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

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

Credit: Meredith Rizzo/NPR

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

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

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

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

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

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

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

Additional Information: Bluer, Grayer, Darker

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

Cornell University

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

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

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

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

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

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

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

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

Copyright 2016 NPR. To see more, visit NPR.
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Japanese City Takes Community Approach To Dealing With Dementia

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

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

Ina Jaffe/NPR

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2016 NPR. To see more, visit NPR.
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Health Officials Struggle To Fight Deadly Sepsis Infections

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

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

Courtesy of Rory Staunton Foundation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Tighter Patent Rules Could Help Lower Drug Prices, Study Shows

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2016 NPR. To see more, visit NPR.
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Doctors Get Disciplined For Misconduct; Drug Firms Keep Paying Them

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

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

One such company is medical device maker Stryker Corp.

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

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

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

Neither Apazidis nor Diab returned emails or calls seeking comment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ina Jaffe/NPR

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

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

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

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

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

Ina Jaffe/NPR

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mon, 08/22/2016 - 7:18pm
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August 22, 20167:18 PM ET Heard on All Things Considered

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

Joe Raedle/Getty Images

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Miami Schools Take Steps To Protect Returning Students From Zika

Mon, 08/22/2016 - 6:17pm
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August 22, 20166:17 PM ET Heard on All Things Considered

A Miami-Dade County mosquito control worker sprays around a school in the Wynwood area of Miami earlier this month.

Alan Diaz/AP

Students returned to school on Monday in Miami amid a new concern: the threat of Zika. Nine schools in Miami-Dade County are in or near a zone where nearly a month ago health officials confirmed that mosquitoes are spreading the virus.

One of them, Jose de Diego Middle School, is in Miami's Wynwood neighborhood, an area known for its restaurants, cafes and street art. It's also home to middle-class and low-income families, many newly arrived from Venezuela, Cuba and Haiti.

Over the weekend, school officials distributed cans of mosquito repellent to parents and made long-sleeved shirts and pants available to students. For the past month, the county has conducted intensive spraying and outreach. While health officials are optimistic about their efforts to control mosquitoes in this neighborhood, on Friday they said that Zika has now spread to another neighborhood several miles away, on Miami Beach.

The start of the school year is always hectic. The principal of Jose de Diego Middle School, April Thompson-Williams, says Zika leaves parents with even more questions. "They just want to know how to protect their children and to ensure that they're safe when they come to school," she says.

Kenyanna Darden brought her daughter, Jaynela, to school today. She says the school district seems to have a good plan in place to protect students. "They sent text messages, emails, voicemail, all that, all day, every day," she says. The message? "Protect yourself, wear 'Off' spray."

Another parent, Nicole Pugh, still has some worries after dropping her daughter off at school. "Yeah, I worry about it," she says. "But I made sure she was sprayed and everything. So hopefully, they'll take care of the situation."

Jose De Diego Middle School teacher Cyd Browne challenged her 7th-grade engineering class to design a plan to protect an area from the mosquitoes that carry Zika.

Greg Allen/NPR

Superintendent Alberto Carvalho was visiting schools in both of Miami's Zika transmission zones today, spreading the message that students should wear repellent, long-sleeved shirts, long pants — and that they should be in school. "Every single school is air-conditioned. Every single bus is air-conditioned," he says. "There is no contact with areas that have standing water. And kids are well-protected in air-conditioned areas. They're going to be fine." Carvalho says recess and sports will go on as usual.

Cyd Browne began her 7th-grade engineering class today with a challenge. She asked her students to design a plan to protect an area from mosquitoes that carry Zika. "We're going to look to see the science behind this, do our research and then come up with a solution to make sure everyone knows to spill the water wherever there's standing water and to drain and cover," she says. Every teacher at Jose de Diego Middle school started today with a Zika information session.

For children and anyone who's not pregnant, the symptoms associated with Zika are usually mild. Most people don't even know they've had the disease. But the chief of Emergency Medicine at Miami's Jackson Memorial Hospital, Bobby Kapur, says that from a public health standpoint it's crucial that students be protected. "We have hundreds, maybe thousands of students clustered in one area," he says, adding that any student infected through a mosquito bite could bring that infection back into their homes and communities.

Controlling the spread of Zika is a major challenge. Along with the two zones already identified, health officials say they're investigating possible cases of Zika transmission in several other areas in South Florida.

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

A Small Town Struggles With A Boom In Sober Living Homes

Mon, 08/22/2016 - 4:37am
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August 22, 20164:37 AM ET Heard on Morning Edition


Nicole Xu for NPR

When Phillip decided to stop using heroin, he knew sticking around home was a recipe for failure.

"It's just, like, a heroin epidemic on Long Island where I'm from. So I had to get away from that and now I'm in Prescott, Ariz.," Phillip says. NPR agreed not to use his last name because he is struggling with addiction and fears it might hurt his chances of future employment.

Phillip and a handful of other young people are filtering through the line at a soup kitchen at the Prescott United Methodist Church just before noon. They are grabbing a bite to eat before their next meeting of recovering addicts nearby.

"Everybody here is basically, I feel like, in recovery and they're more serious about it," says Phillip.

Not like back home in New York, he says, where people shoot up in the parking lot before meetings.

You hear similar stories from others who come to this idyllic mountain community to shake their addiction. Outdoor recreation, a mild climate, scenic vistas and a welcoming attitude toward those in recovery is touted in a promotional video by a group called Drug Rehab Arizona.

Additional Information: YouTube

And with its motto "Welcome to Everybody's Hometown," Prescott has become a hub for the multi-billion-dollar recovery industry. It's even listed by the recovery website TheFix as one of the top 10 destinations in the country to get sober.

This has caused a boom in sober living houses — homes where six to eight recovering addicts live under the supervision of a house manager, who is usually also a recovering addict. During the day, they typically go to outpatient treatment centers, attend meetings and once further into recovery, look for work. At last count, Prescott, population 40,000, had more than 150 of these sober living homes, with new ones opening up frequently. And some Prescott residents are upset.

Group homes have inundated the community, says Connie Cantelme, who lives in one of Prescott's historic neighborhoods where several sober houses have popped up.

"When you've got a hundred boys and men trying to kick a heroin problem, how do you feel safe living next door to them when they're falling off the wagon all the time?" she asks.

Once she remembers coming outside for her morning coffee to find that a man had overdosed under her deck.

Cantelme worries this influx of recovering addicts and the proliferation of group homes is tarnishing Prescott's image.

That's certainly a concern, says Allison Zelms, Prescott's deputy city manager, who says, "We are reaching a tipping point." But Zelms says an even greater concern is the quality of care in some of these programs.

"Are people really being sold a bill of goods, or are they going to come to Prescott to really have a good chance of success in their treatment?" Zelms asks.

That's a difficult question to answer. Group homes are generally easy to start, cheap to run and, in states like Arizona, largely unregulated, other than some city zoning and code enforcement.

As treatment programs have proliferated there, Prescott, Ariz., has become a destination for people trying to overcome addiction.

Jeff Turner/Flickr

In Prescott, the homes tend to be affiliated with outpatient medical treatment centers that are licensed by the state. This arrangement, known as the Florida Model, separates the residential setting from the medical components of treatment. Families looking for a safe place to send an addicted son or daughter are offered a package deal: They pay out of pocket for the living expenses and insurance generally covers the cost of treatment.

