vendredi 29 janvier 2016

Study: Maternal Obesity And Diabetes Bring ‘Multiple Hits,’ May Raise Autism Risk In Children

Study: Maternal Obesity And Diabetes Bring ‘Multiple Hits,’ May Raise Autism Risk In Children

A provocative new study finds that children born to mothers with a combination of obesity and diabetes before and during pregnancy may have up to four times the risk of developing autism spectrum disorder.

On their own, obesity as well as pre-pregnancy diabetes or gestational diabetes increase the risk of autism slightly, researchers report. But the study suggests that co-occurring obesity and diabetes may bring “multiple hits” to the developing fetal brain, conferring an even higher risk of autism in the offspring than either condition on its own.

According to the U.S. Centers for Disease Control and Prevention, about 1 in 68 children has autism spectrum disorder, which also includes Asperger syndrome and other pervasive developmental disorders.

This new study — led by researchers at the Johns Hopkins Bloomberg School of Public Health and published in the journal Pediatrics — was based on analyzing the medical records of 2,734 children who have been followed from birth at the Boston Medical Center between 1998 and 2014. (Of that group, 102 of the children had a diagnosis of an autism spectrum disorder. )

So what might be leading to this increased autism risk? Researchers don’t really know, but they raise several theories in the paper. In general, the possible mechanisms relate to immune and metabolic system disturbances associated with maternal obesity and diabetes that might cause inflammation and other problems for the developing fetus.

One of the study authors, Daniele Fallin, an epidemiologist and chair of the Department of Mental Health at Hopkins’ public health school, said in an interview: “We know that both diabetes and obesity create stress on the body, generally, and a lot of that stress manifests in disruption of immune processes and inflammation. Once you have the disruption in the mom, that may lead to inflammation problems in the developing fetus, and inflammation during neurodevelopment can create problems that manifest as autism.”

She reiterated several possible mechanisms that may be implicated.

First, she said there’s emerging evidence in autism that folate supplementation before or during pregnancy can be potentially protective.

“The reason that connects to this paper is that it’s also known that obesity disrupts your ability to uptake that folic acid supplementation,” Fallin said. “If that’s true, whatever protective effect a mom might get from the folic acid might be undermined by her being obese or diabetic.”

Also, she added, hyperglycemia related to diabetes in that the mom can create oxidative stress on the child and that puts a burden on the child’s cells during development.

But, Fallin says, these remain just hypotheses.

“What we’ve done is shows this association, but it doesn’t prove any of these theories. We need to do a lot more work to figure out which of these might truly be in play,” she said, adding a bit of hope to the findings: “This points to prenatal origins of risk for autism, but it also points to prevention because these are modifiable risk factors.”

In an interview, Dr. Paul Wang — a New York-based pediatrician and vice president of medical research at Autism Speaks, an advocacy group that funds autism research — said the new study is “important” and “advances the field … by taking a very close look at the combined effects of obesity and diabetes, and finding that the presence of both risk factors is much more important than either one alone.”

Wang said there are some weaknesses to the study, notably that it drew data from patients’ medical records rather than examining the affected children directly to determine signs of autism.

He added: “It is still true that the vast majority of children whose mothers who have obesity and diabetes of every type (both before pregnancy and gestational diabetes) will not develop autism.” This study, he says, finds “a moderately increased risk of three of four times” for mothers with diabetes who are also obese.

In the meantime, he said, “clearly from this and other studies, any woman thinking about being pregnant or becoming pregnant should make sure her health is as good as it can be — in terms of nutrition, weight, infection — all of these are factors can can affect risk of autism in children.”

Despite the hypotheses put forth in the paper, Wang said: “We really don’t know exactly how obesity and diabetes might be working to cause autism.”

Why To Exercise Today: Minimizing ‘Menopause Misery’

Why To Exercise Today: Minimizing ‘Menopause Misery’

(pennstatelive/Flickr)

(pennstatelive/Flickr)

A new report suggests a path toward reducing “menopause misery”: Give up your sedentary lifestyle.

A paper — titled “Sedentary lifestyle in middle-aged women is associated with severe menopausal symptoms and obesity,” and published online in the journal Menopause — looks at more than 6,000 women across Latin America ages 40-59. Researchers found that compared to active women, sedentary women (who made up about 63 percent of participants) reported more “severe” menopause symptoms, including hot flashes, joint pain, depressed mood and anxiety and other symptoms like sex problems, vaginal dryness and bladder problems.

Sedentary lifestyle was self-reported (always a possible red flag in a study like this) as less than three 30-minute sessions of physical activity per week; activities included walking, biking, running, jogging, swimming or working out.

From the news release:

The study analyzed data from the Collaborative Group for Research of the Climacteric in Latin America surveys and health records of 6,079 women … who attended one of 20 urban health centers in 11 Latin American countries. The women completed standard questionnaires about depression, anxiety, insomnia, and menopause symptoms. Symptoms on the Menopause Rating Scale (MRS) questionnaire include somatic symptoms … and urogenital symptoms… The women also answered other questions, such as what their activity level and menopause status were.

JoAnn Pinkerton, M.D., executive director of the North American Menopause Society, and not involved in the study, said that being sedentary carries with it all sorts of health risks far beyond menopausal symptoms — from heart disease to some types of cancer. But, she notes, regular exercise can relieve “menopause misery,” and more. In an email, she adds:

Other studies have shown that being active whether women choose gardening, yoga, walking, biking or swimming at least 30 minutes a day improves menopausal symptoms… Being sedentary is bad for your health, physical and mental. Being active every day not only will help you have less severe menopausal symptoms, but it improves mood, coping, and has health benefits as well.

I encourage women including myself to add activity to our days, every day, whenever and however we can. Don’t wait til Saturday or the days you can go to the gym. If you are in your 40s and looking towards menopause, avoid the 12-15 pounds that most women gain by increasing your activity level now.

To be fit and strong after menopause requires women to gradually increase the amount of time and intensity of exercise to get most benefit.

For more inspiration, read Carey’s excellent piece in “My Menopause” on getting her “yum” back in middle age through exercise.

Dr. Donald Thea On What We Know About The Zika Virus

Dr. Donald Thea On What We Know About The Zika Virus

For the first time, a Massachusetts resident has been diagnosed with the Zika virus.

He or she is from Boston and traveled in a country where the virus is being transmitted. The symptoms were mild, the patient did not have to be hospitalized, and is expected to make a full recovery.

Dr. Donald Thea, professor of global health and director of the Center for Global Health & Development at Boston University, joined WBUR’s Morning Edition to discuss the virus and this case in Boston.

Related:

Salisbury Woman’s Death Shows The Complications In Responding To Opioid Crisis

Salisbury Woman’s Death Shows The Complications In Responding To Opioid Crisis

Opioids include drugs like OxyContin, which are arranged in this 2013 file photo at a pharmacy. (Toby Talbot/AP)

Opioids include drugs like OxyContin, which are arranged in this 2013 file photo at a pharmacy. (Toby Talbot/AP)

The death of a Salisbury woman this month shows how difficult it can be to coordinate the response to the opioid addiction crisis.

Gretchen Fordham received the opioid overdose reversal drug Narcan in an emergency room. But she still left the hospital with a prescription for opioid pain pills.

Hours later, police say Fordham was found unresponsive in her home.

Here’s what happened:

It was shortly after 6 a.m. on Jan. 10 when police received a 911 call from the boyfriend of 44-year-old Fordham saying she was unresponsive.

“She was transported to the hospital but was pronounced dead at the hospital,” Salisbury police Chief Tom Fowler explained. “My detective speculates that it could possibly be an accidental overdose.”

At Fordham’s home, police found a bottle of prescription opioid painkillers. Three of them were missing. Fowler says Fordham had the prescription filled just hours earlier, after doctors at Anna Jaques Hospital in Newburyport prescribed them. And after the hospital had administered Narcan.

“She was prescribed painkillers before she left the hospital, she filled the prescription, there were some missing. We don’t know if she took them,” Fowler said. “But she was administered Narcan earlier in the evening — not knowing [that] she was under the influence when she arrived there.”

Fordham arrived at Anna Jaques Hospital after a car accident where state police said she was driving under the influence of drugs. Fowler says at the hospital, Fordham responded to the Narcan and then doctors treated her for a wrist injury and gave her the opioid painkiller prescription.

Anna Jaques Hospital would only confirm that Fordham was treated and released there the night before. A spokeswoman declined further comment and would not say if the hospital is looking into this case or whether it has policies that would prevent an opioid from being prescribed to someone who was also given Narcan.

The Essex County District Attorney says the medical examiner will determine the exact cause of Fordham’s death. Fowler says this case shows that it’s critical for several agencies to communicate and understand the extent of the opioid epidemic.

“I think, as we address the opioid problem, we need health care providers at the table discussing this as well and seeing what we see on the street every day,” he said.

