26 December 2012

Medicare ties payments to patient surveys

originally appeared in USA Today from the Detroit Free Press:

At Providence Park Hospital in Novi, Mich., the artwork hanging on the walls isn't covered with glass, in an effort to absorb noise.

Special air-blowing vests keep patients warm pre-surgery. Private rooms are the norm. Staffers regularly check in with patients to anticipate their toilet and showering needs to cut down on call-light usage. Patients are given clear discharge instructions. Cleaning is no longer done at night. Patients are taught the difference between "pain-free" and "pain-controlled."

The reason for these changes at Providence Park and similar ones at other hospitals across the country is to ensure high scores on patient satisfaction surveys, the results of which will affect Medicare reimbursement rates, starting next year.

At issue are millions of dollars annually, all the more significant as the industry sees so many other dollars slipping away. In fiscal year 2013, for example, the pot is $964 million, according to the federal government's Centers for Medicare & Medicaid Services.

Amenities such as free lattes and valet parking are not new to hospitals. They began offering them years ago in a high-stakes fight to lure patients. However, what hospitals are doing now is, for the most part, tailored to the survey questions they know patients will be asked.

Noise is a big topic. Providence Park has reduced the number of loud carts pushed along its corridors. Instead, patients get "quiet kits" containing ear plugs and relaxation-inducing lavender lotion.

Another survey topic is staff attention.

Bells and whistles make it a nicer environment for patents, but if you're not addressing holistic, spiritual care, they're not going to rate it well, according to St. John Providence Health System's chief quality officer. We take these things and focus it up from there in addressing the patients' needs.

The Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS (pronounced H-caps) — first instituted in 2006 as a 27-question survey for discharged patients — was initially designed to be a comparison tool people could use to choose a hospital. Under the Affordable Care Act, it morphed into a dollars-loaded query in October, the start of the 2013 fiscal year.

In January, another five questions will be added.

Hospitals are at risk of losing 1% of their payouts this year if they don't do well on the surveys. That will jump to 2% by fiscal year 2017.

They have to submit a minimum of 100 surveys. To prevent them from cherry-picking the most favorable replies, the Centers for Medicare & Medicaid Services will do quarterly random audits of data.

In the past, hospitals and other providers were paid almost solely based on how much work they did — not on how well they did for patients, the Centers for Medicare & Medicaid Services said in an e-mail. Since the ACA, however, we have a number of programs in place ... that reward hospitals and doctors based on the quality of care they deliver for patients.

Among the topics in the surveys are:

• Nursing and doctor care (Did they treat you with courtesy and respect and explain things to you clearly?).

• The hospital environment (Was your room clean and quiet).

• Pain (Was your pain well-controlled).

• The discharge process.

At Botsford Hospital, changes include nurses talking to patients hourly to inquire if they need to use the bathroom and to ensure all personal items such as water, the call button and the phone are within arm's reach; audio-video relaxation system in patient rooms, and detailed "Passport to Care" discharge packets.

It's important to score that well, because that reflects we're doing the right thing for our patients, according to Botsford's director of nursing services. We're not doing it just for the money. We're doing it because it's the right thing to do.

But others in southeastern Michigan, like St. Joseph Mercy and Beaumont health systems and Sinai-Grace Hospital, said they aren't motivated by the Medicare payments to improve patient care.

We don't frankly respond to changes in reimbursement or other national surveys and comparisons, said Beaumont's executive vice president of operations. We've been working for decades to improve patient satisfaction.

He said that less than $3 million is at stake, a tiny portion of the hospital's $2.2 billion operation.

A University of Michigan associate professor of pharmacy and public health who has researched patient satisfaction surveys, said this regulatory move is a positive one, citing among other reasons the importance of patient empowerment.

The problem is America is a free-market economy, he said. We need to give patients a way to speak on what they think about health care, what works for them, how health care professionals work for them, because those factors go into determining whether treatments are successful.

23 December 2012

Obamacare, And The Government's Cruel War On Innovation

originally appeared in Forbes:

As a young professor at Johns Hopkins I was around at the beginning of the academic study of health care costs. Over time it became clear that research support in the field was going to be circumscribed by a powerful and largely unspoken common objective.  Foundations and federal research agencies were committed to the view that central control of payment would lead to lower costs and make the expansion of coverage possible.

Simply, national health insurance was the obvious objective, a view commonly but simplistically justified by reference to other “industrialized,” or “advanced,” or, “civilized,” countries.  “Single payer” coverage evolved as the strategy to take the U.S. in this direction. The majority of research grants and demonstration programs were meant to show how government payment would produce more efficient and clinically effective care.  Researchers would construct the path that would force the U.S. healthcare system to get right with history.  The cost of this intellectual hegemony has been that Congress has had very little to draw on by way of credible alternatives to improving our system.  The alternative case is hardly more than descriptions of the failures of the Canadian and British systems.