This was the case for Vincent Rienzie Jr. He flew across the country to attend the Promise Recovery Center in Prescott and stayed in an affiliated group home. But after 60 days sober, Rienzie says he was kicked out of the group home for violating a rule against socializing with women. He ended up on the street.

"Our insurance wasn't paying them and they were looking to make an excuse to throw us out," Rienzie said, moments before his plane took off, bound for his home on Long Island, N.Y.

Promise Recovery did not respond to requests for comment. But Barry Hancock, who was working as a therapist in the program at the time and was later fired, says he was told by people running the program they might need to find ways to kick out clients whose insurance wasn't paying.

"Insurance [payments] come into these programs and people make a lot of money," says Hancock.

"What we do has gotten so big. We don't necessarily have to worry about clients. We don't have to worry about them dropping out," Hancock adds. "There are plenty of them waiting in line."

While it is difficult to nail down numbers, sources inside the insurance industry say out-of-network providers can typically bill from $500 to $800 a day for outpatient treatment.

"The drive to make money sometimes gets to be a greater motivator than the drive for patient safety and clinical care," says Gerald Shulman, a clinical psychologist in Jacksonville, Fla., who studies cost and quality in addiction treatment.

A review of complaints made to the state about treatment programs in Prescott, obtained by NPR member station KJZZ through public records requests, speak to these systemic issues: Recovering addicts enter programs, often without discharge plans. Many will bounce around to three, six or more programs. Sometimes clients are kicked out, allegedly because insurance runs out. Extensive interviews with individuals echo those themes.

Kelly Dwyer has watched the proliferation of sober living homes in recent years. She came to Prescott in 2007 to give up drinking and get sober.

"My main goal was just to wake up every morning and not want to die," Dwyer remembers as she sits on a park bench in the historic town square.

Dwyer entered treatment and was placed in a sober living house.

"It was just kind of like a regular house in a regular neighborhood," says Dwyer. "We would walk to the facility every morning and do some morning groups. Then we would go to a meeting at noon."

But Dwyer's time in the group home didn't go smoothly. Her roommate kept asking her to buy alcohol, she says. And after an argument with a staff member, she was kicked out of the program.

"At that point, I told them I don't have any money. I don't know anybody in Prescott," she says.

Dwyer is sober now and works as a real estate agent in town. She wants to see more regulation and stricter guidelines for the homes. "It's not quantity. It's quality" that's important, Dwyer says.

Take the case of Joey Martin. Like so many parents, Jill and Glenn Martin never imagined their teenage son might become a drug addict.

"He played baseball a lot, and he was into school and girls and just everything a regular teenager would be," recalls Glenn Martin, as he sits with his wife, Jill Martin, at their home in Prescott.

Jill and Glenn Martin's son Joey died of an opioid overdose while living in a group home. He was 22.

Will Stone/KJZZ

But about a year before graduating from high school, Joey was in a head-on collision with a drunken driver. Soon he was using prescription pills and, eventually, abusing them.

"When your kid is addicted, you do whatever you can to help him, and that's what we did," says Glenn Martin.

For three years, they sent Joey to various programs. Eventually he ended up at a sober living home in Southern California. The Martins were hopeful. Joey did well and was talking about going to college. Then one evening they got a call: Joey, 22, was found dead in his room. He had overdosed.

Since their son's death, Glenn and Jill Martin have advocated for more regulation of sober living homes — first in Southern California where Joey died and again when they moved to Prescott.

Just this spring, Arizona took a significant step toward allowing more government oversight of these homes. The Arizona Legislature passed a law that allows a city, town or county to regulate health and safety standards for sober living homes — including supervision requirements and exit plans.

"If they're giving good treatment they should be open to what we are proposing," says Noel Campbell, the Arizona lawmaker who pushed through the legislation.

But some people who run group homes are pushing back.

"There's a tremendous amount of fear associated with the alcoholic and the drug addict," says Mark Temple, who operates Solutions House, which has more than a dozen homes in Prescott.

"Our focus is to help these kids. Our focus has never been on making money," he says. "We are a program based on spiritual principles. We are not a business built on profit and loss."

Temple's homes serve mostly clients of the Bridges Network, a licensed outpatient treatment program. Bridges therapist Bonnie DenDooven says the combination of the treatment program and the sober living home helps integrate people recovering from addiction back into society.

"The challenges of living in a neighborhood, the challenges of working in a community, as much as you can replicate the real world, I think you stand a better chance of them making it," she says.

Jill and Glenn Martin are adamant that more regulation is needed in Arizona and across the country.

"We are not trying to shut sober homes. We're not trying to stop addicts from getting help," says Glenn Martin. "But what we don't want to happen is what happened to us."

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

For Parents Who Have Lost A Baby, Some Help With Their Grief

Sat, 08/20/2016 - 5:24pm
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August 20, 20165:24 PM ET Heard on All Things Considered


Lydia Joy Ziel, whose crib is pictured here, was diagnosed with a serious disease while still in the womb. Miscarriage and stillbirth are common, but often parents feel they're walking through the experience alone. A trained group called Baby Loss Family Advisors seeks to help.

Stina Sieg

Stephen Ziel still carries around a recording of his daughter's heartbeat on his phone. It sounded strong the whole time she was in the womb.

"And the heartbeat's not supposed to be that strong," he says.

Not for babies like her. Lydia Joy Ziel was diagnosed with a rare genetic disorder called Trisomy 18 — also known as Edwards syndrome — a few months after Stephen and his wife, Melissa, found out she was pregnant.

"That was probably the moment where it felt like the world kind of shattered on us," Melissa says.

Most babies with the disorder are either miscarried or stillborn, or die shortly after birth. Melissa and Stephen didn't know how long they would have with their baby, so they tried to make every moment of the pregnancy count. They picked out a name and started a little book documenting her first experiences.

Shots - Health News People Have Misconceptions About Miscarriage, And That Can Hurt Shots - Health News Stillbirths Still Haunt Parents Around The World

They captured moments like "Lydia's first snowfall, Lydia's first Thanksgiving, Lydia's first Christmas," Melissa says. And every night, they read a picture book and a Bible story to Melissa's growing belly.

The couple also read everything they could find on how to deal with their grief. That included a book by Sherokee Ilse, who personally knows the pain of losing a baby.

"It's important to grieve and mourn these little ones, to recognize that our lives are different," Ilse says.

That's been Ilse's mission ever since her son Brennan was stillborn decades ago. Ilse briefly held him, but other than that, she feels she and her husband did everything wrong.

"No pictures, no mementos of any kind," she says. "We literally left with empty arms. I have nothing that he touched."

Ilse says such deep regret is still the norm for grieving parents. And many feel as if they're going through it alone, she says, even though this kind of loss is actually common. Roughly 1 in 5 pregnancies ends in miscarriage in the U.S., and every year thousands of babies are stillborn.

So, in the years since her son's death, Ilse has tried to change our culture's relationship to infant death. She's written books, trained hospital staff and most recently co-founded Baby Loss Family Advisors. It's a certification program that trains professional doulas and others to help people through the death of their babies.