So far this month, there have been six overdoses in Salisbury — two of them fatal.

jeudi 28 janvier 2016

First Case Of Zika Virus In Boston Is Confirmed

First Case Of Zika Virus In Boston Is Confirmed

BOSTON — A Boston resident has been diagnosed with the mosquito-borne Zika virus, the Boston Public Health Commission confirmed Thursday.

The patient, who contracted the virus while traveling abroad, is expected to make a full recovery, BPHC said in a statement.

“The vast majority of people who contract Zika do not get seriously ill, and recover quickly when they do,” Scott Zoback, spokesman for the BPHC, said in a statement.

The Zika virus, which has been found in Africa, Southeast Asia, South America and the Pacific Islands, is spread to people through the bite of an infected mosquito. The Centers for Disease Control and Prevention is advising pregnant women to avoid traveling to countries where the virus is present because there are concerns it may be linked to severe birth defects.

“The species of mosquito that transmits Zika is rarely found in Boston,” Dr. Anita Barry, director of the Infectious Disease Bureau at BPHC, said in a statement. “However, we encourage those traveling to countries with a high risk for Zika transmission — especially those who are pregnant or may become pregnant — to take the utmost care to avoid contracting the virus.”

Earlier Thursday, the head of the World Health Organization, Dr. Margaret Chan, said the virus has escalated from being “a mild threat to one of alarming proportions,” NPR reported.

For more information on the virus, visit the BPHC fact sheet.

Related:

mercredi 27 janvier 2016

Landmark Gene Discovery Cracks Open ‘Black Box’ Of Schizophrenia

Landmark Gene Discovery Cracks Open ‘Black Box’ Of Schizophrenia

Sydney and her mother Lori look into the bedroom mirror where Sydney experienced her first symptoms of schizophrenia. Now 20, Sydney has had no symptoms for almost two years now. (Jesse Costa/WBUR)

Sydney and her mother Lori look into the bedroom mirror where Sydney experienced her first symptoms of schizophrenia. Now 20, Sydney has had no symptoms for almost two years now. (Jesse Costa/WBUR)

One November day in her senior year of high school, Sydney accidentally broke the full-length mirror leaning up against the wall of her bedroom.

She felt a gust of superstitious dread: “Oh my God, I have to put this mirror together or I’m going to have bad luck.” Then, it escalated oddly into religious terror: “The devil’s coming to get me!”

Something inside her seemed to snap, she said. She sensed demons invading through the broken glass.

Not long afterward, President Obama spoke to Sydney inside her head: “OK, this is how the world is now,” he told her. “Everyone is so in love with each other, we can hear each other in our heads.”

The menacing voices of demons started to torment her, especially at night. She became convinced that she was going out with the pop star Justin Bieber, that he was chatting with her on her phone and sending her hidden messages in his Twitter feed. She thought he set up paparazzi in her backyard on Boston’s North Shore, that he was sending planes over her house to let her know he cared.

“Is this really happening?” She would ask the voices in her head. “Is this?” Yes, they told her. Yes.

What was really happening? How does a sunny girl who’d never had psychiatric problems before, who grew up loving dance and Disney princesses, a good student who was rich in family and friends, how does that girl suddenly lose her hold on reality?

Schizophrenia affects about 1 in every 100 people, and one thing is clear: Genetics plays a role. Sydney’s uncle had schizophrenia, and scientists have identified more than 100 genes that can raise the risk for it.

Now, researchers based at the Broad Institute in Cambridge and Harvard Medical School have pinpointed the gene that is the biggest risk factor for schizophrenia discovered so far, and figured out how it does its damage: It makes the brain prune away too many of the connections between neurons.

That finding, just published in the journal Nature, may also explain why schizophrenia tends to hit at such an odd age, in the late teens and early 20s. That pruning of connections is a normal process that ramps up during adolescence, but this genetic culprit may make it go overboard.

Pruning may sound bad, said Bruce Cuthbert, the acting director of the National Institute of Mental Health, but actually, it’s helpful: “It’s like clearing away the underbrush so your brain can function more efficiently.”

But, he said, “in people with this overactive version of the gene, it may be like you have an over-energetic gardener, who prunes back so much that the bushes die off because they don’t have enough branches.”

Cuthbert called the paper a “genetic breakthrough” and “a crucial turning point in the fight against mental illness.” Eric Lander, director of the Broad Institute, said it means we’re finally starting to understand what causes schizophrenia at the level of brain biology.

“For the first time,” Lander said, “we’re opening up the black box and looking inside and seeing, how does the disease really arise? That makes this, in my opinion, perhaps the most important paper in schizophrenia since the disease itself was ever defined,” over a century ago.

This scientific excitement does not mean, however, that the findings will lead to new treatments for schizophrenia any time soon, Lander and others said. It takes years for such basic science to translate into treatments — if it ever does.

But the new paper does suggest some promising new targets for drug development, some already being worked on for other diseases, said Harvard Medical School’s Steve McCarroll, who led the research team.

The findings suggest some promising new targets for drug development, said Steve McCarroll, who led the research team. (courtesy of the Broad Institute)

The findings suggest some promising new targets for drug development, said Steve McCarroll, who led the research team. (courtesy of the Broad Institute)

“You can tap into knowledge that’s already been generated, and that’s very important,” he said. “It’s much better than starting from nothing.”

Tens of thousands of people could arguably claim some credit for the Nature paper; it stems in part from a monumental global collaboration to gather DNA from more than 100,000 people in search of genetic clues to mental illnesses.

But first billing goes to a 29-year-old doctor-scientist-in-training, Aswin Sekar, who has a PhD in genetics and is now finishing up his M.D. degree at Harvard Medical School.

“He grabbed the problem by the horns and wouldn’t let go for three years,” said McCarroll, his supervisor. “He was just brave and fearless about it. He also didn’t care that everyone was telling him it was intractable. He just took that as an invitation to try new things.”

Did McCarroll worry that he might have let Sekar charge off down the wrong path?

“All the time.”

‘Princesses Don’t Lose’

Right around the time that Aswin Sekar began to chase after that intractable problem, Sydney was being pulled against her will onto a journey of her own.

She heard voices of pop stars like Bieber and Ke$ha, and of men and women she didn’t know, voices so compelling they pushed all other thoughts out of her head.

“What color do you want your basket?” a male demon voice would ask her menacingly, referring to the expression “going to hell in a handbasket.”

And the romance with Bieber was stormy. Finally, after several months, she could bear the weirdness no longer and told a teacher about him. The school called home and said Sydney should be picked up, that she was hearing voices.

Sydney’s mother, Lori, a pharmacist, instantly recognized the resemblance between Sydney’s symptoms and her own brother’s, who had been institutionalized after sudden-onset schizophrenia in high school. She immediately started calling around to find treatment.

The first psychiatrist who saw Sydney said automatically, “‘You have schizophrenia,’ ” Lori said. Just as automatically, Sydney and Lori disliked her.

“It’s a big, scary word — schizophrenia,” Lori said. “And my beautiful ballerina — I just couldn’t even reconcile the two terms at all.”

The psychiatrist recommended an antipsychotic, but with Lori’s pharmacy knowledge, she did not want to start Sydney on such a heavy-duty medication. They decided to wait until they could be seen in a few weeks at CEDAR — the Center for Early Detection, Assessment and Response To Risk — a Boston clinic that specializes in helping young people with the earliest symptoms of psychosis.

“So we adopted Justin as our future son-in-law,” Lori said, referring to Bieber. And she resolved to do whatever it took to help her daughter: “If she was going down, I was going down with her. I was going to fight it.”

So was Sydney. When she could feel demons in her room with her, she would draw on her lifelong obsession with Disney princesses and tell herself: “I’m a princess. And princesses don’t lose.”

Aswin Sekar identified C4 as a key gene. (Courtesy)

Aswin Sekar identified C4 as a key gene. (Courtesy)

A Shape-Shifting Suspect

During Aswin Sekar’s early years in medical school at Harvard, it struck him how little we really know about the causes of disease — “pathogenesis,” in the lingo — particularly in psychiatry.

He set out to solve a riddle that had stymied gene researchers for years: signs that the immune system was involved in schizophrenia.

The biggest and most mysterious result in the genetics of schizophrenia was a powerful signal in a DNA area known to contain many immune-system molecules, research team leader McCarroll said.

“It was sort of like the ‘Who shot JFK’ mystery in genetics,” he said. “Everyone had a theory about it, but no one really knew.”

Some speculated that schizophrenia could be caused by an infection — perhaps even a parasite caught from cats — or that it could be an autoimmune disease.

