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Life, Death And Remembering Those Bright College Years

7 hours 50 min ago
Katherine Streeter for NPR

Recently I attended my wife's 25th college reunion. Many aspects of the weekend were what you'd expect: reconnecting with her roommates and friends, catching up on their lives and careers, and (mild) revelry late into the night.

As a spouse tagging along, I was braced for a nightmare of never-ending tales of yesteryear in which I'd played no part (my wife and I met after college) and reprisals of long-ago inside jokes.

But that's not what happened. Instead, I was inspired by the people I met and deeply touched by the stories they shared. Moreover, I was reminded that suffering and death are inevitable parts of life, and how we cope with and accept them seems to be among the greatest challenges of adulthood.

The weekend's festivities had broad-based appeal that any 47-year-old would find compelling. Among the highlights was a "Moth-like" story hour, in which a dozen different classmates volunteered to tell true personal stories in five minutes or less without any notes. Their storytelling prompt was "What's happened since I left college."

Shots - Health News A Diary Of Deaths Reminds Doctor Of Life

The next day, a few members of the class talked on a panel to a packed audience on the theme of resilience. Each panelist recounted tragic personal tales of illness, death and lost dreams; and how courage, faith and college friends helped each of them regain some footing to move forward.

I wasn't emotionally prepared for how much the weekend's final event affected me: The class memorial service.

Led by professional clergy and a literary maven who also happen to be members of the class, the service was an opportunity to remember the names of the 19 Harvard College class of 1991 members who had died.

The service was beautiful, evocative, and created a mood in which class members could remember the full spirit and presence of their classmates now gone.

I didn't know any of the deceased individuals, so I wasn't expecting to feel so moved in honoring their memory. I think what affected me were the raw and authentic feelings of loss, even at a remove of decades in some of the cases. Of course, the dead were people exactly our own age who were struck down far too early.

Upon further reflection, the doctor in me started wondering: Are 19 deaths a lot or a few? In a class of roughly 1,600, that's a little over 1 percent. Dying before age 47 in the U.S. is unusual, extremely so judging by actuarial tables.

Imagine a hundred years ago, when the average American only lived to the age of 52, and we had yet to vanquish the infectious diseases that took the lives of so many children. A 25th college reunion would have served as a life valedictory.

Now that Americans live, on average, to age 79 (men 77 and women 81), the reunion we attended at age 47 is just beyond life's halfway point.

Overlapping with my wife's reunion, her father was celebrating his 55th class reunion. In his (all male) class, there were nearly 250 read and remembered before the traditional tolling of the bell.

Statistically, I would have expected a significantly higher mortality rate among a class of 77-year-old males. But these Harvard graduates of the class of 1961 are outliers — not only on average having enjoyed better access to health care over the course of their lives, but also having benefited from premier educational and economic opportunities in life.

It's such social determinants of health that affect both the quality of our lives and our life spans — much more so than even the direct medical care we are afforded.

[And it certainly doesn't hurt that these men have entered their twilight years during an explosion of knowledge in molecular biology and genetics.]

At our memorial service, there were prayer offerings, songs and readings from several religious traditions. One class member even composed an extraordinary piece of music in remembrance of a deceased classmate that was performed at a Boston Pops concert the night before.

As the service progressed, I was barely able to breathe during the chanting of El Male Rachamim, a haunting Hebrew prayer for the souls of the departed:

God filled with mercy,

dwelling in the heavens' heights,

Grant perfect peace

beneath the wings of Your Presence,

amid the holy and the pure,

Illuminating like the brilliance of the skies

the souls of our beloved and holy

who went to their eternal place of rest.

Tears flowed, and after the service attendees hugged one another and shared remembrances of their departed classmates.

At reunion's end, I was heartened by the beauty and restorative power of the memorial service. It makes sense. Even at 47, many of us haven't had much experience with death. Learning to handle it gracefully becomes ever more important as we begin the downslope of our lives. Though those of us that remain constantly struggle with it, death is part of all of our lives.

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

Copyright 2016 KWGS-FM. To see more, visit KWGS-FM.
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A Young Woman Dies, A Teen Is Saved After Amoebas Infect The Brain

9 hours 14 min ago

The amoebas that can cause rare brain infections resemble white blood cells under the microscope.

CDC

Doctors describe 16-year-old Sebastian DeLeon as a walking miracle — he is only the fourth person in the U.S. to survive an infection from the so-called brain-eating amoeba.

Infection from Naegleria fowleri is extremely rare but almost always fatal. Between 1962 and 2015, there were only 138 known infections due to the organism, according to the Centers for Disease Control and Prevention. Just three people survived. This summer, two young people, one in Florida and one in North Carolina, became infected after water recreation. Only one had a happy ending.

DeLeon is a 16-year-old camp counselor. The Florida Department of Health thinks he got the infection while swimming in unsanitary water on private property in South Florida before his family came to visit Orlando's theme parks.

So many things had to go right for DeLeon to survive. On a Friday, he had a bad headache. The next day, his parents decided this was way more than just a migraine and took him to the emergency room at Florida Hospital for Children.

Doctors persuaded the family to do a spinal tap to rule out meningitis, even though he didn't have a stiff neck, the telltale symptom. Sheila Black, the lab coordinator, looked at the sample and assumed she saw white blood cells. But then she took a second, longer look.

"We are all detectives," Black said. "We literally had to look at this and study it for a while and watch for the movement because the amoeba can look like a white cell. So unless you're actually visually looking for this and looking for the movement, you're going to miss it."

That movement triggered the alarm: This was an amoeba case. And that's when the pharmacy reached out to a small Orlando drug company called Profounda, which has a drug called Impavido that was originally developed as a cancer treatment and approved by the FDA in 2016 to treat the tropical parasitic disease leishmaniasis. It has been used in several cases to treat amoeba infections as well.

Profounda CEO Todd MacLaughlin got the call from the pharmacy, but he was out of town so his son drove the drug to Florida Hospital.

"Within 12 minutes he had picked up the product and was on the way to the hospital," MacLaughlin said. "Everybody was in the right place at the right time."

DeLeon was given the drug along with others. Doctors put him into a coma and lowered his body temperature to give the drugs time to work and slow the infection.

Dr. Humberto Liriano was emotional talking about the experience. They knew the odds were not in DeLeon's favor when he was placed into a coma.

"The family when they came to me, immediately within four hours, I had to tell them to say their goodbyes," Liriano says. "I had to tell them, 'Tell him everything you want to tell your child, because I don't know from the time I put him to sleep to the time I take the tube out, [if he will] wake up.' "

DeLeon's mother, Brunilda Gonzalez, thanked doctors at a press conference.

"We are so thankful that God has given us the miracle through this medical team and this hospital for having our son back and having him full of life," Gonzalez said. "He's a very energetic adventurous, wonderful teen. We're so thankful for the gift of life."

Central Florida has coped with amoeba infections before, including the death of Jordan Smelski, who died at the same hospital where DeLeon was saved. Smelski's parents started a foundation to raise awareness of the disease in the medical community and to advocate for hospitals to stock the drug in case of an infection.

Profounda says seven hospitals have taken it up on stocking the drug at no cost, charging them only when the drug is used. The drug costs $48,000 for a full round of treatment. MacLaughlin said the company will provide the drug free if someone doesn't have insurance.

Sebastian DeLeon, 16, is now the fourth known U.S. survivor of the so-called brain-eating amoeba.

Abe Aboraya/WMFE

DeLeon will soon head to South Florida for rehab, and doctors are optimistic he'll make a full recovery.

But in North Carolina, an 18-year-old Ohio woman died from the amoeba in mid-June, stoking fear in the community. She had been rafting at the U.S. National Whitewater Center in Charlotte, which is among a handful of facilities in the country that have man-made rapids coursing through concrete channels. Its CEO, Jeff Wise, pointed out the lower part of the channel in mid-July.

"This is the bottom pond," he says, "where all of the water in our essentially 12 million-gallon system rests while it's ready to be pumped back up into the top pond, where it'll float back down through the channels."

But there was no whitewater between late June and Aug. 10, because CDC tests found the amoeba after the woman died.

Mecklenburg County Health Director Dr. Marcus Plescia encouraged people to keep perspective.

"This organism, Naegleria fowleri, is actually quite a prevalent or commonly occurring organism in open bodies of water," he said. "We find it in lakes. We find it in ponds. It's very common for people to come into contact with, but it's very uncommon for people to develop this kind of infection with it."

It's harmless if swallowed, because stomach acid kills it. But if it's in water forced up the nose, it can cause the brain infection, which is difficult to diagnose and treat.

The Whitewater Center uses city water that it treats with UV radiation, a filtration system and some chlorine. Still, it's a large, open body of water, and exists in a regulatory no-man's land because it's neither swimming pool nor local river or lake.

North Carolina Gov. Pat McCrory said the state should re-examine whether the center should be treated like a swimming pool. But testing for the amoeba is not part of swimming pool regulations, because chlorine used in pools is effective at killing it. And the county and the state don't have the ability to test for it. It's usually up to the CDC.

As part of its lease agreement with the county, the center does weekly tests for common contaminants such as fecal coliform bacteria.

County health leaders point out that people are much more likely to die from drowning or boating accidents in area lakes and rivers than they are from Naegleria fowleri. In fact, there have already been at least eight of those deaths in the greater Charlotte area this summer.

But people just don't get as worked up about those. David Ropeik, a risk management consultant in Concord, Mass., explains why.

"We worry about things not only based on the likelihood of them happening but the nature of the experience itself," Ropeik says. "The odds may be low of brain-eating amoeba eating your brain, but the nature of a brain-eating amoeba eating your brain sounds pretty scary, doesn't it?"

Ropeik is the author of How Risky Is It, Really? He says the media coverage of rare risks is part of the problem.

"Anything that makes a risk feel scarier like, 'This is the zombie amoeba!' is going to subconsciously interest journalists as something that will get people's attention," he says. "Because the viewer, reader, listener is likely to pay attention to a story that could portend their death."

Dr. Jennifer Cope, an infectious disease epidemiologist at the CDC, said 11 out of 11 tests for the amoeba were positive at the rafting center, which does sound alarming. She called that significant but noted this is the first time the CDC has encountered the amoeba in this type of setting.

Whitewater Center CEO Wise says roughly 1.5 million people have rafted there over the past decade, and this is the first health issue it has had tied to what's in the water.

The CDC says there are ways to make the water less conducive to the amoeba's growth, including bulking up the amount of chlorine. The Whitewater Center worked with consultants to figure out a more effective way of doing that, and it reopened this month with a revamped chlorination system. So far, county health leaders say it is working the way it is supposed to.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News.

Copyright 2016 NPR. To see more, visit NPR.
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A New Course At Arkansas Colleges: How To Not Get Pregnant

Fri, 08/26/2016 - 1:34pm
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August 26, 20161:34 PM ET Heard on All Things Considered Arkansas Campaign To Prevent Unplanned Pregnancy YouTube

Orientation at Arkansas Tech University this year included a surprising topic for a Bible Belt state that pushes abstinence-only in high school. Every freshman was shown a newly produced video in which real students talk about the struggle of an unplanned pregnancy, and the challenge of staying in school as a parent.