That's what Ilse did for Melissa and Stephen Ziel. Melissa says she helped them have those difficult conversations that needed to happen.

"Because I think it is hard to talk about what happens if your baby does die," Melissa says. "It's not something, I think, as you get married and talk about having kids and a family, that [you think] is going to happen or you're going to have to think in this direction."

As the due date got closer, the couple spoke with Ilse many times over the phone and in person, since they all live within miles of one another in Tucson, Ariz. She helped them plan for the birth, even embrace it.

As Melissa puts it: "Being able to say hello and goodbye at the same time."

Melissa Ziel holds up Lydia's christening gown. Lydia's room is still completely in place, with stuffed animals and pink everywhere. Melissa and Stephen Ziel say they feel at peace when they walk in. They both say losing Lydia hasn't scared them away from having more children in the future.

Stina Sieg

When Melissa's water broke, she and Stephen say they felt prepared. Almost a day later, Lydia was delivered. Melissa remembers listening for her baby's cry — and hearing nothing.

"It almost felt you were holding your breath, waiting to figure out what was going on, what was happening," she says.

Stephen remembers asking the nurse to check for a heartbeat "multiple times," he says, "because I thought, 'Well, maybe it just took a minute.' "

Lydia was stillborn. But she was still their baby. So with Sherokee Ilse's help, they started making all the memories they could, as quickly as they could. They got footprints and handprints, took professional photographs, introduced her to their families.

Melissa and Stephen spent hours and hours with Lydia, trying to memorize every little part of her, just as Ilse had suggested.

"You know, look at her eyes, see if she has any birthmarks, who does she look most like? And we all agreed she looked more like Steve," Melissa says, smiling.

"She looked pretty good," Stephen says, as he and Melissa laugh together.

They're able to be happy now when they talk about Lydia, because they say they have no regrets.

"There can be blessings. There can be peace. There can be joy in the midst of difficult circumstances," Melissa says, "and those are things to, no matter how hard they are, they're also things to be able to celebrate."

The Ziels say having someone to help guide their grief made that celebration possible.

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

After IVF, Some Struggle With What To Do With Leftover Embryos

Sat, 08/20/2016 - 7:00am
Michelle Kondrich for NPR

When Scott Gatz and his husband decided to become fathers several years ago, pursuing parenthood meant finding both an egg donor and a surrogate to help them conceive a baby. Their first round of in vitro fertilization produced seven healthy embryos. One of those embryos was successfully transferred to their surrogate's womb, resulting in their son Matthew, who is now 6-years-old.

While the San Francisco couple feels their family is now complete, they are still in a quandary over what to do with their six remaining embryos — what they call their "maybe babies."

Every year they're forced to weigh their options again, Gatz tells Shots, when a letter arrives from the fertility clinic. It asks whether they want to destroy the embryos, donate them for medical research, give them to another infertile couple or continue paying $800 annually to keep the embryos frozen.

Additional Information: Finding Support And Choices Online

After Jake Anderson and Deborah Bialis went through their own IVF struggle a few years ago, they started FertilityIQ, an online platform that helps infertile couples find fertility specialists in their local area.

The website also helps those who have undergone IVF connect with others who have faced similar challenges.

"The best way to reassure families looking for guidance is to connect them with someone who's gone down a similar path," Anderson says.

And some couples, he says, use the site to search for like-minded families who may be able to use their leftover embryos.

"Every time we read the 'destroy' option on the form, my stomach does a somersault," Gatz says. "It feels as if our future children are showing up once a year to confront us."

The men are not alone in their ambivalence. It's estimated that, in the United States, there are almost one million frozen embryos now in storage, a number that includes embryos reserved for research, as well as those reserved to expand families.

In a 2005 study that interviewed 58 couples who conceived through IVF and had at least one frozen embryo in storage, more than 70 percent had not yet decided — even several years after the procedure — how they would dispose of a surplus embryo. Some said they considered the embryos to be biologic tissue or a genetic or psychological "insurance policy." Others told the researchers they thought of the embryos as living entities — "virtual children" that have interests that needed to be considered and protected.

"With the astonishing advancements in reproductive science, IVF now produces far more embryos than it did in the past," says Dr. Anna Glezer, a psychiatrist at the University of California, San Francisco. The choices that abundance poses are very difficult for some couples, she says, "which raises the need for psychological resources, such as peer support groups for these families.'

After conceiving their daughter via IVF, Megan and Jay Khmelev had eight remaining embryos. For two years, says Megan, she was overcome by guilt, anxiety, and sadness as she struggled with what to do with them. At the beginning of her fertility journey, she had imagined one day donating the embryos to science or to another infertile couple.

But after her daughter arrived, she says, she couldn't imagine parting with the surplus embryos in this way. The Khmelevs didn't want eight more children, but discarding the embryos didn't feel like the right choice, either.

"I wish someone had told me that I'd be haunted by the grief of my infertility struggle all over again as I wrestled with my decision," Megan says.

Dr. Aimee Eyvazzadeh, a reproductive endocrinologist in the San Francisco Bay area, says many families she counsels struggle with these choices.

"It's a complicated process," Eyvazzadeh says. "At the beginning of IVF, patients hope for many embryos, because they long to have a baby. They don't realize how their feelings might change once their children are born."

In the 1980s, when fertility clinics began freezing embryos, there wasn't any available research about how patients would feel regarding their frozen embryos after they became parents. More than 30 years later, though the number of IVF babies has steadily climbed, many fertility doctors are still unsure how to handle some patients' ambivalence.

"Our clinic told us that we could freeze our embryos and explained the cost associated with yearly storage fees," Gatz says, "but they didn't mention the feelings that might arise as we faced these choices."

A study published in the March issue of the journal Fertility and Sterility found that that after successful IVF treatment, most of the 131 couples responding to a survey were dissatisfied with the education they obtained from their health care providers about disposal decisions. And less than 50 percent were satisfied with the emotional guidance they got.

Yet other research suggests that peer support can help people make these complicated choices, by giving them a place to disclose their struggles in the company of others who have been through the process.

Francine Lederer, a clinical psychologist in private practice in Los Angeles, offers a "disposition support group," specifically aimed at couples and individuals who are deciding what to do with their embryos.

"After successful IVF treatments, many couples come to view their embryos as human life, which makes it even harder for them to find closure," Lederer says. Some even have funeral ceremonies for the embryos.

For other couples, making these decisions ignites emotional conflict between the spouses, or even beyond — to include the extended family, Lederer finds, because religious beliefs and personal preferences play a role in how each person views the stored embryos. One couple she counseled who had decided to destroy the embryos mentioned that to their parents and discovered the in-laws were aghast.

"Too often, these families have never shared their stories aloud," says Lederer. "Support groups can make a difference by allowing them to talk about their personal experiences with others who understand, which can help them to feel less isolated."

Megan and Jay Khmelev finally decided to do additional rounds of IVF, and use the remaining embryos themselves, but none resulted in a viable pregnancy.

"I'm glad I did the transfers anyway," Megan says. "It gave me and my husband closure, knowing that we had given them a chance to become life."

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

New Zika Outbreak Hits Popular Tourist Destination Of Miami Beach

Fri, 08/19/2016 - 1:38pm

"We believe we have a new area where local transmissions are occurring in Miami Beach," Florida Gov. Rick Scott said Friday about the Zika situation in the state.

