Study examines Mercury in vaccines

  • Author: Health Informer
  • Filed under: Health News
  • Date: Oct 31,2009

The injectable, multi-dose H1N1 vaccine contains the mercury-based preservative thimerosol to reduce risks of bacterial contamination.

The presence of thimerosol has once again raised concerns whether there are risks posed to children when the tiny amount of mercury contained in thimerosol is included in a vaccine. In a recent issue of the Journal of Pediatrics, however, a team of scientists supported by the National Institutes of Health reported findings that should alleviate those concerns.

The researchers, led by author Michael E. Pichichero, MD, Director of the Rochester General Research Institute, Rochester General Hospital, Rochester, NY evaluated levels of mercury in the blood of the smallest children — prematurely born and low birth weight infants after they received a dose of a childhood vaccine containing thimerosol. They found the levels of mercury were exceedingly low.

The issue of administering vaccines containing mercury has been controversial because at very high levels mercury is known to cause organ damage (brain/kidneys). Consequently in 2001, as a precaution, at the prompting of the American Academy of Pediatrics, the Centers for Disease Control, and the Food and Drug Administration, the use of thimerosol in childhood vaccines was reduced or eliminated.

However, after examining the evidence the Institute of Medicine issued an opinion that an association between thimerosol exposure and autism was not supported by the evidence. Nevertheless the contention that mercury in vaccines causes autism continues to be debated. The newly released multi-dose, injectable H1N1 Influenza vaccines contain the preservative thimerosol and thimerosol is 50% ethyl mercury, which has sparked a renewed debate on the safety of administering this new influenza vaccine.

The purpose of the study was to find out how much mercury from a vaccine containing thimerosol stays in a child’s body,” said Dr. Pichichero. “What we found was that blood mercury levels before vaccination were often detectable, even at a level similar to many children after the vaccination. By just breathing the air, mothers were passing to their unborn infants some slight amounts of mercury. The mothers did not eat fish that contains mercury, so in the United States and other countries where fish is consumed by pregnant women the levels of mercury would be presumably even higher. After the babies were given vaccines containing thimerosol, their blood levels of mercury did rise to very low levels and then fell rapidly to baseline levels by day ten after the vaccination.”

Since thimerosol has been largely removed from vaccines in the US since 2001, this study of 72 newborn infants was conducted at the Hospital Durand in Buenos Aires, Argentina. In Argentina, like many countries of the world, vaccines are purchased through sources supported by the World Health Organization and the WHO has rejected the notion that thimerosol in vaccines is unsafe. This is the third and final study by Dr. Pichichero and his colleagues that tested mercury levels following the injection of vaccines containing thimerosol. Previous studies were conducted on term newborns, and on 2-and 6-month old infants. In those studies, the researchers also found the mercury levels in the vaccinated children were very low and quickly returned to pre-vaccine levels, usually within three to seven days. In 1999, when the first concerns about thimerosol in vaccines was raised, it was presumed that the ethyl mercury in thimerosol would behave in the same manner as methyl mercury in fish after ingested. The three NIH-supported studies clearly refuted that idea.

Dr. Pichichero and colleagues concluded that with this latest data, it is time to recognize that the risk of exposure to thimerosol in vaccines is minimal to non-existent. “The H1N1 vaccine is safe and should be given to those at risk as recommended by the US Centers for Disease Control,” Dr. Pichichero said.

Source: Rochester General Health System


Recent survey reflects 146 measure definitions – including 21 for hemoglobin A1c NCDP calls for harmonization of measurement

The National Changing Diabetes® Program (NCDP) announced today results of a study that found extraordinary variety in the measurement of clinical processes critical to optimal diabetes management such as blood pressure and glucose levels.

In the study, Quality Measurement in Diabetes Care, published today in Population Health Management, researchers at Thomas Jefferson University’s Jefferson School of Population Health, Philadelphia, reported 146 distinct measures for 31 medical outcomes – a quilt of measurements that healthcare providers say is complex, disjointed and cumbersome. In the study, the authors note that “although the broad array of existing measures creates valuable opportunities to quantify, benchmark, and improve a wide range of clinical processes and outcomes, providers and other stakeholders report that the broad scope of activities lacks clarity.”

An increasingly common strategy for improving care and adherence to treatment guidelines has been periodic performance assessments of doctors, health systems, and health plans. Several organizations provide such assessments, and the Centers for Medicare and Medicaid Services includes diabetes measures in its doctor-incentive initiatives to encourage improved medical care and promote public reporting of performance data. However, according to the study authors, “currently, the environment is characterized by hundreds of measures that frequently do not conform completely with key facets of measure selection, data sources, and standards for defining high-quality care. Clinicians report dissatisfaction when they encounter mixed messages regarding testing and screening schedules or target goals for key outcome indicators.”

For the study, the Jefferson research team searched the National Quality Measures Clearinghouse, a comprehensive database maintained by the Agency for Healthcare Research and Quality, and reviewed diabetes measures created by national organizations and institutions. The researchers categorized measures by medical procedure, such as managing medication and performing foot exams; health status indicators such as cholesterol and blood pressure levels; and other types of assessed care, such as patient self-management.

The team also conducted interviews between July and October, 2008, with leaders from the organizations who use and develop quality measures, along with other stakeholders in the quality measurement community.