The inevitability of a national healthcare system has shaped the way Congress has attempted to regulate hospitals and doctors ever since the passage of Medicare and Medicaid in 1965.  Two interrelated themes characterize all federal policy related to controlling costs ever since; namely, central planning and resisting technological innovation.

In 1974, the government set up a planning apparatus, advanced as a means to curtail health care cost inflation. One of its central aims was to constrain the development and application of new technology.  Early on the government had determined that technology was the single most important factor in rising health care costs. This view was confirmed by European nationalized systems that worked hard to resist the proliferation of new technologies. The government’s first outing in planning under the 1974 statute was to retard the proliferation of the newly developed magnetic resonance imaging technology that subsequently proved to be the most powerful diagnostic tool since the introduction of x-rays, and the coming of today’s use of sophisticated genetic testing.

While medical technology has survived, largely on its ability to demonstrably improve clinical outcomes, its dispersion has been limited both in scope and scale by the federal government.  Federal regulation of new drugs and devices has expanded hugely over the last thirty years.  Indeed, many innovators and entrepreneurs never start new companies based on a promising new technology because they presume that ultimately the government will deny their ability to enter the market, or the process will be so long that their new company will never survive the wait.  Through device regulation government has undeniably “chilled” innovation in health care.

Interestingly, government planning has distorted the use of the technology that does emerge as well.  By concentrating new technology in hospitals where federal regulation could reach more readily than it could into doctors’ practices, hospitals play home to the most expensive technologies, such as the new proton beam therapy.  With their greater ability to assume debt to pay for machines that may cost as much as a $500 million, our system encourages hospitals to buy the most costly technology, useful in a tiny number of cases. They often compete over who has the newest dramatic technology.

Meanwhile, older, less costly but more profitable technology escapes with government’s encouragement, to private outpatient settings.  For example, same-day surgery for a wide variety of maladies is now performed in the mini-hospitals that many specialists’ offices have become.  The result is decisionmaking by individual doctors relating to procedures from which they profit.  The discipline once provided by hospital practice is gone; America is likely getting too much surgery as a result.

Not surprisingly Obamacare continues government’s dyspeptic attitude toward technological innovation.  Next year the federal government is set to impose a 2.3 percent surtax on the sales of all medical technology.  This move alone is a clear signal of the hostility that the government can send to a specific industry.  But, the legislation proposes another aspect even less congenial to new drugs and technologies:  Various government agencies are now empowered to establish a new threshold for judging products beyond the safety standards now in place.  Clinical efficacy, judged using economic cost data, will have to be proved before new drugs and medical devices are approved.  As I noted in my Fogarty Lecture at Stanford, this standard alone will greatly depress new innovation.    A government that seeks to encourage innovation does not create multiple means to frustrate its champions.

But, Obamacare does encourage one innovation, if a concept well over three decades old can be called new.  As part of a general strategy to control costs (and, it is argued, improve care) the government is mandating a new federal platform for “electronic” medical records.  (The very language makes apparent just how old the technology is.). The idea is that an orthopedist in Aspen fixing a skier’s broken leg would benefit from knowing of her patient’s tonsillectomy in Buffalo twenty years before.  Research suggests that electronic records are unlikely to save money or improve care in all but exceptional settings, such as the Mayo Clinic where all of one’s doctors practice in the same location.  In the end, government would have access to and supervise the retrieval of everybody’s medical information.  Maybe we can be trained that if we must break a leg, it would be best to do so on a weekday between 9 and 4 Washington time.

Obamacare reveals once again that our government seems incapable of seeing our economy as an integrated whole.  Healthcare has been second only to design of chips and software as the most fecund area of innovation in the U.S. for many years.  Tens of thousands of companies, millions of jobs, and many of the most incredible ideas that have translated into longer and more productive lives come from this sector.  To think of purposively making it drink from the “shrink me” bottle has implications for the whole economy.

Recently when asked about layoffs in the health technology industry a government official said that Obamacare’s expansion of coverage should induce increased demand for care that will more than make up for the $20 billion in new taxes the industry will pay every year.  Sounds like gravity-free economics.  Thousands of years of trading have led businesspersons never to buy the proposition that losses can be made up by selling more, the more so when those loses are imposed by a government that has shown that it thinks what you make isn’t necessary.

17 December 2012

Hospital Systems Branch Out as Insurers

originally appeared in The Wall Street Journal:

A increasing number of hospital systems are moving to start their own insurance plans, aiming to broaden their roles and prepare for the changes coming under the federal health-care overhaul.

Piedmont Healthcare and WellStar Health System, both in the Atlanta area, are set to announce a jointly owned insurance arm, with the goal of marketing coverage to employers and Medicare recipients in 2014. They also will consider selling coverage on a health exchange, one of the online insurance marketplaces required in each state by the health-overhaul law.