Alan Diaz/AP

Mosquitoes have begun spreading the Zika virus in a second part of Miami — the popular tourist destination of Miami Beach — Florida officials announced Friday.

As a result, the federal Centers for Disease Control and Prevention expanded its advice to travelers, advising pregnant women to avoid the parts of Miami Beach where the virus is spreading. In addition, women and men who have traveled to the area should wait at least eight weeks to try to get pregnant even if they didn't catch Zika during their visit.

The agency also went a step further, advising pregnant women and their sexual partners "who are concerned about potential Zika virus exposure" that they "may also consider postponing nonessential travel to all parts of Miami-Dade county."

That decision to issue a warning about the entire city was prompted by the agency's concern that there may be other outbreaks in other parts of Miami-Dade that haven't been identified yet, CDC Director Thomas Frieden told reporters during a briefing.

"What we are doing is stepping back and saying, 'There have now been multiple instances of local transmission,' " Frieden said. "We will always err on providing more information to the public."

Five Zika cases have been linked to the new outbreak in Miami Beach, involving three men and two women from Miami, New York, Texas and Taiwan, officials said. That brings the total number of Zika cases that have been spread by mosquitoes in Florida to 36.

"We believe we have a new area where local transmissions are occurring in Miami Beach," Gov. Rick Scott told reporters at a news conference.

Officials believe the virus is only spreading in a 1 1/2 mile part of Miami Beach, but that area includes the much-visited South Beach area, Scott said.

The tourism industry in Florida is particularly concerned with the spread of Zika and the impact it may have on businesses. On Thursday, Scott announced measures designed to limit Zika, including offering mosquito spraying free of charge to businesses in Miami-Dade County.

"Tourism is a driving force of Florida's economy and this industry has the full support of our state in the fight against the Zika virus," Scott said in a statement.

The new outbreak comes as officials believe they are bringing the first outbreak in the trendy Wynwood neighborhood under control. Officials announced Friday they had cleared three new blocks of Wynwood because there is "no continued evidence of transmission" there. Fourteen blocks had been cleared earlier.

But Frieden noted that officials expect it will be harder to contain the outbreak in Miami beach for several reasons. The area's high-rise buildings mean the aerial spraying that has been working in Wynwood won't work in Miami Beach. In addition, it will be more difficult to convince people to wear long sleeves and pants in a part of the city where people go to spend time on the beach, he said.

The Wynwood outbreak prompted the CDC to take the unprecedented step of advising pregnant women to stay away from the area. It was the first time the CDC had ever advised people to avoid any part of the continental United States because of an infectious disease.

In response to the Miami Beach outbreak, Scott said he had requested an additional 5,000 Zika tests, additional lab personnel to expedite testing and 10,000 more Zika prevention kits for pregnant women.

Separately, Puerto Rico is reporting a surge in Zika cases. The island's health department said Friday that 2,496 more cases had been confirmed in Puerto Rico over the last week. That marks the highest weekly tally since the virus was first detected on the island in December. The health department also announced the first death in Puerto Rico from Guillain-Barre syndrome linked to Zika.

The latest cases bring the total number of laboratory confirmed Zika cases in Puerto Rico to 13,186. Of those, 1,106 are pregnant women.

Jason Beaubien contributed to this report.

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

Insurance Alone Isn't Enough To Make Sure Kids Get Eye Exams

Fri, 08/19/2016 - 11:42am

Timely eye exams for kids can help prevent lifelong vision problems.

Portra Images/Getty Images

Kids from less affluent homes, even when they have health insurance, aren't as likely as others to get vision screenings that can identify conditions like lazy eye before the damage becomes irreversible.

Researchers at the University of Michigan examined commercial health insurance claims data between 2001 and 2014 for nearly 900,000 children from birth to age 14. They tracked how often kids at different family income levels visited ophthalmologists and optometrists and the diagnosis rates for strabismus (crossed eyes) and amblyopia (lazy eye).

The two conditions are relatively common, serious eye disorders in children. Because the eyes are seeing different things, the brain suppresses the vision in one eye. If not corrected by age 10, either condition can result in permanent vision loss. Treatment generally involves glasses, surgery, eyedrops or patches, or some combination.

NPR Ed You Can't Learn What You Can't See: Here's How Your State Screens For Vision Problems

Children in families with the lowest net worth (less than $25,000 a year) had 16 percent fewer eye care visits than those in the middle-income category ($150,000 to $250,000 a year), the study found. Meanwhile, kids from families with the highest net worth ($500,000 or more annually) had 19 percent more visits to eye care professionals than those in the middle-income group.

Lower-income kids were also less likely to be diagnosed with strabismus or amblyopia than were children from higher-income families. By age 10, an estimated 3.6 percent of children in the lowest-income category were diagnosed with strabismus, and 2 percent were diagnosed with amblyopia, the study found. For kids in the highest-income bracket, the estimated diagnoses were 5.9 percent for strabismus and 3.1 percent for amblyopia.

"We think that affluence is driving the eye care visit and the visit is driving the diagnosis of eye disease," said Dr. Joshua D. Stein, the study's lead author and an associate professor of ophthalmology and visual sciences at the University of Michigan's medical school. The findings were published in the August issue of the journal Health Affairs.

The researchers estimate that the lack of eye care visits by lower-income children resulted in 12,800 missed cases of strabismus and 5,400 missed cases of amblyopia.

Many children receive vision screening in schools, which wouldn't appear in the claims data that were analyzed. Children who fail a school vision screening, however, should be referred to an optometrist or ophthalmologist for further testing, and that visit would show up in the claims data.

Less affluent parents may have more difficulty taking time off from work or face transportation challenges getting a child to an eye care provider, said Stein, and there may be fewer eye care providers available in less affluent areas.

Under the health law, services recommended by the U.S. Preventive Services Task Force, an independent panel of medical experts, are covered by insurance without requiring most people to pay anything out of pocket. The task force recommends that children between the ages of 3 and 5 receive at least one vision screening to check for amblyopia. That recommendation is being updated.

Please contact Kaiser Health News to send comments or ideas for future topics concerning health insurance.

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

Parents Feel Better About HPV Shots For Preteens If They Can Opt Out

Fri, 08/19/2016 - 11:21am

Abraham Vidaurre, 12, checks his arm after receiving an HPV shot in Corpus Christi, Texas. The vaccine is recommended for 11- and 12-year-old boys and girls.

Matthew Busch/The Washington Post/Getty Images

The human papillomavirus vaccine is the only vaccine invented explicitly for the purpose of preventing cancer. Yet a decade after its approval, the vaccine continues to struggle from a PR problem, as shown in a study that finds just one in five parents would support making the HPV vaccine a requirement for school.

But this first national study of parents' attitudes found that those attitudes shifted if the requirement allowed parents an opportunity to opt out.

"It's interesting; if you had opt-out provisions, it tripled their support, but we know from previous research that if you add the opt-out provisions, you will make the law less effective," says the study's lead author, William Calo, a postdoctoral research associate at the University of North Carolina, Chapel Hill.

Such is the conundrum faced by public health officials and policymakers in attempting to improve the coverage of a vaccine that could save an estimated 30,000 lives a year, according to Calo.

