. An 80 percent relative risk does not mean that 80 percent of women taking hormonal birth control develop depression. It means that if 10 women not taking hormonal birth control develop depression, then 18 women on the birth control will develop depression.
In this study, that 80 percent increase in relative risk referred specifically to the likelihood that those ages 15 to 19 taking combined oral contraceptives — the pill containing both progestin and estrogen — would begin taking antidepressants after going on birth control.
However, looking at absolute risks conveys a less dire interpretation. Among women not taking hormonal birth control, 1.7 percent took antidepressants and 0.28 percent received a depression diagnosis at a psychiatric hospital. By comparison, 2.2 percent of women who started birth control began taking antidepressants afterward, and 0.3 percent were diagnosed with depression at a hospital. Basically, about 0.5 percent of women who began hormonal contraception developed depression who might not have otherwise.
"Therefore for an individual woman, even one using a method of hormonal contraception, the overall probability of experiencing one of these outcomes in this study was still fairly low, particularly for diagnosis of depression," explains Chelsea Polis, a senior research scientist at the Guttmacher Institute.
Rates of those filling antidepressant prescriptions were higher for other forms of hormonal birth control: 4.1 percent for the patch and 3.2 percent for the vaginal ring in the first year, for example. Psychiatric depression diagnoses occurred in 0.7 percent of patch users and 0.6 percent of vaginal ring users.
Even in terms of relative risk, though, many of the risk increases were modest: Among all women taking the combined pill, the increased risk was 10 percent for depression diagnosis and 20 percent for using antidepressants after statistically adjusting for women's age, educational level, weight and history of endometriosis or polycystic ovary syndrome, all factors that could influence depression risk.
Other increased risks ranged from 20 to 70 percent for all women, depending on contraception type. The largest increases — up to triple the likelihood of starting antidepressants — occurred among teens using the ring or patch.
Another thing to consider is that these numbers represent correlations — two things occurring at the same time that may or may not be linked.
"Depression is common. Contraception use is common. So both of those things are commonly going to occur together," explains Jeffrey Jensen, a professor of reproductive & developmental sciences and director of the Women's Health Research Unit at Oregon Health & Science University in Portland.
The study used several methods to reduce the possibility that other things could be causing depression. Jensen pointed out that women who are more likely to take hormones for contraception would probably also be more likely to take antidepressants for depression, but the authors did a separate analysis to compare women to themselves before and after beginning contraception and still found a depression risk.
None of this means that birth control does not cause depression, but it doesn't mean it does, either. Since a half percent of millions of women taking birth control adds up, it's important to know whether such a large number of women could be more susceptible to depression, which can be a very serious illness, after starting hormonal contraception.
But it's complicated, and subtle.
For example, the study also found that depression risk peaked six months after women began using contraceptives, but then decreased to the point that women using hormonal contraception for four years actually had lower rates of depression than those not taking it. Though this likely resulted from many women with depression stopping their birth control, those findings match up with a previous large study finding a protective effect against depression with hormonal contraception. But the studies were done differently: The earlier study included only sexually active women, unlike the new study.
"Unfortunately, the analysis did not provide information on the frequency of depression diagnoses or antidepressant use among women using nonhormonal methods of contraception, such as copper IUDs," says Polis. "Such a comparison would help to clarify whether the associations were related to other factors common to women choosing to use contraception, rather than being specifically related to the hormonal content of certain contraceptive methods."
For example, those who become sexually active in adolescence have a higher risk for depression and anxiety, as previous research has shown. Even among women in their 20s and 30s, the decision to begin hormonal contraception may accompany various other circumstances in their lives that could potentially increase the risk of depression or anxiety — not a stretch when the study identifies just a half percent of women with the increased risk.
But the possibility that sexual initiation might come with mental health risks baffled study co-author Lidegaard. "Sexual relationships are a good experience for the majority of women, so I cannot see why women would get depressed by starting sexual relationships," Lidegaard said in an interview. He pointed out that women not in relationships may experience loneliness, a risk factor for depression, but when asked about single women having sex, he said he believes "the majority feel more happy by realizing how wonderful sexual experiences can be. Why should women get depressed from that?"
What this study does do is suggest that women may respond differently to hormones and medical treatments.
"Doctors should perhaps be more careful when they prescribe hormonal contraception to young women and get a history of previous depression first," Lidegaard says.
There's no question that women are going to respond differently to hormonal contraception. But those differences are not well understood.
"We're all very, very different, and we're moving in the direction of precision medicine," adds Catherine Monk, an associate professor of psychiatry and director of research at the Women's Program at Columbia University Medical Center. "There are some women who are just much more sensitive to these hormone changes."
The higher risk of depression found among teenage girls, both Monk and Lidegaard pointed out, might be biological, since teens may be more sensitive to the hormonal changes happening during puberty.
"You need to know yourself and be really informed," Monk says. "If I were of an age and reading this article right now, I would want to be thinking, 'Who am I? Am I sometimes who has moodiness around my periods?' " She notes the importance of each woman considering these findings in conjunction with what she knows about her own body and her own circumstances.