“We found a measurement system that is both redundant and inconsistent, with many different measures assessing the same clinical indicators,” says Dr. Nash, one of the study’s authors and Dean of the Jefferson School of Population Health. “Methods and assessment goals vary among different organizations, as do, in some cases the sources of data (for example, patient or health plan level data) making uniform standards more difficult to achieve.”

Doctors aren’t alone in grappling with these challenges, researchers say. According to the study, large employers and policymakers are also struggling to understand which measures are most appropriate for their quality initiatives. Ideas proposed by the authors for reconciling different quality measures include: development of a “comprehensive” measure set, which would focus on measuring indicators that are most significant for diabetes care, such as glucose, blood lipids, and blood pressure; and use of a “composite score,” that would combine a range of indicators and generate a single score.

“This study demonstrates that current measurement of diabetes care quality is far too complex and disjointed, and at the same time lacking in a number of key areas, particularly at the population level,” says Dana Haza, senior director of NDCP.

The study also found significant gaps in quality measures, including a lack of population-based or epidemiologic measures. In addition, much of the current focus is on patients who are employed and insured, which ignores “millions of Americans and may not accurately reflect the overall state of diabetes care,” the researchers write. Patient perspectives, access to care, or efforts to identify and advise those with pre-diabetes, those at high risk of developing the disease, are also not commonly measured.

The research was sponsored by the National Changing Diabetes® Program, a diabetes leadership initiative established by Novo Nordisk to drive health systems change at the national and local level. About 24 million Americans have diabetes and health experts say that number could double in the next 20 years. With direct and indirect costs associated with diabetes and pre-diabetes estimated at $218 billion in the U.S. in 2007, much effort has gone into developing practice guidelines that improve care and patient outcomes.

“Streamlining and harmonizing existing measures is an important challenge that must be addressed to encourage wider use of performance assessment,” the researchers conclude. Haza adds that a clearer understanding of the state of diabetes quality measurement is “an important step toward improving their usefulness, and addressing gaps in quality assessment.”

Source: National Changing Diabetes Program


Top 10 business mistakes made by physician practices

  • Author: Health Informer
  • Filed under: Health News
  • Date: Oct 29,2009

Many medical practices are struggling. Shifting reimbursements are a significant factor, but many are making basic business mistakes, according to Andrew Graham, MBA, President of Clinic Service Corporation.

Here are the top reasons practices struggle, said Graham.
1. No business plan. A practice’s strategic plan needs to include goals for revenue generation, customer service, performance and operational processes, and innovation measures.
2. Poor understanding of customer flow. A practice should retain two-thirds of its patients annually. Practice managers need to discover which managed care contracts feed them patients and which doctors send referrals.
3. Revenue cycle confusion. Doctors are typically reimbursed within 30 days. Based on a predictable flow of payments, practice managers should be able to predict cash flow. It might be time for a revenue analysis.
4. Performing procedures that are unprofitable. No one is suggesting doctors perform only treatments that pay best. Medicine is first a humanitarian calling. However, it does not make business sense to focus a practice on an unprofitable sector either. Practices need to code patient visits consistent with the level of care provided and consider whether they are wasting time bundling codes.
5. Unfavorable Payer Contracts. A good place to start this exploration is with a discussion with a practice’s billing company.
6. No marketing plan. Many physicians will spend thousands on phonebook ads, but more savvy doctors understand the Internet can play a big role in their success. Medical marketing firms can be helpful here.
7. Poor office culture. A healthy workplace culture is critical to a practice’s success. Step one is to define the practice’s mission and communicate that mission to all staff.
8. Not hiring help. Doctors today are confronted by fiscal, technological, managerial and communications challenges. Hiring specialists to help is a no-brainer.
9. No staff training. Doctors are required to “sharpen the saw” frequently. It may be time to apply that education mindset to the physician’s staff too.
10. Poor location. Having a poor location can sink all but the most sought after specialists. Many physicians will say they are hunkered down within their current space. They should reconsider. Changing location could be the spark they need.

Source: Clinic Service Corporation


CSMS issues results of health disparities survey

  • Author: Health Informer
  • Filed under: Health News
  • Date: Oct 29,2009

First Connecticut research to examine how physicians care for patients from diverse racial, cultural and ethnic backgrounds

Connecticut physicians believe they could be providing better care to patients of diverse racial, cultural and ethnic backgrounds if they had training that was more accessible, according to the results of a survey released today by the Connecticut State Medical Society. “Providing Medical Care to Diverse Populations” is one of the first studies of its kind to seek physician input in helping reduce disparities in health care. The statewide survey of Connecticut physicians from 17 specialties was conducted from April to July through a grant from the Connecticut Health Foundation.

The findings indicate gaps in physician education programs that highlight cultural competency:

– Fewer than 2 in 5 physicians received some kind of cultural diversity education in medical school or residency.
– 70% of physicians were not aware of educational programs in this area that are available to them today.
– Physicians working in small practices, the setting that describes more than 80% of Connecticut physicians, were less likely to have received training in cultural literacy. Those working in hospital or medical school settings were the most likely to have had formal training in cultural awareness.
– Physicians ages 55-64, and those whose practices were mostly White, gave themselves lower ratings for providing culturally appropriate care.
– Women physicians were significantly more likely to provide interpreter services and patient-education materials in other languages.

In addition, the physicians surveyed identified patients’ health insurance status as the greatest barrier to referrals. Forty-three percent called it “a big problem.”