The HPV vaccine, recommended by the Centers for Disease Control and Prevention for boys and girls ages 11 and 12, boasts one of the strongest safety records of any vaccine and is highly effective in preventing the infection that causes nearly all cervical cancer, 95 percent of anal cancer, 70 percent of throat and neck cancers and substantial proportions of vaginal, vulvar and penile cancers.

Yet despite the clear medical consensus supporting the CDC recommendation, hesitancy among parents and even providers has hindered its uptake over the past decade.

"Now we have the chance to prevent cancer. This is a disease people care a lot about," says Anna Giuliano, director of the Center for Infection Research in Cancer at Moffitt Cancer Center in Tampa, and a researcher who led some of the HPV vaccine clinical trials. "We have a simple intervention to prevent cancer, but the message has gotten diluted and contorted by the general public that we don't need prevention interventions, whether it's to prevent measles or pertussis or HPV, so this is the struggle."

Every state requires public school children to be up to date with some, if not most, of the vaccinations recommended by the CDC. But only two states, Rhode Island and Virginia, and the District of Columbia require students to receive the HPV vaccine.

Calo's study, published Friday in the journal Cancer Epidemiology, Biomarkers & Prevention, sought to quantify national support for such requirements, which have already failed in several dozen states.

In an online survey, his team asked 1,501 parents of 11- to 17-year-old children whether they agreed that laws requiring HPV vaccination for sixth-grade school entry were "a good idea." The parents came from all 50 states and represented a range of incomes and educational levels, though most were mothers and 70 percent of them were white. Their children were an average age of 14, and 46 percent of them had received at least one dose of the HPV vaccine.

The survey also assessed parents' beliefs about the value of the HPV vaccine, the harms of it, challenges to getting it for their children and possible psychological reasons parents might oppose HPV requirements, such as whether they tend to resist things more when they're forced to do them.

Even though half the parents believed the HPV vaccine was at least as important as the Tdap and meningococcal vaccines, the other two recommended for adolescents, only 40 percent believed the vaccine prevented cervical cancer. Nearly a quarter of parents inaccurately believed the vaccine might cause long-term health problems and one-third thought drug companies were pushing it to increase profits.

One-third felt they lacked enough information to decide whether to vaccinate their children, and just 21 percent of parents believed laws requiring the HPV vaccine were a good idea, though that figure jumped to 57 percent if parents could opt out of the requirement.

Calo cautions that the study did not describe specific types of opt-out provisions, so parental support may wax and wane according to what an exemption process might require.

Trying to impose mandates without broad public support can backfire, says Saad Omer, a professor of global health, epidemiology and pediatrics at Emory University Schools of Public Health & Medicine whose research focuses on state exemptions for vaccines required for school. "We're living with the legacy of going for a mandate a little too early," he says. Getting a particular vaccine needs to be a social norm before a law requires it, he adds.

Take the case of Texas, where Gov. Rick Perry issued an executive order in 2007 mandating that all girls entering sixth grade receive the HPV vaccination. That requirement included an opt-out provision that required a signed affidavit for religious or philosophical objections, but it still raised such ire from both sides of the aisle, and especially Perry's own Republican allies, that it was reversed in veto-proof legislation.

But Perry also issued the order just one year after the vaccine had been approved by the FDA, before any baseline immunization coverage existed for that vaccine and with only the clinical trial data, rather than the additional years of safety and effectiveness data available today.

"It was a public health decision that was really sound, but it was a political decision that was disastrous," Giuliano says.

Compare that to Rhode Island, where HPV immunization rates were already well above the national average when the Rhode Island Department of Health began requiring incoming seventh-graders to receive the vaccine in September 2015.

"They pounded the pavement and did due diligence, and then they said let's just codify it," says Giuliano.

Even in Rhode Island, however, the requirement is facing scrutiny and a legislative challenge. That's something to be expected with any attempts to require vaccination, suggests Dorit Reiss, a professor of law at the University of California Hastings College of Law who specializes in vaccine policy.

Political battles about mandates usually arise from the mobilization of an extremely small but very active minority that oppose vaccines, says Reiss, who testified during the SB 277 hearings for California's mandatory vaccination law. "And that minority of antivaccine activists does mobilize against lesser things than mandates." That includes requiring parental education or adding vaccines to existing rosters, even with personal belief exemptions, she says. "So I'm not sure we can go from here to whether a political battle will be easier with opt-outs."

Mandates are also best suited for vaccines whose coverage already exceeds 75 or 80 percent, Omer says. That makes for "an effective policy tool as opposed to a draconian tool." For proponents of mandates, that means there are other goals to focus on first, such as closing the gap between those who start HPV vaccine series and those who complete the third dose, Omer says.

Other approaches include using effective reminders for parents about needed vaccines, making it easier for parents to get their children vaccinated and giving providers the tools to effectively talk about vaccines.

"We need to do a better job informing parents about the real benefits of these vaccines, not only for school requirements but for potentially saving the lives of their kids in the future," Calo says. "I think as parents know and understand the benefits of HPV vaccination, they will support introducing laws requiring it for school entry."

His research bears this out: Parents were more than twice as likely to believe mandates were a good idea if they believed the HPV vaccine was at least as important as other vaccines given to teens or if they believed it effectively prevented cervical cancer.

The trick is waiting for the right moment to propose such legislation and crafting exemptions so that opt-outs aren't the path of least resistance.

"You're using mandates for the last couple of miles of your journey," Omer says. "They work best as nudges" making it more convenient to vaccinate than not to.

Omer's research has revealed that the most effective exemptions — those least likely to be used widely or to erode the herd immunity that keeps young children and the immune-compromised protected — require counseling from a doctor or the health department and an annual renewal process. Most importantly, parents choosing to opt out should be required to receive information about the disease and about the vaccine's safety and effectiveness, Omer says.

"That's where you find the balance between individual freedoms and societal responsibility, and parents' responsibility to their children," Omer says.

In the meantime, it's up to physicians and other health care providers to better educate parents about HPV vaccination, both Calo and Giuliano say.

"This vaccine is an unprecedented opportunity to prevent multiple male and female cancers, and it's covered almost entirely through insurance," Giuliano says. "If you could prevent breast cancer with a vaccine, wouldn't you take the vaccine?"

Tara Haelle is the co-author of The Informed Parent: A Science-Based Resource for Your Child's First Four Years. She's on Twitter: @tarahaelle

Copyright 2016 NPR. To see more, visit NPR.
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For Pete's Sake, Don't Sleep Or Swim In Your Contact Lenses

Thu, 08/18/2016 - 3:07pm

Contact lenses are simple and convenient, but also medical devices.

Erik Tham/Getty Images

Contact lenses are so ubiquitous — about 41 million people in the U.S. wear them — that it's easy to forget that they're actual medical devices, with small but real medical risks.

An analysis published Thursday by the Centers for Disease Control and Prevention examined 1,075 reports of corneal infections related to contact lens use from the Food and Drug Administration's Medical Device Report database over a decade.

To be sure, these were likely the worst of the worst of these types of infection and can't be considered representative of contact lens infections overall. But of those reports, almost 20 percent described a patient with injuries resulting in decreased vision or a corneal scar, or requiring a corneal transplant. The study was published in Morbidity and Mortality Weekly Report.