"I lost a lot of friends," says one young woman in the video who had dreamed of becoming a surgeon. A young man says he "went from not having any responsibility to having a full-time responsibility," while another laments that Friday nights are no longer spent with friends but at home "watching Dora. A lot of Dora."

The message is clear, and it will come up again throughout the year: in a college success course, in group chats in dorms, at a slew of events during Sexual Health Week.

Why in college? Arkansas has the nation's highest rate of teen births, but most of them — here and nationally — are actually to young adults, 18 and 19 years old. Last year, the Arkansas Legislature passed a law directing the state's public colleges and universities to tackle unplanned pregnancy. Schools have each been crafting their own plans for how to do that, and they launched the effort during orientation this month.

After watching the video at one session at Arkansas Tech in Russellville, nearly every student said it hit home.

"I think there was anywhere between five to 10 girls in my grade that got pregnant," says freshman Sydney Blackwell. "I remember in eighth grade there was a girl that never made it to ninth grade because she got pregnant."

Only 4 of 20 students in this group say they had sex ed in high school. Brooklynn Evans says she didn't get much guidance at home, either, not even the basic birds and bees. "My parents were too uncomfortable to talk about it," she says.

Same with Carlos Morales. He thinks it's great that his college is bringing this up, but "it would have been better to have a class earlier, during our middle school."

'The problem in the room that nobody wants to discuss'

Arkansas' law is modeled on one that took effect last school year in Mississippi. Both had bipartisan support and were amazingly uncontroversial.

"It was surprisingly easy; it shocked me," says Rep. Deborah Ferguson, the Democratic co-sponsor of the Arkansas law. Still, she says it would not be politically possible to mandate sex ed in earlier grades. The legislation's Republican co-sponsor believes that's best left to local districts.

But that co-sponsor, Rep. Robin Lundstrum, had an early job in family planning. She says she heard from high school students over and over that they had nowhere to turn for information on how to not get pregnant. "It's the problem in the room that nobody wants to discuss," she says.

At Arkansas Tech, student wellness dean Kristy Davis says it makes sense to target those in college, many of whom are away from home for the first time. She says faculty can help "make sure that they're prepared and they have the information to make good decisions for themselves."

The mandate is so far unfunded. Angela Lasiter, a program specialist with the Arkansas Department of Higher Education, is creating a nonprofit and hopes to attract money to keep the effort going. At community colleges, which usually lack a health center, she's also making sure nearby clinics are stocked with the most effective contraceptives. A substantial share of students at some two-year colleges are already parents, and Lasiter says the state's push can help prevent them from having a second child.

Some universities are even weaving the topic into their curriculum. Lasiter says it's easy to drop into classes like statistics, English, "or, say, Speech 101. 'We would like for you to write a 10-minute speech on how to prevent unplanned pregnancies.' Boom."

Incoming students at Arkansas Tech University in Russellville are now required to attend sessions on preventing pregnancy.

Jennifer Ludden/NPR

The goal, she says, is to get students talking. And if they also talk with their little sisters and brothers, all the better.

There's also a broader benefit for the state, Lasiter says. When young parents drop out of college, or never get there in the first place, it costs Arkansas $129 million a year in "lower income, more people on welfare, a less higher quality of living." That economic hit is compounded because the children of teen mothers are more likely to have an early, unplanned pregnancy themselves.

But is college too late to teach sex ed?

Magical thinking

"They don't know as much as they think they do, and they don't know as much as we wish they did," says Andrea Kane, vice president for policy and strategic partnerships at the National Campaign to Prevent Teen and Unplanned Pregnancy. She says research shows young adults think they know how to not get pregnant, but when pressed for details they're prone to myths and misinformation. For instance, she says, "4 in 10 young adults in this country believe it does not matter if you use birth control or not; when it is your time to get pregnant, you will."

The National Campaign has been pushing for more prevention efforts at the college level, and Kane says other states are showing interest in the new laws in Arkansas and Mississippi. She says even students who had sex education in high school might have forgotten the information, or may find it more relevant now that they're older.

Marie Sandusky has been counseling students at the University of Arkansas at Little Rock since well before the state's law. She directs health services there, and says it's a challenge to help students understand the risk of pregnancy.

"There's this 18- and 19-year-old brain thing that's kind of like magical thinking," she says. "Sort of like, 'It's not going to happen to me.' "

With the new law, the university is being more proactive. This year, incoming freshmen had to complete an online lesson on preventing unplanned pregnancy. In their dorm rooms, they found a postcard with the health services phone number and the tag line, "Plan to postpone parenting."

Marie Sandusky directs student health services at the University of Arkansas at Little Rock. In an orientation session, rag dolls are handed out to symbolize the number of students who will become parents this year if they don't practice safe sex or use birth control.

Jennifer Ludden/NPR

Sandusky also drove home the risk factor at a recent orientation event. In an auditorium of 300 students, 22 of them found a red star under their seat. They received a rag doll on a string that they had to wear around their neck the rest of the evening. "And then we say, 'If you choose to become sexually active, and don't choose to practice safe sex or get on birth control," says Sandusky, "this many people will have a baby by the end of the year.' "

Of course, the hope is that Arkansas' push to prevent unplanned pregnancy will eventually bring down that number.

Copyright 2016 NPR. To see more, visit NPR.
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All U.S. Blood Donations Should Be Screened For Zika, FDA Says

Fri, 08/26/2016 - 11:06am
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August 26, 201611:06 AM ET Heard on All Things Considered

The FDA says that facilities that collect blood donations throughout the United States should be testing donations for Zika within 12 weeks.

Toby Talbot/AP

The Food and Drug Administration is recommending that blood banks screen all blood donations in the U.S. for the Zika virus.

It's a major expansion from a Feb. 16 advisory that limited such screening to areas with active Zika virus transmission.

In a statement released Friday, the FDA says all those areas are currently in compliance with blood screening, but that expanded testing is now needed.

"As new scientific and epidemiological information regarding Zika virus has become available, it's clear that additional precautionary measures are necessary," the FDA's acting chief scientist, Luciana Borio, said in the statement.

The expansion of testing won't happen all at once. The FDA is advising blood establishments in 11 states to begin testing within the next four weeks. Those states include Alabama, Arizona, California, Georgia, Hawaii, Louisiana, Mississippi, New Mexico, New York, South Carolina and Texas.

These states are in proximity to areas where Zika is actively spreading via mosquitoes or where there are a significant number of cases related to other exposures, including sexual transmission.

Within 12 weeks, blood facilities in all states should be testing donations for Zika, the FDA says.

Currently, Zika is being spread by mosquitoes in South Florida, Puerto Rico and the U.S. Virgin Islands, as well as most countries in the Caribbean and Central and South America. There are a total of 2,517 cases of Zika in the U.S. states and D.C., according to the Centers for Disease Control and Prevention, with 9,011 more in U.S. territories.

Most of the cases within the U.S. are related to travel abroad or sexual transmission. The cases in Puerto Rico and the U.S. Virgin Islands are a mix of travel-related cases and locally acquired infections via mosquitoes or sex.

In issuing the new recommendations, the agency noted that 4 out of 5 people infected with Zika virus never develop symptoms. Thus, questions that blood banks routinely ask about the risks of disease might not catch people who have been exposed and who have been infected with the Zika virus.

Zika virus infection during pregnancy has caused serious birth defects in a few cases in the U.S. and hundreds of cases in Central and South America where infants have been born with microcephaly, a condition where the brain and skull are malformed.

There have been no cases of Zika related to blood transfusions in the U.S., according to the Centers for Disease Control and Prevention.

"There is still much uncertainty regarding the nature and extent of Zika virus transmission," says Peter Marks, director of the FDA's Center for Biologics Evaluation and Research. "At this time, the recommendation for testing the entire blood supply will help ensure that safe blood is available for all individuals who might need transfusion."

In a news conference Friday, Marks said that there had been one case in Florida where a unit of donated blood was tested and taken out of the blood supply. Other units where Zika is suspected are currently under investigation, he said.

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Planned Parenthood Joins Campaign To Rid Miami Neighborhoods Of Zika

Fri, 08/26/2016 - 4:45am
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August 26, 20164:45 AM ET Heard on Morning Edition

Lenroy Watt (left) and Blair Brown, both Planned Parenthood canvassers, share information about mosquito control, family planning and the risks of Zika in their informal neighborhood meetings.

Greg Allen/NPR

In Little Haiti, Liberty City, and a number of other neighborhoods in Miami, canvassers are now walking door to door to spread the word about the risks of Zika, one household at a time — hoping to reach 25, 000 people the next six weeks. In some neighborhoods, these workers aren't sponsored by federal or state health agencies, but by Planned Parenthood.

Lillian Tamayo, the CEO of Planned Parenthood of South, East and North Florida, told NPR that Miami-Dade County has the state's largest population of people without health coverage, which leaves these residents particularly vulnerable to Zika. "More than one-third of Florida does not have an OB-GYN," she said. "It also is among the worst states in the country for women's health and women's well-being. And it has staggering infection rates for sexually transmitted diseases. And now we have Zika."

Jean Baptiste is one of the Miami residents Tamayo is eager to reach. Baptiste lives in an apartment above a convenience store in the neighborhood of Little Haiti with her father and several other people. When one of Planned Parenthood's canvassers, Lenroy Watt, showed up at her door recently, Baptiste told him she hadn't heard anything about Zika.

"You're not aware of it?" Watt asked Baptiste, a bit surprised. "All right, not a problem," he continued. "So it's a good thing we're here today then, to make you aware."

Watt talked to Baptiste about the virus and the illness, and left information in Creole, including phone numbers for mosquito control, and for the county's health offices where free Zika tests are available for pregnant women.

In the weeks since local Zika transmission was confirmed in the nearby neighborhood of Wynwood, the mosquito control agency has conducted intensive spraying there. Health workers have also gone door-to-door in Wynwood, testing residents for the virus. But in Little Haiti, just blocks away, people have received very little information about Zika, resident Harry Noel told NPR.

"Nobody ever show up to educate the neighborhood, those people, how to get rid of mosquitoes, what to do," he said. "Nobody! It's for the first time I've seen somebody coming and ... address that problem."

Family planning is a key part of the Planned Parenthood message. The organization is also distributing Zika prevention kits, including condoms and mosquito repellent, to pregnant women at its health centers.

Dr.Christopher Estes, the group's chief medical officer, said Planned Parenthood decided it could best augment the state and federal response by doing outreach in areas where government health workers haven't been active — neighborhoods surrounding the zones of local Zika transmission.

"This is a natural extension of the work we do with reproductive health care and sexually-transmitted infections," Estes said. "It just made sense. And this is a time of a public health crisis. When you have something like this going on, it's, 'All hands on deck.' "

Lenroy Watt talks with residents of Miami's Little Haiti about Zika, leaving brochures in Creole about how to prevent the illness, as well as phone numbers for local mosquito control agencies and the county health department.