The area of DNA where the gene C4 is located towers highest -- meaning it has the strongest link -- on this "skyline" of genome sites with known links to schizophrenia. (Courtesy of the Psychiatric Genomics Consortium via NIMH)

The area of DNA where the gene C4 is located towers highest — meaning it has the strongest link — on this “skyline” of genome sites with known links to schizophrenia. (Courtesy of the Psychiatric Genomics Consortium via NIMH)

Sekar decided to make a bet on a gene called C4. It was known to work in the body’s immune system to tag viruses for destruction; McCarroll described it as like an “Eat Me” sign. But it had no known role in the brain.

And the gene itself was hellishly complex, showing up in varying forms and structures in different people. Sekar knew he would need to develop new molecular methods to analyze it.

He did wet work at the lab bench, analyzing DNA in droplets so small you could fit 100 million of them in a test tube the size of your thumb.

He and his colleagues also tested nearly 700 samples from human brains (donated after death, of course) to check whether C4 was more active in samples from patients with schizophrenia than those without. In general, it was.

And he did big-data analysis looking at DNA from some 65,000 people’s genomes — their full sets of genes.

Cracking the initial problem of identifying C4 as a key gene, he said, was a bit like solving a murder case, with a couple of special challenges. Gene mapping had given him a ZIP code where his suspect could be found, but not the suspect’s address or name. And that ZIP code was in Manhattan — “very densely populated, with lots of buildings, and lots of them are skyscrapers.”

Oh, and by the way, the suspect could shape-shift.

“So in one genome, the suspect would be 5-foot-6 and in another genome the suspect is 5-foot-10. And in one genome the suspect appears to be acting by himself or herself and in another genome the suspect has a twin or maybe a triplet,” Sekar said.

And once he had solved the whodunit, he still had to answer the how: What did C4 do to raise the risk of schizophrenia?

The gene findings pointed the way from the Broad Institute in Cambridge across the Charles River to Boston Children’s Hospital. There, neurobiologist Beth Stevens recently won a MacArthur genius award for her work on molecules like C4 in mouse brains.

Beth Stevens, of Boston Children's Hospital (Courtesy of MacArthur Foundation/Wikimedia Commons)

Beth Stevens, of Boston Children’s Hospital (Courtesy of MacArthur Foundation/Wikimedia Commons)

She and Children’s immunologist Michael Carroll helped connect the final dots: They showed that in mice, C4 is crucial to pruning away connections between neurons. Young mice genetically engineered to lack C4 have much less pruning.

The C4 insights, Stevens said, have “paved a road ahead. We know what we need to do. We didn’t know that five years ago at all. It was this huge black box. And there are probably going to be other pathways and other genes, and more and more of these are going to kind of funnel in — maybe some of them are even related. But we have a plan. There was no plan.”

Seven or eight years ago, she said, if you had asked what her lab would focus on, “I don’t know if schizophrenia would have been top of the list, because it was so hard. Now, it’s a major goal of the lab.”

What they find may extend beyond schizophrenia. Cuthbert of the NIMH and others say the over-pruning process may contribute to other brain diseases, like psychotic bipolar disorder — it remains to be seen. But this is exactly the sort of work that the institute is trying to encourage, Cuthbert said, focusing less on broad behavioral patterns — like schizophrenia — and more on specific aspects of a disorder — like over-pruning.

So what exactly is the immune connection? Lander, the Broad Institute director, summarizes: C4 normally works in the body’s immune system to target germs for destruction, but it turns out that it “moonlights” in the brain.

“It has this second job, and its job in the brain is to mark synapses — connections between nerves — for destruction,” Lander said. “Someday, you could imagine perhaps modulating, tweaking this process of synaptic pruning in somebody who was being affected with early schizophrenia. We’re very, very far from that, but knowing what’s actually the cause is just transformative.”

‘Room To Move The Belief’

When Sydney first got to the CEDAR clinic in mid-2013, the staff was hugely impressed by “how pleasant she was, how socially engaged, just really sweet and bright and charming,” said clinical psychologist trainee Alison Thomas, who worked with her.

That was unusual, Thomas said; young people who come to CEDAR are often in great distress, confused and scared and unable to understand what’s happening.

“And Sydney’s like this little bright ray of sunshine,” she said. “And talking about serious things, but in this way that’s really personally connected.”

That social brilliance could partly mask the disorder, but it became ever more clear that Sydney was having serious symptoms.

“So we revised our thinking on what actually was happening a few months into working with her,” Thomas said.

The staff realized that Sydney fully believed her symptoms — demons, Bieber — were real, so she had moved past early warning signs to an actual psychotic process. But she had enough trust to accept treatment.

(Sydney gave Thomas permission to speak about her treatment, and was present as she did. Sydney hopes to help others who face similar psychiatric challenges, she said, but asked that her last name be omitted here for the sake of privacy.)

The CEDAR staff tries to be very sparing with anti-psychotic medications, which can have significant side effects, but as Sydney’s symptoms grew more severe, they prescribed one: Abilify.

But the demons only got worse. Sydney’s life took on elements from “The Exorcist.” Sometimes, she felt her bed was shaking, felt sure she was becoming possessed. She would run to Lori’s room and sleep with her.

“There was many a night I held her through the night,” Lori said, “and she was just shaking, terrified, awake, listening to these things. And I’m just whispering to her, ‘Sydney, it’s good, I got you, we’re good, remember it’s not real, remember, it’s not real.’ ”

Lori had to be constantly vigilant: Sydney took to sneaking out of the house in search of holy water in the middle of the night.

Once, she turned up across the river from their house, Lori said: “She was going to the cemetery to look for guidance from relatives there. And I didn’t even know she left the house. She had gone through a really, really bad part of the city.”

Sydney’s father and two brothers did their best to help, too. “My dad would say, ‘If there’s demons, you know I’d be out that door,’ ” Sydney said. But for her, the demons stayed put.

Her relationship with Justin Bieber marched on, and her family learned at CEDAR that they shouldn’t force reality checks on her love life.

“It would be like someone telling me I haven’t been married for 30 years,” Lori said. “I wouldn’t believe them. She wouldn’t believe us.”

When Sydney would point to a passing plane and say, “That’s Justin’s plane. He’s waving to us,” her mother and father would be out in the driveway, waving back.

Parents of young people with schizophrenia often have to redefine their roles, Thomas said.

“Your job is no longer to tell people what’s true and what’s not true,” she said. “Your job now is just to make them feel safe, even if you’re doing crazy things like waving to planes, until we have room to move the belief.”

Often, she said, it takes medication to raise doubt about a belief, and then the psychological work to overturn it can begin.

Lori put her trust in the promise of medication, “that someday it’s just going to be gone.”

But for weeks, then months, as Sydney’s doses inched upward to near the maximum, the Abilify just wasn’t working. She switched from Abilify to the anti-psychotic drug risperidone, or Risperdal. More weeks passed.

Laptop Epiphany

Traditionally, stories of scientific advances include “Eureka moments,” named for the famous bathtub-inspired exclamation by the ancient Greek Archimedes.

But the climactic moments of the C4 story would not make for good theater. Film might be better: a sped-up montage of Aswin Sekar during the Christmas break of 2013-’14, sitting on his couch with his laptop for day after day after day, Googling to make up for his lack of computer science knowledge, with Pandora-guided holiday music playing in the background.

“I just could not set my laptop down,” he said. “I was just driven by this intense desire to know the answer as soon as possible.”

He had just gained access to the huge global dataset of tens of thousands of genomes, and thus to the statistical power to make sure that the C4 pattern he’d found in smaller cohorts was no mere fluke or fluctuation.

On the contrary, he found: “It seemed to be a more convincing pattern when we added these new data points.”

The data showed that a person’s structure of the C4 gene was not just linked to schizophrenia risk, but that it was “driving the risk of schizophrenia from that particular region of the genome,” he said.

C4, in green, at synapses (Courtesy of the McCarroll Lab)

C4, in green, at synapses (Courtesy of the McCarroll Lab)

It was a “huge, screaming result,” said Sekar’s colleague and then-office-mate, graduate student Avery Davis, recalling the thrill that spread through the research team. “When you look at 60,000 people and you see that your hypotheses seem to be validated, that’s incredibly exciting.”

So why doesn’t it sound more exciting? Why wasn’t Sekar jumping and dancing on his couch?

Maybe because in some areas of science, hypotheses — even seemingly confirmed ones — are not what they used to be. Asked whether the C4 story involved a Eureka moment, Lander, the Broad Institute director, quashed the whole idea:

“You might think doing genomics is having a Eureka moment when you see an amazing correlation of X and Y — the genetic form of a gene and a risk of a disease,” he said. “In fact, it’s almost the opposite. Those correlations happen all the time. You see correlations like that and almost always, they’re wrong because something was funny about the data.”

With much of science now, he said, the key is disbelieving those putative correlations, resisting their “siren song,” and “pouring acid on them to see if they’ll go away. And finally, when you really, truly can’t make it go away and can’t explain it by anything else, and have looked at it six ways to Sunday and confirmed it all different ways, you actually believe it.”