Philosophical differences about medicine may also influence how people interpret these findings in the absence of studies showing causation. Jensen, for example, pointed out that women in developed countries no longer see other women dying during childbirth, illegal, unsafe abortions or other devastating health effects of unplanned pregnancy, and have come to places less value the effectiveness of hormonal birth control.
"Women are more skeptical of using hormonal therapy than ever before," Jensen says. "It's a tragedy of the riches. If you really want to be depressed, have an unintended pregnancy."
Toward the other end of the spectrum, Monk believes we may have gone too far in using hormones to control contraception. "Getting away from barrier methods of contraception is getting away from our bodies," she says, and she would like to see a much larger range of options for contraception for men and women.
The fact that dissent rages over this issue points out a larger question about women's health research.
"Understanding women's health has been neglected, and there's not enough research into understanding our hormones," Monk says. "This is partially a story about women's health research and how we need more of it."
Tara Haelle is the co-author of The Informed Parent: A Science-Based Resource for Your Child's First Four Years. She's on Twitter: @tarahaelleCopyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Fri, 10/07/2016 - 6:33pm
The federal Medicaid program had accused Mylan of underpaying required rebates for the EpiPen, which is used to reverse serious allergic reactions.Drew Angerer/Getty Images
Drugmaker Mylan N.V. announced Friday that it had reached a $465 million settlement with the U.S. Justice Department and other government agencies to resolve questions over rebates required by the Medicaid program.
The deal settles allegations by the Centers for Medicare and Medicaid Services that Mylan had misclassified the EpiPen as a generic drug and had not paid the appropriate rebates that are required by law.
Andrew Slavitt, the acting head of CMS, detailed the allegations in a letter to Sen. Ron Wyden, D-Ore., this week.
Slavitt told Wyden that Mylan had misclassified EpiPen as a "non-innovator" or generic drug, when it should have been classified as a brand-name product. Slavitt said the agency had informed Mylan multiple times of the misclassification.
Drugs companies pay rebates to the Medicaid program of 23.1 percent for brand-name drugs and 13 percent for generics. Mylan paid only the 13 percent for $1 billion worth of EpiPens that Medicaid bought between 2011 and 2015. That cost state and federal taxpayers $163 million, he said.
Mylan was facing potentially large penalties. Companies are required to report a drug or device's correct classification and can be fined up to $100,000 per violation under the terms of the Medicaid Drug Rebate Program.
Mylan has come under increasing scrutiny by lawmakers on Capitol Hill, federal agencies and state attorneys general after the company raised the price for the EpiPen more than 500 percent since 2008. The device is an auto-injector used to reverse serious allergic reactions.
Mylan said the settlement "did not provide for any finding of wrongdoing."Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Fri, 10/07/2016 - 4:33pm
How California's 'Paid Family Leave' Law Buys Time For New Parents Listen · 5:10 5:10 Toggle more options
New moms and dads get six weeks off at a little more than half their weekly pay — 55 percent, with a cap that's indexed to inflation each year.
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Iris and Eli Fugate with their 6-month-old son Jack, at the family's home in San Diego. Thanks to California's paid family leave law, Iris was able to take six weeks off when Jack was born, and Eli took three weeks, with plans to take the remaining time over the next few months.Sandy Huffaker for NPR
Back in 2002, California passed a law that provides paid family leave benefits to eligible workers. In many ways, the law mimicked paid parental leave policies that are in effect in nearly every other country in the world. But it was the first its kind in the U.S., and several other states have since followed suit.
Here's how California's law, part of of the state's disability insurance program, works: Most workers in the state have small deductions (less than one percent of their wages) withheld from each paycheck.
The program works sort of like the federal Social Security system, creating a pool of money employees can draw from if and when they need to take time off work to care for a seriously ill relative, or when they have a new baby.
New moms and dads get six weeks off at a little more than half their weekly pay — 55 percent, with a cap that's indexed to inflation each year.
Iris and Eli Fugate, who live in San Diego, say the paid leave gave them precious time to welcome their son Jack into the family. Iris took the full six weeks of leave after Jack was born five months ago. Eli took three weeks, and plans to spread the rest out over the next few months.
Iris Fugate says having the time with her husband, Eli, to jointly care for their baby in Jack's first weeks of life helped them learn how to parent together.Sandy Huffaker for NPR
"We both got time to get to know him together," Iris says of that early time with baby Jack. "Really meaningful — I can't imagine it going any other way."
Eli agrees. "It was really important during that first week or two especially," he says. Being able to encourage one of his son's first milestones — turning over for the first time — and share the baby's delight, was priceless, he says.
Since the family leave law went into effect more than a decade ago, it's had a positive impact, says sociologist Ruth Milkman, a professor at City University of New York, who has studied the law and its history. Business interests initially opposed the law, Milkman says, claiming it would kill jobs and drive small business out of business.
But when she and a colleague surveyed large, midsize and small companies in California five years after the state's family leave law went into effect, they discovered those early fears hadn't played out.
