Surgeon general lays out framework to tackle loneliness and ‘mend the social fabric of our nation’ | CNN



CNN
 — 

US Surgeon General Dr. Vivek Murthy released an advisory Tuesday addressing the “epidemic of loneliness and isolation” affecting the country and laying out a framework for a “National Strategy to Advance Social Connection.”

The advisory is part of the Biden administration’s broader efforts to address mental health, White House press secretary Karine Jean-Pierre said Monday.

“In recent years, about one-in-two adults in America reported experiencing loneliness,” Murthy says in the advisory. “And that was before the COVID-19 pandemic cut off so many of us from friends, loved ones, and support systems.”

Research has showed that loneliness and isolation are linked to sleep problems, inflammation and immune changes in younger adults. In older people, they’re tied to symptoms such as pain, insomnia, depression, anxiety and shorter life span. In people of all ages, they may be associated with higher risks of heart disease, stroke, diabetes, addiction, suicidality and self-harm, and dementia.

But social connection can help, Murthy’s office said in a statement, serving as a buffer to health problems while making communities more resilient.

“Loneliness I think of as a great masquerader. It can look like different things,” Murthy told CNN’s Erin Burnett on Monday. “Some people, they become withdrawn. Others become irritable and angry. … I think the time you get concerned is when you start experiencing a feeling of loneliness for prolonged periods of time. If you feel lonely, you pick up the phone and call a friend, and then it goes away, or you get in the car and go see a family member, that’s OK. That’s loneliness acting like hunger or thirst, a signal our body sends us when we need something for survival. It’s when it persists that it becomes harmful.”

Social connection is as essential to humanity as food, water or shelter, the advisory says. Humans have historically needed to rely on each other for survival, and modern people remain wired for that connection and for proximity to others.

“Given the profound consequences of loneliness and isolation, we have an opportunity, and an obligation, to make the same investments in addressing social connection that we have made in addressing tobacco use, obesity, and the addiction crisis,” Murthy says in his advisory. “We are called to build a movement to mend the social fabric of our nation. It will take all of us – individuals and families, schools and workplaces, health care and public health systems, technology companies, governments, faith organizations, and communities – working together to destigmatize loneliness and change our cultural and policy response to it.”

The framework is rooted in six pillars.

The first, strengthening social infrastructure in communities, involves boosting programs like volunteer organizations or religious groups, policies like public transit or education, and physical elements like libraries and green spaces.

“Investing in local communities and in social infrastructure will fall short if access to benefits is limited only to some groups,” the advisory notes. “Equitable access to social infrastructure for all groups, including those most at-risk for social disconnection, is foundational to building a connected national and global community.”

The second pillar calls for more “pro-connection public policies.” Governments and institutions are urged to adopt an approach that recognizes that policies can benefit or hinder connection and that “every sector of society is relevant to social connection.” Policymakers should focus on reducing disparities in connection.

The third pillar relies on the crucial role of public health and health care delivery systems to address social connection. Murthy calls for increased investment in educating health care providers about the physical and mental benefits of social connection and the risks of disconnection. Patients’ needs should be assessed and supported, and organizations should track prevalence of disconnection in communities and advance local solutions, he says.

For the fourth pillar, reforming digital environments, Murthy singles out the “tangible impact” of technology on Americans’ daily lives and connections. “Technology can also distract us and occupy our mental bandwidth, make us feel worse about ourselves and our relationships, and diminish our ability to connect with others. Some technology fans the flames of marginalization and discrimination, bullying, and other forms of severe social negativity.”

The framework calls for more data transparency from tech firms, as well as the establishment and implementation of safety standards such as age-related protections. It also encourages development of “pro-connection technology to promote healthy social connection, create safe environments for discourse, and safeguard the well-being of users.”

The fifth pillar, deepening knowledge, urges stakeholders such as officials, policymakers, health care providers and researchers to collaborate on a research agenda to address gaps in the data. “Consistent measurement will be critical to better understanding the driving forces of connection and disconnection, and how we can be more effective and efficient in addressing these states.”

The final pillar urges a culture of connection in which Americans “cultivate values of kindness, respect, service, and commitment to one another.” Everyone can use their voice to emphasize these values and model healthy connections, Murthy says, and the nation’s institutions should invest in demonstrating them.

The advisory concludes with suggestions about how specific groups – including governments, health organizations, schools, workplaces and individuals – can help advance social connection.

Parents and caregivers have an especially powerful role, the advisory says. They can model healthy connection by spending time together, setting aside time for screen-free socializing, and engaging in constructive conflict resolution. They’re also urged to encourage individual friendships and group activities, to be aware of how young people spend their time online and to watch for potential warning signs of loneliness or isolation.

Individual Americans might take time out of each day to connect with a friend or family member and minimize distractions during conversations. Regularly practicing service and gratitude can encourage others to do the same. Cut back on things that lead to disconnection, such as harmful social media use or time spent in unhealthy relationships. Be open with health care providers about significant social changes that may affect levels of connection, and reach out to a loved one, counselor, provider or crisis hotline in times of struggle.

Source link

#Surgeon #general #lays #framework #tackle #loneliness #mend #social #fabric #nation #CNN

Amid contradictory laws, hospitals in one state were unable to explain policies on emergency abortion care, study finds | CNN



CNN
 — 

Oklahoma’s laws restricting abortions have created a confusing, contradictory environment that may have a chilling effect on health care, new research says.

After the US Supreme Court overturned the right to an abortion last year with the Dobbs v. Jackson Women’s Health Organization decision, several states quickly passed laws that restricted such procedures. A report released Tuesday and described in the medical journal the Lancet finds that the laws in at least one state left workers at many hospitals confused about how to proceed.

When the court made its decision, the Oklahoma law that criminalized abortion in 1910 went back into effect, according to the state’s attorney general. Lawmakers then created multiple overlapping laws that further criminalized abortion and increased penalties for those who performed or assisted in an abortion procedure, according to the new report from Physicians for Human Rights, Oklahoma Call for Reproductive Justice and the Center for Reproductive Rights.

The Oklahoma laws allow abortion in the case of a medical emergency, but one doesn’t define a medical emergency. Another says it allows for the “preservation of life in a medical emergency,” defined as causing “substantial and irreversible body of bodily impairment” – which is not a medical term, experts say.

To understand exactly how well Oklahoma hospitals understood the laws, the researchers used a “secret shopper method,” study co-author Dr. Michele Heisler said.

Researchers posed as prospective patients and called 34 hospitals to ask about the emergency pregnancy care they offered.

Heisler said that when the researchers designed the study, she expected the hospitals to tell the patients that they could get help in an emergency but that a second provider might have to sign off on an abortion or that a doctor would have to get the decision past an “onerous” hospital oversight committee.

“What we weren’t expecting is that there would be so much confusion and contradictory information and really not clear information,” said Heisler, who is medical director at Physicians for Human Rights and a professor of internal medicine and public health at the University of Michigan.

The researchers said that none of the hospitals they contacted in Oklahoma was totally able to articulate clear, consistent policies for emergency obstetric care to potential patients.

Specifically, 65% – 22 of the 34 hospitals – were unable to provide information about policies, procedures or the support provided to doctors when it is clinically necessary to terminate a pregnancy to save the life of a pregnant patient.

In 14 of the 22 cases, hospital representatives provided unclear and/or incomplete answers about whether doctors require approval to perform a medically necessary abortion.

Three of the hospitals said they do not provide abortions at all, even though it remains legal in the case of a medical emergency or to “preserve the life” of the pregnant person. Four others provided information that was factually wrong, the report says.

Four hospitals said they had formal approval processes that clinicians must go through if they have a situation in which it is medically necessary to terminate a pregnancy; they cannot make that decision on their own.

Three hospitals indicated that they have policies for these situations but refused to share any information about them.

“Unfortunately, it is being just left up to individual health systems and clinicians to try to make sense of these laws and provide guidance and support,” Heisler said.

The Oklahoma Hospital Association said it has been in conversations with Oklahoma’s medical licensure boards to seek clarity about the state’s conflicting abortion laws.

The association sent guidance to its members in September to explain what it interpreted as “saving the life of a pregnant woman” and what the laws would mean for a person made pregnant through rape or incest, among other issues. The guidance explains that the state’s criminal laws do not make an exception for these circumstances unless it is to save the life of someone who is pregnant in a medical emergency.

The guidance also warns that a person convicted of “administering, prescribing, advising, or procuring a woman to take any medicine drug or substance, or a person convicted of using or employing any instruction or ‘other means whatever,’ with the intent to procure an abortion, shall be guilty of a felony punishable by two (2) to (5) years imprisonment. From August 27, 2022, forward, a person convicted of performing or attempting to perform an abortion shall be guilty of a felony punishable by a fine not to exceed One Hundred Thousand ($100,000.00) and/or imprisonment not to exceed ten (10) years.”

The guidance says the “persons potentially liable” are the provider, not the pregnant person.

Study co-author Rabia Muqaddam, a senior staff attorney at the Center for Reproductive Rights who is working on multiple cases challenging the abortion bans in Oklahoma, called the overlapping laws a “bizarre” situation.

“Aside from the fact that there are so many of them is that they all conflict,” she said. “All of the laws have inconsistent definitions, which is where a lot of the confusion comes from for health care providers. What’s most dangerous for patients is the fact that the definitions of medical emergency and life-preserving abortions is unclear and inconsistent.”

“If I was the hospital general counsel and I was looking at these laws, I have absolutely no idea what my physician could or could not do in any particular circumstance,” she said.

When there is a lack of clarity and when penalties are involved, “what you get is massive chill.”

“Physicians are terrified. They’re terrified that if they make the wrong decision, they’re going to go to jail. They’re going to lose their license. And at the other end of that is that patients are being seriously harmed,” Muqaddam said.

Sonia M. Suter, a professor of law at George Washington University who was not involved in the new research, said recent abortion laws have created “such a mess.”

“You are telling physicians that they have two conflicting obligations,” said Suter, whose scholarship focuses on issues at the intersection of law, medicine and bioethics, with a particular focus on reproductive rights.

There is an obligation to stabilize patients in emergencies that may not always qualify as “life-threatening,” but doctors and hospitals could also risk being sued because the doctors are not following the standard of care, “which you can’t do with how some of these exceptions are worded.”