Not at all cinematic, sitting on a finding for two years while you try to poke holes in it. But, Lander said, “That’s what science really is: It isn’t the magic Eureka moment, it’s really nailing things down solidly.”

By the way, if you’re wondering how the over-pruning of connections in the brain could give rise to the hallucinations that schizophrenia is best known for, the simple answer is, “We have no idea,” Lander said.

That’s beyond what anyone can explain right now, but it may be possible to devise drugs to dial down over-pruning in the coming years anyway.

“It may not be that we have to fully understand how these cellular events give rise to mental events in order to make a big difference in intervening someday,” he said.

‘My Magic Medicine’

Somehow, through all her demons and delusions, Sydney went on with her life, attending community college and working part-time. Classroom time posed a particular challenge: “Indirects,” her sense that her fellow students’ mundane movements — a cough, a shifting of weight, a sip from a water bottle — were non-verbal communications directly to her. She felt compelled to answer them with her own movements — a blink, a tap of her foot — even while absorbing what the professor was saying.

The demons still tormented her, too. But as her risperidone dose increased each week, Sydney started to feel better.

“That was like my magic medicine,” she said. “Within weeks, I had less symptoms, I felt more comfortable in my skin.”

And then, one morning in January 2014, Justin Bieber was suddenly gone.

“I just woke up one day and I was like, ‘Mom, Justin Bieber’s not real.’ And she was like, ‘Oh my God.’ ”

For Alison Thomas of CEDAR, Bieber’s departure meant the risperidone was hitting the target.

“That’s how we knew that the medication was really working, we had found a good dose, is once Justin shifted — that belief,” she said.

Sydney was bereft at first. “I pictured myself being rich and famous, having a huge house and stuff,” she said. “So I cried. And then I just got over it: ‘Oh, I guess that happened.‘ “

She does get a bit embarrassed now, about the whole Bieber thing, laughing at the self she was back then. But she’s the kind of person who acknowledges what has happened and then moves on, she said.

And she has moved on with extraordinary success.

Still on risperidone — “I don’t ever want to stop taking my medicine,” she said — she has had no symptoms for almost two years now. She has been in a real relationship with an “awesome boyfriend” for nearly as long.

Sydney now (Courtesy)

Sydney now (Courtesy)

Now 20, Sydney works in a group home for young people with mental illness as a peer mentor, and in an after-school child care program. She’s doing so well that she has transferred from CEDAR to a local, less specialized care center.

Such a recovery may be possible for many people, Thomas said, but Sydney is unusual in how quickly it happened, and how well she managed to function throughout.

Schizophrenia involves not just delusions; it has “negative” symptoms as well — loss of motivation and emotional connection, trouble thinking and learning.

Medication can often help dispel the delusions, Thomas said, but those negative symptoms tend to be longer-lasting and tougher to overcome; they’re often the root of poor functioning.

“So Sydney’s ability to stay engaged with the world around her and with people, and to really care about relationships” gave her a rare advantage, Thomas said. “Because that’s what really gives her motivation to keep going — because she cares about people.”

The Future

One percent of the population has schizophrenia and a recent study found that more broadly, up to 6 in 100 have experienced some sort of psychosis at some point. So how can more people with schizophrenia fare as well as Sydney? Or better yet, prevent the disorder altogether?

Researchers have been working for more than a dozen years on ways to predict whether young people’s initial milder symptoms of mental disturbance will actually develop into full-blown psychosis — and most importantly, whether it’s possible to head it off.

They include Larry Seidman of CEDAR and Harvard Medical School, who says research already finds significant progress on early intervention for psychosis.

Among symptomatic young people judged to be at high risk for psychosis, he said, studies show that with good treatment, only 1 in 10 goes on to develop full-blown psychosis, compared to 3 in 10 without it.

Larry Seidman, of CEDAR and Harvard Medical School (Courtesy)

Larry Seidman, of CEDAR and Harvard Medical School (Courtesy)

Treatment does not necessarily involve drugs; it can also include talk therapy and lifestyle measures — exercise, diet, sleep.

The C4 paper, Seidman said, is further cause for hope that treatment — and even prevention — will improve, because it shines new light on a biological pathway to the disorder.

“If we know this pathway, maybe there are very specific times in life when you might be able to intervene and alter that pathway,” he said. “Maybe there are other critical periods before adolescence when it’s more malleable. We don’t know.”

But it does seem possible, he said, that C4 gene testing could become one of the multiple measures used to assess a young person’s risk of progressing to full-blown psychosis. If that happens, he said — and it’s by no means certain, because the genetics is very complex — patients and families will need careful counseling to make sure the information is not misinterpreted.

Schizophrenia may come to resemble Cystic Fibrosis, said Cuthbert of the NIMH, in that genetic insights led to the development of a new targeted drug. True, the new drug only works for 4 percent of Cystic Fibrosis patients, he noted, but for that 4 percent, it makes a huge difference.

Research team leader McCarroll compares the prospects for schizophrenia to the sea change in cancer treatment over the last two decades. It was once a death sentence, he said, but “today, we’re surrounded by people who have been cured of cancer or who are managing cancer as a chronic illness very successfully.”

Still, it’s a daunting prospect to develop a drug that tinkers with the immune system, our defender against infection. How directly might the C4 finding translate into better treatments?

It depends, McCarroll said. Some genes lead to good drug targets. Others do not.

“You could discover 20 genes underlying an illness that were not good drug targets and then find the 21st and it might be the place where you really can push on the system with a molecule,” he said. “That’s why you never give up.”

mardi 26 janvier 2016

Panel Recommends Depression Screening For Women During And After Pregnancy

Panel Recommends Depression Screening For Women During And After Pregnancy

(Chris Martino/Flickr)

(Chris Martino/Flickr)

On Tuesday the U.S. Preventive Services Task Force released new recommendations on screening for depression in adults, notably calling for depression screening in women both during and after pregnancy.

The recommendations, published in the Journal of the American Medical Association, suggest: “All adults older than 18 years should be routinely screened for depression. This includes pregnant women and new mothers as well as elderly adults.”

Why?

“Depression is among the leading causes of disability in persons 15 years and older,” the task force statement said. “It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting. Depression is also common in postpartum and pregnant women and affects not only the woman but her child as well. …The [task force] found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”

The government-appointed panel found that the harms from such screening are “small to none,” though it did cite potential harm related to drugs frequently prescribed for depression:

The USPSTF found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) are associated with some harms, such as an increase in suicidal behaviors in adults aged 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with risk increasing with age; however, the magnitude of these risks is, on average, small. The USPSTF found evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women, but the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.

Nancy Byatt, medical director at the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms) and an assistant professor of psychiatry and obstetrics and gynecology at UMass Medical School, said the new recommendations “are an incredibly important step to have depression care become a routine part of obstetrical care.”

She added: “Depression in pregnancy is twice as common as diabetes in pregnancy and obstetric providers always screen for diabetes and they have a clear treatment plan. The goal [here] is that women are screened for depression [during pregnancy and postpartum] and they are assessed and treated and this becomes a routine part of care just like diabetes.”

Dr. Ruta Nonacs, who’s in the psychiatry department at Massachusetts General Hospital and editor-in-chief at the MGH Center for Women’s Mental Health, sent her thoughts via email:

In that the USPSTF recommendation recognizes pregnant and postpartum women as a group at high risk for depression, this represents a step in the right direction in terms of ensuring that psychiatric illness in this vulnerable population is identified and appropriately treated. However, there remain significant obstacles to overcome. Research and clinical experience indicate that while pregnant and postpartum women with mood and anxiety disorders can be identified through screening, many women identified in this manner do not seek or are not able to find treatment.

While screening is important, we must also make sure we tend to the construction of a system that provides appropriate follow-up and treatment. Because stigma continues to be significant with regard to mental health issues in mothers and mothers-to-be and because there are concerns regarding the use of medication in pregnant and nursing women, we must make sure that after screening, we help women to access appropriate resources and treaters who have expertise in the treatment of women during pregnancy and the postpartum period.

Unlike the so-called “baby blues” — the feelings of exhaustion, worry and unease that impact about 80 percent of new moms but are often short-lived — postpartum depression can be extreme and longer-lasting. The condition occurs in nearly 15 percent of births, according to the National Institute of Mental Health, and can often require treatment, from psychotherapy to medications.

The New York Times’ report Tuesday says the health panel’s new recommendations are “expected to galvanize many more health providers to provide screening,” particularly as emerging evidence suggests “maternal mental illness is more common than previously thought; that many cases of what has been called postpartum depression actually start during pregnancy; and that left untreated, these mood disorders can be detrimental to the well-being of children.”

And here’s what Mark DeFrancesco, M.D., president of the American College of Obstetricians and Gynecologists, said in a statement on the new recommendations:

The American College of Obstetricians and Gynecologists (ACOG) is pleased that the USPSTF recognizes that screening for depression is appropriate for all adults, including pregnant and postpartum women. ACOG has long recommended depression screening for all women, both as a part of the well-woman visit and during the perinatal period. Specifically, ACOG’s Committee Opinion on Screening for Perinatal Depression recommends routine screening for depression for all women at least once during the perinatal period.