More than 90 percent of businesses reported a neutral or even positive impact on their companies after the law. The positive impact had to do with improved employee productivity and morale.
That makes sense, Milkman says. "It's a new benefit and employees are happy about it."
Families too, have reported positive changes, she says. There's been a steady, significant increase in the number of new dads like Eli taking paternity leave to bond with their babies. And, since the law launched, the length of time new mothers like Iris breastfeed has doubled.
The law still requires sacrifice on the part of anyone taking the benefit. It doesn't provide a full paycheck — just 55 percent of an employee's weekly salary. The Fugates say living on a tighter budget each week wasn't easy, but the couple had enough saved to make that work. Eli works as a manager for a large grocery chain, and Iris is a lawyer.
But for many families, especially low-wage workers, living on half-pay is much tougher, or even impossible.
It was financially challenging to live on 55 percent of the family's income in the weeks after Jack was born, Iris Fugate says, but the couple had been able to save enough money to make it work.Sandy Huffaker for NPR
Kitty Jensen and her husband Lasha Gabrichi, live in North Hollywood, where Jensen works as a personal assistant to a clothing designer. Her boss encouraged her to take maternity leave after her baby was born, Jensen says, and never pressured her to return to work early.
Still, in the end, she returned to work much earlier than she wanted to. At the time of their son Leo's birth, Gabrichi was out of work, which meant the new family was living on half of Jensen's moderate salary.
It was money, says Jensen, but it felt like "nothing!" The family still had to pay rent, utilities, telephone, food, health insurance, car insurance plus all the other new costs of having a baby — from medical bills to diapers.
"If you're if you're not in the upper middle class, I don't know how people survive on it," Jensen says. "We certainly didn't."
Jensen turned to her parents for help. They're not well off, she says, but contributed as much as they could. Jensen and Gabrichi also started selling possessions on Craig's list — "furniture and art stuff I had, vintage art pieces, chairs," Jensen says. "I just sold anything I possibly could — all year."
Despite the financial strain, Jensen says she's grateful for the time she was able take away from her job to spend with the baby. But many workers who are eligible for family leave don't take it because they are even more stretched, financially.
Beyond her survey of how companies were affected by the state law, Milkman also looked at whether Californians were able to take advantage of the family benefit. One third of those surveyed said they couldn't afford to take the leave.
The Fugates still make time to stroll their San Diego neighborhood together. In a survey of California companies, more than 90 percent of businesses reported a neutral or positive impact on their companies after the 2002 California family leave law was enacted.Sandy Huffaker for NPR
Even worse, says Milkman, more than half of those surveyed weren't even aware the law exists, she says.
"And the people who need it most — immigrants, young workers, poor people, low wage workers — they are the least likely to know about it," Milkman found.
Service industry workers, like Claudia Chi-Ku, who lives in Los Angeles, are often among those who don't realize they have the option of paid leave. Chi-Ku's worked in numerous restaurants, and is now doing housecleaning at a healthcare facility. But when she got pregnant with her fourth child several years ago, she was working for a large car wash chain.
"At that time, to be honest with you I had no idea — none whatsoever — about the paid leave law and the benefits it came with," Chi-Ku says. Even half a paycheck would have been a godsend, she says.
"I would have used that money," Chi-Ku says. "I really needed it at that time."
Today Chi-Ku works with advocacy groups like the Restaurant Opportunities Centers United, to help other low-wage workers understand their rights under the paid leave law.
And changes are on the way. Come 2018, leave benefits in California will be boosted to 60 percent of an employee's salary, and 70 percent for low-wage workers like Chi-Ku. State lawmakers have also worked to put more job protections in place for people who opt to take the leave.Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Fri, 10/07/2016 - 2:16pm
Shela Bryan of Hull, Ga., is looking for a new health insurance policy but has been stunned by the prices.Steven Bush/Courtesy of Shela Bryan
Shela Bryan, 63, has been comparing prices for individual health insurance plans since May, and she can't believe what she has been seeing.
"They cost a thousand, $1,200 [a month], and they have a deductible of $6,000," she said. "I don't know how they think anyone can afford that."
Bryan, who lives in Hull, Ga., a hamlet of about 200, was on her husband's insurance plan for decades. When he died in 2013, she continued his workplace coverage through COBRA, but she had to pay almost the full price of the insurance, or about $800 a month. But it was "the Cadillac of insurance," Bryan said, with low copays, prescription drug coverage and a $500 deductible.
That option will run out in a few months, so she is turning to the individual insurance market in what is shaping up to be the most expensive year for the 400,000 or so consumers in Georgia who buy their own policies but don't purchase them on the health law's marketplaces.
About 10 million Americans buy individual insurance coverage without cost-reducing federal subsidies on the marketplaces on the open market, according to the Congressional Budget Office.
In Georgia, consumers who don't get insurance through their employers or don't qualify for tax credits to help pay for policies they purchase are facing double-digit premium increases. Blue Cross Blue Shield of Georgia, the only insurer offering plans throughout the state, received an increase of more than 21 percent from the state insurance commissioner. Humana was awarded a 67.5 percent hike.