Piedmont and WellStar said their health plan would be built largely around their 10 hospitals and hundreds of affiliated doctors, and they will offer a competitive premium. We're broadening the reach of our delivery system, according to Piedmont's interim chief operating officer, who added that he expects the strategy to clearly have a positive impact on the quality of care.

In recent months, northern California's Sutter Health and New York's North Shore-Long Island Jewish Health System have said they would start selling health plans. A 2011 survey of 100 hospital leaders by health research firm Advisory Board Co. found that 20% of them intended to market an insurance plan. In 2010, around 10% of community hospitals owned, or were part of systems that owned, health plans, according to the American Hospital Association.

Typically, the new entrants will offer health-maintenance-organization-style plans that allow patients limited access to doctors and hospitals outside their network.

Some systems that have had limited insurance operations are expanding, including MedStar Health in the Baltimore-Washington area, which will add Medicare plans next year and is likely to have a plan on the Maryland health exchange, and Indiana University Health, which expects to start offering health plans to employers in 2013.

The moves reflect a broader blurring of the lines between those who provide health care and those who pay for it, as both sides increasingly aim to provide more efficient, seamless care. The hospital systems themselves are the product of a consolidation that brought together many hospitals and doctors.

Driving the trend is the mounting pressure to reduce costs, as well as the changes set to be unleashed by the health-care overhaul. In addition to adding coverage for millions of people, partly by expanding Medicaid, the federal-state health program for low-income Americans, the law will cut back on hospital payments by Medicare, the federal insurance program for the elderly. Some hospitals are starting their own plans for Medicaid recipients.

The hospitals expect to get a shrinking slice of reimbursements from the fees insurers and others pay for specific services. That payment system has been blamed for fueling rising health costs. Providers who depend solely on fee-for-service revenue will eventually have a slow death, according to the chief executive of North Shore-Long Island Jewish.

He said his hospital system intended to offer its own exchange plan, perhaps in 2014, the first year the health exchanges are supposed to be running. I want to go upstream as much as possible and take the premium dollar at the source, he said.

Because insurers pay claims for all doctor visits, lab tests and other care, they get a full view of their members. Hospital systems say they need direct access to that data, which they can get by offering their own plans, to manage patients better, avoiding duplication and detecting and treating problems early to head off pricey procedures later.

It's so much better for us to have, at least for a slice of our business, a total picture as to what's going on, according to a senior vice president at Sutter Health.

Still, most hospital systems have been stopping short of getting an insurance license, often taking more limited steps like striking reimbursement deals with insurers that reward them for providing more efficient care. Some are also forging partnerships with insurers that sometimes involve jointly selling a health plan built around the system.

Some hospital operators, including the University of Pittsburgh Medical Center and Intermountain Healthcare in Utah, long have had health plans. Others, including some health systems considering them now, have tried and failed with them in the past. The failures in part reflect the difficulties of reconciling conflicting interests: Hospitals typically make money when they fill their beds with patients, and health plans pay the bills for those admissions.

Another factor: Patients revolted against HMOs in the 1990s, when they were popular with employers, because they felt that HMOs limited their choices of providers and access to care.

The hospital systems may also create new fault lines as they compete against the other insurance companies that pay them, though their size and market power will make it tough for insurers to shut them out.

Aetna Inc.'s partnerships are lower cost, more flexible and more scalable for systems than building health plans from scratch, according to the chief executive of Aetna's Accountable Care Solutions business. Aetna's network includes providers who operate their own networks, but if a system became a significant competitor, competitive dynamics might push us…in a direction where we might not want to contract with them in a preferred state, or favor the system in Aetna's own plan designs.

Many of [the hospital systems] are also folks we do business with, according to Blue Shield of California's senior vice president for network management. There's a potential for that to be difficult.

Like insurers, which are building lower-cost narrow network plans for the exchanges, the hospital systems are betting that consumers will be willing to accept a smaller choice of health-care providers in return for the promise of smoothly integrated care and premiums that are likely to be lower. The hospital systems plan to build their coverage around their own networks, but may fill them out with other providers as well.

Hospital systems say their focus is on providing high-quality care, and they think that the better technology that helps them closely track patients will ensure they avoid some of the financial pitfalls of decades ago. Also, today there is financial urgency, according to the chief executive of Evolent Health, which is advising many hospital systems pursuing integrated operations, including Piedmont.

Piedmont and WellStar together have about 30% of the inpatient market share in the Atlanta area. Working together will spread out the fixed costs of starting a health plan, as well as offer greater reach in the combined network, according to the chief executive of WellStar.