ACOG’s Committee Opinion also adds that women at high risk of depression – for example, with a history of depression or anxiety – warrant especially close monitoring.

Perinatal depression – or depression that occurs during pregnancy or in the first 12 months after delivery – is estimated to affect one in seven women, making it one of the most common medical complications associated with pregnancy. Because fewer than 20 percent of women in whom perinatal depression is diagnosed self-report their symptoms, routine screening by physicians is important for ensuring appropriate follow-up and treatment. Fortunately, we have a variety of treatment options – such as lifestyle changes, therapy, and medication – that help women control depression and enjoy their growing families.

Of course, depression also impacts women who aren’t pregnant. Because of the open, close nature of our relationship with our patients, ob-gyns have a unique role to play in identifying depression in the women we treat. That’s why routine mental health screening is an important part of the well-woman visit.

Related:

vendredi 22 janvier 2016

U.S. Health Care Is Less Private, More ‘Socialist’ Than You Might Think

U.S. Health Care Is Less Private, More ‘Socialist’ Than You Might Think

The extent of the government's role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17 in Charleston, S.C. (Mic Smith/AP)

The extent of the government’s role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17. (Mic Smith/AP)

By Richard Knox

Readers, a pop quiz:

The proportion of U.S. health care paid by tax funds is (a) less than 30 percent, (b) about half or (c) more than 60 percent.

If you picked “more than 60 percent,” you’re right — but you’re also pretty unusual.

“Many perceive that the U.S. health care financing system is predominantly private, in contrast to the universal tax-funded health care systems in nations such as Canada, France or the United Kingdom,” David Himmelstein and Steffie Woolhandler write in a new analysis of U.S. health spending in the American Journal of Public Health.

They find that 64.3 percent of U.S. health expenditures are government-financed. And they project the tax-supported proportion will rise to 67.1 percent over the coming decade as the baby boom generation ages and retires — nearly as high as Canada’s 70 percent.

“We are actually paying for a national health program, we’re just not getting it,” Woolhandler says.

Now, Himmelstein and Woolhandler have an agenda. For decades, they’ve been perhaps the leading researchers promoting the kind of single-payer health system that Socialist and Democratic presidential candidate Bernie Sanders has put on the debate agenda. One recent poll suggests more than half of Americans (and 30 percent of Republicans) support the idea.

But even if you disagree with the Himmelstein-Woolhandler ideology, their research is generally regarded as sound, and their method is straightforward.

They added up what federal and state governments spend on health through Medicare, Medicaid, the Veterans Health Administration, government employees’ health care premiums, tax subsidies and other programs. They argue that accounting by government agencies (the Center for Medicare and Medicaid) undercounts the real tax burden because it leaves out major pieces of the pie — such as government employees’ care ($156 billion a year) and tax subsidies for private, employer-sponsored coverage (nearly $300 billion).

And whatever you think about Medicare-for-all, it’s a good idea to see the present U.S. health care system for what it is — an increasingly government-funded financing scheme.

That’s because, however this political season unfolds, you’re going to hear a lot more claims about what’s wrong with the U.S. health care system and how to fix it. Beyond the debate between Sanders and Hillary Clinton over Medicare-for-all versus the Affordable Care Act, or Obamacare, the Republicans are expected to put forward their ideas on replacing Obamacare.

The more you know about the way the current system works, the better able you’ll be to sort through the blizzard of reform ideas.

So here are some facts to take on board from the Woolhandler-Himmelstein paper and other sources:

  • The predominance of tax support in our current system is not just because of Obamacare. It’s been happening for decades. In 1965, before the enactment of Medicare and Medicaid, about one in every three health care dollars was government-funded. By 1980, a little more than half was. Even before Obamacare was passed in 2010, tax dollars accounted for at least 60 percent of the nation’s health care bill. No matter what happens, this trend will not be easy to reverse.
  • The other standout feature of the U.S. health care system is its highest-in-the-world cost. No other nation comes close to the $9,267 cost-per-person of U.S. health care. But even more striking, according to the new analysis, the total health care bill of every other country except Switzerland is lower than what America spends on just the tax-funded portion of its bill — nearly $6,000 per person.
  • Here’s another cost yardstick: how much health care consumes of national wealth, as measured by gross domestic product, the total value of all goods and services. In the U.S., it’s more than 17 percent, again the world’s highest. But consider this: Just the tax-funded portion of U.S. health care — 11.2 percent of GDP, according to the new paper — is more than any other nation, including all those that are totally tax-supported.
  • Momentum is not on the side of health care cost control. The U.S. health care bill just passed $3 trillion a year — 20 percent higher than just seven years ago — according to new government figures in the current issue of Health Affairs. That total bill is bound to increase in coming years because of the graying of America and other factors, such as expensive medical innovations. (Just one recent innovation — new drugs to cure hepatitis C — had substantial impact on total drug spending, government analysts say.) Even modest rates of medical inflation loom large when applied to such staggeringly high spending.

These facts and trends should be kept in mind while weighing political arguments over health care.

For instance, take the recent back-and-forth between Sanders and Clinton. Sanders can take heart from the Himmelstein-Woolhandler analysis, because it shows the nation is already most of the way toward a totally tax-funded health system.

“We’re not that far away from collecting the taxes we would need to pay for a single-payer system like Canada’s,” Woolhandler says. “We already pay so much in taxes for health care that it’s not that big a stretch.”

In the most recent Democratic candidates’ debate on Jan. 17, Sanders said his plan would offset the needed tax increase to fund Medicare-for-all by abolishing private health insurance premiums. “My proposal — provide health care to all people, get private insurance out of health insurance — (would) lower the cost of health care for middle-class families by 5,000 bucks,” Sanders said.

Clinton countered that Sanders’ plan is politically unrealistic. She pointed out that even when the Democrats controlled Congress, they couldn’t pass a more modest proposal — allowing Americans to “buy into” Medicare. “There are things we can do to improve [Obamacare], but to tear it up and start over again, pushing our country back into that kind of a contentious debate, I think is the wrong direction,” Clinton said.

Vermont Gov. Peter Shumlin, seen here in January 2015, signed a single payer bill into law in 2011, but then the effort was abandoned in late 2014. (Andy Duback/AP)

Vermont Gov. Peter Shumlin, seen here in January 2015, signed a single payer bill into law in 2011, but then the effort was abandoned in late 2014. (Andy Duback/AP)

But one important aspect of that debate got little attention — the failure of Vermont, Sanders’ home state, to implement Medicare-for-all. Sanders slid by a question on that. “You might want to ask the governor of the state of Vermont why he could not do it,” he said.

By one recent analysis, the cost of the project is what sank it.

The administration of Vermont Gov. Peter Shumlin figured it would cost the state $2.5 billion to implement a single-payer health system. “The state only raises $2.7 billion in taxes a year,” journalist Sarah Kliff pointed out this week in Vox. “The single-payer plan would mean doubling tax collections. … That’s a big lift even if it would replace existing health premiums.”

Kliff says totally government-financed health care needn’t cost Vermont $2.5 billion a year. But she says making it affordable would require a massive rollback in payments for doctors, hospitals, pharmaceuticals and diagnostic tests such as MRIs, to levels comparable with those across Vermont’s border with Canada. That’s an even heavier political lift.

Woolhandler takes issue with that analysis. “The main lesson from Vermont is you do need a national program, or at least national support for a state program,” she says. After all, that’s how Massachusetts was able to implement its more modest Obamacare precursor program in 2006.

Woolhandler says Vermont could have squeezed more administrative costs out of health care than it was planning to do. And she said it’s “a piece of mythology” that doctors and other health care providers would have to be impoverished to make a single-payer plan affordable.

So the feasibility of Medicare-for-all isn’t yet clear. But at least the debate is venturing into territory never before covered in a national political debate.

SharingClinic, To Help Patients Tell Their Stories, Opens At Mass. General Hospital

SharingClinic, To Help Patients Tell Their Stories, Opens At Mass. General Hospital

Four years ago, Dr. Annie Brewster had a vision.

Brewster, a Boston internist, who was diagnosed with multiple sclerosis in 2001, had become frustrated that a crucial element of medicine — the human connection between patients and doctors — seemed to be lost in the modern era of 15-minute appointments and overly burdensome record-keeping. As a patient and a doctor, Brewster yearned for a therapeutic arena in which patients could tell their full health stories and feel they were actually heard, not rushed out the door; and where doctors, as well, could share a little more with patients.