Prices are going up in other states, too. BlueCross BlueShield of Tennessee was granted a 62 percent rate hike, while state officials approved a 46 percent increase for Cigna. Florida authorities gave plans there an average 19 percent bump. And last week, Minnesota officials announced that premiums for the seven insurers on the individual market are rising 50 to 67 percent.Shots - Health News Aetna Joins Other Major Insurers In Pulling Back From Obamacare
The insurers are now adjusting for some miscalculations, said Graham Thompson, executive director of the Georgia Association of Health Plans. "The prices are up this year, but our hope is that things will settle down after this year," he said.
While consumers have faced sticker shock, the insurers have faced what might be called "sicker shock." They are raising premiums after finding that many of the customers buying plans on the individual market were sicker and more costly to insure than expected when the health law was implemented.
Federal and Georgia officials note that customers can change plans each year to find a better price, but the switches can result in higher deductibles and changes in doctors and hospitals available to the insured.
Bryan, who makes just over the $47,520 limit for a subsidy, finds herself on her own in the individual market now. "I've worked ... all my life," said Bryan, a maintenance supervisor.. "We're the ones entitled to something, because we've worked. They tear me up in taxes and then they say my income is too high for a subsidy?"
She could end up paying as much as $14,000 in premiums for a pared-back policy, she said, which is $4,400 more than she is paying for the COBRA plan. The deductible would also rise by $5,800, and she wouldn't have drug coverage. The cheapest policies would amount to more than a quarter of her yearly income, or double her mortgage.
Bryan said she feels like she is paying for other people's subsidies with her high premium.
But Linda Blumberg, a senior fellow at the Urban Institute, says that's not how subsidies work. "It is not the people paying full premiums who are paying for the lower-income person," she said. Federal dollars are already allocated to do that.
"For a lot of modest income people, this can still feel expensive to them. I actually think we've underinvested" in the amount set aside for subsidies, she said. "I sympathize with it enormously."
Bob Laszewski, a health policy consultant in Washington, D.C., said the Obama administration needs to listen to the complaints of people who aren't getting assistance.
"These people are invisible," Laszewski said. The Affordable Care Act "is working very well for lower income people, but the Obamacare supporters missed the fact that if you're raising a family of four on $100,000, you're not rich. This is the ... guy who remodeled your house, who drives a pickup truck and he's wearing a Trump hat."
This flaw in the law needs correcting, he said. A wider range of insurance options, he said, could help more middle-class people afford coverage.
Individual insurance brokers said they are calling their clients, bracing them for higher premiums.
Athens, Ga., broker Jim Carrow said he's starting to hate his job. He once thought he was helping people. Now, he's delivering bad news.
"It's a mess," Carrow said. "I had one gentleman call me and I had to tell him that because he made $5,000 more this year, he won't be eligible for a subsidy. And who knows what he'll end up paying. It's just one string of misery after another."
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
NPR Health Blog - Fri, 10/07/2016 - 5:00am
Following up a mammogram with an ultrasound exam can find more cancers. But the additional test can also find more false positives that aren't cancer at all.F. Astier/Centre Hospitalier Regional/Science Source
Mammography can prevent deaths from breast cancer, but it's not a perfect test.
It misses some cancers, especially in women with dense breast tissue, and flags abnormalities for follow-up tests that turn out to be benign, among other issues. So there's a lot of interest in additional tests that might make screening more accurate in women who have dense breasts.
Many of those women may be wondering about extra screening after receiving notification letters saying that their mammogram was clean, but that their dense breasts put them at higher risk of cancer.
But there is no clear path for those women, who make up about 45 percent of women ages 40 to 74. The goal with breast imaging technology is not only to detect more cancers earlier, but to actually prevent deaths from breast cancer, says Dr. Otis Brawley, chief medical officer for the American Cancer Society. "That's a very separate and different question," he says. And so far, only mammography has met that standard, he says.Shots - Health News Federal Panel Finalizes Mammogram Advice That Stirred Controversy
Investigating that question requires large, randomized clinical trials that follow women for many years to track whether the group screened with the extra technology has fewer deaths from breast cancer than the group screened with mammography alone. And that kind of trial is expensive and logistically tough.
Because cancer isn't as common as many people think, "the number of women you have to screen to achieve statistical significance is huge," says Barbara Monsees, a professor of radiology and women's health at the Washington University School of Medicine in St. Louis. The full effects won't be apparent for decades. "It's a long-term commitment, and it costs a lot of money," she says.
So researcher, clinicians and policymakers who evaluate tests have to rely on studies of shorter-term outcomes like cancer detection rates and stage at detection — which may or may not translate to saved lives. They also look at what those studies say about false positive findings, since those can lead to invasive biopsies to see if cancer is actually present.
The New England Comparative Effectiveness Public Advisory Council, whose members are from the fields of medicine, economics and policy, looked at the evidence supporting any kind of supplementary screening in women with dense breasts and a clear digital mammogram. Their conclusions, published in 2014, found that there's not a ton of evidence on long-term outcomes, but that the available research suggests a net benefit depending on a person's underlying cancer risk from additional factors, namely age and family history of the disease.