And the risk factors for these serious cases of keratitis — med-speak for inflammation of the cornea — are the same as for more common, less serious cases, says Thomas Steinemann, a clinical spokesman for the American Academy of Ophthalmology and practicing ophthalmologist at MetroHealth Medical Center in Cleveland. Corneal infections prompt about 1 million clinic and ER visits a year, and contact lens use is the top risk factor, he says.

Shots - Health News Dirty Little Secret: Almost Nobody Cleans Contacts Properly

One big mistake: sleeping in your lenses, which was associated with infection in 7 percent of the reports. Previous research shows that overnight wear increases the risk for contacts-related infections by more than six-fold. "I advise patients not to sleep in them, regardless of whether or not a lens is approved for extended or continuous wear," says Steinemann.

Not throwing them out when you're supposed to is another risk factor and was associated with 8 percent of the reported infections.

Then there are the cleaning mistakes, such as using tap water instead of disinfectant solution, or reusing the previous day's solution. "Many people get busy, look in the lens case and think, 'Oh, there's still some solution in there,' " says Steinemann. But using old solution is "a terrible idea," he says, because it loses potency and can get contaminated with germs. Dump out the old solution, clean out the case with a little extra solution, and let it air dry before using again, he says.

Previous research has suggested that only about 2 percent of contact lens wearers follow the rules for safe contact lens use. Other no-nos are showering and swimming with your lenses in and hanging on to your storage case for too long.

Also, it should be obvious that contacts should be acquired through the proper medical channels. But in 1.5 percent of the reports, the lenses were bought from "an unapproved source such as a flea market or costume shop."

"Used properly, [contacts are] a very, very successful and safe method of correcting vision, says Steinemann. "But [they are] not without responsibility."

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

Falls From Strollers And Baby Carriers Can Cause Serious Injuries

Thu, 08/18/2016 - 12:55pm

Buckle up for safety in strollers, too.

Ghislain and Marie David de Lossy/Getty Images

When parents are trying to keep their children safe, one thing many of them do is transport their kids in a stroller or baby carrier.

While strollers and carriers are generally safe when used properly, a new study is a reminder that even these devices can be dangerous, especially when parents don't use them properly.

Almost 361,000 children ages 5 and younger were treated in U.S. emergency rooms between 1990 and 2010 for injuries they suffered in connection with a stroller or carrier, according to the study published in the journal Academic Pediatrics.

That works out to about two children every hour, or about 50 a day, according to the analysis of data collected by the National Electronic Injury Surveillance System.

Most of the injuries occurred when a child fell from the stroller or carrier or when the stroller or carrier tipped over.

"As parents we use these devices to transport our most precious cargo. And it's easy to look away just for a second. We want to encourage parents to always buckle their child into these devices and make sure they're properly restrained," says Kristin Roberts of the Center for Injury Research and Policy at the Nationwide Children's Hospital in Columbus, Ohio.

Most of the injuries involved the child's head and face. While many were just bumps and bruises, one-quarter of the stroller injuries — and more than one-third of carrier injuries — resulted in traumatic brain injuries or concussions, the researchers found.

The proportion of stroller-related brain injuries doubled during the study period, increasing from 19 percent to 42 percent. The proportion of carrier-related brain injuries tripled, rising from 18 percent to 53 percent.

The increases don't necessarily mean strollers and carriers are becoming less safe, the researchers cautioned. It could be that doctors are becoming more aware of the seriousness of head injuries.

"We know that traumatic brain injuries can lead to long-term consequences on cognitive development," Roberts says. "So we really want to make sure these injures are avoided."

The researchers also recommended that parents get a stroller or carrier that fits their child. Parents should never hang heavy items on a stroller's handles that can cause it to tip over.

And make sure to lock the stroller's wheels when it is parked. Carriers should be kept as close to the ground as possible to minimize injuries if falls do occur, researchers say.

Copyright 2016 NPR. To see more, visit NPR.
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Where Insurers' Exits Are Hurting Obamacare Exchanges — And Where They Aren't

Thu, 08/18/2016 - 12:24pm

Alina Nurieva (right) sat with Gabriela Cisneros, an insurance agent from Sunshine Life and Health Advisors, and picked an insurance plan at the Mall of the Americas in Miami last November.

Joe Raedle/Getty Images

Some of the Affordable Care Act's insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall. What's ahead for consumers depends very much on where they live.

Competition on some exchanges will be diminished next year when three of the nation's largest health insurers — Aetna, UnitedHealthcare and Humana — will sell individual plans in many fewer markets. The departure of several Blue Cross and Blue Shield plans in various states will also hurt. These pullbacks also come on top of the closure of 16 nonprofit co-ops, another coverage option, since January 2015.

Aetna's exit announcement Monday that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the health law's failure a fresh chance to proclaim, "I told you so."

Shots - Health News Aetna CEO To Justice Department: Block Our Deal And We'll Drop Out Of Obamacare

That story line got more complicated Wednesday after the Huffington Post reported Aetna CEO Mark Bertolini sent a letter to the Justice Department on July 5 threatening to withdraw from the Obamacare marketplaces if the government sued to block his company's planned merger with Humana. The Justice Department did just that a couple weeks later.

Still, most marketplace consumers won't see any ill effects from insurers' withdrawals, say the health law's advocates and independent analysts.

"The effect on consumers is going to be mixed around the country," said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation. "Most of these marketplaces are not dependent on" the large national carriers.

Also, the big insurers' announcements apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Many major metropolitan areas, such as those in California, New York and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas — including Austin, Dallas, Houston and San Antonio — will have at least three insurers after Aetna and UnitedHealthcare exit.

That's true also for most urban exchange customers living in the Northwest, the Midwest and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 1.

Remaining insurers might raise their monthly premiums as a result, but more than 8 in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

One concern is that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it's also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave four of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (Kaiser Health News is an editorially independent project of the foundation.)

"We could be looking at about 1 in 4 counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November," said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers' withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they're doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance analysts say three insurers are needed for a healthy competitive market.

"We've had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options," said Ciara Zachary, health policy analyst for the North Carolina Justice Center's Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer — Florida Blue — next year, unless other insurers step in.

"There are some headwinds, but it's not a question of whether the market will stabilize but how quickly and how well," said Hempstead.

Strong winds are already blowing with hurricane force toward Arizona's Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85 percent received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers — UnitedHealthcare and Blue Cross and Blue Shield of Arizona. "Clearly this is a big concern for consumers," said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful another insurer will step in, but not confident.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers in the area left on its marketplace next year. Gjersvig questions whether those two — Cigna and Phoenix Health Plan — will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely — Aetna, UnitedHealthcare, Humana and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Gjersvig said thousands of people have gained coverage through them and he is confident they will survive. "We do not see this as a death knell for the marketplace," he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. The pullouts by UnitedHealthcare and Aetna mean there will be only one carrier in the state in 2017 — Blue Cross and Blue Shield of South Carolina.

That's a particular concern in Columbia, she said, because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians. "People will be left unable to see the doctors they are now using," King said.

King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. "You can't blame them because ... they have to do something to control costs," she said.

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation.You can follow Phil Galewitz on Twitter: @PhilGalewitz.

