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Are We Reaching The End Of The Trend For Longer, Healthier Lives?

Fri, 09/23/2016 - 4:57am
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September 23, 20164:57 AM ET Heard on Morning Edition Andrew Baker/Ikon Images/Getty Images

American lives have been getting steadily longer, and since the 1960s that trend has been driven mostly by a remarkable reduction in heart disease. But those improvements have slowed dramatically. Scientists are now wondering whether we're approaching the end of the trend of longer, healthier lives.

That's because the steady decline in heart disease is fading.

Most people alive today don't remember the days when many people in their 40s and 50s would simply drop dead of a heart attack. But 79-year-old John Kenneth "Ken" Carbaugh Jr. does.

"When I was a kid a long time ago I remember a lot of people died from 'indigestion,' " he told Shots. "That's what they said it was, but that's not what it was. They were having heart attacks and they didn't even know it."

Carbaugh has lived through a remarkable period of history. During his lifetime, cardiovascular disease dropped dramatically as a cause of death. It went from killing about half of all Americans back in the 1960s, to only about one-quarter today.

Carbaugh has helped tell that success story himself. For the past 30 years he has volunteered in a study to track heart health in the United States. On the day we meet, he has driven in from his home on a country road in Washington County, Md., to Hagerstown, where he is getting a periodic exam.

The low-slung building is an outpost of the Johns Hopkins Bloomberg School of Public Health. It's right next to Antietam Creek, about 10 miles upstream from the Civil War battlefield.

Carbaugh will get a battery of tests, which will take five hours to complete. He's one of about 4,000 people here in Washington County recruited in the 1980s for this long-term study. The youngest is now 75. More than half are still alive.

This is one of four counties nationwide that has been providing a very detailed look at heart health for a federally funded study called Atherosclerosis Risk in Communities (ARIC), according to Josef Coresh, an epidemiology professor and physician at the Hopkins Bloomberg School.

Researchers in these representative counties — in Maryland, Minnesota, Mississippi and North Carolina — have been following about 16,000 volunteers since the late 1980s.

"They've been kind enough to volunteer for examinations and phone calls twice a year," Coresh says. "That means they've contributed invaluable data that will stick around forever. So ARIC [and the Framingham Heart Study] have become national resources and treasures for research."

The point of this study isn't to track the national trends in heart disease and stroke per se, but to understand on a very personal level what's behind them.

The lesson from here and elsewhere is clear. "Of the decline in heart attacks, about half is due to a management of risk factors and half is due to improved medical care," Coresh says.

People stopped smoking. They started taking drugs to control blood pressure and cholesterol. Surgeons reopened arteries, and hospitals built cardiac care units. So why is the trend in improving heart health leveling out? That's partly because the easier steps have been taken. But there's another big reason.

"The greater cause of the stagnation in cardiovascular death rates is that the obesity epidemic, which started in this country in about 1985, is finally coming home to roost," says Donald Lloyd-Jones, a physician and chair of the department of preventive medicine at Northwestern University.

Obesity raises blood pressure, cholesterol levels and the risk of diabetes.

"All the things that put us at risk for heart disease and stroke get much, much worse," he says.

And considering the burden of obesity in this country now, by 2030 heart disease could cost a whopping $800 billion a year, Lloyd-Jones says. That's equivalent to the stimulus package that Congress passed in 2008 to prevent a global financial disaster.

"That was a hard lift for our political system," Lloyd-Jones says. "By 2030 the American Heart Association is projecting that we'll have to pass that bill every single year just to pay for cardiovascular diseases."

This is not just a potential financial disaster. It could also be a blow to the expectation that our collective health will just keep getting better.

That idea was first challenged when the former Soviet Union collapsed, according to David Jones, a medical historian and physician at Harvard University. When that happened, life expectancy there fell by five years. AIDS in sub-Saharan Africa led to an even worse decline.

"Those two warning signs really burst the bubble that people had had about this expectation of inevitable progress," Jones says. "And people realized that the great gains we had made over the 20th century were potentially vulnerable if certain things went wrong."

Obesity is a slow-moving epidemic, so it may not result in a rapid rise in deaths. And even with the burden of obesity, Jones says, it still might be possible to reduce heart disease rates further, by eliminating smoking and controlling blood pressure and cholesterol.

So would that be purely good news? That depends.

"The question of what we would die of in the absence of heart disease is one of those million-dollar questions, and one of these things that people have been puzzling about for a long time," Jones told Shots.

That question is starting to come into focus at the medical building in Washington County. As the study group has grown older, the research has evolved to address their ongoing health challenges and to look at the risks that now loom for this generation.

For example, hearing tests have been added to the list, as part of an effort to understand the next potential epidemic in this country: dementia.

Memory loss can be hastened by failing hearing. It can be caused by degenerating neurons, as is the case in Alzheimer's, and it can also be triggered by what causes heart disease: clogged and hardened arteries.

Coresh says some dementia is probably amenable to prevention if research projects like his can pin down the risk factors, "but it's going to need decades of prevention, so we probably need to have risk factors treated in middle age if we're going to prevent disease in older age."

If medical science can indeed hold the line on heart disease, it would be disheartening if that simply meant people died of dementia instead.

You can reach Richard Harris by email.

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Breaking Taboo, Swedish Scientist Seeks To Edit DNA Of Healthy Human Embryos

Thu, 09/22/2016 - 5:07am
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September 22, 20165:07 AM ET Heard on Morning Edition Alicia Watkins for NPR

A scientist in Sweden has started trying to edit the DNA in healthy human embryos, NPR has learned.

The step by the developmental biologist Fredrik Lanner makes him the first researcher known to attempt to modify the genes of healthy human embryos. That has long been considered taboo because of safety and ethical concerns.

Lanner is attempting to edit genes in human embryos to learn more about how the genes regulate early embryonic development. He hopes the work could lead to new ways to treat infertility and prevent miscarriages. He also hopes to help scientists learn more about embryonic stem cells so they can someday use them to treat many diseases.

The fear is that Lanner's work could open the door to others attempting to use genetically modified embryos to make babies.

Making changes to the DNA in human embryos could accidentally introduce an error into the human gene pool, inadvertently creating a new disease that would be passed down for generations, critics say.

Some also worry the experiments could open the door to so-called designer babies that would let parents pick and choose the traits of their children.

Lanner, however, says he is initially planning only to study the modified embryos for the first seven days of their growth and would never let them develop past 14 days. The potential benefits could be enormous, he argues.

"Having children is one of the major drives for a lot of people," Lanner says. "For people who do struggle with this, it can tend to become an extremely important part of your life."

Lanner also hopes to learn things that could help scientists who are trying to turn stem cells from human embryos into new treatments for diseases.

"If we can understand how these early cells are regulated in the actual embryo, this knowledge will help us in the future to treat patients with diabetes, or Parkinson, or different types of blindness and other diseases," he says. "That's another exciting area of research."

Fredrik Lanner (right) of the Karolinska Institute in Stockholm and his student Alvaro Plaza Reyes examine a magnified image of an human embryo that they used to attempt to create genetically modified healthy human embryos.

Rob Stein/NPR

NPR recently got exclusive access to Lanner's labs at the Karolinska Institute in Stockholm to watch some of his early efforts.

During the visit, Lanner and a graduate student carefully thawed five embryos donated by couples who had gone through in vitro fertilization at the Karolinska University Hospital to try to have children.

One of the embryos didn't survive the freezing and thawing process. The researchers gingerly placed each of the remaining 2-day-old embryos into a dish on a special microscope.

"You need to be stable on your fingers and hands while doing this," Lanner said, quipping, "You don't want to be dropping the embryos while taking them out."

Shots - Health News In Hopes Of Fixing Faulty Genes, One Scientist Starts With The Basics

With Lanner looking on, the student injected one of each embryo's four cells with a genetic engineering tool known as CRISPR-Cas9 while holding the embryo in place with a thin glass rod.

The gene-editing tool comprises two molecules that can zero in on individual genes and make very precise changes to the DNA. It lets scientists modify DNA much more easily and precisely than ever before. Lanner calls the technique a "game changer."

"It's not just quicker or cheaper," Lanner says. "This actually opens the door to start to look at this for the first time, because we could not do this at all previously in the human embryo. The technology was just not efficient enough to try to look at individual gene function as the embryo develops."

Lanner is planning to methodically knock out a series of genes that he has identified through previous work as being crucial to normal embryonic development. He hopes that will help him learn more about what the genes do and which ones cause infertility.

He declined to specify which genes he's targeting until the work is reviewed and published.

During the visit by NPR, one of the embryos got severely damaged when the injection needle got clogged. But the researchers successfully injected the remaining three embryos and placed them in an incubator to continue developing. One embryo divided again immediately after being injected, showing that it could still grow.

Two of the embryos survived in good enough shape to be analyzed later, Lanner explained in an email afterward.

Lanner has now done this on at least a dozen embryos, but is still studying his results and refining his techniques. He remains unsure how well the editing is working so far. However, he's confident he'll be able to modify individual genes in the embryos to determine their function.

"It will be very exciting. We're fortunate to be in this position," Lanner says. "This is a privilege to be in this position."

Shots - Health News Scientists Debate How Far To Go In Editing Human Genes

But just the act of attempting to edit the DNA in healthy human embryos is extremely controversial. Chinese scientists triggered an international uproar earlier last year when they tried to edit the DNA of human embryos even though they used only defective embryos that had no hope of developing.

Experiments like these intensified calls for a moratorium on such research, and the National Academies of Sciences, Engineering and Medicine launched the Human Gene-Editing Initiative to sort through the complex scientific and ethical issues they raise.

Organizers of an international summit convened in Washington, D.C., last year as part of that process concluded that it was far too early to try to create a baby from embryos that had their genes edited.

But the organizers said basic research like Lanner's could be acceptable. A final report from the gene-editing initiative is expected late this year or early next.

Still, not everyone agreed with the summit organizers' assessment. Some people have moral objections to doing any research on human embryos because they consider a human embryo to have the moral standing of a person.

And editing the DNA in embryos is controversial even among people who think human embryonic research is acceptable. That's the position of Marcy Darnovsky, who heads the Center for Genetics & Society, a watchdog group based in California that supports human embryonic research.

"The production of genetically modified human embryos is actually quite dangerous," Darnovsky says. "It's a step toward attempts to produce genetically modified human beings. This would be reason for grave concern."

One fear is that scientists could make some kind of mistake, accidentally creating new diseases that would be passed down for generations.

"When you're editing the genes of human embryos, that means you're changing the genes of every cell in the bodies of every offspring, every future generation of that human being," Darnovsky says. "So these are permanent and probably irreversible changes that we just don't know what they would mean."

But even if it's safe, Darnovsky and others still worry about what designer babies would do to society.

"If we're going to be producing genetically modified babies, we are all too likely to find ourselves in a world where those babies are perceived to be biologically superior. And then we're in a world of genetic haves and have-nots," Darnovsky says. "That could lead to all sorts of social disasters. It's not a world I want to live in."

Lanner says he has no interest in ever doing anything like that. In fact, at the moment it would be illegal in Sweden. And, Lanner says, much more research would be needed to make sure it would be safe before anyone tries to use a genetically modified embryo to make a baby to prevent diseases.