“The results of our survey tell a sobering story about our ability to communicate with patients, which is the foundation of the physician-patient relationship,” said Kathleen A. LaVorgna, MD, president of CSMS. “The good news is that we can have an immediate impact on this situation by providing the kind of cultural awareness education physicians want and need.”

CSMS is developing materials to educate physicians and office staff, working closely with national organizations dedicated to this issue. It plans to provide patient outreach materials through patient rights groups. A recent state mandate requires cultural diversity training for medical license renewal; CSMS hopes to assist in developing the curriculum so the end result is valuable for physicians. Near the conclusion of the two-year grant, CSMS will survey physicians again to measure progress in improving cultural competency.

Robert Aseltine, PhD, professor in the Division of Behavioral Sciences and Community Health and Director of the Institute for Public Health Research at the University of Connecticut Health Center, contributed to the report.

Source: Connecticut State Medical Society


Technology provides most accurate view inside human body

Doctors at the annual meeting of the American Society for Reproductive Medicine got a glimpse into the future of women’s health with the presentation of endoscopic gynecologic surgery performed for the first time using “4K” technology.

Steven F. Palter, MD, an obstetrician, gynecologist, reproductive endocrinologist and fertility specialist performed the world’s first 4K super high-definition (HD) laparoscopy at Syosset Hospital, part of the North Shore-LIJ Health System, and presented images from that surgery on October 20 at the 65th annual meeting of the American Society for Reproductive Medicine (ASRM) at the Georgia World Congress Center in Atlanta.

“The images are the sharpest, most detail-rich and color-correct endoscopic images ever created anywhere,” Dr. Palter said. “There is not a more accurate view inside the human body.”

Produced in conjunction with RED Digital Cinema Camera Company; Sony Electronics, Inc., an ultrahigh definition projector company; and the University of Southern California Cinema Arts School, the diagnostic images were presented in a specially built digital theater with a projector designed to run “ultra-HD” movies in high-end movie theatres. “It’s a prime example of how Hollywood film technology can be used to transform medicine by enabling doctors to see more accurately inside the body to study and treat disease,” Dr. Palter said.

Ultra-high resolution digital cameras are transforming the art of cinema. Leading Hollywood directors such as Peter Jackson and Stephen Soderbergh are filming the next generation of cinema blockbusters using cameras with “4K” resolution, four times the resolution of HD with 4,096 lines of resolution to give audiences unprecedented realism.

“Through the use of this digital technology, Hollywood is moving from observation to immersion — you’re not just watching something, you are there,” said Dr. Palter, medical and scientific director of Gold Coast IVF in Syosset, NY, who presented the plenary presentation, Film and Medicine: The Technological Transformation of Medicine. “In this session we showed how tomorrow’s film technology can apply to laparoscopic surgery, which is all performed using video techniques.”

Dr. Palter joined with the Red Digital Cinema Camera Company that manufactures the 4K Red One system to create Hollywood movies of tomorrow, and Sony, the leading ultra-HD theatrical projector company, to perform laparoscopic surgery using the Hollywood camera system.

During the film presentation, the 3,500 reproductive medicine specialists in attendance were able to visualize the surgery as if they were standing in the operating room. However, by combining unprecedented resolution and magnification, the surgical images were beyond what a surgeon would see in traditional surgery. The progress from regular surgical film technology is like comparing sitting in an HD home theater to watching a video on a cell phone,” said Dr. Palter.

“Dr. Palter’s research and vision of surgery’s technological future opened the eyes and minds of the audience to fantastic treatments beyond what can be done today,” said R. Dale McClure, MD president of ASRM.

The session also included a projection of the largest HD three-dimensional (3D) surgical images ever. Using the same system as 3D blockbuster Cloudy With a Chance of Meatballs, surgeons felt as if they could “reach out and conduct the operation.” These images were enabled by converting Sony’s 4K and 3D theatrical systems to show medical footage of what Dr. Palter has called “futurevision.” To obtain the images, Dr. Palter and researchers from USC Cinema Arts created a method to attach the Red One 4K camera to a laparoscope. Offhollywood, a leading movie production company converted these images into a 4K digital cinema movie that was projected on $200,000, 700-pound Sony SRX-R220 projectors back to back with 4K Hollywood images of such stars as Tom Cruise, Julia Roberts and Will Smith. RealD 3D lenses projected HD 3D surgery as well as Hollywood images from 3Ality of movies, sports and the rock music band U2.

Source: North Shore-LIJ Health System


Breast cancer and critical illness insurance

  • Author: Health Informer
  • Filed under: Health News
  • Date: Oct 28,2009

As breast cancer awareness month winds to a close and pink ribbons symbolizing the brave fight against this disease take their place on survivors’ dressers, the fight continues. Putting the spotlight on this devastating disease has made people think about their own mortality and what would happen if they were diagnosed with a critical illness, says Frank N. Darras, America’s top Long Term Disability Lawyer.

If your family’s medical history includes, heart disease, stroke, cancer, diabetes or renal disease, then critical illness insurance might add an additional layer of financial protection for you.

“Critical illness insurance fills the gap in existing medical insurance coverage or can be a last stop if you’re not able to afford or you lost your major health insurance. Generally, critical illness insurance pays a lump sum monetary benefit for hospital charges, an I.C.U. stay, organ transplants, ambulance fees, or transportation and lodging. This sum can be used for payment towards any aspect of the illness or for food, clothing, gas or the mortgage,” says Darras the Insurance Attorney.

