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Children In Foster Care Aren't Getting To See The Doctor

Mon, 09/28/2015 - 10:52am

Children in foster care typically haven't been to the doctor or dentist regularly.


On any given day, about half a million children are living in foster care. They've been removed from violent or abusive households; many suffer physical and mental health problems that have gone untreated.

Their need is acute but the response is often dangerously slow, according to a policy statement from the American Academy of Pediatrics. The recommendations, published Monday in the journal Pediatrics, are intended as a wake-up call for pediatricians who care for foster kids.

According to the report, more than 70 percent of these children have a documented history of child abuse or neglect, and 80 percent have been exposed to significant violence, including domestic violence. Almost all are further traumatized by being removed from their families, says author Moira Szilagyi, a professor of pediatrics at the David Geffen School of Medicine at UCLA.

Foster care becomes a "window of opportunity for healing," Szilagyi says, often the first chance these children have to get the help they need.

And the need is great. Thirty to 80 percent of these children have an untreated medical condition. That can be as simple as eczema or asthma or far more severe and complicated, such as cerebral palsy or neurological damage from shaken impact injuries.

"We see the spectrum," Szilagyi says, including teenagers who have multiple mental health conditions such as conduct disorder, bipolar disorder, depression, ADHD — "a laundry list of diagnoses."

The problem is that many of these children face barriers to care, starting with the permission to treat them in the first place. The process for foster parents to get consent from a family member or guardian can be cumbersome and often stops before it even begins.

And if foster parents do obtain consent, medical providers typically face an incomplete if not invisible medical history.

"Often these children have gone from one relative to another," says Szilagyi, adding it's often not clear how many caregivers the child had prior to foster care. There's no record of treatment, no history of vaccinations, no information about psychosocial development, behavior or mental health problems. The children have a very high prevalence of dental problems.

While the report finds that the number of children in foster care has decreased over the past few decades, the number labeled as "emotionally disturbed" has increased. Szilagyi says these findings should serve as a heads-up for health care providers to refer children to get the care they need, be it from dentists and pediatric mental health providers.

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Club Drug Ketamine Gains Traction As A Treatment For Depression

Mon, 09/28/2015 - 5:20am
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A mind-altering drug called ketamine is changing the way some doctors treat depression.

Encouraged by research showing that ketamine can relieve even the worst depression in a matter of hours, these doctors are giving the drug to some of their toughest patients. And they're doing this even though ketamine lacks approval from the Food and Drug Administration for treating depression.

"It became clear to me that the future of psychiatry was going to include ketamine or derivatives of ketamine," says David Feifel, a professor of psychiatry at the University of California, San Diego, who began administering the drug to patients in 2010.

Ketamine was developed as an anesthetic and received FDA approval for this use in 1970. Decades later, it became popular as a psychedelic club drug. And in 2006, a team from the National Institute of Mental Health published a landmark study showing that a single intravenous dose of ketamine produced "robust and rapid antidepressant effects" within a couple of hours.

Since then, thousands of depressed patients have received "off-label" treatment with ketamine.

One of those patients is Paul, 36, who lives in San Diego and is a patient of Dr. Feifel. We're not using his last name to protect his medical privacy.

Paul's depression began with anxiety. "I was an extremely anxious child," he says. "I would always make choices based on fear. My life was really directed by what was the least fearful thing that I could do."

As Paul grew up, his extreme anxiety led to major depression, which could leave him unable to get out of bed for days. "I lived in pain," he says.

Paul managed to get through college and a stint in the Peace Corps. But most days were a struggle. And Paul has spent much of his adult life searching for a treatment that would give him some relief.

He tried just about every drug used for depression, as well as cognitive behavioral therapy, acupuncture, and even electroconvulsive therapy, which induces a brief seizure. But nothing worked — at least not for very long.

Paul says he was increasingly haunted by "this comforting thought of pressing a cold gun against my forehead where I felt the pain the most."

Then one day, while investigating depression on the Internet, Paul discovered the research on ketamine. "It was clear to me that this was real," he says.

Ordinarily, there would have been no legal way for Paul to get ketamine. He didn't qualify for most research studies because of his suicidal thoughts. And doctors usually won't prescribe a mind-altering club drug to someone with a mental illness.

But the studies of ketamine have produced results so dramatic that some doctors, including Feifel, are bypassing the usual protocols.

By the time Feifel began hearing about ketamine, he had become frustrated with existing depression drugs. Too often, he says, they just weren't helping his patients.

David Feifel, a psychiatrist at the University of California, San Diego, has treated about 100 people with ketamine.

Courtesy of David Feifel

A major study on antidepressant medication published in 2008 seemed to confirm his suspicions. It found that current antidepressants really aren't much better than a placebo.

Many psychiatrists criticized that study. But not Feifel. "I was kind of like, I'm not surprised," he says. "These really don't seem like powerful tools."

Feifel remembers feeling "professionally embarrassed" that psychiatrists didn't have something better to offer their depressed patients. Something like ketamine.

He knew the drug had risks. It could be abused. It could produce hallucinations. And it didn't have the FDA's OK for treating depression.

But he also knew that doctors had a lot of experience with ketamine. It's been used for decades as an anesthetic that can rapidly stop pain without affecting vital functions like breathing. And ketamine's safety record is so good that it's often the painkiller of choice for children who arrive in the emergency room with a broken bone.

So in 2010, Feifel decided he wanted to offer low doses of the drug to some patients. The decision put him at odds with some prominent psychiatrists, including Tom Insel, director of the National Institute of Mental Health. "While the science is promising, ketamine is not ready for broad use in the clinic," Insel wrote in his blog a few months ago.

"There are a lot of pundits who remain skeptical or feel we need to research this ad infinitum before it's ready, which doesn't make sense to me," Feifel says. It's hard to take the wait-and-see approach when you're treating patients who are desperate for help, he adds.

Paul was one of those desperate patients when he was referred to Feifel in March of 2014. The referral was from a local psychiatrist who had run out of ideas, Feifel says.

And Paul jumped at the chance to try ketamine. "If there was even a 1 percent chance that this worked, it would have been worth it to me," he says. "My life was hanging in the balance."

And for Paul, the benefits of ketamine became obvious soon after one of his early injections.

"I remember I was in my bathroom and I literally fell to my knees crying because I had no anxiety, I had no depression," he says

For the past year, Paul has been getting ketamine every four to six weeks. He feels an altered sense of reality for an hour or two after getting the drug. The effect on depression and anxiety, though, lasts more than a month.

Ketamine doesn't always work that well, Feifel says. After treating more than 100 patients, he's beginning to understand the drug's limitations.

One is that its ability to keep depression at bay can fade pretty quickly. Feifel recalls one patient whose depression would disappear like magic after a dose of ketamine. But "we could never get it to sustain beyond maybe a day," he says.

Shots - Health News Depression Treatments Inspired By Club Drug Move Ahead In Tests

Also, ketamine treatment is expensive because patients need to be monitored so closely. Feifel charges about $500 for each injection and $1,000 for an intravenous infusion, which takes effect more quickly. Insurers don't cover the cost because the treatment is still considered experimental.

Even so, ketamine clinics are popping up around the country and they have already treated thousands of patients willing and able to pay out of pocket. Some of the clinics are run by psychiatrists. Others have been started by entrepreneurial anesthesiologists and emergency room doctors, who are familiar with ketamine but may not know much about depression.

"We've seen ketamine clinics open up as pure business models," Feifel says. "I'm a little bit concerned about that."

Feifel fears something bad will happen to a depressed patient at one of these clinics. And that could set back efforts to make the drug more widely available.

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Trauma Workers Find Solace In A Pause That Honors Life After A Death

Sun, 09/27/2015 - 5:00pm
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Practicing resuscitation techniques on a mannequin is just the start of trauma training at the University of Virginia Medical Center in Charlottesville. Workers there also learn to take a moment together after every patient's death to silently reflect.

Kara Lofton/WMRA

Jonathan Bartels is a nurse working in emergency care. He says witnessing death over and over again takes a toll on trauma workers — they can become numb or burned out.

But about two years ago, after Bartels and his team at the University of Virginia Medical Center, in Charlottesville, Va., tried and failed to resuscitate a patient, something happened.

"We had worked on this patient for hours, and the chaplain came in and kind of stopped everyone from leaving the room," Bartels recalls.

"She said, 'I'm just going to pray over this patient and then you all can leave,' " he says. "And I watched it and I felt ­— it was the act of stopping people that really inspired me."

Jonathan Bartels, an emergency care nurse at the University of Virginia Medical Center, recognized early the value of "The Pause." The practice is now part of the curriculum at the university's nursing school, and has begun to spread to other hospitals across the U.S.

Kara Lofton/WMRA

While the prayer wasn't totally comfortable to Bartels, because he, like many at the hospital, is from a different religious tradition than the chaplain, the act of pausing to pay silent respect and acknowledge the loss felt right.

"So the next time we worked on another person who didn't make it, I decided to be bold and stop people from leaving," he says. "I just said, 'Can we stop just for a moment, to recognize this person in the bed? You know, this person before they came in here was alive — they were interacting with family, they were loved by others, they had a life.' "

The team did it. Standing together silently, they stopped — just for a minute.

"When it was done, I said, 'Thank you all, and thank you for the efforts that we did to try and save them.' People walked out of the room, and they thanked me," Bartels says. "And they thought it was really awesome."

The idea of taking a moment of silence together after a death began to spread to other teams throughout the hospital — other emergency workers picked it up, as did an anesthesiologist and a surgeon. What's come to be called The Pause is now being taught as part of the curriculum at the university's nursing school. Emergency medical technician Jack Berner says it helps him handle the toughest cases.

"It makes it so we can actually view the person as a person, rather than as a patient that we see on an everyday basis," he says. "You can relate more to the case, [knowing] it's somebody's father or their mother, their sister or their uncle, rather than somebody you just see for five minutes."

Bartels hopes The Pause will help medical workers like Berner acknowledge and accept the loss without disconnecting emotionally.

"So you are able to feel, and you are also able to sense and give back," Bartels says. Even if the person who died wasn't a relative, health workers share some of the pain in the loss of each life — and need to be able feel it, but without being overwhelmed.

"I can also acknowledge the pain that I bore witness to, in caring for that family, and caring for that patient," he explains.

The concept is spreading beyond the University of Virginia. After the dean of its school of nursing talked about the practice in a speech at a national conference, a nurse from Providence Sacred Heart Medical Center took it home to her co-workers in Spokane, Wash.

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

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Pruning Back Prescriptions For Better Health

Sun, 09/27/2015 - 11:40am
Katherine Streeter for NPR

If you follow health news, by now you may have heard about a federally funded study that was stopped early because of impressive evidence that aggressively lowering blood pressure saves lives.

For more than half a century we've known that controlling blood pressure (getting the numbers below 140/90) is important in preventing heart attacks, strokes and kidney failure. The so-called SPRINT study that was just stopped tells us that lowering the systolic blood pressure (the top number) to 120 or lower is even better in preventing complications and death from cardiovascular causes.

While we wait for the study details to be published in a medical journal, the news about the study has given me pause. How low should we go and for how long?

I think about a patient of mine in his 80s. For decades, he's taken a combination pill (two medicines in one) to keep his blood pressure below 140/90. Six months ago, he told me that he'd been having episodes of lightheadedness once or twice a week. That's a common side effect among older people taking blood pressure medicine.

"It's as though I'm just going to pass out," he told me. "My vision fades and I get wobbly legs."

Fortunately, his episodes had passed without him actually falling.

He and I agreed that it would make sense to try stopping his blood pressure medicine for a month and see what happened. The pause would be something we doctors call a drug holiday. My patient agreed to buy a home blood pressure cuff and use it two or three times a week, then share the results with me.

A month went by, and he sent me the promised letter with his results. His blood pressure, over multiple readings, was fine. And no more lightheadedness!

I wrote him back: "Stay off the medication — it's clear from your readings that you no longer need it." He was thrilled to pare down his list of daily medicines. The decision saved him money and meant he could forget about one of his many daily pills.

I'm satisfied the decision to stop this man's blood pressure medicine was a good one. Since the medicine was something he no longer needed, I helped him avoid a drug-related problem like a fall, and, with it, maybe a hip fracture — one of the banes of our aging population.

What's more, he and I pushed back against medical inertia, the tendency to keep things the way they are because it's easier than making a change. Inertia is especially strong when a medical treatment conforms to accepted guidelines.

There are dozens of guidelines in the world of cardiovascular medicine. Many of them have lifestyle changes as their primary recommendation. All too often, though, people, including doctors, have a hard time improving their diets, losing weight and getting enough exercise. So we resort to medications, often several of them, to treat or prevent illness.

Now that the early results from the SPRINT trial suggest that lower blood pressure is protective, the inertia to keep people on blood pressure pills — or to add more of them — will be even stronger.

My patient's experience, and stories like his, have led me to believe me that there comes a point in aging when, for many of us, our physiology changes. No doubt there are many factors, such as our senior brains, stiffening blood vessels and changes in the ratios of our hormones. Sometimes the changes bring more illness, but in other cases the problems that afflict patients seem to diminish with advanced age.

In other cases, the preventive measures that I recommend as a doctor no longer matter as much. There's not much sense in treating an 80-year-old for high cholesterol who hasn't had a heart attack or stroke already. It's a debatable point, to be sure, and ultimately decisions like these depend on the values of individual patients and an estimate of how long they'll live.

So how do we pinpoint this time of change for individuals and what do we do when we get there?

An obvious but often overlooked choice we can make is something that is called deprescribing, which means discontinuing medications in older people who take a lot of them. A recent article in the journal JAMA Internal Medicine examined this idea, reviewing more than two dozen other studies in which medications were discontinued while tracking the effects (or lack of them) on patients.

People in the study did surprisingly well having their medications stopped (among them blood pressure drugs and sedatives known as benzodiazepines, such as Valium). Adverse symptoms abated, and patients' health generally improved.

As a doctor looking first to do no harm, I draw the following conclusion: Though I'm ready to believe the better low blood pressure outcomes promised by the SPRINT trial, I'm also going to be looking for opportunities to minimize the overuse of drugs in older patients by discontinuing prescriptions whenever possible.

For many of us, less medicine means more health.

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

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Parents Can Learn How To Prevent Anxiety In Their Children

Fri, 09/25/2015 - 2:07pm

Letting children try something that provokes anxiety can help them learn coping skills, researchers say.


Children of anxious parents are more at risk of developing an anxiety disorder. But there's welcome news for those anxious parents: that trajectory toward anxiety isn't set in stone.

Therapy and a change in parenting styles might be able to prevent kids from developing anxiety disorders, according to research published in The American Journal of Psychiatry Friday.

The researchers, led by psychiatry professor Golda Ginsburg, a professor of psychiatry at UConn Health in Farmington, Conn., looked at 136 families. Each family had at least one parent who had been diagnosed with an anxiety disorder and at least one child in the 6-to-13 age range who had not yet been diagnosed with an anxiety disorder.

Roughly half the families received eight weekly sessions of family therapy, while the other half received only a 30-page handout describing anxiety disorders, without specific strategies for reducing anxiety.

After one year, only 5 percent of children from the families who received the family-based therapy had been diagnosed with an anxiety disorder. Among families who received just the handout, that number jumped to 31 percent.

"The basic question was, because we know that anxiety runs in families, could we prevent children from developing an anxiety disorder whose parents had the illness?" says Ginsburg, who conducted the study with colleagues from Johns Hopkins University. The answer was yes, at least over a year.

The researchers will now continue to study these same families, thanks to funding from the National Institute of Mental Health. They will look at whether the children of the families who received the therapeutic intervention go on to develop an anxiety disorder later on in adolescence or early adulthood.

The message from the study's findings so far, Ginsburg says, is that the focus needs to shift from reaction to prevention. "In the medical system there are other prevention models, like dental care, where we go every six months for a cleaning. I think adopting that kind of model — a mental health checkup, a prevention model for folks who are at risk — is I think where we need to go next."

All humans feel anxiety. It's normal, and in many cases, it's a good thing — it makes us run when we see that bear coming toward us or study for that tough exam that's coming up tomorrow.

But in people with an anxiety disorder, that dose of healthy anxiety goes awry. People might feel levels of anxiety that are out of proportion to the situation or feel anxiety in a situation where there is simply no threat. Ginsburg likens it to an "alarm clock going off at the wrong time."

In children, excessive anxiety can come in a variety of ways. Some might struggle with separation anxiety, where they're afraid to go anywhere without their parents.

Others might struggle with social anxiety, afraid of anything from raising their hand in class to eating in front of others in the school cafeteria. Still others struggle with overwhelming worry. They might think, "If I fail this test, I'll fail this grade, fail out of high school, never go to college, never get a job and become homeless."

Whatever the form that the anxiety takes, it's a combination of overestimating the risk of danger — whether that danger is in the form of embarrassment, a dog or a test — and underestimating one's ability to cope, says Lynne Siqueland, a clinical psychologist who specializes in treating anxiety disorders in children and adolescents and was not involved in the study.

There is no single cause for anxiety disorders, Ginsburg says. They're the product of an interaction of genetic and environmental factors. But the disorders do run in families, she says, and there are certain parenting behaviors that can promote anxiety — like modeling anxiety in front of your kids. Modeling might be direct, like jumping up on the kitchen table when you see a mouse, or indirect, like overcautioning your kids to be careful when there's no danger.

Ginsburg has recruited participants for many clinical trials; she says it was easiest to recruit families for this one. "The parents who suffered with anxiety themselves had it since they were children, and they did not want their children to suffer in the same way that they did."

The first two therapy sessions were with the parents alone, where they discussed the impact of the parents' anxiety disorder on the family and how often they do things that could inadvertently raise levels of anxiety in their children.

In the remaining six sessions with the entire family, the therapist worked with the family on how each person could recognize anxiety and use coping strategies to deal with it.

Shots - Health News Anxious Parents Can Learn How To Reduce Anxiety In Their Kids

One key strategy is helping parents understand that kids have to face their fears, Ginsburg says. Sometimes parents help their children avoid anxiety-provoking situations because they're worried it's too much for the child, "when in fact they need to help them face their fears in order to reduce their anxiety," she says.

Siqueland, who provides workshops for parents on how to help their kids cope with anxiety, agrees. Armed with the right information, Siqueland says, parents can help their children prevent anxiety or coach their kids through it when it happens. If your child is scared to walk into that first soccer practice alone because he doesn't know anyone, don't throw the car in reverse and speed back home, she says. Sit calmly with him as he musters the courage to walk in.

The biggest message Siqueland tries to impart to parents she works with is not to try to prevent anxiety, but instead promote their child's competence in handling it. If your child doesn't like to go play at friends' houses, they need to go play at more friends' houses, she says.

"That is kind of an 'aha' moment in the parent workshops," Siqueland says, "that kids who worry about these things need more practice, not less."

Another message Siqueland gives parents: Anxiety is very treatable. "Kids are not doomed to distress."

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Does Hillary Clinton Have The Prescription For Out-Of-Pocket Health Costs?

Fri, 09/25/2015 - 8:56am

Democratic presidential candidate Hillary Clinton has ideas about how to rein in health costs that hit consumers in the pocketbook. But would they work?

Darren McCollester/Getty Images

While the Republicans running for president are united in their desire to repeal the federal health law, Democrat Hillary Clinton is fashioning her own health care agenda to tackle out-of-pocket costs.

But would her proposals solve the problem?

In addition to defending the Affordable Care Act this week, Clinton released two separate proposals. One would seek to protect people with insurance from having to pay thousands of dollars in addition to their premiums for prescription drugs; the other would set overall limits on out-of-pocket health spending for those with insurance.

"When Americans get sick, high costs shouldn't prevent them from getting better," said Clinton in a statement provided by the campaign. "My plan would take a number of steps to ease the burden of medical expenses and protect health care consumers."

The drug plan would, among other things, cap payments for covered prescriptions at $250 per month and let the government negotiate prices for the Medicare program. The overall health spending plan would let people see a doctor at least three times a year without having to first satisfy their deductible and create a new tax credit for those whose out-of-pocket spending is more than 5 percent of their annual income.

But while surveys show that health costs, and particularly drug costs, are a top concern for many voters, it's not at all clear that Clinton's proposals — some of which have been mentioned for decades — would provide an actual cure.

"There's no magic bullet here except getting health costs down," said Len Nichols, a health economist at George Mason University and longtime backer of the federal health law.

The fundamental problem, says Nichols, was built into the health law itself. By requiring many new benefits, such as maternity care and coverage for mental health and substance abuse, insurers were left with few choices when trying to keep premiums from spiraling. Many insurers narrowed their provider networks and collected more from customers who use the system most.

"The degree to which these out-of-pocket realities hit those with chronic conditions harder, it means we're not accomplishing the social objective of sharing the risk," said Nichols.

But setting specific limits for those who are sick will simply drive up premiums for everyone, says the insurance industry. "When you look at mandating additional benefits, that has a huge impact on the cost of coverage," said Clare Krusing, a spokeswoman for America's Health Insurance Plans, the industry trade group.

And even if that is a trade-off the public — and policymakers — decide they are willing to make, there is a phalanx of lobbyists in Washington bent on making sure many of these changes never happen.

For example, John Castellani, head of the Pharmaceutical Research and Manufacturers of America, said Clinton's drug proposal "would restrict patients' access to medicines, result in fewer new treatments for patients, cost countless jobs across the country and could end our nation's standing as the world leader in biomedical innovation."

Meanwhile, Clinton's proposed limit on advertising to consumers for prescription drugs has drawn the ire of the advertising industry. The Association of National Advertisers in a statement called the proposal "wrong and misguided."

Even the insurance industry, which has been relentlessly campaigning against high drug prices, has come out against Clinton's plan. Marilyn Tavenner, AHIP president and CEO, said in a statement that "proposals that would impose arbitrary caps on insurance coverage or force government negotiation on prescription drug prices will only add to the cost pressures facing individuals and families across the country."

Still, the advent of blockbuster new drugs that cost tens or sometimes even hundreds of thousands of dollars, and sudden price hikes for old generic medications, may prove to be a tipping point.

More than a half-dozen states have already imposed some sort of limits on out-of-pocket costs for drugs, either through law or through regulation.

Republicans, meanwhile, have yet to settle on how they would replace the Affordable Care Act, concedes Chris Jacobs, a senior editor for the Conservative Review.

"Republicans need to have a better and more substantive alternative than health savings accounts, liability reform and cross-state purchasing," he said, referring to ways people can save tax-free for their own health bills, medical malpractice reform and allowing individuals to purchase insurance from states other than their own. All are Republican ideas dating back several campaigns.

But when it comes to cost, Republicans have a major case against the authors of the health law, Jacobs says.

"They were never honest with the American people about how much this was really going to cost and the trade-offs needed to pass it," he said. He likened President Obama, when he was lobbying for the bill, to Oprah Winfrey on her television show's famous giveaway episode — "YOU get a car, and YOU get a car," he said. Basically the backers were offering everything to everyone at the same time many of the costs were either hidden or pushed off to the future, he said.

Nichols agrees, at least to a point. The health "law did answer all questions, but now we're ready to revisit because we didn't like all the answers."

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FDA Advisers Call For More Safety Data On Essure Sterilization Device

Thu, 09/24/2015 - 9:36pm

Bayer HealthCare, of Whippany, N.J., brought Essure to market in 2002 as a nonsurgical alternative for women seeking sterilization. Bayer acknowledges the device can lead to complications, but says they are rare.

Julio Cortez/AP

The Food and Drug Administration should gather more information to try to get a better sense of the safety of the Essure sterilization device, a panel of experts assembled by the agency recommended Thursday.

"To be honest, we don't know what we don't know," said Dr. Cheryl B. Iglesia of the MedStar Washington Hospital Center, who chaired the FDA's Obstetrics and Gynecology Devices Panel, summarizing frustration expressed by several members.

The recommendation to gather more safety data was one of a series the panel made at the conclusion of a daylong hearing the FDA convened to review Essure, which has been on the market since 2002. In addition to establishing a patients registry to elicit more information about possible complications from the use of Essure, some committee members also urged the FDA to require that a formal study be conducted.

Shots - Health News FDA Revisits Safety Of Essure Contraceptive Device

Essure consists of tiny coils made of nickel-titanium alloy that doctors insert into a woman's fallopian tubes to permanently block them. The FDA originally approved it as an easier way for women to safely get sterilized. But thousands of patients have reported a variety of complications after having the device inserted, including chronic, severe pain, heavy bleeding, fatigue and reactions of the immune system. That prompted the FDA to ask the panel to review Essure again.

Committee members also said Thursday that women receiving the device need more detailed, explicit information about the possible risks it poses. One option for remedying that problem, several suggested, might be requiring women who want the device to review a checklist of potential complications.

The panel also said doctors need better training about which patients are the best candidates for the device, how to insert it and how to remove it if problems arise.

During the hearing, the committee heard a formal presentation from FDA scientists, who said there has been a significant increase in recent years in reported problems with Essure. But it's unclear, they said, whether the increase was because the device was actually causing more problems.

Shots - Health News FDA To Take Another Look At Essure Contraceptive Device After Health Complaints

The committee also heard from representatives from Bayer HealthCare, who acknowledged that their device could trigger complications. But such negative events are uncommon, said the representatives, who stressed that for most women Essure is safe and highly effective.

The committee also heard testimony from women who have used Essure and developed a variety of problems. Many ask the FDA to pull the device from the market.

The Planned Parenthood Federation of America, the American Congress of Obstetricians and Gynecologists and Physicians for Reproductive Health jointly urged the FDA to keep Essure on the market, saying it offered some women an important contraceptive option.

The FDA usually follows the advice of its advisory committees, but not always. It's unclear when the agency might take any further action.

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Could Delaying Retirement Be Great For Your Health?

Thu, 09/24/2015 - 7:03pm
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Michael Doucleff Sr. (right) talks to a longtime customer at Duke Bakery in Alton, Ill.

Dan Brannan/Courtesy of

He's been at it for 45 years. Wake up before 2 a.m. Turn on the fryer. And have the glazed doughnuts and peanut-topped coffeecakes ready by 6 a.m.

Yup, Michael Doucleff Sr. is a baker and small-business owner in Alton, Ill.

At at age 70, he doesn't show many signs of slowing down. He's still working more than 40 hours a week, still carrying 50-pound bags of flour upstairs from the basement.

"You've got to wake up sometime in the morning — might as well have a purpose," Doucleff says. "I think I still contribute to society. For me, that's enjoyable."

Despite having an autoimmune disease, Doucleff is in pretty good shape. No heart disease. No diabetes. And sharp as a tack.

Doucleff is my father-in-law. And in our family, he's one of the healthiest for his age — and one of the hardest workers.

That might not be a coincidence.

A study published Thursday in the journal Preventing Chronic Disease finds that working in one's 60s and 70s is associated with better physical and mental health.

"There's something about the aging process — that if you stay working, then you stay hardy," says University of Miami epidemiologist Alberto Caban-Martinez, who contributed to the study.

Caban-Martinez and his colleagues analyzed survey data from more than 85,000 adults age 65 and older. (The mean age was around 75.) In general, people who kept working were nearly three times as likely to report being in good health than those who had retired.

Compared with white-collar workers, blue-collar workers still on the job were 15 percent less likely to report multiple chronic diseases, like heart disease, diabetes and cancer. And all types of workers reported better mental health, compared with those who were retired or unemployed.

"Not to encourage workaholics, but there's something to be said about part-time or full-time work," Caban-Martinez says. "And there's not much difference whether you're in the service sector or you're a white-collar worker."

But the study does come with a big caveat. It couldn't determine whether working leads to good health or if it's good health that keeps people working.

"It's kind of the chicken or egg problem," Caban-Martinez says. "Maybe poor physical health is not allowing people to be in the workforce."

Still, other research has shown that being active and socially engaged helps prevent problems as we age, Caban-Martinez says. "Maybe the workplace is giving you the physical activity that keeps you mentally and physically healthy."

And it likely doesn't take much, he says. Getting up early and making sure the bakery is open and running smoothly is certainly enough.

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California Counties Add Health Care For Immigrant Adults

Thu, 09/24/2015 - 12:13pm

Jane Garcia, CEO of La Clinica de la Raza, which serves 25,000 patients in Contra Costa County, Calif., addresses supporters of expanding health care for undocumented adults.

Farida Jhabvala Romero/KQED

A California county voted Tuesday to restore primary health care services to undocumented adults living in the county.

Contra Costa County, east of San Francisco, joins 46 other California counties that have agreed to provide non-emergency care to immigrants who entered the country illegally.

"Providing health care coverage to all is not only about the human morality issue that we should address, but also from a cost-effective point of view ... this is absolutely the right thing," said Jane Garcia, CEO of La Clínica de la Raza, which serves 25,000 patients in Contra Costa, many of them low-income Latinos.

Adult immigrants who are undocumented are not able to participate state health exchanges under the Affordable Care Act, but can get emergency care in hospitals.

The program is not full scope insurance, but will provide preventive care. Health care providers and other supporters say that increasing access to preventive services will cut down visits to the emergency room and save the county money in the long run.

"It will mean better health care access for all, improved public health, lower cost to our health care system, and it's just the right thing to do for people, especially undocumented adults who are not covered under the Affordable Care Act," said County Supervisor John Gioia, a supporter of the measure.

The movement to increase health care access to more residents has also made strides at the state level. In June, the California legislature and Gov. Jerry Brown announced a budget deal to provide public healthcare coverage for undocumented children from low-income families as early as May 2016.

A number of California counties were already covering children regardless of immigration status, says Tanya Broder, staff attorney at the National Immigration Law Center. That paved the way for the statewide agreement.

"California is one of the few states with a large immigrant population that recognizes that it makes sense to provide health care to immigrants ineligible for federal care," said Broder. "And the state is taking steps to provide coverage to all residents, but it's not there yet."

At least two recent proposals to expand health coverage to undocumented adults have been unsuccessful in the state legislature. However, Broder believes the issue will resurface next year.

Alvaro Fuentes, executive director of the Community Clinic Consortium, led efforts to revive health care services for undocumented adults in Contra Costa County.

Farida Jhabvala Romero/KQED

"Now, the conversation is not whether we should cover people regardless of immigration status. It's how do we do it," said Broder.

Washington, Illinois, New York, Massachusetts and the District of Columbia already provide health coverage for immigrant children. But D.C. goes even further. At the state level, only D.C. allows all qualifying residents, including the undocumented, to receive public health coverage through the DC Healthcare Alliance program, according to data from the National Immigration Law Center.

In its first year, the program, Contra Costa Cares, will assign up to 3,000 people a "medical home" at a community health center. Benefits will include regular physician check-ups, immunizations, a nurse advice line and mental health services.

Rosa Arriaga, 72, joined the dozens of supporters wearing "Health4All" t-shirts who packed the supervisors' meeting. She buys over-the-counter medication to help ease the arthritic pains she feels in her knees and along her left arm, but hopes to get regular medical treatment for her asthma and depression as well.

"I have worked, paid taxes and never asked for anything from the government. But now I feel sick, and I need to see a doctor," said Arriaga in Spanish. She has lived in Richmond for 24 years.

"It's not just me. A lot of other people in the county need this program," added Arriaga, who is currently unemployed and says she has trouble paying the rent for a single room she shares with her nephew.

The Cares program is being established as a year-long pilot program. It will benefit 16 percent of the estimated undocumented population in Contra Costa, about 19,000 people. Advocates hope the program will continue and be expanded after this first year.

The Board of Supervisors agreed to allocate $500,000 to Cares. In addition, three local hospitals — including Kaiser, Sutter Health and John Muir Health — have promised an additional $500,000 in funding.

Supervisor Candace Andersen cast the lone dissenting vote, saying that she worries that funding for the program is not sustainable.

"To me when you start a pilot program, you need to see where to go next, and I don't see the funding in place right now," said Andersen. "I'm very troubled that we are having to take half a million dollars from our general fund."

Before the summer, only a few counties in California provided health care services to immigrants in the country illegally. In June, a group of 35 mostly-rural counties in California opted to cover all residents regardless of immigration status, according to the advocacy group Health Access. Last week, the Monterey County Board of Supervisors gave a thumbs-up to expanding health care services.

"Contra Costa is in good company in regards to this," said Anthony Wright, executive director of Health Access. "It's a really important step forward."

In California, an estimated 1 million undocumented immigrants remain uninsured, said Wright.

Farida Jhabvala Romero covers community health for KQED's Vital Signs series. This story was first published on KQED's State of Health blog.

Copyright 2015 KQED Public Media. To see more, visit
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When Deciding To Live Means Avoiding Guns

Thu, 09/24/2015 - 5:04am
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People who have easy access to firearms are about three times more likely to kill themselves than people who don't have access to guns, a recent study from the University of California, San Francisco indicates.


When you're managing a mental health issue, home's not always a safe place.

I recently talked with a 23-year-old in Oakland, Calif., who says he's worried about an upcoming visit to his aunt's home on the East Coast. He's afraid of what he might do to himself there.

"I know that in my aunt's house there are three guns in the basement," says the young man, who asked that NPR not use his name.

He goes back to visit his family once a year, he explains, and usually stays with the aunt who owns the guns. Knowing where those weapons are stored is a particular problem for him, he tells me — he's tried to commit suicide nine times over the past 13 years.

"Having tools for suicide completion ... makes it way more tempting to attempt or complete suicide," he says.

A recent research review from the University of California, San Francisco suggests he's not the only person who feels this way: The analysis indicates that people who have access to firearms are about three times more likely to kill themselves than people who don't have access to guns.

But what happens when you can't control the fact that there's a gun nearby?

Some states, like Missouri and Florida, have laws forbidding doctors to ask patients about gun access and ownership. But that's not the case in California, where managed care provider Kaiser Permanente asks all teen patients about guns during their checkups, as part of its screening for potential health risks.

To give us a better idea of how those conversations go,




/ncal/provider/laurenhartman/about/professional?professional=aboutme.xml&ctab=About+Me&cstab=Professional&to=1&sto=0">Dr. Lauren Hartman, who helped found Kaiser's East Bay teen clinic, ran through the typical interview — with Youth Radio's Kasey Saeturn playing the role of the patient:

Hartman: "So I see on the questionnaire you've checked 'yes' to having exposure to guns. Do you, your parents, or any of your friends have access to a gun?"

Saeturn: "Yes."

Hartman: "Where is the gun kept in your home?"

Saeturn: "Typically, like, on top of the closet."

Hartman: "The gun isn't locked up?"

Kasey: "No."

That's a red flag for the doctor, and a signal she needs to intervene.

Additional Information: Know The Warning Signs Of Suicide

About 80 percent of the time, young people who kill themselves "have given definite signals, or talked about suicide," according to the Youth Suicide Prevention Program. The organization offers this list of warning signs to watch for:

  • A previous suicide attempt
  • Current talk of suicide or making a plan
  • Strong wish to die or preoccupation with death
  • Giving away prized possessions
  • Signs of depression, such as moodiness, hopelessness, withdrawal
  • Increased alcohol or other drug use
  • Hinting at not being around in the future, or saying goodbye

These warning signs are especially noteworthy in light of:

  • A recent death or suicide of a friend or family member
  • A recent breakup, or conflict with parents
  • News reports of other suicides by young people in the community

Other key risk factors:

  • Ready access to firearms
  • Impulsiveness, or excessive risk-taking
  • Lack of connection to family or friends

What if you spot warning signs?
Take them seriously. If your friend mentions suicide and has expressed an immediate plan, or has access to a gun or other deadly means, get help immediately. The National Suicide Prevention Lifeline is a good place to start: 1-800-273-8255. It's staffed 24/7.

Hartman: "So, Kasey, if it's OK with you, I would like to talk to your parents about how to keep the gun safely at home."

Hartman estimates that 15 to 20 percent of her patients tell her they have access to a gun. And when they do, she takes it seriously. How often do Hartman's patients say they have thoughts about harming themselves?

"That unfortunately gets a lot of yeses," she tells me.

Dr. David Brent, a psychiatrist at the University of Pittsburgh School of Medicine who studies suicide and suicide prevention among at-risk teens, says thinking about suicide isn't always a danger signal. About 20 percent of adolescents have fleeting thoughts of death, he says, adding that the percentage of people who actually have a plan about how to carry that out is much lower.

But when someone who is actively considering killing himself or herself also has access to a gun, the possibility of suicide gets a lot more real. In a study published by researchers at the Centers for Disease Control and Prevention in 2001, 1 in 4 survivors of nearly lethal suicide attempts estimated that once he decided to kill himself, he took less than five minutes to attempt it. Though underlying depression may be chronic, suicidal acts are often impulsive and fleeting, the scientists say — get past the temptation and the urge may recede.

It's not unusual for kids to struggle with mental health issues. Brent says that teaching young children coping skills — or how to handle overwhelming emotions — can help prevent serious mental health crises later in life.

The 23-year-old in Oakland I spoke with says he remembers feeling sad and alone as far back as first grade.

"Kinda wish someone had actually asked me what I was feeling," he says, "versus assuming I was doing OK."

Today, although he still has suicidal thoughts at times, he says the way he reacts to his emotions has changed.

He says he now starts preparing mentally, months in advance of visiting his aunt, making what he calls "safety contracts" with his therapist and his friends. Since learning how to avoid and cope with his psychological triggers, he says, he's at a place where he no longer sees suicide as inevitable.

"I think as I grow older," he says, "I can see further into the future."

Reporter Desmond Meagley is 18 years old and lives in Berkeley, Calif. This story was produced by Youth Radio.

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Sad To Say, Most Remedies For Hot Flashes Fizzle

Wed, 09/23/2015 - 4:36pm

Better keep that window open, lady. There aren't many effective options for reducing hot flashes and other symptoms of menopause.

LM Photo/Corbis

We know who we are: women of a "certain age" trying to hold back the assault of menopausal symptoms, and we are often desperate. Some of us remain on hormone replacement therapy. But many of us are unable to use hormones for medical reasons or by choice. As a result, droves of us turn to all sorts of treatments, everything from acupuncture to yoga to antidepressants to herbs. And surveys show most women are completely befuddled as to whether any of these treatments actually work.

This is exactly why the North American Menopause Society assembled a panel of experts to look into the scientific evidence, evaluate it and offer recommendations about what works, what might work and what doesn't work at all.

"Many women try one thing after another, and it is months before they stumble upon something that truly works for them," says Janet S. Carpenter, chairwoman of the panel and associate dean of research and scholarship at the Indiana University School of Nursing. Here are the nuts and bolts.

Recommended: The NAMS panel found solid evidence that two behavioral techniques work.

  • First, a cognitive behavioral therapy approach that combines relaxation techniques, sleep hygiene and learning how to feel more positive about menopause challenges. This reduced the severity (but not the number) of hot flashes.
  • Second, clinical hypnosis. While evidence is limited, the panel found it is likely a promising strategy for managing hot flashes. The panel concludes that both of these mind-body strategies can be recommended to health care providers to advise patients how to handle hot flashes without hormones.

Recommend with caution: Weight loss and stress reduction are always good ideas, but the panel says evidence just isn't there yet to say these lifestyle changes make a difference in hot flashes. When it comes to prescription medication, the panel concludes that selective serotonin reuptake inhibitor antidepressants offer mild to moderate improvement in hot flashes, adding that patients should start out at the lowest dose possible.

Not recommended at this time: The panel reports strong evidence that exercise, yoga and acupuncture, while good for many things, do not work for hot flashes. Over-the-counter and herbal therapies (such as black cohosh, dong quai, evening primrose, flaxseed, maca, omega-3s, pollen extract and vitamins) as well as chiropractic intervention are also unlikely to help.

When it comes to compounded hormones, sometimes called bioidentical therapy, Dr. Wulf Utian, a reproductive endocrinologist, clinical researcher and founder of NAMS, says the label is a marketing ploy without scientific basis.

When considering the variety of herbal products touted to treat hot flashes, Utian says, "virtually" none of them work. He adds the caution that none have been evaluated or monitored for safety and effectiveness by the Food and Drug Administration, which regulates prescription medications.

The hope is these new recommendations will help providers and patients alike make decisions about how to try to regulate their own menopausal symptoms. The position statement was published online Wednesday in the journal Menopause.

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Obesity Maps Put Racial Differences On Stark Display

Wed, 09/23/2015 - 2:50pm

Take a look at the latest obesity data from the Centers for Disease Control and Prevention and you can see that the country's obesity epidemic is far from over.

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Even in Colorado, the state with the lowest rate, 21.3 percent of its population is obese. Arkansas tops the list with 35.9 percent.

"It is the largest epidemic of a chronic disease that we've ever seen in human history," says Dr. Donald Lloyd-Jones, chair of the department of preventive medicine at the Northwestern University Feinberg School of Medicine.

Click on the CDC's obesity prevalence maps and you'll see something even more startling — the disparity among different ethnic groups. It's not new that the obesity epidemic is hitting African-Americans the hardest, followed by Hispanics, but the maps highlight this worrying trend.

For African-Americans for example, there are 33 states with an obesity rate of at least 35 percent, whereas for white Americans only 1 state reports that rate. Nine states estimate the Hispanic obesity rate at 35 percent or higher.

"It is not about one group doing something wrong," says Lloyd-Jones, who was not involved in creating the CDC maps. "It is about the environment that we have built that sets people up to fail."

Race and ethnicity are often a surrogate for low socioeconomic status, he says.

"Our neighborhoods, workplaces and schools expose people, especially poor people, to less choices of healthy foods," Lloyd-Jones says. There are also fewer places outside to be safe and burn off calories.

This has huge implications for the health of individuals and for health costs in the future, because obesity causes significant downstream health problems like diabetes, heart disease and cancer.

The CDC created the maps using self-reported information from the 2014 Behavioral Risk Factor Surveillance System (BRFSS.)

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To Sell Medical Students On Joys Of Geriatrics, Send In 90-Year-Olds

Wed, 09/23/2015 - 10:41am

Belle Likover, a 95-year-old retired social worker, told Case Western Reserve medical students that growing old gracefully is all about being able to adapt to one's changing life situation, including health challenges.

Lynn Ischay/Kaiser Health News

When doctors told Robert Madison that his wife had dementia, they didn't explain very much. His successful career as an architect hardly prepared him for what came next.

"A week before she passed away her behavior was different, and I was angry because I thought she was deliberately not doing things," Madison, now 92, told a group of nearly 200 students at Case Western Reserve School of Medicine in Cleveland. "You are knowledgeable in treating patients, but I'm the patient, too, and if someone had said she can't control anything, I would have been better able to understand what was taking place."

Belle Likover recounted for the students how she insisted when her husband was dying of lymphoma that doctors in the hospital not make decisions without involving his oncologist. "When someone is in the hospital, they need an advocate with them at all times," said Likover, who turns 96 next month. "But to expect that from families when they are in crisis is expecting too much. The medical profession has to address that."

Madison and Likover were among six people all over the age of 90 invited to talk to second-year medical students this month. The annual panel discussion, called "Life Over 90," is aimed at nudging students toward choosing geriatric medicine, the primary care field that focuses on the elderly. It is among the lowest-paid specialties, and geriatricians must contend with complex cases that are time consuming and are often not reimbursed well by Medicare or private insurance. And their patients can have diseases that can only be managed but never cured.

Debt Weighs On Decisions About Specialties

Students often are attracted to more lucrative specialties such as orthopedics or cardiology, said Jeremy Hill, who was in the audience. Student loans are a burden for many medical students. The 35-year-old North Carolina native may owe as much as $300,000 when he graduates — enough, he is quick to point out, to buy "a nice-sized house."

Yet Hill is one of the few Case students who say they are leaning toward choosing geriatrics.

The American Geriatrics Society estimates that the nation will need about 30,000 geriatricians by 2030 to serve the 30 percent of older Americans with the most complicated medical problems. Yet there are only about 7,000 geriatricians currently practicing. To meet the projected need, the society estimates medical schools would have to train at least 1,500 geriatricians annually between now and 2030, or five times as many as last year.

The low number of geriatricians is not surprising considering that their average salary was $184,000 in 2010, almost three times lower than what radiologists earned, the American Geriatrics Society has reported.

Elizabeth O'Toole, a geriatrician and med school professor who arranged the panel discussion, acknowledged in her introduction that most students were interested in other specialties. Yet she warned them not to overlook the needs and outlooks of older patients.

"No matter what you'll be doing, you are going to be working with these folks," she said. More than 400,000 people 80 years old and older received knee replacements last year; 35 percent of men over 80 and 19 percent of women have coronary heart disease; and the most common medical procedure among people over 65 is cataract surgery. Successful outcomes depend on the patient's cooperation and that, she said, requires "an understanding of who the patient is."

Students who braced themselves for a solemn litany of medical problems from the panel were in for a surprise. It wasn't just what the visitors said that made an impression, but how they said it.

Seniors Share Their Secrets With Budding Doctors

The group offered the students advice, telling the doctors-to-be to look at their patients instead of typing notes into a computer, take more time with older patients and answer their questions.

"Having to see so many patients a day is tragic," said Simon Ostrach, 92, a professor emeritus of engineering at Case, who recalled being rushed through an appointment with an orthopedic surgeon who did little for "excruciating pain" after his hip replacement.

When it was her turn, Likover pushed back her chair, stood up and had no need for the microphone she was offered.

Likover swims at least three times a week, serves on several committees addressing seniors' issues and calls herself a huge Jon Stewart fan.

Lynn Ischay/Kaiser Health News

"Getting old is a question of being able to adapt to your changing life situation, having a little less energy, not being quite as healthy as you were before," said Likover, a retired social worker. Four years ago, she was hospitalized twice for congestive heart failure until she learned how to manage the disease through diet. She also has an occasional irregular heartbeat and only recently began walking with a cane. She swims at least three times a week, serves on several committees addressing seniors' issues and is a Jon Stewart fan because "getting a laugh every day is very, very helpful."

Likover told students: "I have lived a very good and hopefully useful life and death does not concern me. It is going to happen. And I think that kind of outlook, not worrying about every little ache and pain, makes a big difference and a very happy life."

"That's a perfect segue to my story," Ostrach said. "I attribute my longevity to smoking, drinking and overeating," he told the students. And doctors who tried to reform him "are all long dead and gone." He was an athlete in college, wrestling and playing tennis. "But as I got past 60," he said, "I found that listening to opera, smoking good cigars and having a little cognac was much more pleasant." All in moderation, he added.

Efforts to introduce relatively healthy older adults to medical students can "reduce the sense of futility and show [the students] that there are real people with real lives who can benefit from quality health care," said Chris Langston, program director at the John A. Hartford Foundation, which focuses on aging and health. Langston has been analyzing the trend for the past several years.

But Jeremy Hill and the roughly two dozen members of Case's geriatric interest group are the exception. For them, the challenge of a complicated patient — "figuring out the puzzle," as one student put it — is what makes geriatric medicine worthwhile, even when a cure is out of reach.

"I have such respect and admiration for this population, and if I could somehow give them one extra good day they would not have had otherwise," said Hill, who then paused for a moment, "I would be privileged to work with them."

After the session, Hill chatted for a few minutes with Ostrach, who had said he's been lonely since his wife died. "If you'd like to have lunch sometime, please call me," Hill said, handing Ostrach a scrap of paper with his phone number.

Copyright 2015 Kaiser Health News. To see more, visit
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Rising Health Deductibles Take Bigger Bite Out Of Family Budgets

Tue, 09/22/2015 - 2:12pm

Health care costs continue to rise, and workers are shouldering more of the burden.

The big reason? Skyrocketing deductibles.

More companies are adding deductibles to the insurance plans they offer their employees. And for those who already had to pay deductibles, the out-of-pocket outlays are growing.

Note: Bars represent the average family premium for employer-based insurance. They are the total paid and reflect contributions by employers and workers.

Source: Kaiser Family Foundation survey

Together that means that the average worker has to pay $1,077 before their health plan will cover any medical expenses, according to a survey released Tuesday by the Kaiser Family Foundation and The Health Research and Education Trust. That's a 67 percent increase in five years.

The higher deductibles — combined with more modest but consistent increases in premiums — mean health cost for consumers are growing faster than income, and taking an ever larger bite out of household budgets.

"Deductibles have been going up so much faster than wages, almost seven times faster than wages," said Drew Altman, president and CEO of the Kaiser Family Foundation. "When out-of-pocket costs are going up at a time when wages are flat, the pain level is still pretty high."

He said higher deductibles are particularly difficult for people with chronic illnesses. "They may not get the health care they need if they have a very big deductible," he said.

Nearly 2,000 employers were surveyed during the first half of 2015 about their health insurance benefits. The survey found that premiums rose about 4 percent. The average premium for family coverage obtained on the job is $17,545 annually, or $1,462 a month, the survey found. The worker's contribution, or share of the premium, averages $4,955 a year for a family plan.

The rise in 2015 continued a decade-long trend of relatively modest premium increases. Prior to 2005, insurance rates were rising at double-digit rates each year.

Still, smaller premium increases and higher deductibles are likely related.

"If you're an employer ... one of the things you can do to hold your premium down now — right away — is increase the deductible," Altman says.

The premium slowdown is all but invisible to consumers, Altman says, because their own costs have risen so dramatically.

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Surgeon Seeks To Help Women Navigate Breast Cancer Treatment

Tue, 09/22/2015 - 1:30pm
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Dr. Elisa Port is the chief of breast surgery at Mount Sinai Medical Center in New York and the director of its Dubin Breast Center.

Bill Truslow

As a surgeon who specializes in the care and treatment of patients with breast cancer, Elisa Port says one of the hardest parts of her job is delivering bad news to patients.

"I wish I could say it got easier as it goes along, but it certainly doesn't. ... It affects me every single time," Port tells Fresh Air's Terry Gross.

But, Port adds, the survival rates for breast cancer are better than they have ever been, which means that frightening diagnoses are often coupled with treatment options. "I think it would be much harder for me as a person to take care of a kind of cancer where there weren't so many amazing options for treatment, and there wasn't as much room for optimism," she says.

Port is the author of The New Generation Breast Cancer Book, which seeks to relieve patients of the information overload that frequently accompanies a cancer diagnosis and advise them of their options. When it comes to treatment, Port says it's essential to consider each case individually: "There's no more one-size-fits-all approach" to breast cancer.

Interview Highlights

On mammograms and 3-D mammograms

Additional Information: The New Generation Breast Cancer Book

How to Navigate Your Diagnosis and Treatment Options—And Remain Optimistic—In an Age of Information Overload

by Elisa, M.D. Port

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This is a real hot-button issue because there are so many mixed messages that are being sent to women across this country. Mammograms are definitely the most effective way to pick up breast cancer for the general population, and that's why the current recommendations are that every woman gets screened with a mammogram starting at age 40. Period, end of discussion. That said, every person is different and their risk factors are different and there absolutely may be a role for adding onto the mammogram — not instead of — for women depending on their risk level, their breast density and again their underlying health. ...

[Editor's note: The U.S. Preventive Services Task Force recommends that women with typical risks for breast cancer have screening mammograms every two years, rather than annually, starting at age 50 and until they turn 75.]

Three-D mammography is kind of a software update to conventional imaging, where basically for a slightly higher dose of radiation it takes multiple pictures through the breast. ... The way I explain it to women is it's almost like it's paging through a book. So rather than generating one image in one direction and a second image in the other direction you get multiple images, slices through the breast. The thing that it's most helpful with is reducing the risk of what we call false positives.

On cancer spreading from one breast to the other

The most important thing for a woman to know is that when she has breast cancer on one side, breast cancer can spread, can spread to other parts of the body, it does not spread to the other breast. So women can develop a new separate cancer in the other side, but for most women that likelihood is extremely low, and most women do tend to overestimate their risks of getting a new cancer on the other side. Also critically important to know is that the removal of the other healthy breast in no way reduces a woman's chances of the cancer that they have, particularly an invasive cancer, spreading. So there's really no difference in survival between removing the other healthy breast and not.

On deciding to remove the healthy breast

They want a more symmetric cosmetic result. Plastic surgeons in today's day and age are very good, and they can absolutely lift or reduce the other breast, particularly if it's ... hanging or saggy, they can do that to match a reconstructed breast, but for sure it's more symmetrical when you do both sides. That may be a very big price to pay, because there's a lot of tightness, etc., across the chest rather than just one side, but for some women the driving factor is symmetry. For some women the driving factor is not really wanting to have another mammogram again or screening. If you keep that other breast, every year a woman's going to have to come in for a mammogram or ultrasound ... and that's a factor. Lastly, even if the risk of developing a new cancer on the other side is small, it's not zero, and some women will choose to do that ... [to reduce the risk]. It's never going to be zero, and that's really important to know.

On genetic testing for the BRCA mutation

It is kind of a moving target. The groups of people, like the red-flag situations where we think genetic testing may be appropriate, keep expanding, but here are some of the big ones: women who are diagnosed with breast cancer pre-menopausally, usually in their 20s, 30s, 40s, especially who have a family history of other pre-menopausal breast cancers; women who have combined family histories of both breast and ovarian cancer; any family where there's a history of male breast cancer.

I think one of the important things to know is not that it's exclusive at all, but the gene is way more common in Ashkenazi Jewish women. ... So nowadays, pretty much any Jewish woman diagnosed with actual breast cancer can and should be tested. The number of Ashkenazi Jewish women who have the gene ... is actually 1 in 40, so a full 2 percent of the Ashkenazi Jewish population actually has the BRCA gene, whereas in the general population it's more like 1 in 400.

On the biggest change in breast cancer treatment since she started

Thirty years ago no one even used the words "breast cancer" in public. Twenty years ago you couldn't even find an advertisement with the word "breast" in it, and you flash forward to times like today, where there's absolutely no shortage of information out there and the problem no longer is lack of information, it's actually too much information, no filter. ...

[Patients] were coming [into my office] inundated, defeated, completely perplexed by all the information out there and how to navigate it, whether it was emails from friends, whether it was websites they needed to read.

I thought there was a need for a new type of book, a new generation of book for a new generation — the age of information overload.

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Report: Errors In Diagnosis Are Common And Will Take Teamwork To Fix

Tue, 09/22/2015 - 11:53am

Errors in diagnosis, such as inaccuracies or delays in making the information available, account for an estimated 10 percent of patient deaths, a blue-ribbon report says.


Almost every American will experience an error in diagnosis at some point in life. But the problem has taken a back seat to other patient safety concerns, an influential panel said in a report released Tuesday.

The report from a blue-ribbon panel of the Institute of Medicine called for widespread changes in health care to improve diagnoses.

Errors in diagnosis — defined as inaccuracies or delays — account for an estimated 10 percent of patient deaths, hundreds of thousands of adverse events in hospitals each year and are a leading cause of paid medical malpractice claims, the report said.

Such errors can occur with very rare conditions, such as the Liberian man with undetected Ebola who was sent home from a Dallas hospital last September. But there are more common problems, such as acid reflux being mistaken for a heart attack or a pathology report showing cancer that is never communicated to a patient.

Reducing the number of errors won't be easy, in part because there is no standard or required way to track them. Reversing current trends, the report concludes, will require better medical teamwork, training and computer systems.

"Some people go to their graves with a diagnostic error that is never detected," said Robert Berenson, a research fellow at the Urban Institute in Washington, D.C., and one of the committee members who wrote the report. "It's much more difficult to measure than a medication error."

The report, called "Improving Diagnosis in Health Care," is the latest in a series launched 15 years ago with "To Err is Human: Building a Safer Health System," which helped fuel the patient-safety movement. The first report estimated that as many as 98,000 patients die each year because of medical errors. The IOM is part of the private, nonprofit National Academies of Sciences, Engineering and Medicine.

Tuesday's report has a role for just about everyone in the health system, from computer programmers to clinicians to patients. It recommends better teamwork among health care providers, patients and families. Citing the dearth of data about diagnostic errors, the report calls for voluntary efforts to report such problems. Dedicated funding is needed for research, the report says, and hospitals and doctors need to develop better ways to identify, reduce and learn from near misses.

Ironically, the report notes that computerized health records, which can help track and coordinate care, can also become a barrier to efficient and correct diagnoses.

The systems, it says, often aren't compatible from one physician's office to another or among hospitals. Auto-fill functions sometimes enter the wrong information. And the sheer volume of inputs and alerts can overwhelm medical staff.

The report cites a study of emergency department staff that found clinicians spent more time entering information into computers than taking care of patients. Another study found that while electronic health records provide alerts in response to abnormal diagnostic test results, 70 percent of medical staff surveyed said they receive more alerts than they could manage.

Making the systems more efficient and allowing patients more timely access to their own medical records to check for and correct errors "could be a game changer," said Berenson.

Indeed, patients "are going to be critical to the solution," said Dr. Michael Cohen, another report author and a pathologist at the University of Utah in Salt Lake City. "There's a real opportunity for patients to advocate for themselves and at the same time to challenge the health care providers about the diagnosis being made."

Helen Haskell, who formed Mothers Against Medical Error after her 15-year-old son died because of a hospital medication error, said she was pleased the report focused on better teamwork and communication. She also said patients need better access to their records — particularly hospital records.

Consumers, she said, should be prepared to ask questions about their diagnoses. "What else can it be? Does this diagnosis match all my symptoms?" are two of the best questions to ask, said Haskell. If there is any doubt, she said, "people should get a second opinion."

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Text Reminders Help People Lower Cholesterol, Blood Pressure

Tue, 09/22/2015 - 11:16am

Texting gentle reminders on heart-healthy habits helped people make real changes.


Much of the buzz over mobile health interventions seems to be about how we can use an ever-growing variety of shiny new smartphone apps and sensors to better manage our health.

But texting, that old-school technology, may deserve some of that spotlight, too.

Getting texts with motivating and informative messages led patients with coronary heart disease to make behavior changes like exercising more and smoking less, according to a study published Tuesday in JAMA, the journal of the American Medical Association. By the end of the six-month study, patients who had received the text messages had reduced their cholesterol, blood pressure and body mass index.

"I have to say, we were pretty surprised that it worked," says Clara Chow, lead author of the study and program director of community-based cardiac services at Westmead Hospital in Sydney, Australia.

And it worked to improve not just one risk factor for heart disease, but many. "These are the things that medications usually do, not text messages," says Chow, who is also an associate professor at Sydney Medical School at the University of Sydney.

In a randomized clinical trial, more than 700 patients with coronary heart disease were split into two groups: half received four text messages per week for six months plus usual care, while the other half received just usual care.

The texts that patients received were semi-personalized, based on background information about each person, such as smoking status and preferred name. For example, vegetarian participants wouldn't receive the text message about how grilling steak is healthier than deep-frying it.

Other texts might include something like, "Hi, Elizabeth. Have you gone for your walk today?" or "Have you taken your medications yet today? It's important to take them at the same time each day."

There's a lot of hype over mobile health interventions these days, Chow says. "Everyone thinks it has a lot of potential, but there's actually very little evidence."

While there are more than 100,000 health-related apps on the market, the evidence to date is lacking as to whether many of those apps are safe or effective, according to Zubin Eapen, a cardiologist and assistant professor of medicine at Duke University School of Medicine.

"We [as physicians] are always looking for evidence to make sure that we are recommending the right things for our patients, whether it's a drug, a device or a digital product, like an app," says Eapen, who is also medical director of the Duke Heart Failure Same-Day Access Clinic.

Eapen coauthored an editorial, which was published alongside Chow's study, with Eric Peterson, the Fred Cobb Distinguished Professor of Medicine in the division of cardiology at Duke and an associate editor of JAMA.

Not only does this research provide evidence that a text-based program can improve heart disease risk factors, but it also shows that a bunch of bells and whistles aren't required for successful health outcomes. A simple, low-cost program of text messaging can do the trick.

"I like to look for things that are able to be used in multiple corners of our world, from low-income settings to high-income settings," Chow says. "Everybody owns a mobile phone these days. You don't have to have a smartphone to text."

That means more access across more sectors of a population. While almost two-thirds of American adults own a smartphone, that number rises even higher when you're talking about plain old cell phones – a full nine out of 10 American adults own some kind of cell phone.

Globally, cardiovascular disease is the leading cause of death. "If we are going to reach a global population, we need solutions that are both scalable and affordable," Eapen says. "And mobile health – and text messaging, maybe, in particular – represents both a scalable and affordable approach."

Making healthy changes in behavior can be tough, but for patients with heart disease, it can be vital.

Yet those daily decisions – whether to smoke that cigarette, eat that piece of cake or skip the gym – are often "far removed from the rewards or consequences," Eapen says. It can be hard to view those everyday decisions in light of more distant consequences, like having another heart attack or not living as long a life as desired. Encouraging text messages may help to inform those everyday decisions and keep a bigger goal in mind.

Chow and Eapen say the study has its limitations. It can't tell us whether text messaging could eventually lead to fewer subsequent heart attacks among the patients receiving those messages or whether the positive health outcomes would continue past the six-month study window. Yet patients in Chow's study resoundingly said that the text messaging helped them make the necessary changes – more than 90 percent of the participants found the program useful.

"People said things like, 'It wasn't actually what the messages said, it was that someone was there supporting me, thinking about me,' " Chow says.

And although Chow and her colleagues told study participants that they did not need to reply to the text messages, many of them still did. "Heaps of them replied to us," she says. "They would say, 'Thanks for the message. I've been on my walk, my blood pressure is better.' "

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Wherever You Go, Your Personal Cloud Of Microbes Follows

Tue, 09/22/2015 - 8:38am
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Remember Pig-Pen? The little kid from Charles Schulz's Peanuts cartoons who walked around in a cloud of dirt? Well, the human body does spew a cloud, but instead of dirt it contains millions of microorganisms.

"It turns out that that kid is all of us," says James Meadow, a microbial ecologist who led research about the microbes shadowing us during postdoctoral work at the University of Oregon. "It's just a microscopic cloud that's really hard to see."

The findings from Meadow and his colleagues were published Tuesday in the journal PeerJ.

Each of us carries around millions of microorganisms – including bacteria, fungi and viruses — on the inner and outer surfaces of our bodies. Most of them aren't dangerous. In fact, growing evidence indicates that they help us in lots of ways. Scientists call this collection of organisms our microbiome.

"A lot of the recent work on the human microbiome has revealed that we're kind of spilling our microbial companions all over our houses and our offices and the people around us," Meadow says.

We do that by touch, and by sharing objects — dishes, computers, toys, beds and so much more. But Meadow and his colleagues wondered if we're also spewing our microbial companions into the air. So they asked 11 healthy volunteers in their 20s and 30s to sit quietly in a special, closed booth for four hours while the researchers analyzed the air.

"The results really surprised us," Meadow says.

By analyzing DNA from bacteria in the air, the researchers could clearly detect plumes containing thousands of different types of bacteria. They could discern all sorts of things from each plume, such as whether the person in the booth was a man or a woman.

"More importantly," Meadow says, "we found that each person is unique in two

First of all, "we each give off different amounts of bacteria to the air around us," he says, probably because of factors such as how much we scratch and how much we fidget. Beyond that, Meadow says, "we each give off a slightly different cocktail of those bacteria. There are just really subtle differences."

Meadow says the findings raise a number of possibilities, including, maybe, one day being able to identify a criminal by analyzing the microbial cloud he or she leaves behind at the scene.

"There are a lot of reasons why we might want to know if some nefarious character's been in a certain room in the last few hours," Meadow says. "Maybe there's a way to use microbes for that."

Microbiome researcher Rob Knight, of the University of California, San Diego, calls the research "exciting" and says it may offer insights into how each of us develops a personal microbiome.

"We know that if you live with people, and even if you just work with people, your microbial communities come to resemble theirs over time," Knight says. "And in the past we used to think that was due to touch. It may be just that you're releasing microbes into the air and some of those microbes are colonizing the people you're with."

Knight says there may be a wealth of information yet to be decoded from your microbiome that could one day yield information about "where you've been, who you've been in contact with" and more.

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To Curb Pain Without Opioids, Oregon Looks To Alternative Treatments

Tue, 09/22/2015 - 5:11am
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Doris Keene (right) talks with her acupuncturist before a treatment at Portland's Quest Center for Integrative Health. Keene says the treatments have eased her chronic back pain at least as effectively as the Vicodin and muscle relaxants she once relied on.

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When Portland resident Doris Keene raised her four children, she walked everywhere and stayed active. But when she turned 59, she says, everything fell apart.

"My leg started bothering me. First it was my knees." She ignored the pain, and thinks now it was her sciatic nerve acting up, all along. "I just tried to deal with it," Keene says.

Eventually she went to a doctor, who prescribed Vicodin and muscle relaxants. In 2012, about 1 in 4 Oregonians received an opioid prescription — more than 900,000 people.

The state also currently leads the nation in nonmedical use of opioids, and about a third of the hospitalizations related to drug abuse in Oregon are because of opioids.

Keene says the drugs helped her, but only to a limited degree.

"My body was saying, 'Well, if I take another one, maybe it'll work.' So, I mean, that's just human nature. Especially when you're in the kind of pain I was in. You get to the point after months and months of pain where you're begging for anything — anything — to relieve the pain," she says.

In the end, Keene became addicted. Her doctor ended up cutting off her supply of pills.

"I got very upset," Keene recalls. "I said, 'What do you mean? You gave them to me. Why'd you give them to me and then tell me that I couldn't have them?' I was begging."

Then Keene went to the Quest Center for Integrative Health, a pain management center in Portland.

Lying on a foldout chair in a darkened room, Keene has about a dozen acupuncture needles in place — all part of her treatment.

"I came in here wearing back braces, and knee braces and a crutch, and Dr. Dave told me, 'Get rid of them! They're just weakening your muscles,' " Keene says. "And when I could walk out of here after the first acupuncture [treatment], I wanted to grab him and kiss him."

David Eisen, executive director of the Quest Center, is Keene's "Dr. Dave." He is board-certified in traditional Chinese medicine and acupuncture, and he says doctors need to stop thinking of opioids as a first-line defense against pain.

"There should be an array of things for people to choose from," Eisen says, "whether it be chiropractic care, or naturopathic care, or acupuncture, nutrition, massage. Try those things — and if they don't work, you use opioids as a last resort."

Oregon wants more patients to try this approach. Denise Taray, coordinator of the Oregon Pain Management Commission, says Medicaid's traditional way of dealing with back pain involved bed rest and prescription painkillers.

"The only thing that might have been covered in the past was narcotics," Taray says. "But treatments such as acupuncture, chiropractic, massage therapy, physical therapy and rehab would never have been covered."

Starting in January 2016, the state will fund many of these alternative treatments for patients who get their health care via Oregon's version of Medicaid — the Oregon Health Plan. While the treatments may cost more than a course of pain pills, the hope is to save money by reducing the number of people who become addicted to opioids or abuse them.

Plus, pain pills aren't always as effective as some people assume.

"Research is out there that suggests that with back conditions we're spending a lot of money on health care treatments and services that aren't improving outcomes," Taray says.

Oregon has not found overwhelming evidence that acupuncture, yoga or spinal manipulation work better than other options. But, as Taray points out, these alternatives don't involve drugs.

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

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Doubts Rise About Surge In Statin Prescriptions For Oldest Americans

Mon, 09/21/2015 - 3:16pm

Tablets of Lipitor and its generic equivalent, atorvastatin, are among the drugs commonly prescribed to prevent heart attacks and strokes among people at risk.

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Many doctors are choosing a better-safe-than-sorry approach to heading off heart trouble in very elderly patients.

Inexpensive statin drugs are given to millions of people to reduce cholesterol, even many who don't show signs of heart disease. A recent study has found that seniors with no history of heart trouble are now nearly four times more likely – from 9 percent to 34 percent – to get those drugs than they were in 1999.

Here's the catch: For patients of that age, there is little research showing statins' preventive heart benefits outweigh possible risks, which can include muscle pain and the onset of diabetes. There have only been a handful of studies that included the over-79 population, according to a review in the American Journal of Cardiology in 2012.

With the average life expectancy at 76 for men and 81 for women in the U.S., drug companies haven't funded such studies in people above 79. There have been many studies involving younger people.

Statins have been shown to reduce the risks of a heart attack or stroke in patients who have had one and possibly prevent an episode in people with high cholesterol who haven't. The drugs, which include the well-known brands Lipitor and Crestor as well as generics, have been on the market for almost 30 years.

Arta Bakshandeh, a senior medical officer with Alignment Healthcare, a company that advises Medicare insurance plans, summed up the dilemma for health plans and doctors with elderly patients. "With health reform there is a push to have primary prevention ... if you can prevent [beneficiaries] from having a heart attack that will cost way more than the $30,000 for a statin over the lifetime, we should focus on primary prevention," he said. "But if we're overprescribing and not taking into account all the drugs patients are on, that is going to land people in the hospital as well. It's a fine balance."

The rate of statin use among octogenarians and beyond who don't have a history of heart attack, stroke, coronary heart disease or vascular heart disease quadrupled between 1999 and 2012, according to two researchers from Ohio State University and the University of Alberta in Edmonton, Canada. Their research was published in the JAMA Internal Medicine in August.

Despite the lack of evidence to guide the use of statins in this population, "the very elderly have the highest rate of statin use in the United States," they said, citing past studies.

Concerns about statins' effects in those older than 79 are being raised as some cardiologists question whether statins are overprescribed even among some younger people.

Guidelines published by the American Heart Association and the American College of Cardiology in 2013 recommended statins as a preventive measure for people with high cholesterol but no overt heart disease if their 10-year risk of suffering a heart attack or stroke is 7.5% or higher.

A risk calculator developed to help doctors apply the guidelines overestimates risk, some researchers have said.

Citing past studies, cardiologists at Johns Hopkins and the Mayo Clinic said last month that "overreliance on such algorithms can lead to unnecessary treatment with statins." They called for further updates to heart disease prevention guidelines. Their comments were published online in August by Mayo Clinic Proceedings.

In any case, the risk calculator only provides guidance for patients up to age 75 due to the lack of clinical trial data for the very elderly. That leaves doctors to weigh whether giving a very elderly person statins as a preventive measure is beneficial considering the potential side effects and the patient's life expectancy.

Endocrinologist Robert Eckel, a professor of medicine at the University of Colorado Denver and member of the American Heart Association who helped draft the guidelines, says more clinical trials are needed to explore statins' risks and benefits in seniors. "It's a gray zone ... evidence-based medicine only goes so far," Eckel said, adding that doctors can instead use judgment and talk with patients about their preferences to compensate for lack of data.

Dr. Steven Nissen, department chair of cardiovascular medicine at the Cleveland Clinic, suggests Congress legislate incentives for drugmakers to study a wider array of drugs and their effects on the very elderly. Most drugs aren't supported by hard clinical evidence to back up treatment in the elderly, he said.

Ohio State's Dr. Michael Johansen, a co-author of the recent statins study, suggests doctors be more cautious about which elderly patients take them for prevention in the absence of more hard data.

Muscle pains that some seniors on statins complain of might be so severe as to cause a fall, which could lead to life-threatening injuries, he suggested.

"We just don't know," he said.

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