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Can Mental Illness Be Prevented In The Womb?

8 hours 25 min ago
Katherine Streeter for NPR

Every day in the United States, millions of expectant mothers take a prenatal vitamin on the advice of their doctor.

The counsel typically comes with physical health in mind: folic acid to help avoid fetal spinal cord problems; iodine to spur healthy brain development; calcium to be bound like molecular Legos into diminutive baby bones.

But what about a child's future mental health? Questions about whether ADHD might arise a few years down the road or whether schizophrenia could crop up in young adulthood tend to be overshadowed by more immediate parental anxieties. As a friend with a newborn daughter recently fretted over lunch, "I'm just trying not to drop her!"

Yet much as pediatricians administer childhood vaccines to guard against future infections, some psychiatrists now are thinking about how to shift their treatment-centric discipline toward one that also deals in early prevention.

In 2013, University of Colorado psychiatrist Robert Freedman and colleagues recruited 100 healthy, pregnant women from greater Denver to study whether giving the B vitamin choline during pregnancy would enhance brain growth in the developing fetus.

The moms-to-be were randomly given either a placebo or a form of choline called phosphatidylcholine. Choline itself is broken down by bacteria in the gut; by giving it in this related form the supplement can more effectively be absorbed into the bloodstream.

Those in the treatment group received 3,600 milligrams of phosphatidylcholine in the morning and 2,700 milligrams at night. Since phosphatidylcholine is roughly 13-15 percent choline, the amount the women received was about 900 milligrams of choline a day, twice that recommended by the Health and Medicine Division of the National Academies (and about the same amount contained in three large eggs).

The Salt Can Mom's Pregnancy Diet Rewire Baby's Brain For Obesity?

After birth, infants were given either 100 milligrams of liquid phosphatidylcholine or placebo once a day for approximately three months. Given that both groups were also getting choline from regular feeding, the dose ensured that those supplemented received well over the Institute of Medicine's guideline that infants receive at least 125 milligrams a day.

At 5 weeks old, the children were exposed to a series of clicking sounds in the lab while their brain activity was monitored by electroencephalogram, or EEG, a method for recording electrical brain activity via electrodes placed on the scalp. Normally, when exposed to the same sound successively, both infant and adult brains will exhibit "inhibition," or a far weaker pulse of activity in response to the second sound. We realize that the now familiar tone is insignificant; our brains are unmoved.

However, in some kids this inhibition doesn't occur — a finding linked with an increased risk for attention problems, social withdrawal and, later in life, schizophrenia.

The results published in 2013 in the American Journal of Psychiatry by Freedman's group show that 76 percent of newborns whose mothers received choline supplements had normal inhibition to the sound stimuli. The proportion fell to 43 percent in those born to mothers who didn't get them. It appeared that choline might steer the infant brain away from a developmental course that predicted mental health problems.

A follow-up study at 40 months found that the children who had received choline supplements in utero and after birth had fewer attention problems and less social withdrawal.

Excessive choline consumption — or that over 7,500 milligrams a day — has been associated with drops in blood pressure, sweating, gastrointestinal side effects and a "fishy" body odor. But most diets contain adequate choline, and supplementation to optimal levels poses no known side effects or risk to fetal development, Freedman says.

A genetic theory

One of the first genes to be linked to schizophrenia goes by the catchy name "CHRNA7." Normally it encodes for a receptor on neurons in the brain that respond to the neurotransmitter acetylcholine as well as nicotine, a transmission essential to normal brain function and cognition. Genetic mutations in the CHRNA7 gene cause decreased levels of the neuronal receptor to be produced in people with schizophrenia.

A light bulb glowed for Freedman.

And the idea, he admits, is rather simple when you think about it: Choline is known to be essential to brain development and function and is also frequently deficient in pregnant women.

Couple these facts with animal and human research by Freedman and his colleagues showing that choline in the amniotic fluid also activates the CHRNA7 receptor in the developing fetal brain.

"It occurred to us that just as folic acid can help overcome defects in brain and spinal cord development, perhaps supplementing mothers with choline could help prevent mental illness," Freedman recalls. "And now that the children in our study are over 4 years old, we can see that those given the supplement appear to be on a different developmental track, one with fewer mental problems."

Moreover, though experimental psychosis treatments targeting the CHRNA7 gene and the receptor it codes for are being explored by other researchers, Freedman explains that levels of the receptor peak in the fetal brain and diminish after birth. "We realized the optimal time to try this intervention is during pregnancy," he says.

Though choline is available in a number of foods — eggs, seafood and liver are particularly rich in the nutrient — Freedman's work suggests that for many women, dietary sources may be inadequate during pregnancy. Also, prenatal supplements tend not to include it.

The Salt Nutrition In 'The First 1,000 Days' Of Life Can Shape A Child's Future

Two past observational studies — conducted with diet questionnaires rather than the more rigorous placebo-controlled supplementation Freedman's group tried — also found beneficial effects associated with higher maternal choline intake during pregnancy. At 7 years of age, children of moms consuming over 400 milligrams of choline a day performed better on memory and intelligence tests. At 18 months, infants whose mothers had higher blood levels of choline had significantly higher cognitive test scores.

Dr. Steve Zeisel of the University of North Carolina was one of the first doctors to strongly advocate for choline supplementation in pregnancy. In 2012, Zeisel published the only other placebo-controlled trial of the vitamin in pregnant moms. While he did not assess for future mental health risks, the findings suggested that choline supplementation did not enhance infant cognitive function at 1 year of age. However, Freedman point outs that all of the women included in the trial were highly educated and were found to have blood metabolites reflecting diets high in healthful, choline-containing foods.

The prospects of choline supplementation in pregnancy have piqued medical interest, but also notes of caution. "I think the choline research is really intriguing, and we're starting to investigate maternal choline levels as well," says Catherine Monk, an associate professor in psychiatry and obstetrics and gynecology at Columbia University Medical Center. "Some prenatal vitamins do contain it and foods rich in choline are readily available. But we have a lot more research to do before we start recommending it widely."

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In general, evidence-based interventions during pregnancy and early childhood to prevent mental illness are scant. Yet there are some modifiable risk factors that might make a difference, many of which focus on improving maternal wellbeing.

Monk's own research explores on the impact of an expecting mother's emotional state on the developing fetus. She and others have shown that stress, depression and anxiety during pregnancy increase a child's risk for ADHD, conduct disorders and depression later in life. At Columbia, Monk and her colleagues employ a program Practical Resources for Effective Postpartum Parenting, or PREPP, in which pregnant women who are distressed and at high-risk for postpartum depression are counseled and taught coping skills to make pregnancy and parenting more manageable emotionally.

Optimal nutrition, including choline and adequate amounts of zinc and omega-3 fatty acids, may also have developmental and mental health benefits as might avoiding smoking.

The future of funding

Despite incomplete data on choline supplementation, Freedman's research colleague Dr. Camille Hoffman-Shuler, an obstetrician, sees it as a promising intervention that should continue to be explored.

"Obstetricians and midwives are not widely aware of choline supplementation," she says. "But I do recommend it to pregnant women, especially if they have other mental health vulnerabilities. And I'd personally want it with a future pregnancy based on existing data."

Both Freedman and Hoffman-Shuler hope to continue choline research, yet decry the obstacles to securing the money to do it.

"The NIH is currently funding no trials of any intervention in humans during pregnancy to prevent mental illness," says Freedman, "yet ideally we'd follow these children for another 20 to 25 years to see if they develop mental illness. This is beyond the scope of most imaginable — and fundable — experiments."

Hoffman-Shuler is prepared to do what it takes. "The hardest part is getting this across to the funding agencies and the public," she says. But this is a serious public health issue in which prevention during pregnancy is far more preferable to the loss of health and consequences that come with mental illness!"

Bret Stetka is a writer based in New York and an editorial director at Medscape. His work has appeared in Wired, Scientific American and on The He graduated from University of Virginia School of Medicine in 2005. You can follow him on Twitter: @BretStetka.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

No Snapchat In The Bedroom? An Online Tool To Manage Kids' Media Use

Fri, 10/21/2016 - 12:03am
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October 21, 201612:03 AM ET Heard on All Things Considered

Pediatricians realize parents need strategies beyond "Put down that phone!"

Jiangang Wang/Moment Editorial/Getty Images

Whether your kid is 3 and obsessed with Daniel Tiger videos or 15 and spending half her conscious hours on Snapchat, you are probably somewhat conflicted about how to think about their media habits.

How much time? What kind of media? What should our family's rules be?

When the American Academy of Pediatrics released its latest recommendations on these burning questions Friday, it also did something pretty cool: it launched an online tool that parents can use to create their own family media plan.

The interactive tool lets you set guidelines for each child, with suggested items based on the AAP's age-specific recommendations and space to add or substitute your own family's rules. At the end, you can print out a document that lays out your family's own media policy.

I went through the process for my 4-year-old daughter a few days ago. It took about five minutes to indicate the screen-free areas and times in our household, specify our device curfews and where they will recharge, how we will watch media with our daughter, what kind of media we'll avoid (unboxing videos) and answer other questions.

We've certainly had some of these rules in vague form floating around in our heads, but it helps to have something concrete to remind us that there are no screens allowed at the dining room table, in my daughter's bedroom, in the stroller or in the bathroom (No iPotty for us, thanks.)

Our plan also includes a list of things we can do more of by decreasing time spent with media, like coloring, going to the library and playing outside. It reminds us about digital safety rules, like reviewing privacy settings on sites our kid may use. And by making these the family's rules, it reminds my husband and me that we need to set a good example ourselves by putting our devices aside at the agreed-upon times and places. (I haven't had a chance to run it by my kid yet, but that's on my list for the weekend.)

It's not that a printout is going to automatically change behavior, says Jenny Radesky, a developmental pediatrician at the University of Michigan's C.S. Mott Children's Hospital and lead author of the AAP's policy statement on media use for young children. But it helps parents lay out their values in advance rather than simply reacting to the latest app or platform.

The AAP's updated recommendations are more nuanced than in the past, when the group discouraged any digital media use for children under 2 and recommended limiting screen time to two hours or less for those older than that.

Those lines in the sand are "too simplistic," says Ari Brown, a pediatrician in private practice in Austin, Texas, and a former member of the AAP's Council on Communications and Media. (She wasn't involved in writing these latest guidelines.)

NPR Ed American Academy Of Pediatrics Lifts 'No Screens Under 2' Rule

(NPR Ed lead education blogger Anya Kamenetz explains what we know about media use and learning in very young children here.)

In fact, the recommendations for elementary school-aged kids and teens don't set any specific time limit. The AAP says that's a decision that depends on the type of media being used and the child using them.

But they do say that children and teens' priority should be getting enough physical activity (one hour per day), and sleep (8-12 hours). They recommend that kids not sleep with devices in their room, and that they avoid exposure for one hour before bedtime, since that can disrupt sleep.

And they make it clear that parents have a huge role in their children' media use, even when they're teenagers. Parents should talk about online citizenship and safety, form a network of trusted adults their kids can engage with on social media, and take an active role in selecting and watching media with their children.