This coverage sounds simple, but folks must understand exactly what they are paying for and exactly what is covered.

According to Darras, critical illness insurance is not meant to replace health, life or disability insurance. Instead, its purpose is payment for illness and specific kinds of treatment not ordinarily covered by traditional insurance or for any other expenses the insured wants to spend the lump sum on. Dire medical conditions are difficult enough to get your arms around, you don’t need mounting financial worries to add insult to the illness.

Before buying critical illness insurance do your homework. Find a licensed agent you trust and ask for three quotes from three different companies. Take the time and ask your agent to walk you through the policy features, advantages and benefits so you know what you bought and how to access the benefits should you need them.

A family history of a certain illness may be enough for the company to exclude that disease. Most policies are priced based on the age, gender and family history so the more medical questions you can honestly answer no to, the better. Find the pre-existing limitation clause and understand or have it explained to you so there is no gray area.

Does the insurance company you are planning on giving your hard earned dollars to have stellar claims paying history? If you satisfy the claim requirements, when will you get paid?

Darras defines terms you need to know:
Pre-existing Conditions: Pre-existing condition limitations vary, so read the fine print.
Covered Illnesses: What specific illnesses are covered? Will they be paid at 100%?
Underwriting: Simplified underwriting applies to policy benefits less than $100,000; full underwriting applies to benefits over $100,000.
Guaranteed Renewable “To Age”: Most policies are guaranteed renewable; some continue for life, others terminate at age 75-80.
Issue Ages: Generally 18-69; some companies have maximum issue ages of 65, 70 or 75.
Minimum and Maximum Benefit Amounts: $10,000 up to $1 million or more.
Waiting Period: How many days you must wait before benefits are paid.
Survival Period: Number of days the insured must live following diagnosis, to receive benefits.
Conditions of Payment: Specific criteria that must be met before the benefit is paid.
Benefit Reduction Age and Amount: Most policies maximum benefit drops by 50% at age 65.
Return of Premium: Most policies refund your premium less the benefits paid only upon the death of the insured.

“Making smart choices and having a trustworthy, knowledgeable professional to give you competent advice, can save you big dollars in the long run,” says Darras the ERISA Lawyer.

www.darrasnews.com

Source: Frank N. Darras


Teenagers difficult to ‘Capture’ for vaccinations

  • Author: Health Informer
  • Filed under: Health News
  • Date: Oct 27,2009

Rates on rise overall, but still low

New Vote on Whether to Vaccinate Males Against HPV Leaves it up to Parents and Health Care Providers; Prompts Robust Discussion Disparities in Some Adolescent Vaccination Rates Defy Expectations

More teenagers are being vaccinated against human papillomavirus (HPV), meningococcal meningitis and pertussis (whooping cough), though the rates are still too low, according to recently released government data and a panel of experts convened by the National Foundation for Infectious Diseases (NFID). Now, in addition to urging routine HPV vaccination for girls, providers can educate adolescent boys, young men – and their parents – about HPV and its potential consequences, and offer vaccination to boys as well. Last week, the Advisory Committee on Immunization Practices (ACIP) to the Centers for Disease Control and Prevention (CDC) voted for a ‘permissive’ HPV vaccination strategy for boys.

In taking the vote, the Advisory Committee considered research specific to the impact of genital warts in males and whether vaccination in males would be unnecessary if females were vaccinated at high rates. Presently, only about 40 percent of teenage girls receive the first dose of HPV vaccine with fewer than 20 percent receiving the complete three-dose series. Committee members could not consider research about HPV-related cancers in males in their deliberations, though that may leave the door open to revisit or even expand the recommendation to prevent cancer in the future.

“Voting for a permissive HPV vaccination strategy in boys puts the choice squarely in the hands of the parents and puts the onus for educating boys and their parents about HPV squarely on the health care providers’ shoulders,” said William Schaffner, M.D., president-elect of NFID. “It is a good way to get the conversation going about human papillomavirus in boys, but if current rates are any indication, this strategy will not make a big dent in vaccination coverage.”

Even for those vaccinations that are routinely recommended, rates do not yet reach target rates set forth in 2000 for the year 2010. “Adolescents are less likely to have regular wellness visits,” according to Amy B. Middleman, M.D., M.P.H, MsEd, Director of Adolescent and Young Adult Immunization at Texas Children’s Hospital Center for Vaccine Awareness and Research and Liaison Representative to the ACIP for the Society for Adolescent Medicine. “They’re a challenging group to reach, with increasingly busy lives; their health needs are uniquely different from those of infants and adults. We need to address this challenge and develop immunization delivery strategies that make sense for this specific age group. Our youth deserve to move into adulthood with every health advantage we can give them and immunity against vaccine-preventable diseases is a big step toward that goal.”

Another obstacle to vaccination is that parents and providers don’t make vaccination a priority during adolescence. While infants and toddlers regularly have wellness visits where they are weighed, measured and inoculated, adolescents are more likely to see a health care provider only when they’re ill, and vaccinations are not likely to be offered during these sick visits. Sports physicals are a good opportunity to capture this age group, but that leaves out a large contingent of teens. Regular wellness visits including vaccinations are recommended for all adolescents at 11-12 years of age.