"It's not a technology that should be taken lightly," he says. "So I really, of course, stand against any sort of thoughts that one should use this to design designer babies or enhance for aesthetic purposes."

But Lanner argues that basic research is necessary and morally acceptable, and banning it would be counterproductive.

"I think it's wise to be allowed to do fundamental research so we can gain more information about this technology and potentially use it in the future," he says.

Lanner plans to continue attempting to edit the DNA in healthy human embryos until he develops efficient editing techniques that will allow him to study the genes involved in early embryonic development. Scientists in Britain are planning to start similar experiments later this year.

Research using human embryos is legal in the U.S., but not with the support of federal funds. U.S. labs that are known to be active in human embryo research have not announced any plans to proceed with gene-editing experiments.

Copyright 2016 NPR. To see more, visit NPR.
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How A 'Sixth Sense' Helps Simone Biles Fly, And The Rest Of Us Walk

Wed, 09/21/2016 - 5:01pm
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September 21, 20165:01 PM ET Heard on All Things Considered

Simone Biles flies through the air while performing on the balance beam at the Olympics in Rio de Janeiro.

Dmitri Lovetsky/AP

A rare genetic disorder is helping scientists understand our mysterious ability to sense where we are in space, known as proprioception.

This "sixth sense" is what dancers and gymnasts rely on to tell them the exact position of their body and limbs at every moment. It also tells them how much force each muscle is exerting.

"The most beautiful demonstration of proprioception in action is Simone Biles when she is spinning and somersaulting through the air," says Carsten Bonnemann, a pediatrician and geneticist at the National institute of Neurological Disorders and Stroke.

Scientists have known about proprioception for more than a century. But they didn't realize how much people depend on it until they got a chance to study two young patients with a rare genetic disorder that leaves them completely lacking this sense.

The results of that study were published Wednesday in the New England Journal of Medicine.

One of the participants in the study was a 10-year-old girl named Damiana, who lives in San Diego.

She's "a happy and bubbly" kid who has no problems with senses like taste, hearing, sight and smell, Bonnemann says. But Damiana was born with a genetic mutation that left her with a limited sense of touch and no proprioception, he says.

When Damiana was younger, her condition baffled doctors, says her mother, Diana Sawyer.

"She was very late at doing everything," Sawyer says. Her daughter didn't start crawling until she was about 18 months old. And she still can walk only a few steps on her own.

Damiana was born with some abnormalities in her feet and hips, Sawyer says. And her spine was curved. But those problems didn't explain why her daughter had so much trouble with precise movements, like fastening a button.

Damiana's condition might have remained a mystery if Bonnemann hadn't seen her a few years ago while holding a clinic in San Diego.

He was puzzled by her symptoms and ordered a state-of-the-art genetic analysis. It turned up a mutation in a gene called PIEZO2, which allows certain cells to detect mechanical pressure.

Unfortunately, "I didn't know what PIEZO2 was, really," Bonnemann says.

Then one day Bonnemann heard about a colleague at the National Institutes of Health who knew a lot about PIEZO2. "It turns out he's in the same building, just a floor down," Bonnemann says. "So I sent him an email saying, 'Can you help me?' "

The colleague was Alex Chesler from the National Center for Complementary and Integrative Health. Chesler read the email from Bonnemann, "and 30 seconds later I was up in his office," he says.

Chesler had spent years studying PIEZO2 in mice. But he'd never had a good way to study its function in people.

So last year, Bonnemann, Chesler and a team of researchers invited Damiana and another patient with a similar PIEZO2 mutation to the NIH.

The visit was a revelation. Trying to understand proprioception from mouse experiments had been a bit like trying to understand Beethoven by reading sheet music, Chesler says. "But when I talked to the patients it was like going to the symphony," he says.

The researchers were able to show that the PIEZO2 gene is involved in certain kinds of touch sensation as well as proprioception. And they learned a lot about what proprioception makes possible by studying what the patients were unable to do.

"They've never run, they've never jumped," Chesler says, "because those kind of actions really require precise control over your limbs in space."

The scientists also discovered that both patients had found ways to compensate for their lack of body awareness — mostly by closely watching their own limbs as they move.

For example, the older patient, who is in college, has even learned to walk pretty well — as long as she can see what's she's doing.

"If you take away her vision, she literally crumples to the ground," he says. "And the same is true for reaching. When she reaches for an object under visual control she is actually quite precise doing that. If we cover her eyes, she gets completely off target."

Of course, gymnasts like Simone Biles also rely on vision during a routine, Bonnemann says. But it's the extra information from their "sixth sense" that makes a gold-medal performance possible.

Copyright 2016 NPR. To see more, visit NPR.
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Mylan CEO Claims EpiPens Aren't As Profitable As Everyone Thinks

Wed, 09/21/2016 - 12:31pm
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September 21, 201612:31 PM ET Heard on All Things Considered

Heather Bresch, CEO of Mylan Pharmacueticals, will face lawmakers' questions Wednesday about the company's steep price hikes for the company's life-saving EpiPen auto-injector.

Dale Sparks/AP

The drug company that makes the EpiPen says it isn't nearly as profitable as many people assume it is.

At least that's the message Mylan NV CEO Heather Bresch will try to deliver to members of Congress today.

Bresch, who is scheduled to testify before the House Oversight and Government Reform Committee, is expected to tell lawmakers that the company earns $100 profit on each two-pack of EpiPen auto-injectors, even though they carry a $600 price tag.

"The misconception about our profits is understandable, and at least partly due to the complex environment in which pharmaceutical prices are determined," Bresch says in prepared testimony. "The pricing of a pharmaceutical product is opaque and frustrating, especially for patients."

Bresch says it costs the company about $69 to make two EpiPens, and after rebates and fees, Mylan receives $274 per EpiPen pack. She says other, unnamed costs absorb an additional $105, leaving $100 in profit for the company.

Shots - Health News EpiPen's Dominance Driven By Competitors' Stumbles And Tragic Deaths

While the company apparently is looking to use the analysis to downplay its profits, analysts say the margin is still quite high.

Ronny Gal, a pharmaceutical industry analyst at the investment firm Sanford Bernstein, says Bresch's numbers mean Mylan makes a 40 percent profit margin on the device.

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 a serious allergy — perhaps to bee stings or tree nuts — that may trigger anaphylaxis, a life-threatening reaction in which the airways swell and close.

The company has come under fire in recent months, however, because it raised the price of the device, which has been available for decades, more than 500 percent.

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 $634, according to GoodRX.

Mylan has tried to quell the criticism first by offering customers a coupon worth up to $300 to offset the price of the device, and then announcing it would bring a generic version of the EpiPen to market for half the retail price.

In addition to the investigation by the House Oversight committee, at least three senators have also called for investigations into Mylan's pricing practices. Sens. Charles Grassley, R-Iowa, and Richard Blumenthal, D-Conn., have sent letters to Mylan demanding an explanation for the increase.

Mylan responded with a letter that Grassley, in a press release, said was "incomplete."

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 the Senate Finance Committee is reviewing the rebates that Mylan offered to the Center for Medicare and Medicaid Services.

In her testimony, Bresch says the company did not intend for its price hikes to hurt patients.

"Looking back, I wish we had better anticipated the magnitude and acceleration of the rising financial issues for a growing minority of patients who may have ended up paying the full [Wholesale Acquisition Cost] price or more," she says. "We never intended this."

Copyright 2016 NPR. To see more, visit NPR.
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Flabby And Fertile: How Men Age Could Be Huge For Humans

Wed, 09/21/2016 - 9:28am

Big muscles help young men find mates. But as men get older, losing muscle mass and testosterone might actually aid in reproduction.

Westend61/Getty Images

Most animals die once they can no longer have kids, but men and women tend to totally buck this trend, living decades beyond their reproductive years despite drastic changes in their bodies.

A book out in September, How Men Age: What Evolution Reveals About Male Health And Mortality, explores the toll that children take on their parents' bodies, how love handles and paunches can turn "evolutionary lemons into lemonade," and how men may be responsible for humans' relatively long lives.

Here's our conversation with author Richard Gutierrez Bribiescas, a biological anthropologist at Yale University, edited for length and clarity.

Let's start with a simple question. Why does hair go gray?

The cells that actually give your hair color are constantly bombarded by free radicals. And eventually the cells that make the pigment melanin, which colors your hair, go away and your hair turns the neutral color that you would see without these pigments. You see it in other animals, too. Dogs start getting a white muzzle.

On to bigger things. What are some weird things about humans when it comes to aging? Is human aging unique?

Human aging is primarily unique because it's not correlated with the end of reproduction. If you're a female, about a third of your life span is postmenopausal. That's huge and very, very strange.

We also provide care to the elderly. Older individuals who probably would not be able to survive on their own are able to survive well into their 70s and 80s with the help of relatives and friends. That's another thing that's very unique about humans.

Why do we age in the first place? Why don't we just live forever?

Aging and the evolution of sexual reproduction seem to go hand and in hand. An organism that has to reproduce requires energy and resources that would otherwise go to keeping it alive, like repairing or replacing damaged cells.

That reminds me of your quote that "natural selection does not care about your health or if you feel good." What does natural selection care about, if we're going to personify it?

Natural selection favors traits that allow us to reproduce more efficiently. This is the reason why we end up with organisms like mice, which live a couple of years if they're lucky, compared with elephants that can live 70 years.

Longevity is just one trait that will be selected for, but only if it serves to improve reproduction. And if it makes us feel good along the way, that's great. But that's not the goal of natural selection.

Reproduction comes with a huge cost. What's the toll that children can take on females?

It's known pretty well that the more females invest in reproduction, the more their lifespans are compromised. One of my colleagues in Poland, Grazyna Jasienska, did a demographic study on rural women and, looking at church records, showed that their lifespans were shortened by about 18 months for every child that they had. There's a pretty significant inverse relationship between number of children and lifespan, and this has been shown in different populations and other organisms.

Additional Information: How Men Age

What Evolution Reveals about Male Health and Mortality

by Richard G. Bribiescas

Hardcover, 177 pages |

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Why?

My lab's hypothesis has to do with oxidative stress. Every time you take a breath, you support oxidative metabolism, but you also generate toxins in the form of free radicals that cause you to age faster. They cause cellular damage and genetic damage, and it's the reason why you've heard about antioxidants. That's why you eat salmon and blueberries and things like that.

We hypothesized that the more children females have, the more bouts of oxidative stress they have — because every time a woman undergoes a pregnancy, the amount of oxygen that she uses goes up dramatically to support the fetus. So, we looked at biomarkers of oxidative stress in the women in rural Poland. And sure enough, the ones who had more children had higher levels for these biomarkers of oxidative stress.

How about for males?

The reproductive costs of males are a little bit different.

What's interesting is that a lot of the costs are associated with behavioral risks. For example, we know that between the ages of about 15 and 25, in pretty much every population including in nonhuman primates, there's a big increase in male mortality, and usually it's due to risky behavior. You end up seeing males do stupid things to procure mates. That's why it's very expensive to insure an 18-year-old if he has a car.

Risky behavior is one cost. The other cost is energetic.

Like big muscles?