So-called "co-viewing" is crucial for younger children. "It should be like reading a book together," says Georgene Troseth, an associate professor of psychology at Vanderbilt University. "You should be talking about what you're watching." As with books, the goal is to help children compare what they're watching to the real world. That's a valuable skill to work on, since "that's how adults use media: we use it to get information or to be entertained," she says.

Shots - Health News Trying To Get The Kids To Put Down Those Phones? Here's Help

Still, the AAP says that parents shouldn't feel pressured to buy apps or gadgets because they think kids will be left behind. (They're intuitive enough so that they'll pick them up quickly whenever they start.) "Your kid doesn't know how to do a Google search when they enter kindergarten," says Brown.

The bottom line: Your family's media policy should be informed by your own values and intuition as well as what the science says.

"I want parents to trust their gut," says Radesky. "If they're sitting with a child [using media] and the child is liking it and seeming to be learning something, that kind of a test is totally great." And if you decide you'd rather ditch all devices in your house, that's fine too. "We support that 100 percent," she says. "Your child is not missing out on anything."

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.
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Will A Study Save Victims Of Violence, Or Gamble With Their Lives?

Thu, 10/20/2016 - 4:14pm
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October 20, 20164:14 PM ET Heard on All Things Considered


An ambulance pulls out of the emergency entrance at Temple University Hospital in North Philadelphia.

Brad Larrison for NewsWorks

Dr. Zoe Maher has never been busier. In addition to being a trauma surgeon and a new mom, she's spent the last year and half talking to hospital patients and community groups across Philadelphia about a study she's confident will save more adult gunshot and stab wound victims.

On a recent Saturday morning, Maher stood before a dozen members of a North Philadelphia neighborhood association to walk them through the specifics of the Philadelphia Immediate Transport in Penetrating Trauma Trial. At the heart of the study is a simple but counterintuitive idea. For patients who are potentially bleeding to death, Maher and her colleagues say, just basic care is better until they reach the hospital.

To test this, patients in the study would get different medical attention based on the dispatch number city paramedics receive – what's called a randomized study.

"It's like the flip of a coin if patients are getting advanced or basic," said Maher, who works at Temple University Hospital.

Odd numbers will get what's called advanced care, which is what the majority of patients transported by paramedics get now. It includes inserting a breathing tube or supplying intravenous fluids.

Even numbers will get what's known as basic care, which can include hemorrhage control, breathing assistance with a bag-valve mask, dressing wounds and aligning bones. They would then be immediately transported to the hospital.

But the idea of assigning types of care randomly got mixed reviews at the community meeting in North Philadelphia.

Joanne Taylor was wary, but, like nearly everyone in the room, she has first-hand experience with gun violence. She said she is mourning a husband, son, grandson and cousin, so she's willing to support anything that may save more lives.

"It shakes me up a little bit, but I know something has to be done somewhere," said a teary-eyed Taylor afterwards.

Dr. Zoe Maher interviews a shooting victim at Temple University Hospital for a citywide study of care of violent trauma victims.

Emma Lee/WHYY

Others had more trepidation.

"In the interim, you're still sacrificing people, somebody," said Charles Lanier.

Yanitza Gonzalez, a staffer with City Councilwoman Maria Quinones-Sanchez, nodded from across the room.

"It almost seems like we'll be gambling with people's lives," said Gonzalez.

Community buy-in is key for Maher. She wants to tell as many people about the study before patients are enrolled, potentially this fall, and she told them residents can opt out.

Maher has heard the gambling response before, but she's convinced that her study is closer to a sure thing. She said previous research has proven as much, and that her trial is just about confirming those results.

The study would look only at use of IV fluids and breathing tubes, explained Maher.

That's because if someone is shot or stabbed and bleeding to death, the body instinctively tries save itself by constricting blood vessels and forming clots. For those clots to stick, the body needs to maintain a lower-than-normal blood pressure. IV fluids can raise a patient's blood pressure and potentially cause more internal bleeding.

Maher said a breathing tube could also be problematic and cardiopulmonary resuscitation or CPR is a better option because it keeps more blood moving from the heart to the rest of the body.

On average, about 30 percent of patients who would qualify for this study die. If basic care becomes the norm for paramedics in Philadelphia, Maher says the rate could get down to roughly 20 percent. In a city that routinely records 250-plus murders each year, that could potentially mean a lot of lives being saved.

Dr. Brent Myers, president-elect of the National Association of EMS Physicians, said that would be a big deal for medical professionals, especially paramedics.

"This has been one of the great questions, is how much advanced life support is beneficial for victims of penetrating trauma. You could probably go to any paramedic in any city in the United States and engage in a debate, because we just don't have the appropriate evidence to guide the decision," said Myers.

It's part of why Myers said he wouldn't expect a lot of grousing from paramedics, even though it will effectively dictate what they do in the field.

Dr. Amy McGuire, a medical ethicist at Baylor University in Texas, said while the study does carry some risk for patients, there's nothing inherently unethical it.

"The only way to really know whether this is better or not is to do a randomized trial and to compare it to what is currently the standard of care," McGuire said.

Where she does see some moral gray area is in the community outreach piece of the trial. It's impossible for everyone in the city to know about the study before it gets underway.

"They'll be enrolled in the study, and they may not have wanted to have participated," said McGuire.

Every resident in Philadelphia is a potential enrollee in the study, all 1.5 million people. But residents can choose to not participate. They would get a wristband that they'd have to wear for the duration of the study, which is expected to last five years, maybe more.

Researchers hope to enroll roughly 1,000 patients, half of whom would get advanced care, half would get basic care. Anyone who is under 18, pregnant or a prisoner will be excluded.

Maher said the study would end early if it's clear that one kind of care is doing more harm than good.

"All of the evidence points to us being right, but if we are wrong, we will not complete the study," said Maher. "We surely don't want to hurt anyone."

Every trauma center in the city is participating. That includes: Temple University Hospital, Hospital of the University of Pennsylvania, Hahnemann University Hospital, Thomas Jefferson University Hospital, Albert Einstein Medical Center, Aria Health Torresdale, and City of Philadelphia Fire Rescue.

This story is part of a reporting partnership with NPR, WHYY's health show The Pulse and Kaiser Health News.

Copyright 2016 WHYY, Inc.. To see more, visit WHYY, Inc..
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STD Infections Rise To New Highs After States Close Health Clinics

Thu, 10/20/2016 - 3:33pm

The bacteria that causes gonorrhea can cause infertility in women and men.

BSIP/UIG via Getty Images

The number of people infected with three major sexually transmitted diseases is at an all-time high, according to a CDC report released Wednesday. And the increase in reported cases of chlamydia, gonorrhea and syphilis is hitting teenagers and young adults hardest.

Over half of gonorrhea and chlamydia cases are in people under the age of 25, says Dr. Jonathan Mermin, director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention for the CDC.

These STDs can have serious long term health consequences, including chronic pain and fertility problems. Pregnant women can pass syphilis on to their children, leading to stillbirth or birth defects.

State and local budget cuts to STD care and prevention programs are major drivers in the surge in STDs, Mermin says. "Our ability to prevent STDs is only as strong as the public health infrastructure to support it," he says. "More than half of state and local STD programs have experienced budget cuts. In 2012, 20 health departments reported having to close their STD clinics."

Syphilis infections have been increasing at a particularly troubling rate, according to the report. In 2015, 23,872 cases were reported, a 19 percent increase since 2014. Syphilis cases have been going up over the past decade, while the spike in cases of chlamydia and gonorrhea is more recent. There were 395,216 cases of gonorrhea in 2015, for an increase of 13 percent, and 1.5 million cases of chlamydia, for an increase of 6 percent.

All three infections can be treated with antibiotics, though gonorrhea is becoming increasingly resistant to antibiotics.

"This basically tells us we have to do a better job of reach out to some of these communities that are disproportionately affected by these infections," says Dr. Jose Bazan, a medical director for an STD clinic at Columbus Public Health and an assistant professor of internal medicine at Ohio State University who was not involved with the report.

Shots - Health News More Babies In The U.S. Are Dying Because Of Congenital Syphilis

Men who have sex with men face a greater risk of being infected with syphilis. Over 80 percent of male syphilis cases were reported among gay and bisexual males, and over 90 percent of all syphilis cases were in men. People in racial and sexual minority groups can have more than the usual trouble finding care for preventing and treating STDs.

According to a congressional briefing last April by Dr. Gail Bolan, the director for the CDC Division of STD Prevention, over 40 percent of health departments reduced clinic hours, screening, or tracing people who may have been infected. "If that infrastructure gets eroded, people are more likely to have their STDs for a longer period of time, and that can lead to increased transmission," Mermin says.

The federal government also helps fund state and local STD programs through the CDC, but federal funds have not helped make up for some of the budget cuts on the local level, according to David Harvey, the executive director for the National Coalition of STD Directors. "We believe there's a direct relationship between budget cuts and increases in STDs in the United States. There has been no federal increases for STD programs in this country since 2003," he says.

If the trend is to be reversed, Mermin says there needs to be a real investment in STD prevention so that clinics can monitor these diseases and quickly diagnose and treat people who are infected. "We've seen success in the past where investments have paid off," he says. "We know what we need to do. We just need to do it more effectively than we've been able to do with this eroding infrastructure."

Copyright 2016 NPR. To see more, visit NPR.
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When A Fainting Spell Is Caused By A Serious Blood Clot

Thu, 10/20/2016 - 1:43pm

A fainting episode, though usually no big deal, can sometimes be caused by a blood clot.

Whisson/Jordan/Getty Images

Unexplained fainting episodes may be caused by a dangerous blood clot in the lung more frequently than many doctors suspect, according to an Italian study.

Episodes of fainting (known as syncope) are quite common in elderly people. About half the time, doctors identify an underlying heart condition. Other cases are caused by shock or some other passing cause. But many cases remain mysterious.

Doctors in Italy decided to see how often these fainting spells were caused by blood clots in the lung, known as pulmonary embolisms. These clots usually dislodge from a leg and get jammed in the lung, with potentially deadly consequences.

Blood clots are on the list of conditions that doctors are supposed to consider when figuring out the cause of a fainting spell, but physicians don't routinely do full work-ups to look for them. So Dr. Paolo Prandoni and colleagues asked doctors at 11 hospitals to take those extra steps.

The doctors screened for blood clots among 560 elderly patients (average age 76). And they report in the latest issue of the New England Journal of Medicine that 17 percent of the patients with fainting spells also had blood clots in the lung. That's a surprisingly high figure — about 1 in 6 patients who had syncope serious enough to require hospitalization.

Prandoni and his colleagues note that current international guidelines for evaluating unexplained fainting "pay little attention" to the possibility it could be caused by a blood clot in the lung. "Hence, when a patient is admitted to a hospital for an episode of syncope, pulmonary embolism — a potentially fatal disease that can be effectively treated — is rarely considered as a possible cause," they wrote.