Now, with the launch this week of the SharingClinic, an interactive “listening booth” stocked with audio stories from patients facing a range of illnesses, Brewster is a little closer to realizing her vision. Housed at the Paul S. Russell Museum of Medical History and Innovation at Massachusetts General Hospital, Brewster expects SharingClinic will continue to grow over time as more stories are collected and added to the kiosk. Eventually, she says, trained staff will begin to facilitate the storytelling in regularly scheduled “clinics” in a way that research suggests might offer an actual health boost

To be clear, the listening booth isn’t a booth yet. It’s an interactive screen that allows users to hear a range of stories from different perspectives: hospital patients facing very serious illnesses, their families and friends, doctors, nurses, psychiatrists and others. A touchscreen allows listeners to select the stories by diagnosis, theme or perspective. Currently, over 100 clips are collected, and the process is ongoing. The software, designed in collaboration with computer programmer David Nunez, previously at the MIT Media Lab, allows for easy, regular addition of new content. A downloadable app is coming soon.

“My hope is that SharingClinic will fundamentally transform the culture of the hospital by encouraging and facilitating storytelling,” Brewster said at the opening of SharingClinic at the MGH museum on Thursday night. “Hospitals can be cold, scary, lonely places. SharingClinic aims to build community and to lessen this sense of isolation.”

Brewster spoke of the emerging field of “interpersonal neurobiology,” built on the idea that empathy, and being attuned to the person you are talking to — really seeing and hearing them, with compassion and body language and eye contact — “has clear biological impacts on the brain — how our brain and neural circuits change in response to our interpersonal interactions.”

She also discussed fairly new research that suggests patients get a mental health boost when they frame their medical stories in a manner that puts them in the driver’s seat; that is, when they feel they have some sense of control.

One of the social workers involved in collecting stories for SharingClinic, Barbara Olson, said that when patients go through the process of figuring out how they want to talk about their own illness and then tell their stories aloud, it “gives them a place to ponder what’s happened to them.”

One of Olson’s patients is Kathryn, a 68-year-old with end-stage renal disease who has been on dialysis for 10 years after a failed kidney transplant. Dr. Brewster, who is also a friend of mine, closed her talk at MGH with Kathryn’s words. Here’s part of the clip, with Kathryn choking back tears near the end:

You have these poignant moments that remind you of the goodness of people…Once I was in terrible pain in the hospital…the nurse came rushing in…she was very hassled that day…she was in a rush and was going to do a quick medication dispensation and be out the door. So she did her stuff and she was headed out…and she looked at me, and all of a sudden, she just stopped and she came over and she brushed the hair out of my eyes and she put her hand on my face and she stroked my face and i just thought, [it] didn’t take the pain away, but it changed the whole day.

If you’re interested in sharing your story, contact Brewster at: abrewster@healthstorycollaborative.org

Earlier:

Analysis: Can Mindful Eating Really Help You Lose Weight Or Stop Binging?

Analysis: Can Mindful Eating Really Help You Lose Weight Or Stop Binging?

(t-mizo/Flickr)

(t-mizo/Flickr)

By Jean Fain
Guest Contributor

Mindfulness is all the rage. But does mindful eating — paying very close attention to your food and to your body’s signs of true hunger and satiety — really help you lose weight or stop binging?

On the one hand, paying closer attention to how you eat and why seems like a no-brainer for improved health. But in fact, mindful eating is steeped in controversy — pitting doctors against nutritionists, parents against children, therapists against clients, even colleagues against one another.

Proponents of mindful eating (also known as intuitive eating) like nutrition researcher Linda Bacon and other advocates of “Health at Every Size” — a self-described political movement promoting healthy habits and self-acceptance, rather than strict diets — recite a lengthy list of benefits related to mindful eating, including sustainable weight loss.

Critics of mindful eating offer a number of negatives: some say such navel-gazing about food makes it unappetizing, while others say mindful eating is superficial and ineffective, even irresponsible when it supplants traditional treatments for life-threatening eating issues.

Still others, like many who posted comments on my recent NPR interview with Jean Kristeller, author of the book, “The Joy of Half a Cookie,” dismiss mindful eating as a joke. One example: “Yes, let’s add more dietary neurosis to the babel of nutritional advice. How about this: eat the whole cookie. Have two, even. Just eat cookies less often, and eat nutritious food as the rule rather than the exception.”

According to Dr. James Greenblatt, an eating disorder expert, chief medical officer of Walden Behavioral Care and the author of “Answers to Binge Eating,” mindful eating is not only pointless in some cases, it’s potentially dangerous.

“Mindful eating clearly has a place in our treatment plans,” Greenblatt explained in a recent email exchange. “But, as a sole intervention for some of our patients, it is like asking opiate abusers to utilize mindful heroin detox. Many eating disorders reflect a severe neurochemical abnormality that needs to be addressed with biological interventions first, before adding other psychotherapeutic strategies and mindfulness.”

Given the growing popularity of mindfulness-based interventions for the range of eating problems, the question of whether mindfulness works either for weight loss or to alleviate other eating disorders is a fair question. Based on an analysis of recent research, I’ll conclude that the truth lies somewhere in between.

One 2014 comprehensive review, published in the journal Eating Behaviors, provides preliminary answers about which eating issues are more or less responsive to mindfulness interventions. In reviewing the best research to date on the effectiveness of mindfulness meditation for eating issues, psychologist Shawn Katterman and colleagues concentrated on studies about binge eating, emotional eating and weight loss (not anorexia or bulimia) in which mindfulness was the primary intervention. The 14 studies that met their criteria included some popular programs, notably, mindfulness-based stress reduction and mindfulness-based eating awareness training, but excluded others, such as dialectical behavior therapy and acceptance and commitment therapy.

After careful analysis, Katterman’s team concluded that mindfulness training effectively decreases binge eating and emotional eating in people who engage in these eating behaviors, but it’s not all that effective as a stand-alone intervention for significant or consistent weight loss. If these general conclusions leave you slightly peckish and wanting more, read on.

Emotional Eating

The conclusion — that mindfulness training effectively decreases emotional eating for those who struggle with it — is based on five studies. Turns out, the evidence is actually mixed: Two studies showed statistically significant improvements; three failed to find such improvements. Despite the mixed evidence, the researchers concluded mindfulness is an effective intervention for emotional eating because of the limitations of the non-supporting studies. So, not so convincing, really.

Most notably, in two of the three studies that failed to show statistically significant improvements, the subjects weren’t recruited to address emotional eating and they reported low baseline levels of emotional eating. Apparently, emotional eating was neither a concern for the participants nor a focus of those interventions.

Binge Eating

Of the seven studies on mindfulness-based interventions for binge eating disorder, all the studies found significant reductions in binge eating. What’s more, these interventions proved equally effective in reducing binge eating in bariatric surgery patients and participants diagnosed with both substance abuse and binge eating, among other populations. Because mindfulness proved effective in reducing binge eating across a range of populations, the researchers concluded that “it may be a powerful tool” regardless of a client’s characteristics or diagnoses.

Weight Loss

Before you jump to the disheartening conclusion that mindful eating doesn’t really “work” for weight loss, hold on. While it’s true that after reviewing 10 studies on mindfulness training and weight researchers found the effects on weight to be small and insignificant, that’s not the full story. In fact, the researchers found the evidence on weight to be mixed. Mindfulness training did facilitate significant weight loss when losing weight was the focus of training as it was in three studies.

Conversely, mindfulness training produced a small weight gain in the two studies in which stress reduction was the focus. In other words, the focus of the training makes a real difference. So does the total package of interventions. When participants did lose a significant amount of weight, the mindfulness program included either nutrition education, or standard psychotherapy techniques or both. That is what led researchers to conclude that mindfulness training alone may not produce significant or consistent weight loss.

That said, an encouraging 2009 study that did not meet the researchers’ criteria (comparing standard weight-loss treatment to acceptance-based behavioral treatment, an intervention for accepting thoughts and feelings while pursuing behaviors consistent with one’s values) suggests a combination of behavioral strategies and mindfulness training may, in fact, lead to greater weight loss than traditional behavioral weight-loss treatment.

Honestly, I’m not all that surprised by Katterman’s findings, which reflect what I’ve found in my own practice. Clients who practice mindful eating and other mindfulness strategies generally decrease binge eating and emotional eating, but they don’t necessarily lose a significant amount of weight.

Which raises two more important questions. First, does focusing exclusively on weight loss really work? Although the question is beyond the scope of this article, it’s within the scope of a recent study on the effectiveness of regular weigh-ins as a weight-loss intervention. Second: Is a short-term mindfulness intervention long enough to facilitate significant weight loss?

Maybe not, Katterman and colleagues conclude that maybe mindfulness is a process that takes some time: “Mindfulness is one mechanism utilized for developing intrinsic or autonomous motivation, and given that this type of motivation is most strongly associated with long-term behavior change, it is possible that the positive effect of mindfulness on weight would be more delayed.”