Yeah, absolutely. Skeletal muscle is expensive. A calorie that is burned by skeletal muscle is one calorie that can't be used to repair a damaged kidney cell. So, having big muscles may be great for your social life, but it's not very useful if you have an infection.

Later in life, those muscles go away. If I'm a middle-aged man with love handles and a paunch, are those signs that I've failed?

I call it turning evolutionary lemons into lemonade, because as men get older, it's harder to keep muscle on, their testosterone goes down, and they may develop a little paunch. But it turns out that those traits — say, a little extra fat and lower testosterone — may actually help them reproduce later in life.

It was assumed that when females underwent menopause and stopped reproducing that men did the same. But there was a paper that came out a few years ago by this brilliant biologist at Stanford named Shripad Tuljapurkar. He showed that when you looked at non-Western populations, men sometimes have kids well into their 80s.

It struck me, because it suggested that perhaps the evolution of menopause or longevity might not totally lie with females, but actually with males. If males are reproducing at older ages, they're passing on those longevity genes not only to their sons but also to their daughters.

So, is it a failure or success? I think the ability to actually leverage this paunch in a way that makes you still able to produce children and to increase your fitness — I think you could put that in the win box.

One of your colleagues summarized your early research as "macho makes you sick." Why do men have shorter life spans than women?

Well, it just seems that the physiology of males make them more frail as they get older. And it seems to be universal.

Males and females tend to die of the same things once they get past older ages, like cancer and cardiovascular disease. But it turns out that males simply don't recover as well as females do.

For example, with infections, testosterone suppresses immune function. It's kind of ironic that the hormones and things that make men physically stronger are the same things that actually make males the more frail sex.

Males are the more frail sex. Is that a controversial statement?

No, I think people confuse strength and virility. The cost associated with the way males reproduce results in shorter life spans.

I think a lot of people assume that research going on in North America or Europe is true for all humans, but you say that's not necessarily so. What are some assumptions about aging that non-Western populations have overturned?

You turn on the radio and you hear these commercials for testosterone supplements. It's assumed that as you get older, your testosterone is going to decline and somehow that's bad and you have to fix that. But there's a lot of fuzziness around that assumption. For example, within the United States there's a huge range of variation in testosterone levels at younger and at older ages. They vary by tenfold and we don't know why.

So, what could be "low" or "high" really depends on the individual, and age only accounts for about 15 percent of the variation.

There is sort of a very faint signal to show that testosterone does decline with age in Western males. But it's not universal. If you look at hunter-gatherer groups, their testosterone levels don't change very much throughout their lifetimes. They start out with lower levels as adults and they pretty much maintain that their entire lives. So, the assumption that testosterone is going to change as you age is not necessarily true everywhere.

The other study we did was in Japan, where we looked at testosterone levels. And what we found was really interesting. These were urbanized men living in a suburb of Tokyo. And just like men in the U.S., their testosterone levels were highest when they were in their mid-20s and then they started to drop off. But after about age 40, their testosterone levels stayed constant.

We're trying to figure out why there's this difference compared with what you see in the United States.

So it's very interesting to understand where culture and biology are going to affect each other. And it's going to be reflected in things we may assume to be universal in terms of health. But we have to be cautious about that, because sometimes that's not the case.

Read an excerpt of How Men Age

Copyright 2016 NPR. To see more, visit NPR.
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Doctors Who Treat Opioid Addiction Often See Very Few Patients

Tue, 09/20/2016 - 12:01pm

Health care providers have to have permission from the federal government to provide medication-assisted treatment for opioid addiction.

The Washington Post/Getty Images

Many people struggling with opioid addiction can't find a doctor to provide medication-assisted treatment, even though it's highly effective. One reason could be that doctors who are qualified to prescribe the medication typically treat just a handful of patients.

Researchers at the RAND Corporation looked at pharmacy records from the seven states with the most doctors approved to prescribe buprenorphine, which helps people manage cravings and avoid withdrawal. They found 3,234 doctors who had prescribed the drug, also known as Suboxone, to new patients from 2010 to 2013. The median number of patients by a doctor treated each month was 13. About half of the doctors treated 4 to 30 patients; 22 percent treated less than 4; 20 percent treated 31 to 75.

"We were really surprised," says Dr. Bradley Stein, a psychiatrist and lead author of the study, which was published Tuesday in JAMA, the journal of the American Medical Association. "We found that only about 10 percent of doctors were what we would call heavy prescribers, with more than 75 patients a month."

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Only a fraction of the 4 million people thought to abuse prescription painkillers or heroin in the U.S. are getting medication-assisted treatment.

There's been a big push to make it easier for doctors to prescribe buprenorphine, including new rules announced by the Obama administration in July that raised the number of patients a doctor can treat from 100 to 275. But this data suggests that those limits aren't the only barrier to getting treatment to more people.

The researchers also were surprised to find that most patients weren't prescribed buprenorphine for very long, even though it can be used long term. The mean length of prescribing was 53 days per patient.

"This really brought home for us the need for multiple approaches, so doctors are willing and able to prescribe buprenorphine," Stein says.

Urban areas have typically been better equipped to provide treatment for opioid addiction, whether with methadone clinics or with buprenorphine, which people can take at home and doesn't require people a daily clinic visit. But many people struggling with opioid addiction live in smaller cities or rural areas where physicians have little experience with treating addiction to heroin and prescription opioids.

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That includes towns like Bridgton, Maine, where family physicians shied away from treating addicts until they realized that their own patients were the ones overdosing and dying.

Just taking an online course on how to prescribe buprenorphine won't be enough for many providers, Stein says, especially since many patients with opioid addiction also have other problems that need care. "We really need to think about providing mentorship, providing consultation, providing clinical support," Stein says.

Medication-assisted treatment is supposed to include counseling, and that can be hard to find, especially in rural areas. "So we may need to think about telehealth or online counseling," Stein says. "We may need to be creative to have people receive effective treatment, no matter where they live."

Treatment can work, "People can recover. They go on to live incredibly productive lives. And we want to have the high-quality treatment to get them there."

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

Weight Loss On Your Wrist? Fitness Trackers May Not Help

Tue, 09/20/2016 - 11:19am

They're so cute. So colorful. But are they really making you fitter?

Paul Marotta/Getty Images for Fitbit

Fitness trackers remain wildly popular, but do they make us fit? Maybe not, according to a study that asked overweight or obese young adults to use the tiny tracking tools to lose weight.

The 470 people in the study were put on a low-calorie diet and asked to exercise more. They all started losing weight. Six months in, half the group members started self-reporting their diet and exercise. The other half were given fitness trackers to monitor their activity.

After two years, both groups were equally active. But the people with the fitness trackers lost less weight.

Wait. What? We asked John Jakicic, a researcher of health and physical activity at the University of Pittsburgh and the lead author on the study, why this could be.

"These technologies are focused on physical activity, like taking steps and getting your heart rate up," says Jakicic. "People would say, 'Oh, I exercised a lot today, now I can eat more.' And they might eat more than they otherwise would have."

It's also possible, he says, that meeting daily fitness goals and step counts might motivate one person, but missing those same goals could discourage another.

The device in the study, which was published Tuesday in JAMA, the journal of the American Medical Association, wasn't a wrist-tracker like the Fitbits, Jawbones, Apple watches and Nike bands many use now. This device was worn around the upper arm. Instead of using heart rate to estimate activity like some devices do, it measured the heat generated by exercise.

Still, he says, the results from this study are relevant to the devices of today.

Overall the participants without fitness trackers lost 13 pounds, while the tech-enhanced group lost 7.7 pounds. They ranged in age from 18 to 35 years and had BMIs from 25 to 39. The study hopes to see whether helping young adults lose weight early on can head off more weight gain in middle age.

We reached out to Fitbit to see what it thought of the study.

"We are confident in the positive results users have seen from the Fitbit platform, including our wearable devices," the company said in a statement, adding that researchers use Fitbits and similar devices in clinical studies.

While those studies use wearable technology to investigate everything from heart disease to breast cancer, very few have looked at how good these trackers actually are at helping people achieve fitness goals.

"There aren't many — if any — long-term studies of wearable tech," says Dr. Mitesh Patel, an assistant professor of medicine at the University of Pennsylvania. Patel also studies fitness trackers but was not involved in this study. This study, Patel says, is the longest yet, "and that's why this research is important. We need more studies like this to show what wearable tech can and can't do."

A handful of short-term studies have looked at fitness trackers, with mixed results. One study, also conducted by Jakicic, found that fitness trackers could replace counseling in a weight-loss program. But another found that users get bored and abandon their wristbands after just a few months.

Ultimately, Patel says, these devices are most effective when the people using them are already dedicated to tracking their fitness. People who are less motivated might not get the same results.

"Overall, it doesn't look like assigning someone wearable technology will make that big of a difference," says Jakicic.

So should you bin your Fitbit? Not yet. Jakicic thinks that combining this technology with behavioral research can help scientists figure out which groups of people benefit from fitness trackers and even design interfaces that will be more motivational.

"These devices have some really cool tech, but how do you use them in a way that helps people?" asks Jakicic. "That's a science in and of itself."

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

Tax Rule Limits Care For Chronic Ills Under High-Deductible Health Plans

Tue, 09/20/2016 - 10:49am

Under Internal Revenue Service rules, high-deductible insurance plans that can link to health savings accounts can only cover preventive services, such as vaccinations and mammograms, until patients pay down their deductible.

Andrew Caballero-Reynolds/AFP/Getty Images

As the number of people covered by high-deductible health plans soars, some insurers and employers are easing the strain on consumers' wallets by covering certain benefits like doctor visits or generic drugs before people have reached their plan's deductible.

But there's a hitch: Under Internal Revenue Service rules, high-deductible plans that can link to health savings accounts can only cover preventive services, such as vaccinations and mammograms, until patients buy enough services on their own to pay down their deductible.

A bipartisan bill was introduced in Congress in July that would allow high-deductible plans that can link to health savings accounts to cover care for chronic conditions like diabetes and heart disease before plan members have met their deductibles.

HSAs were introduced in 2004, reflecting the popular belief that if consumers had more financial skin in the game they would make smarter, more cost-effective decisions. Individuals and their employers can deposit money into the accounts tax free, where it grows tax-free and can be withdrawn tax-free to use for medical expenses.

The accounts must be linked to health plans that meet certain federal standards, including minimum deductibles of $1,300 for individuals and $2,600 for families in 2016. The plans are required to cover preventive services without cost sharing, but consumers must pay for all other services until they meet their deductible.

Many high-deductible plans don't meet those standards. The deductible coverage restrictions for HSA plans can be a sticking point when employers and insurers consider which plans to offer.

"I've worked with numerous clients that chose not to pursue an HSA strategy because they wanted their employees to be able to get coverage not subject to the deductible," said Jay Savan, a partner at Mercer Health and Benefits, a consulting firm.

This legislation would lift those restrictions to some degree, but its passage is far from assured.

The law could make a big difference to Cheri Amos-Prater. Diagnosed with rheumatoid arthritis and psoriasis 10 years ago, the 54-year-old drug sales representative had been paying approximately $50 in monthly copayments to her health plan for Humira, a drug sold by AbbVie, the company she works for. This year, she switched to a high-deductible plan with a health savings account, not realizing that she would be responsible for paying the first $3,000 of her medical care to satisfy her deductible before her plan's coverage kicked in. Her Humira alone would have cost $2,100 in January. Unable to afford it, she stopped taking the drug.