"It's a very important study," Dr. S. Adam Strickberger told Shots. A cardiologist at Inova hospitals in the Washington, D.C., area, Strickberger co-authored the American Heart Association's 2006 guidelines for evaluating syncope. Those make only passing reference to blood clots in the lung as a possible cause.

"If you don't think of [a blood clot] all the time, you're going to miss it," he said. "And once you think about it, you have to rule it out." Doctors evaluating patients with fainting spells should add blood clots to the list, he said.

That can be an expensive proposition. A blood test called a D-dimer assay can sometimes rule out a blood clot in the lung. But in the Italian study, that only eliminated about 60 percent of patients. The rest underwent an expensive CT scan of the blood vessels (called CTA).

And that triggered chatter among emergency room doctors on Twitter that the number of CTA scans could go through the roof if doctors fully embrace the results from Italy. On Twitter, University of California, San Francisco cardiologist Ethan Weiss quipped: "I expect all patients with syncope will have CTA from this point and forever."

A colleague in Texas cautioned that procedures in Italy for evaluating syncope differ from those in the United States, so the European findings might not translate directly.

Copyright 2016 NPR. To see more, visit NPR.
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Breathing Less Oxygen Reduces Jet Lag, At Least In Mice

Thu, 10/20/2016 - 12:38pm
Nanette Hoogslag/Ikon Images/Getty Images

Whether it's jet lag, a new work schedule, daylight saving time or just a Monday morning, shifting sleep schedules takes a toll. But scientists think they might have found a way to reset our internal timers that's more than hot air.

At least, it works if you're a mouse. The solution, it seems, is thin air. A study published Thursday in the journal Cell Metabolism found that decreasing oxygen levels for a short period of time helped mice recover from jet lag faster.

According to Dr. Gad Asher, a clinician and assistant professor at the Weizmann Institute of Science in Rehovot and lead researcher on the study, this is because of our circadian clocks, molecular pathways that tell us when to sleep, move and eat. Scientists think these clocks are present in almost every cell in our body.

"If there are so many clocks, how do they all show the same time?" Asher wanted to know. Researchers had already identified a few universal clock resetting cues, including temperature. When we sleep, our body temperature drops. Because all the cells in our body use oxygen, Asher thought oxygen levels might be another cue.

First, Asher and his team put a bunch of mice in special cages designed to measure oxygen consumption and used a monitor to track their blood oxygen level. They found that the amount of oxygen the mice used rose and fell over the course of the day.

Then, they gave a bunch of mice jet lag — not by putting them on an airplane, but by moving their light-dark cycle up by six hours to throw off the brain's clock. When they exposed some of the mice to 12 hours of decreased oxygen before the shift, or two hours after, the mice adapted to their new light-dark cycle much faster.

Asher also wanted to identify which proteins helped these circadian clocks sense the changes in oxygen levels. He chose HIF1α, a protein that helps cells know when and how to use oxygen. The researchers knocked out one set of HIF1α genes in a group of mice and repeated the experiment. Low oxygen didn't help cure jet lag in the mice without HIF1α.

"It's not shocking, exactly, that oxygen is involved in circadian rhythm. But I don't think it was ever established before now," says John Hogenesch, a professor of pediatrics at Cincinnati Children's Hospital Medical Center and circadian rhythm researcher who was not involved in the study. "And it's great that they show HIF1α is involved, though I think we'll find there's more to it than that."

Because HIF1α is involved in a lot of different cell processes, Hogenesch hopes this research could help scientists understand some of the negative consequences of long-term fatigue and working night shifts. But there's still a lot more work to do first.

"One big question is: Is this oxygen-resetting mechanism unique to mice? To mammals? Or is it present in all organisms?" says Asher.

Assuming the results of this study hold true in humans, there are still more things Asher would like to know. For example, does changing the oxygen level work best before, during or after a flight? Would you need to be exposed multiple times, or is once enough to treat the tired? Does raising oxygen have the same effect as lowering it?

Still, Asher imagines a future where passengers might step off an airplane and into an oxygen bar, sipping O2 while they wait for their bags to be unloaded. Or, perhaps, oxygen masks will drop as a plane descends (in first and business class only — coach can caffeinate their way through circadian delay like they always have) and people will disembark bright-eyed and well-adjusted to their new time zone.

And there are other, more practical applications of this research, Hogenesch points out. Jet-lagged jet-setters aren't the only people whose internal clocks are out of whack.

According to the Bureau of Labor Statistics, 21 million Americans work night shifts, evening shifts, or have shifting work schedules that sometimes include evenings or nights.

Working an irregular schedule doesn't just make someone sleepy, says Hogenesch. Fatigue from shift work is associated with a suite of health impacts, including heart disease, obesity and diabetes. And working while fatigued can increase the risk of on-the-job injury.

There's still a long way to go to find out whether manipulating oxygen levels could ever become a treatment for the impacts of shifting circadian rhythms in humans.

But mouse and rat sightings on airplanes are pretty common, so frequent-flying rodents can rejoice! A cure for their jet lag, at least, may be on the way.

Copyright 2016 NPR. To see more, visit NPR.
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Fall Enrollment Efforts Could Be Pivotal For Federal Health Law

Wed, 10/19/2016 - 8:35pm

Secretary of Health and Human Services Sylvia Burwell at a Senate hearing in 2014. "We expect this to be a transition period for the marketplace," she told reporters Wednesday. "Issuers are adjusting their prices, bringing them in line with actual data on costs."

Alex Wong/Getty Images

Rate hikes are likely on the way for insurance plans issued under the Affordable Care Act, health policy analysts say. Consumers' out-of-pocket costs are expected to climb in 2017 and some major insurers have signaled they are pulling out of the health insurance exchanges in a number of states.

In a meeting Wednesday with reporters and representatives of groups working to increase enrollment in the health plans, Department of Health and Human Services Secretary Sylvia Burwell acknowledged that the Affordable Care Act's fourth enrollment season — scheduled to begin Nov. 1 and run until Jan. 31 — is a pivotal time for the federal health law.

"Building a new market is never easy," she told the group at HHS headquarters. "We expect this to be a transition period for the marketplace. Issuers are adjusting their prices, bringing them in line with actual data on costs."

Burwell's comments foreshadow the higher premiums expected when federal officials release details on the health plans to be offered on for 2017. Those details are likely to come just days before a presidential election that could determine whether the ACA is repealed or revamped.

While the health law hasn't been a central issue in the current election season, it has been at the center of a bitter battle between political parties since it was passed in 2010. The House of Representatives has voted more than 60 times to repeal all or part of the measure. The law has survived some court challenges and faces others.

Burwell noted those fights Wednesday when talking about issues that arose in the law's implementation. "It also hasn't helped," she said, "that at nearly every turn, we've had to overcome partisan attempts to repeal and undermine the law through legislation and litigation."

Enrollment in the state and federal marketplaces is expected to grow by about a million people next year — from about 12.7 million to 13.8 million, according to federal estimates released Wednesday. The number of consumers who actually pay premiums and stay in the market is expected to average about 10.5 million per month in 2016 and about 11.4 million per month in 2017.

Consumers flow in and out of ACA plans because they change jobs, get coverage from other sources and face other factors that affect where and how they enroll in health insurance, including affordability. About 9.2 million of the 13.8 million people who now have ACA coverage are expected to reenroll, according to HHS.

This year, Burwell said, health officials working to increase insurance coverage among the uninsured are intent on making the enrollment process faster and simpler, and will particularly focus on signing up healthier consumers – including people between the ages of 18 and 34, who tend to have fewer ailments. They will also remind consumers of the penalty for not having coverage, which for adults in 2016 is $695 or 2.5 percent of income, whichever is higher. The flat penalty will be adjusted for inflation in 2017.

Federal officials are also focusing enrollment efforts on the 5.1 million Americans who are eligible to purchase health care coverage on the exchanges but buy it elsewhere, according to HHS figures. Of that group, 2.5 million people could be eligible for the law's financial assistance if they sign up for coverage during open enrollment, which ends Jan. 31.

The outcome of the November elections may well determine the future of the ACA. Republican presidential nominee Donald Trump has promised to repeal and replace the law, while Democratic nominee Hillary Clinton has said she wants to fix the law, making it more affordable for consumers who don't qualify for subsidies, yet struggle to afford coverage.

Burwell called on Congress to work with her and the Obama administration to make needed changes to the law. "To make more substantial changes — like a public option to encourage competition — we'll need cooperation from Congress," she said. "And we are hopeful that soon, we'll see more bipartisan efforts to make improvement."

Bipartisan cooperation isn't likely to happen until the next Congress meets, if then. Much will depend on the outcome of the presidential and congressional elections – on who is in power and whether GOP leaders think the ACA is still a potent political issue, as well as on how willing Democrats are to make changes that appeal to Republicans.

Mary Agnes Carey reports for Kaiser Health News, an editorially independent 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.
Categories: NPR Blogs

Emergency Room Use Stays High In Oregon Medicaid Study

Wed, 10/19/2016 - 5:45pm
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October 19, 20165:45 PM ET Heard on All Things Considered


Although expanding Medicaid in Oregon didn't drive down the recipients' overall use of hospital emergency rooms, the state has seen a decline in avoidable use of ERs by 4 percent in the past two years, according to state statistics.

Paul Burns/Getty Images

Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care?

Not yet, suggest the latest findings from a landmark study published online Wednesday in the New England Journal of Medicine.

The study of Medicaid patients in Oregon who got Medicaid in 2008 found their ER use stayed high two years after they gained the health insurance coverage — even as they also increased their visits to doctors' offices.

All eyes have been on Oregon to answer this question about ER use because, eight years ago, the state tried an experiment. It wanted to expand Medicaid, but it didn't have the money to cover every eligible resident.

So it held a lottery to give coverage to as many people as possible, in the fairest way possible. The result was something of a gift to researchers like Bill Wright, director of the Providence Center for Outcomes Research and Education.

Bill Wright, one of the authors of the study, called the results "a surprise to a lot of folks."

Kristian Foden-Vencil/Oregon Public Broadcasting

"You couldn't do this as a researcher," Wright says. You couldn't design a study that randomly gave some people insurance, but not others. It wouldn't be ethical to leave some people without coverage just to have a control group.

"As a researcher," Wright says, "you don't want to put someone in that position, just to study it."

But, since Oregon was already conducting the insurance lottery, that offered an invaluable chance to study the differences between people who have Medicaid insurance and similar people who don't.

It was the first randomized study on the impacts of health insurance, and it's one of the largest, surveying about 25,000 people.

The study's first findings, published a few years ago, showed that Medicaid was beneficial in many ways. It improved people's financial security. They went to the doctor when they were sick. And having the insurance correlated with a drop in rates of depression.

"These are all things that are really important benefits of Medicaid expansion," says Wright.

But the study also found Medicaid enrollees increased their emergency room visits by 40 percent over the first 15 months.

"That was a surprise to a lot of folks," says Wright.

It was widely believed that having insurance would encourage people to get routine medical care in doctors' offices or clinics, instead of waiting until they have more serious symptoms and have to head to the ER, where care is most expensive.