Courtesy of Planned Parenthood

Although Planned Parenthood is working to coordinate with the state, relations are still strained. In recent years, the group's dealings with Florida officials, including Gov. Rick Scott, have been contentious. A federal judge recently struck down a Florida law signed by Scott that would have cut a half million dollars annually for preventive health care from Planned Parenthood. The family planning group is also one of many healthcare providers that have been critical of Florida's governor for blocking an Obamacare-authorized expansion of Medicaid in the state.

State officials declined comment to NPR on the Planned Parenthood canvassing operation. The effort to cut federal funding for the organization has also gotten tied up in Washington with the fight against Zika. Congress became deadlocked over a White House request for $1.9 billion in emergency Zika funding after House Republicans added several riders to the bill — including provisions to defund Planned Parenthood.

At a news conference this week in Miami, Democratic Congresswoman Frederica Wilson called on congressional leaders to stop targeting Planned Parenthood and to get serious about Zika.

"Call us back to Washington, D.C.," she said. "The House and Senate should reconvene and pass a clean bill to fight Zika."

In South Florida, Planned Parenthood expects to knock on some 25-thousand doors in medically underserved areas through September. That's the most recent estimate of when Zika cases are likely to peak in Florida.

Copyright 2016 NPR. To see more, visit NPR.
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Teaching Medical Teamwork Right From The Start

Fri, 08/26/2016 - 4:42am
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August 26, 20164:42 AM ET Heard on Morning Edition

From

A project now under construction in Cleveland will eventually house the Case Western Reserve University's medical, dental and nursing schools, as well as the Cleveland Clinic's in-house medical school.

Courtesy of Cleveland Clinic

There's a new building going up on the campus of the Cleveland Clinic. A very big building.

"The skylight that we're standing under will eventually cover the area of an entire football field," says Russ Saghy, who oversees construction projects for the Cleveland Clinic.

The skylight is part of the new Case Western Reserve University Heath Education campus. The joint project with the Cleveland Clinic will eventually house the Case Western Reserve University's medical, dental and nursing schools, as well as the Cleveland Clinic's in-house medical school.

When it opens to the first classes of students in 2019 it will provide an estimated 8.5 football fields worth of space and enough concrete to build a sidewalk that's 75 miles long. The cost: almost $500 million.

"The idea is to create a 'mini campus' that gives each school its own identity, but fosters collaboration," says Chris Connell, one of the architects, who is with Foster & Partners.

Collaboration is the ultimate goal, those involved in the project say. Health care in the 21st century is increasingly being provided by teams, yet most health care professionals don't encounter their "teammates" until they are well along in their training.

"Health care is no longer a gladiatorial sport, where you had the one health care provider — you know, mano a mano, one on one — battling a disease," says Dr. James Young, a cardiologist who heads the Cleveland Clinic Lerner College of Medicine.

"I'm involved with heart transplantation and mechanical devices for the heart," he says. "Boy, you can't do it by yourself!"

The new building, however, is less the beginning and more the culmination of a long-running effort at Case to train different types of health professionals together.

As construction workers pour concrete and erected scaffolding, about a mile down the road at the Case main campus, a small group of students from the schools of medicine, dentistry, nursing and social work gather around a table in a conference room.

Their mission: to figure out how to best treat their pretend patient — a 35 year-old woman with hypertension, obesity, and diabetes. In the hypothetical scenario the students have been asked to work through in this training exercise, the patient has come to their clinic with a series of injuries she says she got falling down a flight of stairs. Meanwhile, according to the scenario, her boyfriend is in the lobby acting disruptively.

The students discuss and argue about which of the patient's problems to address first, and what to do about the boyfriend.

They don't end up reaching much of a consensus, but faculty members overseeing the group say that's OK.

"I think that's fabulous," says Kristin Victoroff, an associate dean at the dental school. "It is actually an indicator of a functioning group, where's there enough trust in the group where you can say what you really are thinking."

The twice-a-year seminars aren't the only collaborations that bring students from different health professions together. At a free oral health clinic in Cleveland, for example, nurses and dental students work together to treat real patients. Other activities bring students together to discuss interdisciplinary problems — like obesity or pain.

"We all have to deal with pain whether [we're] dentists or social workers or nurses," says Carol Savrin, a nurse practitioner and senior administrator at the Case nursing school. "So they're taking a common thread and coming at it from a variety of different angles."

This approach isn't new. Efforts to train doctors, nurses, and other health professionals together have been tried for years. And they haven't always been successful.

"I think they come in with some preconceived or stereotyped notions of what a doctor [or] a social worker is," says Scott Wilkes, an assistant dean at Case Western's school of social work. Breaking down those stereotypes by giving students from various disciplines a place to hear other perspectives and different types of knowledge, in their earliest training days, could make a difference, proponents of the new joint-campus say.

Getting everyone on the same page when that happens is critical to preventing medical mistakes, says Dr. Patricia Thomas, an internist and vice dean overseeing medical education at the Case Western Reserve medical school.

In studying the problem, she says, "the root of many of our errors had to do with the fact that our professions were not working effectively together for patient care.

Update at noon ET: This post should have noted that the Cleveland Clinic is among NPR's financial supporters. Kaiser Health News was not aware of that.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Discounts Aren't Enough to Halt Outrage At High EpiPen Prices

Thu, 08/25/2016 - 2:41pm
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August 25, 20162:41 PM ET Heard on All Things Considered

The cost of an EpiPen two-pack has risen more than 400 percent in recent years. The drug is used to halt severe allergic reactions.

Joe Raedle/Getty Images

The EpiPen, an injectable drug that reverses severe allergic reactions, just got a little cheaper for some consumers.

The device's manufacturer, Mylan NV, announced Thursday that it will offer coupons worth as much as $300 off a two-pack.

The move is a reaction to harsh criticism from consumers and several lawmakers over repeated price increases that have boosted the cost of the medication to more than $600 from less than $100 just a few years ago.

The company says it will offer the discounts to patients whose insurance doesn't cover the costs because of high deductibles or limited pharmacy benefits.

But coupons may not be enough to tamp down anger over the price hikes.

"This step is much more a PR fix more than a real remedy," Sen. Richard Blumenthal, D-Conn., said in an interview Thursday. "What's needed is robust, real action to lower the price for everyone, not just a select few."

He says the EpiPen has such enormous market share that the company may be violating antitrust laws by exploiting that. A report by the health care website Stat says some of Mylan's contracts to give schools free or discounted EpiPens may have done just that, because they bar the schools from buying competitors' products.

Mylan told Stat that the provision restricting school purchasing has since been discontinued, but did not say when it was halted.

Blumenthal is just one of several lawmakers who have called for investigations into Mylan's business practices and have asked for justifications of its price increases in recent days. He and a few others say the discounts aren't enough.

Blumenthal sent a letter to the company earlier this week demanding that it lower the price.

Sen. Charles Grassley, R-Iowa, sent a letter to Mylan demanding an explanation for the increase. And Sen. Amy Klobuchar, D-Minn., has asked the Federal Trade Commission to investigate whether Mylan has violated antitrust laws in its marketing of the EpiPen.

Rep. Elijah Cummings, D-Md., says his Oversight and Government Reform Committee would hold hearings. "Offering a meager discount only after widespread bipartisan criticism is exactly the same tactic used by drug companies across the industry to distract from their exorbitant price increases," Cummings said in a statement.

And Democratic presidential hopeful Hillary Clinton weighed in on her Facebook page. "It's wrong when drug companies put profits ahead of patients, raising prices without justifying the value behind them," she wrote.

The wholesale price of a single pen was about $47 in 2007. It rose to $284 this summer, according to Richard Evans, a health care analyst at SSR. But consumers can no longer buy a single pen, so the retail price to fill a prescription today at Walgreens is about $633, according to GoodRX.

Blumenthal says a solution could require new laws.

"At the end of the day there may need to be stronger legal protections against these types of price gouging and profiteering at the expense of people who need a lifesaving drug where the company has a stranglehold on the market," he says.

Copyright 2016 NPR. To see more, visit NPR.
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Illegally Made Fentanyl Seems To Be Fueling A Spike In Overdoses

Thu, 08/25/2016 - 1:02pm

These pills were made to look like Oxycodone, but they're actually an illicit form of the potent painkiller fentanyl. A surge in police seizures of illicit fentanyl parallels a rise in overdose deaths.

Tommy Farmer/Tennessee Bureau of Investigation/AP

Federal data suggest illegally manufactured fentanyl, a drug that is 50 to 100 times stronger than morphine, is behind an increase in synthetic opioid deaths.

A report from the Centers for Disease Control and Prevention says that there was a 426 percent increase in seized drug products that tested positive for fentanyl from 2013 to 2014. And separate data show the number of deaths involving synthetic opioids, a class that includes fentanyl and tramadol but not hydrocodone, rose 79 percent during that same period.

Shots - Health News Illicit Version Of Painkiller Fentanyl Makes Heroin Deadlier

Among 27 U.S. states analyzed, there was a strong correlation between increases in synthetic opioid deaths and in seized fentanyl products, but not with changes in fentanyl prescribing, according to data published Thursday in the Morbidity and Mortality Weekly Report.

That suggests, the authors say, that illegally manufactured fentanyl is driving the spike in overdoses. (Deaths attributed specifically to fentanyl aren't reported in national data.)

"What concerns us here is the rapid increase, especially in a small number of states," says Matthew Gladden, an author of the report and a researcher at the CDC. In eight "high-burden" states, the death rate from synthetic opioids rose 174 percent, to 3.6 per 100,000, from 2013-14.

Shots - Health News In Prince's Age Group, Risk Of Opioid Overdose Climbs

Fentanyl is available by prescription to treat severe pain. But the fentanyl that's currently on the streets — usually mixed into heroin and often without the user's knowledge — isn't from diverted pharmaceutical products. Instead it's being illicitly manufactured, according to the government.

"Starting in 2013, the production of illegally manufactured fentanyl increased to unprecedented levels, fueled by increases in the global supply, processing and distribution of fentanyl and fentanyl-precursor chemicals by criminal organizations," the report says. Between 2014 and 2015 alone, the number of seized fentanyl products rose from 5,343 to 13,882.

Fentanyl is cheaper to make than heroin and very potent, which means manufacturers can wring out more doses per batch. "There's a huge profit margin," says Gladden.

More recently, the U.S. Drug Enforcement Administration said in July that fentanyl was also showing up in counterfeit pain pills. Prince died of a self-administered dose of fentanyl, and the Minneapolis Star Tribune recently reported that pills identified as hydrocodone found at the musician's Paisley Park studio actually contained fentanyl.

"It's quite a game-changer," says Carol Falkowski, CEO of Drug Abuse Dialogues, an education and training organization. "It's imperative that the word gets out that prescription pills purchased on the black market can be deadly. It's an extreme case of buyer beware."