Clearly more research is needed to examine the long-term effects of mindfulness training on the range of eating issues. In the meantime, while we wait for researchers to determine what’s most effective, now is the time to try it yourself, then draw your own conclusions.

Finally, one last word from Kristeller, the “Half a Cookie” author, Indiana State psychology professor emeritus and senior research scientist: “The latest scientific review of mindfulness for eating issues concludes that mindfulness decreases binge eating and emotional eating, but evidence for its effect on weight loss is mixed. That said,” Kristeller concluded via email, “with adding in mindful awareness of nutrition information and mindful ways to reduce calories, mindfulness-based approaches may become more effective for both losing and maintaining weight.”

Jean Fain, MSW, LICSW, is a Harvard Medical School-affiliated psychotherapist and the author of “The Self-Compassion Diet.” In addition to seeing individual clients in her Concord private practice, she writes for newspapers, magazines and online publications. 

jeudi 21 janvier 2016

Commentary: When Sexual Violence Survivors Give Birth, Here’s What You Should Know

Commentary: When Sexual Violence Survivors Give Birth, Here’s What You Should Know

By Sarah Beaulieu
Guest Contributor

Sarah Beaulieu (Courtesy of the author)

Sarah Beaulieu (Courtesy of the author)

It shouldn’t have been a surprise that childbirth would leave me traumatized.

In retrospect, it seems obvious that when a survivor of sexual violence feels pain in her vagina caused by a strange being inside of her, the experience might trigger memories of an earlier trauma. But what wasn’t so obvious were the many ways that the childbirth and medical professionals didn’t prepare me for these unexpected and painful emotions related to giving birth.

With 20 years of therapy under my belt, I consider myself to be a fairly confident survivor with many tools in my resilience box. None of these tools prepared me for what happened during the birth of my son. After 12 hours of relatively peaceful labor in the hands of midwives, I dozed off, preparing for a long night. I woke up with at least two sets of hands inside of me, alarms ringing and a sense of panic in the room. My son’s heart rate had dropped dangerously low, and I needed an immediate C-section.

This experience — traumatic for even the healthiest woman — wrecked me, surfacing old post-traumatic stress disorder symptoms and pulling me into depression and anxiety. With the help of a hospital social worker, I emerged from my emotional dark place a few months later, and immersed myself in learning more about birthing as a sexual assault survivor. My experience was scary, but it couldn’t be that uncommon, I thought. After all, 1 out of 4 women share a sexual abuse history like mine, and U.S. women gave birth to nearly 4 million babies last year.

My research led me to Penny Simkin and Phyllis Klaus, two legendary birth educators who compiled much of the existing research into a single manual, “When Survivors Give Birth.”

I learned that, in fact, there were approaches to childbirth that were especially helpful to survivors of sexual violence. Not only that, but it was fairly common for pregnancy and birth to re-trigger memories and emotions related to past sexual violence. Yet despite this, the topic of sexual violence wasn’t typically covered by my midwifery practice, recommended childbirth literature or my natural childbirth class.

First and foremost, health care providers can adopt a trauma-informed approach to care for laboring mothers. Knowing that 25 percent of patients in labor and delivery will have a history of sexual violence, there is a benefit for all staff to be educated about sexual violence and its impact on birth. There are medical reasons too: Childhood trauma, including child sexual abuse, is a documented risk factor of postpartum depression and anxiety, which impacts 10 to 15 percent of new mothers — and their babies and families — each year.

Knowledge starts with screening for a history of sexual violence on standard intake forms and first visits. It also means creating a health care environment where survivors feel comfortable disclosing such histories. In my midwife’s office, there were pamphlets for every possible pregnancy complication, from gestational diabetes to heartburn to exercise during pregnancy. So, why not a pamphlet on giving birth as an abuse survivor?

Cat Fribley, an Iowa-based sexual assault advocate and doula whose practice focuses specifically on sexual violence survivors, describes trauma-informed care as “supporting the whole person with collaboration, choice and control, cultural relevance, empowerment and safety — both physical and emotional. This requires making certain adjustments to the way they work with survivors, acknowledging both the challenges that arise from sexual trauma, as well as unique coping skills — such as dissociation — that may help the survivor through the process of childbirth.”

Here’s an example: At one birth Fribley attended, “the birthing mother became visibly upset when new and unknown staff would enter the room while she was laboring. A simple sign on the door asking people to knock and announce themselves before entering helped make the birthing mom feel more in control of her environment — and the exposure of her body.”

These adjustments can appear minor, but have a lasting impact on survivors. I experienced this myself: In the midst of the chaos of my first birth, the surgeon took 15 seconds to stop, look me in the eye, and explain what was happening. She let me give consent — real consent — to the C-section. Those 15 seconds stuck with me as a single moment of empowerment in an otherwise powerless situation.

Fribley shared another story about a client that illustrates how this plays out. “The survivor wanted her provider be supportive during her labor and delivery, but elaborated that it would be painful for her to hear phrases such as ‘you’re doing a good job, honey’ or ‘just relax’ because of the way that her perpetrator had talked to her when she was sexually abused. A conversation with her OB/GYN helped set the stage for a more empowering birth process when the provider listened, noted, and asked about what encouragement she would prefer.”

Health care providers, birthing partners and birth educators can help survivors explore possible triggers or concerns that may arise during labor and delivery. These vary from person to person, and are often connected to the type of trauma that took place. For some women, there may be concerns about nudity, secretions or being touched by strangers. Others might be afraid of pain, strong emotions or even the sounds they might hear on the floor. By fully discussing these concerns, the survivor and birth team can come up with solutions that will work within the particular hospital or delivery setting.

At my second birth, for instance, I asked for an IV when I was admitted — a small act of control that meant I wouldn’t have anyone unexpectedly poking me with needles if something went wrong.

Health care providers can empower survivors, or re-traumatize them. Let’s give new moms and birth professionals the tools they need to make childbirth a positive, rewarding experience, rather than a trigger for very bad memories.

Sarah Beaulieu is founder of The Enliven Project, a board member of the Boston Area Rape Crisis Center and a strategic adviser to national nonprofit organizations. She is working on a practical guide for men to comfortably advocate against sexual violence. You can find her on Twitter at @sarahbeaulieu.

mercredi 20 janvier 2016

Health Policy Commission Outlines Cost Control Recommendations

Health Policy Commission Outlines Cost Control Recommendations

In an effort to combat rising health care spending in Massachusetts, the Health Policy Commission on Wednesday called on the state to take a series of actions including implementing consumer protections and easing practice restrictions for certain nurses.

The policy recommendations come as part of the commission’s 2015 cost trends report, which examines the 4.8 percent increase in per capita health care spending in 2014.

As main drivers of the spending growth, the report cites high pharmaceutical spending — based on the introduction of new high-cost drugs, large price increases and some drugs going off-patent — and spikes in MassHealth enrollment brought about by the Affordable Care Act.

The commission’s 13 recommendations focus on advancing alternative payment methods, improving transparency and data availability, promoting quality and efficiency in care delivery, and fostering a value based market.

One proposal tackles high charges for patients served by out-of-network providers, urging the Legislature to require that providers inform consumers whether they are in- or out-of-network before delivering services. The commission also calls on legislators to require that insurance carriers hold their members harmless in cases of out-of-network emergency services and boost awareness of existing “surprise billing” protections.

“There is no area which is more egregious than this one,” commission chairman Stuart Altman said. “If we could sort of have little flashing lights on one of the recommendations, it would be this one.”

The commission also calls on lawmakers to: require greater transparency in drug pricing and manufacturer rebates, limit the definition of providers eligible for hospital outpatient payments, and remove scope of practice restrictions for advanced practice nurses.

Scope of practice laws set legal boundaries on what tasks a medical professional can perform and under what level of oversight. Suggesting that easing the restrictions could increase access to primary care, the report says that nurse practitioners provide lower-cost care and are more likely to treat Medicaid patients and practice in rural areas.

Health and Human Services Secretary Marylou Sudders said she hoped to see commission staff also develop recommendations addressing what she identified as major spending themes that have come up in discussion for years — use of emergency rooms, re-hospitalization rates and a disproportionate use of long-term care compared to other states.

“Let’s understand more of the root causes here as we also look at some of these other issues,” Sudders told reporters.

Mass. Men Hit Particularly Hard By Opioid Crisis, New Data Show

Mass. Men Hit Particularly Hard By Opioid Crisis, New Data Show

The opioid crisis in Massachusetts is hitting men particularly hard.

Over the first nine months of 2015, 76 percent of the confirmed overdose deaths in the state were men, according to the latest quarterly opioid snapshot from the Department of Public Health.

From January through September of last year, 604 men died of opioid-related overdoses, compared with 187 women who overdosed and died over the same period, the department said.

Wednesday’s snapshot is the first time the state has released demographic data on the crisis.