"I didn't realize that in the fine print of the policy it said that if I made this choice I couldn't get the drug at a discount" until meeting the deductible, said Amos-Prater, of Birmingham, Ala. She plans to go back to a regular preferred provider organization plan next year.

The legislation has been endorsed by consumer groups and policymakers who are proponents of "value-based insurance design," which encourages health-plan features that nudge consumers to get clinically effective care by reducing or eliminating out-of-pocket costs for such services.

"We need to spend money differently," said Dr. A. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design. "We should put a very high deductible on those things we don't need and incentivize consumers to get the care they need."

For example, he said people with diabetes need to have annual eye exams to prevent adult-onset blindness, "yet the fastest growing type of health plan, HSA high-deductible plans, covers those exams not at all."

Twenty-nine percent of workers with employer-sponsored coverage are enrolled in a high-deductible plan with a savings account of some sort, according to the Kaiser Family Foundation's annual survey of employer-sponsored benefits, up from 17 percent in 2011. (KHN is an editorially independent program of the foundation.)

These enrollees also generally pay more out of pocket for care than do people in traditional plans. People in high-deductible plans were responsible for 24 percent of their medical costs between 2010 and 2014, on average, compared with 14 percent for people in traditional plans, according to a recent study by the Health Care Cost Institute that examined claims data from three major insurers for 40 million Americans. Annual per capita spending out of pocket was $1,030 on average for those in high-deductible plans compared with $687 for people in traditional plans.

Both employer-sponsored and marketplace plans often cover services before the deductible in plans. Two-thirds of plans on the federal marketplace exclude primary care visits from the deductible, according to Avalere Health. Similarly, the deductible doesn't apply to a majority of workers in employer-sponsored plans when they visit their primary care doctor.

Insurers that want to attract people, especially healthy people, realize that offering a plan with hardly any coverage before a huge deductible may not do the trick, said Caroline Pearson, senior vice president at Avalere Health, a research and consulting firm.

Still, it's unclear that insurers would jump at the chance to offer plans that are particularly attractive to people with chronic illnesses, said Linda Blumberg, a senior fellow at the Urban Institute's Health Policy Institute.

America's Health Insurance Plans, a trade group, has endorsed the proposed legislation, because it would give insurers more flexibility to design plans that ensure that consumers get the right treatment at the right time, said AHIP spokesperson Clare Krusing.

Even if there is the political muscle to pass the bill, it could be difficult to design plans that provide pre-deductible coverage for chronic conditions without pushing premiums up, said Pearson.

Advocates of value-based design "would say that if you're covering the right services, it shouldn't increase costs," she said. But how do you discourage coverage of the ineffective physician visits while encouraging coverage of the effective ones? "We are not yet particularly skilled about designing services that are nuanced," Pearson said.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter: @mandrews110

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

Reporter's Notebook: Pregnant And Caught In Zika Test Limbo

Tue, 09/20/2016 - 8:40am
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September 20, 20168:40 AM ET Heard on Morning Edition

From

A Florida Department of Health employee processes a urine sample to test for the Zika virus on Sept. 14 in Miami Beach.

Lynne Sladky/AP

I'm the health reporter covering the Zika story here at WLRN in Miami, and I'm a pregnant woman.

When Florida Gov. Rick Scott made free Zika testing available to all pregnant Floridians through the Florida Department of Health, I was one of the more than 2,200 women who took him up on the offer.

My station's main studios are five blocks south of the Wynwood Zika zone, an area that authorities are recommending pregnant women avoid (though the advisory was updated to a less dire warning on Monday). As it turned out, I had been inside the suspected transmission zone before we knew the risks.

So on the morning of Aug. 12, I went to my obstetrician's office, gave blood and urine samples and was told that it would take about seven to 10 business days to get my results.

Four and a half weeks later, I was still waiting. I had plenty of company.

My colleague Kate Stein has been helping me cover the story, whenever it veers into an area where the Centers for Disease Control and Prevention has advised pregnant women to avoid. Stein covered a Miami Beach town hall I didn't attend. There, she met Joseph Magazine, who pleaded with officials to help his wife get her Zika test results back. She was more than five months pregnant, had experienced Zika-like symptoms a month earlier, and was waiting to hear if she had been infected.

Press releases and other communications from the Florida health department officials have repeatedly insisted it takes one to two weeks to get results.

But at another town hall, after some pushing, Dr. Lillian Rivera, head of the Miami-Dade County Department of Health, said women may wait longer. "It could be four weeks, it could be five weeks," Rivera said. "We are preparing them for that."

Rivera was quick to point out that complete testing can take a long time, depending on the first round of results. That's because the Zika test for a pregnant woman can actually be a couple of different tests. The first test is to see if she has an active infection. If that's negative, there's a test to see if she has had the virus in the past 12 weeks. If that's negative, case closed.

Sammy Mack got tested for the Zika virus after realizing she had been in the suspected transmission zone in Miami while pregnant.

Courtesy of Sammy Mack

But if the second test is positive, or inconclusive somehow, then the woman's samples are sent to the CDC for an even more specialized test to confirm it's Zika and not dengue or another virus that can cause false positives.

As of last week, Florida had sent 174 tests to the CDC for clarification, including the tests of people who aren't pregnant. That total doesn't explain the backlog in which I was snarled.

Obstetrician Christine Curry, with the University of Miami and Jackson Health System, says it's helpful that all pregnant women in Florida can be tested. But getting timely test results is important, too.

"If someone's early first trimester or second trimester and we delay disclosure because we don't have a result by two weeks, four weeks, six weeks, eight weeks — that may be long enough for them to be out of the window of being able to terminate that pregnancy," she said.

Florida law restricts abortion access after 24 weeks. Later-term abortions are also more complicated procedures and more emotionally fraught for parents.

Delays in test results can change the way doctors screen the newborns of women who are still waiting on their Zika test results, Curry says. "Do we do more invasive, more aggressive testing? Do we do blood tests and urine tests and a spinal tap on the child?"

I spoke to Curry after I had been waiting more than a month for my results, and that image jars me: a spinal tap on my newborn because of a bureaucratic backlog on test results?

This is when I start to get nervous and angry.

Zonnia Knight, a fellow pregnant South Floridian, compares the waiting period for the test results to being told there are spiders in the room.

"You find yourself scratching, or looking around, swatting off ghosts and stuff," she says. "To me, there was a mosquito everywhere."

Knight waited three weeks with those ghosts before her Zika results came back. She was negative.

Dr. Christine Curry is an obstetrician who has treated pregnant women infected with Zika. She says the health of women and their babies may be in jeopardy when Zika virus test results are delayed.

Sammy Mack/WLRN

Another pregnant woman, Tracy Towle Humphrey, went to a private lab for her test and bypassed the health department. Without insurance, those tests can range from about $150 to almost $800.

Humphrey's insurance covered it, though. Within one week, she got her negative results back.

But she says for that week, she had trouble sleeping. She would wake up in the middle of the night "thinking, 'Oh my gosh, what if it's positive? What are we going to do?'"

After 4 1/2 weeks, I called the Florida Department of Health.

I didn't identify myself as a reporter. I was afraid that might affect my ability to get information on my own records. I was repeatedly told the health department doesn't give out results over the phone and they'll be sent to my doctor.

But after explaining a couple of times that I just wanted to know where my test was, I ended up talking to someone in the local epidemiology department who said she might be able to look up my test. She did, and I learned my test results were completed in the state lab in Jacksonville on Aug. 19 and Aug. 26.

So my completed tests were sitting there, I learned, for more than two weeks, and neither I nor my doctor had been informed of the results.

"Your story is completely consistent with my understanding," says Dr. David Andrews, who runs the pathology laboratories at Jackson Health System and is on faculty at the University of Miami's med school.

He told me he has had upward of 900 pregnant women waiting on their Zika test results. The backlog is so large, he can't even make a good calculation on the average turnaround time. "It is my sense that most of these specimens have been tested and are being tested in a reasonable amount of time, but the bottleneck appears to be getting us back the reports," Andrews says.

Mara Gambineri, a spokesperson for Florida's health department, sent an email that didn't specifically respond to my question about why it takes so long to release results once the tests are completed:

"The department has been working with area hospitals and providers, particularly in Miami-Dade County, to ensure doctors are receiving test results quickly and communicating the information with their patients. We continue to work to improve and streamline the process."

Another spokesperson named Sarah Revell said in the same exchange of emails:

"The department continues to dedicate significant resources to our public health labs and we have contracted with a private lab to assist with processing Zika tests quickly and accurately. Florida is the first and only state to offer such extensive resources to pregnant women and we are constantly working to improve our process."

On Wednesday, Sept. 14, Gov. Scott announced the CDC is sending seven more people to help out with labs and testing "in order to ensure pregnant women get results back faster."

On Friday, Sept. 16, a few hours after WLRN aired a story about the testing backlog and my wait, I got a call from the county health department asking for my doctor's contact information. They released my test results to my obstetrician, who shared them with me: They are negative.

Kate Stein contributed to this report. This story is part of a reporting partnership with NPR, WLRN and Kaiser Health News.

Copyright 2016 WLRN Public Radio. To see more, visit WLRN Public Radio.
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When Blind People Do Algebra, The Brain's Visual Areas Light Up

Mon, 09/19/2016 - 2:08pm
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September 19, 20162:08 PM ET Heard on All Things Considered Stuart Kinlough/Getty Images/Ikon Images

People born without sight appear to solve math problems using visual areas of the brain.

A functional MRI study of 17 people blind since birth found that areas of visual cortex became active when the participants were asked to solve algebra problems, a team from Johns Hopkins reports in the Proceedings of the National Academy of Sciences.

"And as the equations get harder and harder, activity in these areas goes up in a blind person," says Marina Bedny, an author of the study and an assistant professor in the department of psychological and brain sciences at Johns Hopkins University.

In 19 sighted people doing the same problems, visual areas of the brain showed no increase in activity.

"That really suggests that yes, blind individuals appear to be doing math with their visual cortex," Bedny says.

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The findings, published online Friday, challenge the idea that brain tissue intended for one function is limited to tasks that are closely related.

"To see that this structure can be reused for something very different is very surprising," says Melissa Libertus, an assistant professor of psychology at the University of Pittsburgh. "It shows us how plastic our brain is, how flexible it is."

Earlier research found that visual cortex could be rewired to process information from other senses, like hearing and touch. But Bedny wanted to know whether this area of the brain could do something radically different, something that had nothing to do with the senses.

So she picked algebra.

During the experiment, both blind and sighted participants were asked to solve algebra problems. "So they would hear something like: 12 minus 3 equals x, and 4 minus 2 equals x," Bedny says. "And they'd have to say whether x had the same value in those two equations."

In both blind and sighted people, two brain areas associated with number processing became active. But only blind participants had increased activity in areas usually reserved for vision.

The result suggests the brain can rewire visual cortex to do just about anything, Bedny says. And if that's true, she says, it could lead to new treatments for people who've had a stroke or other injury that has damaged one part of the brain.

