Month: November 2018

U.S. life expectancy declines again, a dismal trend not seen since World War I

Appalling…

https://wapo.st/2FPATOI

Life expectancy in the United States declined again in 2017, the government said Thursday in a bleak series of reports that showed a nation still in the grip of escalating drug and suicide crises.

The data continued the longest sustained decline in expected life span at birth in a century, an appalling performance not seen in the United States since 1915 through 1918. That four-year period included World War I and a flu pandemic that killed 675,000 people in the United States and perhaps 50 million worldwide.

Public health and demographic experts reacted with alarm to the release of the Centers for Disease Control and Prevention’s annual statistics, which are considered a reliable barometer of a society’s health. In most developed nations, life expectancy has marched steadily upward for decades.

“I think this is a very dismal picture of health in the United States,” said Joshua M. Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health. “Life expectancy is improving in many places in the world. It shouldn’t be declining in the United States.”

“After three years of stagnation and decline, what do we do now?” asked S.V. Subramanian, a professor of population health and geography at Harvard’s T.H. Chan School of Public Health. “Do we say this is the new normal? Or can we say this is a tractable problem?”

Overall, Americans could expect to live 78.6 years at birth in 2017, down a tenth of a year from the 2016 estimate, according to the CDC’s National Center for Health Statistics. Men could anticipate a life span of 76.1 years, down a tenth of a year from 2016. Life expectancy for women in 2017 was 81.1 years, unchanged from the previous year.

Drug overdoses set another annual record in 2017, cresting at 70,237 — up from 63,632 the year before, the government said in a companion report. The opioid epidemic continued to take a relentless toll, with 47,600 deaths in 2017 from drugs sold on the street such as fentanyl and heroin, as well as prescription narcotics. That was also a record number, driven largely by an increase in fentanyl deaths.

Since 1999, the number of drug overdose deaths has more than quadrupled. Deaths attributed to opioids were nearly six times greater in 2017 than they were in 1999.

In a third report, the government detailed the ongoing growth of deaths from suicide, which has climbed steadily since 1999 and grown worse since 2006.

Most notable is the widening gap between urban and rural Americans. Suicide rates in the most rural counties are now nearly double those in the most urban counties.

 

The Organ Transplant Story You Don’t Hear

http://bit.ly/2FQmQbH

Ten years ago, James “Bo” Calvert received a transplant to replace his only kidney. Now that kidney is failing.

His arms are covered with the sticky gunk left after bandages come off. There is a blue bruise on the inside of his right forearm. A long plastic tube enters a hole near his belly button. When it’s not in use, James “Bo” Calvert tucks the tube that he uses for dialysis into a spandex “bra” that circles his chest.

Calvert has stage 4 kidney disease, which means his kidney function is only 15 to 30 percent. There are six stages of chronic kidney disease — stage 4 is the last stage before end-stage renal disease (ESRD), when the kidneys cannot filter waste and excess fluid from the blood. At this point, you need a transplant or dialysis to stay alive.

Calvert has had both.

He is 37 and the kidney he received 10 years ago is failing. He has dark hair and pale skin and a day or two of dark stubble. His private room at Norton Audubon Hospital in Louisville, Kentucky, overlooks a forest of mostly deciduous trees. The walls are turquoise, a color that Calvert explains is supposed to induce happiness and calm.

“It’s the same color they use in execution chambers,” he says.

He isn’t being morbid, just factual. Calvert is a bit of a trivia nerd. When he was 21 he was diagnosed with Asperger syndrome, which is on the high-functioning end of the autism spectrum. At 25 he was diagnosed with chronic kidney disease. He learned then that he had been born with only one kidney — and it was failing.

Ten years ago I wrote about the kidney Calvert received. Like so many kidney donation stories, it had a happy ending, but that ending was premature. That is why I came back in Louisville — the story was incomplete.

Kids Born in August More Likely to Have ADHD Diagnosis

This is an old story. I first heard it in the early ’70s. Bureaucracy trumps common sense….

http://bit.ly/2rcjHbU

Immature but age-normal behaviors may be taken for ADHD symptoms.

Children born in August had higher rates of attention deficit-hyperactivity disorder (ADHD) diagnosis and treatment than peers born a few weeks later in September, according to a large-scale nationwide analysis.

In states with a Sept. 1 birthdate cutoff for kindergarten entry, children born in August — the youngest in their class — had a 34% higher risk of ADHD diagnosis and a 32% higher risk of ADHD treatment than children with September birthdays, reported Anupam Jena, MD, PhD, of Harvard Medical School and co-authors in the New England Journal of Medicine.

“This is important not only because it highlights how subjective the diagnosis of ADHD can be, but it also emphasizes a particular channel that may be important: the assessment of inattentive symptoms in a child may rely heavily on peer-to-peer comparisons made by teachers, other educational providers, parents, and ultimately doctors,” Jena told MedPage Today.

The findings suggest the possibility that younger children may be over-diagnosed and over-treated for ADHD: “What may be perceived as normal, developmentally appropriate inattentive behavior in one child may be perceived as ADHD in another child,” Jena said.

Most states have arbitrary cutoff birthdates to determine when a child can start school. These cutoff dates create a distribution of ages of children in a classroom, with the oldest child approximately 1 year older than the youngest child.

While problems associated with arbitrary cutoffs have been known for some time — they have been tied to ADHD diagnoses and medications, academic performance, and other factors — this analysis shows they persist, Jena pointed out: “The issue has arguably been known for more then a decade and yet as recent as 2015, we still observe meaningful differences in the likelihood of ADHD diagnosis and treatment among August- versus September-born children in states with a Sept. 1 cutoff.”

Can Parents Lose Custody Simply Because They Are Disabled?

http://bit.ly/2rfC53I

In 2009 Kaney O’Neill, a veteran and quadriplegic mother, faced an unexpected battle when her former boyfriend filed for custody of their ten-week-old son, alleging that O’Neill was “not a fit and proper person” to care for their son and that her disability “greatly limits her ability to care for the minor, or even wake up if the minor is distressed” (Chicago Tribune, December 20, 2009, tinyurl.com/l6jqkss). Refuting this allegation, O’Neill demonstrated her ability to care for their son. Indeed, she had prepared for motherhood by working with an occupational therapy program for expectant mothers and parents, adapting her house for parenting, securing adapted baby care equipment, and using personal assistants to help her as needed (The Legal Program, November 23, 2011, tinyurl.com/lzd5wxr). Illustrating the bias that pervades the family law system, an attorney who was not affiliated with the case remarked, “Certainly, I sympathize with the mom, but assuming both parties are equal (in other respects), isn’t the child obviously better off with the father?” This attorney, who has specialized in divorce and custody cases for more than 40 years, said that O’Neill “would likely not be able to teach her son to write, paint, or play ball.” The attorney asked a news reporter, “What’s the effect on the child—feeling sorry for the mother and becoming the parent?”

O’Neill’s battle endured for a year and a half before both parties came to an agreement that gives the father visitation rights (ABC 7 Chicago, May 4, 2011, tinyurl.com/qhua84l). Although she was elated with the outcome, O’Neill told reporters that she was “disappointed that the courts allow for someone to question your ability to have custody based on your disability.”

Similarly, in 2010 a Missouri couple had their two-day-old daughter taken into custody by the state because both parents were blind (NBC Action News, July 21, 2010, tinyurl.com/ovc4o4h). This removal was not based on allegations of abuse, just a fear that the parents would be unable to care for their daughter. Because the couple was presumed unfit, for nearly two months they were permitted to visit their daughter only two to three times a week, for just an hour at a time, with a foster parent monitoring.

The fundamental right to parent without interference is protected by the U.S. Constitution and balanced by the judicially recognized power of the state to interfere to protect the well-being of its children. Factors used in both dependency court and family court proceedings to determine whether children need to become wards of the state and to determine which parent is the more competent custodian may be reasonable. Nonetheless, these rules have not been objectively or justly applied to parents with disabilities.

Study finds 5 types of alcohol use disorder that vary with age

http://bit.ly/2FKLVos

5 age-related AUD profiles revealed

Linden-Carmichael and her colleagues examined the data on 5,402 participants, aged between 18 and 64 years old, who were enrolled in the National Epidemiologic Survey on Alcohol and Related Conditions and had met the criteria for an AUD in the past year.

The researchers applied a new method called latent class analysis to study subtypes or “profiles” of people with an AUD, clustering together those who shared the same symptoms, as well as drinking too much. The analysis revealed five AUD classes:

  • “Alcohol-induced injury” characterized 25 percent of the participants. People with this profile engaged in risky behavior and got into dangerous situations that might have caused injury.
  • “Highly problematic, low perceived life interference” characterized 21 percent of the participants. This group said that their alcohol consumption did not have any adverse effect on their lives and did not affect their family, work, or social obligations, despite also reporting that they experienced many AUD symptoms.
  • The “Adverse effects only” profile included 34 percent of the participants, who reported hangovers or alcohol withdrawal symptoms.
  • “Difficulty cutting back” was a profile prevalent among 13 percent of the participants. People in this category struggled or were unable to cut back on their drinking.
  • “Highly problematic” was the final category, which made up 7 percent of the total number of participants who had every symptom of AUD.

Additionally, the analysis revealed how common each profile was when people were at different ages.

“The adverse effects only and highly problematic, low perceived life interference classes were particularly prevalent among younger adults,” write the authors, whereas “the difficulty cutting back and alcohol-induced injury classes were more prevalent as age increased.”

The main implication of the findings, says the study’s lead author, is that we need tailored treatments for people with AUD.

“We need to think beyond whether someone has an alcohol use disorder, yes or no, and take a look specifically at what they’re struggling with and whether they’re in a particularly risky class,” says Linden-Carmichael.

CMS Unveils Proposed Changes to Part D Drug Policies

http://bit.ly/2r9UGOB

The Centers for Medicare & Medicaid Services (CMS) announced several new policies aimed at lowering drug prices for Medicare beneficiaries, but critics say the savings may be quite modest and that the proposals may reduce beneficiaries’ access to needed drugs.

“Foremost in our mind was the impact on patients and ensuring affordability and access to prescription drugs,” CMS administrator Seema Verma said Monday on a phone call with reporters. “From day one, President Trump has made it clear that lowering prescription drug costs is a top priority … and CMS is hard at work to make the president’s vision a reality, because the status quo is unacceptable.”

The proposals CMS announced Monday include:

Allowing Part D plans more flexibility to negotiate discounts for drugs in “protected” classes — groups of drugs for which Part D plans must cover every drug in the class. Beneficiaries who take “protected” drugs “haven’t seen the discounts that beneficiaries taking other drugs experience, and this is not fair,” CMS Administrator Seema Verma said on a phone call with reporters Monday. “Typical private market discounts for these drugs are in the 20%-to-30% range, but the average discount for all protected class drugs in Part D is just 6%…. Because every individual drug has to be covered, competition is thwarted.”

To encourage more price competition, CMS is proposing to allow Part D plans to exclude protected class drugs who increase prices greater than the rate of inflation, as well as drugs that are not a significant innovation over the original product, Verma said, noting that plans would be required to cover at least two drugs in each protected class. “We also propose that plans could use prior authorization and step therapy, so plans could ensure that patients receive the lower-cost and most appropriate option first.”

Step therapy could only be used with patients starting new drugs, and it would have to be approved by the Part D plan’s pharmacy and therapeutics committee, she added. “Some say allowing step therapy would restrict access to prescription drugs; however, Part D protects patient access as the program is embedded with strong patient protections; CMS reviews plan formularies to guard against discriminatory practices, and the agency has in place an expedited appeals process for cases in which a physician recommends an exemption to prior authorization or other forms of management,” she said. Under the proposed rule, Medicare Advantage plans could also use step therapy for Part B drugs they cover.

That appeals process would be similar to expedited appeals already taking place for other drugs covered under Medicare Advantage and Part D, she told MedPage Today. “[That is] an expedited appeals process where [appeals] would have to be adjudicated within a 24-hour period,” Verma said.

Requiring Part D plans to provide a way for doctors and patients to know, at the time a prescription is being written, how much that particular drug will cost the patient out of pocket.

Overshadowed by opioids, meth is back and hospitalizations surge

I’ve been watching these cycles since the late ’60s. The War on Drugs has less and less effect on them every year….

http://bit.ly/2FPw6g5

The number of people hospitalized because of amphetamine use is skyrocketing in the U.S., but the resurgence of the drug has largely been overshadowed by the nation’s intense focus on opioids.

Amphetamine-related hospitalizations jumped by about 245% from 2008 to 2015, according to a recent study in the Journal of the American Medical Association. That dwarfs the rise in hospitalizations from other drugs, such as opioids, which were up by about 46%. The most significant increases were in western states.

The surge in hospitalizations and deaths due to amphetamines “is just totally off the radar,” said Jane Maxwell, an addiction researcher. “Nobody is paying attention.”

Doctors see evidence of the drug’s comeback in emergency departments, where patients arrive agitated, paranoid and aggressive. Paramedics and police officers see it on the streets, where suspects’ heart rates are so high that they need to be taken to the hospital for medical clearance before being booked into jail. And medical examiners see it in the morgue, where in a few states, such as Texas and Colorado, overdoses from meth have surpassed those from the opioid heroin.

Amphetamines are stimulant drugs, which are both legally prescribed to treat attention deficit hyperactivity disorder and produced illegally into methamphetamine. Most of the hospitalizations in the study are believed to be due to methamphetamine use.

Lupita Ruiz, 25, started using methamphetamine in her late teens but said she has been clean for about two years. When she was using, she said, her heart beat fast, she would stay up all night and she would forget to eat.

Ruiz, who lives in Spokane, Washington, said she was taken to the hospital twice after having mental breakdowns related to methamphetamine use, including a monthlong stay in the psychiatric ward in 2016. One time, Ruiz said, she yelled at and kicked police officers after they responded to a call to her apartment. Another time, she started walking on the freeway but doesn’t remember why.

“It just made me go crazy,” she said. “I was all messed up in my head.”

The federal government estimates that more than 10,000 people died of meth-related drug overdoses last year. Deaths from meth overdose generally result from multiple organ failure or heart attacks and strokes caused by extraordinary pulse rates and skyrocketing blood pressure.

In California, the number of amphetamine-related overdose deaths rose by 127% from 456 in 2008 to 1,036 in 2013. At the same time, the number of opioid-related overdose deaths rose by 8.4% from 1,784 to 1,934, according to the most recent data from the state Department of Public Health.

 

How ACA Marketplace Premiums Are Changing by County in 2019

http://bit.ly/2r85Jb0

Premiums for ACA Marketplace benchmark silver plans are decreasing on average across the U.S. in 2019. However, premium changes vary widely by location and by metal level, including premium increases in a number of counties and plans. Additionally, the amount an exchange enrollee actually pays in premiums depends largely on their income – as most enrollees receive significant premium subsidies – and the difference in cost between the benchmark (second-lowest silver plan) and the premium for the plan they choose.

We analyzed premium data from insurer rate filings to state regulators and healthcare.gov to see how premiums are changing at the county level both before and after subsidies in 2019. The map below illustrates changes in premiums for the lowest-cost bronze, silver, and gold plans by county. Results are shown for a 40-year-old paying the full premium and for a 40-year old with an income of $20,000 (165% of poverty), $25,000 (206% of poverty), $30,000 (247% of poverty), $35,000 (288% of poverty), and $40,000 (329% of poverty), who would be eligible for a premium tax credit.

For these people with depression, all treatment approaches had failed, but then they adopted a pet …

http://bit.ly/2FMvjwy

For people diagnosed with what’s known as “treatment-resistant major depressive disorder” the prognosis is not good – the low mood and emotional pain for these individuals has not lifted even though they are on a combination of antidepressant medications and may also have participated in psychotherapy. However a glimmer of hope comes via a research group in Portugal who reported recently in the Journal of Psychiatric Research that adopting a pet “enhanced” the effects of anti-depressant medication for a significant minority of their participants with previously treatment-resistant depression.

Jorge Mota Pereira and Daniela Fonte at the Clínica Médico-Psiquiátrica da Ordem in Porto recruited 80 outpatients with severe treatment-resistant depression and invited them to adopt a pet as part of a study into the effects of pet adoption on depression. Thirty-three of them agreed to do so (20 adopted a dog or dogs, 7 a cat); another 33 who declined were allocated to form a control group.

All the participants were assessed for their depression symptoms and general functioning at baseline and then again at 4, 8 and 12-week follow-up. Thirty individuals in each group successfully attended all the required assessments. 

The main finding is that by the end of the study (at the 12-week assessment), just over a third of the pet-adoption group had remitted – that is, their scores on the Hamilton Depression Rating Scale and the Global Assessment of Functioning Scale had reduced to the point that their problems were now considered only mild. By contrast, none of the control group had entered remission or in fact showed any signs of change in their symptoms at all. These improvements in the pet group actually began manifesting by week 4 follow-up, suggesting the apparent benefits of pet ownership were rapid.

Cerebellar TMS May Improve Gait, Balance in Post-Stroke Hemiparesis

http://bit.ly/2r8UFKJ

“Very exciting” results with magnetic stimulation in small trial.

Transcranial magnetic stimulation of the cerebellum led to improved post-stroke motor functions in a phase IIa randomized, double-blind sham-controlled trial in Italy, researchers said.

After 3 weeks of repetitive, intermittent theta-burst magnetic stimulation to the cerebellum (CRB-iTBS) and physical therapy, hemiparetic patients following ischemic stroke improved their ability to walk and keep their balance more than patients who received sham stimulation and physical therapy, reported Giacomo Koch, MD, PhD, of the Santa Lucia Foundation in Rome, and colleagues in JAMA Neurology.

“For the first time, we modulated the neural activity of the cerebellum in the context of a clinical trial in patients suffering from large stroke in the territory of the middle cerebral artery,” Koch told MedPage Today. “We found that cerebellar stimulation was able to improve the outcome when coupled with rehabilitation by changing the activity of neural networks connecting the cerebellum with the parietal cortex.”

Studies using non-invasive brain stimulation methods for post-stroke rehabilitation have had mixed results to date, Koch said. “But these studies mainly tried to modulate the activity of the primary motor cortex,” he pointed out. “Our study shows that targeting alternative networks connected with motor cortex may be a more successful strategy.”

The novelty here is targeting the cerebellum, noted Pablo Celnik, MD, of the Johns Hopkins University School of Medicine in Baltimore, who was not involved in the study.

“These results are very exciting because they suggest that stimulation of the cerebellum can be paired with physical therapy to augment the effects of rehabilitation,” Celnik told MedPage Today. “This is especially so for chronic stroke patients, whose condition is more difficult to improve.”