For otherwise low-risk women with dense breasts, the New England group determined that there wasn't enough evidence to recommend extra screening. They mentioned the potential of overdiagnosis and overtreatment, since some percentage of breast cancers — and there is much controversy over how many — would likely never have caused a woman harm had they been left undiscovered.
But for women with dense breasts who are at moderate or high risk of breast cancer according to family history and age, they voted that from the available evidence, the benefits of routine supplemental screening are more likely to outweigh the harms.Shots - Health News Got Dense Breasts? That Can Depend On Who Is Reading The Mammogram
If a woman and her doctor decide that supplemental screening is needed because of her risk factors, the next question is what kind of screening. There are pluses and minuses of each technology:
Hand-held ultrasound devices use sound waves to visualize breast tissue. Ultrasound is often used in women with dense breasts. And research suggests that it can pick up more cancers in these women, ones missed by mammograms. "But there's a price for that," says Debra Monticciolo, chair of the American College of Radiology's Commission on Breast Imaging and a professor of radiology at Texas A&M University College of Medicine. There are many, many more false positives, she says, which in turn can lead to unneeded biopsies.
And it's unclear how those benefits and harms balance out. "Does finding those cancers impact long-term outcomes? You can't really prove it, because all you know is that you found additional cancers," says Monsees. "Can you guess if those would translate into saved lives? Perhaps not all of them, but what percentage of them?"
Magnetic resonance imaging, or MRI, uses magnetic waves to produce images of the breast. MRI finds more cancers, but it also leads to more false positive results than mammography, although fewer than ultrasound. It requires an intravenous catheter for the contrast agent used in the test, and is more expensive than ultrasound.
Most of the members of the New England group said MRI was their first choice for women with dense breasts and a high risk of cancer, citing research on its utility among high-risk women in general. And despite the lack of direct evidence that it saves lives, the American Cancer Society recommends it be added to mammography for women at very high risk of breast cancer, including women who carry certain genetic mutations. That group says there's not enough evidence to say whether women who are moderate risk or who have dense breasts should get the test, and it recommends against its use in low-risk women.
Tomosynthesis is basically a souped-up mammogram; it uses the same X-rays to generate multiple images. It's sometimes called a 3-D mammogram. And unlike the other technologies, it's being suggested for use in all women, says Dr. Janie Lee, associate professor of radiology at the University of Washington and director of breast imaging at the Seattle Cancer Care Alliance. (Lee was one of the authors of the New England group's technology assessment but not a voting member.) It can be used along with a separate 2-D digital mammogram or a virtual 2-D image digital mammogram image can be derived from the 3-D one. (Using the latter technique keeps the radiation dose comparable to a standard digital mammogram.)
Studies suggest that tomosynthesis may improve the cancer detection rate, lower the proportion of women who are called back for follow-up tests, or both, says Monsees, which makes it attractive when performed with the method that produces the lower radiation dose. But it likely won't significantly improve the callback rate in experienced radiologists who already have low recall rates, says Brawley.
Molecular breast imaging involves injecting a radioactive tracer that circulates through the body and is attracted to cancer. Research suggests that it can pick up more tumors in women with dense breasts, and it's cheaper than MRI. But the doses of radiation administered are generally larger than with mammography, notes Monticciolo. And while mammography exposes just the breast to radiation, MBI exposes other organs such as the GI tract. That means that at this point, says Lee, it's more of a candidate for head-to-head studies against MRI for women with dense breasts who are also at high risk of the disease because of other factors.
Researchers are pushing ahead to see if screening methods can be more tailored to an individual woman's risk. So far, though, there's no proven ideal option — which means the best course of action is to know your risk, and talk to your physician about your options.
Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She's on Twitter: @katherinehobson.Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Thu, 10/06/2016 - 3:08pm
Sure, keeping a teenager's thoughts corralled may seem like lion taming. But that impulsivity may help them learn, too.Luciano Lozano/Getty Images
The teenage brain has been characterized as a risk-taking machine, looking for quick rewards and thrills instead of acting responsibly. But these behaviors could actually make teens better than adults at certain kinds of learning.
"In neuroscience, we tend to think that if healthy brains act in a certain way, there should be a reason for it," says Juliet Davidow, a postdoctoral researcher at Harvard University in the Affective Neuroscience and Development Lab and the lead author of the study, which was published Wednesday in the journal Neuron.
But scientists and the public often focus on the negatives of teen behavior, so she and her colleagues set out to test the hypothesis that teenagers' drive for rewards, and the risk-taking that comes from it, exist for a reason.
When it comes to what drives reward-seeking in teens, fingers have always been pointed at the striatum, a lobster-claw-shape structure in the brain. When something surprising and good happens — say, you find $20 on the street — your body produces the pleasure-related hormone dopamine, and the striatum responds.
"Research shows that the teenage striatum is very active," says Davidow. This suggests that teens are hard-wired to seek immediate rewards. But, she adds, it's also shown that their prefrontal cortex, which helps with impulse control, isn't fully developed. Combined, these two things have given teens their risky rep.
But the striatum isn't just involved in reward-seeking. It's also involved in learning from rewards, explains Daphna Shohamy, a cognitive neuroscientist at the Zuckerman Mind Brain Behavior Institute at Columbia University who worked on the study. She wanted to see if teenagers would be better at this type of learning than adults would.
To test this, Shohamy and her colleagues used an fMRI scanner to watch brain activity in a group of adults and teenagers. They were looking at the striatum, but also in a different part of the brain called the hippocampus. The hippocampus (which looks like, and is named after, a seahorse) helps people remember things like dates and times: the who, what, when and where.
"Think back to the last time something really great and surprising happened," says Shohamy, "You might remember a lot of little irrelevant details, like the weather or the shirt you were wearing. That's your episodic memory."
As the adults and teens had their brains scanned, they played a game that rewarded players for guessing correctly. Between questions, participants saw random pictures of neutral objects. As expected, the reward-hungry teenagers figured out the game faster than the adults did. Surprisingly, the striatum was equally active in both teenagers and adults. But in teens, it also worked closely with their hippocampus.
To see if this cooperation changed how the teens learned, the adults and adolescents were given a memory test. They had to recall the random pictures that had flashed on the screen as they played the game.
Overall, teenagers and adults were equally good at remembering the pictures. But they were good in different ways. When the picture was associated with getting something right in the learning test, adolescents were more likely to remember it than adults were.
Adolescence is a time of growing, Shohamy says, when teenagers transition from dependence to independence. She thinks that being sensitive to rewards could help youth explore and leave the safety of their home, to try new things and learn from them. Having a sharp episodic memory could help with that.
"Too many people describe the teen brain like it's a defective car with no steering wheel or brakes, just an accelerator," says BJ Casey, a cognitive neuroscientist and professor of psychology at Yale who was not involved in the study. "What we need to understand in terms of the adolescent brain is that while there are circumstances get them into trouble, there are also ones in which they excel. This study shows that not only do teens have cognitive capabilities, they're even better in some situations!"
Casey likes how this study treats the teenage hunger for new, positive experiences as normal, not deviant. But it doesn't explain everything about how teenagers learn, not by a long shot.
"It's just one snapshot in time, and it's only one study," says Shohamy. To draw further conclusions, first they'd have to replicate their findings. Then, Shohamy would like to know if the hippocampus and striatum cooperate in other age groups, too. She wants to follow children as they grow up and find out when these two brain regions start talking to each other, and when they stop.
"This field of research is still in its adolescence," Shohamy adds. In other words, it's got a lot of growing to do.Copyright 2016 NPR. To see more, visit NPR.
NPR Health Blog - Thu, 10/06/2016 - 2:02pm
Florida Department of Health workers at a temporary clinic set up in Miami Beach in September package up a urine sample to be tested for the Zika virus. Pregnant women in Texas and Florida have complained it can take as long as a month or more to get their Zika test results.Joe Raedle/Getty Images
Houston-based Legacy Community Health Services, a federally qualified health center, is trying hard to fight the Zika virus. It's screening pregnant women and following federal guidelines to test people at risk.
But despite best efforts, there's a problem, says Legacy's chief medical officer, Dr. Ann Barnes. Pregnant women (and, often, their sexual partners) who get tested for Zika frequently have to wait as long as a month to know if they are indeed infected, and the pregnancy is at risk. That's the turnaround time from the state public health lab, where blood samples are sent for testing.
"In that situation, the anxiety a pregnant woman has to live with is great," Barnes says. "Ideally, we'd be able to speed up the process."Shots - Health News Reporter's Notebook: Pregnant And Caught In Zika Test Limbo
It's not just an issue in Houston. Florida radio reporter Sammy Mack, of WLRN, got tested for the Zika virus in August after realizing she had been in the suspected transmission zone in Miami while pregnant. The testing was free, she explained, in a recent Shots post, but more than four weeks later, she was still waiting to learn the results.
In all areas where Zika poses a threat, public health departments are struggling to meet the need to test patients for the mosquito-borne virus — even if the government has classified the patient as being "at risk" of facing serious complications, particularly with regard to pregnancy.
Doctors and infectious disease specialists say last month's approval by the U.S. Congress of $1.1 billion in emergency funding to fight the virus could help these women, by giving local labs the resources to efficiently determine if people have been infected.
Federal health officials this week gave a rough outline of how this funding will be distributed.
Specifically, Congress directed $394 million to the Centers for Disease Control and Prevention.The bulk of that funding will go to supporting state and local Zika response efforts — such as mosquito control and emergency response teams and public education campaigns — as well as to efforts to improve diagnostic tests, and research to track how the virus affects children long-term. The federal funds also include money for expanding lab capacity, though it is still unclear exactly how much.
The U.S. Department of Health and Human Services, which includes the CDC, has until the end of October to craft a spending plan.
"These funds will hopefully allow the infrastructure for testing to be expanded," says Andrew Pekosz, a professor of microbiology at Johns Hopkins University's Bloomberg School of Public Health.
Zika is already spreading in Florida. The CDC has recommended that pregnant women in particular get tested, since the virus can cause birth defects and other complications. About 80 percent of infected people don't show symptoms, so a test is the only way to know if they have contracted Zika.
"Especially for a pregnant woman, getting an answer quickly is a big deal," says Dr. Jesse Goodman, a professor of medicine and infectious diseases at Georgetown University Medical Center in Washington, D.C. "You're going to be very concerned. If that concern can be reduced, that's going to be good for you."
But the additional federal funding will not be an immediate fix.
Given how long processing and budgeting can take, public health labs aren't expecting the cash infusion until early 2017, said Peter Kyriacopoulos, senior director of public policy at the Association of Public Health Laboratories.
While the congressional funding is a promising start, more investment is necessary, said Chris Gould, senior director for federal government relations at the Association of State and Territorial Health Officials. Local health departments have been shrinking over the past six years, he says, and many don't have staffs large enough to operate laboratories at the level needed, given the volume of samples coming in.
These local health departments need to expand manpower, Gould says, especially since testing for Zika isn't their only responsibility.
Kyriacopoulos estimates that labs would need about $39 million to adequately meet the challenges. And public health officials expect the virus to return next summer, he points out, which could create a need for further funding down the line.
Meanwhile, the CDC has already tried to alleviate some of the strain on these laboratories. Last month, it purchased $2.5 million worth of diagnostic supplies for states that offer Zika testing. And laboratories have been working on their own to try to expand capacity — especially labs that serve regions such as Florida, Texas and California, where the warmer, mosquito-friendly climate heightens the risk that Zika could spread.
Still, local health departments offering Zika testing remain "understaffed and overwhelmed," says Dr. Martha Rac, a maternal-fetal medicine specialist at Texas Children's Pavilion for Women and at Baylor College of Medicine, in Houston.
The burden doesn't fall evenly, Rac notes. In urban centers such as Houston, women who may have been infected are more likely to get a Zika test than are women from a poorer, rural town in south Texas. Public health clinics or lab systems in rural areas may not be as well-resourced, so women have fewer options.
Predicting future need is also tricky. States have been encouraging pregnant women to get tested, along with men who may have been exposed and are showing the virus' flu-like symptoms. But that leaves out other groups — such as asymptomatic men who may have contracted Zika and could pass it on to female partners. If states start to push for that testing as well, it could exacerbate the strain on the labs.
Plus, it's difficult to gauge whether demand will dip in the coming months. Technically, mosquito season peaks in the summer. But in high-risk states like Florida or Texas, the insects carrying Zika can persist into December and even January, says Dr. Umair Shah, executive director of the public health department in Texas' Harris County, which encompasses Houston.
Beyond expanding the nation's capacity to test for Zika, HHS is also planning to invest some of its new funding into developing better tests to detect the virus. Currently, labs use one test that can find the virus within two weeks of exposure, and another that can detect it for up to three months. But the second test — which is more commonly used — is less precise and can, for instance, turn up false positives if someone's been exposed to other, similar diseases.
The investment in improving and then testing some better diagnostics is crucial, Rac says, especially given the magnitude of threat Zika still poses.
"There's still a lot we need to know we need to figure out," she says. "And who knows what's going to happen? ... This mosquito's pretty resilient to destruction. This is something we're going to see for some time."
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
NPR Health Blog - Thu, 10/06/2016 - 5:00am
A number of states recently have dedicated more money to educating women and health care providers about the 99 percent effectiveness of long-acting, reversible forms of contraception, like the intrauterine device, or IUD — shown here.Michael Tomsic/WFAE
Nurse practitioner Kim Hamm talks in soothing tones to her 14-year-old patient as she inserts a form of long-acting contraception beneath the skin of the girl's upper arm.
"This is the numbing medicine, so you're going to feel me touch you here," she says, taking the teen's arm. "Little stick, one, two three, ouch. And then a little bit of burn."
Hamm works at the Gaston County Teen Wellness Center, in Gastonia, N.C., which provides counseling, education and medical care. The teenager has already talked through her birth control options with another health care provider and chosen the implant — a flexible rod, about the size of a matchstick, that slowly releases low levels of hormones to prevent pregnancy.
"You're going to feel tons of pressure here," Hamm says, using a small device to insert the implant. "That's it!"
And, in terms of preventing pregnancy, that will be it for the teen for the next several years.
Long-acting reversible contraception methods — including implant rods and intrauterine devices, or IUDs — are safe forms of birth control, and 99 percent effective, say specialists in reproductive medicine.They are endorsed by the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists as a good line of defense against teen pregnancy.
But in the U.S., these long-acting, reversible devices are still not as frequently used by young women as elsewhere. They can be expensive, and problems with older versions of the devices — issues that have since been resolved — hurt their reputation. Only about 10 percent of American women use the devices, says Megan Kavanaugh a senior research scientist at the Guttmacher Institute, which studies reproductive issues.
"Some of the other developed countries that we look at are in the high teens, maybe low 20s in terms of percentage of use," she says.
Kavanaugh says better provider training and patient education should lead to higher usage of the long-term devices in the United States.
That's exactly what is happening in Gaston County, N.C., where clinics have seen usage rates climb to nearly 30 percent among teens. Since 2009, all providers in Gaston County clinics have been trained to insert the devices. The county uses federal funding to help cover the cost for the uninsured, which can be roughly $1,000 for an IUD.
Colorado is also subsidizing the cost of long-acting, reversible contraceptive methods, says Jody Camp of Colorado's public health department, and has seen higher usage and subsequent drops in teen pregnancy and abortion.
"While we are not claiming full responsibility for all the decreases in these public health indicators, we do believe that our LARC investment made a huge impact on those," Camp says.
Recently, the federal Department of Health and Human Services has started encouraging all states to make the methods more accessible through Medicaid, government insurance that covers many low-income women. The government is asking doctors to talk to their patients about long-acting, reversible contraception and allowing higher reimbursement rates for the devices.
By using effective contraception to space out their children, teens and other young women can help reduce the risk of delivering a premature or low-birth-weight baby, research shows. And preventing unplanned pregnancies can be "essential to a woman's long-term physical and emotional well-being," according to HHS.
There are versions of the implants that can be left in place to prevent pregnancy for five or 10 years at a stretch. But women can also choose to get them removed whenever they want, and restore their fertility. Kie'Ja Phillips is from Gastonia and 19-years-old. She had the three-year implant in her arm before heading to college last year.
"I do not want to have children until I'm done getting my education," she says. "I want to be able to provide for my children and give them a stable household — financially and emotionally and physically."
Phillips also teaches her friends and other teens about their options. She says a lot of them know about the contraceptive pill, but very few about IUDs or implants.
"They have a lot of misconceptions and myths about it," she says. "Like, 'how am I supposed to get it out?' You go to a doctor to get it out. You don't take it out yourself. It's just things like that — common misconceptions that people have."
Last year, nearly 30 percent of teens who got contraception at the Gaston County clinics chose the long-acting kind.
Gaston County Medical Director Dr. Velma Taormina says the increased use of long-term contraception is a key reason the county's teen pregnancy rate has been dropping faster than the state as a whole. Gaston County has also largely erased the disparity between African-Americans and whites in teen pregnancy rates.
"We feel very strongly that this is making a huge impact here," Dr. Taormina says.
Medicaid in the state next-door — South Carolina — has also seen an increase in the use of these long-acting, reversible contraceptives. In 2012, the state implemented a new way of paying hospitals so medical providers could offer and insert long-acting, reversible contraception right after a woman gives birth, which the nation's leading obstetrician's group says can be a "particularly favorable time."
The University of South Carolina School of Medicine takes this SimCOACH — outfitted with two simulated hospital delivery rooms — throughout the state to train health care providers in a variety of procedures. Among the topics: the insertion and removal of contraceptive implants and IUDs.Michael Tomsic/WFAE
Staff with the Palmetto Health-USC School of Medicine in Columbia demonstrated the procedure to health care providers recently in its SimCOACH, which is basically a truck outfitted, for training purposes, with two hospital rooms and high-tech mannequins that can simulate a variety of birth outcomes. Palmetto Health drives the coach around the state to teach hospital staff about a variety of procedures and topics, including contraception.
"The IUD is inserted 10 minutes after delivery of the placenta when a patient has had a vaginal delivery," Dr. Judy Burgis says.
B.Z. Giese is director of the South Carolina Birth Outcomes Initiative, a project within the state's department of health and human services. Giese says the choice to have an IUD or implant inserted is always completely up to the woman, and only after she's consulted with a health care provider. But the reason obstetricians within her program started offering it immediately after birth is simple: About half of women on Medicaid who gave birth weren't showing up to their postpartum visit.
"We were missing a lot of moms who did not come back," Giese says. "And, actually, the next time the doctor saw them, they came back pregnant with another child."
Ana Walker, an 18-year-old in Columbia, S.C., chose to have an implant that lasts three years inserted in her arm. Walker got the implant after giving birth to her daughter Bella. She says she likes that she won't have to remember to take a pill every day.
"Right when I heard about it, I went for it," she says.
Breanna Martin, who is 20 and also lives in Columbia, recently chose an IUD after she had her baby. Martin says the device puts her in control of her fertility.
"That's the wonderful thing about it," she says. "If I want to wait five years, I'm protected for five years. And if I want to have kids sooner, then I can get it taken out."
Giese calls getting the device after childbirth a win-win for the baby and the mom. "It is a cost savings," she says. "It is a convenience for the mom. The satisfaction rate of the moms that we know leaving the hospital is extremely high."
Now, she says, at some hospitals in South Carolina, around a third of new mothers leave with an IUD or implant in place. That number, Giese says, was basically zero just a few years back.
This story is part of NPR's reporting partnership with WFAE and Kaiser Health News.Copyright 2016 WFAE-FM. To see more, visit WFAE-FM.