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

To Fight Off Diabetes, Latina Women Find Power In A Group

Thu, 08/18/2016 - 10:27am

The goal is to intervene early so that fewer Latino women develop Type 2 diabetes.

Hero Images/Getty Images

Beatrice Sanchez and Mariana Arias drive around their city, Winston-Salem, N.C., in search of a very specific population of residents: Latinos with prediabetes.

The two women, both bilingual and Hispanic, are recruiting participants for a Type 2 diabetes prevention study called "La Comunidad," a lower-cost local version of the landmark Diabetes Prevention Program trial that staved off diabetes through changes in diet and physical activity in about 50 percent of study participants.

The results of that study suggested it was possible to fight a disease that affects about 29 million Americans without drugs and their side effects. It was more effective than using a common diabetes drug called metformin, which cut that number by just 30 percent.

The Diabetes Prevention Program is "still the gold standard," says Mara Vitolins, an epidemiologist at Wake Forest University Medical Center in Winston-Salem who is leading La Comunidad.

When the results of the Diabetes Prevention Program were first published, Vitolins was eager to test this concept in her own city, but cost was a big challenge. The program required six months of one-on-one counseling with case managers trained in nutrition or fitness, followed by personal visits every month for another year and a half. The first two years of intervention amounted to more than $2,600 per person.

To reduce the cost, Vitolins decided to focus on a part of the earlier program that relied on group counseling for her two-year study, called Healthy Partnerships in Preventing Diabetes (HELP).

"The whole idea was to take something that was extremely expensive and find every way that we could to make it more community friendly and that it can be sustained," she says.

HELP replaced case managers with community health workers and group meetings to help participants lose weight and bring their blood sugar levels down. It worked. The two-year study, which was completed in 2011, met goals close to or the same as those reached by the DPP for about a third of the cost—$850 per person. But the study was small, with only 301 participants, so it was impossible to tell if it lowered participants' risk of developing diabetes.

And the HELP study had another shortcoming. Though it was designed to reach a high-risk, underserved population, it included very few Latinos, a group that makes up about 15 percent of Winston-Salem residents. Latinos are more susceptible to developing diabetes at a young age; according to CDC data from 2011, the average age for diabetes diagnosis among whites was 55, but 49 for Hispanics.

To reach the Latino population, Vitolins launched La Comunidad in 2014, translating the HELP program materials into Spanish.

But she knew she needed to do more than just change the language. So she hired Arias and Sanchez as recruiters and ambassadors to the city's Latino population, which includes undocumented immigrants. "We've got to establish communication," says Sanchez. "We're targeting a group of people that are very cautious."

The team determines whether the participants' blood-glucose levels are high enough to be classified as prediabetic. Some are turned away because they are pregnant or unknowingly already have full-blown diabetes. Pregnancy was not an issue in Vitolins' former study because the average HELP participant was 60 years old, says Vitolins. But most of the people joining La Comunidad are in their early 40s. "We're finding that the Latino community, especially the women, are qualifying at a younger age."

The project team is also finding that more Latino women than men qualify for the program. They speculate that Latino men may have more physically active lifestyles, keeping them from developing prediabetes.

After qualifying, La Comunidad participants meet with a registered dietician. They also visit an outpatient clinic for general health assessments and blood work every six months for two years. The first recruits finished in May.

But the bulk of the work happens during group meetings, which are held weekly for the first 24 weeks. After that, members gather once every other month for the rest of the study. Topics cover everything from basic nutrition to what kind of shoe is best for particular workouts.

Group members share their own advice and experiences. One woman could not afford to buy prepared food, says Carmen Vazquez, a health adviser who helps lead the group meetings. Despite limited resources, she still manages to eat healthy and exercise. So far, she's lost 40 pounds. "She has been an example to the rest," Vazquez says.

The meetings help participants become aware of how foods and activities affect their bodies. "One of the major emphases of the program is to be sure people take control of their own life," says Vazquez. Information may have been missed because of health disparities, language barriers or just lack of education, and "We are trying to fill that gap."

Vazquez is quick to point out that she and the other health advisers are laypeople — in fact, her background is in fashion. Vitolins says this is one of the keys to making the program affordable. "It didn't matter that the person leading it didn't have a high school degree. It's the fact that that person can communicate a message."

The ultimate goal of studies like La Comunidad, Vitolins says, is to determine whether group-based techniques are helpful from both a health and medical reimbursement perspective. In March, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare would cover preventive programs that meet the Centers for Disease Control and Prevention's (CDC) requirements, such as data reporting.

Vitolins agrees that community-level programs must have good data to support their use. "We're testing before we say everyone who's in the Latino population should use this approach," she says. "We want it to be effective."

Not everyone shares Vitolins' enthusiasm. Richard Kahn, a professor of medicine at the University of North Carolina at Chapel Hill says it's too early for Medicare and health insurance companies to be covering such programs, since they delay diabetes rather than prevent it totally.

"The question which is unanswered is whether that delay actually makes a difference," Kahn says. Another question is whether weight loss in the first few years of a program makes a difference if participants just gain it back, which many do. "We need more studies about how the body regulates weight."

In the meantime, Vitolins focuses on getting the message of diabetes prevention out to people who may not know their risk. Estimates vary depending on how blood glucose is measured, but the CDC reports that 86 million Americans are prediabetic, and many don't know it.

"With the numbers that we think are out there, every single program that shows efficacy should be at the table," Vitolins says.

Amanda B. Keener is a freelance science journalist who writes for Nature, The Scientist and

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Categories: NPR Blogs

Study Of Sudden Cardiac Death Exposes Limits Of Genetic Testing

Wed, 08/17/2016 - 8:41pm

The condition known as hypertrophic cardiomyopathy, or HCM, is inherited and can be a killer. But some of the genetic mutations once thought linked to the illness are actually harmless, geneticists say.

Afton Almaraz/Getty Images

Scientists have discovered that a common cause of sudden heart death has been misunderstood because researchers didn't appropriately account for racial differences in their studies.

The findings, published online Wednesday in the New England Journal of Medicine, have implications far beyond this particular inherited disease, called hypertrophic cardiomyopathy, or HCM. Researchers say the results also sound a cautionary note for many other illnesses that have been identified through genetic markers.

HCM gained attention in the 1980s after several seemingly healthy athletes, including the rising basketball talent, Hank Gathers, suddenly died from it. Scientists had figured out that the propensity for developing HCM is passed along as a genetic trait; the condition affects about one in 500 Americans.

Tarika Mingo, a psychiatric social worker in New York City, first realized something was wrong with her own heart several years ago, when she became so short of breath during gentle activity that she nearly passed out. In 2014 her doctors accurately diagnosed her with HCM. They performed open-heart surgery and reduced her risk of sudden death. She still feels the effect of the disease, however.

"I have to see the cardiologist every three to six months," she tells Shots. "I have to take my medicine every day. The heat is not my best friend, so it limits my social activities. We just had a heat wave and I was stuck in the house."

The diagnosis also sent reverberations through her family. That's because the likelihood of developing HCM follows a simple, inherited pattern: If your parent has the disease, your likelihood of developing it is 50:50. So she urged her entire family to get checked out. Mingo's 16-year-old son shows no signs of having inherited the condition, but her 29-year-old sister has some ominous symptoms.

As part of the diagnosis, doctors turn to genetic testing. But, while the inheritance of this disease follows a simple pattern, the genes that control it reveal a much more complicated story than geneticists realized until very recently.

And that applies to many other genetic traits that are now commonly diagnosed in medical labs.

In HCM, it turns out, any one of about a dozen genes can be damaged in ways that lead to the illness, and there are many different possible mutations in each of these genes. So there are many ways the disease can be passed down.

What's more, some of the variants that researchers originally flagged as disease-causing mutations have actually turned out to be benign.

Dr. Isaac Kohane at Harvard Medical School says a postdoctoral fellow working with him, Arjun Manrai, came across this serious problem of misdiagnosis quite by accident.

They were studying the genetic variants related to HCM. While the disease is observed to occur in about one in 500 people, "we saw that the variants that were ostensibly causing disease seemed to add up to much more than one in 500," he says.

In fact, the supposedly risky gene variants appeared in one out of 10 or one out of 20 people of African descent — an impossibly high number.

"Something must be wrong," Kohane realized. "Something must have been awry."

Kohane and his colleagues think they now may have solved that mystery.

When scientists originally went looking for these genes, Kohane explains, they compared the genetics of families affected by the illness with a sample of healthy people.

But here's the catch: People in the healthy comparison groups in these studies were white; whereas some people in the studies with HCM apparently had some African ancestry. As a result, some of the gene variants flagged as being linked to the illness simply represented racial differences between the groups and had nothing to do with HCM.

That problem would likely have been avoided if the original scientists had added four or five African-Americans to the control group, Kohane says.

It turns out that two of these variants commonly identified in African-Americans actually don't pose a health risk at all. That means many people may have been inadvertently misled about their risk of developing this disease.

"I've had to evaluate a large number of athletes with borderline anatomical findings," suggesting they had the heart condition, said Dr. Barry Maron, a leading expert on hypertrophic cardiomyopathy at Tufts Medical Center. He has also served as a consultant for top college athletic departments.

"Could some be false positives, and [mistakenly] disqualified from sports?" Maron asks. "I don't know for sure, but it's possible."

Promising athletic careers may have come to an abrupt halt, based on the results of genetic tests that turned out to be misleading. On the other hand, Tarika Mingo worries that insurance companies and doctors won't be as committed to diagnosis and treatment of HCM patients if there is no clear genetic marker. So she's nervous about seeing any genetic marker reclassified as benign.

Meanwhile, it's not clear whether these misidentified traits are still being linked with the disease, Kohane says. Genetic testing labs work independently, so the test for HCM can vary from one company to the next.

"The leading laboratories that do genetic testing make sure that they update their findings as these results come in," he says. But other labs may just adopt a panel of tests and stick with it.

Maron and Kohane say this discovery has implications that go far beyond sudden cardiac death. It underscores the point that even diseases that appear to have simple genetics are in fact usually quite complicated.

"Is HCM one of these diseases you either have or you don't?" Kohane asks. "Or is it like almost everything else we're coming to learn about, where it's a matter of degree."

Genetic testing, he says, has lulled us all into thinking that diseases can be boiled down to yes or no questions. But, increasingly, that does not seem to be the case.

"It just turns out that the genome is as complicated and as unique as each one of us," Kohane says.

Copyright 2016 NPR. To see more, visit NPR.
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Scientists Engineer An Opioid That May Reduce Pain With Less Risk

Wed, 08/17/2016 - 3:31pm
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August 17, 20163:31 PM ET Heard on Morning Edition TS Photography/Getty Images

Once people realized that opioid drugs could cause addiction and deadly overdoses, they tried to use newer forms of opioids to treat the addiction to its parent. Morphine, about 10 times the strength of opium, was used to curb opium cravings in the early 19th century. Codeine, too, was touted as a nonaddictive drug for pain relief, as was heroin.

Those attempts were doomed to failure because all opioid drugs interact with the brain in the same way. They dock to a specific neural receptor, the mu-opioid receptor, which controls the effects of pleasure, pain relief and need.

Now scientists are trying to create opioid painkillers that give relief from pain without triggering the euphoria, dependence and life-threatening respiratory suppression that causes deadly overdoses.

That wasn't thought possible until 2000, when a scientist named Laura Bohn found out something about a protein called beta-arrestin, which sticks to the opioid receptor when something like morphine activates it. When she gave morphine to mice that couldn't make beta-arrestin, they were still numb to pain, but a lot of the negative side effects of the drug were missing. They didn't build tolerance to the drug. At certain dosages, they had less withdrawal. Their breathing was more regular, and they weren't as constipated as normal mice on morphine.

Before that experiment, scientists thought the mu-opioid receptor was a simple switch that flicked all the effects of opioids on or off together. Now it seems they could be untied. "The hope is you'd have another molecule that looks like morphine and binds to the same receptor, but the way it turns the receptor on is slightly different," says Dr. Aashish Manglik, a researcher at Stanford University School of Medicine who studies opioid receptors.

After Bohn's discovery, a number of people, including a team that includes Manglik, started looking for a drug that could connect to the mu-opioid receptor in a way that avoids the negative effects of beta-arrestin.

To do that, they mapped the receptor's structure in a computer program and started looking for chemicals that would stick to it. "We tried to look for molecules that would still bind to this 3-D structure, but are as far away from morphine and codeine as possible," Manglik says.

The team ran 3 million possibilities through the computer and picked the 23 best candidates to test in a lab. One chemical, PZM21, seems to do what they hoped: Turn the opioid receptor on without using much beta-arrestin. They report their findings in Nature on Wednesday.

The scientists then tweaked the chemical to make it more potent and gave it to mice. The mice had pain reduction similar to that with morphine. But their breathing was more normal, and they didn't seem to get high.

"If you give a mouse a drug that activates its reward pathways like cocaine, amphetamine or morphine, the mice just run around more. In this compound, we saw very little of that," Manglik says. The mice also didn't seem to have a preference between the chemical and salt water.

That means it's possible that the compound is less lethal and has less potential for abuse compared to something like morphine, but it still might be as effective of a painkiller. If, of course, it turns out to work in humans. So far it's only been tested in mice.

And the role that beta-arrestin plays in opioids is just one hypothesis. It would be eerily convenient if only the negative effects of opiates are tied to this one protein. The mice that didn't have any beta-arrestin actually seemed to have a stronger preference for morphine over saline. So there may be other things going on that science hasn't teased out yet.

But the work that Manglik and his collaborators have done is encouraging in the search for the next generation of painkillers — ideally ones that are safer and non-addictive.

"I think this was really a tour de force," says Gavril Pasternak, a researcher at the Memorial Sloan Kettering Cancer Center who's also trying to develop new opioids but was not involved in this study. "They're new entities with totally different pharmacological profiles. These are great promise for opiates over the course of the next five to 10 years."

Bohn, now a professor at The Scripps Research Institute in Jupiter, Fla., is hopeful that a safer opioid may be coming to the clinic, too.

Manglik and some of his collaborators have founded a company that will try to bring these new drugs to market, and the pharmaceutical company Trevena is running a very similar molecule through clinical trials now.

But that safe, effective painkiller isn't here yet, Bohn says. "We have some really gorgeous compounds, and I think opiates are a terrible epidemic. But I would be careful of overselling this as the answer."

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