Foreseeing the Issues in Medicare's Future

originally appeared in The New York Times:

The projected growth of Medicare costs is the single biggest contributor to the country’s long-term budget deficits, many estimates show. No cohort of Americans, with the possible exception of the very affluent, pays enough in Medicare taxes and premiums to cover its eventual Medicare costs.

Much of the early public discussion of the fiscal deadline has focused on taxes, and the decline of tax rates in recent decades has played a crucial role in creating the deficit. But the question of how to reduce the growth of Medicare costs will become increasingly important as the population continues to age and health costs continue to increase.

In the current fiscal talks, Republicans are pushing for significant changes to Medicare, in exchange for agreeing to tax increases. Democrats are arguing that Medicare is not the most pressing budget problem.
What follows is a primer on Medicare costs.

Q. Is Medicare really a bigger long-term problem than Social Security or military spending?

A. Yes. Over the next 25 years, the Congressional Budget Office projects that Medicare spending will rise to 6.7 percent of the gross domestic product, from 3.7 percent this year. (Other federal health care spending — like Medicaid, the insurance program principally for low-income families — is projected to rise to 3.7 percent of the G.D.P. in 2037, from 1.7 percent this year.)

In total, health care spending’s percentage of the G.D.P. is expected to rise by five points. Social Security spending is projected to rise by only 1.2 percentage points, to 6.2 percent in 2037. All other federal spending is expected to shrink by two percentage points, to 9.6 percent.

These estimates assume that some current policies continue, rather than that the various tax increases and spending cuts scheduled to take effect on Jan. 1 occur and remain in place.

Q. Why is Medicare the big problem?

A. As much attention as the aging of society receives, the rise of medical costs is a bigger budgetary problem. The faster growth of Medicare costs, relative to Social Security costs, highlights this difference.

Social Security costs will indeed grow in coming years, adding to the government’s fiscal problems. But those costs will not grow nearly as rapidly as Medicare’s, because Medicare costs are a function of both the aging society and the cost of treating any one person. Social Security’s costs stem almost entirely from the number of elderly people.

Q. Don’t most Americans pay for their Medicare benefits, through payroll taxes over their working lives?

A. No, and it is not even close. Two married 66-year-olds with roughly average earnings over their lives will end up paying about $122,000 in dedicated Medicare taxes through the payroll tax, including the part their employers pay, according to the Urban Institute. That married couple can expect to receive about three times as much — $387,000, adjusted for inflation — in benefits. The projected gap is even larger for younger people because of growing health care costs.

In short, the single biggest cause of the long-term deficit is that most people receive much more from Medicare than they give to it.

Q. Why are health costs growing so rapidly?

A. For a good reason and a bad one.

The good reason is that our medical system has made enormous progress in recent decades and can treat conditions that once would have killed people. Cancer treatment and cardiac care are two examples of areas with beneficial new treatments that are often not cheap. An American who turns 65 today can expect to live almost 20 more years on average, up from about 16 years in 1980.

The bad reason is that our health care system wastes large amounts of money. The United States spends roughly twice as much money per person on health care as many other rich countries, without getting vastly better results. Americans receive better care in some areas (some cancers) and worse in others (higher error rates).

It is hard to make the case that the American health system provides a good return on the money it spends. Life expectancy is higher and has grown over the last 30 years in Australia, Britain, Canada, France, Germany and Japan, among other countries.

Q. What are the possible solutions?

A. For starters, we could pay more in taxes. Tax revenues are near a 60-year low as a share of the G.D.P. They will rise somewhat as the economy recovers and incomes increase, but not by nearly enough to pay for growing health care costs.

Covering the future costs of Medicare and Medicaid solely through higher taxes would involve sharp increases — much greater than anything being debated now. So most budget experts believe that changes to Medicare need to be part of the deficit solution.

Among the options are raising the eligibility age, which is now 65; reducing benefits for affluent families; introducing more competition; and paying for quality of care, rather than quantity.

Q. What are the upsides and downsides of each?

A. Let’s take the options one at a time:

The main arguments for raising the eligibility age are that Americans live longer than they used to and that the 2010 health care law makes it easier for people to get insurance if they do not receive it from an employer. The main counterargument is that the longevity increase has been smallest for low-income people, who are most likely to benefit from Medicare coverage.

Reducing benefits for high-income families has some bipartisan support, given the recent increases in income inequality. But some Democrats worry that it could eventually undermine Medicare’s popularity, making it more akin to a welfare program.

Many Republicans advocate for more competition in health care, noting that competition has reduced prices and raised the quality of service in many industries. It has an uneven record of doing so in health care, though, in part because insurers can often profit by denying care.

Paying for quality rather than quantity has support from many economists. But it is not always easy. Patients and doctors often want to proceed with high-cost care even when research has not shown it to be effective.

Q. Does Medicare need to be fixed before Jan. 1?

A. Obviously not. