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Florida Keys Weigh Options For Battling Mosquitoes And Zika

Fri, 04/22/2016 - 5:25pm
Florida Keys Weigh Options For Battling Mosquitoes And Zika Listen· 3:55 3:55
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April 22, 20165:25 PM ET Heard on All Things Considered

From

Key Haven, a Florida neighborhood about a mile east of Key West, is where a test of Oxitec's genetically engineered mosquitoes might take place later this year. Some neighbors have strongly dissented — at public meetings and via yard signs.

Nancy Klingener/WLRN

Billy Ryan visits Roy's Trailer Park on Florida's Stock Island every two months. It's part of his regular rounds as an inspector for the Florida Keys Mosquito Control District.

"Hey, I'm just checking on the yards for the mosquito control," he tells one resident, Marie Baptiste, as he heads into her yard. "OK?" No problem, she tells him.

People who live in the Keys are used to seeing mosquito control inspectors. Since an outbreak of dengue fever in 2009, the inspectors have conducted routine house-to-house checks in areas where the Aedes aegypti mosquito breeds.

And their eradication campaign — part education, part enforcement — has been effective. The last reported case of mosquito-borne dengue fever in the area was six years ago.

That same species of mosquito can carry the Zika virus. And although there have been no locally transmitted cases of the virus reported in Florida yet, and no signs that it's in local mosquitoes, state and local officials are more determined than ever to do what they can to protect residents from disease-carrying insects.

Ryan's eradication tools are pretty simple. He's got a turkey baster, a dipper — which is a stick with a cup at the end — and a plastic jar to collect samples. He also has pellets of larvicide to treat areas where mosquitoes breed.

In the narrow side yard next to Baptiste's trailer, Ryan finds a plastic barrel with a couple of inches of water at the bottom, and he spots some mosquito larvae bouncing around. Bingo. A. aegypti's favorite breeding ground.

Mosquito control inspector Billy Ryan climbs atop a stack of lobster traps on Stock Island, near Key West, to check a boat for water — and for mosquito larvae.

Nancy Klingener/WLRN

Ryan takes a sample and shows the larvae to Baptiste, as he tips over the bucket.

"I'm going to just flip this over, OK?" he says. "If you ever see anything holding water — or any little buckets or anything — please turn them over, because we don't want to get Zika, or chikungunya or dengue fever. OK?" Baptiste agrees.

This level of attention has been effective in the Keys, thanks largely to cooperation from residents. But another approach that local and state officials are considering to get rid of mosquitoes hasn't been as popular.

The British company Oxitec wants to hold its first U.S. trial of genetically modified mosquitoes in Key Haven, not far from the trailer park.

The plan is to release about 3 million male mosquitoes that have been engineered to produce offspring that die young and can't reproduce. According to Oxitec, experiments with this approach in other countries have reduced the population of A. aegypti mosquitoes in the test areas by as much as 80 or 90 percent.

The U.S. Food and Drug Administration's center for veterinary medicine issued a preliminary assessment in March that called the likelihood of any harm to humans, animals or the environment of the proposed Oxitec experiment in Florida negligible or low. (Members of the public have until May 13 to file formal comments on the FDA's preliminary finding.)

Oxitec releases almost exclusively male mosquitoes — and only female mosquitoes bite humans, so only female mosquitoes can transmit dengue, chikungunya or Zika viruses. But Derric Nimmo, chief of mosquito research at Oxitec, acknowledges that the sorting process isn't perfect. About one in 10,000 of the released insects, he says, will be female. Still, he says, that shouldn't worry anyone.

"We looked at the females and we found there was no difference between being bitten by one of our females to being bitten by a normal female," Nimmo says. "Those female [mosquitoes] are still sterile, so their offspring inherit the gene and they will not survive."

Nonetheless, at a public meeting of the mosquito control board this week, residents of the Keys had lots of questions and concerns. Assurances from Oxitec were not enough to persuade resident Michael Kane, for example, that the test is safe.

"Nature always adapts," Kane says. "No matter how much you think you tweaked it, something else is going to happen. There's going to be unintended consequences."

After all the questions and comments, the board decided to allow residents of Key Haven to weigh in further, via a vote in August on whether to go forward with the Oxitec field test. Though the vote will be nonbinding, three of five board members have said they will abide by the results — at least in regards to Key Haven.

Copyright 2016 WLRN Public Radio. To see more, visit WLRN Public Radio.
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More Marketplace Health Plans Ease Access To Some Expensive Drugs

Fri, 04/22/2016 - 12:21pm

If you need to reach for a top-shelf medicine, some marketplace plans are making it more affordable.

Tetra Images/Getty Images

Some people with cancer, HIV and multiple sclerosis have better access to high-cost specialty drugs in marketplace plans this year, yet a significant proportion of these plans still place many expensive drugs in cost-sharing categories that require the highest patient out-of-pocket costs.

The report released Tuesday by Avalere Health, a consulting firm, examined how silver-level plans handled 20 classes of medications that are used to treat complex and expensive diseases such as HIV, cancer, hepatitis C and bipolar disorder.

Health plans generally place covered drugs into tiers. Generics and preferred brand-name drugs are in lower tiers with lower cost sharing, while higher-priced drugs are often placed in tiers that require patients to pay a percentage of the cost of the drug rather than a flat copayment.

The study found that for five classes of drugs — two used to treat cancer, two for HIV and one class of multiple sclerosis drugs — fewer plans in 2016 placed all the drugs in the class in the top specialty drug tier with the highest patient cost-sharing requirements or charged patients more than 40 percent of the cost for every covered drug in the class.

For example, in 2015, 57 percent of silver marketplace plans put all cancer drugs called anti-angiogenic agents (which inhibit the growth of blood vessels) in the top specialty tier. In 2016, that dropped to 50 percent. Last year, a quarter of silver plans charged patients more than 40 percent coinsurance for every drug in that class. In 2016, 15 percent of such plans did so.

Likewise, 14 percent of 2015 silver plans placed protease inhibitors, a class of HIV drugs, in the top tier, compared with 10 percent in 2016. The percentage of plans charging more than 40 percent coinsurance for those drugs dropped to 6 percent in 2016 from 9 percent the previous year.

The changes are likely driven by protests and legal challenges from patient groups and from increased regulatory oversight, said Caroline Pearson, a senior vice president at Avalere. For example, California next year will prohibit insurers from placing most or all of the drugs for a specific condition in the highest cost tier. In addition, the federal Department of Health and Human Services has signaled in guidance to insurers that placing all or most of the drugs in a high-cost tier may be discriminatory.

"There's been a lot of discussion about discriminatory drug benefits, and that attention has moved health plans to make changes," said Pearson.

Carl Schmid, deputy executive director at the AIDS Institute, an advocacy group, said of the study results: "It does show some progress, which we are pleased to see."

The organization drew attention to the problem in 2014 when it filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that the plan designs of four Florida health plans were discriminatory because they discouraged people with HIV/AIDS from enrolling. The Florida Office of Insurance Regulation subsequently set maximum limits on cost-sharing for HIV medications in marketplace plans.

"We can celebrate this," Schmid said, but "our goal is zero, there should be no plans" that place all the HIV drugs in a class in the top tier and charge high coinsurance.

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

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Suicide Rates Climb In U.S., Especially Among Adolescent Girls

Fri, 04/22/2016 - 12:02am
Suicide Rates Climb In U.S., Especially Among Adolescent Girls Listen· 3:49 3:49
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April 22, 201612:02 AM ET Heard on Morning Edition Rae Ellen Bichell

Suicide rates for women and girls are on the rise.

Eva Bee/Ikon Images/Getty Images

In the '80s and '90s, America's suicide trend was headed in the right direction: down.

"It had been decreasing almost steadily since 1986, and then what happened is there was a turnaround," says Sally Curtin, a statistician with the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.

The suicide rate has risen by a quarter, to 13 per 100,000 people in 2014 from 10.5 in 1999, according to an analysis by Curtin and her colleagues that was released Friday.

She says it's heartbreaking to work with these data. While other causes of death are on the decline, suicide just keeps climbing — and it's doing so for every age group under 75.

"I've been losing sleep over this, quite honestly," says Curtin. "You can't just say it's confined to one age group or another for males and females. Truly at all ages people are at risk for this, and our youngest have some of the highest percent increases."

There is one age group that really stands out — girls between the ages of 10 and 14. Though they make up a very small portion of the total suicides, the rate in that group jumped the most — it experienced the largest percent increase, tripling over 15 years from 0.5 to 1.7 per 100,000 people.

And, Curtin points out, in any given year, there are a lot more suicide attempts than there are suicide deaths. "The deaths are but the tip of the iceberg," she says.

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Until the suicide trend reversed upward, there had been a number of improvements in the past few decades.

In the late '80s, things were probably looking up partially due to new antidepressants that were more effective and had fewer side effects, says Dr. Maria Oquendo, a psychiatry professor at Columbia University Medical Center and president-elect of the American Psychiatric Association. "We saw this very encouraging decrease in suicide deaths," she says, and the parallel between antidepressant prescription and a decline in suicide was mirrored in other countries. "It was really very remarkable, and somehow that trend toward decreasing suicide rates abruptly stopped in 1999."

What changed? One possibility is economic stagnation, which left more people out of jobs and probably made it harder for people to access health care and treatment. There was also a switch from the use of cocaine and crack to use of heroin and prescription painkillers, which can be lethal in case of an overdose.

And there's also the matter of health insurance — a lot of people weren't covered or didn't have access to treatment for depression, the most common risk factor for suicide. (Since 2014, however, the Affordable Care Act has led to a substantial increase in insurance coverage.)

"Now, the other thing that we were anticipating with some dread was the aftermath of the black box on antidepressants," says Oquendo, referring to a warning label that in 2004 the Food and Drug Administration required for commonly prescribed antidepressants.

The label says that in people under age 26, the medications can actually increase the risk of suicidal thoughts and actions. Research has suggested that the warning scared doctors away from prescribing antidepressants to people of all ages.

"And some of the increment in suicide deaths in the younger populations is potentially linked to an understandable reluctance by physicians who see these youngsters to prescribe antidepressants, even when they're aware that the individual is suffering from depression," says Oquendo. Research has shown that the benefits of prescribing antidepressants to mentally ill children tend to outweigh the risk of suicidal tendencies.

But why such a sharp rise among adolescents, particularly girls? "We don't know what's going on, to be quite honest," says Arielle Sheftall, who works at the Center for Suicide Prevention and Research at the Research Institute at Nationwide Children's Hospital in Columbus, Ohio. "We have thoughts, that maybe it's this, maybe it's that. It's really hard to pinpoint one specific risk factor that really, truly is driving this trend."

She and her colleagues study the risk factors that might push a depressed child or teen to attempt suicide. One hypothesis about what's going on with girls is pretty surprising: earlier puberty.

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"It's usually been referred to as the storm-and-stress period of life because there's just a lot of change happening all at one time," says Sheftall.

Boys tend to hit peak puberty around 13 years old, and girls around 11 years old, though some studies show that girls are starting their periods earlier.

"Research has shown that puberty, unfortunately, is associated with the onset of psychological disorders, specifically depression," says Sheftall.

And depression is a big risk factor for suicidal thoughts and actions. So, because of the shifting age of puberty onset, girls might be opening the door to anxiety, depression and other psychiatric disorders earlier on in life.

Sheftall and Oquendo say the hypothesis hasn't been carefully studied, but it's possible. Another potential factor is that girls attempting suicide could be using more lethal methods, resulting in more deaths.

"It's frustrating because you want to never ever see these trends increase," says Sheftall. "That's what we kind of have dedicated our lives and research to: What is causing these increases to occur?"

For now, there are still more questions than answers.

If someone shows the warning signs of suicide: Do not leave the person alone, remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt, call the U.S. National Suicide Prevention Lifeline at 1-800-273-TALK (8255), and take the person to an emergency room or seek help from a medical or mental health professional.

Copyright 2016 NPR. To see more, visit NPR.
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New Overtime Rules May Put Squeeze On Caregivers For Those With Disabilities

Thu, 04/21/2016 - 5:46pm
New Overtime Rules May Put Squeeze On Caregivers For Those With Disabilities Listen· 4:11 4:11
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April 21, 20165:46 PM ET Heard on All Things Considered

Thomas Mangrum of Washington, D.C., has used a wheelchair for 15 years. The company that provides his helper --€” who assists him with his day-to-day activities — will have some tough choices to make once new regulations regarding overtime pay for lower-salaried workers come into effect.

Courtesy of Amy Brooks

In coming weeks, the White House is expected to finalize key new rules on overtime pay that could benefit an estimated 6 million lower-paid salaried workers. Workers' advocates say it's a long-awaited change. Most employer groups vocally oppose the new rules, because they might have to raise their minimum salaries, pay overtime — or limit their workers' hours.

Much of the debate has pitted workers against employers.

But at least one group is sympathetic to both sides: the American Network of Community Options and Resources, or ANCOR, an association that represents employers offering support services to intellectually disabled people.

ANCOR doesn't oppose the rules, because it wants to pay its workers more. At the same time, member employers won't be able to comply with the rules, because their revenue relies on Medicaid reimbursement rates, which aren't set to change.

"When we brought this issue to our board, the response was emphatically, 'Yes, we want to pay the people that work for us what they're worth,' " says Gabrielle Sedor, chief operating officer of ANCOR.

But the states set Medicaid reimbursement increases, and those typically take a lot of time to change, she says.

Numbers That Don't Work

Currently, most salaried workers earning less than $23,660 a year are automatically eligible for overtime pay. With the changes, that salary threshold is expected to roughly double — making far more people eligible for overtime.

Business Giving More Workers Overtime Could Have Downsides, Employers Say

A study commissioned by ANCOR shows if the industry adjusts by increasing overtime pay, it will increase costs by about $1 billion. If it raises salaries for those under the anticipated new salary threshold, the added costs could be nearly $2 billion.

The numbers, Sedor says, don't work.

"What's most troubling to me is that over 20 percent thought that they would be forced to reduce services, and that's a real challenge, because in every state the need for services to people with intellectual disabilities is growing," she says.

And that might have an impact on people like Thomas Mangrum, who has a helper come to his row house in Washington, D.C., every weekday.

Shots - Health News Big Financial Costs Are Part Of Alzheimer's Toll On Families

For 15 years, Mangrum has been wheelchair-bound due to spinal injuries, and also has difficulty reading because of a childhood brain injury. Mangrum has a helper, John Floyd, who cooks, cleans, opens his mail and takes him to appointments.

While Floyd is there most days, sometimes things happen during off-hours. The previous weekend, Mangrum was stranded, alone, with a broken wheelchair, so Floyd's employer, RCM, had to dispatch someone to fix it.

That requires odd hours of work that the new overtime rules might limit, because it would mean paying additional overtime.

Amy Brooks, RCM's chief executive, says her company and others will likely lobby states for a Medicaid rate increase, but "it often takes a lot of time, because states have to get approval for rate changes, so that's not gonna be an easy fix."

Difficult Balance Between Costs And Services

Meanwhile, Diana Hernandez, RCM's human resources manager, says she has considered staggering shifts, or offering compensatory time off for hours worked instead of increasing pay. But she cannot reduce pay or she'll lose staff, and she can't cut staff because she doesn't want to hurt clients.

U.S. New Rules Could Create A New Class Of Overtime Workers

"Talking about the different scenarios, none of them seem like the right way to go for us," Hernandez says. "And so we know that we have to come up with something, but we don't want to lose services to the people. I mean, that's why we're here, that's why we do what we do."

Ivan Parker is a coordinator who manages caregivers and their schedules for RCM, and he worries about other effects. Caregivers aren't interchangeable, he says; they know their patients' routines and they have relationships.

"When you disrupt these peoples' lives, they have behaviors, because their schedules are disrupted," Parker says. His schedule doesn't neatly fit into a 40-hour workweek, he says.

Mangrum, sitting nearby, chimes in. Disabilities, he says, don't only affect people between the hours of 9 and 5.

Copyright 2016 NPR. To see more, visit NPR.
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Task Force Calls For More Safety Oversight At NIH Research Hospital

Thu, 04/21/2016 - 5:06pm
Task Force Calls For More Safety Oversight At NIH Research Hospital Listen· 3:36 3:36
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April 21, 20165:06 PM ET Heard on All Things Considered

This week's critique marks the second time in less than a year that the National Institutes of Health has faced questions on safety standards. Dr. Francis Collins tells NPR the last time was "the darkest moment since I've been NIH director."

Chip Somodevilla/Getty Images

The largest research hospital in the world, the National Institutes of Health Clinical Center in Bethesda, Md., needs reform so that patient safety is always the priority — and never subservient to the demands of science.

That's the conclusion of a sweeping review by a task force of independent experts convened by the NIH. The team has made a slew of recommendations, including the creation of an outside hospital board to oversee the clinical center and a new central office to coordinate research quality and safety oversight.

"The emphasis on research is so great, and on trying to save people's lives, that there became a cultural attitude that overshadowed handling some of the details that are important details," says Norman Augustine, former CEO of Lockheed Martin, who chaired the task force.

NIH Director Dr. Francis Collins tells NPR that he intends to immediately respond to those recommendations.

Indeed, Collins told a meeting of his advisory committee on Thursday afternoon that he is forming a new hospital board, to be chaired by Dr. Laura Forese, chief operating officer of New York-Presbyterian Hospital. Collins is also setting up a new compliance office and making other changes to strengthen safety oversight.

In a written statement posted on the NIH website, Collins says "patients who come to the Clinical Center can be confident that they will continue to be cared for by highly dedicated medical professionals. Continuous improvement is an essential part of hospital management, and this is an opportunity to strengthen our patient safety framework."

"We are an exceptional place, a research hospital with 240 beds," Collins tells NPR. "Patients who come to the clinical center are all on experimental protocols. It makes us rather different than any other hospital you could think of."

He says the doctors and nurses there are working hard to develop new treatments for terrible diseases. "Their focus is on research, and understandably so," says Collins. "And I think in some instances that took precedence over thinking very carefully about, 'Do we have every other kind of oversight in place to be sure that we're not putting people at any kind of unnecessary risk?' "

The NIH safety review comes following embarrassing problems that last year forced the closure of part of the pharmacy service at the Clinical Center. The facility manufactured sterile medical products to be given to people at the center. But inspectors found everything from vials contaminated with a fungus to insects in the ceiling lights to flaws in the air handling system.

"That was, for me, the darkest moment since I've been NIH director, which is now going on seven years," says Collins.

The report from the task force notes that problems in that facility were long-standing, and workers apparently raised concerns regularly but they were never reported beyond the pharmacy department. "People at the bottom were aware of problems and they didn't get up to where the people who could really solve them had a chance," says Augustine.

Earlier this week, NIH temporarily halted work in the cell therapy lab of Dr. Steven Rosenberg, chief of surgery at the National Cancer Institute, pending a review of safety standards there.

Courtesy of National Cancer Institute

Since then, the agency has hired outside companies that specialize in quality assurance for manufacturing to review about a dozen other NIH facilities that make materials intended to be injected or infused into people.

Earlier this week, the NIH announced that it was temporarily halting work at two facilities. One of them was the cell therapy lab of Dr. Steven Rosenberg, chief of surgery at the National Cancer Institute, who makes experimental treatments for cancer. The other was a facility at the National Institute of Mental Health that makes imaging agents given to people who are getting PET scans for research studies — mostly healthy volunteers.

"The good news is that we have no evidence that any patients have been harmed," says Collins."Certainly the motivation here is to find the problems and fix them as quickly as possible."

Rosenberg is famous for his pioneering work in immunotherapy — harnessing people's own immune systems to fight cancer. He has spent four decades at the NIH and has given infusions of immune cells to more than 1,000 people with metastatic cancer.

The results can be dramatic. Some people with metastatic melanoma, for example, have seen complete regressions that have lasted for years. Rosenberg's work was featured in a recent Ken Burns documentary on cancer.

In that documentary, one man's infusion of cells is delayed because the first batch of cells got contaminated by a virus. "The cells from the gentleman in the Ken Burns program was one of the rare instances of contamination — and the cells were discarded," Rosenberg tells NPR via email. "We started over, generated new cells that passed all tests, and the cells were administered. That patient has experienced a complete regression of his cancer ongoing to the present time."

Are the safety problems found in Rosenberg's lab worth putting his clinical trials on hold, given that they involve sick people who may have no other options? Collins tells NPR the risks are difficult to quantify but significant enough to hold off enrolling new volunteers for now.

Rosenberg says he totally supports the NIH effort to improve its facilities and minimize potential risk. "Although it is not ideal to temporarily pause treatments to improve the facility, I firmly believe that these renovations will further minimize risk and patients will benefit," he writes in an email. "I am working very hard, with the full support of the NIH leadership, to complete these renovations as soon as possible."

He further notes that his lab has procedures in place to try to detect any contamination that might make someone ill: "We culture the cells three days prior to the infusion and analyze the cell cultures microscopically on the day of infusion. If there is any evidence of contamination, the cells are discarded and we start over. In addition, a sample of the actual infused product is sent to our microbiology department for culture, and none have ever had evidence of contamination."

Rosenberg says he looks forward to enrolling new patients in his studies in the very near future.

Copyright 2016 NPR. To see more, visit NPR.
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Electric Currents And An 'Emotional Awakening' For One Man With Autism

Thu, 04/21/2016 - 1:50pm
Electric Currents And An 'Emotional Awakening' For One Man With Autism Listen· 43:41 43:41
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April 21, 20161:50 PM ET Heard on Fresh Air

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As someone with autism spectrum disorder, John Elder Robison knows what it's like to feel emotionally removed from situations. Robison tells Fresh Air's Terry Gross that throughout his life people have told him, "There's this emotional language you're missing. There are stories in people's eyes. There are messages."

Robison didn't fully understand what they meant until he received transcranial magnetic stimulation, a noninvasive procedure in which areas of the brain are stimulated with electromagnetic fields to alter its circuitry.

Neurologist Alvaro Pascual-Leone, who treated Robison, explains TMS as a "tool that allows us to introduce a small amount of current into specific parts of the brain without having to use surgery to do so. ... By introducing current in it, we can probe the function of certain parts of the brain [and] we can even modify how different parts of the brain work."

Additional Information: Related NPR Stories Shots - Health News 'NeuroTribes' Examines The History — And Myths — Of The Autism Spectrum Health After The Diagnosis: How Families Experience Autism

Though TMS is already being used to treat certain conditions, including depression, it is still in the experimental stage for autism. Robison participated in a six-month-long study, in which he received weekly TMS treatments. He details the treatments — and the emotional awakening that resulted — in a new memoir, Switched On.

Robison says that the treatments left him with a sense of empathy that he'd never experienced before. But, he adds, not all of the changes caused by TMS were welcome. Ordinary conversations would leave him feeling emotionally overwhelmed, and, in some cases, his memories of past events were tainted.

"It's like I lost a protective shield," he says. "All these memories that hurt me because I was like the butt of a joke or something, I now realize that I just kind of went through life and people maybe said mean things about me but I never knew, so it didn't hurt. Now, stuff like that, it really hurts a lot."

Interview Highlights

On how TMS is used for autism, stroke, depression, epilepsy, Parkinson's

Additional Information: Switched On

A Memoir of Brain Change and Emotional Awakening

by John Elder Robison and Alvaro, M.D., Ph.D. Pascual-Leon

Hardcover, 296 pages |

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Pascual-Leone: There are two very different goals in those applications. The first set of goals is to understand better how the brain works in those conditions, in patients that have those diseases. Part of the reason [we want] to understand it better is [so we can] develop new ways to diagnose the conditions earlier ... [and] to be able to develop new treatments.

In addition to those diagnostic applications, there are also therapeutic applications. It turns out that by applying transcranial magnetic stimulation to different parts of the brain repeatedly, day after day after day, we can modify the brain activity in those areas, and that can translate into a benefit for patients with different disorders.

Those type of therapeutic applications are now, for example, approved for treatment of patients with medication-refractory depression, the form of depression that [doesn't] respond to treatment. In the case of autism, we are earlier in those applications and it is premature to use TMS for therapy, but it's a very powerful tool to try to understand better how the brain of people with autism is different from the brain of people that don't have autism.

On what these brain disorders have in common that allows them to be treated with TMS

Pascual-Leone: One can think of any one disorder — depression or autism or Parkinson's — as a label that is applied to people that have certain symptoms. Take, for example, Parkinson's: It's hard to get going, it's hard to move fast enough; it's hard to think thoughts. There is tremor and involuntary movements, each one of those symptoms maps onto a given circuit of the brain. The reason why that circuit of the brain is not functioning properly, in the case of Parkinson's, has to do with a deficit of a certain chemical in the brain. But the point is, that if we can identify the circuit that causes the symptoms, we can target that circuit and make it function better with brain stimulation. So, in a sense, it's not a treatment for the disorder, for the ultimate cause of the disorder, but it's an intervention that improves how the person — the patient — is able to function.

On treating John Robison

Pascual-Leone: Even a short-term intervention where we learned something about the functioning of the brain can have a profound and lasting impact on the way people live.

We targeted different areas in the frontal part of the brain, the frontal lobe that is right under the forehead, both on the left and the right side. We targeted those areas because we wanted to understand the role in relationship to empathy, to be able to read emotions in people's eyes. In a second series of studies we targeted the motor areas to try to understand how long the effects last, how efficient the brain is in terms of its ... capacity to change.

On why he was willing to try TMS treatment

John Robison is neurodiversity scholar in residence at the College of William and Mary and serves on the federal government's Interagency Autism Coordinating Committee.

Courtesy John Robison

Robison: When I learned about this study from one of Alvaro's researchers, I was just immediately captivated by the idea of TMS. I had never heard of TMS before, but I had worked with the underlying electronic technology in my career as an engineer, and I just thought, "How cool is that? To apply the technologies I used in rock 'n roll sound systems to change the brain," and at the same time, the goal of the study to maybe improve emotional insight as Alvaro said, that spoke to the heart of something that I felt had disabled me all my life. So I was fascinated and captivated by it.

On his experience hearing music before and after the TMS treatment

Robison: There were two things that were really profound for me. First, when I worked as an engineer in music I used to hear every little detail of the performance. The guy would hit a note on the bass guitar and I would hear the buzzing of the snares on the bottom of the drum, or the singer would walk across the stage and I would hear the swishing as he dragged the cable behind him. To me, those were all clues that things were working or not working.

After I stopped working in music that kind of rich detail faded away and I sort of went from hearing music through a wonderful sound system to hearing it like through a cheap transistor radio. It was a gradual thing over 30 years.

When I came out of the lab, after one stimulation and I turned on the stereo in my car, just the majesty of it and the brilliance and clarity, it was so real and so alive. It made me cry all the way home. I wrote Alvaro and I told him that when I got home, and the thing is, it wasn't that they created something new, it reactivated something that was so central to my life and it had faded away. It was like magic.

On being able to read emotions after a targeted TMS session

Robison: I was always possessed of strong emotions, what I wasn't possessed of was reaction to situations with other people, and indeed after another stimulation, when I could look in your eyes and feel like I was just reading your thoughts, which was really weird and powerful for me, because that had never ever happened in my life. ...

Just looking at somebody and having her tell me about putting a water pump on her car, but I would look at her and I would see that she was worried and frightened and anxious and I thought, "Excuse me, I have to go outside and gather myself for a second," because I was almost reduced to tears by an ordinary conversation of commerce and I think that looking back on that time I now see that having this unregulated ability to read emotion was actually, for me, perhaps more disabling than being oblivious to the emotion, because when I was oblivious I could just listen to her tell me about the water pump leak, and I didn't even notice if she was scared or anxious.

On how experiencing the ability to read emotions changed him

Robison: When I volunteered for this study I had, I guess, this fantasy in my mind. I thought, "Well, people could say bad things about me, and I've gotten that all my life," and I thought, because I was oblivious to these emotional signals that there must be all these messages of beauty and sweetness and light that I was missing, and if only I could get them things would be wonderful for me.

When I was able to see emotion it wasn't just in my marriage, it was in the people all around me, and I saw that the world was filled with angst and fear and worry. But you know the really hardest thing was seeing people that I had thought had been my friends and realizing that they were laughing at me and I thought we were all laughing together at jokes, and I was the joke.

On the long-term effects of having his emotions "switched on"

Robison: I can't go to movies anymore. I can't watch TV. Ten years ago I could've sat through the Texas Chainsaw Massacre eating popcorn and stuff and wouldn't have cared. Now it's really upsetting and really stressful to me just to watch the evening news. I can't do it. ...

But at the same time, I know that my ability to serve on these autism committees, I think that's the greatest thing I've ever done in my life, and I'm really proud [that] I can do that, and I think this made it possible. So there's pain that I felt from having these emotions come on, but I'm just so proud that I can do this thing that's important to young people and other people with autism and differences. ...

After all this seeing of emotion, though, one thing that I've come away with is the knowledge that I wanted all my life to be able to read these emotions, but of course reading emotions just makes me like everyone else. I think a debt that I could never repay Alvaro and those scientists is that they showed me that my geeky ability to see into machines and see into things, that's my true gift in life too, that nobody else can do that.

Copyright 2016 Fresh Air. To see more, visit Fresh Air.
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Half Your Brain Stands Guard When Sleeping In A New Place

Thu, 04/21/2016 - 12:02pm
Half Your Brain Stands Guard When Sleeping In A New Place Listen· 2:50 2:50
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April 21, 201612:02 PM ET Heard on All Things Considered parema/Getty Images

When you sleep in unfamiliar surroundings, only half your brain is getting a good night's rest.

"The left side seems to be more awake than the right side," says Yuka Sasaki, an associate professor of cognitive, linguistic and psychological sciences at Brown University.

The finding, reported Thursday in the journal Current Biology, helps explain why people tend to feel tired after sleeping in a new place. And it suggests people have something in common with birds and sea mammals, which frequently put half their brain to sleep while the other half remains on guard.

Sleep researchers discovered the "first-night effect" decades ago, when they began studying people in sleep labs. The first night in a lab, a person's sleep is usually so bad that researchers simply toss out any data they collect.

But Sasaki wanted to know what was going on in the brain during that first night. So she and a team of researchers studied the brain wave patterns of 35 Brown University students.

The team measured something called slow-wave activity, which appears during deep sleep. And they found that during a student's first night in the lab, slow wave activity was greater in certain areas of the right hemisphere than in the corresponding areas of the left hemisphere.

After the first night, though, the difference went away.

To confirm that the left side of the brain really was more alert, the team did two other experiments. First, they had the sleeping students listen to a repeated standard tone followed by a single tone of a different pitch.

When someone is awake or sleeping lightly, the brain responds to this "deviant tone." And the students' brains did respond — but only on the left side.

Then the researchers played a sound loud enough to wake someone who was sleeping lightly. And they found that students woke up faster when the sound was played into the right ear, which is connected to the left side of the brain.

The ability to rest just one side of the brain has never been demonstrated in people before, says Niels Rattenborg, leader of the avian sleep group at the Max Planck Institute for Ornithology in Seewiesen, Germany. But he says it's a trick many animals can do.

"We've known for quite a while that some marine mammals like dolphins and some of the seals as well as many birds can sleep with one half of the brain at a time," he says.

A few years ago, Rattenborg did an experiment with ducks that suggests at least one way in which half-brain sleeping provided an evolutionary advantage. The experiment involved putting ducks in a row, literally, and watching them sleep.

Rattenborg found that ducks with a bird on either side of them put their entire brain to sleep and kept both eyes closed. "However, the ducks at the end of the row slept more with one half of the brain at a time," he says. "And when they did that they directed the open eye away from the other birds, as if they were looking for approaching predators."

Predators aren't a big problem for people these days. But the human brain was shaped during a time when nights were dark and full of terrors, Rattenborg says.

"When we're sleeping in a new environment and we don't know how many predators are around," he says, "it would make sense to keep half the brain more alert and more responsive to bumps in the night."

Sasaki says that brain response is involuntary and there's nothing people can do to prevent it, even if they've just flown in for a big presentation the next morning. So lots of coffee the next morning.

Copyright 2016 NPR. To see more, visit NPR.
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Teen Moms Trust Their Gut, Even When It Puts Their Babies At Risk

Thu, 04/21/2016 - 12:02am

Teen mothers said they didn't follow advice to keep blankets and pillows out of the baby's crib, a study finds.

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Does mother always know best? As a mom, I try to create the healthiest environment possible for my kids. I like to think my decisions are based on fact, but emotion plays a role, too. What happens if my choices aren't supported by medical research, and could even put my children at risk?

Teenage mothers who know about safe-sleeping practices to reduce the risk of infant death often deliberately do not follow those recommendations, a study published Thursday finds. Each year, sudden unexpected infant death will claim about 3,500 babies up to a year old in the U.S., with about a quarter of those due to accidental suffocation or strangulation in bed.

Almost all of the 43 teens in the study reported bed sharing and using loose blankets or soft bedding, which are all listed as practices to be avoided in safe-sleeping recommendations for babies. The national Safe to Sleep campaign, which started in 1994, has helped reduce sudden infant death syndrome in the U.S. by half. But while SIDS rates have declined, rates of other sleep-related causes of death — such as accidental suffocation or strangulation — have increased.

Nevertheless, the teenage mothers in the study felt their instincts trumped professional advice and the results of medical research. The study was published in the Journal of Pediatrics.

I was 30 when I had my first child, but I often felt as these teen moms did: My baby is safer next to me than in a crib, my baby is cold and needs a blanket, my baby is more comfortable in a softer environment. I have dozed off while holding my baby on a fluffy couch or tried to bond by letting my baby sleep stomach-down on my chest rather than face-up in a crib.

Where I did differ from teenage moms was in my approach: Although generally aware of the sleep recommendation guidelines, the teenage mothers in the focus groups had an almost cavalier confidence in their choice to act against them. Like many first-time mothers, I was timid and uncertain about my choices. I mostly followed the guidelines, and yet I felt so strongly about staying close to my baby that I did sometimes "cheat," attributing it to maternal instinct.

There is a difference between instinct and drive, however. Instinct is an unmodifiable behavioral response to the environment, and cannot be resisted. Drive can be both resisted and changed.

What I actually felt was drive. I had a choice, though the pull to do the opposite was very strong. In the study, all of the teenage mothers believed that their "instincts" (the word the teens used) were more accurate than anyone else's — and then acted on them — even when those feelings were in direct contradiction to research to the data on infant sleep-safety.

"Adolescence in general is associated with immaturity and brain development and impulsive, risk-taking behavior," says Michelle Caraballo, an assistant professor of pediatrics at UT Southwestern Medical Center and an author of the study. "They also feel very judged by the people around them, so they want to prove that they can take care of their babies. I don't know if they actually feel that confidence or just project that."

Most of the teenage moms in the study reported getting conflicting advice from trusted sources, often leading them to make decisions based on their own personal preference.

Although Caraballo calls for new approaches such as consistently providing accurate information and creating public service announcements aimed at teen moms, she says she isn't sure what it's going to take to alter their decision-making process.

But she says the message should start by example, while new mothers are still in the hospital: "A lot of babies in hospital nurseries are placed with blankets. Co-sleeping is also encouraged. Many health care professionals aren't up to date on the recommendations."

In addition, many teenage moms are still living with their own mothers. The grandmother often looks after the baby while the mom is in school or working. As of 2011, more than 2.7 million grandparents not only lived with a grandchild, but also served as the primary caregiver.

Caraballo says more research is needed to target people who are influential in a teen's life, such as grandmothers, sisters or friends. "There is a lot of groupthink going on. They have a lot of influence over each other. Like anything in adolescence, there is a need to feel like they belong."

Grandmothers might be giving outdated information to their daughters simply because they don't know about updated safe-sleep procedures. Furthermore, the teens in the study said they tended to rely on health professionals for medical concerns, but on family and friends for parenting advice.

"If the teen gets one story from the doctor and one from Mom, who lives in the home, who are they more likely to believe?" Caraballo asks.

Indeed, as a mother with my mother living in our home, I often deferred to her way of doing things. I figured she had experience with babies and I didn't. Many times she would discount current childrearing recommendations as "overworry." For a teen, I imagine it would even be harder to question your mother, especially if you feel guilt and you are reliant on her for childcare.

And while Caraballo emphasizes that repeated and consistent messaging is important, she doesn't think it's enough to produce behavior change.

"The fact is you can do everything wrong, and your baby might not die, so how do you convince them that it's not a safe behavior?" she asks.

Laurel Dalrymple is a freelance writer and journalist living in Centreville, Va. Her work has been published in The Washington Post, Success magazine and several parenting blogs.


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Some Firms Save Money By Offering Employees Free Surgery

Wed, 04/20/2016 - 3:55pm
Some Firms Save Money By Offering Employees Free Surgery Listen· 4:06 4:06
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April 20, 20163:55 PM ET Heard on All Things Considered

From

Employees at all Lowe's home improvement stores, including this one in South San Francisco, Calif., are eligible to have certain surgeries paid for by the company at selected hospitals.

Justin Sullivan/Getty Images

Lowe's home improvement company, like a growing number of large companies nationwide, offers its employees an eye-catching benefit: Certain major surgeries at prestigious hospitals are free.

How do these firms do it? With a way of paying that's gaining steam across the health care industry, and that Medicare is now adopting for hip and knee replacements in 67 metropolitan areas, including New York, Miami and Denver.

Here's how the program works: Lowe's and other employers pay one flat rate for a particular procedure from any of a number of hospitals they've selected for its quality. And, under the agreement, the hospital handles all the treatment within a certain time frame — the surgery, the physical therapy and any complications that arise — all for that one price.

It was Bob Ihrie, senior vice president for compensation and benefits at Lowe's, who came up with the idea in 2010. When he told managers at other companies about it, he says, "The first question was always, 'Oh, this is just for executives, right?' And I said no, absolutely not, this is for any Lowe's employee in the Lowe's health care plans."

The program is optional for employees. They can still use their local surgeon, if they prefer, and pay out of pocket whatever their insurance doesn't cover. But more than 700 Lowe's employees have taken the company up on its offer, Ihrie says.

It's a great deal for patients, he says, and for his company.

"We were able to get a bundled price, which actually enables us to save money on every single operation," Ihrie says.

The Pacific Business Group on Health negotiates that price for Lowe's, Walmart and a number of other large employers. Associate director Olivia Ross oversees these deals, and says her team is able to negotiate rates that are 20 to 30 percent below what the companies used to pay for the procedures.

"We're seeing savings at the front end," she says, because Lowe's pays less for the surgery. And, because the hospital is responsible for all that care, the institution has a strong incentive to be careful and thorough, Ross says.

That means "huge savings on the back end," she says, "from things like reduced re-admissions, reduced return to the O.R. and lower rates of blood clots. Those are hugely expensive, preventable complications."

Lowe's comes out ahead, even after paying for the patient's travel, Ihrie confirms.

Participating hospitals win, too, by attracting more patients, says Trisha Frick, who handles such negotiations on behalf of Johns Hopkins Medicine in Baltimore.

"It's new business for us," Frick says. "And, for the most part, the reimbursement is acceptable; we believe that we can provide that, within that amount of money."

Medicare, the health insurance program for people 65 and older, started using bundled rates for hip and knee replacements this month in Miami, Los Angeles and 65 other metro areas. Medicare had some early evidence from pilot programs that "the model works well," according to Rob Lazerow, a health care consultant with The Advisory Board Company.

"Medicare is saving something like $4,000 on orthopedic cases," he says.

Medicare's deal is somewhat different from the one at Lowe's. Patients may pay something out of pocket, depending on the type of Medicare policy that insures them. And while the few hospitals selected in Lowe's program can bank on increasing their revenue and the number of surgeries they'll get, the rates established by Medicare's bundled payment system hold for every hospital in a participating market.

"Entire markets are selected for participating," Lazerow explains. "If you're in the San Francisco market or you're in the New York market, all of the hospitals are actually participating in the program."

But there are similarities, too, and Medicare may learn some lessons from Lowe's experience. Lowe's initially had trouble wrangling all a patient's medical records from local doctors. And the company found that patients who had questions weeks or months after an operation sometimes had trouble following up with the out-of-town doctor who had performed the surgery.

"You have some setbacks, and things happen, and you just have questions," Ihrie says. "So what we give every patient now is a little card with the doctor's name and direct phone line and the nurse's name and direct phone line. And all of a sudden, things were a lot better."

Another lesson was startling, Ross says. In addition to cutting the cost of procedures, another chunk of savings to the companies came from avoiding surgeries that probably shouldn't happen in the first place.

"We're seeing up to 30 percent — close to 30 percent of cases — who should not be moving forward with the joint replacement," Ross says.

What typically happens in these cases, she says, is that employees get a recommendation from a local doctor that they should have surgery, only to have physicians at the selected hospitals deem the operation inappropriate.

In some cases that may be because the employee hasn't first tried less invasive treatments, such as physical therapy, Ross says. Or the employee may need to lose weight first, to make the surgery safer.

Ihrie says what heartens him most about his company's program is that Lowe's employees are now taking a more active role in decisions about their care.

"What treatment you receive is not always very black and white," he says. "The mere fact that people now think about what they're doing helps us control costs across the board."

This story is part of NPR's partnership with WFAE and Kaiser Health News.

Copyright 2016 WFAE-FM. To see more, visit WFAE-FM.
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Medicare Delays Plans For New Star Ratings Of Hospitals

Wed, 04/20/2016 - 12:51pm

Members of Congress complained to the administration that hospitals needed more time to check the accuracy of quality ratings.

Win McNamee/Getty Images

Updated April 20 at 1:50 ET with a statement from the American Hospital Association.

Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch.

The new "overall hospital quality" star rating aimed to combine the government's disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.

But this month, 60 senators and 225 members of the House of Representatives signed letters urging CMS to delay releasing the star ratings. "We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate CMS's work to ensure that the methodology is accurate or fair," the letter from the House members said.

In a notice sent Wednesday morning, CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July. "CMS is committed to working with hospitals and associations to provide further guidance about star ratings," the notice said. "After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience."

But in a conference call with hospital representatives, CMS officials said they might delay release of the ratings past July if they are still analyzing or revising the methodology, according to people who participated in the call.

Mortality, readmissions, patient experience and safety of care metrics each accounted for 22 percent of the star rating, while measures of effectiveness of care, timeliness of care and efficient use of medical imaging made up 12 percent in total.

The hospital industry for months has been urging this delay the star ratings, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital's death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.

The industry's major trade groups said in a letter to CMS that some hospitals perform poorly because their patients tend to be lower income and don't have the support at home. Many of the nation's most prestigious hospitals have been bracing for middling or poor ratings.

Rick Pollack, president of the American Hospital Association, said in a statement that "the delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients, and the AHA commends CMS for their decision."

Last year, CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.

Hospital Compare received 3.7 million unique page views last year, according to a paper published this month in the journal Health Affairs. The author, analyst Steve Findlay, called the traffic "not at a level commensurate with [the] stature and potential" of the federal government's health care facility comparison sites.

Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this specific mix of measures raises concerns. "The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me," he said.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Jordan Rau is on Twitter: @jordanrau.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Webcast: Health Care Inequalities In America

Wed, 04/20/2016 - 10:42am
Harvard T.H. Chan School of Public Health YouTube

One of the chief goals of the Affordable Care Act was to expand insurance coverage so that all Americans could have access to quality health care. How's that working out?

According to the Department of Health and Human Services, about 20 million people have gained coverage because of the ACA — either signing up for insurance through one of the marketplaces established by the law or enrolling in Medicaid or the Children's Health Insurance Program.

All told, the sign-ups drove the uninsured rate down from 15.7 percent in 2011 to 10.1 percent in 2014, according to the latest figures from the U.S. Census Bureau. A further decline in 2015 is anticipated, given the increased volume of people signing up for insurance last year.

But behind these positive trends lie areas of deep concern to health policy leaders. In a series of polls, NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that a surprising share of Americans, particularly those with low incomes, are having problems with the quality of care they receive.

You can find the detailed results of the national poll here and results on how income affects health care here.

Results for the individual states:

Florida

Kansas

New Jersey

Ohio

Oregon

Texas

Wisconsin

We found that among people living in households with incomes of less than $25,000, 34 percent rate the quality of health care they receive as fair or poor. That compares with just 13 percent of people with higher incomes.

The significance of this finding is that low-income people are more likely to be sick than people of other incomes. Forty-one percent of low-income adults rate their health as fair or poor, versus just 18 percent of people of other incomes.

The polls are part of an in-depth study to assess the changing health care landscape in the two years since the ACA took full effect. We conducted a national survey of 1,002 people, along with seven separate state polls of approximately 1,000 people each in Florida, Kansas, New Jersey, Ohio, Oregon, Texas and Wisconsin.

Other findings show the use of emergency rooms has not declined as many had predicted prior to the ACA. The use of urgent care centers, which are often lower in cost, is rising.

As part of our series, "Perceptions of Health," Harvard is presenting a webcast Wednesday at 12:30 p.m. ET in collaboration with NPR and the Robert Wood Johnson Foundation to discuss whether efforts to extend coverage have improved the health care experiences of Americans and narrowed the gap in access to high-quality care between low-income and other Americans.

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Joe Neel, deputy senior supervising editor on NPR's Science Desk, will moderate a discussion with:

  • Robert Blendon, professor of health policy and political analysis, Harvard T.H. Chan School of Public Health and Harvard Kennedy School
  • Benjamin Sommers, assistant professor of health policy and economics, Harvard T.H. Chan School of Public Health
  • Katherine Hempstead, senior advisEr, Robert Wood Johnson Foundation
  • Jackie Jenkins-Scott president, Wheelock College
Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Life Expectancy Drops For White Women, Increases For Black Men

Wed, 04/20/2016 - 12:02am
Life Expectancy Drops For White Women, Increases For Black Men Listen· 3:15 3:15
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April 20, 201612:02 AM ET Heard on Morning Edition Daniel Fung/iStockphoto

White women are dying at a slightly younger age than in the past. That's according to a report released Wednesday by the Centers for Disease Control and Prevention's National Center for Health Statistics.

The life expectancy for non-Hispanic white women in the United States declined by one month — from 81.2 years to 81.1 years — from 2013 to 2014. Though one month may not seem like much, demographers worry — it's the first time since the government began keeping records that white women's life expectancy has declined, according to the report.

The numbers don't include cause of death, but demographer Elizabeth Arias, who wrote the analysis, decided to dig deeper. She looked at cause of death among white people in the U.S. over the past 15 years. And the changes she found troubled her.

"For the age group 25 to 54, suicide went up," she says. " 'Unintentional poisonings,' which is mainly alcohol and drug poisoning, and chronic liver disease — those went up by quite a bit."

Those underlying factors affected men and women, Arias says, but affected women more. The life expectancy of white men over the same time period did not change.

Many other causes of death declined, she says — including heart disease, cancer and stroke. But those health improvements were offset by the increases in drug overdose, suicide and chronic liver disease.

The report comes just a few months after a separate study by Princeton economists Anne Case and Angus Deaton showed that middle-age mortality among white people is on the rise. The authors of that study also said the increase in deaths was likely due to suicides, drug overdoses and alcoholism.

Ellen Meara, a professor at Dartmouth's Institute for Health Policy and Clinical Practice, said the numbers are surprising because mortality has been in decline for so long.

"There are people for whom life expectancy is falling — and that's happening at a time where everywhere else and for every other group we're seeing all these amazing gains in survival," Meara says.

The NCHS report does have some good news: The average life expectancy for non-Hispanic black men increased by about a half-year — from 71.8 years to 72.2 in that same time period. Arias says that improvement seems linked to declines in cancer deaths, homicides and heart disease.

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NIH Halts Some Research Amid Concerns Over Contamination And Safety

Tue, 04/19/2016 - 5:26pm

The Clinical Center on the campus of the National Institutes of Health, in Bethesda, Md., is an internationally renowned hospital where patients are also research subjects.

NIH/Flickr

The National Institutes of Health has suspended work in two facilities that manufacture products given to people who are enrolled in research studies, saying the facilities haven't complied with safety standards designed to protect already-sick people from inappropriate risks.

"There is no evidence that any patients have been harmed, but a rigorous clinical review will be undertaken," the NIH said in a statement provided to NPR Tuesday. "NIH will not enroll new patients in affected trials until the issues are resolved."

The NIH says work has been halted in two facilities that manufacture sterile or infused products: a National Cancer Institute laboratory engaged in cell therapy production and a National Institute of Mental Health facility producing positron emission tomography materials.

The cell therapy research is run by a scientific superstar named Dr. Steven Rosenberg, chief of surgery at the National Cancer Institute. He's spent four decades at the NIH, where he pioneered the idea of using the immune system to fight cancer. He's also the doctor who treated President Ronald Reagan's colon cancer.

Rosenberg did not respond to an email and a phone message left at his office. A representative of the company involved with his clinical trials, Kite Pharma, declined to provide information beyond what's in a press release.

The shutdowns of these facilities and research studies comes as the NIH is struggling to recover its credibility following embarrassing revelations last year that halted sterile manufacturing operations at a facility that serves the prestigious NIH Clinical Center.

The Clinical Center is a world-famous hospital where the patients are also research subjects. It's often a place of last resort for desperately ill people who are willing to try unproven medicines.

But in April 2015, fungal contamination was discovered in two vials of the drug albumin that were manufactured by the Clinical Center's Pharmaceutical Development Service. At least six patients received injections from that batch, but the NIH has said none have suffered any problems.

Shortly after that episode, in May 2015, the Food and Drug Administration received a complaint and conducted an unannounced inspection of the pharmaceutical service facilities. The inspection found worrisome deficiencies, such as insects in the lights of so-called clean rooms, flaws in the air-handling system, and inadequate training of staffers. In June, the NIH announced that sterile operations at the facility were suspended.

Since then, an internal investigation at the NIH revealed that this wasn't an isolated problem but rather part of a disturbing pattern. "We learned that there was a prior history of contamination events and a systemic failure to adhere to a set of standard safety and compliance principles," reported an NIH task force. "Instead, priority had been put on producing a high volume of products to meet the requests of intramural investigators."

That's why, a few months ago, the NIH put together what it is calling a red team to examine the structural and cultural issues underlying these failures. The team was also tasked with reviewing "other research activities at the Clinical Center that pose a potential risk to research participants," including other sites at the NIH that make experimental compounds intended for administration into sick people.

The red team is scheduled to brief an advisory committee to the NIH director on Thursday afternoon.

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UnitedHealth To Leave Most Obamacare Exchanges In 2017

Tue, 04/19/2016 - 3:36pm

UnitedHealth Group, based in Minnetonka, Minn., says it expects to lose $650 million on health exchange plans this year. Many people who bought the plans are in relatively poor health, the company says.

Mike Bradley/Bloomberg via Getty Images

Insurance giant UnitedHealth Group says it will stop selling insurance on Obamacare exchanges in most states starting next year.

In a Tuesday call detailing UnitedHealth's first quarter earnings, CEO Stephen Hemsley said the company would "remain only in a handful of states," after losing money on the individual health plans it sold on state exchanges.

The decision won't affect UnitedHealth customers who have insurance through the company this year. However, customers in the states that the company is leaving will likely have to shop for a new plan for 2017.

The company, which is the largest U.S. health insurer, has about 795,000 customers who bought plans for 2016 through the exchanges, which were created under the Affordable Care Act. That's just a fraction of the 13 million people who bought Obamacare plans this year.

On Tuesday the company said it expects to lose $650 million on exchange plans this year, in part because the health status of the people who bought plans is worse than expected.

Still, UnitedHealth's overall revenue rose 25 percent in the first quarter and profits rose 14 percent — to $1.6 billion.

UnitedHealth has already informed several states that it intends to pull out of the exchange markets in 2017. Those include Michigan, Oklahoma, Arkansas and parts of Georgia.

"We have been evaluating public exchanges on a state-by-state basis," Hemsley said on a conference call with reporters and equity analysts. "Our own experience and performance have been unfavorable in these markets."

Officials at the Department of Health and Human Services, which administers the Affordable Care Act and the federal HealthCare.gov insurance exchange, say UnitedHealth's plans were priced higher than many others. In at least seven states, more than 90 percent of residents could buy plans that were cheaper than UnitedHealth's offerings.

"As with any new market, we expect changes and adjustments in the early years with issuers both entering and exiting states," said HHS spokesman Ben Wakana, in a prepared statement. "We have full confidence — based on data — that the marketplaces will continue to thrive for years ahead."

The effect of the company's withdrawal on consumers depends on where they live. An analysis released Monday by the Kaiser Family Foundation shows that premiums could increase as little as $1 a month in some counties, while in other areas they could rise by as much as $100 a month.

Residents of Oklahoma, for example, may be left with only one company offering health insurance through the exchanges unless another company enters the market, the report shows.

Nationwide, however, premiums for health plans on the exchanges would likely rise only modestly — about 1 percent on average — if UnitedHealth pulls out of the market altogether. The premium increase would amount to about $4 a month.

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Your Invisible Neighbors: Each City Has Unique Microbes

Tue, 04/19/2016 - 1:06pm
Agnes Elisabeth Szucs/Getty Images

If you're like most people in North America, you probably spend most of your time indoors. Leave home in the morning, drive to work, stay in your cube all day, head home again. Ninety percent of our lives are spent inside a built environment of some kind – ones that we share with millions of invisible microbes.

Scientists increasingly recognize that rooms and buildings have their own microbiomes, and that those microbial roommates may affect the health of human inhabitants. Those microbes vary depending on what city you're in, according to a study published Tuesday.

The researchers looked at what drives the composition of microbes inside nine different offices across three cities. Gregory Caporaso and his team at Northern Arizona University, where he studies microbiomes as an assistant professor in the Department of Biological Sciences, collected samples in offices in Flagstaff, Ariz., San Diego and Toronto, chosen for their varied climates. Collection plates were covered with materials such as carpet, drywall and ceiling tile. They were then installed on the floors, walls and ceilings of offices. The researchers collected samples in four six-week periods over a year.

In all nine offices, human skin bacteria accounted for 25 to 30 percent of the office microbial communities, but the largest numbers looked like microbes that also live outdoors. And it turned out that each city has a unique, city-specific microbial signature. Plates from offices in the same city were more similar to each other than those from the other cities. They're not sure exactly why that would be, but they suspect that microbes migrate inside on people's shoes and in air circulated through the ventilation system.

Caporaso's team also found that the bacterial communities did not differ based on the type of material, but did differ based on the location in the room, two variables that had been conflated in prior studies. The work was published in the journal mSystems.

"This is a benchmark study," says Jack Gilbert, a microbial ecologist and professor of surgery at the University of Chicago, and senior editor of the article. "Previous studies haven't really controlled for a lot of those variables, so most of the results have been assumptions. This is really a wonderful paper because it's clearing up many of those assumptions."

It's intriguing to think that our homes, offices, hospitals, and cars are not just inanimate places where we conduct our business; they're also complex ecosystems. Our indoor environments appear to be affected by changes in the outdoors, as well as by the people who come through it. Those people bring with them their own microbes which affect, and are affected by, the microbes in the built environment.

Caporaso says eventually it may be possible to make good use of those microbial connections to design and construct buildings with healthier microbiomes that are in balance with the surrounding environment. The goal would be to create healthier environments in the places where we spend most of our lives.

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For The Insured But Cash-Strapped, Free Health Clinics Still Have A Place

Tue, 04/19/2016 - 11:00am

When deductibles and copays are high, quite a few people with insurance turn to free clinics for care.

Jens Magnusson/Ikon Images/Getty Images

Denise Johnson works two jobs, but neither of them offers health insurance to part-timers like her. She signed up for a marketplace plan this year, but for routine medical care Johnson still goes to the free clinic near her home in Charlottesville, Va.

The problem is her plan's deductible of at least $1,000. She can't recall the precise figure, but it doesn't really matter. "It's absolutely high," said Johnson, 58. "Who can afford that?" She struggles to pay her $28 monthly premium.

By continuing to visit the free clinic where she's been a patient for a few years, Johnson said she saves hundreds of dollars a year on blood pressure and diuretic medications, her EpiPen and allergy pills. In addition to the drugs, she also sees a primary care doctor every six months at the clinic to keep tabs on her borderline diabetes. She also sees an allergist once a year.

"If you're a working-class person and you've got a free clinic near you, buying a bronze plan and using the free clinic for primary care makes sense," said Sara Rosenbaum, a professor of health law and policy at George Washington University.

Denise Johnson said she saves hundreds of dollars a year on prescription medicines by going to the Charlottesville Free Clinic.

Courtesy of Charlottesville Free Clinic

Of the 1,300 people who visited the medical clinic at the Charlottesville Free Clinic in the past year, roughly 15 percent have enrolled in insurance through the marketplace, said Colleen Keller, executive director of the clinic. The clinic, which limits services to lower-income people, provides medical, pharmacy, mental health and dental services through a combination of staff and volunteer medical professionals.

In addition to serving the working uninsured, the clinic has expanded its target population to include the underinsured — people who have coverage but whose premium and deductible represents 10 percent or more of their income.

Nicole Lamoureux, CEO of the National Association of Free and Charitable Clinics, said in many states these organizations are expanding their mission to make sure they can serve the underinsured.

"I think there definitely is a shift," she said. "Prior to the [federal Affordable Care Act], we were seeing primarily the uninsured, but since the passage of the ACA, we're seeing more of the underinsured." Clinics define underinsured differently to meet the needs of their local populations, she said.

A study by the Commonwealth Fund found that 23 percent of adults younger than 65 who had coverage all year in 2014 were underinsured. The study considered someone underinsured if their out-of-pocket health care costs, excluding premiums, were at least 10 percent of their income, or 5 percent if their income was less than 200 percent of poverty (which was $22,980 for an individual in a 2014 plan). People whose health insurance deductibles were at least 5 percent of their income were also included.

Some people expected that the need for clinics to provide free medical care would wind down as people got coverage under the health law, said Jack Hoadley, research professor at the Georgetown University Health Policy Institute. Undocumented immigrants and people who don't qualify for Medicaid would continue to rely on them, but few others would need to. But that hasn't happened. Hoadley co-authored a recent study on the effect of the health law on consumer coverage in Richmond, Va., Tampa, Fla., and Columbus, Ohio.

Free clinics in those cities are "very much needed by people who qualify for insurance subsidies, but still can't afford the copays or deductibles to get care," Hoadley said.

The health law also expanded eligibility for coverage under the Medicaid program to adults with incomes up to 138 percent of the federal poverty level (about $16,000), but the Supreme Court ruled that adoption of the provision was optional. So far, 31 states and the District of Columbia have expanded coverage. The Medicaid expansion has helped ease the burden on free clinics, but sometimes even Medicaid beneficiaries come back.

Cost isn't the only factor that the newly insured are grappling with. Some people come to free clinics because they can't get appointments with providers, especially in rural areas, said Deborah Miller, executive director of the Ohio Association of Free Clinics.

"Access is a problem across the board," she said, referring to people in marketplace and Medicaid plans.

Many Ohio free clinics have expanded their missions to serve those who are uninsured, underinsured or without access to care, Miller said.

Then there are those who return to a free clinic after dropping their marketplace plan because of the cost.

"They may have a penalty for not having insurance, but it's lower than their copays," said Judith Robinson, a health insurance support specialist at the Charlottesville free clinic.

The health law requires most people to have insurance or pay a penalty. In 2015, the penalty was the greater of $325 or 2 percent of household income. There are exceptions to the requirement for financial and other hardships. If the least expensive coverage available would cost more than 8.05 percent of someone's household income, for example, people aren't required to have coverage.

Surprise expenses can undermine even the best intentions, Miller said. Someone's car breaks down and then they get behind on their electric bill. Suddenly they're two months behind on their health insurance premium and they can't catch up.

"All it takes is one unexpected expense, it's life, and they don't have a cushion to help with those unexpected things. And then it's a crisis," she said.

And they're back at the free clinic.

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

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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Analysis: Modest Effect If UnitedHealth Withdraws From Exchanges

Mon, 04/18/2016 - 2:35pm

If UnitedHealth Group. based in Minnetonka, Minn., pulls back from the Obamacare exchanges, premiums nationwide would go up around 1 percent, a Kaiser Family Foundation reports finds.

Mike Bradley/Bloomberg via Getty Images

Insurance giant United Healthcare Group has griped that the Obamacare insurance exchanges for health coverage are money-losers and has threatened to stop selling plans on them.

United Healthcare's latest move is to drop out of the Obamacare insurance market in Oklahoma in 2017. It's the fourth state that the company is abandoning because it says selling insurance plans on exchanges there is unprofitable.

United Healthcare has already said it's pulling out of the exchanges in Michigan, Arkansas and parts of Georgia. The company may announce more changes when it reports first quarter financial results Tuesday.

If the company withdraws from markets across the country (and isn't replaced by rivals), premiums for exchange plans could rise modestly — about 1 percent on average — according to a county-by-county analysis released Monday by the Kaiser Family Foundation Monday. The premium increase would amount to about $4 a month.

In some markets, the rates could go up much more. The study shows premiums rising more than $100 a month in 13 counties where there is little competition. And more than half of U.S. counties would have only two insurance companies offering plans on the exchanges, the analysis found.

"With millions of Americans insured through the marketplaces, it's clear that this is a growing business for insurers, and it's a product consumers want and need," Department of Health and Human Services spokesman Ben Wakana said in a statement. "The marketplace should be judged by the choices it offers consumers, not the decisions of any one issuer. That data shows that the future of the marketplace remains strong."

In January, UnitedHealth said it had recorded losses of $720 million on individual exchange policies, including $245 million put on the books in 2015 for losses the company expected to incur in 2016.

In February, Peter Lee, who runs Covered California, the state's insurance exchange, said UnitedHealth has only itself to blame. The insurer, he said, blundered on setting its rates and in putting together networks of hospitals and doctors to provide care.

"Instead of saying, 'We screwed up,' they said, 'Obamacare is the problem and we may not play anymore,' " Lee said in an interview with California Healthline. "It was giving an excuse to Wall Street and throwing the Affordable Care Act under the bus."

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Secrets Of The Very Old And Healthy — Start When You're Young

Mon, 04/18/2016 - 2:25pm
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When it comes to getting old, some of us are a lot better at it than others. If I'm going to live to be 95 I would much prefer to be healthy, cogent and content. So I want to know the secrets of the healthy and very old.

Fortunately, scientists are starting to figure that out, "The good news is that there's a lot we can do about it," says Dr. Luigi Ferrucci, a geriatrician and scientific director at the National Institute on Aging. He wants to see more and more people in that state of "aging grace."

I've been thinking a lot about what makes for a robust old age because my dad just turned 95. On his birthday, he pruned trees in the yard, took a walk, played a little online solitaire and had dinner with the family. We stayed up late and laughed a lot. Last week he did his taxes — the old-fashioned way, with a pencil, a calculator and a stack of IRS forms.

Jim Shute is 95 and still wielding a mean pole saw.

Nancy Shute/NPR

Clearly Dad has genetics in his favor; his father lived to be 97. But genes aren't fate, Ferrucci says: "There's some destiny; we are children of our genome and what we inherit from our parents. But we can do a lot to avoid the destiny that was predisposed to us."

Studies have found that genes are a factor in extreme longevity just about 20 percent of the time, but being physically healthy while very old is much more likely to run in families. Clearly those families must be doing something right.

To find out, in 2009 the NIH launched the IDEAL study, which focuses on the families of people who were able to delay or evade ill health in their 80s and beyond.

They've already gotten some physiological clues. Healthy old people are much more likely to have a lower resting metabolic rate, Ferrucci says, which means that their bodies are still working efficiently. "They have energy left for other activities," he says. "It allows them to do many, many things during daily life."

The lucky ones also tend to have fasting glucose numbers more typical of people in their 20s. Obesity and lack of exercise increase the risk of insulin resistance, so keeping weight under control and staying active from early adulthood can help there, Ferrucci says. Medications like metformin for people with insulin resistance help, too. "There's a lot you can do to manage your insulin resistance as soon as you realize it's there."

Other studies, including the landmark Baltimore Longitudinal Study on Aging, have found that participants' attitude about the inevitable losses of aging matters, too.

"Some of them thought that aging sucks — your friends die, you get disease, you can't do whatever you want, you can't eat and drink what you like," Ferrucci says. "But others thought aging was not so bad." And people who had a positive view of aging at age 40 had significantly less cardiovascular disease later on.

"How that works will require a lot more work from us," Ferrucci says. "But clearly these people have found ways of behaving and thinking and interacting with the environment and other people that works for them."

I have no idea what my dad's fasting glucose level is, but I've got to think that still doing his own yardwork and playing duplicate bridge has got to play a role in his good health. That and the fact that when I ask him how he's doing he says "fantastic," even when I know that's a stretch.

My chat with Ferrucci has made my realize that I shouldn't count on lucky genes to give me a free pass. He envisions a day when the science on aging will have become so good that young men and women would get individualized prescriptions on reducing risk. But for now, I think it's time for me to hit "publish" and go out for a walk. That would be fantastic.

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More People Seek Genetic Testing, But There Aren't Enough Counselors

Mon, 04/18/2016 - 4:30am
More People Seek Genetic Testing, But There Aren't Enough Counselors Listen· 4:27 4:27
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April 18, 20164:30 AM ET Heard on Morning Edition Todd Bookman

From

When Erika Stallings was 22, she found out that she might have a genetic mutation that greatly increased her risk of cancer.

Misha Friedman for NPR

Erika Stallings' mom was diagnosed with breast cancer at the age of 28. When it came back in her early 40s, her physicians started looking for clues.

"That's when the doctors realized there may be something genetic going on, and that's when she was tested, and found out she was a carrier for BRCA2," says Stallings.

BRCA1 and BRCA2 are genes. Carrying a mutated BRCA gene increases a person's risk for developing certain cancers, including breast and ovarian cancer.

Because Erika Stallings' mom tested positive, Erika had a 50 percent chance of inheriting a mutated BRCA2 gene.

But Erika was only 22 years old when she learned of her mother's diagnosis and not yet ready to put herself through the testing process.

"I had just gotten accepted into law school, I was going to be moving to D.C., my ultimate goal was to get a job and move to Manhattan," she says. "I don't want to say I pushed it to the back of my mind, but it didn't seem super pressing."

Fast forward a few years. Her law career and her New York life are settled, and she has a supportive boyfriend. She says she finally felt ready to take the BRCA test, and deal with the potential results. In December 2013, Stallings called to make an appointment and was told she first needed to meet with a genetic counselor. The first available appointment was the following May.

This five-month wait was unexpected and unwelcome.

"It just sort of adds a level of stress to something that is already stressful," Stallings says.

Erika's mother found out that her breast cancer was caused by the BRCA2 mutation. That meant Erika had a 50 percent chance of having the mutation, too. Her mother is doing well.

Misha Friedman for NPR

Genetic testing can help diagnose a disease and estimate your future risks, based on DNA. It can even help patients and doctors select the best medicines. In came on the scene in the late 1960s and was employed mainly to screen prospective parents and newborns for deadly inherited diseases like Tay-Sachs.

In the early 1970s, scientists identified the extra copy of a chromosome that causes Down syndrome, and also realized that a fetus' genes were present in amniotic fluid that could be extracted through amniocentesis. By the 1980s, prenatal screening was common for conditions like Down syndrome and cystic fibrosis.

The sheer number of genetic tests has exploded in the past decade or so. There are now thousands of different testable genetic disorders. In fact, demand for genetic tests has been strong since 2013. And there are two main reasons for that.

"The first was the Supreme Court decision that patenting of genes was no longer an option," says Joy Larsen Haidle, a genetic counselor and past president of the National Society of Genetic Counselors.

She's referencing the Supreme Court's ruling that Utah-based testing company Myriad Genetics, which developed the BRCA gene tests, couldn't own naturally-occurring DNA. Almost immediately, other, cheaper tests for these mutations came to the market.

And that same year, Angelina Jolie captured the world's attention with her op-ed in The New York Times disclosing her "faulty" BRCA1 gene, and her decision to have a double mastectomy to reduce her breast cancer risk.

"Her sharing that information was really important, because it allowed people to identify with her story. If it could happen to Angelina Jolie, it could happen to me," says Haidle.

She says people became much more willing to talk about their genetic predispositions and seek out testing for conditions like Alzheimer's disease and cystic fibrosis. The number of patients seeking genetic counseling and testing has increased dramatically, according to a 2014 study that looked at how Jolie's announcement affected interest in testing.

But the number of genetic counselors, the people who help both doctors and patients make sense of these tests, hasn't expanded enough to keep up with that demand. There are just 4,000 certified genetic counselors in the country today. That's one for every 80,000 Americans.

"As genetic testing is growing and becoming more widely adopted by everyone for all sorts of different things, not just pregnancy, but cancer, heart disease, there is a disconnect," says Neha Kumar, chief product officer at Recombine and a trained genetic counselor. "Who will actually interpret and provide those results to patients?"

Recombine offers a screening test for more than 250 genetic diseases parents may pass on to a child, including conditions such as cystic fibrosis and Tay-Sachs.

Clients typically are offered genetically counseling both before and after a test. They discuss the tests, what they may reveal and what the gray areas might mean. Each counseling session lasts between 30 minutes and an hour.

Genetic counselors also are well versed on genetic risk and family history, and can help people choose the most appropriate tests.

Haidle points out that for lots of patients, especially those not getting breast cancer screenings, the current genetic counseling workforce is meeting demand — appointment wait times are often just a week or two.

Still, the field is facing a bottleneck as it works to increase the number of certified counselors.

"It is going to take a while before we really have the workforce we need to provide the care that individuals out there need," says Anne Greb, director of the Joan H. Marks Graduate Program in Human Genetics at Sarah Lawrence College.

Thirty-one universities offer the required two-year master's program and fewer than 300 counselors will graduate this spring, far short of the estimated 650 current job openings around the country.

"They all get jobs," says Greb of her graduates. "I get emails or phone calls daily from recruiters looking to hire."

The average starting salary for a counselor is $65,000 to $75,000. Many insurers, including Medicare, typically don't cover counseling sessions, meaning hospitals can be forced to cover a share of the costs of having counselors on staff.

One insurer is taking the opposite approach, though. After the Angelina Jolie spike, Cigna began mandating that anyone interested in getting a BRCA test had to first meet with a counselor, even if a doctor already approved the screening. The move was intended to limit unnecessary tests and save money.

Erika Stallings tested positive for the BRCA2 mutation. She says her genetic counselor helped her make sense of the results.

"I just always tell people, it's not just enough to know you are positive. You have to see someone who can put those results in context with you," she says.

Stallings decided to have a preventive double mastectomy in 2014 at the age of 29. She's now volunteering with a breast cancer awareness group, helping to share her genetic story with more women.

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

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The Human Body's Complicated Relationship With Fungi

Sat, 04/16/2016 - 7:00am

When it comes to the trillions of microorganisms that inhabit our bodies, bacteria get almost all the attention.

Changes in our resident microbiota and their collective genome — called the microbiome — have been linked with a wide range of diseases, from various forms of arthritis to depression. At this point scientists tend to focus on which bacterial species might hinder or maintain health.

But our biota comprises a menagerie of microbes. And a growing number of researchers feel that alongside bacteria, the fungi that inhabit our bodies – or, collectively, the "mycobiome" — may also be influential in both our well-being and, at times, disease.

It was Case Western Reserve medical mycologist Mahmoud Ghannoum who first coined the term mycobiome. "Back around 2008, I was attending meetings and noticed people were really starting to talk about the microbiome," he recalls, "But for the most part they were only talking about bacteria, not the fungus and viruses that also comprise our biome. I thought to myself that we should also start looking at fungal communities."

In 2010 Ghannoum's group published a study in PLoS Pathogens that for the first time used advanced genetic sequencing technology to characterize what constitutes a normal mycobiome in the human mouth. The idea was to establish a baseline fungal profile to which altered fungal populations in disease could be compared. Whereas previous research reported a relatively limited number of fungal species in our oral cavities — primarily Candida, which when overgrown causes thrush – Ghannoum and his colleagues identified a veritable zoo of fungal colonists in the mouths of the 20 study participants.

In all they reported 101 fungal species, with each person harboring between 9 and 23 strains. They considered a healthy fungal community to include those species present in at least 20 percent of the participants, including, most commonly, various Candida species. This core mycobiome also included Cladosporium, a known asthma trigger; Aureobasidium, which can cause fungal infections in organ transplant patients; and some potentially beneficial species, like Saccharomyces boulardii.

Fungi Out Of Balance

Also found in the baseline biome were, after Candida, the most common disease causing fungi: Aspergillus, Fusarium and Cryptococcus. That so many potentially harmful fungi were found to be common, Ghannoum believes, could mean that under normal conditions other fungi and microbes may keep these pathologic strains in check.

Supporting this idea that disrupting the body's fungal equilibrium can bring about disease was a paper Ghannoum published a few years later looking at the fungi present in the mouths of HIV-infected patients. They found that Pichia – a yeast used in agriculture to prevent the growth of other fungi on various crops – inhibits the growth of Candida and other pathologic fungal species.

"By growing Pichia in the lab we found that it secretes a compound that can treat fungal infections in animals," Ghannoum explains. In mice with compromised immune systems, which served as an animal model of HIV, those exposed to Pichia developed far less severe infections when inoculated with Candida.

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On the heels of Ghannoum's work, a number of other research groups set out to better understand our relationship with fungi. In 2012 and 2013 respectively, a Japanese team and researchers from the National Institutes of Health profiled the mycobiome of the skin and reported distinct communities based on body location, findings that could contribute to the search for new treatments for fungal skin disorders.

More recently, French researchers distinguished the fungi present in healthy human lungs compared with those afflicted with cystic fibrosis. Aspergillus was most prevalent in the lungs of healthy people, whereas various Candida species dominated in those afflicted with CF and other lung disorders.

A Telltale Sign For Unwanted Fungi

Another early player mycobiome research was UCLA professor David Underhill. In 2012 Underhill and his colleagues published a study in Science that used sequencing tools similar to those used by Ghannoum to profile a baseline gut mycobiome in mice. On average they found between 50 and 60 fungi genera (the plural of genus) in each rodent's gastrointestinal tract, and many species within each genus.

"We showed that there is considerable fungal diversity in mice," comments Underhill, "but we were also interested in how these fungi might be contributing to disease."

In the same study Underhill's group found that mammalian fungi interact with the immune system to control inflammation in the gut. Specifically they looked at the importance of a protein found on the surface of immune cells called Dectin-1 that helps our bodies recognize and eradicate unwanted fungi.

Mice in which the gene encoding for Dectin-1 was inactivated and in which colitis was induced came down with far more severe disease than mice with the active gene. With these findings in hand they then identified a Dectin-1 gene variant in humans that predicted a severe form of inflammatory bowel disease called ulcerative colitis.

Underhill posits that alterations in the gut fungal population could be a significant contributor to at least some forms of inflammatory bowel disease cases and could represent a potential treatment avenue. However he acknowledges that a host of other factors seem to contribute to the condition as well.

"None of these factors are working in isolation," he says. "I think it's probably a confluence of them all interacting with each other and with us – what we eat, what kind of nutrients they have, genetic influences and how our immune system reacts to both fungi and bacteria in the gut."

Ghannoum agrees that a give and take among bacteria, viruses, fungi and each person's specific biology likely influences our health. "We know that when somebody takes an antibiotic they can develop fungal infections," he says. "So clearly there is interaction between these communities. From my point of view, I say, 'Look, it's not bacteria alone, it's not fungi alone – you have to put them together.' And I'm sure that viruses also play a role. We really need to look at the total picture."

Recent unpublished findings by Ghannom's lab show that an interaction between fungi and bacteria in the gut aggravates the body's autoimmune response in Crohn's disease, another form of inflammatory bowel disease.

In collaboration with a group at Cleveland Clinic, Ghannoum and his colleagues also beginning to show that oral fungal populations are different in people with head and neck cancers. That finding, Ghannoum says, could help replace or help confirm biopsies, if the work is confirmed in larger studies. Fungi may also contribute to some cases of arthritis. Recent research found that autoimmune arthritis can be induced in mice injected with certain compounds found in fungal cell walls.

Treating Patients By Transplanting Feces

But what does this research all mean for treating disease?

The biome-based therapy with perhaps the best supporting evidence is, like it or not, fecal transplantation: putting the stool of a healthy donor in a patient with Clostridium difficile colitis — a severe bacterial infection that often results as a side effect of antibiotic therapy. Patients receiving the healthy stool have a good chance of getting better. And there is growing evidence that probiotic approaches, including both bacterial and fungal species, might have benefits in various disorders, particularly once clinicians are better able to personalize regimens to individual patients.

However as New York University rheumatologist and microbiome researcher Dr Jose Scher, points out, probiotic research — especially the area involving fungi — is in its adolescence. "All the probiotic hype can get patients thinking 'Oh, my problem is caused by a bug. All I have to do is be on a certain diet and take certain probiotics or antibiotics and I my disease will be cured.' Unfortunately it's not as simple as that."

Still, Scher is hopeful. "This is just the beginning of this field," he says. "But I think understanding how bacteria, viruses and fungi can play a role in health maintenance and disease will help us develop more effective therapies."

Case Western's Ghannoum is also optimistic. "I think that the idea of probiotic and antibiotic therapies is a very important question," he says, "Should we use antifungals? Should we use antibiotics? Finally, should we use probiotics? They all make sense to me." But the key is first identifying the "friendly fungi," as he puts it; and the friendly viruses and bacteria; and how all of these microbes interact with the environment.

One of the roadblocks for researchers in studying marginalized microbes like fungi is knowing which species they're dealing with at all. "Fungal taxonomy is really complicated and not quite what we learned in school," explains Underhill, who notes that modern DNA sequencing has in many cases revealed that previous classifications that were incorrect.

Many fungi haven't yet been classified at all. As in many other areas of Linnaean cataloguing, technology has revealed the fungi kingdom to be a tangled thicket, not a cleanly branched family tree.

There are plenty of mycologists out there actively trying to address this confusion and construct a more precise taxonomy. And by continuing to hone fungal identification technology and illuminating fungi's potential relevance in better understanding, diagnosing and treating disease, UCLA's Underhill and his colleagues are helping to accelerate this work.

"We're in a stage where we're recognizing the biological significance of the fungi in our systems to help develop a common language and set of research approaches," Underhill says. "Soon, hopefully, we'll know how they can be good for us, bad for us and manipulated to our benefit."

There's a certain beauty in our biologic cooperative; a reminder that mammalian life is complicated and communal, and that in nature imbalance has consequences. But perhaps tinkering with our fungal dwellers will one day help restore our biologic balance and fend off disease.

As Russian chemist and periodic table architect Dmitri Mendeleev ruminated, "There exists everywhere a medium in things, determined by equilibrium."

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

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