Vaccination Rates Demonstrate Need for Improvement; Surprising Disparities in Coverage

Overall, vaccine coverage rates for the nation’s preteens and teens are increasing, but they remain low. The CDC’s National Immunization Survey (NIS) Teen survey estimates the proportion of teens aged 13 through 17 years who have received six recommended vaccines by the time they are surveyed. Three of these are recommended to be given at age 11-12: meningococcal vaccine, tetanus-diphtheria-acellular pertussis (Tdap), and, for girls, HPV vaccine. The survey also covers three other vaccines recommended to be given at an earlier age: measles- mumps-rubella (MMR), hepatitis B and varicella (chickenpox) vaccine. Influenza vaccine is also recommended every year for all adolescents up to age 18, but vaccination rates for influenza are not measured yet by the NIS-Teen survey.

The survey results reveal some ethnic and socioeconomic disparities. Hispanic females were more likely than Blacks and Whites to start the vaccination series against HPV, but less likely to complete the recommended three-dose series. Overall, Hispanics were also more likely than Blacks and Whites to be vaccinated against meningococcal disease, hepatitis B, varicella and Tdap. In another surprising finding, teens living below poverty were more likely than those living at or above poverty to start the HPV series. Teens living at or above the poverty level had the highest vaccination rates for MMR and the lowest rates for HPV.

Key findings–racial and ethnic disparities:
– Hispanic females were more likely than Blacks and Whites to start the HPV vaccination series (44.4 percent), but less likely to complete the recommended three-dose series (14.7 percent).
– Fewer White females than Hispanics started the HPV vaccination series (35.0 percent), but more completed the three-dose series (19.5 percent).
– Hispanic teens were also more likely than Black and White teens to be vaccinated against meningococcal disease. Hispanics (46.8 percent); Blacks (43.1 percent), Whites (39.7 percent).

Key findings–poverty level:
– Teens living below poverty level are more likely to start the HPV vaccination series (46.4 percent) than those living at or above the poverty level (35.8 percent).
– For all other diseases, teens living at or above the poverty level are more likely than those living below to be vaccinated against MMR (89.6 percent vs. 87.1 percent), hepatitis B (88 percent vs. 86.7 percent), varicella (82.9 percent vs. 77 percent), tetanus-diphtheria-pertussis (41.2 percent vs. 38.6 percent) and meningococcal disease (42 percent vs. 40.8 percent).

The complete NIS Survey, including state-by-state vaccination rates, can be found at http://www.cdc.gov/vaccines/stats-surv/nis/nis-2008-released.htm.

“It’s great to report that we’re doing better at reaching Hispanic females and those living below the poverty level about the threat of the human papillomavirus, but we need to do more to increase the rate of those actually completing the three-dose schedule,” said Lance E. Rodewald, MD, Director, Immunization Services Division; National Center for Immunization and Respiratory Diseases (NCIRD); Centers for Disease Control and Prevention.

National Foundation for Infectious Diseases Expands Its Adolescent Immunization Initiative

In an effort to educate healthcare professionals and parents about adolescent immunization, the National Foundation for Infectious Diseases is expanding its adolescent immunization initiative. Later this fall, NFID will re-launch an expanded Web site, www.adolescentvaccination.org, dedicated to providing scientifically-based information for parents, teens, healthcare professionals and the media. NFID is also actively partnering with nearly two dozen other organizations to proactively communicate that immunization rates in adolescents need to be improved to reduce the impact of vaccine-preventable diseases in this population.

Vaccine-Preventable Diseases

Vaccine-preventable diseases can cause serious morbidity and mortality in adolescents. Even when treated quickly and appropriately, meningococcal disease kills about 10 to 14 percent of people infected, with 11 to 19 percent of survivors suffering serious long-term effects, such as hearing loss, brain damage and digit or limb amputation. Pertussis is underreported, making it difficult to pinpoint U.S. incidence, but some estimates range from 1 million to over 2 million cases each year. Infected adolescents can pass the disease to infants and others who are at higher risk of serious illness or death. There are more than 6 million new HPV infections in the U.S. each year, nearly 75 percent are in females 15 to 24 years of age. HPV infection can lead to cervical cancer.

Source: National Foundation for Infectious Diseases (NFID)


Changes in brain chemicals mark shifts in infant learning

  • Author: Health Informer
  • Filed under: Health News
  • Date: Oct 27,2009

Mother-Child Attachments in Animals and Possible Parallels in People

When do you first leave the nest? Early in development infants of many species experience important transitions — such as learning when to leave the protective presence of their mother to start exploring the wider world. Neuroscientists have now pinpointed molecular events occurring in the brain during that turning point.

Based on animal studies, the findings may shed light on the strength of attachments in many species — including the conundrum of why human children form strong attachments to even abusive caregivers.

“This is one of the few times we know what causes this type of early transition,” said psychologist Gordon A. Barr, Ph.D., of The Children’s Hospital of Philadelphia, co-author of a study that appeared online Sept. 27 in Nature Neuroscience. Barr performed the studies in rats with a longtime collaborator, neuroscientist Regina M. Sullivan, Ph.D., of the Nathan Kline Institute and New York University Langone Medical Center.

The youngest rats, called pups, first experience the mother’s presence with both positive and negative stimuli. Even if the mother does something unpleasant, like stepping on or biting a pup, the baby rat stays close by the mother, something called preference learning. “From an evolutionary standpoint, this makes sense,” said Barr. “The dependent baby has a better chance of survival if it doesn’t stray from the mother’s side.”

However, at about ten days of age, the rat pups experience a transition to so-called aversion learning, in which they learn to avoid unpleasant stimuli. Said Barr, “Once an animal is better able to move around, it needs to be able to escape from stressful situations, again in the interests of its survival.” The maturing rat learns a type of safe behavior while away from parental protection.

For neuroscientists, one puzzle has been how to understand the underlying biological events in the changeover from preference learning to aversion learning. In a series of studies reported in the current paper, the authors focused on neurotransmitters in the brain, then manipulated those chemical messages to mimic their natural effects in rats.

They conditioned the rat pups to associate a new odor with a negative event — a mild electric shock. In adult rats, but not in immature rats, a shock induces a telltale increase in levels of the stress hormone corticosterone. Increased corticosterone, in turn, causes the amygdala, a learning center in the brain, to have increased levels of the neurotransmitter dopamine.

Using microarrays (to detect changes in dopamine-related gene expression) and microdialysis (to measure changes in dopamine levels), the study team confirmed that changes in dopamine levels were linked to changes in learning patterns.

On about their tenth day of life, rat pups start to make the transition from preference learning to aversion learning. Based on their corticosterone/dopamine findings, Barr and Sullivan were able to chemically manipulate the learning transition. By injecting eight-day-old rat pups with corticosterone, the scientists advanced the animals’ learning behaviors — the young rats avoided the new (shock-associated) odor, just as older rats did. Eight-day-old control rats did not show such avoidance behavior.

Injecting dopamine directly into an eight-day-old rat’s amygdala had a similar effect, switching their usual preference learning to aversion learning typical of older animals. The researchers also toggled the switch in the other direction. By blocking dopamine receptors in eight-day-old rats already treated with corticosterone, the rats showed preference learning instead of the aversion learning induced by corticosterone.

The neural mechanisms they found, said Barr, may also apply to infant behavior in dogs, rats and people. “For humans,” said Barr, “the findings may shed light on the pathologically strong attachment that children are known to have even for abusive caretakers.” In addition, he said, the findings suggest that scientists may detect neural mechanisms at the heart of other developmental transitions, such as an infant’s switch from breastfeeding to eating solid food.

The National Institutes of Health provided grant support for this study, for which Barr was the principal investigator and Sullivan was co-principal investigator. Barr began the study while at Hunter College and New York State Psychiatric Institute in New York City. Sullivan began the study at the University of Oklahoma, in Norman, Okla.

Source: The Children’s Hospital of Philadelphia


Ineffective pain care costs Americans more than $100 billion annually

  • Author: Health Informer
  • Filed under: Health News
  • Date: Oct 27,2009

Businesses Lose $61 Billion Annually in Lost Productive Time Due to Pain; Population-Based Approach Now Being Fostered

A new Pain Medicine Position Paper published by leaders of the American Academy of Pain Medicine (AAPM), reveals businesses lose $61 billion annually due to ineffective pain care and the lack of optimal pain care delivery. Leaders from the organization are now implementing and teaching a new, “population-based” approach to delivering care with the goal of alleviating pain so patients can get on with their lives.

AAPMedicine’s President Rollin M. Gallagher, MD MPH comments, “Pain affects everyone, and for many millions, pain becomes chronic, a scourge that affects every part of their lives–their work, their hobbies, their friendships, their families, their sex, their fun, their finances, their mood, and even their fundamental sense of identity, who they are. According to the National Institutes of Health, pain is one of our most important national health problems, costing the American public more than $100 billion each year in health care, compensation and litigation. The AAPMedicine’s Position Paper offers solutions that will fundamentally change the way pain is approached in the health care system. The Paper proposes a population-based approach to pain management that will both improve the competency of the health care system to manage pain for the millions of patients suffering needlessly in hospitals with acute pain and on into their lives with chronic pain, and will also reduce the cost of pain to our society. People will be able to work who couldn’t work before. People who work will work longer, better and more productively. People with terminal cancer will die in comfort, preserving their personal dignity and mitigating the emotional suffering of their families. The Proposal is consistent with the medical home approach being fostered as a solution to the problems besetting our health care system, an approach that emphasizes patient responsibility, early effective treatment, and when pain becomes chronic, competent longitudinal treatment, what we call ‘chronic illness management’.”

A population-based approach to pain includes stepped care that is designed to deliver timely access to levels of care that are needed to prevent chronic pain from beginning, or when pain persists, minimizing morbidity through effective care:

Step One: Prevention of disease or injury with the use of evidence-based self-care, such as diet, exercise, ergonomics (alteration of work activities) or cessation of smoking and other drug abuse to reduce the risk of injury or disease.

Step Two: If self-care is not working, patient will then visit their primary care physicians for evaluation and management using evidence-based algorithms.

Step Three: If disabling pain persists, the patient will be referred to a pain medicine specialist who will collaborate with a team of providers, including, nurse case managers, psychologists and physical therapists.

Step Four: If the patient remains in disabling pain, he or she will be referred to a pain medicine specialist within a subspecialty of care.