The report says an "urgent" response from law enforcement and public health is necessary to tackle the problem, including more testing for fentanyl in areas where it's a big problem. The government has advocated the expanded use of naloxone, an antidote to opioid drugs, as well as expanding the use of addiction treatment that includes medications.

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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Gas Relief Drops May Raise Risk Of Contaminated Medical Scopes

Thu, 08/25/2016 - 5:00am

Scopes used to diagnose gastrointestinal problems are typically cleaned and reused.

Dave King/Dorling Kindersley/Science Museum, London/Science Source

A surprising ingredient — gas relief drops designed for infants — may be contributing to the contamination of medical scopes and putting more patients at risk of infection, according to a small but provocative study.

Researchers in Minnesota unexpectedly found cloudy white fluid inside several colonoscopes and gastroscopes after they had been disinfected and deemed ready for use on the next patient.

Further analysis revealed that the fluid contained simethicone, the main ingredient in over-the-counter anti-gas medications available at grocery stores and pharmacies. Doctors regularly inject the liquid drops into gastrointestinal scopes during colonoscopies and other procedures to reduce bubbles inside the body that can impede visibility.

However, that routine practice may be helping bacteria grow inside a wide variety of scopes and making the bacteria harder to remove. The authors of the study, published in August in the American Journal of Infection Control, recommend that hospitals and doctors minimize the use of these products pending further research into their effect on patient safety.

No infections have been linked to the drops. The study only suggests that they could heighten the risk of contamination. "Finding residual fluid in scopes that should be dry would be troubling alone," says Cori Ofstead, the study's lead author. "The finding of fluid containing simethicone suggests we have more serious problems. It could explain why we are having more trouble getting these scopes clean."

Infant gas relief drops, which are available over the counter, contain sugars and thickeners to make the liquid solutions more palatable for babies, the researchers say. Ofstead said those ingredients "could provide the perfect habitat for the growth of bacteria" inside scopes.

The liquid drops contain silicone, which doesn't dissolve in water and can't be removed using detergents or disinfectants. The researchers said that silicone could add an impenetrable coating to blood, tissue and other organic material trapped inside scopes. It can also foster the growth of biofilm, a slimy material that protects bacteria and other microbes from being removed during cleaning.

Ofstead, an epidemiologist and chief executive of the medical research firm Ofstead & Associates in St. Paul, Minn., said these findings were "absolutely surprising" and that her research team stumbled upon them during a broader look at scope cleaning techniques.

The seven-month study was conducted with physicians and a surgery center affiliated with the University of Minnesota Health system. There was also funding for the study from 3M Co.; Medivators Inc., which sells scope cleaning equipment; Healthmark Industries, which provides cleaning products and accessories; and Ofstead & Associates.

Dr. Michael Shaw, a gastroenterologist and a co-author of the study, says halting the use of simethicone products would hinder doctors' ability to accurately treat patients with endoscopy. He's pursuing funding for larger studies at other endoscopy centers to determine the extent of the problem and possible alternatives.

"I don't want to see the public alarmed, but this study did raise a huge number of questions," says Shaw, an associate professor at the University of Minnesota Medical School.

Federal prosecutors, lawmakers and government regulators have been investigating a series of outbreaks of antibiotic-resistant "superbugs" across the country tied to a device known as a duodenoscope, which is used in about 700,000 procedures annually. As many as 350 patients at 41 medical centers worldwide were infected by or exposed to contaminated duodenoscopes from 2010 to 2015, according to the Food and Drug Administration.

Regulators and medical experts have said the complex design of the tip of the duodenoscope can make it difficult to clean even when following the manufacturer's instructions. The infant gas relief drops are used occasionally with duodenoscopes, doctors say, and it's unclear what role, if any, those products might have had on patient infections.

This study focused on more widely used colonoscopes and gastroscopes, which have simpler designs and tend to be easier to disinfect. The researchers found bacteria in some of the scopes that were analyzed, but the bacteria weren't the drug-resistant superbugs that can be deadly for patients.

At the Minnesota surgery center, researchers examined colonoscopes and gastroscopes three different times during the seven-month period. They confirmed that technicians were following the manufacturer's cleaning instructions during nine unannounced audits.

In the final examinations, researchers observed multiple fluid droplets inside 19 of the 20 endoscopes that were cleaned and disinfected. In eight of those 19 scopes, the fluid appeared cloudy, white, opaque, shimmery or viscous.

The discovery was unexpected and puzzling, the researchers say, so they contacted other experts who suggested it might be simethicone. The study's authors then examined the infant gas relief drops the surgery center was using and noted similarities to what they saw inside the scopes.

The researchers were able to obtain samples from just three of the scopes because the fluid was in narrow channels or other hard-to-reach areas. Simethicone was found in two of the three samples.

The findings raise questions for the three largest manufacturers of gastrointestinal endoscopes and the doctors who use the devices to treat millions of patients annually.

Scope manufacturers are well aware that anti-gas products are used to reduce bubbles during procedures. Two companies — Pentax Medical and Fujifilm — have told health care providers that injecting these drops into endoscopes is not recommended because residue can build up and impede cleaning.

"Due to their nature, these silicone-based agents cling tenaciously to surfaces," Pentax wrote in its scope cleaning instructions in 2014. "Unless they are rinsed very thoroughly, a barrier which could reduce the effectiveness of the disinfection/sterilization process could be created."

The leading manufacturer of gastrointestinal scopes, Olympus Corp., told customers in a 2009 letter that because simethicone may be difficult to remove from endoscopy equipment, health care providers should use the "lowest concentration possible to achieve the desired effect."

Representatives of Olympus and Fujifilm didn't respond to requests for comment. Pentax Medical said in a statement via email that "maintaining patient safety and quality is our utmost priority."

The American Society for Gastrointestinal Endoscopy, which represents physicians using these instruments, has acknowledged that anti-gas drops are not FDA approved for this use, but doctors are free to use medications and devices in off-label ways not specifically approved by the FDA.

Shaw, the gastroenterologist involved in the study, said the amount of liquid drops used by doctors to prevent bubbles varies widely. For now, he recommends the lowest concentration necessary. "There is really no guidance for physicians," he says.

The Minnesota study also noted that some liquid simethicone products have been recalled in recent years due to contamination with molds, yeasts and bacteria, posing another potential threat to patients undergoing endoscopy.

These drops aren't sterile, yet doctors conducting the procedures often mix them with sterile water that's used for irrigation and other purposes. In other instances, doctors inject the drops directly into the scope.

Wava Truscott, a microbiologist and infection prevention consultant in Atlanta, said the study's findings "definitely raise a yellow flag."

Truscott says more studies are needed, but in the meantime scope manufacturers should issue stronger warnings to hospitals and doctors to limit the use of anti-gas drops.

"That would be the fastest way to decrease it, and it would have the most weight right now," Truscott says.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Here's Looking Achoo! Debunking The Sneeze

Wed, 08/24/2016 - 5:44pm

For such a commonplace bodily function, the sneeze has messed with our minds (and noses) for centuries. It will kill us, it won't kill us. We'll have bad luck, we'll have good luck. Watch out for Satan, he's wily and knows how to get into your nasal membranes. Did you have too much to eat? Are you sad? Do you have a weak heart?

Technically, sneezing is a reflex to the usual irritants such as germs, dust or pollen. But it turns out your nose can get ruffled by some of the strangest things. One false move may trigger an epic sneezing fit, and the 1969 978-day record is ripe for the taking.

Let's look deeper into your nose and all of its mysteries, shall we?

Sneezing is bad for the soul.

In 1515, Leonardo da Vinci dissected a human brain in an effort to find the soul. Though his soulsearching came up empty, this did not stop people from believing that the soul lives inside the head – a concept widely held during that time. When someone sneezed, the soul was believed to have been thrown from the body, thereby leaving it open for invasion by evil spirits.

Sneezing is good for the soul.

The good news is that once invaded, the body would try to quickly force the spirit out; this is best accomplished, of course, by sneezing. No matter which way the spirits are moving, however, sneezes were thought to be a gateway to the supernatural.

If you say "God Bless You," God might spare you. Or not.

Shots - Health News Itchy Eyes? Sneezing? Maybe Blame That Allergy On Neanderthals

The origin of this custom is varied, but one of the more prevalent theories is that during the 6th-century plague, which originated via disease-carrying mice in Egypt, Pope Gregory I urged divine intercession to help ward off illness. Because sneezing was one of the first signs of the deadly plague, he commanded people to say "God Bless You" after a sneeze. Even so, by the time the plague had run its course, it had killed half the population of Europe. Pope Gregory may have benefited from a backup plan.

Your heart stops or skips a beat when you sneeze.

It doesn't. However, the increase in pressure in the chest during the sneeze reduces blood flow into the heart from the veins, says Dr. Nancy Sweitzer, chief of cardiology at the University of Arizona's Sarver Heart Center. That leads to a weaker, less forceful beat, which can cause the sensation of a skipped beat.

"The heartbeat is determined by the electrical system of the heart, which is typically on autopilot and just keeps going," Sweitzer says. "The electrical activity of the heart is constant through a sneeze, but the mechanical 'pumping' may be reduced in force, particularly during a forceful sneeze."

The sneeze: once again proving that feelings are not facts.

Tweezing your eyebrows can make you sneeze.

Weird, but true. Those darn nasal nerves are so capricious. Even something as simple as plucking your eyebrows can irritate the nerve endings in your face, which in turn makes them fire a signal to hassle the nasal nerve. And when you irritate your nasal nerve, it irritates you right back – by making you sneeze.

"The eyebrows and the nose are both innervated by the same branch of the trigeminal nerve, which can be stimulated by tweezing the eyebrows," says Dr. Apple Bodemer, an assistant professor of dermatology at the University of Wisconsin. "The neuronal excitation from plucking can travel to the nose — resulting in a sneeze."

But take heart! You can enlist your eyebrows to fight back. "Putting pressure on the eyebrow while plucking can short circuit the response and block the sneeze," says Bodemer.

Sneezing always comes in threes.

First of all, if you sneeze three times it does not mean that someone is gossiping about you or that you're going to win the lottery. Save that stuff for the playground. Most people sneeze more than once because their first sneeze just didn't pack the punch needed to rid their nasal passages of all irritants. Whether that's three times or 10 times all depends on the power of your nose. The person in the next cubicle who sneezes 15 times in a row has truly wimpy sneezes. Sneezing once is something to brag about, maybe even put on your resume.

Health What 'Ah-Choo!' Can Do For You

Bright light can make you sneeze.

This true phenomenon is called the photic sneeze reflex, and it affects up to 35 percent of the population. This sneeze tends to happen when suddenly moving from dim light to bright light, such as emerging from a movie theater or driving out of a tunnel. The photic sneeze reflex is thought to be genetic, but scientists are still puzzling over this one.

Satiation Brings On Snatiation (What?)