After those early findings were published, health care analysts scrambled to explain why the number of ER visits didn't decline. Some thought it was a reflection of pent-up demand from people who hadn't seen a doctor in years because they didn't have insurance.

Others thought some of these newly insured patients simply hadn't yet had time in that first 15 months to establish a relationship with a primary care doctor. As more time passed, that theory suggested, and more patients had primary care providers, their reliance on emergency rooms would drop.

But Wright, one of the study's authors, says he and his colleagues have now studied two years of data — and that's not what they're finding.

"There was no sign that this [ER] use went down," he says. "So this idea of pent-up demand sort of fading away — at least in the first couple of years, it didn't happen."

Quite the opposite.

"If your hope is that, in the short term — the first couple of years — you're going to see savings that come out of reduced [ER] use from Medicaid expansion alone, I don't think I'd be super optimistic about that," Wright says. "I think that it is going to cost money in the short term."

However, there may be savings in other areas, he says, like an increased use of preventive services that could stave off problems that would become more expensive later.

And, Leslie Clement, with the Oregon Health Authority, says over the past two years, Oregon has seen avoidable use of emergency rooms drop by 4 percent.

That's because the state is now coordinating care better, she says, by doing things like helping people get to their doctors' appointments and take their medication.

"It is not just a 'open up coverage and let people used health care services as they have done historically,' " she says. "It's reforming that system."

The researchers won't be able to tease much more information out of what's come to be known as the Oregon Health Insurance Experiment — the experiment had to stop once the state expanded Medicaid fully under the Affordable Care Act.

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

Copyright 2016 Oregon Public Broadcasting. To see more, visit Oregon Public Broadcasting.
Categories: NPR Blogs

Small Savings For Drugs Made To Mimic Biotech Blockbusters

Wed, 10/19/2016 - 3:48pm

A patient with Crohn's disease receives an IV infusion of Remicade, or infliximab.

Dr P. Marazzi/Science Source

Generic drugs generally cost 80 percent less than brand-name drugs, so hopes were high when a law enacted in 2010 paved the way for competition among the highest-priced drugs of all, known as biologics.

But, as these competing drugs start to appear on the market, consumers aren't reaping a windfall.

On Monday, Pfizer said it would start selling Inflectra, its version of the blockbuster rheumatoid arthritis drug Remicade, in late November. But Inflectra, the second so-called biosimilar set to hit the market, isn't exactly a steal.

Note: Chart shows the highest annual price, according to wholesale acquisition cost, for a vial containing 100 milligrams of powder for preparing an intravenous solution.

Truven Health Analytics

The wholesale acquisition cost (a benchmark price in the drug industry) for Inflectra is $946 a vial, only 15 percent off $1,113 for a comparable vial of Johnson & Johnson's Remicade, according to data from Truven Health Analytics. (The WAC price doesn't reflect rebates drugmakers typically offer.)

Early indications are that the prices for these substitute medications will only lop 15 or 20 percent off the price, said Dr. Mark McClellan, director of the Duke-Margolis Center for Health Policy, at a Tuesday meeting in Washington, D.C.

That discount is a far cry from the one for standard generic drugs, McClellan said at a forum hosted by Duke and Friends of Cancer Research. "On the other hand, 15 to 20 percent of a very big price – a very large number — is still a big number."

Steady price increases for Remicade mean that Inflectra, even at a 15 percent discount, will cost about what Remicade did in 2014.

Pricing this new class of drugs is just one challenge. Drugmakers will also have to persuade consumers and physicians that they are every bit as good as the drugs they would replace. Because these biotech drugs are similar but not identical to the brand-name medicines they mimic, pharmacists generally are restricted from substituting one for the other automatically, unlike most traditional generics.

The case for biosimilars as these new medicines are sometimes called isn't quite as straightforward as it is for standard generics. Typical drugs are simple molecules, so generic versions can be built atom by atom to be identical with the original.

These new "biologic" drugs are complex biological molecules. These drugs are produced in living cells. As a result, even the brand-name drugs vary a bit from batch to batch. The generic versions of these drugs, known as biosimilars, also vary. The Food and Drug Administration considers them essentially the same as the original drug, as long as their variations fall into the same range as the brand-name biologics.

So far, scientists have found no meaningful differences between these drugs and their mimics. Europe, which is a decade ahead of the United States in developing these drugs, has gathered 400 million patient life-years of data (which, for example, would be studies of 40 million people for 10 years), and hasn't identified any safety issues, said Lisa Bell, senior vice president of regulatory affairs for Coherus Biosciences.

The latest reassuring data, announced at a meeting Tuesday in Vienna, Austria, come from a government-funded study in Norway of 481 patients, half of whom switched from brand-name Remicade to another biosimilar called Remsima. After a year of follow-up, there was no meaningful differences between the two groups (though there were nonsignificant findings that provided potential fodder for skeptics).

In Europe, governments have a big hand in deciding which drugs are made available to patients in government-sponsored health systems. The system in the United States is a much more complicated picture, involving patients, doctors, insurance companies, middlemen and government providers such as Medicare. Doctors, in particular, have a big voice and will need to be convinced that the substitutes are just as good as the original drugs.

For example, doctors routinely prescribe Herceptin to treat certain forms of breast cancer. Dr. Richard Schilsky, senior vice president and chief medical officer of the American Society of Clinical Oncology, said a competitive product was shown to be at least as good as the original drug in a study that measured the likelihood that a woman taking the drug would suffer a relapse. But Herceptin has a 25-year-history that looks not only at relapse rates, but at long-term survival and other significant endpoints.

"At what point does the doctor and the patient have the confidence to make that switch" to the substitute brand, Schilsky asked at the meeting in Washington.

A patient may or may not see any savings, given the convoluted system of insurance and medical reimbursement in this country.

And the doctor may have a financial incentive to opt for the more expensive drug, including some cancer drugs. Currently, Medicare bases some payments to doctors on the price of chemotherapy drugs, so doctors make more when they prescribe more expensive drugs, Schilsky noted. (He said his organization is trying to change that payment system).

Time is running short to sort out all these issues. Leah Christl, at the FDA's Center for Drug Evaluation and Research, says that as of Oct. 5, the agency is processing 66 projects involving biosimilar drugs, which are potentially substitutes for 20 existing medications. Four products have already been licensed, though only one, Sandoz's Zarxio, is currently on the market, she said. Inflectra will be the second.

These applications all result from the 2010 law called the Biologics Price Competition and Innovation Act. It remains to be seen whether the hoped-for price competition will make a significant dent in American health care costs.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Don't Look Now! How Your Devices Hurt Your Productivity

Wed, 10/19/2016 - 10:32am
Nick Shepherd/Ikon Images/Getty Images

I'll admit it. I even take my phone with me when I head to the restroom, to fire off a few texts. Or I'll scroll through my email when I leave the office for lunch. My eyes are often glued to my phone from the moment I wake up, but I often reach the end of my days wondering what I've accomplished.

My productivity mystery was solved after reading The Distracted Mind: Ancient Brains in a High Tech World, by Dr. Adam Gazzaley, a neuroscientist at the University of California, San Francisco, and Larry Rosen, a research psychologist and professor emeritus at California State University, Dominguez Hills. Their book explains why the brain can't multitask, and why my near-obsessive efforts to keep up with email are likely lowering my productive output.

How the digital age zaps productivity

I visited Gazzaley in his UCSF laboratory to learn more about the science. On a video screen, he pulled up a 3-D image created from an MRI scan of a human brain. He pointed to different sections to explain what's going on when our attention flits between tasks.

How To Boost Productivity

Feeling chronically distracted? Dr. Adam Gazzaley has been there, too, and says these tricks can help you buckle down and think!

• Clear your work space. Remove mobile devices and extraneous papers.
• Use one computer screen. Shut down all unnecessary programs and apps.
• Open one browser, and use only one tab.
• Turn off email.
• Set expectations. Tell your boss you're going offline for a while. Or, set an auto response for texts and emails, explaining that you'll be offline for a set period of time.
• Work in a quiet environment. If you must work in a coffee shop use noise-canceling headphones.
• Display a "no interruption zone" sign at your desk or on your office door.
• Check out helpful apps like SelfControl, Freedom or FocusMe.

"The prefrontal cortex is the area most challenged," Gazzaley said. "And then visual areas, auditory areas, and the hippocampus — these networks are really what's challenged when we are constantly switching between multiple tasks that our technological world might throw at us."

When you engage in one task at a time, the prefrontal cortex works in harmony with other parts of the brain, he explained, but when you toss in another task it forces the left and right sides of the brain to work independently. It's this process of splitting your attention that usually leads to mistakes.

In other words, each time our eyes glance away from our computer monitor to sneak a peek at a text message, the brain takes in new information, which reduces our primary focus. We think the mind can juggle two or three activities successfully at once, but Gazzaley thinks we woefully overestimate that ability.

Skeptical? Try checking your email on a conference call.

"The act of doing that makes it so incredibly obvious how you can't really parallel process two attention-demanding tasks," he said. "You either have to catch up, and ask what happened in the conversation, or you have to read over the email before you send it — if you're wise!"

Answering an email takes much longer than you think

Our tendency to respond immediately to emails and texts gets in the way of high-level thinking, he said. If you're in the middle of a project and stop to answer somebody's note, it could take you nearly a half-hour to get back on task, some studies suggest.

"When a focused stream of thought is interrupted, it needs to be reset," explained Gazzaley. "You can't just press a button and switch back to it. You have to re-engage those thought processes, and re-create all the elements of what you were engaged in. That takes time, and frequently one interruption leads to another."

And that can make you less productive.

Based on his research, when UCSF neuroscientist Adam Gazzaley needs to focus on a big project he now clears his desk, works on one screen and turns off his phone.

Sierra Niblett/Courtesy of UCSF

Plus, mounting evidence shows a heavy diet of multitasking with multiple media could be hurting the brain's ability to think, in important ways — and that's true even for tech-native young people. Stanford researchers in 2009 studied the minds of students and others who regularly engage in several digital communication streams at once and found that, in general, high-tech jugglers struggle to pay attention, recall information or complete one task at a time.

"When they're in situations where there are multiple sources of information coming from the external world or emerging out of memory, they're not able to filter out what's not relevant to their current goal," said Stanford neuroscientist Anthony Wagner. "That failure to filter means they're slowed down by that irrelevant information."

The researchers are still studying what's causing multitaskers to perform poorly on cognitive tests. It could be that they are born with an inability to concentrate, or digital distractions are taking a toll. In any case, the researchers believe the minds of multitaskers are not performing optimally.

Create digital boundaries

But, take heart, Gazzaley said. You don't have to opt out of technology to get some of that brainpower back. In fact, there's a time and place for multitasking. If you're in the midst of a mundane task that just has to get done, for example, it's probably not detrimental to have your phone nearby or a bunch of tabs open. The distractions may reduce boredom and help you stay engaged.