She said hospitals also don’t know how the laws will be applied. Lawyers typically will instruct institutions to interpret the law as conservatively as possible, and physicians may be equally conservative because they don’t want to risk their licenses or face stiff penalties.

“It’s just devastating for everybody,” Suter said. “It’s just cruel.”

Molly Meegan, general counsel for the American College of Obstetricians and Gynecologists, said state laws to restrict abortion with emergency exceptions are not comprehensive.

“They can’t be applied in a medical situation. They just aren’t practical,” she said. “They have an ethical and personal duty to their patients to do what is best for their patients. It can at times be in direct conflict with whatever the laws are, especially if they’re vague, and most of the ob/gyns throughout the country, including in Oklahoma, are in an impossible situation.”

Meegan and Suter both believe the confusion will lead to the deaths of more women. Those who survive may be left with dire health problems, including losing the ability to have children in the future.

“They already have horrific maternal mortality and infant mortality rates,” Suter said. “It feels like the end of evidence-based medicine.”

According to the US Centers for Disease Control and Prevention, Oklahoma persistently ranks among the states with the worst rates of maternal deaths, even before the new abortion laws went into effect. The state had a maternal mortality rate of 25.2 deaths per 100,000 live births for 2018-20, well above the national average.

For communities of color, the rate is significantly worse, according to the Oklahoma Health Department.

White women had 23.2 maternal deaths per 100,000 live births for 2018-20, the lowest rate overall in Oklahoma. The rates for Black women and Native American women were about twice as high: 49.4 and 44.4, respectively.

Oklahoma is not alone. The 13 states where most abortions are banned generally have some of the highest infant and maternal mortality rates in the country, Heisler said. Even more states could be restricting abortion access soon, the experts believe, with potentially more problems to come.

“The hostile climate many states are creating for the health care field by enacting criminal and other penalties for abortion care is an outcome whose reverberations we are only just beginning to see,” said Kelly Baden, vice president for public policy at the reproductive health nonprofit Guttmacher Institute.

Heisler noted that the researchers don’t blame the hospitals or the doctors for this confusion. Overall, she said, the staffers who talked to the researchers “were wonderful,” despite the circumstances.

“They were empathetic. They said, ‘I completely understand.’ They tried to give answers. They acted in good faith. But really, none of the hospitals were really able to say what we were hoping for, which is to unequivocally state that they would stand behind their clinicians and that clinicians at their facilities would be able to use their best clinical judgment for the individual case and that it would be made as medical decisions should be in collaboration with the patient, taking into account to their needs, their preferences and their values,” she said.

“We are recognizing that hospitals and clinicians are in an untenable situation,” Heisler added.

Source link

#contradictory #laws #hospitals #state #unable #explain #policies #emergency #abortion #care #study #finds #CNN

The cost of senior care is rising while caregivers are ‘drowning’ without help | CNN



CNN
 — 

For most of her life, Tammy La Barbera has been taking care of someone other than herself. First, it was her two children. Then, it was her brother and father, who both died after being diagnosed with cancer. Now, Tammy is taking care of her 90-year-old mother, Ada, who was diagnosed with dementia five years ago.

In recent months, Ada’s condition deteriorated so quickly that Tammy resigned from her job as an event manager to become a full-time caregiver.

“I don’t have help here, and I know it’s going to get worse,” she said.

Tammy, 53, struggles to provide her mother with the care she needs and would like to place her in a memory care facility equipped to handle the mood swings and outbursts that her mother has due to her condition. But Tammy says she doesn’t expect to ever have enough money to pay for that care.

Recently, she said, she looked into an assisted living facility near her home in Murrieta, California. She says placing her mother at the facility – or others like it – would cost between $7,000 and $10,000 a month out-of-pocket.

Across the country, millions of caregivers like Tammy are looking after a loved one – a relative or a friend. About 53 million US adults are caregivers, according to a 2020 report from AARP.

Sixty-three percent of US caregivers who look after adults said the person they were looking after needed care because of “long-term physical conditions,” the report says.

Since her mother’s diagnosis, Tammy’s life has been turned upside-down.

Ada cannot bathe herself or cook for herself. Most days, she doesn’t even remember who her daughter is.

“All her daily duties are done by me,” Tammy said, caring for her mother all day is like being a prisoner in her own home.

Sooner or later, she said, she will have to move her mother to a long-term care facility and do whatever she can to pay for it.

“I know that I’m reaching a crossroads with my mom’s care, and I’m trying to do this as long as I can,” Tammy said. “But I know the way things are going, and if she’s progressing pretty rapidly, I’m not going to have a choice.”

Ada La Barbera was a teacher for 20 years, so she gets a pension check each month. Tammy puts that money, along with her mother’s monthly Social Security checks, toward bills.

It’s just over $3,300 a month, and along with Tammy’s dwindling savings, it’s barely enough to keep them afloat, Tammy says. She can barely afford her rent.

It’s because of her financial struggles that Tammy has been putting off long-term care for her mother.

Where Tammy and Ada live in California, a home health aide would cost about $137 for one hour of care, according to an online calculator from AARP.

“When you’re on a fixed income, you can’t afford that,” Tammy said. “So I don’t have the luxury to do that.”

A long-term care facility is even more expensive. On average, it costs $10,830 a month to stay at a nursing home and $5,806 per month for an assisted living facility, according to the nonprofit National Investment Center for Senior Housing and Care.

Then there is memory care, where Tammy says her mother belongs.

Memory care facilities are the fastest-growing sector of the senior housing market, according to the National Investment Center. On average, memory care costs just over $7,500 a month, center COO Chuck Harry says.

These facilities offer more hands-on care for people with dementia. They can include special features like locked units that prevent wandering patients from leaving the facility unattended and enclosed outdoor spaces where patients can move about safely.

A nurse comes to see Ada at home every other week. During that 40-minute visit, Ada’s vitals are checked, and her medications are adjusted. Those visits are covered by Medicare, Tammy says.

Medicare is a medical health insurance program that is for people 65 years or older. But Medicare does not cover the cost of a long-term care facility.

And although Ada and Tammy are on a fixed income, Ada doesn’t qualify for other federal safety net programs like Medicaid because Tammy says they are not considered low-income.

For middle-income families, Medicaid goes into effect only after a family has gone through the process of “spending down” their assets until they qualify for the program.

“That is usually the path of anyone going into a nursing home for the long term: spending your own money – which is all out of pocket – and then reaching a Medicaid level of eligibility,” said Susan Reinhard, senior vice president and director of the AARP Public Policy Institute, noting that each state has its own Medicaid program and process.

Until a family qualifies for Medicaid, the program will only cover the medical costs of a stay at a long-term facility, not room and board.

Caroline Pearson, the lead author of a landmark 2019 demographic study called “The Forgotten Middle,” says most middle-income Americans find themselves in a position where they are too “wealthy” to receive Medicaid coverage for long-term care services but too “poor” to afford the out-of-pocket costs of that care.

So why does putting a loved one in a nursing home or an assisted living facility cost so much? Providing long-term care services is expensive, Pearson says, adding that the senior housing industry requires a large workforce of nurses and staff to support it. That is also expensive.

Additionally, as seniors sell their homes and move into these facilities, long-term care facilitators are essentially providing housing, she said. And housing is not cheap.

The senior housing industry also caters to a high-income population, according to Pearson, who is now executive director of the Peterson Center on Healthcare.

“The fit and finish at the buildings … [residents] expect to be really high-end. The amount of amenities and services that are part of that senior housing property … they expect to be high-end,” she said. “The market has seen good returns and then replicated that model.”

And the demand for high-quality, long-term care is only expected to go up as the baby boomer generation continues to age, according to Pearson.

“Most people don’t begin to need long-term care services until between 75 and 85. And so as the baby boomers hit those ages, that is where we’re going to see that demand really explode,” she said.

According to the US Census Bureau, baby boomers – people born from 1946 to 1964 – will all be over the age of 65 by 2030. The oldest members of that generation will be 84 at that point.

In 2019, there were about 8 million middle-income seniors – people 75 and older – living in the United States, Pearson says in her study.

She projects that there will be 14.4 million middle-income seniors in the US by 2029, with 60% expected to have mobility limitations and 20% expected to have “high health care and functional needs.”

“We are going to [have] double the number of middle-income seniors when the baby boomers age,” Pearson said. “Fewer of those baby boomers are going to have spouses or children who live nearby to provide unpaid caregiving support.”

Most family caregivers are spouses or middle-age daughters, the study notes.

At the end of the day, Pearson says, many Americans don’t think about aging until it’s staring them in the face.

“People [think] that they will live healthy and independently until they die, and sadly, that’s just statistically very unlikely for most people,” she said.

Tammy, with her parents and brother, says her family thought they were prepared for the future.

Tammy says her family thought they were prepared for the future.

In 1965, Ada married Tammy’s father, Peter “Jazz” La Barbera, an accountant.

“My dad was a very, very good saver, and he did have a little bit of savings,” Tammy said. “He was set just for the future, not for anything unexpected.”

In 1970, Tammy was born in Queens. She and her older brother, Peter Jr., grew up an hour outside New York City.

“We had a small house, and we lived in that house our whole lives, and … we were the perfect family,” Tammy said.

She eventually moved to California, where she had two kids. Her parents followed, along with her brother and his wife.

Tammy says the physical and mental toll of caring for her husband and son kickstarted Ada's health problems.

But soon after the move, Peter Jr. was diagnosed with cancer, and he died a year later. Two years after that, Tammy’s father received a cancer diagnosis and died within seven weeks.

Tammy believes that the physical and financial toll of taking care of her son and husband kickstarted her mother’s health problems. Shortly after her husband died, Ada had a minor stroke and was diagnosed with dementia.

“It’s almost like her grief was so overwhelming. Especially losing her son. I don’t think her brain had the capacity to deal with anything else anymore,” Tammy said.

The stress associated with taking care of a loved one full-time, or even part-time, can have negative consequences, research has shown.

Some of the physical symptoms associated with taking care of someone with dementia include higher levels of depression and anxiety, worse self-reported physical health, compromised immune function and increased risk of early death, the US Centers for Disease Control and Prevention reports.

Over half (53%) of caregivers indicate that a decline in their health compromises their ability to provide care, according to the CDC.

“I have sacrificed 10 years of my life being a caretaker, and I don’t have a life,” Tammy said. “It’s an honor to take care of my mother. But doing this every single day … it’s a lot.”

Tammy is preparing for her own future by taking part in genetic testing that will tell her whether she is more likely to develop dementia like her mother.

“I would like to prepare as much as I can, whether it’s medication or adjusting my life,” she said. “I just don’t want to put my kids through this.”

She would also like to see changes to the system.

Pearson says the solution to the cost issue is not simple and will probably be resolved only through a combination of incremental Medicaid expansion, changes to the senior housing industry and federal subsidies.

AARP’s Reinhard says tax credits for family caregivers could help people like Tammy get a break. Employers could also help by supporting workers who need to stop working to care for a family member or friend.

In September, the US Department of Health and Human Services, through its Administration for Community Living, announced a national strategy aimed at supporting family caregivers, highlighting nearly 350 actions the federal government will take.

The strategy also includes 150 actions that it says local governments, communities and private businesses can adopt to help build a more supportive system.

“Supporting family caregivers is an urgent public health issue, exacerbated by the long-term effects of the COVID-19 pandemic,” HHS Secretary Xavier Becerra said in a news release. “This national strategy recognizes the critical role family caregivers play in a loved one’s life.”

Gal Wettstein, a senior research economist for the Center for Retirement Research at Boston College, says it would be beneficial for middle-income Americans to speak to a financial adviser as early as possible and transfer assets to a family member if they think they might need to enter a long-term care facility in the near future.

This way, if their only option is to spend down their assets to become eligible for Medicaid, they hit that eligibility sooner.

Long-term care insurance is another option, but experts say it’s rarely sold anymore because it is typically more expensive than other kinds of insurance.

Pearson says Americans can plan ahead by investing in long-term care insurance in their 40s for it to benefit them when they will most likely need it, in their 80s.

Wettstein also recommends long-term care insurance.

“[Long-term care insurance] plans are getting harder and harder to sign, but they do still exist. Some insurers will still sell them,” he said.

Ultimately, covering the cost of senior care comes down to families and how much they save for the future, until changes are made by senior housing providers and policy makers.

“We are so far away from having any sort of swift and universal solution,” Pearson said.

For now, Ada is on a waitlist for a spot at a skilled-nursing home about an hour from where they live. If she moves there, her cost of living might be partially covered through a Medicaid program.

Tammy was told that Ada is one of more than 2,000 people waiting for a spot.

“We’re drowning. We’re care workers, and we’re drowning,” Tammy said. “We don’t have help.”

Source link

#cost #senior #care #rising #caregivers #drowning #CNN

Maternity units are closing across America, forcing expectant mothers to hit the road | CNN



CNN
 — 

In picturesque Bonner County, Idaho, Leandra Wright, 40, is pregnant with her seventh child.

Wright is due in August, but three weeks ago, the hospital where she had planned to deliver, Bonner General Health, announced that it would be suspending its labor and delivery services in May.

Now, she’s facing a potentially precarious drive to another hospital 45 minutes from her home.

“It’s frustrating and worrisome,” Wright said.

Wright has a history of fast labors. Her 15-year-old son, Noah, was born on the way to the hospital.

“My fifth child was born on the side of the highway,” Wright said. “It was wintertime, and my hospital at the time in California was about 40 minutes away, and the roads were icy, so we didn’t make it in time.”

By the time she and Noah got to the hospital, about 15 minutes after he was born, his body temperature was lower than normal.

“It worries me not to have a doctor there and worries me to have to go through that,” Wright said.

Residents of Bonner County aren’t the only ones dealing with unexpected maternity unit closures.

Since 2011, 217 hospitals in the United States have closed their labor and delivery departments, according to a report by the health care consulting firm Chartis.

A CNN tally shows that at least 13 such closures have been announced in the past year alone.

Services provided at maternity units vary from hospital to hospital. Most offer obstetrics care in which an obstetrician will deliver a baby, either vaginally or via cesarean section. These units also provide perinatal care, which is medical and supportive care before and after delivery.

Other services provided may include lactation specialists and private delivery rooms.

After May 19, Bonner General Health will no longer offer obstetrical services, meaning there will be zero obstetricians practicing there. Consequently, the hospital will no longer deliver babies. Additionally, the unit will no longer provide 24-hour anesthesia support or post-resuscitation or pre-transportation stabilization care for critically ill newborns.

Some hospitals that have recently closed their maternity units still offer perinatal care, along with routine gynecological care.

Bonner General is planning to establish a clinic where perinatal care will be offered. Gynecological services – such as surgical services, preventative care, wellness exams and family planning – will still be provided at a nearby women’s health clinic.

The Chartis report says that the states with the highest loss of access to obstetrical care are Minnesota, Texas, Iowa, Kansas and Wisconsin, with each losing more than 10 facilities.

Data released last fall by the infant and maternal health nonprofit March of Dimes also shows that more than 2.2 million women of childbearing age across 1,119 US counties are living in “maternity care deserts,” meaning their counties have no hospitals offering obstetric care, no birth centers and no obstetric providers.

Maternity care deserts have been linked to a lack of adequate prenatal care or treatment for pregnancy complications and even an increased risk of maternal death for a year after giving birth.

Money is one reason why maternity units are being shuttered.

According to the American Hospital Association, 42% of births in the US are paid for by Medicaid, which has low reimbursement rates. Employer-sponsored insurance pays about $15,000 for a delivery, and Medicaid pays about $6,500, according to the Health Care Cost Institute, a nonprofit that analyzes health care cost and utilization data.

“Medicaid funds about half of all births nationally and more than half of births in rural areas,” said Dr. Katy Kozhimannil, a public health researcher at the University of Minnesota who has conducted research on the growing number of maternity care deserts.

Kozhimannil says communities that are most likely to be affected by maternity unit closures tend to be remote towns in rural counties in states with “less generous Medicaid programs.”

Hospitals in larger cities are often able to offset low reimbursement rates from Medicaid births with births covered by employer-sponsored insurance, according to Dr. Sina Haeri, a maternal-fetal medicine specialist and CEO of Ouma Health, a company that provides virtual prenatal and perinatal care to mothers living in maternity care deserts.

Many large hospitals also have neonatal intensive care units.

“If you have a NICU, that’s a substantial revenue generator for a hospital,” Haeri said.

Most rural hospitals do not have a NICU, only a nursery where they care for full-term, healthy babies, he said. Due to that financial burden, it does not make financial sense for many rural hospitals to keep labor and delivery units open.

A low volume of births is another reason for the closures.

In announcing the closure, Bonner General noted that in 2022, it delivered just 265 babies, which the hospital characterized as a significant decrease.

Rural hospital administrators providing obstetric care say it takes at least 200 births annually for a unit to remain safe and financially viable, according to a study led by Kozhimannil for the University of Minnesota’s Rural Health Research Center.

Many administrators surveyed said they are working to keep units open despite low birth rates.

“Of all the folks that we surveyed, about a third of them were still operating, even though they had fewer than 200 births a year,” Kozhimannil said. “We asked why, and they said, ‘because our community needs it.’ ”

Another issue for hospital administrators is staffing and recruitment.

The decision to close Bonner General’s labor and delivery unit was also directly affected by a lack of experienced, qualified doctors and nurses in the state, said Erin Binnall, a Bonner General Health spokesperson.

“After May 19th, Bonner General Health will no longer have reliable, consistent pediatric coverage to manage neonatal resuscitations and perinatal care. Bonner General’s number one priority is patient safety. Not having board-certified providers certified in neonatal resuscitation willing to provide call and be present during deliveries makes it unsafe and unethical for BGH to provide these services,” Binnall told CNN by email.

The American Hospital Association acknowledges the staffing challenges some hospitals face.

“Simply put, if a hospital cannot recruit and retain the providers, nurses, and other appropriately trained caregivers to sustainably support a service then it cannot provide that care,” the association said in a statement. “Such challenges are only magnified in rural America, where workforce strain is compounded by aging demographics that in some communities has dramatically decreased demand for services like Labor and Delivery.”

Wright is considering moving because of the lack of maternity and pediatric care available in Bonner County.

More stringent abortion laws may be playing a role in the closures, too.

Bonner General said in a news release last month that due to Idaho’s “legal and political climate, highly respected, talented physicians are leaving. In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”

According to the Guttmacher Institute, Idaho has one of the strictest anti-abortion laws in the country: a complete ban that has only a few exceptions.

Idaho requires an “affirmative defense,” Guttmacher says, meaning a provider “has to prove in court that an abortion met the criteria for a legal exception.”

No matter the reason, Kozhimannil said, closures in rural communities aren’t just a nuisance. They also put families at risk.

“That long drive isn’t just an inconvenience. It actually is associated with health risks,” she said. “The consequence that we saw is an increase in preterm births. Preterm birth is the largest risk factor for infant mortality. It is a huge risk factor for developmental and cognitive delays for kids.”

Haeri says the decline in maternal care also has a clear effect on maternal mortality rates.

The maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births in the US, compared with rates of 20.1 in 2019 and 23.8 in 2020, according to a report from the National Center for Health Statistics. In raw numbers, 1,205 women died of maternal causes in the US in 2021.

Conditions such as high blood pressure, obesity, and diabetes may raise a person’s risk of complications, as can being pregnant with multiples, according to the National Institutes of Health. Pregnant women over the age of 35 are at a higher risk of pre-eclampsia.

As labor and delivery units continue to shut their doors, possible solutions to the growing problem are complex, Haeri says.

“I think anyone that comes to you and says the current system is working is lying to you,” he said. “We all know that the current maternity system is not good.”

Kozhimannil’s research has found that many women who live in maternity care deserts are members of minority communities.

“When we conducted that research, we found the communities that were raising the alarm about this … tended to be Black and indigenous, or tribal communities in rural places,” she said. “Black communities in the South and East and tribal communities throughout the country, but especially in the West, Mountain West and Midwest.”

Haeri says one possible solution is at a woman’s fingertips.

“I always say if a woman’s got a cell phone, she should have access,” he said.

A 2021 study found that women who live in remote areas of the US could benefit from telehealth visits, which would decrease the number of “in-person prenatal care visits and increase access to care.”

The American College of Obstetricians and Gynecologists recommends 12 to 14 prenatal care appointments for women with low-risk pregnancies, and the study suggests that expansion of prenatal telehealth appointments could help women living in remote areas better adhere to those guidelines.

Ouma works with mothers who are typically remote and high-risk, Haeri says.

He also believes that promoting midwifery and doula services would help bolster maternity care in the US.

Certified nurse midwives often assist remote mothers who are high-risk or who decide to give birth at home, he says.

Midwives not only deliver babies, they often work with medical equipment and can administer at-home physical exams, prescribe medications, order lab and diagnostic tests, and assess risk management, according to the American College of Nurse Midwives. Doulas – who guide mothers through the birthing process – are often present at home births and even hospital births.

“That midwifery model shines when it comes to maternal care. [And] doula advocacy involvement leads to better outcomes and maternity care, and I think as a system, we haven’t made it easier for those two components to be really an integral part of our maternity care in the US,” Haeri said.

After living in Idaho for 10 years, Wright says, she and her fiancé have considered leaving the state. The lack of maternity and pediatric care at Bonner General Health is a big reason why.

“I feel safe being with [my] doctors. Now, I have to get to know a doctor within a couple of months before my next baby is born,” Wright said.

As she awaits the arrival of her new son, she feels doubtful that there is a solution for mothers like her.

“Everywhere – no matter what – everybody has babies,” she said. “It’s posing a problem for people who have babies who don’t have the income to drive or have high risk pregnancies or first-time mothers who don’t even know what to expect.”

Source link

#Maternity #units #closing #America #forcing #expectant #mothers #hit #road #CNN

Fossilized eggs crack open the mysteries of the past | CNN

Sign up for CNN’s Wonder Theory science newsletter. Explore the universe with news on fascinating discoveries, scientific advancements and more.



CNN
 — 

Eggs have been laid on land by birds, reptiles, dinosaurs and a few oddball mammals for more than 200 million years.

And humans have been using some of these eggs as a nutritious source of food, and their shells as bowls, bottles and jewelry for most of our history on the planet.

Though they’ve often been overshadowed by skeletons and bones, fossilized eggshells are a fascinating source of information, illuminating the behavior and diet of ancient creatures, detailing changes in climate and revealing how our prehistoric relatives lived and communicated.

This Easter, here are six surprising things eggs have revealed about the past.

Did dinosaur blood run cold, like a lizard, or warm, like a bird? It’s a topic that’s long divided paleontologists.

An analysis of fossilized dinosaur egg shells suggests it’s the latter. By looking at the order of oxygen and carbon atoms in the fossilized egg shells, researchers were able to calculate a dinosaur mom’s internal body temperature. It’s a process called “clumped isotope paleothermometry.”

“Eggs, because they are formed inside dinosaurs, act like ancient thermometers,” said Pincelli Hull, an assistant professor at Yale University’s department of geology and geophysics, and a coauthor of the study, which published in 2020.

Hull and her colleagues found that the samples they tested suggested dinosaurs’ body temperatures were warmer than their surroundings would have been.

The research indicates that unlike reptiles, which rely on heat from the environment, dinosaurs were capable of internally generating heat – more like birds.

A study of fossilized eggshells revealed humans may have been hatching and raising cassowaries for more than 18,000 years.

You might think that chickens—or even ducks or turkeys—were the earliest birds to be domesticated by humans.

However, eggshell fragments found at two prehistoric sites in Papua New Guinea suggest that humans may have been raising cassowaries—often described as the world’s most dangerous birds because of a daggerlike claw they have on each foot—as early as 18,000 years ago.

Territorial, aggressive and often compared to a dinosaur in looks, the bird is a surprising candidate for domestication. But a study of more than 1,000 fossilized Papua New Guinea eggshell fragments has suggested the birds were deliberately hatched.

To reach their conclusions, the researchers first studied the eggshells of living birds, including turkeys, emus and ostriches. The insides of the eggshells change as the developing chicks get calcium from the eggshell. Using high-resolution 3D images and inspecting the inside of the eggs, the researchers were able to build a model of what the eggs looked like during different stages of incubation.

The scientists tested their model on modern emu and ostrich eggs before applying it to the fossilized eggshell fragments found in New Guinea. The team found that most of the eggshells found at the sites were all near maturity—suggesting they were hatched, not eaten.

The first oviraptor fossil—from a family of dinosaurs with parrotlike beaks—was discovered in Mongolia in the 1920s, lying near a nest of eggs thought to belong to a rival. Paleontologists at the time assumed that the animal had died while attempting to plunder the nest and named the creature “egg thief.”

It wasn’t until the 1990s that its reputation was restored when another discovery revealed that the eggs were its own. Subsequent finds, including an oviraptosaur hunched over 24 eggs made public last year, have revealed that this particular type of dinosaur was a doting parent.

At least seven of the 24 eggs preserved the bones of partial embryos found inside; it was the first time a fossil had preserved this level of detail. These embryos were at a late stage of development, and the close proximity of the parent confirmed that this dinosaur really did incubate its nest like its modern bird cousins.

The neat layout of oviraptor nests also suggested that they were brooders that sat upon eggs to hatch them—even giant oviraptors that weighed 1,500 kilograms (3,307 pounds) and laid half-meter long eggs, said Darla Zelenitsky, a dinosaur egg expert and associate professor in the department of geoscience at the University of Calgary in Canada.

“These fossils also show very precisely arranged eggs, stacked in rings, probably optimized for sitting on the eggs,” she explained.

The 2-meter-wide (6.6-foot-wide) nests of giant oviraptors were a slightly modified shape to stop them from being crushed, she added.

Dinosaurs eggs—including one with a perfectly preserved baby dinosaur curled up inside—increasingly show that birds inherited many characteristics from dinosaurs. Not all dinosaurs, however, were caring parents.

Pores on the surface of eggs allow the diffusion of water, oxygen and carbon dioxide, and the orientation, density and number of pores on the eggs of living animals can reveal whether they are laid in open nests or underground. Applying this knowledge to fossilized dinosaur eggs has shed light on their nesting behavior.

Analysis suggests that many dinosaurs, including hulking plant-eating sauropods, laid their eggs underground in burrows, more like reptiles.

A string of modern ostrich eggshell beads from eastern Africa is shown.

Ostrich eggshells are found in archaeological dig sites throughout Africa. Early humans used the large eggs as water bottles and, for tens of thousands of years, ancient humans took the remains and fashioned them into decorative beads that are still made today.

These beads have been found all over Africa—including in areas where ostriches never lived – sparking the question of how they got there.

The answer is hidden in the eggs’ geochemistry. Researchers looked at the signatures of different isotopes or variants of the element strontium in the beads—these vary depending on where the ostriches would have fed before laying the eggs.

Older rock formations including granite are found to have more strontium than younger rocks like basalt, and this is reflected in the vegetation that grows around them.

The geochemistry of the beads showed they traveled long distances. They were traded or exchanged in what was described as an early social network.

Eggs are a big part of our diet today – something that was also true in the Stone Age.

In fact, ancient Australians’ appetite for the eggs laid by the 2-meter-tall (6-foot-tall) Genyornis could have been one significant reason why the large, flightless birds went extinct 47,000 years ago.

Burn patterns on eggshell fragments of the giant bird found at around 200 sites across Australia, were created by humans discarding eggshell in and around makeshift fires, presumably made to cook the eggs.

Chemical signatures of nitrogen and carbon isotopes in fossilized egg shells can also track vegetation changes, gleaning information about past changes in climate, which can reveal ecological shifts that could impact the survival of these species over time.

A study of emu eggshells found across Australia over a 100,000-year time period do not show a massive shift in climate that researchers believe could have led to the extinction of Genyornis.

This suggested that the extinction of these giant birds was caused by humans, not ecological changes, the study said.

Fossilized penguin, ostrich and emu eggshells have revealed what the climate was like in the ancient Antarctic, South Africa and Australia. More recent egg collections are revealing how the current climate crisis is changing the natural world today.

By comparing birds’ eggs collected during the Victorian era and modern eggs held by the Field Museum and other institutions, researchers found that several bird species in the Chicago area nest and lay eggs almost a full month earlier now than they did a century ago.

Of the 72 species documented in the data, a third have been nesting earlier and earlier, the team found. Birds that changed their nesting habits laid eggs around 25 days sooner, on average.

Similar patterns are seen in insects, which many birds eat, and plants, suggesting that climate change is already changing ecosystems, the authors of the study said.

Source link

#Fossilized #eggs #crack #open #mysteries #CNN

The haunting Masters meltdown that changed Rory McIlroy’s career | CNN



CNN
 — 

Slumped on his club, head buried in his arm, Rory McIlroy looked on the verge of tears.

The then-21-year-old had just watched his ball sink into the waters of Rae’s Creek at Augusta National and with it, his dream of winning The Masters, a dream that had looked so tantalizingly close mere hours earlier.

As a four-time major winner and one of the most decorated names in the sport’s history, few players would turn down the chance to swap places with McIlroy heading into Augusta this week.

Yet on Sunday afternoon of April 10, 2011, not a golfer in the world would have wished to be in the Northern Irishman’s shoes.

A fresh-faced, mop-headed McIlroy had touched down in Georgia for the first major of the season with a reputation as the leading light of the next generation of stars.

An excellent 2010 had marked his best season since turning pro three years earlier, highlighted by a first PGA Tour win at the Quail Hollow Championship and a crucial contribution to Team Europe’s triumph at the Ryder Cup.

Yet despite a pair of impressive top-three finishes at the Open and PGA Championship respectively, a disappointing missed cut at The Masters – his first at a major – served as ominous foreshadowing.

McIlroy shot 74 and 77 to fall four strokes short of the cut line at seven-over par, a performance that concerned him enough to take a brief sabbatical from competition.

But one year on in 2011, any lingering Masters demons looked to have been exorcised as McIlroy flew round the Augusta fairways.

Having opened with a bogey-free seven-under 65 – the first time he had ever shot in the 60s at the major – McIlroy pulled ahead from Spanish first round co-leader Alvaro Quirós with a second round 69.

It sent him into the weekend holding a two-shot cushion over Australia’s Jason Day, with Tiger Woods a further stroke behind and back in the hunt for a 15th major after a surging second round 66.

And yet the 21-year-old leader looked perfectly at ease with having a target on his back. Even after a tentative start to the third round, McIlroy rallied with three birdies across the closing six holes to stretch his lead to four strokes heading into Sunday.

McIlroy drives from the 16th tee during his second round.

The youngster was out on his own ahead of a bunched chasing pack comprising Day, Ángel Cabrera, K.J. Choi and Charl Schwartzel. After 54 holes, McIlroy had shot just three bogeys.

“It’s a great position to be in … I’m finally feeling comfortable on this golf course,” McIlroy told reporters.

“I’m not getting ahead of myself, I know how leads can dwindle away very quickly. I have to go out there, not take anything for granted and go out and play as hard as I’ve played the last three days. If I can do that, hopefully things will go my way.

“We’ll see what happens tomorrow because four shots on this golf course isn’t that much.”

McIlroy finished his third round with a four shot lead.

The truth can hurt, and McIlroy was about to prove his assessment of Augusta to be true in the most excruciating way imaginable.

His fourth bogey of the week arrived immediately. Having admitted to expecting some nerves at the first tee, McIlroy sparked a booming opening drive down the fairway, only to miss his putt from five feet.

Three consecutive pars steadied the ship, but Schwartzel had the wind in his sails. A blistering birdie, par, eagle start had seen him draw level at the summit after his third hole.

A subsequent bogey from the South African slowed his charge, as McIlroy clung onto a one-shot lead at the turn from Schwartzel, Cabrera, Choi, and a rampaging Woods, who shot five birdies and an eagle across the front nine to send Augusta into a frenzy.

Despite his dwindling advantage and the raucous Tiger-mania din ahead of him, McIlroy had responded well to another bogey at the 5th hole, draining a brilliant 20-foot putt at the 7th to restore his lead.

The fist pump that followed marked the high-water point of McIlroy’s round, as a sliding start accelerated into full-blown free-fall at the par-four 10th hole.

His tee shot went careening into a tree, ricocheting to settle between the white cabins that separate the main course from the adjacent par-three course. It offered viewers a glimpse at a part of Augusta rarely seen on broadcast, followed by pictures of McIlroy anxiously peering out from behind a tree to track his follow-up shot.

McIlroy watches his shot after his initial drive from the 10th tee put him close to Augusta's cabins.

Though his initial escape was successful, yet another collision with a tree and a two-putt on the green saw a stunned McIlroy eventually tap in for a triple bogey. Having led the field one hole and seven shots earlier, he arrived at the 11th tee in seventh.

By the time his tee drive at the 13th plopped into the creek, all thoughts of who might be the recipient of the green jacket had long-since switched away from the anguished youngster. It had taken him seven putts to navigate the previous two greens, as a bogey and a double bogey dropped him to five-under – the score he had held after just 11 holes of the tournament.

Mercifully, the last five holes passed without major incident. A missed putt for birdie from five feet at the final hole summed up McIlroy’s day, though he was given a rousing reception as he left the green.

Mere minutes earlier, the same crowd had erupted as Schwartzel sunk his fourth consecutive birdie to seal his first major title. After starting the day four shots adrift of McIlroy, the South African finished 10 shots ahead of him, and two ahead of second-placed Australian duo Jason Day and Adam Scott.

McIlroy’s eight-over 80 marked the highest score of the round. Having headlined the leaderboard for most of the week, he finished tied-15th.

McIroy was applauded off the 18th green by the Augusta crowd after finishing his final round.

Tears would flow during a phone call with his parents the following morning, but at his press conference, McIlroy was upbeat.

“I’m very disappointed at the minute, and I’m sure I will be for the next few days, but I’ll get over it,” he said.

“I was leading this golf tournament with nine holes to go, and I just unraveled … It’s a Sunday at a major, what it can do.

“This is my first experience at it, and hopefully the next time I’m in this position I’ll be able to handle it a little better. I didn’t handle it particularly well today obviously, but it was a character-building day … I’ll come out stronger for it.”

Once again, McIlroy would be proven right.

Just eight weeks later in June, McIlroy rampaged to an eight-shot victory at the US Open. Records tumbled in his wake at Congressional, as he shot a tournament record 16-under 268 to become the youngest major winner since Tiger Woods at The Masters in 1997.

McIlroy celebrated a historic triumph at the US Open just two months after his Masters nightmare.

The historic victory kickstarted a golden era for McIlroy. After coasting to another eight-shot win at the PGA Championship in 2012, McIlroy became only the third golfer since 1934 to win three majors by the age of 25 with triumph at the 2014 Open Championship.

Before the year was out, he would add his fourth major title with another PGA Championship win.

And much of it was owed to that fateful afternoon at Augusta. In an interview with the BBC in 2015, McIlroy dubbed it “the most important day” of his career.

“If I had not had the whole unravelling, if I had just made a couple of bogeys coming down the stretch and lost by one, I would not have learned as much.

“Luckily, it did not take me long to get into a position like that again when I was leading a major and I was able to get over the line quite comfortably. It was a huge learning curve for me and I needed it, and thankfully I have been able to move on to bigger and better things.

“Looking back on what happened in 2011, it doesn’t seem as bad when you have four majors on your mantelpiece.”

A two-stroke victory at Royal Liverpool saw McIlroy clinch the Open Championship in 2014.

McIlroy’s contentment came with a caveat: it would be “unthinkable” if he did not win The Masters in his career.

Yet as he prepares for his 15th appearance at Augusta National this week, a green jacket remains an elusive missing item from his wardrobe.

Despite seven top-10 finishes in his past 10 Masters outings, the trophy remains the only thing separating McIlroy from joining the ranks of golf immortals to have completed golf’s career grand slam of all four majors in the modern era: Gene Sarazen, Ben Hogan, Gary Player, Jack Nicklaus, and Tiger Woods.

The Masters is the only major title to elude McIlroy.

A runner-up finish to Scottie Scheffler last year marked McIlroy’s best finish at Augusta, yet arguably 2011 remains the closest he has ever been to victory. A slow start in 2022 meant McIlroy had begun Sunday’s deciding round 10 shots adrift of the American, who teed off for his final hole with a five-shot lead despite McIlroy’s brilliant 64 finish.

At 33 years old, time is still on his side. Though 2022 extended his major drought to eight years, it featured arguably his best golf since that golden season in 2014.

And as McIlroy knows better than most, things can change quickly at Augusta National.

Source link

#haunting #Masters #meltdown #changed #Rory #McIlroys #career #CNN

FDA approves first over-the-counter version of opioid overdose antidote Narcan | CNN



CNN
 — 

With drug overdose deaths continuing to hover near record levels, the US Food and Drug Administration on Wednesday approved for the first time an over-the-counter version of the opioid overdose antidote Narcan.

“The FDA remains committed to addressing the evolving complexities of the overdose crisis. As part of this work, the agency has used its regulatory authority to facilitate greater access to naloxone by encouraging the development of and approving an over-the-counter naloxone product to address the dire public health need,” FDA Commissioner Dr. Robert Califf said in a statement.

“Today’s approval of OTC naloxone nasal spray will help improve access to naloxone, increase the number of locations where it’s available and help reduce opioid overdose deaths throughout the country. We encourage the manufacturer to make accessibility to the product a priority by making it available as soon as possible and at an affordable price.”

Dr. Rahul Gupta, director of the White House’s Office of National Drug Control Policy, said accessibility is key to ensuring that the Narcan nasal spray saves lives.

“It’s really important that we continue to do everything possible in our power to make this life-saving drug available to anyone and everyone across the country,” Gupta said.

The White House drug czar said businesses, such as restaraunts and banks, and schools will be encouraged to purchase over-the-counter naloxone.

“We will encourage businesses, restaurants, banks, construction sites, schools, others to think about this – think about it as a smoke alarm or a defibrillator, to make it as easily accessible, because it’s not just you. It could be your neighbor, it could be your family, your friend, a person at work or school who might need it, ” Gupta said.

The nasal spray will come in a package of two 4-milligram doses, in case the person overdosing does not respond to the first dose. However, the drug’s maker, Emergent BioSolutions, says most overdoses can be reversed with a single dose. The product could be given to anyone, even children and babies.

The nasal spray is expected to be available for purchase in stores and online by late summer, Emergent said Wednesday.

More than a million people have died of drug overdoses in the two decades since the US Centers for Disease Control and Prevention began collecting that data. Many of those deaths were due to opioids. Deaths from opioid overdoses rose more than 17% in just one year, from about 69,000 in 2020 to about 81,020 in 2021, the CDC found.

Opioid deaths are the leading cause of accidental death in the US. Most are among adults, but children are also dying, largely after ingesting synthetic opioids such as fentanyl. Between 1999 and 2016, nearly 9,000 children and adolescents died of opioid poisoning, with the highest annual rates among adolescents 15 to 19, the CDC found.

Nearly every state in the US has standing orders that allow pharmacists or other qualified organizations to provide the medication without a personal prescription to people who are at risk of an overdose or are helping someone at risk, but making it available over the counter can make it easier for people to access the opioid antidote.

Research shows that wider availability could save lives as opioid overdoses have skyrocketed in recent years – much of it due to synthetic opioids like illicitly made fentanyl.

Emergent President and CEO Robert Kramer hailed the FDA’s decision as a “historic milestone.”

“We are dedicated to improving public health and assisting those working hard to end the opioid crisis – so now with leaders across government, retail and advocacy groups, we must work together to continue increasing access and availability, as well as educate the public on the risks of opioid overdoses and the value of being prepared with Narcan Nasal Spray to help save a life,” Kramer said in a statement.

Narcan works by blocking the effects of opioids on the brain and restoring breathing. For the most effectiveness, it must be given as soon as signs of overdose appear.

The drug works on someone only if there are opioids in their system. It won’t work on any other type of drug overdose, but it won’t have adverse effects if given to someone who hasn’t taken opioids.

Naloxone reverses an overdose for up to about 90 minutes, but opioids can stay in the system for longer, so it’s still important to call 911 after giving the drug.

People given naloxone should be watched carefully until medical help arrives and monitored for another two hours.

About 1.2 million doses of naloxone were dispensed by retail pharmacies in 2021, according to data published by the American Medical Association – nearly nine times more than were dispensed five years earlier.

Emergent said it does not have information on how much OTC Narcan will cost.

Harm reduction experts say the price of naloxone has inhibited its accessibility to people who need it most. And although the cost will probably drop as it becomes available over the counter, they say it will probably still be out of reach for many.

“We’re not going to be able to ramp up naloxone distribution in a game-changing way until we get a better handle on the price,” said Nabarun Dasgupta, a scientist at the University of North Carolina’s Injury Prevention Research Center who studies drugs and infectious diseases. “There’s the promise on paper versus on the street, and it’s going to come down to the dollars and cents.”

Separate changes to grant funding by both the CDC and the Substance Abuse and Mental Health Services Administration will make it easier for states and local health departments to buy naloxone, he said.

Gupta said the Biden administration is asking the drugmakers to keep the price of the antidote low.

“That’s one of the things that the president has been very clear: that we’ve got to make sure that these life-saving medications, as well as treatment, is accessible across no matter where you live, rural or urban, rich or poor. We want to make sure this is accessible across broad swaths of people,” he said.

However, experts said the most meaningful work in the fight against the devastating outcomes of the drug overdose epidemic will come with ongoing emphasis on treatment for opioid use disorder and other harm-reduction strategies.

“While enabling people to access quality treatment for substance use disorders is critical, we must also acknowledge that people need to survive in order to have that choice,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse, said in January.

Caleb Banta-Green, principal research scientist at the University of Washington’s Addictions, Drug & Alcohol Institute, has described naloxone as the “gateway drug” to a conversation about what substance use disorder is.

“It’s a conversation starter. It’s life-saving for the individual. It’s not a game-changer at the population level,” he said. “We need to do more. And we need to use treatment medications – methadone and buprenorphine – which are far higher overdose preventive approaches.”

Source link

#FDA #approves #overthecounter #version #opioid #overdose #antidote #Narcan #CNN

Pediatric hospital beds are in high demand for ailing children. Here’s why | CNN



CNN
 — 

Effie Schnacky was wheezy and lethargic instead of being her normal, rambunctious self one February afternoon. When her parents checked her blood oxygen level, it was hovering around 80% – dangerously low for the 7-year-old.

Her mother, Jaimie, rushed Effie, who has asthma, to a local emergency room in Hudson, Wisconsin. She was quickly diagnosed with pneumonia. After a couple of hours on oxygen, steroids and nebulizer treatments with little improvement, a physician told Schnacky that her daughter needed to be transferred to a children’s hospital to receive a higher level of care.

What they didn’t expect was that it would take hours to find a bed for her.

Even though the respiratory surge that overwhelmed doctor’s offices and hospitals last fall is over, some parents like Schnacky are still having trouble getting their children beds in a pediatric hospital or a pediatric unit.

The physical and mental burnout that occurred during the height of the Covid-19 pandemic has not gone away for overworked health care workers. Shortages of doctors and technicians are growing, experts say, but especially in skilled nursing. That, plus a shortage of people to train new nurses and the rising costs of hiring are leaving hospitals with unstaffed pediatric beds.

But a host of reasons building since well before the pandemic are also contributing. Children may be the future, but we aren’t investing in their health care in that way. With Medicaid reimbursing doctors at a lower rate for children, hospitals in tough situations sometimes put adults in those pediatric beds for financial reasons. And since 2019, children with mental health crises are increasingly staying in emergency departments for sometimes weeks to months, filling beds that children with other illnesses may need.

“There might or might not be a bed open right when you need one. I so naively just thought there was plenty,” Schnacky told CNN.

The number of pediatric beds decreasing has been an issue for at least a decade, said Dr. Daniel Rauch, chair of the Committee on Hospital Care for the American Academy of Pediatrics.

By 2018, almost a quarter of children in America had to travel farther for pediatric beds as compared to 2009, according to a 2021 paper in the journal Pediatrics by lead author Dr. Anna Cushing, co-authored by Rauch.

“This was predictable,” said Rauch, who has studied the issue for more than 10 years. “This isn’t shocking to people who’ve been looking at the data of the loss in bed capacity.”

The number of children needing care was shrinking before the Covid-19 pandemic – a credit to improvements in pediatric care. There were about 200,000 fewer pediatric discharges in 2019 than there were in 2017, according to data from the US Department of Health and Human Services.

“In pediatrics, we have been improving the ability we have to take care of kids with chronic conditions, like sickle cell and cystic fibrosis, and we’ve also been preventing previously very common problems like pneumonia and meningitis with vaccination programs,” said Dr. Matthew Davis, the pediatrics department chair at Ann & Robert H. Lurie Children’s Hospital of Chicago.

Pediatrics is also seasonal, with a typical drop in patients in the summer and a sharp uptick in the winter during respiratory virus season. When the pandemic hit, schools and day cares closed, which slowed the transmission of Covid and other infectious diseases in children, Davis said. Less demand meant there was less need for beds. Hospitals overwhelmed with Covid cases in adults switched pediatric beds to beds for grownups.

As Covid-19 tore through Southern California, small hospitals in rural towns like Apple Valley were overwhelmed, with coronavirus patients crammed into hallways, makeshift ICU beds and even the pediatric ward.

Only 37% of hospitals in the US now offer pediatric services, down from 42% about a decade ago, according to the American Hospital Association.

While pediatric hospital beds exist at facilities in Baltimore, the only pediatric emergency department in Baltimore County is Greater Baltimore Medical Center in Towson, Maryland, according to Dr. Theresa Nguyen, the center’s chair of pediatrics. All the others in the county, which has almost 850,000 residents, closed in recent years, she said.

The nearby MedStar Franklin Square Medical Center consolidated its pediatric ER with the main ER in 2018, citing a 40% drop in pediatric ER visits in five years, MedStar Health told CNN affiliate WBAL.

In the six months leading up to Franklin Square’s pediatric ER closing, GBMC admitted an average of 889 pediatric emergency department patients each month. By the next year, that monthly average jumped by 21 additional patients.

“Now we’re seeing the majority of any pediatric ED patients that would normally go to one of the surrounding community hospitals,” Nguyen said.

In July, Tufts Medical Center in Boston converted its 41 pediatric beds to treat adult ICU and medical/surgical patients, citing the need to care for critically ill adults, the health system said.

In other cases, it’s the hospitals that have only 10 or so pediatric beds that started asking the tough questions, Davis said.

“Those hospitals have said, ‘You know what? We have an average of one patient a day or two patients a day. This doesn’t make sense anymore. We can’t sustain that nursing staff with specialized pediatric training for that. We’re going to close it down,’” Davis said.

Registered nurses at Tufts Medical Center hold a

Saint Alphonsus Regional Medical Center in Boise closed its pediatric inpatient unit in July because of financial reasons, the center told CNN affiliate KBOI. That closure means patients are now overwhelming nearby St. Luke’s Children’s Hospital, which is the only children’s hospital in the state of Idaho, administrator for St. Luke’s Children’s Katie Schimmelpfennig told CNN. Idaho ranks last for the number of pediatricians per 100,000 children, according to the American Board of Pediatrics in 2023.

The Saint Alphonsus closure came just months before the fall, when RSV, influenza and a cadre of respiratory viruses caused a surge of pediatric patients needing hospital care, with the season starting earlier than normal.

The changing tide of demand engulfed the already dwindling supply of pediatric beds, leaving fewer beds available for children coming in for all the common reasons, like asthma, pneumonia and other ailments. Additional challenges have made it particularly tough to recover.

Another factor chipping away at bed capacity over time: Caring for children pays less than caring for adults. Lower insurance reimbursement rates mean some hospitals can’t afford to keep these beds – especially when care for adults is in demand.

Medicaid, which provides health care coverage to people with limited income, is a big part of the story, according to Joshua Gottlieb, an associate professor at the University of Chicago Harris School of Public Policy.

“Medicaid is an extremely important payer for pediatrics, and it is the least generous payer,” he said. “Medicaid is responsible for insuring a large share of pediatric patients. And then on top of its low payment rates, it is often very cumbersome to deal with.”

Pediatric gastroenterologist Dr. Howard Baron visits with a patient in 2020 in Las Vegas. A large portion of his patients are on Medicaid with reimbursement rates that are far below private insurers.

Medicaid reimburses children’s hospitals an average of 80% of the cost of the care, including supplemental payments, according to the Children’s Hospital Association, a national organization which represents 220 children’s hospitals. The rate is far below what private insurers reimburse.

More than 41 million children are enrolled in Medicaid and the Children’s Health Insurance Program, according to Kaiser Family Foundation data from October. That’s more than half the children in the US, according to Census data.

At Children’s National Hospital in Washington, DC, about 55% of patients use Medicaid, according to Dr. David Wessel, the hospital’s executive vice president.

“Children’s National is higher Medicaid than most other children’s hospitals, but that’s because there’s no safety net hospital other than Children’s National in this town,” said Wessel, who is also the chief medical officer and physician-in-chief.

And it just costs more to care for a child than an adult, Wessel said. Specialty equipment sized for smaller people is often necessary. And a routine test or exam for an adult is approached differently for a child. An adult can lie still for a CT scan or an MRI, but a child may need to be sedated for the same thing. A child life specialist is often there to explain what’s going on and calm the child.

“There’s a whole cadre of services that come into play, most of which are not reimbursed,” he said. “There’s no child life expert that ever sent a bill for seeing a patient.”

Low insurance reimbursement rates also factor into how hospital administrations make financial decisions.

“When insurance pays more, people build more health care facilities, hire more workers and treat more patients,” Gottlieb said.

“Everyone might be squeezed, but it’s not surprising that pediatric hospitals, which face [a] lower, more difficult payment environment in general, are going to find it especially hard.”

Dr. Benson Hsu is a pediatric critical care provider who has served rural South Dakota for more than 10 years. Rural communities face distinct challenges in health care, something he has seen firsthand.

A lot of rural communities don’t have pediatricians, according to the American Board of Pediatrics. It’s family practice doctors who treat children in their own communities, with the goal of keeping them out of the hospital, Hsu said. Getting hospital care often means traveling outside the community.

Hsu’s patients come from parts of Nebraska, Iowa and Minnesota, as well as across South Dakota, he said. It’s a predominantly rural patient base, which also covers those on Native American reservations.

“These kids are traveling 100, 200 miles within their own state to see a subspecialist,” Hsu said, referring to patients coming to hospitals in Sioux Falls. “If we are transferring them out, which we do, they’re looking at travels of 200 to 400 miles to hit Omaha, Minneapolis, Denver.”

Inpatient pediatric beds in rural areas decreased by 26% between 2008 and 2018, while the number of rural pediatric units decreased by 24% during the same time, according to the 2021 paper in Pediatrics.

Steve Inglish, left, and registered nurse Nikole Hoggarth, middle, help a father with his daughter, who fell and required stiches, inside the emergency department at Jamestown Regional Medical Center in rural North Dakota in 2020.

“It’s bad, and it’s getting worse. Those safety net hospitals are the ones that are most at risk for closure,” Rauch said.

In major cities, the idea is that a critically ill child would get the care they need within an hour, something clinicians call the golden hour, said Hsu, who is the critical care section chair at the American Academy of Pediatrics.

“That golden hour doesn’t exist in the rural population,” he said. “It’s the golden five hours because I have to dispatch a plane to land, to drive, to pick up, stabilize, to drive back, to fly back.”

When his patients come from far away, it uproots the whole family, he said. He described families who camp out at a child’s bedside for weeks at a time. Sometimes they are hundreds of miles from home, unlike when a patient is in their own community and parents can take turns at the hospital.

“I have farmers who miss harvest season and that as you can imagine is devastating,” Hsu said. “These aren’t office workers who are taking their computer with them. … These are individuals who have to live and work in their communities.”

Back at GBMC in Maryland, an adolescent patient with depression, suicidal ideation and an eating disorder was in the pediatric emergency department for 79 days, according to Nguyen. For months, no facility had a pediatric psychiatric bed or said it could take someone who needed that level of care, as the patient had a feeding tube.

“My team of physicians, social workers and nurses spend a significant amount of time every day trying to reach out across the state of Maryland, as well as across the country now to find placements for this adolescent,” Nguyen said before the patient was transferred in mid-March. “I need help.”

Nguyen’s patient is just one of the many examples of children and teens with mental health issues who are staying in emergency rooms and sometimes inpatient beds across the country because they need help, but there isn’t immediately a psychiatric bed or a facility that can care for them.

It’s a problem that began before 2020 and grew worse during the pandemic, when the rate of children coming to emergency rooms with mental health issues soared, studies show.

Now, a nationwide shortage of beds exists for children who need mental health help. A 2020 federal survey revealed that the number of residential treatment facilities for children fell 30% from 2012.

“There are children on average waiting for two weeks for placement, sometimes longer,” Nguyen said of the patients at GBMC. The pediatric emergency department there had an average of 42 behavioral health patients each month from July 2021 through December 2022, up 13.5% from the same period in 2017 to 2018, before the pandemic, according to hospital data.

When there are mental health patients staying in the emergency department, that can back up the beds in other parts of the hospital, creating a downstream effect, Hsu said.

“For example, if a child can’t be transferred from a general pediatric bed to a specialized mental health center, this prevents a pediatric ICU patient from transferring to the general bed, which prevents an [emergency department] from admitting a child to the ICU. Health care is often interconnected in this fashion,” Hsu said.

“If we don’t address the surging pediatric mental health crisis, it will directly impact how we can care for other pediatric illnesses in the community.”

Dr. Susan Wu, right, chats with a child who got her first dose of the Pfizer-BioNtech Covid-19 vaccine at Children's Hospital Arcadia Speciality Care Center in Arcadia, California, in 2022.

So, what can be done to improve access to pediatric care? Much like the reasons behind the difficulties parents and caregivers are experiencing, the solutions are complex:

  • A lot of it comes down to money

Funding for children’s hospitals is already tight, Rauch said, and more money is needed not only to make up for low insurance reimbursement rates but to competitively hire and train new staff and to keep hospitals running.

“People are going to have to decide it’s worth investing in kids,” Rauch said. “We’re going to have to pay so that hospitals don’t lose money on it and we’re going to have to pay to have staff.”

Virtual visits, used in the right situations, could ease some of the problems straining the pediatric system, Rauch said. Extending the reach of providers would prevent transferring a child outside of their community when there isn’t the provider with the right expertise locally.

  • Increased access to children’s mental health services

With the ongoing mental health crisis, there’s more work to be done upstream, said Amy Wimpey Knight, the president of CHA.

“How do we work with our school partners in the community to make sure that we’re not creating this crisis and that we’re heading it off up there?” she said.

There’s also a greater need for services within children’s hospitals, which are seeing an increase in children being admitted with behavioral health needs.

“If you take a look at the reasons why kids are hospitalized, meaning infections, diabetes, seizures and mental health concerns, over the last decade or so, only one of those categories has been increasing – and that is mental health,” Davis said. “At the same time, we haven’t seen an increase in the number of mental health hospital resources dedicated to children and adolescents in a way that meets the increasing need.”

Most experts CNN spoke to agreed: Seek care for your child early.

“Whoever is in your community is doing everything possible to get the care that your child needs,” Hsu said. “Reach out to us. We will figure out a way around the constraints around the system. Our number one concern is taking care of your kids, and we will do everything possible.”

Nguyen from GBMC and Schimmelpfennig from St. Luke’s agreed with contacting your primary care doctor and trying to keep your child out of the emergency room.

“Anything they can do to stay out of the hospital or the emergency room is both financially better for them and better for their family,” Schimmelpfennig said.

Knowing which emergency room or urgent care center is staffed by pediatricians is also imperative, Rauch said. Most children visit a non-pediatric ER due to availability.

“A parent with a child should know where they’re going to take their kid in an emergency. That’s not something you decide when your child has the emergency,” he said.

Jaimie and Effie Schnacky now have an asthma action plan after the 7-year-old's hospitalization in February.

After Effie’s first ambulance ride and hospitalization last month, the Schnacky family received an asthma action plan from the pulmonologist in the ER.

It breaks down the symptoms into green, yellow and red zones with ways Effie can describe how she’s feeling and the next steps for adults. The family added more supplies to their toolkit, like a daily steroid inhaler and a rescue inhaler.

“We have everything an ER can give her, besides for an oxygen tank, at home,” Schnacky said. “The hope is that we are preventing even needing medical care.”

Source link

#Pediatric #hospital #beds #high #demand #ailing #children #Heres #CNN

How to reduce PFAS in your drinking water, according to experts | CNN

Editor’s Note: Get inspired by a weekly roundup on living well, made simple. Sign up for CNN’s Life, But Better newsletter for information and tools designed to improve your well-being.



CNN
 — 

In the next three years, drinking water in the United States may be a bit safer from potentially toxic chemicals that have been detected in the blood of 98% of Americans.

Perfluoroalkyl and polyfluoroalkyl substances or PFAS are a family of thousands of man-made chemicals that do not break down easily in the environment. A number of PFAS have been linked to serious health problems, including cancer, fertility issues, high cholesterol, hormone disruption, liver damage, obesity and thyroid disease.

The US Environmental Protection Agency proposed on Tuesday stringent new limits on levels of six PFAS chemicals in public water systems. Under the proposed rule, public systems that provide water to at least 15 service connections or 25 people will have three years to implement testing procedures, begin notifying the public about PFAS levels, and reduce levels if above the new standard, the EPA said.

Two of the most well-studied and potentially toxic chemicals, PFOA and PFOS, cannot exceed 4 parts per trillion in drinking water, compared with a previous health advisory of 70 parts per trillion, the EPA said.

Another four chemicals — PFNA, PFHxS, PFBS and GenX — will be subject to a hazard index calculation to determine whether the levels of these PFAS pose a potential risk. The calculation is “a tool the EPA uses to address the cumulative risks from all four of those chemicals,” said Melanie Benesh, vice president of government affairs for the Environmental Working Group, a consumer organization that monitors exposure to PFAS and other chemicals.

“The EPA action is a really important and historic step forward,” Benesh said. “While the proposed regulations only address a few PFAS, they are important marker chemicals. I think requiring water systems to test and treat for these six will actually do a lot to address other PFAS that are in the water as well.”

For people who are concerned about PFAS exposure, three years or so is a long time. What can consumers do now to limit the levels of PFAS in their drinking water?

First, look up levels of PFAS in your local public water system, suggested David Andrews, a senior scientist at the Environmental Working Group. The advocacy nonprofit has created a national tap water database searchable by zip code that lists PFAS and other concerning chemicals, as well as a national map that illustrates where PFAS has been detected in the US.

However, not all water utilities currently test for pollutants, and many rural residents rely on wells for water. Anyone who wants to personally test their water can purchase a test online or from a certified lab, Andrews said.

“The most important thing is to ensure the testing method can detect down to at least four parts per trillion or lower of PFAS,” he said. “There are a large number of labs across the country certified to test to that level, so there are a lot of options available.”

If levels are concerning, consumers can purchase a water filter for their tap. NSF, formerly the National Sanitation Foundation, has a list of recommended filters.

“The water filters that are most effective for PFAS are reverse osmosis filters, which are more expensive, about in the $200 range,” Andrews said. Reverse osmosis filters can remove a wide range of contaminants, including dissolved solids, by forcing water through various filters.

“Granular activated carbon filters are more common and less expensive but not quite as effective or consistent for PFAS,” he said, “although they too can remove a large number of other contaminants.”

Reverse osmosis systems use both carbon-based filters and reverse osmosis membranes, Andrews explained. Water passes through the carbon filter before entering the membrane.

“The important part is that you have to keep changing those filters,” he said. “If you don’t change that filter, and it becomes saturated, the levels of PFAS in the filtered water can actually be above the levels in the tap water.”

Carbon filters are typically replaced every six months, “while the reverse osmosis filter is replaced on a five-year time frame,” he added. “The cost is relatively comparable over their lifetime.”

Another positive: Many of the filters that work for PFAS also filter other contaminants in water, Andrews said.

Drinking water is not the only way PFAS enters the bloodstream. Thousands of varieties of PFAS are used in many of the products we purchase, including nonstick cookware, infection-resistant surgical gowns and drapes, mobile phones, semiconductors, commercial aircraft, and low-emissions vehicles.

The chemicals are also used to make carpeting, clothing, furniture, and food packaging resistant to stains, water and grease damage. Once treated, the report said, textiles emit PFAS over the course of their lifetimes, escaping into the air and groundwater in homes and communities.

Made from a chain of linked carbon and fluorine atoms that do not readily degrade in the environment, PFAS are known as “forever chemicals.” Due to their long half life in the human body, it can take some PFAS years to completely leave the body, according to a 2022 report by the prestigious National Academies of Sciences, Engineering, and Medicine.

“Some of these chemicals have half-lives in the range of five years,” National Academies committee member Jane Hoppin, an environmental epidemiologist and director of the Center for Human Health and the Environment at North Carolina State University in Raleigh, told CNN previously.

“Let’s say you have 10 nanograms of PFAS in your body right now. Even with no additional exposure, five years from now you would still have 5 nanograms.

“Five years later, you would have 2.5 and then five years after that, you’d have one 1.25 nanograms,” she continued. “It would be about 25 years before all the PFAS leave your body.”

The 2022 National Academies report set “nanogram” levels of concern and encouraged clinicians to conduct blood tests on patients who are worried about exposure or who are at high risk. (A nanogram is equivalent to one-billionth of a gram.)

People in “vulnerable life stages” — such as during fetal development in pregnancy, early childhood and old age — are at high risk, the report said. So are firefighters, workers in fluorochemical manufacturing plants, and those who live near commercial airports, military bases, landfills, incinerators, wastewater treatment plants and farms where contaminated sewage sludge is used.

The PFAS-REACH (Research, Education, and Action for Community Health) project, funded by the National Institute of Environmental Health Sciences, gives the following advice on how to avoid PFAS at home and in products:

  • Stay away from stain-resistant carpets and upholstery, and don’t use waterproofing sprays.
  • Look for the ingredient polytetrafluoroethylene, or PTFE, or other “fluoro” ingredients on product labels.
  • Avoid nonstick cookware. Instead use cast-iron, stainless steel, glass or enamel products.
  • Boycott takeout containers and other food packaging. Instead cook at home and eat more fresh foods.
  • Don’t eat microwave popcorn or greasy foods wrapped in paper.
  • Choose uncoated nylon or silk dental floss or one that is coated in natural wax.

Source link

#reduce #PFAS #drinking #water #experts #CNN

Most men with prostate cancer can avoid or delay harsh treatments, long-term study confirms | CNN



CNN
 — 

Most men who are diagnosed with prostate cancer can delay or avoid harsh treatments without harming their chances of survival, according to new results from a long-running study in the United Kingdom.

Men in the study who partnered with their doctors to keep a close eye on their low- to intermediate-risk prostate tumors – a strategy called surveillance or active monitoring – slashed their risk of the life-altering complications such as incontinence and erectile dysfunction that can follow aggressive treatment for the disease, but they were no more likely to die of their cancers than men who had surgery to remove their prostate or who were treated with hormone blockers and radiation.

“The good news is that if you’re diagnosed with prostate cancer, don’t panic, and take your time to make a decision” about how to proceed, said lead study author Dr. Freddie Hamdy, professor of surgery and urology at the University of Oxford.

Other experts who were not involved in the research agreed that the study was reassuring for men who are diagnosed with prostate cancer and their doctors.

“When men are carefully evaluated and their risk assessed, you can delay or avoid treatment without missing the chance to cure in a large fraction of patients,” said Dr. Bruce Trock, a professor of urology, epidemiology and oncology at Johns Hopkins University.

The findings do not apply to men who have prostate cancers that are scored through testing to be high-risk and high-grade. These aggressive cancers, which account for about 15% of all prostate cancer diagnoses, still need prompt treatment, Hamdy said.

For others, however, the study adds to a growing body of evidence showing that surveillance of prostate cancers is often the right thing to do.

“What I take away from this is the safety of doing active monitoring in patients,” said Dr. Samuel Haywood, a urologic oncologist at the Cleveland Clinic in Ohio, who reviewed the study, but was not involved in the research.

Results from the study were presented on Saturday at the European Association of Urology annual conference in Milan, Italy. Two studies on the data were also published in the New England Journal of Medicine and a companion journal, NEJM Evidence.

Prostate cancer is the second most common cancer in men in the United States, behind non-melanoma skin cancers. About 11% – or 1 in 9 – American men will be diagnosed with prostate cancer in their lifetime, and overall, about 2.5% – or 1 in 41 – will die from it, according to the National Cancer Institute. About $10 billion is spent treating prostate cancer in the US each year.

Most prostate cancers grow very slowly. It typically takes at least 10 years for a tumor confined to the prostate to cause significant symptoms.

The study, which has been running for more than two decades, confirms what many doctors and researchers have come to realize in the interim: The majority of prostate cancers picked up by blood tests that measure levels of a protein called prostate-specific antigen, or PSA, will not harm men during their lifetimes and don’t require treatment.

Dr. Oliver Sartor, medical director of the Tulane Cancer Center, said men should understand that a lot has changed over time, and doctors have refined their approach to diagnosis since the study began in 1999.

“I wanted to make clear that the way these patients are screened and biopsied and randomized is very, very different than how these same patients might be screened, biopsied and randomized today,” said Sartor, who wrote an editorial on the study but was not involved in the research.

He says the men included in the study were in the earliest stages of their cancer and were mostly low-risk.

Now, he says, doctors have more tools, including MRI imaging and genetic tests that can help guide treatment and minimize overdiagnosis.

The study authors say that to assuage concerns that their results might not be relevant to people today, they re-evaluated their patients using modern methods for grading prostate cancers. By those standards, about one-third of their patients would have intermediate or high-risk disease, something that didn’t change the conclusions.

When the study began in 1999, routine PSA screening for men was the norm. Many doctors encouraged annual PSA tests for their male patients over age 50.

PSA tests are sensitive but not specific. Cancer can raise PSA levels, but so can things like infections, sexual activity and even riding a bicycle. Elevated PSA tests require more evaluation, which can include imaging and biopsies to determine the cause. Most of the time, all that followup just isn’t worth it.

“It is generally thought that only about 30% of the individuals with an elevated PSA will actually have cancer, and of those that do have cancer, the majority don’t need to be treated,” Sartor said.

Over the years, studies and modeling have shown that using regular PSA tests to screen for prostate cancer can do more harm than good.

By some estimates, as many as 84% of men with prostate cancer identified through routine screening do not benefit from having their cancers detected because their cancer would not be fatal before they died of other causes.

Other studies have estimated about 1 to 2 in every five men diagnosed with prostate cancer is overtreated. The harms of overtreatment for prostate cancer are well-documented and include incontinence, erectile dysfunction and loss of sexual potency, as well as anxiety and depression.

In 2012, the influential US Preventive Services Task Force advised healthy men not to get PSA tests as part of their regular checkups, saying the harms of screening outweighed its benefits.

Now, the task force opts for a more individualized approach, saying men between the ages of 55 and 69 should make the decision to undergo periodic PSA testing after carefully weighing the risks and benefits with their doctor. They recommend against PSA-based screening for men over the age of 70.

The American Cancer Society endorses much the same approach, recommending that men at average risk have a conversation with their doctor about the risks and benefits beginning at age 50.

The trial has been following more than 1,600 men who were diagnosed with prostate cancer in the UK between 1999 and 2009. All the men had cancers that had not metastasized, or spread to other parts of their bodies.

When they joined, the men were randomly assigned to one of three groups: active monitoring or using regular blood tests to keep an eye on their PSA levels; radiotherapy, which used hormone-blockers and radiation to shrink tumors; and prostatectomy, or surgery to remove the prostate.

Men who were assigned monitoring could change groups during the study if their cancers progressed to the point that they needed more aggressive treatment.

Most of the men have been followed for around 15 years now, and for the most recent data analysis, researchers were able get follow-up information on 98% of the participants.

By 2020, 45 men – about 3% of the participants – had died of prostate cancer. There were no significant differences in prostate cancer deaths between the three groups.

Men in the active monitoring group were more likely to have their cancer progress and more likely to have it spread compared with the other groups. About 9% of men in the active monitoring group saw their cancer metastasize, compared with 5% in the two other groups.

Trock points out that even though it didn’t affect their overall survival, a spreading cancer isn’t an insignificant outcome. It can be painful and may require aggressive treatments to manage at that stage.

Active surveillance did have important benefits over surgery or radiation.

As they followed the men over 12 years, the researchers found that 1 in 4 to 1 in 5 of those who had prostate surgery needed to wear at least one pad a day to guard against urine leaks. That rate was twice as high as the other groups, said Dr. Jenny Donovan of the University of Bristol, who led the study on patient-reported outcomes after treatment.

Sexual function was affected, too. It’s natural for sexual function to decline in men with age, so by the end of the study, nearly all the men reported low sexual function, but their patterns of decline were different depending on their prostate cancer treatment, she said.

“The men who have surgery have low sexual function early on, and that continues. The men in the radiotherapy group see their sexual function drop, then have some recovery, but then their sexual function declines, and the active monitoring group declines slowly over time,” Donovan said.

Donovan said that when she presents her data to doctors, they point out how much has changed since the study started.

“Some people would say, ‘OK, yeah, but we’ve got all these new technologies now, new treatments,’ ” she said, such as intensity-modulated radiation therapy, brachytherapy and robot-assisted prostate surgeries, “but actually, other studies have shown that the effects on these functional outcomes are very similar to the effects that we see our study,” she said.

Both Donovan and Hamby feel the study’s conclusions still merit careful consideration by men and their doctors as they weigh treatment decisions.

“What we hope that clinicians will do is use these figures that we’ve produced in these papers and share them with the men so that newly diagnosed men with localized prostate cancer can really assess those tradeoffs,” Donovan said.

Source link

#men #prostate #cancer #avoid #delay #harsh #treatments #longterm #study #confirms #CNN