If you were born into a line of snatiators, then your genetically cursed family will have trouble talking over a big meal. That's because they'll be too busy sneezing as a result of their full stomachs. Scientists still don't fully understand the connection, but the neurons activated during digestion are perilously close to the sneezing neurons, and, well, you can glitch. Depending on who comes to Thanksgiving dinner, this can be a good or bad thing.

A study on snatiation found that the sneezing has no relation to what you're eating, and it occurs only when you are so full you can't possibly take another bite. Use this knowledge wisely.

Sneezing is "catching," like a yawn.

It is true that emotions can affect your nasal membranes. Fear makes them shrink (which can make you sneeze), and sadness makes them swell (which can also make you sneeze.) Though there is conflicting evidence, yawning has been linked to empathy, and one study showed that psychopaths — people who lack empathy — may even be immune to contagious yawning.

If sneezing fits are like yawning fits, does that mean that if we are tuned into others' emotions, we might sneeze out of sympathy? Though hard evidence is murky, there is some reason to believe that both yawning and sneezing fits may be powered by the mind, and some sneezing fits have been successfully treated through psychotherapy.

The definitive answer is "maybe."

Did you sneeze while reading this article? Copyright 2016 NPR. To see more, visit NPR.
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Watch: A Slow-Motion Sneeze Looks A Lot Like Breathing Fire

Wed, 08/24/2016 - 5:43pm

Source: New England Journal of Medicine, 2016

Credit: Lydia Bourouiba

To a mathematician, it's a violent explosion that shoots out missiles of hot, wet air, slamming a turbulent cloud of moisture into anybody or anything that crosses its path.

To the rest of us, it's a sneeze.

And Lydia Bourouiba has made a career out of studying it. Bourouiba, a mathematical physicist, leads a research group at the Massachusetts Institute of Technology that studies fluid dynamics. On Wednesday, her team published a slow-motion video of a sneeze in the New England Journal of Medicine.

It's mesmerizing. It's also important.

"Respiratory infectious diseases still remain the leading infectious diseases in the world," Bourouiba explains. Many of them hop from person to person in coughs and sneezes, or "violent emissions," as she calls them. If she can understand how a sneeze moves, she says, she can better understand how to prevent microbes from moving from a sick person or contaminated surface to somebody else.

Additional Information: Debunking Sneeze Myths

Did you know that sneezing itself can be contagious? And why do people say "God bless you" after somebody spews infectious particles? Shots investigates some of the myths and truths behind this commonplace bodily function in a special bonus story here.

But as the researchers watched videos of these mini-explosions, they quickly realized that a sneeze involves complicated physics.

"There's a whole range of droplet sizes in this cloud, and the cloud is made of hot and moist air," says Bourouiba. "And it's turbulent, so that means that it has swirls and eddies, and it's moving very fast." The conditions in the surrounding room — like airflow, moisture and temperature — can change how all those swirls and zigzags move, she says.

A lot of the sanitation measures we're all told to take to stay out of the way of someone else's sneeze are educated guesses at best, says Bourouiba. For example, people have assumed that standing a few feet away from a sick person would be enough to stay out of firing range. But Bourouiba and her colleagues found that the tiny droplets in a sneeze can, under certain conditions, travel across a room in just a few seconds. They can also hover in the air for many minutes.

"It's actually quite amazing that we can produce such a high-speed flow that contains all these ranges of sizes of droplets," Bourouiba says.

A sneeze is "quite a fantastic tool for clearance," she adds, "but also a fantastic tool to sustain the overall colonization of other bodies and other people with viruses and pathogens."

To map the path of a sneeze — and of any infectious particles it might contain — Bourouiba had to become an expert in high-speed photography. So far, her subjects have been healthy sneezers. But now, Bourouiba and her colleagues have started enlisting the help of volunteers who have symptoms of a cold or flu, inviting these sick folks to sneeze in a special room that has controlled moisture, airflow and temperature, as well as camera equipment.

The ultimate goal of this study, she says, is to understand in detail how sneezes travel in different conditions.

"So, for example, in a typical hospital room, with a given ambient temperature and moisture and a given airflow, what is the ultimate distribution of the position of these droplets and the pathogens they contain?" says Bourouiba. "And if we change the room and ventilation and different environmental conditions, how does that change?"

Armed with that information, the researchers hope to make risk maps for which parts of a room are likely to get contaminated by a sick person, or figure out how far away a visitor needs to stand from a patient to stay out of the line of fire. The information might also improve the design of ventilation systems to help prevent infected droplets from dispersing through a building.

As for Bourouiba's own technique for squelching the spread of a cold, she recommends sneezing into your elbow. What's the physics there? The elbow reduces the cloud's momentum, she says, limiting how far those virus-filled droplets will travel.

Copyright 2016 NPR. To see more, visit NPR.
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Study Of Breast Cancer Treatment Reveals Paradox Of Precision Medicine

Wed, 08/24/2016 - 5:01pm
Study Of Breast Cancer Treatment Reveals Paradox Of Precision Medicine Listen · 3:58 3:58 Toggle more options
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August 24, 20165:01 PM ET Heard on All Things Considered

By testing tumors, researchers hoped to identify women who could avoid chemotherapy without increasing their risk of a cancer recurrence.

Voisin/Phanie/Science Source

A major study about the best way to treat early-stage breast cancer reveals that "precision medicine" doesn't provide unambiguous answers about how to choose the best therapy.

"Precision doesn't mean certainty," says David Hunter, a professor of cancer prevention at Harvard's T.H. Chan School of Public Health.

That point is illustrated in a large study published Wednesday in the New England Journal of Medicine, involving decisions about chemotherapy.

As is true for many cancers, breast cancer responds best to treatment when it is caught early, before it has spread throughout the body. Dr. Fatima Cardoso, the study's lead author and a breast cancer specialist at the Champalimaud Clinical Center in Lisbon, Portugal, says that creates a conundrum for doctors and patients alike.

Because it's the only opportunity to cure the cancer, "when in doubt we tend to treat" women with early-stage breast cancer, she told Shots. "So we know that we overtreat the patients with early breast cancer."

That means that women could end up undergoing chemotherapy even if it wouldn't really improve their survival odds.

Hoping to refine those treatment decisions, Cardoso helped organize a huge study throughout Europe to see whether a commercially available genetic test called MammaPrint could help reduce that overtreatment. More than 6,600 women participated at 112 institutions in nine nations.

Scientists identified women with breast cancer whose physical exams suggested they were at relatively high risk for having the cancer return eventually after surgery, but who seemed to be at low risk of recurrence based on the genetic test results.

They were invited to participate in the study, which would randomly assign them to have chemotherapy or not. "You know that chemotherapy is a treatment that scares people, so overall and for the majority of patients, it was not difficult to convince them," Cardoso says.

The genomic test, which studies 70 distinct features of a tumor, did a pretty good job of predicting who was at low risk for recurrence of breast cancer and could therefore avoid the pain, discomfort and risks of chemotherapy. (The test, priced at $4,200, is covered by some insurance in the United States.)

The scientists found that 46 percent of women who were deemed to be at high risk of recurrence based on physical symptoms could actually skip chemotherapy with little consequence to their long-term survival.

But the test results weren't always definitive. About 95 percent of women who skipped chemotherapy as a result of the genetic test results were free of metastasis five years later, but those who had the additional treatment did about 1.5 percentage points better, give or take.

"It's possible that the benefit is zero, and it's possible that's 2 percent or maybe even a little more, you can't be sure," says Dr. Clifford Hudis, chief executive officer of the American Society of Clinical Oncology. He was not involved in the European study but co-wrote an editorial accompanying it. It would take another huge clinical trial to figure out whether chemotherapy does in fact add a small survival advantage.

But the study raises a bigger point here: The genomic test, as precise as it is, offers only probabilities, not absolute guidance. And that's a lesson that applies to the whole new realm of precision medicine, which is billed as potentially transformative for medical care.

"The new tools will definitely be helpful, but they often will pose challenges about what the right decision is," says Hunter, who wrote a perspective piece noting that people will need to develop a tolerance for uncertainty when using precision medicine tests.

Is it worth all the trouble of chemotherapy for women who are found to be at low risk for recurrence in this genomic test? That's a tough call, because it requires grasping the rather abstract idea of improving survival odds by maybe just 1 percentage point.

"As humans, we're notoriously poor at assessing risk and making those calculations," Hunter says.

He says doctors and patients need better tools to understand and communicate the subtleties that are inherent in precision medicine.

Cardoso is already seeing this play out in her clinic. Women shown to be at low genetic risk on the MammaPrint test are usually opting not to have chemotherapy after their surgery. "But there always [are] some patients for whom 1 percent benefit is enough — and you need to respect the wishes of each individual patient."

She says the women clearly benefit from the new information, even though it doesn't provide an absolute answer.

Copyright 2016 NPR. To see more, visit NPR.
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EpiPen Manufacturer Says It Will Help With Out-Of-Pocket Costs

Wed, 08/24/2016 - 4:51pm
EpiPen Manufacturer Says It Will Help With Out-Of-Pocket Costs Listen · 3:52 3:52 Toggle more options
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August 24, 20164:51 PM ET Heard on Morning Edition

An aggressive marketing campaign has made the EpiPen the go-to drug for treating anaphylaxis.

Mark Zaleski/AP

Editor's note: Updated at 9:20 am ET to include Mylan's announcement that it will reimburse consumers for some of their out-of-pocket costs.

EpiPens are in your friend's purse and your kid's backpack. The school nurse has a few, as does Grandma.

The medicine inside — epinephrine — has been around forever, and the handy gadget that injects it into your leg is not particularly new either.

Shots - Health News Physician Group Calls On Government To Rein In Drug Prices

So members of Congress, responding to their angry constituents, want to know why the price of the EpiPen, which can reverse a life-threatening allergic reaction, has risen about fivefold in the past decade.

The wholesale price of a single pen was about $47 in 2007, and it rose to $284 this summer, according to Richard Evans, a health care analyst at SSR. But consumers can no longer buy a single pen, so the retail price to fill a prescription today at Walgreens is about $633, according to GoodRX.

It's the latest in a string of controversies over rising drug prices that have caught the attention of lawmakers on Capitol Hill.

The drug's manufacturer, Mylan NV, responded to the criticism Thursday, announcing it will offer customers whose insurance doesn't pay the full cost coupons for up to $300 off the injectors. But it's unclear if that will be enough to tamp down the anger.

At least three senators have called for investigations into the price of the EpiPen, and Sens. Charles Grassley, R-Iowa, and Richard Blumenthal, D-Conn., have sent letters to Mylan demanding an explanation for the increase.

Blumenthal went a step further. "I demand that Mylan take immediate action to lower the price of EpiPens for all Americans that rely on this product for their health and safety," he wrote in a letter to the company.

Sen. Amy Klobuchar, D-Minn., has asked the Federal Trade Commission to investigate whether Mylan has violated antitrust laws in its marketing of the EpiPen.

And Hillary Clinton weighed in, calling the price increases "outrageous."

"It's wrong when drug companies put profits ahead of patients, raising prices without justifying the value behind them," the Democratic presidential nominee said in a statement on her Facebook page.

Mylan spokeswoman Nina Devlin said in an email, "We have reached out to every member of Congress who has sent us a letter, and we look forward to meeting with them and responding to their questions as soon as possible."

Shots - Health News Tighter Patent Rules Could Help Lower Drug Prices, Study Shows

She did not immediately comment on Clinton's statement.

The EpiPen is a long, plastic tube that automatically injects a dose of epinephrine — or adrenaline — into a person's thigh to stop an allergic reaction. It's easy to use and portable.

Mylan bought rights to the EpiPen in 2008 and launched an aggressive marketing and awareness campaign. That effort has made the so-called auto-injector a must-have for anyone with an allergy — perhaps to bee stings or tree nuts — that may trigger anaphylaxis, a life-threatening reaction in which the airways swell and close.

According to an account by Bloomberg Businessweek, the company considered selling off rights to the drug, which is an old product, but instead launched a campaign to boost sales. Revenue rose from $200 million to more than $1 billion a year.

The company itself touts its campaign "for increased anaphylaxis awareness" as what has helped drive prescriptions and sales of the device.

"Ensuring access to epinephrine — the only first-line treatment for anaphylaxis — is a core part of our mission," Mylan said in a press release this week.

And certainly people with life-threatening allergies are better off with easy access to the drug.

But Mylan is better off too.

That's because each EpiPen prescription creates a win-win sales cycle for Mylan.

An EpiPen prescription actually includes two injectors. The FDA in 2010 recommended that patients have access to two, in case the first doesn't work, and Mylan complied by taking its single EpiPens off the market and offering them in two-packs.

But often one prescription is not enough. People want the pens at home, in their offices or schools, perhaps in the car. So they might buy three or more two-pen packs. Schools and businesses also often keep them on hand in case a student or customer has an unexpected reaction.

That's a lot of EpiPens.

Plus, epinephrine has a short shelf life, so people have to replace their EpiPens each year, even if they've never used them.

The Salt When Your Child's Food Allergies Are A Matter Of Life And Death

That's how the drug has become a cash cow for Mylan, which last year moved its headquarters from the U.S. to the Netherlands.

But consumers are fed up. Almost 90,000 people signed a petition to Congress asking for an investigation. About 40,000 of those signatures came in on Wednesday.

Mylan says it is working to keep the medication cheap for consumers, by offering $100 coupons to offset high insurance copayments. In a statement released Monday, the company said about 80 percent of patients with insurance get the EpiPen free.

The statement didn't mention the retail price or the price increases at all. Instead, the company focused on insurance policies with high deductibles that shift costs to patients.

"We encourage all patients and families to thoroughly review and understand their healthcare insurance coverage," the statement said.

EpiPen's name recognition means doctors who want to prescribe adrenaline to an allergy-prone patient usually just turn to it. There is no specific EpiPen generic, so pharmacists can't substitute a cheaper alternative.

But that alternative does exist. Another auto-injector known as Adrenaclick is available in generic form at Wal-Mart for $141, according to GoodRX.

It's unclear how far the threats of a congressional investigation into the EpiPen will go.

But the prospect does present one awkward situation. The CEO of Mylan, Heather Bresch, is the daughter of Sen. Joe Manchin, D-W.Va. In the time that the price of the EpiPen has been skyrocketing, so has Bresch's compensation. Last year, she earned about $18.2 million, according to the New York Times. That's up from about $2.5 million in 2007.

In earlier investigations into drug prices, the chiefs of many companies have been grilled and lectured harshly by lawmakers. It's unclear whether the angry senators will be as inclined to be as aggressive with the daughter of one of their colleagues.

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

Instagramming In Black And White? Could Be You're Depressed

Wed, 08/24/2016 - 10:19am

Credit: Meredith Rizzo/NPR

Vincent Van Gogh's paintings might not make it obvious that he was an artist troubled with depression and mania. But a computer algorithm might be able to figure that out. Computer programs are getting pretty good at discovering health information by studying heaps of social media data.

A computer script analyzed galleries of photos posted to Instagram and accurately predicted if the users had depression, according to a study posted this month to the public online repository arXiv.com.

The researchers asked 166 Instagram users for permission to analyze their posts and also asked whether or not they had a diagnosis of clinical depression from a mental health professional. First, the researchers had their algorithm just sort 70 percent of the information to find out what photo features are common among people with depression and people without depression.

The program looked through four distinct categories of information: color and brightness, number of faces in the photo, use of Instagram filters, and metadata including number of comments or likes. "In general, each one of these things has some relationship to what people have already found in studying depression," says Andrew Reece, the lead author and a psychology and computational science graduate student at Harvard University.

For example, there's some research that suggests people with depression prefer darker colors and more grays or blues. "There's evidence people who are depressed tend to interact in smaller social settings. If there's a ton of faces in the photos, then it probably means you're interacting in large social settings," Reece says. The same might be true for the number of likes or comments someone gets for their posts.

The program was able to find associations in the Instagram data that backed these theories up. Photos from people with depression tend to be bluer, darker and grayer. "[People with depression] tend to have more comments on their posts, but fewer likes.

Depressed people were less likely to use any filters at all, but when they did use filters they went for Inkwell, which makes everything black and white," Reece says. "And depressed people have fewer faces in their photos, but they tend to post more photos with faces."

Additional Information: Bluer, Grayer, Darker

Instagram photos posted by depressed individuals had values that shifted towards those in the bottom photograph, compared with photos posted by people who weren't depressed. The bottom photo has higher hue (bluer), lower saturation (grayer) and lower brightness (darker).

Cornell University

Then Reece and his coauthor removed the depression diagnosis information from their remaining untouched Instagram photos. They gave those to the computer program and had the machine figure out which of those users had depression and which of them didn't. "We were right about people being healthy 84 percent of the time. About a third of the people who were truly depressed, the machine found," Reece says.

When the machine gave a depression marker, it was right about 54 percent of the time, compared to unassisted primary physicians who correctly make a depression diagnosis about 42 percent of the time. "It's not an A+, but it's a 25 percent improvement over those human rates," Reece says.

This study hasn't been peer reviewed, but it looks like the algorithm is doing a a fairly good job. Reece says it doesn't mean that computer programs are going to replace primary doctors when it comes to diagnosing depression. Primary doctors look at the general population, rather than just Instagram users, and don't separate people into binary categories like depression or no depression like the program does. "You can't even really compare the two in a formal sense," Reece says.

And the algorithm can't truly diagnose someone with depression or rule it out the way a psychologist or psychiatrist would. Ideally, programs like this might help clinicians quickly find people who are struggling and need help. Right now, Reece says that patients wait several months on average between depression sets in and treatment. "If someone is depressed and really needs services, and they don't get that assessment, anything that can help them get assessed is good," he says.

And computers are able to look at vast amounts of social media information, something which a doctor could never do. Researchers have created computer scripts that can parse out signs of depression from Twitter, Facebook or Tumblr feeds. That means a program like this could provide useful information that doctors otherwise wouldn't have, says Munmun De Choudhury, a social and computer scientist at Georgia Tech who was not involved in this study. "The goal lies in empowering the clinician with tools that would help people manage or cope with these challenges above and beyond what they're currently using."

But we aren't quite there yet, says Dr. Megan Moreno, an adolescent psychiatrist at Seattle Children's Hospital who studies social media and mental illness. "We're probably still a ways away from having these types of approaches normalized as part of clinical care," she says. "I think this is a cool and interesting piece to the puzzle."

Actually using this information for depression screening comes with legal and privacy issues. "We're talking about the perspective that we could find people who need help. There's so much hope and optimism, but if we develop ways to monitor [social media data], then who else will monitor?" Moreno says. "Could these things come back and affect someone's employment or insurability? To some extent, people assume some of that is already happening."

Companies could already be collecting the data for this type of use. After all, Tweets, Tumblr and many Instagram posts are freely available to anyone with an Internet connection.

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

Japanese City Takes Community Approach To Dealing With Dementia

Tue, 08/23/2016 - 2:10pm
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August 23, 20162:10 PM ET Heard on All Things Considered

Hiroyuko Yamamoto, a crossing guard in Matsudo, Japan, has been trained in how to recognize and gently approach people who are wandering, or have other signs of dementia, in ways that won't frighten them.

Ina Jaffe/NPR

Early mornings are routine for 69-year-old Hiroyuko Yamamoto. He's typically at a busy intersection in the city of Matsudo, near Tokyo, where he volunteers as a school crossing guard. But one rainy morning a little over a year ago, an old woman caught his attention.

She was pushing a bicycle. She was kind of disheveled. Despite the rain, she didn't have an umbrella. When Yamamoto spoke to the woman, she said she was trying to get to the city of Kamisuwa. That's about four hours away by train.

Yamamoto recognized that the woman had several signs of dementia he'd learned about when he took his city's dementia awareness training.

Yamamoto volunteers with Matsudo's Orange Patrol. The organization's formal name in Japanese — Olenji koe kake tai — translates awkwardly into English as "Troop that calls out to the elderly." But the name accurately describes what the members do. Yamamoto says that just a simple, "Hello, what a nice day," can tell you if someone is OK or needs help.

Because of his training, Yamamoto says, he knew how to talk with the old woman pushing the bicycle.

"I talked to her about things that, according to the training manual, would not upset her," he says. "And I spoke in a gentle manner." These things helped him persuade the woman to stay with him until the police arrived about 20 minutes later.

If it hadn't been for her chance encounter with Yamamoto, the woman might have gone missing, or worse. Last year, 12,208 people with dementia were reported missing to the National Police Agency in Japan. Most were found alive within a week. But 479 were found dead, and 150 were never found.

These numbers have been increasing every year as the number of older people in Japan continues to rise. Nearly 27 percent of the Japanese population is now 65 or older. And, as the number of older people grows, so does the number of people with Alzheimer's disease or other dementia. The Japanese government expects that by 2025 more than 7 million of the nation's residents will have dementia.

A comprehensive plan for dealing with that expected rise in dementia cases was passed by the national government last year. But Matsudo has been providing dementia awareness training for city residents since 2010. Thousands of people have taken it.

Atsuko Yoshioka conducts dementia awareness classes for the city of Matsudo. She says the sessions are brief — just 60 to 90 minutes — so she tries to customize the content for students.

For example, pharmacist Takayuki Yoshida says he sometimes had clients who "even after I gave the medication to them, they'd come back and say they didn't get the drugs." Now he knows that may be a sign of dementia, and he contacts the patient's doctor.

Many post office workers have also taken the training. In Japan, post offices also conduct some banking transactions. Hiroki Yaita says sometimes an older client will come in several times to say that someone has stolen their bankbook. Now, because of the training, "we would think that maybe that person has dementia and we would talk to the family about that possibility."

The purpose of the training isn't to make Matsudo residents experts in dementia, says Tadashi Watanabe, chief of the city's Welfare and Longevity Department. The goal, he says, is just "to support those with dementia, as well as their families, and make this a town where it's more comfortable for them to live."

Some communities in the United States have begun similar programs. And in Japan what's been going on in Matsudo is now national policy. The comprehensive plan adopted by the government last year includes research and prevention and nursing services. It also includes a campaign for increasing dementia awareness among the general public. The country is on track to train 8 million people by the end of the next fiscal year.

Hidenori Kawashima, deputy director for dementia policy in Japan's Ministry of Labor, Health, and Welfare, says the expected rise in dementia cases should not be seen as a threat. Interacting with people with dementia will become normal.

"It would be a familiar thing," says Kawashima. "So we wanted the plan: First, to create a structure in the local communities to support those with dementia and, second, to create a society where it will be natural for them to live."

No government plan can keep people with dementia from wandering. But health officials in Japan hope there eventually will be entire communities prepared to help keep them safe, if and when they do.

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

Health Officials Struggle To Fight Deadly Sepsis Infections

Tue, 08/23/2016 - 1:01pm

Four days after Rory Staunton cut himself in gym class, he died from septic shock.

Courtesy of Rory Staunton Foundation

After Rory Staunton fell at the gym and cut his arm in March of 2012, the 12-year-old became feverish. He vomited during the night and complained of a sharp pain in his leg. When his parents called his pediatrician the next day, she said there was a stomach virus going around New York City, and his leg pain was likely due to his fall.

But she did advise his parents, Orlaith and Ciaran Staunton, to take Rory to the emergency department because of possible dehydration. The hospital workers did some blood work, gave him fluids and sent him home.

The next day, Rory's pain and fever were worse. His skin was mottled and the tip of his nose had turned blue. The Stauntons raced back to the hospital, where he was admitted to intensive care. The diagnosis: septic shock. Rory was fighting an infection that was turning his skin black and shutting down his organs.

On Sunday, four days after he dove for the ball in gym class, Rory died.

Sepsis, which is a body's overwhelming response to infection, kills more than 250,000 people in the U.S. every year. People at highest risk are those with weakened immune systems, the very young and elderly, and patients with chronic conditions such as diabetes, cancer or kidney disease. It is also risky for people with pneumonia or those who use catheters that can cause infections. But it can strike anyone, even a healthy child like Rory.

Sepsis typically occurs when germs from an infection get into the bloodstream and spread throughout the body. To fight the infection, the body mounts an immune response that may trigger inflammation that damages tissues and interferes with blood flow. That can lead to a drop in blood pressure, potentially causing organ failure and death.

"It was frightening to think that something could kill my son so fast and it would be something that I had never heard of," said Orlaith Staunton.

Shots - Health News Sepsis, A Wily Killer, Stymies Doctors' Efforts To Tame It

She's not alone. Many people don't know about sepsis. Health care providers struggle to identify it early, but there's no simple diagnostic test. Many symptoms — elevated heart and respiratory rates, fever or chills, pain — are common ones that are present in many conditions.

A growing number of doctors, hospitals, patient advocates and policymakers are pushing to educate consumers and clinicians about sepsis. The goal is to ensure that procedures that focus on prevention and early detection are followed.

The Stauntons established a foundation to raise awareness about the deadly infection, and in 2013 New York became the first state to require all hospitals to implement procedures for early recognition and treatment. This month, Illinois Gov. Bruce Rauner signed a law requiring similar actions by hospitals in that state.

The Centers for Disease Control and Prevention released a study Tuesday about sepsis as part of an effort to draw attention to the importance of prevention and early detection.

"Early treatment is vital," says Dr. Anthony Fiore, chief of the epidemiology research and innovations branch at the CDC's Division of Healthcare Quality Promotion. "It's an emergency that you need to deal with, like heart attack and stroke."

When sepsis advances to septic shock, characterized by severely low blood pressure, each hour of delay in administering antibiotics decreases the odds of survival by an average 7.6 percent, one study found.

In 2013, sepsis (sometimes called septicemia) accounted for nearly $24 billion in hospital costs, the most expensive condition treated. Up to half of people who get it die. Many cases are related to health care, such as catheter use or an infection acquired in the hospital. But contrary to the common perception, approximately 80 percent of cases develop outside the hospital or at a nursing home, according to the CDC.

As the front line in identifying these cases, emergency departments typically have sepsis protocols in place to screen for it.

"The work you do in those first three to six hours in the emergency department makes more difference in cost than the whole next several weeks in the ICU," said Dr. Todd L. Slesinger, who co-chairs a task force on sepsis at the American College of Emergency Physicians, which has developed a tool to help emergency department staff screen and treat the condition.

Last fall, the Centers for Medicare & Medicaid Services started requiring hospitals to measure and report on screening and treatment efforts. In addition, Medicare sets penalties for a variety of hospital-acquired conditions, including high rates of post-operative sepsis.

Patient advocates and policymakers agree that patients themselves are key to improving prevention and early detection. Good hygiene can help prevent sepsis, including cleaning wounds. If someone gets injured, look for signs of sepsis, including rapid breathing or heart rate, confusion, fever or chills and pale or discolored skin.

Don't assume health care providers have it covered, experts advise. If you or someone you're caring for has these symptoms, ask the health care provider directly: "Do you think it might be sepsis?"

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.
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Tighter Patent Rules Could Help Lower Drug Prices, Study Shows

Tue, 08/23/2016 - 11:14am
Bull's Eye/Imagezoo/Getty Images

The U.S. could rein in rising drug prices by being more selective about giving patents to pharmaceutical companies for marginal developments, a study concludes.

That's because brand-name drugs with patents that grant exclusivity account for about 72 percent of drug spending, even though they are only about 10 percent of all prescriptions dispensed, according to the study, published Tuesday in JAMA, the journal of the American Medical Association.

"You've got a bunch of different tactics that are being used that can extend that exclusivity," says Aaron Kesselheim, a professor at Harvard Medical School and the study's lead author.

He says the patent office is too permissive in granting patents for drug properties that have no bearing on its therapeutic value.

Under the current law, new chemically based medications approved by the Food and Drug Administration get the right to sell their drugs with no competition from generics for five to seven years. More complex biologic drugs get 12 years of protection.

But drugmakers can also use their patents to keep competitors out of the market.

The study found that new drugs have a median 12.5 years of exclusive market access, and it's even longer for completely new medications.

Kesselheim says drugmakers often use "life-cycle management" tactics to extend their exclusive market access.

He pointed to a cholesterol drug named Tricor-1 as an example. The medication was made by Abbott Labs. When a company applied to make a generic version, Abbott sued, delaying the competitor's entry to the market, according to an account excerpted in the blog The Incidental Economist.

As the lawsuit proceeded, Abbott changed the dosage of the drug, named it Tricor-2, and aggressively moved patients to the new version. When the generic version of Tricor-1 was finally approved, very few people were taking it anymore.

Kesselheim says the patent office is charged with protecting inventions that are "novel, useful and non-obvious," but that it has been lax in interpreting those parameters. If patents were harder to get on nonessential properties of medications, there would likely be more competition sooner.

"We did a study a while back and found one HIV medication has over 100 different patents covering formulations and crystal structures and methods of use," he says.

Drugmakers often argue that high prices help them recoup the costs of developing new drugs. But the JAMA study found no relationship between development costs and profits on medications.

Still, the patent system does give companies incentives to take risks on new medications, says Jacob Sherkow, a professor of law at New York Law School.

"Companies spend billions of dollars researching drugs and ushering them through FDA approval," Sherkow says. "They wouldn't do that unless they could charge supercompetitive prices to make up for those investments."

Patents aren't the only price reduction tool available to the government.

The JAMA study concludes that if Medicare and other government programs were allowed to refuse to cover some medications, that may also put downward pressure on prices.

The health care program for the elderly and disabled buys about one-third of the prescription drugs sold in the U.S. But the federal law that created the Medicare prescription drug program bars it from negotiating for lower prices, while requiring it to cover almost all drugs on the market. Medicaid is also required to pay for all FDA-approved drugs.

Ameet Sarpatwari, a study co-author, says the lack of information on drugs' prices and effectiveness makes it hard for government programs and consumers to compare them.

"Those comparisons need to be done, and that information needs to be disseminated," he says.

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

Doctors Get Disciplined For Misconduct; Drug Firms Keep Paying Them

Tue, 08/23/2016 - 8:00am
Rob Weychert/ProPublica

Hundreds of pharmaceutical and medical device companies continue to pay doctors as promotional speakers and advisers after they've been disciplined for serious misconduct, according to an analysis by ProPublica.

One such company is medical device maker Stryker Corp.

In June 2015, New York's Board for Professional Medical Conduct accused orthopedic surgeon Alexios Apazidis of improperly prescribing pain medications to 28 of his patients. The board fined him $50,000 and placed him on three years' probation, requiring that a monitor keep an eye on his practice.

Despite this, Stryker paid Apazidis more than $14,000 in consulting fees, plus travel expenses, in the last half of 2015.

Stryker paid another orthopedic surgeon, Mohammad Diab of San Francisco, more than $16,000 for consulting and travel, even though California's medical board had disciplined him for having a two-year-long inappropriate sexual relationship with a patient, whose two children he also treated. He was suspended from practice for 60 days, required to seek psychological treatment and given seven years' probation. He is still required to have a third party present while seeing female patients.

Neither Apazidis nor Diab returned emails or calls seeking comment.

Stryker officials also would not answer questions. The company is one of more than at least 400 pharmaceutical and medical device makers that have made payments to doctors after they were disciplined by their state medical boards.

ProPublica reviewed disciplinary records for doctors in five states — California, Texas, New York, Florida and New Jersey — and checked them against data released by the Centers for Medicare and Medicaid Services on company payments to doctors. That included payments for things like speaking, consulting, education, travel and gifts, but not for meals, as these often don't reflect a formal relationship between companies and doctors. (The database can be searched on ProPublica's Dollars for Docs tool.)

All told, the analysis identified at least 2,300 doctors who received industry payments between August 2013 and December 2015 despite histories of misconduct.

While many doctors were sanctioned for minor offenses such as failing to attend required continuing medical education courses, hundreds were disciplined for more severe offenses, including providing poor care, inappropriately prescribing addictive medications, bilking public insurance programs and even sexual misconduct.

At least 40 physicians had their licenses revoked or surrendered them, in most cases permanently. More than 180 had their licenses temporarily suspended or restricted. Almost 250 were placed on probation.

The industry's relationships with sanctioned physicians have come under scrutiny before. In 2010, ProPublica analyzed payments by seven drug companies that had been required to make them public, finding 250 recipients who had been disciplined, many for serious misconduct.

After that article, companies such as Johnson & Johnson, Pfizer and AstraZeneca promised to revise their screening processes for doctors they pay for services. Still, even drug and device makers that profess confidence in how they vet doctors today offer few details on what checks they run or whether they flagged the disciplinary cases ProPublica identified.

Device company Arthrex doesn't hire doctors who "do not possess the proper credentials and licensure for the task assigned," said spokeswoman Lisa Gardiner. She acknowledged, however, that the company checks the status of doctors only when their contracts begin, not annually as some companies do. A Florida doctor Arthrex hired in 2013 surrendered his license in 2014, but Arthrex paid him almost $7,500 in consulting fees after that, records show. While his contract obliged him to inform Arthrex if his licensure status changed, Gardiner said he never did.

The Pharmaceutical Research and Manufacturers of America, the industry trade group, wouldn't comment on the vetting processes of specific companies or whether there should be an industrywide standard for such checks. Spokeswoman Holly Campbell said in an email that companies typically check lists of doctors barred from doing business with the government and confirm doctors' "general medical expertise, reputation and knowledge regarding a particular disease."

Industry payments to doctors are legal as long as they are not an inducement to use a particular product.

Campbell defends the benefits of such financial ties, saying they compensate doctors for providing crucial feedback on products and help doctors teach their colleagues about what's out there.

Critics of industry payments to doctors say they can influence recipients to prescribe drugs that cost more, may not be necessary or are similar to cheaper generics.

Dr. Charles Rosen, the co-founder of the Association for Medical Ethics, which seeks to reduce manufacturers' influence on doctors, says he was not surprised to hear that disciplined doctors are among the industry's consultants and speakers.

"I think it's crystal clear that their fiduciary duty is not to educate physicians and make public welfare better. It's to sell a product," Rosen says. "I think they'd pay the devil if no one knows and he sells a lot."

Some companies that were making payments to disciplined doctors in 2010 appear to still do so, ProPublica found.

Johnson & Johnson paid Dr. Michael Reiss of New Jersey $85,000 for consulting through its pharmaceutical arm, Janssen, in December 2015. He'd just regained full use of his medical license that August; it had been suspended since 2012 because he'd pleaded guilty in federal court to hiding $2.5 million from the IRS in Swiss bank accounts.

When reached by phone, Reiss said that Janssen had performed a background check, but couldn't recall whether his disciplinary history had come up as part of his interview process. "Apparently it wasn't an issue; they hired me," he said. Reiss said he's retired from practice aside from his consulting work, but declined to say what this consists of or whether he does work for Janssen or any other company.

Janssen spokeswoman Meredith Sharp says the company's contracts require doctors to have active medical licenses, and that it conducts "additional reviews to verify eligibility" and requires doctors to disclose changes in status. "We are committed to working with the most qualified individuals," Sharp says. "We are looking at the information you provided to determine if there is opportunity to further improve our process."

AstraZeneca paid Miltiadis Leon, a Texas physician, more than $26,000 in 2014 and 2015, mostly for speaking fees and travel expenses. In 2006, the doctor's license was limited after he was found to have sexually harassed and inappropriately touched several female patients and staff members. He was not allowed to see female patients without a chaperone for two years. Leon referred ProPublica to his attorney, who said he would speak to his client, but then did not return a call for comment.

In a statement, AstraZeneca spokeswoman Abigail Bozarth said doctors with whom the company has financial relationships are reviewed both by an external organization and by the company's own compliance department. Bozarth said the process includes checks of government databases, including discipline by state medical boards, but would not respond to inquiries specifically about Leon.

By contrast, drug company Eli Lilly, which was flagged by ProPublica in 2010 for paying disciplined doctors, has made only a few recent payments to doctors with disciplinary records and none to those with serious issues.

Spokesman Mark Taylor says the company began using a third-party vendor in 2013 to conduct background checks and screen out doctors who had faced sanctions. Doctors flagged during this process are referred to an internal committee at Eli Lilly for a final decision.

Prior to these changes, the company conducted its own checks and looked exclusively at federal databases, not state-level discipline. "So we could have been missing some actions or sanctions," says Taylor. This realization, he adds, "was kind of a big 'aha' moment."

Eli Lilly now checks the licenses of all doctors the company considers for hire against federal databases and in all 50 states.

Drug maker Boehringer Ingelheim, by contrast, checks only federal databases on an annual basis. Its contracts with physicians require doctors to attest that they are in good standing with their state boards, but the company does not independently check for state-level discipline unless it has "received information to suggest a speaker or consultant was not being truthful," says spokeswoman Erin Crew.

Novo Nordisk spokeswoman Marisa Sharkey describes a similar process, adding that the company checks state disciplinary databases "as needed." It requires doctors to inform the company if they have been disciplined or if they are placed on a list barring them from receiving government contracts.

Does your doctor accept payments from pharmaceutical and medical device companies? Find out using Dollars for Docs.

Copyright 2016 ProPublica. To see more, visit ProPublica.
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Beyond Slurpees: Many Japanese Mini-Marts Now Cater To Elders

Tue, 08/23/2016 - 4:32am
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August 23, 20164:32 AM ET Heard on Morning Edition

This Lawson convenience store in Kowaguchi, Japan, sells a selection of prepared meals and fresh vegetables and meats, along with products aimed at the elderly. Many of the store's older customers find it hard to get to the supermarket, the store's manager says.

Ina Jaffe/NPR

In Japanese cities, space is at a premium. So convenience stores that cram everything from Kleenex to rice balls into a few square yards are everywhere. You can't walk five minutes in most cities without running into one or two or even half a dozen.

But they're not just a place for Slurpees and snacks. Nearly 27 percent of Japan's population is now 65 or older, and convenience stores are changing to serve this growing market.

Case in point is a Lawson convenience store in the city of Kawaguchi, north of Tokyo. It sells products that an American consumer would never find tucked between the aspirin and the candy bars. For example, there's a whole rack of ready-to-heat meals in colorful pouches. They're rated at levels from 1 to 5, based on how hard it is to chew what's inside.

Or, as the store's manager, Masahiko Terada, puts it, "the higher the level, the less need for you to chew. In the end it's porridge."

The Kawaguchi mini-mart also sells some ready-to-eat meals in pouches that are ranked from 1 to 5 — based on how difficult it is to chew what's inside.

Ina Jaffe/NPR

Of course, not all older people have trouble chewing, and many still cook for themselves. So Terada points out a fresh food section unlike anything you'd see in most U.S. mini-marts. There are packages of raw vegetables and meat, much of it already cut up and packaged in single-serving amounts for the increasing number of older people living alone these days in Japan.

There are also dozens of products intended not so much for older consumers as for their caregivers — items to deal with incontinence and its consequences, for example, like especially strong, deodorizing laundry detergent or devices that are useful for giving bed baths.

"So, basically, we have this lineup of products so that the elderly don't need to go to the big supermarkets," says Terada. "They can use this store as a substitute."

Because older adults make up nearly 27 percent of Japan's population, they are a market that can't be ignored, says Ming Li, who works in communications for Lawson.

"We try to accommodate the changes in society," he says.

The convenience store industry in Japan is dominated by three major chains. Lawson is second largest. The leader is 7-Eleven, which is now owned by a Japanese company. Li says the industry is highly competitive.

"We're like, OK, if one chain is doing something, then we'll do it, too," says Li.

In fact, other chains are also experimenting with services that might appeal to older consumers, such as home delivery of meals or being located alongside pharmacies.

This Lawson store in Kawaguchi is one of six in a special line called Care Lawson. The company plans to expand to 30 by early next year. And these Care Lawson stores have another special feature: staff like Mika Kojima.

She's a nursing care manager and she's stationed at this Lawson store. In fact the franchise owner of this store is actually a nursing services company. Anyone who comes in can ask for Kojima's help. For example, she'll go to an older client's home to make sure it's set up so they can live there safely. And she'll connect families with adult day care services.

Whatever the request, she says, "I make sure that I'm always prepared to listen with a smile on my face."

Kojima's tiny office is next to a cafe area meant to give older people a place to hang out and drink tea or watch television. This is where she sees most of her clients.

"People in the neighborhood come in for tea and they start talking to me," Kojima says. "And they come in four or five times a week."

So, most of the time, Kojima deals in tea and sympathy — one of the oldest therapies in the world. And it's coming soon to a growing number of convenience stores in Japan.

Copyright 2016 NPR. To see more, visit NPR.
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How Big, Really, Is The Zika Outbreak In Florida?

Mon, 08/22/2016 - 7:18pm
How Big, Really, Is The Zika Outbreak In Florida? Listen · 2:20 2:20 Toggle more options
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August 22, 20167:18 PM ET Heard on All Things Considered

A plane sprays pesticide over the Wynwood neighborhood of Miami on Aug. 6. That's just one way health officials are battling back Zika-carrying mosquitoes in the area.

Joe Raedle/Getty Images

As expected, the Zika outbreak in Florida is growing — though how fast is still difficult to say.

State and federal health officials say mosquitoes are spreading Zika in two neighborhoods of Miami, including Miami Beach. The Centers for Disease Control and Prevention told pregnant women Friday not to go into these neighborhoods — and to consider postponing travel to all parts of Miami-Dade County.

Just 37 people have been reported to have caught the virus in these neighborhoods so far.

But many scientists are concerned that the outbreak in Florida may be larger and more widespread than the number of cases suggests.

"Zika is one of those diseases that is always like an iceberg — you just see the tip," says Alessandro Vespignani, a computer scientist at Northeastern University in Boston, who has been tasked with modeling the spread of the virus.

Most people who get Zika don't even know they have it, Vespignani explains. About 4 in 5 people don't have any symptoms, he says. And those who do get sick often have only mild symptoms that could be confused with the flu. So only about 5 percent of cases get detected, Vespignani has found.

To get better estimates of the number of silent infections in Miami and beyond, Vespignani and his colleagues built computer models that estimate how the virus is likely to spread.

"We estimate there will be 395 infected people by Sept. 15 [in Florida]," says Ira Longini, a biostatistician at the University of Florida, who collaborates with Vespignani.

About 80 of those people will show symptoms, Longini estimates. And about eight pregnant women are likely to get infected during their first trimester — which would put their fetuses at risk for microcephaly.

The number of Zika cases in Florida will very likely continue to rise until October or November, when cooler weather stops the mosquitoes, Longini says, though a number of variables could speed the spread before that.

"For example, on Monday the University of Florida opens its first day of classes," he says. "Tens of thousands of students will be coming from the Miami area, as well as from all over Latin America. So we could see a burst of cases by mid-September here in Gainesville."

Because of these uncertainties, many doctors around the country are recommending that their pregnant patients — and those trying to get pregnant — not travel to southern Florida.

And Florida isn't the only place in the continental U.S. at risk.

Longini has used the computer models to predict where Zika could show up next in the States. He says the big concern is Texas — which has roughly a 25 percent chance of having a small outbreak in the next month, according to the models.

"I would not be surprised if we see cases in Texas and Louisiana," Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told ABC News Sunday, citing the flooding in Louisiana as something Zika watchers will be keeping an eye on.

"There's going to be a lot of problems getting rid of standing water [there]," Fauci says — puddles where Zika-carrying mosquitoes could breed and thrive.

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