Currently there is no unified organizational model of pain medicine, which has led to ineffective and fragmented pain care with poor outcomes and higher costs than necessary. This fragmentation threatens patient safety and causes the passing of a patient from doctor to doctor for a diagnosis and pain treatment, even though that doctor may have had minimal or even no specific training in chronic pain management. The Academy believes one of the solutions to this complex problem is the establishment of Pain Medicine as a recognized primary medical specialty. This recognition would allow Pain Medicine’s specialized knowledge, education, training, and multidisciplinary approach to provide standardized training for all physicians and integrated and comprehensive pain care to millions of Americans suffering with acute, cancer and chronic pain.

One segment of society that has carried the burden of an ineffective pain care delivery system is the business community. It is estimated to cost $61.2 billion annually in lost productive time. The majority of this cost (76.6%) is attributed to reduced performance while at work, not work absence. During the course of two weeks, 13 percent of the total workforce experienced a loss in productive time due to a common pain condition. An estimated 3.8 billion hours of work are also lost annually due to pain. For additional statistics on the cost of pain care to businesses visit www.painmed.org.

As the largest purchasers of healthcare, businesses have much to lose from ineffective pain treatment of their employees. Finding a unified approach to pain medicine is critical. Back pain alone cost businesses $19.8 billion in lost productive time, with almost three-quarters of the cost attributed to complications of back pain from the lack of proper care.

“The ineffective treatment of pain results in an escalating cascade of health care issues. Acute pain that is not treated adequately and promptly results in persistent pain that eventually causes irreversible changes in the brain and spinal cord. This is referred to as neuropathic pain, a neurobiological disorder that is difficult to diagnose and manage. Persistent pain of this nature often results in further bio-psycho-social changes, which in turn result in further pain and increasing disability. This vicious cycle transforms a human being into a patient who unwittingly becomes a burden to himself, his family and society at large. The emotional, societal and financial costs are immeasurable,” according to AAPMedicine’s Executive Medical Director, Philipp M. Lippe.

Currently there are not enough pain medicine specialists to treat back pain and other pain conditions, and the system for training physicians in the discipline of pain medicine remains insufficient. The Academy’s solution calls for better residency training programs in pain medicine, which will lead to better and more cost-effective pain care.

Recognizing pain medicine as a primary medical specialty would also increase federal funding into pain research. As the population ages, there will be an increased need for physicians who have both specific expertise in pain medicine and broader training in the needs of an aging population. An increase in federal funding for pain research is critical to keep pace with the growing problem of pain in America.

Taking these steps will also improve health care coverage for pain care. Insurance companies often refuse to cover pain-relieving treatments, and access to pain rehabilitation is non-existent in many parts of the country. The Veteran’s Affairs’ medical system has recognized the need for change in pain care and now requires VA health care institutions to provide organized pain assessment and management. Developing an optimal system of pain care delivery would not only address better healthcare for the millions of Americans in daily pain, but its benefits would filter down to both businesses and society. Safe, effective and affordable pain treatment is possible, and the benefits are immeasurable. Click here to view the Pain Medicine Position Paper.

Source: American Academy of Pain Medicine


Significant Clinical and Economic Benefits Found in Analysis of More than 25,000 Procedures

Ethicon Endo-Surgery announced results from two newly published studies that demonstrate a minimally invasive approach in three common procedures resulted in a reduced rate of complications and lower overall cost of care, including a difference of more than $15,000 on average for minimally invasive colectomies, when compared to open surgery. One study compared two types of minimally invasive hysterectomy procedures to open abdominal hysterectomy(i) and another study analyzed outcomes of minimally invasive approaches for appendectomy and colectomy procedures compared to open surgery(ii).

The study titled “Open Abdominal versus Laparoscopic and Vaginal Hysterectomy: Analysis of a Large United States Payer Measuring Quality and Cost of Care” showed, in line with previous studies, minimally invasive hysterectomy reduced rates of postoperative infection and length of stay in the hospital when compared to open abdominal hysterectomy. Open surgery was also associated with higher costs than those who underwent laparoscopic and vaginal hysterectomy. Given these findings, the study authors concluded a substantial opportunity exists to shift more hysterectomies from an in-patient to an outpatient setting while maintaining or improving the clinical outcome for patients.

“The clinical and economic outcomes of the study demonstrate the need for higher adoption of minimally invasive hysterectomy procedures in patients who are candidates for this approach,” said Lori Warren, M.D.,* lead author of the study and an advanced gynecologic laparoscopic surgeon with Women First of Louisville. “In this age of comparative effectiveness, this study shows that when it comes to hysterectomy, a minimally invasive approach gives physicians the opportunity to increase the quality of care women are receiving while potentially saving the healthcare system millions of dollars. Clinicians who have had concerns that minimally invasive procedures may be riskier for patients should be reassured because this real-world data demonstrates the overall complication rate is actually higher with the open abdominal approach.”

When compared with patients that underwent an open abdominal hysterectomy, the vaginal approach was associated with an average cost-savings of more than $4,000 and laparoscopic hysterectomy an average of $2,000 in cost-savings. Among the three methods of hysterectomy, open abdominal hysterectomy remains the most common approach as 70 percent(iii) of procedures are still performed in this manner, despite the clear benefits of minimally invasive approaches. The retrospective analysis was performed on 15,404 patients using claims data from a large U.S. managed care plan. The results of the study, which was sponsored by Ethicon Endo-Surgery, were published in the September issue of The Journal of Minimally Invasive Gynecology.