Confirmed opioid deaths in Massachusetts, from January through September 2015, by gender (Massachusetts Department of Public Health)

Confirmed opioid deaths in Massachusetts, from January through September 2015, by gender (Massachusetts Department of Public Health)

Confirmed opioid deaths in Massachusetts, from January through September 2015, by age group (Massachusetts Department of Public Health)

Confirmed opioid deaths in Massachusetts, from January through September 2015, by age group (Massachusetts Department of Public Health)

Of the 791 confirmed opioid-related overdose deaths in Massachusetts over the first nine months of 2015, 81 were 15- to 24-year-olds, 247 were 25- to 34-year-olds, 203 were 35- to 44-year-olds, 178 were 45- to 54-year-olds and 82 were above 55 years old.

About 83 percent of all opioid-related overdose deaths over the first three quarters of 2015 were white non-Hispanic victims; 90 percent of all deaths in the state over that period were white.

The snapshot also revised down slightly the total number of overdose deaths (confirmed cases, plus estimated data) in 2014, from a previous tally of 1,256 to a revised estimate of 1,173.

But that new revision includes 1,099 confirmed overdose deaths in 2014, which represents a 21 percent increase over 2013 — and a 65 percent increase over 2012 figures.

Confirmed and estimated opioid deaths in Massachusetts in 2014 (Massachusetts Department of Public Health)

Confirmed and estimated opioid deaths in Massachusetts in 2014 (Massachusetts Department of Public Health)

Social Contagion

As deaths from opioids continue to rise in Massachusetts on a yearly basis, many people wonder: When will this end, or at least plateau and begin to decline? The state isn’t making a public prediction. The only published forecast I could find has the epidemic peaking in 2017 and 2018.

“Before then we would experience a continuing rise,” said Gouhua Li, a professor of epidemiology at Columbia University’s Mailman School of Public Health.

Annual mortality from drug overdose in the U.S. from 1980-2011, with projections (in gray) through 2035 (Chart from the journal Injury Epidemiology)

Annual mortality from drug overdose in the U.S. from 1980-2011, with projections (in gray) through 2035 (Chart from the journal Injury Epidemiology)

Some epidemiologists question Li’s forecast because it uses a prediction model for infectious disease epidemics like smallpox or HIV. A heroin overdose is not contagious; there’s no mosquito transporting a parasite or exchange of body fluid that leads to death.

But there is this theory called social contagion, which Dr. Li says applies to the opioid epidemic.

The opioid epidemic “spreads through social interactions, mostly,” Li said. The exchange between a heroin user and their dealer would be an example. “[The dealers] make the drug available in the vulnerable population,” Li said.

‘Ridiculously Easy’ To Get Heroin

Doctors have also come under fire for helping spread the epidemic — by prescribing too many opioids. So far, most of the effort to stop the spread has been focused on physicians. Some patients say the restrictions have gone too far, but there are signs that the attention to prescriptions is slowing the rate of overdose deaths from prescription painkillers.

“Our prescribing has flattened out, but yet the opioid overdose has increased, mainly because of heroin,” said Dr. Scott Weiner, who works in the emergency room at Brigham and Women’s Hospital in Boston and studies physician prescribing patterns.

Weiner says easy access to heroin on the streets is now fueling the epidemic.

Weiner is disturbed by what he learned from a patient he revived recently after an overdose.

“I said, ‘How easy is it to get heroin?’ And she said ‘it’s ridiculously easy.’ She said, ‘I just call the dealer, he comes to my house and he delivers it within an hour,’ ” Weiner recalled.

Even delivered, heroin is pretty cheap, less than a pack of cigarettes in some states. Based on what he sees in the emergency room, Weiner predicts the epidemic won’t peak for several more years. That’s if public health and law enforcement can slow the supply of heroin and other opioids, which could be seen as the germs in this epidemic.

Dr. Sandro Galea, an epidemiologist and dean at Boston University’s School of Public Health, agrees that supply is the big open question.

“Have we seen the worst of this epidemic? Are we now going to be getting better and seeing fewer people dying from this? A lot of that is going to depend on availability through both legal and illegal means, and that’s very hard to tell,” Galea said.

The illegal supply is thriving. A recent bust in Tewksbury took 30 kilograms of suspected fentanyl, another opioid considered 100 times more powerful than heroin, out of the disease pipeline.

Suffolk County Sheriff Steven Tompkins says so far, the dealers are winning.

“The abundance of this type of drug on the street is incredible, outrageous,” Tompkins said, adding that dealers are giving away free samples. “When drug dealers can actually give it away it’s very scary. But they know that if folk get addicted to it that they’ve got a new client, a new customer, so they’re going to make that money back 100-fold.”

Tompkins says the focus must be on education in homes and schools.

“We have to be very vigilant every day with telling people just how bad this stuff is, particularly with our kids,” Tompkins said.

(Source: Boston Public Health Commission)

(Source: Boston Public Health Commission)

Public health workers and police are tracking the epidemic, looking at who is overdosing, when and where. Public bathrooms, for example.

The Boston Public Health Commission is warning restaurants and public building managers to monitor restrooms and help avoid overdose deaths. Some police and EMTs are mapping so called hotspots, the locations of frequent overdose calls.

Epidemiologists say Massachusetts is doing a number of smart things to flight the epidemic, including the widespread distribution of naloxone, which reverses some but not all opioid overdoses, and passing Good Samaritan laws that offer immunity to friends or dealers who witness an overdose and call for help.

But “the fundamental question is whether what Massachusetts is doing is enough or whether it needs to do more,” said Galea, who has studied substance use, addiction and interventions around the world.

And that will depend on many things: education, reducing the supply of opioids, easier access to treatment and continued monitoring to understand what’s happening with this epidemic.

With additional reporting by WBUR’s Benjamin Swasey

Earlier Overdose Estimates:

More Evidence That Growing Up Poor May Alter Key Brain Structures

More Evidence That Growing Up Poor May Alter Key Brain Structures

Allan Ajifo/flickr

(Allan Ajifo/Flickr)

Poverty is bad for your brain.

That’s the basic takeaway from an emerging body of research suggesting that the distress associated with growing up poor can negatively influence brain development in many ways, and in certain cases might also lead to emotional and mental health problems, like depression.

The latest study, led by researchers at Washington University School of Medicine in St. Louis, found that poverty in early childhood may influence the development of important connections between parts of the brain that are critical for effective regulation of emotions.

The study, published in the Journal of American Psychiatry, adds “to the growing awareness of the immense public health crisis represented by the huge number of children growing up in poverty and the likely long-lasting impact this experience has on brain development and on negative mood and depression,” researchers report.

Specifically, the researchers conclude: “…Poverty in early childhood, as assessed by at least one measure, may influence the development of hippocampal and amygdala connectivity in a manner leading to negative mood symptoms during later childhood.”

The study involved 105 St. Louis-area children participating in a larger study looking at the development of emotions. Starting in pre-school, the children underwent behavior assessments for up to 12 years, researchers report, then at school-age they underwent brain scans with functional MRI.

I asked Harvard professor, Dr. Charles Nelson, a Boston Children’s Hospital neuroscientist not involved in the St. Louis study, for his thoughts.  Nelson, who studies how children’s early experiences shape their developing brains, wrote back in an email, which is lightly edited, here:

This paper represents an emerging literature that links exposure to early adversity writ large with alterations in brain and behavioral development; in this case, it specifically focuses on the effects of poverty on neural connectivity.

The sample reported on here is part of an ambitious longitudinal study that has been yielding very exciting findings. For example, in an earlier paper by [Joan] Luby et al., published in JAMA Pediatrics, the authors reported that children growing up in low [socio-economic status] households showed changes in the volume [size] of the hippocampus and amygdala, structures that play an essential role in learning, memory, and emotion.

The Luby finding is consistent with other work by Kim Noble and colleagues, that collectively suggest that growing up poor alters the course of key brain structures; however, in the Luby paper the authors went one further and demonstrated that the effects on brain structure were mediated by parental sensitivity — thus, it isn’t simply being poor that accounted for the findings, it was parental responsiveness.

The current paper extends the earlier findings by Luby by suggesting that it is not only the volume [size] of the hippocampus and amygdala that is compromised by growing up poor, it is the connections between these structures. Importantly, then they report that altered connectivity is associated with (i.e., can account for) depressive symptoms in this sample.

The work is well done and moves the ball further downfield (since we’re in the midst of Patriot fever I thought I’d use a football analogy), informing us that of the potential hazards of growing up poor.

Now, is there a down side here? Yes. We still need to “peak inside” of poverty; poverty per se doesn’t cause anything, it is the host of things that travel with poverty. Is it access to resources? Stress? Less than adequate care-giving? We really don’t know. But, the work is very important in pointing to the neurobiological toll of growing up poor.

As I note in my commentary on the Luby paper, the costs of the effects reported in this paper and in this group’s other papers extends far behind childhood; these effects can be biologically embedded and lead to less than desirable outcomes in the adults these children become.