Drugs or even mental exercises might help a patient "use a different part of your brain to do the same function," Bedny says. "And that would be really exciting."

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

For Some Seniors Without Housing, A Parking Lot Is Home

Sun, 09/18/2016 - 5:21pm
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September 18, 20165:21 PM ET Heard on All Things Considered

Marge Giaimo stands with her gold Oldsmobile, where she currently sleeps.

Gloria Hillard for NPR

Marge Giaimo makes her way to a picnic table under the shadow of an oak tree. Santa Barbara's trees, like its oceans and mountains, are one thing she says she never tires of here. After losing her senior housing three years ago, this table is where she does her painting these days.

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"I feel very fortunate to have my car," Giaimo says. "It's a little cramped, but it's softer than cement."

Of all her once-valued possessions, today her 20-year-old, gold Oldsmobile is her most important one. It is her home, and she keeps it as neat as a pin.

"And then this is where I sleep," she says. "I have the three pillows and I have sponges under there or foam to sleep on."

In the wealthy coastal city of Santa Barbara, north of Los Angeles, the demand for senior housing is so great the wait list is now closed. After all, California's senior population is expected to grow by 50 percent in the next decade.

For the seniors left out in the cold, their only option is living in their cars.

'It's Hard To Walk Away'

"It is a hidden population and a growing population," says Cassie Roach, who oversees Safe Parking, a city-funded program at the New Beginnings Counseling Center. "And it is quite different from the street homeless."

Safe Parking has designated 115 parking spaces in church, county and city lots where people living in their cars — such as Giaimo — can park safely overnight.

Roach says many of those living in their cars have fallen upon hard times for the first time in their lives.

Among them is 61-year-old Lise MacFarlane. She is grateful for one of those Safe Parking spots.

"I'm more comfortable sleeping now," MacFarlane says.

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MacFarlane says she lost the home she grew up in last December after being evicted by the new owner.

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"I was sleeping in front of my house and the park," MacFarlane says. "It's hard to walk away. That's it."

She shares her Toyota Highlander with her two dogs and a very large white cat named Willie.

"They don't like being in the car all the time," MacFarlane says. "They want to be in a home."

While most people are having dinner, MacFarlane rolls into her assigned church parking lot.

"It's really hard sitting in the car watching people, watching people I know go by," she says, crying.

Safety And Support

The sun has gone down, but Giaimo's gold Oldsmobile is hard to miss. It's parked a few spaces away from a Honda CRV owned by 74-year-old Barbara Harvey.

"We support one another very much," Harvey says.

"She puts up with me," Giaimo responds.

"There is no putting up with Marge, OK," Harvey says, laughing.

In this women-only lot, friendships are forged. There are seven designated spaces, and later in the evening a lot monitor stops by to check in on them.

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By 7 a.m. they will need to be gone.

The sound of a trash truck heralds the morning in this parking lot. Giaimo and MacFarlane are getting ready to leave for the day.

"It's dog walking time," Giaimo says. "Did I drop something out my trunk?"

"I think you did," MacFarlane responds.

"I can't find my brush. See, this is what we go through," Giaimo says, laughing. "Where did I put my brush?"

MacFarlane loads up her dogs as Willie the cat reluctantly makes room for them on the stacked blankets. Giaimo smiles and waves goodbye.

Giaimo's day continues with a shower at the Y. Then, she'll return to her picnic table.

The 75-year-old painter is on a wait list for senior housing in Santa Barbara. She's been told it could take another seven years.

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

Cancer Immunotherapy At A Crossroads

Sat, 09/17/2016 - 6:00am

The human body is on alert for malignant cells. Scientists and doctors are getting better at harnessing the human immune system as a weapon against cancer.

Coneyl Jay/Getty Images

It was in 1909 that Nobel Prize-winning German physician Paul Ehrlich proposed the idea that our bodies are fighting constant battles with cancer and that, thankfully, most of the time we win.

Ehrlich was a visionary in recognizing the interaction between cancer and the immune system. Specifically, that cancerous cells are continuously arising in the body but that our immune defenses in many if not most cases keep them at bay.

German physician Paul Ehrlich theorized that our bodies are always fighting off cancer and that usually we win.

U.S. National Library of Medicine

Now, after his and related ideas sputtered along for decades, the theory is at the core of one of oncology's hottest areas, immunotherapy, or the mobilization of the human immune system to fight malignancy.

Few would argue that in just the past few years this field has begun to transform cancer care. Newly approved immunotherapies have increased treatment options and improved patients' odds for a variety of tumors, while also allowing many with cancer to avoid, cut back on or delay chemotherapy. Former President Jimmy Carter's successful treatment for melanoma, including a regimen of immunotherapy along with radiation therapy and surgery, helped push the approach into the public spotlight.

Yet immunotherapy has faced some prominent setbacks. In August a clinical trial of the Bristol-Myers Squibb drug Opdivo, or nivolumab, for a group of patients with newly diagnosed lung cancer, unexpectedly failed as a first-line therapy. The announcement shaved $20 billion off the value of Bristol-Myers in a single day.

Though immunotherapy is generally more tolerable than chemotherapy and radiation, there are side effects to consider. Immunotherapies can cause symptoms like fatigue, nausea and diarrhea; and a recent case report review revealed a possible link between the medications and chronic arthritis.

And then there's the staggering cost, with some immunotherapies running well over $100,000 a year. The immunotherapy drug Yervoy, also from Bristol-Myers, is priced at $157.46 per milligram. "To put that into perspective, that's approximately 4,000 times the cost of gold," Dr. Leonard Saltz, of the Memorial Sloan Kettering Cancer Center, said at last year's American Society of Clinical Oncology Annual Meeting.

Perhaps the biggest question of all about immunotherapies is why don't more people respond to them.

Data presented at this year's American Association for Cancer Research Annual Meeting in April showed that over one-third of patients with malignant melanoma who were treated with Opdivo were still alive after five years, more than double the five-year survival rate for metastatic melanoma patients diagnosed between 2005 and 2011 who were treated with standard cancer therapies of the day.

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Yet as the AACR points out on its blog, "Despite the obvious cause for excitement, this means that about two-thirds of patients with metastatic melanoma who were treated with [Opdivo] had cancer that did not respond to the immunotherapeutic or progressed after initially responding."

And response rates for other tumors tend to be markedly lower: in lung cancer, for example, they hover around 20 percent.

Oncologists and scientists are now faced with determining why some patients respond and others don't, and also how to better predict which treatments are best for which patients. Equally important is understanding how the new treatments should be used with surgery, chemotherapy, and radiation; and whether or not, at least in some cases, immunotherapies can replace these more established options altogether.

Mobilizing the immune system

In 2016, over a century after Ehrlich first proposed his ideas, immunotherapy takes many forms: There are cancer vaccines, antibody therapies, and drugs that drive the immune system to fight off cancer.

But two newer immunotherapy approaches are generating particular buzz.

The first involves engineering a patient's own white blood cells to recognize and attack tumor cells. Called "CAR T-cell therapy," it's still experimental. But it has had some early success for blood cancers like leukemia.

Further along are so-called checkpoint inhibitor therapies. Normally our bodies have what are called immune checkpoints, mechanisms that restrain immune activity so our bodies don't attack our own tissues or get overly aggressive when fighting infection.

The only problem is that cancer can co-opt these off switches by sending out molecular signals that shut down our defenses. Checkpoint inhibitor drugs interrupt the signals cancers use to shield them from the immune system. While earlier immunotherapies broadly activate the immune system, these newer agents specifically boost the activity of a subtype of white blood cell called T-cells, which when activated can zero in on and destroy cancer cells. The improved selectivity reduces collateral damage and side effects.

There are now four checkpoint inhibitors approved for various cancers — including certain lung and kidney cancers, melanoma and most recently bladder cancer — with trials underway in nearly every major tumor type.

Shots - Health News Harnessing The Immune System To Fight Cancer

In addition to Opdivo, trial data presented at this year's ASCO annual meeting in June found another checkpoint inhibitor called Keytruda to be effective in advanced melanoma patients. Of the 655 patients in the study, 40 percent were still alive after three years. Other data presented at the meeting suggest that immunotherapies hold promise in a number of difficult-to-treat cancers, including including advanced lung, kidney, bladder and head and neck cancers and Hodgkin lymphoma.

Tailoring cancer care

But where do oncologists go from here? Can patient response rates go from improved to impeccable?

One way is by identifying biological markers that can predict treatment response in a specific person.

Researchers from the University of California, San Francisco recently reported that melanoma patients whose immune cells have higher levels of two checkpoint proteins called PD-1 and CTLA-4 respond significantly better to Keytruda therapy. The group is using the finding to determine which patients are more likely to respond to the treatment.

Similarly, the 15 percent to 20 percent of colorectal cancer patients with what is called an "MSI-high" subtype of tumor respond especially well to immunotherapy.

Another, perhaps more grueling method of improving patient response to immunotherapy is methodically determining how to use and sequence the new drugs with the vast armory of other cancer treatment options — and whether, in some cases, they could replace unpleasant stalwarts like chemo altogether.

"In melanoma this has pretty much already happened in many cases. We're often using these drugs as front-line therapy," says Dr. Elizabeth Buchbinder, an oncologist at the Dana Farber Cancer Institute in Boston. "However in other tumors it's a lot more variable and I think in general these will be something to consider alongside the other treatments."

Buchbinder explains that while melanoma patients treated with a single checkpoint inhibitor see response rates between 30 percent and 40 percent, those rates climb to 60 percent when a second immunotherapy is added.

"I think these will become part of a combination of strategies," concurs Sloan-Kettering oncologist Marcel van den Brink. "Just look at chemo. There are almost no situations where one chemotherapy alone would even come close to curing a cancer of any type. The big breakthroughs here came when we carefully figured out combination therapies."

Improving cancer outcomes will involve personalizing care in a variety of ways. After all, each of our bodies operates — and falls ill — at the hands of its own exclusive biology.

Shots - Health News A Scientist's Dream Fulfilled: Harnessing The Immune System To Fight Cancer

But van den Brink is hopeful about the possibility of profiling the microbiota to determine how certain bacteria in the gut can influence cancer immunotherapy. "The biome can stimulate T-cells all over the body," he explains. "Maybe we can come up with a strategy to foster a particular type of bacteria in a particular patient that improves treatment response."

Genetic interventions will also play an increasing role in customizing cancer care.

By sequencing not only the genomes of patients, but those of their tumors and even their immune cells specifically, oncologists will be better able to determine which treatments will work best in which patients.

University of Chicago oncologist Jason Luke says oncologists are already trying this.

"Even now we can use genetic techniques to look at which genes are turned on in the cancer tissue and to tell us whether immunotherapy is likely to work or not," he says, explaining that this technique could help identify patients whose immune system is already "primed for attack" and may need only an immunotherapeutic nudge, versus those that might also require chemo and radiation.

Luke also believes that tinkering with DNA using genome editing technologies like CRISPR could help doctors not only excise cancer-causing genes but also improve treatment efficacy. In fact, in June a federal biosafety panel approved the first study of the technique in humans — a study that aims to use the technique to augment cancer immunotherapy by genetically modifying immune cells.

"I think eventually we'll get to the point where we'll look at someone's tumor, immune system and genetics and say, 'This treatment is the way to go,' " foresees Buchbinder. "I think with time, immunotherapy will be part of many, many cancer treatments."

Van den Brink encourages optimistic caution: "We need to be honest here. These therapies look very powerful and promising, but a fair number of patients don't respond to them upfront," he says. "These aren't absolute cures for most people just yet."

Defeating one of humanity's oldest scourges, he says, has years of trial and error ahead.

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

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

HHS Issues New Rules To Open Up Data From Clinical Trials

Fri, 09/16/2016 - 12:11pm
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September 16, 201612:11 PM ET Heard on All Things Considered Simone Golob/Getty Images

Universities and drug companies that use human volunteers for research face tough new rules designed to make sure that valuable information from these volunteers is widely available, not only to the volunteers themselves but to scientists trying to advance medical science.

The rules currently on the books are confusing and often ignored.

Since 2007, scientists have been required to post results of experiments on a government website, ClinicalTrials.gov. But many top universities and drug companies have failed to meet those standards, according to academic studies and investigative journalists.

"We as a community have had a disappointing track record," said Francis Collins, director of the National Institutes of Health. Collins and other officials are now hoping that will change with clearer, more expansive rules and potentially stinging new penalties put forth by the Department of Health and Human Services.

The new rules, published Friday in the Federal Register, are designed to make it easier for scientists, universities and corporations to understand what experiments must be included in the federal database. It also expands the list of studies that must be registered, to include experimental behavioral interventions — such as a study that compares different diets among diabetics — as well as early-stage (Phase 1) drug trials if they have NIH funding.

Shots - Health News Results Of Many Clinical Trials Not Being Reported

For the first time, these rules also require companies to post results of trials for drugs that don't make it to market, not just the ones that do. "This has been a very opaque world up until to now," Food and Drug Commissioner Robert Califf told reporters during an embargoed phone conference Thursday. "These are tremendous changes."

Researchers must also say in advance how they plan to analyze their results. That is designed to discourage researchers from changing the focus of a study after the fact and dredging through their data to highlight findings that may simply be coincidental, and which might not be robust enough to appear in a study that was specifically designed to look for them.

Clinical trials "are the gold standard for understanding the effect and effectiveness of medical interventions, understanding what works and what doesn't work," Collins said in the press conference.

If information from them is widely shared, it can help scientists identify potentially serious side effects, and it can help scientists avoid wasting federal tax dollars by conducting redundant studies. Right now, scientists often don't report their failures, so other researchers may try the same useless strategy.

Reporting results is also an ethical issue. Millions of patients volunteer to participate in studies, Collins said. "Sharing the results from clinical trials helps fulfill society's responsibility to those individuals who volunteered in these studies with an understanding that their participation will contribute in advancing medical knowledge."

Shots - Health News Medical Studies Involving Children Often Go Unpublished

For studies that are regulated by the FDA, companies can face fines of $10,000 a day if they don't comply with the existing rules. Those fines have not been imposed, however, and the FDA will not have additional funding to hire enforcement staff, Califf said. "I really believe that it won't take much to get people to comply with this once they realize how serious this is."

Collins said the NIH will cajole university scientists to comply as well. If they don't, the NIH would consider withholding funds on planned clinical trials at the offending university until scientists there are following the new rules. This would not apply to research that started before the rules take effect, and the NIH would not stop clinical trials that are already under way.

The new rules come into effect in January 2017. Researchers will have 90 days to comply.

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

Yes, People Really Are Driving While Playing Pokemon Go

Fri, 09/16/2016 - 11:14am

Sure, you could get run over trying to catch that Zubat. But is it worth it? They're the worst.

Mike Coppola/Getty Images

Pokemon Go trainers will do almost anything for a rare find, including getting into a car and speeding around to catch them. And then they tweet about it. According to a study, there were over 113,000 social media messages in 10 days last July that showed people getting into potentially unsafe traffic situations while trying to catch cute virtual monsters.

One Twitter post came from the Baltimore Police Department, which posted body camera footage of officers talking on the sidewalk late at night on July 18. In a moment, an SUV strikes their parked cruiser and skids down the street.

"Are you OK?" one of the officers says while hurrying up to the car.

#PokemonGO is not all fun and games. Here is a video of a distracted driver who struck one of our cars. #PlaySafe pic.twitter.com/kOTfbTcILo

— Baltimore Police (@BaltimorePolice) July 19, 2016

"That's what I get for playing this dumbass game," the driver replies. He shakes his head at his phone and palms his face.

A lot of people have been dangerously close to getting into similar accidents, according to the study published Friday in JAMA Internal Medicine.

In an effort to plumb how much of a menace players of the wildly popular augmented reality game present, the researchers analyzed 345,433 tweets between July 10 and 19 that contained the words "Pokemon" and "driving, drives, drive" or "car."

You know you've got an honest guy when he feels guilty clicking the "I'm a Passenger" button on PokemonGO while he's driving.

— Miriam (@okmir_) September 10, 2016

Eighteen percent of those showed that someone was playing and driving. Eleven percent suggested a passenger was playing, and 4 percent suggested a pedestrian was playing near traffic.

It's difficult to assess from Twitter just how big the problem is overall. Not everyone uses social media, and of the people who do tweet, not all of them will post about their motor vehicle adventures with Pokemon Go. "[So] we know we're undercounting," says John Ayers, a big data scientist at San Diego State University and an author of the study.

Driving kids home from school....a #Charizard appears! I pulled over to catch him

Categories: NPR Blogs

Studies Link Cancer Patients' Survival Time To Insurance Status

Fri, 09/16/2016 - 5:00am

Eliminating disparities in cancer care requires more than just expanding Medicaid coverage, say cancer epidemiologists who found that patients with private insurance seemed to have a survival advantage.

Thomas Barwick/Getty Images

Privately insured people with cancer were diagnosed earlier and lived longer than those who were uninsured or were covered by Medicaid, according to two recent studies.

In one study, researchers examined data from more than 13,600 adult patients who had glioblastoma multiforme, the most common type of malignant brain tumor, between 2007 and 2012. The other study analyzed data from more than 10,200 adults who were diagnosed with testicular cancer between 2007 and 2011.

Both studies, published online in the journal Cancer in August, relied on data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. SEER tracks cancer incidence and survival in the United States.

The two cancers generally progress very differently. Glioblastoma multiforme is very aggressive; patients generally don't live much more than a year following diagnosis and the five-year survival rate is less than 5 percent. Conversely, testicular cancer responds well to chemotherapy even if it has spread to other parts of the body. The five-year survival rate overall is 95 percent.

But regardless of cancer type, patients with private insurance had a survival advantage.

In the testicular cancer study, uninsured patients were 26 percent more likely to be diagnosed with metastatic disease (meaning their cancer had spread elsewhere) than privately insured patients. Medicaid patients were 62 percent more likely to have metastatic disease.

Shots - Health News N.J. Factory Turns To Medicaid To Insure Lowest-Paid Employees

Though the Medicaid patients fared worse than the uninsured patients in this regard, that might be because, until recently, some of them, too, had been uninsured, the researchers say, and only enrolled in Medicaid after their cancer was diagnosed.

Compared to privately insured men in the study, uninsured men were 88 percent more likely to die of the cancer, and Medicaid patients were 51 percent more likely to die of the disease.

A similar pattern emerged in the glioblastoma multiforme study. Patients who were either uninsured or on Medicaid were more likely to have a larger tumor at the time of diagnosis. An uninsured patient was 14 percent more likely to have a shorter survival time than someone who was privately insured, while a patient on Medicaid was 10 percent more likely to have a shorter survival time, the study found.

There were some treatment differences, as well, between the patients with private insurance, and those who either had Medicaid or were uninsured. And those treatment differences could affect survival.

"We were expecting that the uninsured would do worse than insured patients, but we didn't expect that Medicaid patients would do significantly worse than [privately insured] patients," said Dr. Wuyang Yang, a research fellow at Johns Hopkins University School of Medicine, who co-authored the study about patients with brain tumors.

Sarah C. Markt, the lead author on the testicular cancer study, says she found the Medicaid results in their study striking as well. The findings indicate that eliminating disparities in cancer care requires more than just expanding Medicaid coverage, says Markt, a research associate in cancer epidemiology at the Harvard T.H. Chan School of Public Health. Under the health law, roughly two-thirds of states and the District of Columbia have expanded Medicaid coverage to adults with incomes up to 138 percent of the federal poverty level (about $16,400).

"These are young men dying of a potentially curable disease," Markt says. "There are many opportunities for improvement here."

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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Kitten Conundrum: Cat-Scratch Disease Is Making People Sicker

Thu, 09/15/2016 - 11:37am

Fleas carry the bacteria that cause cat-scratch fever, so if your kitty is flea-free, you should be in the clear.

Sara Lynn Paige/Getty Images

Cat-scratch disease, as the name suggests, is spread by cats. It has long been considered a mild illness, but a study finds that people are getting more serious complications, which can be fatal.

"The scope and impact of the disease is a little bit larger than we thought," says Dr. Christina Nelson, a medical epidemiologist with the Centers for Disease Control and Prevention and lead author on the study. It's the first large-scale evaluation of the illness in the United States in over 15 years.

While the total number of people infected with the disease has gone down, the number of people becoming seriously ill has increased. Symptoms typically involve fatigue, fever and swollen lymph nodes. But in a small number of cases, cat-scratch disease can cause the brain to swell or infect the heart. Infections like those can be fatal if they aren't properly treated.

"Most of the people who get seriously sick from cat-scratch are immunocompromised. The classic example is patients with HIV," says Dr. Aaron Glatt, chairman of medicine and hospital epidemiology of South Nassau Community Hospital in New York. Glatt was not involved in the study.

The fact that there are more people with suppressed immune systems today may be why a larger number of patients are getting dangerously ill, Glatt says. But Nelson thinks that severe cases of cat-scratch disease may have been misdiagnosed in the past. Either way, she says, this study, which was published Wednesday in Emerging Infectious Diseases, is a good first step.

"Cat-scratch is preventable," Nelson says. "If we can identify the populations at risk and the patterns of disease, we can focus the prevention efforts."

It's preventable because you need direct contact with a cat to get it. The disease is caused by bacteria, usually Bartonella henselae, and passed between cats by fleas. The bacteria are also present in flea dirt — the official name for flea feces — which build up in the cats' fur. It gets on their paws and in their mouths when they groom themselves. If a person is scratched by contaminated claws, they're at risk of getting the disease.

The study combed health insurance claims from 2005 to 2013, and charted when and where cat-scratch disease is most likely to strike. It found that about 12,000 people will be diagnosed with cat-scratch disease each year, and 500 of them will be sick enough to be hospitalized.

Many of those infected will be children, probably because of the ways kids play with cats. And most of the infections will occur in the South, where heat-and-moisture-loving fleas are more common.

If you want to avoid cat-scratch disease altogether, says Nelson, go somewhere arid — like Colorado or Utah.

But moving to the Rockies isn't an option for everyone. If you're in the South, how can you skip cat-scratch?

"Stay away from cats," says Glass, although he acknowledges that in a country full of cat lovers, this isn't really realistic.

"Use adequate flea control and keep your cats indoors," suggests Nelson. The bacteria can also enter your body through your nose, eyes or mouth, so the CDC recommends washing your hands after touching a cat. Letting them lick you if you have any scrapes, scabs or open wounds isn't a good idea.

Oh. And avoid kittens.

"Younger cats are more likely to have bacteria in their blood," explains Nelson. Kittens aren't immune to cat-scratch, so they're an easy target for the bacteria.

So try not to let Felix kiss you ... at least until he's flea-free.

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

Life After A Brain Injury: 'I'm Not Terrified Of Death Anymore'

Thu, 09/15/2016 - 11:28am

Tim Page, former music critic for The Washington Post, is rebuilding his life after a traumatic brain injury in July 2015.

Maggie Smith/Courtesy of University of Southern California

Tim Page is no longer afraid of death. That's the one positive takeaway for him after surviving a traumatic brain injury.

Last year, the University of Southern California music and journalism professor — who was also a child prodigy filmmaker, Pulitzer-winning critic, person with Asperger's and father of three — collapsed at a train station. He woke up in an ambulance speeding to the hospital. He's still recovering, still fumbling a bit with the jigsaw pieces of a life a now a little more puzzling, a little more amazing.

Deceptive Cadence Critical Condition: Revisiting Composer Virgil Thomson's Masterful Prose

Page, 61, has a new book out, Thomson: The State of Music & Other Writings, which is the second volume of works he's edited by the American critic and composer Virgil Thomson. Over at NPR Music, we had a long discussion about Thomson, his legacy and the state of classical music criticism in America. I should mention that Page was my mentor while he was classical music critic for The Washington Post. He was unflagging in his support of a greenhorn stringer. For two years, I read my reviews to him over the phone before I filed them. Then there were the "Brewtorials," our meetings at pubs to mark up reviews with red pens.

As you can read in our conversation, Tim has lost none of his generous spirit. This account has been edited for length and clarity.

You recently wrote a harrowing and sometimes humorous account of your continuing recovery from brain surgery you had just 13 months ago. First, may I ask how you are doing?

Well, thank you, and I'm really glad you mentioned that piece because I am quite proud of it. [In July 2015] I was in New London, Conn., waiting for a train to Washington, when all of a sudden I woke up in the back of an ambulance. It was as if I blinked my eyes and I was in another world. And I didn't even remember who I was or anything like that. It was like being just knocked off the face of the Earth.

An acute subdural hematoma, a clot of blood in the tissue surrounding the brain, put pressure on Page's brain. Surgery was required to save his life.

Courtesy of Tim Page

I had what is called an acute subdural hematoma with transhemispheric tentorial something or other. And it turns out that the kind I had kills outright something like three-quarters of the people who have it. The people who survive manage to, some of them, come back as I did, but it's a tiny amount. And a lot of survivors are permanently disabled. I was fortunate enough that I wasn't seriously damaged intellectually.

I don't happen to be religious at all, but I do believe that if you come so close to death and are fortunate enough to be spared, you have a duty to tell what it was like, especially if you are a writer. So many people have had these things over the centuries and, you know, very few people live to tell.

Well I must say it's a beautiful essay about being dealt a pretty bad hand. I imagine that it was, without sounding too clichéd, cathartic to write it. I'm wondering also if you've heard from others who have suffered a TBI?

Yes, I've had a tremendous response to it. I got a lovely letter from the wife of a gentleman who had a terrible traumatic brain injury. And he couldn't write to me himself, but she wrote a letter telling me that he was grateful. I wouldn't call it cathartic to write; it was a real bitch to write. It was the hardest thing I ever wrote. But I will say it was cathartic to finish it.

Another result of your injury is how you fully embraced Facebook, and how much love you got back from your legions of Facebook friends throughout your ordeal.

It was vastly important. It was a chance for me to keep in touch with people. When people would write me something or send a compliment I could just reach out and press "like," which acknowledged my gratitude. And then, every week or so, I would work hard on a paragraph that told my friends what had happened and what was happening now. I'm addicted to it. But in part because it's really all I can do now without a lot of work. I'm not very good talking on the phone now, at least most of the day.

I think a lot of people feel like Facebook is a good place to be validated and, frankly, to be loved.

I don't care that much about validation these days. I care about communication. I do care a lot about being loved and hearing from people who matter to me. But that's not really the main reason I do it. Look, I've been a writer and I've been a radio guy. With Facebook, I can put up a gorgeous recording that I love and let others play that for themselves. Or I can grump about something and get really smart responses from all over the world. So it's for me it's a blast — a great way for a near-recluse to have a public life.

You say you're better in public than in private. And that resonates in the book that you wrote called Parallel Play, which is a frank account — again told with a mix of anguish and humor of living with Asperger's syndrome. You were 45 years old when you were finally diagnosed in 2000. In one passage you wrote, "It would be easier for me to improvise an epic poem before a sellout crowd at Madison Square Garden than approaching an attractive stranger across the room and strike up a conversation." Do you still feel that way?

Absolutely. I'm not sure about the epic poem. I think I was exaggerating. But very, very definitely, because I've spent pretty much all of my life in public, from A Day With Timmy Page, which showed me as a filmmaking prodigy when I was about 12.

I was always used to being able to talk to a group. But I'm still paralyzingly shy if I'm just talking to somebody who attracts me and I don't have anything immediately to talk about. If they're interviewing me or if they're in my class or if they're old friends that's a very different matter. I never go to parties. I'm pretty much a recluse. And yet I have this urge to communicate and to reach lots of people.

You must have been relieved when you got the Asperger's diagnosis.

It explained a hell of a lot. And after that I learned how to prepare myself for things. There are times where I have to go to concerts or parties with strangers and basically I can sort of make a deal with myself like, "Well, this is only going to take an hour, and so I'll just act for an hour and then I'll be fine."

Author Interviews Undiagnosed Asperger's Leads To 'Life As An Outsider'

And you know, it's funny — one of my early friends and mentors, Glenn Gould, who I swear was on the autistic spectrum, was the same way. He used to talk about the years before he quit performing live when he was 31, and he said the only way he got through those last years on the concert stage was a recognition that this was bringing him acclaim and was gradually preparing for him to do what he wanted. And then he finally got to a point where he didn't have to do it anymore. And that's sort of the way I feel about my own arrangements with myself. I remain convinced that Asperger's syndrome is responsible as much for my triumphs in my life as it is for a lot of loneliness and a lot of unhappiness that I've also experienced.

Do you feel any differently since the brain injury?

Not a whole lot, really. I don't have the energy I once had and can't work as hard as I once did. I am damaged, you know, and I'm very upfront about that, and people accept it. But I'm still pretty much here, intellectually speaking, and there are still things that I want to do and can do, however slowly. I want to collect the writings of Seymour Britchky, the greatest of all restaurant critics, whose articles sum up the New York City I loved in the 1970s and 1980s better than anything else. I'd like to record the suite I created for the St. Louis Symphony from the Musica Poetica of Carl Orff and Gunild Keetman. And a lot of other things too.

Still, if I don't get to do these things there is now a side of me that is resigned and pretty much says the hell with it. I wrote or edited more than 20 books. I gave radio premieres to hundreds of new works. I founded a record company that made some interesting discs. I put Glenn Gould's ideas into a book and helped rediscover Dawn Powell. I have three wonderful sons and I've helped set some brilliant young people on their paths. I'm not trying to brag, but if I want to rest now and spend time mostly with the people I love, that's what I'll do. I've earned that rest.

One of the only really good things that came out of this catastrophe for me was I spent almost all my life terrified of death, and I'm not terrified of death anymore.

Wow. So what's making you happy these days?

The same things that always did: people, music, film, literature. Teaching at USC is the best job I've ever had. Despite my troubles over the last year, that capital-D depression that affected me almost all of my life isn't really there anymore.

I thought maybe you would mention your little puppy.

Page says that having his dog Mila to care for has been restorative.

Courtesy of Tim Page

Mila! I got my little terrier when I was just not able to do much of anything last fall. She came from the South Los Angeles pound. And to have something to care for and something that so obviously cares for me has been so restorative.

I have to say that I have a greater and greater respect for dogs than ever. I am astounded by how much they seem to know. I traveled across the country alone for the first time since my brain injury almost exactly a month ago. And somehow when Mila got her service dog uniform put on, I don't know how she knew it, but she knew she was now doing a duty, and just sat on my lap and looked out for me.

Another thing that interested me in your essay about your brain injury was what you call your music therapy.

[Music] requires intense concentration now, whereas for years it was something I could listen to but I could also do other things. Back in the day I never had any trouble multitasking. These days, I have a fair amount of trouble even uni-tasking. I'm finding myself often with my eyes shut listening to music that I know a little bit but not that well and becoming profoundly interested in where it will go. It's kind of a way of putting the world together. It reminds me of when I was a boy and wandering in the woods and finding a road and then finding a path and then a road and finding, eventually, my way home.

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

Yes, It Is Possible To Get Your Flu Shot Too Soon

Thu, 09/15/2016 - 5:00am

The start of flu season is still weeks or months away, but you can get a flu shot now at many pharmacies. "It's a way to get people into the store to buy other things," says Tom Charland, an analyst who tracks the walk-in clinic industry.

Darron Cummings/AP

The pitches from pharmacy chains started in August: Come in and get your flu shot.

Convenience is touted. So are incentives. CVS offers a 20 percent-off shopping pass for everyone who gets a shot, while Walgreens donates toward international vaccination efforts.

The start of flu season is still weeks, if not months, away. Yet marketing of the vaccine has become an almost year-round effort that starts when the shots become available in August and is hyped as long as the supply lasts — often into April or May.

Not that long ago, most flu-shot campaigns started as the leaves began to turn in October. But two things have stretched the flu-shot season: the decade-long increase in the number of drugstores that have a retail medical clinic inside, and state laws that allow pharmacists to give vaccinations.

Drugstores have figured out how "to deliver medical services in an on-demand way," says Tom Charland, founder and CEO of Merchant Medicine, which tracks the walk-in clinic industry. The approach appeals to customers, particularly millennials, and turns out to be good business.

"It's a way to get people into the store to buy other things," Charland says.

But some doctors warn that the marketing may be overtaking medical wisdom, since it's unclear how long the immunity imparted by the vaccine lasts, particularly in older people.

Federal health officials say it's better to get the shot whenever you can. An early flu shot is better than no flu shot at all. But the science is mixed when it comes to how long you'll get optimal protection from a flu shot promoted and given during the waning days of summer; the typical flu season peaks in midwinter or beyond. Immunologists and public health officials are divided on how patients should respond to such offers.

"If you're over 65, don't get the flu vaccine in September. Or August. It's a marketing scheme," says Laura Haynes, an immunologist at the University of Connecticut Center on Aging.

A combination of factors makes it more difficult for the immune systems of people older than 65 to respond to the vaccination, she says, and the protective effect may also wear off faster than it does in young people.

So, when is the best time to vaccinate?

The Centers for Disease Control and Prevention advises physicians that it's safe to make flu shots available to all age groups whenever the vaccine becomes available, each year. While "delaying vaccination might permit greater immunity later in the season," the CDC notes, citing evidence from a 2013 study, that "deferral could result in missed opportunities to vaccinate."

How long will the immunity last?

"The data are very mixed," says Dr. John J. Treanor, an infectious disease specialist at the University of Rochester medical school. Some studies suggest vaccines lose some protectiveness during the course of a single flu season. Flu activity generally starts in the fall, but peaks in January or February and can run into the spring.

"So some might worry that if [they] got vaccinated very early and flu didn't show up until very late, it might not work as well," he says. But other studies show "you still have protection from the shot you got last year," Treanor adds, "if it's a year when the strains didn't change."

In any given flu season, the effectiveness of immunization varies, partly dependent on how well the vaccine matches the strain of flu virus that's predominant that year. In the overall population, the CDC says studies show a vaccine can reduce the risk of flu by about 50 to 60 percent when the vaccine is well-matched.

It's especially important to vaccinate children, to help keep parents and grandparents healthy, as well as the kids themselves, doctors say. While most people who get the flu recover, it is a serious disease responsible for many deaths each year, particularly among older adults and young children.

The intensity of illness provoked by each influenza strain can vary, too; U.S. deaths associated with the flu have ranged from about 3,300 a year to 49,000 in the past 31 seasons.

To develop vaccines, manufacturers and scientists study what's circulating in the Southern Hemisphere during its winter flu season — June, July and August. Then, based on that evidence, they forecast what flu strains might be circulating in the U.S. the following November, December and January, and incorporate that information into flu vaccines that are generally ready by late July.

For the upcoming season, the vaccines will include three or four strains — including two influenza A strains, an H1N1 and an H3N2, as well as one or two B strains, according to the CDC. The federal health officials recommend that everyone older than 6 months gets vaccinated, unless they have a health condition that would prevent it.

The vaccines can't give a person the flu because the virus is killed before it's used in the shot. This year, the nasal vaccine — a squirt of liquid that includes a live attenuated virus — is not recommended for use, as studies showed it was not effective during several of the past flu seasons.

So, talk to your doctor, and weigh your options for the timing of that flu shot. "The ideal time is between Halloween and Thanksgiving," says Haynes, who specializes in the immunity of older people. "If you can't wait, and the only chance is to get it in September, then go ahead and get it. It's best to get it early rather than not at all."

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente. Follow Julie Appleby on Twitter: @Julie_appleby.

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

Trying To Get The Kids To Put Down Those Phones? Here's Help

Wed, 09/14/2016 - 3:07pm
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My mother swears I learned to read by watching The Electric Company on TV, so maybe that's why I was initially a bit lax when it came to my daughter and screen time.

But after realizing she would be perfectly content to spend every free minute switching between the PBS Kids app and toy unboxing videos on YouTube, my husband and I drew several lines in the sand and drastically limited her screen use by both time and content.

She's only 4, which means that we still face years of decisions surrounding smartphones, Minecraft, Snapchat and the yet-to-be developed apps, games and devices that will be competing for kids' attention in the years to come. And it's not only her I'm worried about; my own habits of constantly checking email after 6:30 p.m. and reading political Facebook posts at any hour make me anxious.

In short, like many parents, I'm confused.

Most families have accepted digital technology into their homes, but many of us are unclear on how to use it wisely. And we worry about the mental and physical effects that excess tech may be having on our kids and ourselves. Melanie Hempe, founder and executive director of the nonprofit Families Managing Media in Charlotte, N.C., says she is concerned that overuse of digital technology isolates, rather than brings together, parents and kids both emotionally and physically. It also takes them away from activities that are shown to benefit their bodies and brains, like playing outside with a friend or reading a book. Here are some guiding principles for parenting in the digital age from conversations with Hempe and other experts:

Be aware that not all tech is the same. Rather than making rules based strictly on screen time, figure out what your kids are actually doing when they're on the computer or their phone, says Devorah Heitner, who founded Raising Digital Natives and is the author of Screenwise: Helping Kids Thrive (and Survive) in Their Digital World. Ask them to show you exactly which sites they visit and how they spend their time. They might be doing homework, composing music or writing a novel. Or they might be playing a first-person shooter game or following the Kardashians' every move on Instagram. Your limits on their use are likely to vary accordingly.

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If you're concerned about compulsive use, current research suggests that online games seem to be the technology most likely to "potentially result in problems," says Daria Kuss, a psychologist and member of the International Gaming Research Unit at Nottingham Trent University in the U.K. "They're highly interactive and can engage players to such an extent that they easily forget about the time and their environment." (Internet gaming disorder is identified in the current Diagnostic and Statistical Manual, the DSM-5, as a condition that warrants further study.) That doesn't mean your kid can't game, but it does mean you might want to be more alert to the potential for problems if that's his main online activity.

Think about the role tech plays in your family life. "You should be focused on your values and what you think is important," says Hempe. Does everyone sit around the living room watching their own shows on their own iPads? Maybe it's time to institute family game or movie night. Can your children name three things they like to do as much as or more than an online activity? If not, maybe it's time to help them broaden their horizons. Do you spend more time posting witty remarks on Twitter than saying them out loud to your spouse? Schedule a regular tech-free date night.

Model good behavior, online and off. "We've fallen into this mental sinkhole where we get a communication and feel we have to respond to it," says Larry Rosen, a psychologist and professor emeritus at California State University, Dominguez Hills. That didn't happen overnight, but by now many people feel compelled to check social media constantly and to read and respond to emails and texts within minutes.

"We act out of this creeping anxiety of not being current," says Rosen, who is co-author of The Distracted Mind: Ancient Brains in a High-Tech World. And if your kids see you drop everything to respond to an email during dinner, they're going to get the idea that it's OK to drop everything and respond to a text during their homework.

Rosen suggests weaning yourself by taking increasingly long tech breaks during the day, starting at one minute and working up to 30 minutes. And help kids with their own connectivity anxiety by telling them they're not bad friends if they aren't immediately answering a late-night text, says Heitner. "Model boundaries, and model being unplugged," she says.

Also, show your kids when and how to take your communications offline. "Show you need to be able to go to someone face to face to resolve relationship difficulties," says Heitner. "Show them how to move away from an Instagram comment to 'I'm sorry I hurt your feelings.' "

Have tech-free zones and times. One way to help everyone curb overuse is to create tech-free zones, says Rosen. Those can be geographical, like banning technology at the kitchen table or bathroom. Removing smartphones and tablets from the bedroom is also helpful — at the very least, take out the devices a few hours before bedtime, since for a variety of reasons, they seem to contribute to poor sleep.

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One 2014 review of research found an association between more screen time and later bedtimes and shorter sleep lengths in kids and teens. And a study published this year found that young adults who reported greater social media use also had greater odds of a sleep disturbance.

You can also carve out time or situations where no tech is permitted. Ann Steel, a licensed mental health counselor and former practicing physician in Seattle who sees a lot of patients with technology dependence, suggests one family tech-free day a week. Or require everyone to turn devices off during family dinners or car rides.

Let them learn for themselves. Heitner is a firm believer in allowing your kids to come to their own conclusions about tech when at all possible. That may mean allowing them to face the natural consequences of staying up late chatting online the night before a test. Or it could be letting them figure out for themselves the benefits of being unplugged during tech-free periods like sleepaway camp. But on the other hand, you know your kids, and it's perfectly fine to step in and curb their technology adoption if you think they can't handle it. "If you think your kid is too immature to get a phone, don't discount that," she says.

Keep an eye out for signs of serious trouble. "There's a continuum of behavior," says Heitner. Just because you have a hard time tearing your child away from Minecraft doesn't mean he's "addicted." But in some cases kids can have serious issues with technology — whether it's gaming, social media or something else — that require professional help. If your kid is using tech to the exclusion of things like sleeping, friends and school and can't change his or her ways, Steel says, it may be time to seek out therapy.

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.
Categories: NPR Blogs

Employees Are Paying A Bigger Chunk Of Health Insurance Costs

Wed, 09/14/2016 - 11:05am
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September 14, 201611:05 AM ET Heard on All Things Considered John Labbe/Getty Images

High deductible health plans are the new normal.

Just over half of employees this year have a health insurance policy with a deductible of at least $1,000, according to a survey of employers from the Kaiser Family Foundation.

It's the continuation of a multiyear trend of companies passing more of the costs of employee health care back onto workers.

Overall, health insurance premiums for a family covered by an employer health plan rose an average 3 percent this year to $18,142. Of that, employees pay an average of $5,277.

Historically, that's not much of an increase. But it still outpaces the rate of inflation, so it takes a larger chunk of worker income and employer profits.

"There's been a gradual sea change in what insurance is for most Americans, from more comprehensive coverage to skimpier coverage," says Drew Altman, president of the Kaiser Family Foundation.

Covenant Care, a Pensacola, Fla.-based hospice and home health care nonprofit, is one organization that has made the switch. About 450 of its 600 workers now have high-deductible health plans.

"At Covenant, we pay 80 percent of the costs of the plan and even at that point, there are some business decisions that need to be made regarding what we can afford to do," says Pat Holtman, senior manager of human resources.

She says the company offsets some of that deductible by putting cash into accounts that workers can use for health care costs. And if employees participate in wellness programs, they get points to pay even more.

That includes doing a health risk assessment at the beginning of the year. "If they go online and do a wellness assessment, they can accrue points that way," Holtman says. "If they're non-tobacco users there are a certain number of points that are accrued there."

Premiums have risen 20 percent since 2011, the Kaiser survey released Wednesday shows. They rose 31 percent in the previous five years and 63 percent in the five years before that.

With the continuous increases, companies like Covenant are getting creative, Altman says.

"Your typical employer is using everything in the toolkit to control their premiums," he says. They use those wellness programs. They try to help workers manage their chronic illnesses.

"But if you want to bring down the premium increase quickly in any given year, the immediate step you can take is to increase deductibles and other forms of cost sharing," Altman says.

Employers can lop about 20 percent off insurance premiums simply by raising deductibles from $200 to $1,000, says Dave Anderson, CEO of HealthNow Inc., which runs BlueCross BlueShield of Western New York.

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Anderson says companies do think hard before they bump up deductibles because employees don't like it.

"I would say no one goes there lightly," he says. "Many employers have felt like they just had to go in that direction. They had to fix premium costs in some way."

BlueCross BlueShield of Western New York offers its own employees a high deductible plan. And like Covenant in Florida, it encourages its workers to participate in wellness programs to knock down their share of the cost.

The company will pay $500 toward a $1,000 deductible if employees undergo a health risk assessment each year. Anderson says the risk assessment will help employees embrace more healthy behavior and stick with exercise and nutrition plans.

"We believe we'll have that kind of overall reduction in our health care costs," he says.

But Anderson says high deductibles raise troubling issues as well.

"And that is whether it is inherently disadvantageous to lower-income employees. And we struggle with that," he says. "A $1,000 deductible if you're making $100,000 is no big deal. If you're making $30,000 a year, a $1,000 deductible is a big deal."

In the future, Anderson says, he expects employers and insurance companies will have to address that inherent unfairness by offering health plans with deductibles indexed to workers' income.

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