In similar findings, another study titled “Comparison of the Clinical and Economic Outcomes Between Open and Minimally Invasive Appendectomy and Colectomy: Evidence from a Large Commercial Payer Database” concluded minimally invasive appendectomy and colectomy were associated with lower infection rates, fewer complications, shorter hospital stays and lower expenditures than open surgery. The results of the retrospective analysis, which was also sponsored by Ethicon Endo-Surgery, has been accepted for publication in the peer-reviewed journal Surgical Endoscopy and is currently available on the journal’s Web site. The data included analysis of 7,532 appendectomy and 2,745 colectomy procedures using a large commercial payer database.

“This data strongly suggests that if someone needs a colectomy, regardless of age, a minimally invasive procedure will result in fewer complications, get them out of the hospital several days sooner and cost the healthcare system $15,000 less than if the patient underwent open surgery,” said Terrence Fullum, M.D*., Associate Professor of Surgery at Howard University College of Medicine and lead author of the study. “Unfortunately, there is a great disparity between the number of colectomy procedures performed with open surgery compared to minimally invasive procedures. This study is the latest in a substantial and growing body of clinical and economic evidence that I believe supports a call to action among the entire healthcare community to increase access to the benefits of minimally invasive colectomy.”

“Open Abdominal versus Laparoscopic and Vaginal Hysterectomy: Analysis of a Large United States Payer Measuring Quality and Cost of Care”

Investigators of the study collected data on intraoperative and postoperative complications, length of stay, rates of readmission, and insurer and patient payment totals for inpatient and outpatient procedures. Of 15,404 patients, MIP was performed in 43 percent of subjects, with 23 percent (3,520) undergoing laparoscopic hysterectomy, and 20 percent (3,130) a vaginal hysterectomy. The study demonstrated that postoperative infection rates were higher for patients undergoing open abdominal hysterectomy: 18 percent as compared with 15 percent of laparoscopic and 14 percent of patients undergoing vaginal hysterectomy (P<.05). With open abdominal hysterectomy, average length of stay was 3.7 days versus 1.6 and 2.2 for patients undergoing MIP laparoscopic and MIP vaginal hysterectomy, respectively.

In addition to the clinical benefits, the data indicated costs associated with MIP were lower than for patients undergoing open abdominal hysterectomy. Healthcare spending, represented as the expenditures for inpatient and outpatient care associated with the procedure, included expenses related to surgical and medical therapy. Adjusted expenditures associated with outpatient MIP were markedly lower than expenditures for inpatient open abdominal hysterectomy, indicating significant savings can be realized when patients can be treated with an MIP procedure in an outpatient setting rather than undergoing an inpatient procedure – MIP or open. When adjusting for the setting, the cost of outpatient laparoscopic hysterectomy averaged $9,426 and vaginal hysterectomy $7,627 compared to $11,739 for inpatient open hysterectomy.

“Comparison of the Clinical and Economic Outcomes Between Open and Minimally Invasive Appendectomy and Colectomy: Evidence from a Large Commercial Payer Database”

Investigators analyzed medical and pharmacy claims data from a large U.S. managed health care insurer and measured post-operative infection rates, procedure-specific complications, length of hospital stay, readmission rates and expenditure rates. The data included 2,745 patients who underwent colectomies; 842 (31 percent) were treated using a minimally invasive approach whereas 1,903 (69 percent) underwent open surgery. Post-operative infection rates for those who underwent an MIP were lower (24 percent) than those who had open surgery (38 percent) as were minor (17 percent vs. 23 percent) and major bleed rates (4 percent vs. 10 percent). When measuring the predicted length of stay (with adjustments for factors such as surgical approach, patient age, and co-morbidities), the data indicated open surgery resulted in a length of stay four days longer when compared to MIP. Overall, the investigators concluded minimally invasive colectomy procedures were associated with a cost of care $15,200 less than open surgery.

When assessing these same outcomes for open and minimally invasive appendectomies the investigators found similar results. The data on 7,532 patients who underwent appendectomies included 5,304 (70 percent) who underwent an MIP and 2,228 (30 percent) treated with open abdominal surgery. Post operative infection rates (16 percent for MIP vs. 20 percent for open) and overall procedure specific complication rates (2.51 percent for MIP vs. 3.82 for open) were lower for minimally invasive procedures when compared with open surgery. Additionally, minimally invasive appendectomy was associated with a lower cost of care ($700) and about a half day shorter hospital stay (3.27 vs. 3.91 days) than open surgery.

Notes:

*Paid consultant for Ethicon Endo-Surgery

(i) Warren L, Ladapo JA, Borah BJ, Gunnarsson CL. Open Abdominal versus Laparoscopic and Vaginal Hysterectomy: Analysis of a Large United States Payer Measuring Quality and Cost of Care. Journal of Minimally Invasive Gynecol. 2009; 581-587.

(ii) Fullum TM, Ladapo JA, Borah BJ, Gunnarsson CL. Comparison of the clinical and economic outcomes between open and minimally invasive appendectomy and colectomy: evidence from a large commercial payer database. Surgical Endoscopy 2009 (published online).

(iii) Babalola E, Bharucha AE, Schleck CD, Gebhart JB, Zinsmeister AR, Melton LJ 3rd. Decreasing utilization of hysterectomy: a population-based study in Olmsted County, Minnesota, 1965-2002. Am J Obstet Gynecol. 2007;196:214-217.

Source: Ethicon Endo-Surgery


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