Still, if you're finishing a business plan or a high-level writing project and need to focus, there are some steps you can take that should help. Check out Gazzaley's tips for turning off distractions in the sidebar above.

Then, get back to work!

This story was produced by KQED's health and technology blog, Future of You. The blog's host and editor is Jon Brooks.

Copyright 2016 KQED Public Media. To see more, visit KQED Public Media.
Categories: NPR Blogs

7 Insurers Alleged To Have Discriminated Against HIV Patients

Tue, 10/18/2016 - 4:20pm

Once-a-day HIV pills that combine multiple medicines, such as Truvada, are easier to take, but they can be more expensive than pills that contain only one active ingredient.

Justin Sullivan/Getty Images

The Affordable Care Act prohibits insurers from discriminating against people with serious illnesses, but some marketplace plans sidestep that taboo by making the drugs that people with HIV need unavailable or unaffordable, complaints filed recently with the Department of Health and Human Services' Office for Civil Rights allege.

The effect may be to discourage people with HIV from buying a particular health plan or getting the treatment they need, according to the complaints.

The complaints – brought by Harvard Law School's Center for Health Law and Policy Innovation – charge that plans offered by seven insurers in eight states are discriminatory because they don't cover drugs that are essential to the treatment of HIV or require high out-of-pocket spending by patients for covered drugs.

The center filed complaints against Humana plans in six states: Alabama, Georgia, Illinois, Louisiana, Tennessee and Texas. Cigna plans were targeted in three states: Georgia, Tennessee and Texas. The group filed complaints against five other insurers: three in Pennsylvania, including Highmark, Independence Blue Cross and UPMC Health Plan; a complaint against Community Health Choice in Texas and a complaint against Anthem Blue Cross Blue Shield in Wisconsin.

"What's most important to us is that there's a robust enforcement mechanism around the promises ... in the [Affordable Care Act] and its regulations, especially the anti-discrimination provisions," said Kevin Costello, director of litigation at the health law center.

Shots - Health News Complaint Says Insurance Plans Discriminate Against HIV Patients

Although the center's focus is on HIV drugs, the complaints may help people with other chronic illnesses who may face similar hurdles on access to drugs, Costello said.

The HHS Office for Civil Rights investigates and enforces violations of civil rights and health information privacy. The Harvard center complaints were filed in September.

Federal rules prohibit marketplace plans from adopting benefit designs — such as coverage rules or reimbursement rates — that discriminate based on age, illness, race, gender or sexual orientation, among other things. But federal regulators have declined to define discriminatory plan design, noting that they will examine the facts on a case-by-case basis.

They've hinted, however, at some specifics in the regulations. They say, for example, that refusing to cover a single-tablet drug regimen, which is often associated with better compliance because a number of different drugs are combined in one pill, or placing most or all of the drugs that treat a specific condition in the highest cost tiers are examples of "potentially discriminatory practices."

Working with local AIDS groups in several states, the Harvard center examined hundreds of silver-level plans sold on the marketplaces to gauge whether their formularies would allow access to six treatment regimens that are the current standard of care for treating people who are newly diagnosed with HIV. In addition, they looked at the plans' cost-sharing requirements, Costello said.

They found, for example, that this year Anthem silver plans in Wisconsin cover only four of the 16 drugs or combination products that are recommended to meet the current standard of care, and they fail to cover any single-tablet regimens. In Illinois, the center charged that Humana's silver plans place 16 of the 24 most commonly prescribed HIV drugs in the highest cost-sharing tier, which requires patients to pay 50 percent of the cost. With estimated monthly costs ranging from $377 to $684 for different drug regimens, enrollees in the Illinois Humana plans would have to pony up between 8 and 14 percent of their average monthly income, according to the complaint.

"All Humana health insurance plans offered through the Health Insurance Marketplace fully comply with state and federal laws and regulations," said Alex Kepnes, Humana's director of corporate communications. He added, "Humana shares the concerns of HIV/AIDS organizations regarding the high cost of HIV/AIDS drugs and we are committed to working with them to lower prescription drug costs."

Similarly, Anthem spokesman Scott Larrivee said, "Anthem Blue Cross and Blue Shield is committed to providing all of our members with access to the care and services they need, including appropriate coverage of medications for the treatment of HIV/AIDS. Anthem Blue Cross and Blue Shield in Wisconsin covers more than a dozen medications for the treatment of HIV/AIDS and all required therapeutic drug categories are included on our formulary/drug list which is compliant with (marketplace) requirements."

Cigna spokesman Mark Slitt said his company doesn't comment on pending legal matters.

The center's work builds on an earlier discrimination complaint filed in 2014 with the Office for Civil Rights by two advocacy groups, the AIDS Institute and the National Health Law Program, against four Florida insurers that were selling marketplace plans. That complaint, against some of the same insurers highlighted by the Harvard center, charged that the insurers placed all the HIV drugs in the highest cost-sharing tier. The Florida insurance commissioner reached agreements with the four plans to move the HIV drugs to generic tiers and reduce cost sharing, and the same arrangement will continue in 2017, said Carl Schmid, deputy executive director of the AIDS Institute.

"We've been talking about these issues for years now," Schmid said. "These things need to be addressed, and it could be through enforcement" by the Office for Civil Rights.

Marketplace coverage of drugs to treat HIV and other serious conditions have improved somewhat in recent years, according to research by Avalere Health, a consulting company. An analysis found that in the case of five classes of drugs that treat cancer, HIV and multiple sclerosis, fewer silver plans in 2016 placed all the drugs in the class in the top tier with the highest cost sharing or charged patients more than 40 percent of the cost for each drug in the class.

Speaking about HIV drugs, Caroline Pearson, a senior vice president at Avalere, said that while access and costs in marketplace plans are improving, they vary widely from plan to plan. Employer plans tend to offer better coverage, she said.

The new complaints may put more pressure on the Office for Civil Rights to address this issue, said Katie Keith, a steering committee member for Out2Enroll, a health insurance advocacy group for the lesbian, gay, bisexual and transgender community.

"It's smart to do this in multiple states," she said. "People are really pushing for more concrete guidance."

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.
Categories: NPR Blogs

WEBCAST: The Cost And Quality Conundrum Of Child Care

Tue, 10/18/2016 - 10:05am
Harvard T.H. Chan School of Public Health YouTube

There's a major gap between what parents view as quality child care and what developmental psychologists and other specialists define as good care. That's according to a poll released this week by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

Nearly 90 percent of parents say the quality of their child care is very good or excellent. But a major study in the field of child development has suggested that most child care is of only fair quality.

What's a parent to do? Quality care in a child's early years can help that young person develop lasting social, emotional and learning skills and can promote healthful eating and play.

But high-quality care, whether it comes from a nanny, a sitter, a day care or a preschool, can be difficult to find — and to afford.

There are solutions out there. A lively forum discussion at the Harvard Chan School covered the issues. We streamed the webcast, where specialists in child care and health will talk more about the findings, and what they mean for today's kids. (When the archived video becomes available, we'll add it to this post.)

Some of the issues that were discussed: How do parents find and select child care, and how does that care influence the health and well-being of families? How can child care be made accessible, high quality and affordable? How do we even measure quality in a meaningful and accountable way? The forum panelists discussed ways to equip parents with better information about child care and explained policy changes they thought could help children thrive.

Joe Neel, deputy senior supervising editor on NPR's Science Desk, moderated the discussion with:

Susan Hibbard, executive director of the BUILD Initiative

Kristin Schubert, managing director, Robert Wood Johnson Foundation

Rachel Schumacher, director, Office of Child Care, U.S. Department of Health and Human Services

Gillian SteelFisher, senior research scientist and deputy director of the Harvard Opinion Research Program, Harvard T.H. Chan School of Public Health

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

What Makes For Quality Child Care? It Depends Whom You Ask

Tue, 10/18/2016 - 4:44am
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October 18, 20164:44 AM ET Heard on Morning Edition Michelle Kondrich for NPR

When Jolie Ritzo was looking for day care for her son Cannon in Falmouth, Maine, she checked out as many centers as she could.

She was looking for a place with the right feel.

"Most importantly, the people who are providing the care are loving and kind, nurturing and interested in developing these little beings," she says.

There was one center in town that had a great reputation, but it was so pricey, Ritzo says, "It would break the bank."

She enrolled Cannon in a family child care based in a church. It was small and cozy with a sweet name and a nice playground. But after a few months, she started to get a bad feeling about the place.

"Let's just say she wasn't cut out for child care," Ritzo says of the woman who ran the center.

So the hunt was on again. She settled on a place called Little Hands.

Ritzo says it was convenient to get to, had a good reputation and a nice facility. It had good safety measures in place. It cost about $900 a month for four days a week. And it had space for Cannon immediately.

Ritzo is happy with the choice. Cannon just started kindergarten after going to Little Hands for three years, and now his 2-year-old sister is enrolled.

"It gives me peace of mind knowing that when I drop my daughter off for the entire day that someone is going to be loving, sweet and nurturing," Ritzo says

Like most parents, Ritzo says her children's day care is high quality. In fact, a new poll from NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health shows that the overwhelming majority of parents who use child care are happy with it.

The poll shows 88 percent of parents say their child care is very good or excellent.

It's an interesting result, because researchers in early child development say most child care in the U.S. is mediocre to poor.

A 2006 study by the National Institute of Child Health and Human Development showed that only 9 percent of child care arrangements in the U.S. were considered very high quality.

And a report by the New America Foundation says that only 11 percent of child care centers are accredited by one of the two main organizations that certify day care centers and preschools.

The disconnect between parents and researchers may be because the quality benchmarks measured aren't always the same as what parents are looking for, says, Mary Beth Testa, a child care policy consultant to the National Association for Family Child Care, the organization the accredits home-based child care centers.

"People are looking for, 'Do you care about my child? Is my child happy here?' " Testa says. "How do we regulate whether your child is going to be happy here?"

The NAFCC rates home-based child care and the National Association for the Education of Young Children rates centers. Each group evaluates child care providers on dozens of criteria such as curriculum, whether teachers have college degrees, how children interact with each other and the teachers, and the ratio of children to caregivers.

"There's research to back up that those things are important. The science says this is what children need in order to thrive," Testa says. "But parents are still looking for price, location and 'Do you love my kid?' "

The poll shows parents want quality child care, but that's not always the only deciding factor.

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Like Ritzo, parents are also looking for child care they can afford and that they can get to conveniently. Our poll shows that 27 percent of parents say location played a major role in their child care choice, more than any other single factor. And 18 percent point to price.

"The bottom line is, there's still this three-legged stool of quality, access and cost, and to find all three, unless you are upper middle class, it is very difficult to do," says Rhian Allvin, chief executive of the National Association for the Education of Young Children.

"You find something that's affordable, and often it's not the highest quality," Allvin says. "To find an affordable provider that is high quality, you're driving an hour and a half. And to really find affordable high quality care that is convenient for your family and your situation is incredibly challenging."

That's the situation for Jennifer Nuesi, a single mother who responded to our poll and lives in Northport, Fla. Her mother cares for her 4-year-old daughter, Cairo, while she's at work, and she's not happy about it.

"She's not at all the person I would like to watch my child," Nuesi says.

She says her mom, who is from the Dominican Republic, doesn't share her values in terms of how to raise Cairo. They disagree on everything — from rules to schedules to diet.

"My mom just lets her do whatever she wants. Eat whatever you want, do whatever you want, if you want to go to bed at 12 at night, that's totally OK," says Nuesi.

But she had to go with her mother because "unfortunately she's free, and I can't find better than that," she says.

Two years ago Congress updated the Child Care and Development Block Grant Program, which gives money to states to help low-income families get subsidies for child care. The $9 billion program requires child care providers that receive block grant funding to meet strong quality standards.

But Mary Beth Testa, a policy consultant for NAFCC, says Congress didn't actually increase federal funding enough to help child care centers reach the goals, which include requiring states to create training standards for child care providers, provide parents with the ability to compare child care options and spend 7 percent of their federal grant on quality improvement. She estimates a funding shortfall of about $1.2 billion.

"They are good reforms, they are good ideas," Testa says. "We needed to raise this bar."

But if parents are as happy with their child care as our poll shows, Testa worries there won't be much pressure on lawmakers to spend tax money to make it better.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

How Gaps In Mental Health Care Play Out In Emergency Rooms

Mon, 10/17/2016 - 5:18pm

Too often, pediatricians say, the teen depression that went undiagnosed in the community shows up in the ER as a suicide attempt.

Studio 642/Blend Images/Getty Images

Nearly 1 in 5 children each year suffers a psychiatric illness, according to research estimates. But a national shortage of medical specialists and inpatient facilities means that many still go untreated — despite national efforts to improve mental health care.

New research is driving home the consequences. Scientific abstracts presented Monday in Las Vegas, at the annual meeting of the American College of Emergency Physicians, offer insights into how frequently patients with mental health issues land in the emergency room — often because opportunities to intervene earlier are missed. Pediatricians and child psychiatrists say children are among the hardest hit.

The researchers analyzed data compiled by the National Hospital Ambulatory Medical Care Survey, which tracked mental health visits to hospital emergency departments between 2001 and 2011.

Compared with physically ill patients, people with mental health conditions rely more on the emergency department for treatment and are more often admitted to the hospital from the ER, the scientists found. Also, they tended to be stuck in the ER longer than people who show up in the ER with physical symptoms.

Specifically, the researchers found that about 6 percent of all the emergency department patients — of all ages — had a psychiatric condition. More than 20 percent of these psychiatric patients were admitted to the hospital, compared with just over 13 percent of the medical patients. About 11 percent of these patients with mental health problems required transfer to another facility, compared with 1.4 percent of the patients with physical ailments.

About 23 percent of mental health patients stayed in emergency care for longer than six hours, and about 1.3 percent for more than 24 hours. Only 10 percent of medical patients were under treatment in the ER for more than six hours, and just half a percent were there for more than 24 hours.

The researchers have not yet determined the distribution of ages among the patients in their study who came to the ER because of mental health symptoms. Anecdotally, though, ER patients with psychiatric problems tend to include more children and elderly patients than you'd expect to see based on the age range of the general population, says Suzanne Lippert, a clinical assistant professor in emergency medicine at Stanford University and lead author on the study.

The findings highlight what can happen when patients can't find good outpatient treatment for mental health problems, Lippert says. The evidence also underscores, she says, that when psychiatric patients arrive at the ER in a crisis, there is often no good place where they can continue treatment, once the immediate issue has been addressed.

Patients who come to the ER because of physical ailments can usually be sent home, Lippert says, "because we know they'll be evaluated by [their] doctor in one or two days." But psychiatric patients don't always have that option because of gaps in the mental health care system.

And young patients may be affected the most, says Dr. Steven Schlozman, a research psychiatrist at Harvard Medical School and associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital. He was not affiliated with the research.

"It's a numbers game," Schlozman says. "Unless you live in a large urban area, you're very unlikely to find a child psychiatrist."

Lippert's study found that the most severely ill psychiatric patients typically spent more time in the ER. Patients with bipolar disorder, depression or psychosis and those diagnosed with multiple conditions were more likely than others to be held in the ER longer than 24 hours.

A national shortage of inpatient beds for psychiatric patients is part of the problem, Lippert says. She has seen patients have to wait longer than a week to get the inpatient treatment they need.

Such delays in cramped, overused emergency quarters hurt patients, says Dr. Thomas Chun, an associate professor of emergency medicine and pediatrics at Brown University. Doctors often agree a child needs to be transferred, he says, only to find no outside beds available.

"We are the wrong site for these patients," says Chun, who was not involved in Lippert's study. "Our crazy, chaotic environment is not a good place for them."

Meanwhile, the young patients are even less likely to get reliable care after they are discharged from the ER. Whether they need regular follow-up with a psychiatrist, or a transfer to specialized facility, the resources often aren't in place. The American Academy of Child and Adolescent Psychiatry estimates there are only 8,300 such specialists in the U.S., for more than 15 million young patients.

Dr. Lindsay Irvin, a pediatrician in San Antonio, says the dearth of psychiatrists who specialize in treating young people means many young patients simply don't get the mental health treatment they need. By the time they wind up in the ER, she says, undiagnosed depression may have progressed to suicidal intent. And after leaving the ER, many are lost to follow-up.

"They'll land in a pediatric or family practice," Irvin says, where most primary care doctors haven't been trained "to navigate the ins and outs of psychotropic meds."

Lippert and her colleagues also found that the emergency psychiatric patients were more likely to be uninsured than medical patients were. About 22 percent of mental health patients lacked coverage, versus 15 percent of patients treated for physical conditions.

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.
Categories: NPR Blogs

A Reboot For Wheelchair That Can Stand Up And Climb Stairs

Mon, 10/17/2016 - 4:16pm
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October 17, 20164:16 PM ET Heard on All Things Considered

Gary Linfoot was paralyzed in a helicopter crash in Iraq. He's one of the few veterans still using an iBOT, which allows him to rise up to eye level using Segway-style balancing technology. The wheelchair was discontinued in 2009, but may soon be reissued.

Quil Lawrence/NPR

Thirteen years ago, just as the United States began what was to become its longest war, a futuristic wheelchair hit the market.

The iBOT allowed paralyzed people, including many veterans of Iraq and Afghanistan, to stand up by rising to eye level. It also did something no wheelchair ever had: climb stairs.

But even though users loved it, the iBOT went out of production in 2009 when Johnson & Johnson discontinued it.

"I was very disappointed," says disabled veteran Gary Linfoot, a former Army helicopter pilot. "I knew my tent was up, I had one, but I knew there were other people out there who could use this device, this technology and it would not be available to them."

Now, however, the iBOT could be coming back.

Toyota announced this year that it's bankrolling a reboot of the iBOT, which the machine's inventor, Dean Kamen, says will allow him to make some improvements.

"With advances in computers, the advances in solid-state gyros and electronics ... we can take a hundred pounds out of it. We can take a lot of cost out of it. We can improve it," he told NPR.

Kamen is widely known as the inventor of the Segway, which was actually a byproduct from development of the iBOT. The first iteration of the wheelchair had a $25,000 price tag — too high even for the department of Veterans Affairs in most cases. Most veterans who had iBOTs got them from veterans charities, and all but a few are now sitting in the garage, with nowhere to service them.

Today, Toyota is interested in some of the machine's balancing technology, possibly to be used in the company's robotic helpers for the aging. And that could mean new parts and new life for existing iBOTs as well as a new version of the chair.

It also helps that the Food and Drug Administration reclassified the iBOT from its strictest regulatory category for medical devices Class 3, alongside replacement heart valves, to Class 2, alongside condoms. That will also lower the expense of the machine, and Kamen says testimony by veterans using the machine was one key to persuading the FDA to make that switch.

For people like Linfoot, it was a game changer.

He lost the use of his legs after a 2008 helicopter crash south of Baghdad. "I wasn't shot down or anything," he says. "It was just a mechanical malfunction. Probably a $25 part failed and we lost all power to the rotor system."

Linfoot and his co-pilot survived, but the impact left Linfoot paralyzed below the chest. The iBOT allows him to navigate street curbs and the hills around his home north of Nashville, Tenn.

"It goes beyond just reaching in the cabinet to get the cookies that my wife might hide up there, or the good booze," he says, sitting on top of what looks like an easy chair balanced on a pair of unicycles.

Plus the ability to stand up is huge.

"When you go out to a social setting, back up at 6 feet, talking to somebody eye to eye, you get this sense of dignity," he says. "The disability just kind of fades into the background."

Kamen said he hopes stories like Linfoot's will help persuade his new backers to return the iBOT to production and make it available to a wider group of people.

"The reason some of these veterans need these things is they've literally given up pieces of their body for this country," he says. "The least we can do is give them back the best technology that is currently available."

The Two-Way Department Of Veterans Affairs To Pay For Robotic Legs

Several other companies have designed chairs that can get people with spinal injuries up to eye level and even off-road. But doctors at the department of Veterans Affairs are more excited about inventions that can actually get veterans walking again. The health effects of immobility for paralyzed people are just like the effects of sitting down all the time for able-bodied people, they say.

"Sitting is the new smoking," says Dr. Will Bauman, director of the Center of Excellence on the Medical Consequences of Spinal Cord Injury at the James J. Peters VA Medical Center in the Bronx. He and Dr. Ann Spungen, associate director of the center, have studied the secondary health effects of paralysis.

"Just like you and I, if we sat around all day, we already know that's the worst thing can do to ourselves," says Spungen.

Immobilized people are prone to weakened bones, higher blood pressure, urinary tract infections and constipation that can be debilitating. At the Bronx VA, veterans have been using an exoskeleton called a ReWalk to get them moving again. It's like a backpack with robotic leg braces that allows patients to walk using crutches.

So far, devices like these aren't that useful outside a safe, flat surface. Regular therapy with these machines can help reduce pain and promote better sleep, Spungen says.

With as little as four to six hours of walking a week, about half of patients lost more than a kilogram of body fat, says Spungen. For many problems, she says, "the best cure is to take a walk."

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

NPR Poll: Are Parents Overrating The Quality Of Child Care?

Mon, 10/17/2016 - 1:03pm

Parents' views of child care are a little like life in Lake Wobegon — the vast majority say it's way above average.

That's just one of the findings in a poll looking at child care and health from NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, released Monday.

In it, we found that a remarkable 88 percent rated their child care as "very good" or "excellent."

That stands in stark contrast to the most comprehensive and most recent study on child care and child development, which rated the quality of fewer than 10 percent of child care arrangements in the U.S. as "very high." The vast majority of child care was rated as only "fair."

That 15-year-long study by the National Institutes of Health looked at a wide range of quality measures, from basic safety to daily activities and interactions with providers and other children.

That led us to think about how there could be such a big disconnect between parents' perceptions and apparent reality.

It may be that parents' measures of quality are very different from those who study childhood development. Or parents may be reluctant to tell a pollster that they've got their child in anything other than the best child care.

"Our findings suggest that parents value and seek out quality child care and believe it benefits their child and themselves," says Gillian SteelFisher, research scientist and deputy director of the Harvard Opinion Research Program and the poll's academic leader. "However, we also found that parents face challenges related to the limited options they have for child care, the cost, and a lack of information about its quality."

To get a reading on the state of child care and health in America today, we looked for parents of children up to age 5 who were not yet in kindergarten and whose child receives regularly scheduled care at least once a week from someone other than a parent.

We conducted interviews in English or Spanish and on landlines and cellphones. The margin of error is plus or minus 3.4 percentage points.

When it comes to the individual features of the care their child receives, safety of the indoor and outdoor environment was most frequently rated as excellent, followed closely by other measures.

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But just finding child care can be a major challenge, with 1 in 5 parents saying there was only one "realistic" child care option for his or her child.

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It will come as no surprise, but cost was the most common challenge in finding child care, with 27 percent of people saying it's an issue. Four in 10 parents (39 percent) say that the cost of paid child care in their area is not affordable for them.

That could be a major reason why child care is one of the few domestic social issues getting any attention in the current presidential campaign. (We've detailed the candidates' positions below.)

In addition to asking parents about quality and cost in our poll, we wanted to find out how they perceive the impact that child care has on their child and themselves — and whether child care has lasting effects.

The most surprising finding was that parents, particularly mothers, feel child care has benefited their own health and well-being, as well as their relationship with the child.

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Half the mothers said it had a "very positive effect" on their relationship with their spouse and an even larger percentage, 64 percent, saw a very positive effect on their relationship with their child.

We also wanted to find out what happens when a child is sick and can't go to child care. The results: Mothers are more likely to stay home than fathers. And our results suggest that traditional views of gender roles may foster this dynamic. When parents said mothers are most likely to stay home, 16 percent said it was because it was their responsibility to take care of the child, while just 4 percent of parents viewed it as the father's responsibility.

One of the strongest findings in the poll was that 86 percent feel that care in early childhood has a "major impact" on a child's long-term well-being.

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While it is perhaps not terribly surprising that 84 percent said there was a major impact on kindergarten readiness, it's worth noting that 52 percent said there was a major impact on job success later in life.

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Presidential candidates' child care platforms

Hillary Clinton has proposed universal access to preschool for 4-year-olds within 10 years, and she would seek to double funding for the Early Head Start and Early Head Start-Child Care Partnership programs as well as increasing funding for child development and support programs for children under age 3 and pregnant women. She is also calling for 12 weeks of paid family and medical leave for both parents. And she has proposed capping the amount a family spends on child care at 10 percent of income, among several other actions aimed at reducing costs.

Stretched: Working Parents' Juggling Act On Your Mark, Give Birth, Go Back To Work

Donald Trump has proposed allowing all parents to deduct the average cost of child care in their state from their income taxes, limiting it to those who make under $250,000 as a single parent or $500,000 for a couple. He would also allow tax-free contributions of up to $2,000 a year to dependent care savings accounts, with a 50 percent federal government match for low-income parents, up to $1,000. Trump also has proposed a paid maternity leave program.

Libertarian candidate Gary Johnston has not proposed anything specific on child care, while the Green Party's Jill Stein has called for universal child care.

Detailed fact checks of the Clinton and Trump positions are here and here.

The child care and health series

There's a lot more in the full poll report, but one final note: Parents perceive significant differences in quality depending on where they get care — from a relative versus a nonrelative versus a center.

NPR will provide in-depth reporting on the results of this poll in a series of radio and online reports over the coming weeks, including a story on Morning Edition Tuesday that explores the giant disconnect between parents and experts when it comes to quality.

We'll also live stream an expert panel at Harvard discussing these issues, Tuesday at 12:30 p.m. ET on

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Is 20-Something Too Late For A Guy To Get The HPV Vaccine?

Mon, 10/17/2016 - 4:45am
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October 17, 20164:45 AM ET Heard on Morning Edition

From Side Effects Public Media

WFYI's Jake Harper reports health stories for Side Effects Public Media in Indianapolis. His newest health anxiety stems from the human papillomavirus, or HPV.

Brian Paul/Side Effects Public Media

Sex with someone new has always made me nervous. Now, TV is making it even worse.

I keep seeing scary ads featuring young people asking their parents why they didn't get the vaccine to protect against the human papillomavirus — HPV. If you're unfamiliar with HPV, it's a sexually transmitted infection that has been linked to various cancers, including cervical cancer in women.

I didn't get vaccinated. So lately I've been wondering: Now that I'm 29, is it too late for me to get the vaccine?

I found out about HPV eight years ago when a college girlfriend got immunized. Back then, the Centers for Disease Control and Prevention only recommended the vaccine for girls and young women between the ages of 11 and 26. The earlier the better, they said, to try to reach girls before they become sexually active. The vaccine is also more effective at a younger age.

At the time, I remember thinking that limiting it to females was strange — after all, males still spread HPV, right? But with my partner vaccinated, I let it go. I didn't know HPV could cause health problems for men.

But HPV absolutely affects men. It causes genital warts and is pulling past tobacco and alcohol as a leading cause of cancers in the back of the mouth and throat, the area called the oropharynx. The CDC now estimates about 70 percent of all oropharyngeal cancers may be caused by HPV, including roughly 12,600 cases in men each year.

"There are now more oropharynx cancers in men in the United States each year than there are cervical cancers in women," says Dr. Erich Sturgis, a surgeon and researcher at the University of Texas MD Anderson Cancer Center in Houston.

And there's no way to screen for oropharyngeal cancer, so Sturgis says most people catch it late.

"Typically it's a man, while he's shaving," says Sturgis. "He notices a lump in his neck. That means it's already a cancer that has spread."

HPV also puts men at risk for cancers of the anus and penis. Those are rare, but still make me anxious.

So, for men like me who missed the vaccine, is it still worth it?

The answer is complicated. In 2011, the CDC began recommending the vaccine for males ages 11 through 21 years old (26 for some high-risk groups).

Despite my age, researchers I talked to said that the vaccine could still help — if I haven't already been exposed.

But therein lies a complication. An estimated 80 percent of sexually active people will be exposed to HPV by age 45. In most people, the virus goes away on its own after two years. For men, there's no commercially available test to find out if you have been exposed. Women can be checked for HPV exposure as part of a Pap test.

To have 80 percent of sexually active young adults exposed sounds bleak. But there's a caveat: "There are several dozen types of HPV that infect the genital region," says psychologist Greg Zimet, who co-directs the Center for HPV Research in Indianapolis. Only a fraction of those cause cancer or warts, and the latest version of the vaccine Gardasil protects against nine of those HPV types — the ones responsible for a vast majority of HPV-related problems.

So let's say — hypothetically — you're kind of shy and haven't had that many partners. Is it possible you've been spared?

"The chances you've been exposed to all nine types are actually vanishingly small," says John Schiller, a microbiologist who studies HPV and HPV vaccines at the National Cancer Institute.

Schiller says the vaccine might not be a bad idea for someone outside the CDC's recommended age range. Still, it's not cheap.

"You're past the age where your health insurance is going to pay for it," says Schiller, so getting the vaccine isn't imperative — it's a personal decision.

"Peace of mind for you may be worth more than it is for some other people," he tells me.

So, I got the vaccine. It's costing $130 out of pocket per dose, and the CDC recommends three shots. But it could help me, even if it just calms my anxious inner voice. And it might keep me from spreading the virus to someone else.

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

Copyright 2016 Side Effects Public Media. To see more, visit Side Effects Public Media.
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Skeptics Question The Value Of Hydration Therapy For The Healthy

Mon, 10/17/2016 - 4:45am
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October 17, 20164:45 AM ET Heard on Morning Edition


Yana Shapiro relaxes while taking an intravenous vitamin treatment at RestoreIV in Philadelphia.

Emma Lee/WHYY

Yana Shapiro is a partner at a Philadelphia law firm with an exhausting travel schedule and two boys, ages 9 and 4. When she feels run-down from juggling everything and feels a cold coming on, she books an appointment for an intravenous infusion of water, vitamins and minerals.

"Anything to avoid antibiotics or being out of commission," the 37-year-old says.

After getting a 100-milliliter drip of a liquid the clinic calls immune protection pumped directly into her bloodstream via a needle in her arm, Shapiro says she feels like "a new person." The infusion, which costs $179, takes less than a half-hour. While she waits, she can recline in one of the cushy seats, watch the 64-inch, flat-screen TV or dim the lights in the room.

"I take this time as 'me time' — to relax and kick back and close my eyes for a couple of minutes," she says.

But if you mostly eat your kale and quinoa, why would you need a boost of vitamins delivered straight to a vein? Skeptical physicians say you probably don't need it. A healthy gut absorbs all the nutrients we need from food. And anyone well enough to drink fluid, they say, can get all the rehydration they need by mouth.

Still, clinics that market treatments of intravenous fluid to the stressed out and worried well can now be found nationwide.

Shapiro gets her infusions at RestoreIV in Philadelphia, but there are similar clinics in New York, Las Vegas, New Orleans, Santa Monica and Dallas, with names like The Remedy Room or Hangover Heaven. The first wave of such companies billed their treatments as a remedy for excess alcohol and partying, or too little sleep; you could get the treatment in a mobile van parked at a music festival, say, or in your hotel room.

Newer firms offer a menu of drips that claim to help rid the body of toxins, balance hormones, improve chronic medical conditions or simply give the skin a healthier glow.

Osteopathic medicine physician Jason Hartman, who launched RestoreIV with a partner out of his Philadelphia integrative medicine practice, says people want the experience he offers. Hartman's specialty is using touch to diagnose and treat patients.

He sometimes helps people remedy a hangover, he says, but his business also includes people with more serious illnesses, including chronic fatigue and migraines. For those patients, he says, IV treatment supports healing. Other clients are generally healthy and want to stay that way.

The basic IV therapy cocktail includes vitamin C, zinc and B vitamins. If you have a headache, the doctor might add a little magnesium.

"These are your natural pharmacy," Hartman says, "and in chronic diseases these things can be depleted [by] just a stressful lifestyle. And if they become deficient enough, it alters your internal pharmacology enough to possibly manifest as a symptom or disease."

The promised benefits of this sort of intravenous treatment vary from company to company.

At the bottom of the website for The Hangover Club, you'll find this warning:

"These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. This service is intended only for healthy adults."

Hartman says any intravenous infusion comes with a small risk of infection — or pain, bruising or bleeding if the needle misses the vein. More serious complications of an IV treatment can include a blood clot, or inflammation of the vein.

And people with certain medical conditions — some metabolic diseases, for example, or congestive heart failure — shouldn't get these treatments, Hartman cautions. That's why, he says, his clinic questions every client about their medical history before a treatment begins.

At RestoreIV, the treatments cost from $150 to $200, and there's an initial $35 fee to consult with the doctor. The business doesn't accept health insurance; patients pay Hartman's office directly.

So, with the out-of-pocket expense, and only anecdotal evidence of benefit, why do people sign up for these sessions?

Ather Ali, a doctor of naturopathic medicine and health researcher at the Yale School of Medicine, says that if an IV infusion of this type makes people feel better, it's probably because of the placebo effect. And the placebo effect can be powerful.

Several years ago, Ali and his colleagues tested a popular IV treatment called the Myers' cocktail on a small group of people with fibromyalgia, a syndrome of muscle pain and fatigue that can be hard to ease. Half the 34 participants in his pilot study got Myers' intravenous cocktail of vitamins and minerals in weekly treatments for eight weeks, and the other half got a standard solution without vitamins.

"The interesting finding," Ali says, "was that everyone got better." People in both groups reported less pain, and said they were better able to do the things they need to do every day.

The placebo phenomenon is more complicated than many people understand, Ali explains. Research has shown, for example, that injections, or other invasive procedures, can generate a stronger placebo effect than dummy pills do.

If, as in the case of his study, people feel a fairly innocuous treatment is helping them, and they haven't been able to get relief in other ways, that may be a reason to use it, Ali says — even if the "fix" is 100 percent placebo effect.

"When your child falls down and scrapes their knee, you give them a kiss," he says. "There's value in that, whether or not there's clinical trial data showing that giving a kiss is better than doing nothing."

Still, Ali says he can't ethically recommend the intravenous vitamin treatments for healthy patients.

"If people are just using it to feel good or for an energy boost," he says, "I would just say go exercise for 30 minutes and you'll get more out of that."

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

Copyright 2016 WHYY, Inc.. To see more, visit WHYY, Inc..
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West Virginia Grapples With High Drug Costs

Sat, 10/15/2016 - 5:04pm
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October 15, 20165:04 PM ET Heard on All Things Considered


Skyrocketing prices for essential medicines like the EpiPen, are generating public outcry, congressional hearings and political promises for policy fixes. In the meantime, the increases continue to hit pocketbooks — even of people who don't rely on these expensive drugs. In a state like West Virginia, where dire budget shortfalls have been a problem over the last few years, the problem is especially pronounced.

Kimberly Earl, of Charleston, W.Va., is feeling the pinch. She has four children, all of whom need medication.

"I have a 13-year-old who's a pediatric cancer survivor," she says. "I have two children who are allergic to foods, medication and environmental factors, and both of those children both have asthma."

Last year, two of her children needed new EpiPens — which come in a 2-pack. (The dose of epinephrine each pen delivers is designed to be used in an emergency, to stop a severe allergic reaction.) The Earls have private health insurance, but had yet to meet their $10,000 family deductible for 2015. They didn't have enough money for two boxes of EpiPens at the $600 price — even with a $100 discount from the drug's manufacturer. So the family improvised.

"We took the pens and we split the two pens between two kids," Earl explains. "I actually took the pens out and wrote on the top — 'use this one first' on the current pens, and 'use this one second' on the expired pens. So each kid was walking around with one current pen and one expired pen. And we were just hoping that if there was an issue they wouldn't have to use that second pen."

While Earl paid for the drugs out of pocket, about a third of West Virginians are insulated from these direct costs because they are covered by Medicaid. The state expanded Medicaid under the Affordable Care Act, giving lower-income people the government-sponsored insurance. Most Medicaid patients don't have premiums or copays.

But in the end, rising drug prices affect everybody in West Virginia. When lawmakers consider the state's budget, they only have so much revenue to divvy up among priorities that include health care services, roads and schools, says Dr. James Becker, the medical director of Medicaid in West Virginia.

"So when the cost of a drug goes up dramatically," he says, "that impacts our system and we have to step in and make adjustments to regulate the drug appropriately."

The West Virginia Department of Health and Human Resources can regulate the cost of drugs by negotiating lower prices through the federal rebate program. The rebate program is a complex system, but basically comes down to this: The more Medicaid patients enrolled in the program, the more bargaining power the government has to make drug companies lower their prices. Another way Medicaid manages costs is by including older, cheaper, but still effective drugs in its formulary, rather than relying on more costly new brands.

But even with these measures, the overall increase in the price of medications has forced some shifting of funds in other parts of the state budget, says Ron Stollings, a Democrat and state senator from Boone, W.Va.

"Certainly for Medicaid funding in West Virginia, [the hike is drug prices] is a huge cost," says Stollings, a former chairman of the state senate's health committee. "So when we have to put money into funding Medicaid, we have to cut funding for higher education and secondary education; we have to put off paving projects, etc."

Stollings says these rising Medicaid costs — partially due to higher drug costs — fall on the taxpayer, who may end up paying more state taxes to fund the budget.

"If you're a taxpayer, it impacts you," Stollings says. "If you're an insured person it will impact your premiums, and if you are on Medicaid you may get this expensive medication, but they may be ratcheting down coverage for other things."

Medicaid is a large portion of the West Virginia's budget, right behind public education. And it will probably get even bigger next year, as the state picks up more of the Medicaid expansion costs from the federal government.

This story is part of a reporting partnership with NPR, West Virginia Public Broadcasting and Kaiser Health News.

Copyright 2016 West Virginia Public Broadcasting. To see more, visit West Virginia Public Broadcasting.
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You Can Monitor Heart Rhythm With A Smartphone, But Should You?

Sat, 10/15/2016 - 5:00am
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Digital gizmos can monitor your heart, whether it's a wrist-worn fitness tracker or a smartphone app to help cardiologists analyze diagnostic tests. The question is whether they're going to do your heart any good. The short answer: It depends.

One thing to consider is whether the device is a consumer fitness monitor for tracking heart rate, or if it's a medical device approved by the Food and Drug Administration for detecting potentially dangerous heart rhythm irregularities.

First, the fitness monitors. Wrist-worn fitness trackers become less accurate with more vigorous exercise, which presumably is when you'd most want to know your heart rate. The study, published Wednesday in JAMA Cardiology, tested the Apple Watch, Fitbit Charge HR, Basis Peak and Mio Alpha wristbands.

"We have patients come in who have different kinds of monitors like these. Many of them are very concerned because they've recorded values that seem way outside of the normal range," says Dr. Marc Gillinov, a cardiac surgeon at the Cleveland Clinic and an author on the study. The study was designed to find out whether those readings are accurate.

Overall, the Apple Watch and Mio Fuse did best, with about 91 percent accuracy. The others fell in the 80 percent accuracy range, both overestimating and underestimating wearers' heart rates.

For most people, errors like these aren't a big deal, says Gillinov. But for elite athletes and cardiac patients who try to keep their heart rates in certain ranges, these devices might not be the best choice.

"For those groups, I'd recommend medical-quality chest-strap monitors," says Gillinov, adding that he doesn't think that inaccurate heart rate monitors are dangerous, just that they might not be useful.

Part of the problem is how they work, he explained.

If you've ever been in a hospital, you might have had a little plastic clip attached to your big toe (or your ear, or your finger). Those are pulse oximeters — they measure heart rate and oxygen content by shining a light through your skin. Different amounts of light bounce back depending on how much blood is flowing. By measuring changes in reflected light, pulse oximeters can track how fast your heart is beating. Hospital pulse oximeters are wrong all the time. "We often have to move the monitors around because we lose the signal," says Gillinov.

The heart rate monitors in Fitbits and Apple Watches work the same way, except they shine the light through your wrist. If you have dark skin, a tattoo or a birthmark where the monitor sits, Gillinov says that can confuse the monitor.

This isn't the first time wrist-born heart rate monitors have been called inaccurate. A class-action lawsuit filed against Fitbit in early 2016 claimed just that.

In a statement provided to NPR, Fitbit says that "Fitbit trackers are not intended to be medical devices" and that internal research shows that their trackers meet "industry standard expectations for optical heart rate on the wrist."

But there are growing numbers of heart-monitoring apps that are intended to be used as medical devices, which unlike fitness trackers have to be approved by the FDA. Some are designed for home use, while others are for health care providers.

Screening for atrial fibrillation has gotten a lot of attention, because this irregular heartbeat can cause blood clots, parts of which can break off and move to the brain, causing stroke. Patients with atrial fibrillation are five times more likely to have strokes, and it affects 9 percent of people over 65.

It's possible to be experiencing atrial fibrillation and not know it. Since this condition can come and go, there's no guarantee that doctors will catch the errant heartbeats. Right now, the only way to detect it is with an electrocardiogram, or EKG, which involves visiting a medical professional and using a machine to monitor the heart's electric signals.

One iPhone app, called Cardiio Rhythm, monitors the heart using a phone's camera. The concept is similar to a pulse oximeter or wrist wearable. Researchers used this phone-based device to detect atrial fibrillation. In a study published in July in the Journal of the American Heart Association, researchers used the app to screen a little over 1,000 patients for atrial fibrillation. They caught the erratic heartbeats in 92.9 percent of patients who had it, and correctly identified 97.7 percent of patients who didn't.

That's not accurate enough to make a diagnosis, but it is accurate enough for widespread at-home screening, says Ben Freedman, deputy director of cardiovascular strategy at the Heart Research Institute in Sydney, in an editorial accompanying the study. The app could tell people if they were at risk, but confirmation would have to come from a doctor's office.

Another device, called AliveCor, scans for atrial fibrillation using a small handheld EKG. The AliveCor EKG can connect to a smartphone and analyze heart rhythm. A study published Wednesday in Heart trained 13,122 participants to use the AliveCor EKG on themselves. Only 0.4 percent of their results could not be interpreted, and they caught 98 percent of atrial fibrillation cases in participants over 60. However, it had a high rate of false positives and only correctly identified 29.2 percent of those without atrial fibrillation.

"Our study found that a significant number of citizens with previously undiagnosed atrial fibrillation were picked up by community screening," says Dr. Ngai-Yin Chan, a cardiologist at Princess Margaret Hospital in Hong Kong and the lead author on the study. People with atrial fibrillation can be prescribed blood thinners to reduce the risk of clots, and beta blockers or other medications to slow heart rate. "Whether this will be translated into people seeking medical help needs to be answered by future studies."

A cardiologist and director of the Ahmanson-UCLA Cardiomyopathy Center, Dr. Gregg Fonarow, hopes that technologies like this will help identify atrial fibrillation early on and reduce the risk of stroke. "These applications can change the way cardiologists treat atrial fibrillation and prescribe better drug protocols," he told NPR via email.

But we're not there yet. Gillinov, the author of the fitness-tracker accuracy study, deals with a lot of atrial fibrillation patients in his work as a cardiac surgeon. He thinks that self-screening could save a lot of lives, but that it's important doctors be included in the process.

Plus, he says, not everyone should be screened for atrial fibrillation. "If young people start screening themselves, we're going to see a lot of false positives, even with very accurate devices."

Shots - Health News Sure You Can Track Your Health Data, But Can Your Doctor Use It?

The American Heart Association plans to release a policy statement on telehealth, including at-home heart monitoring, sometime in the next six months.

Copyright 2016 NPR. To see more, visit NPR.
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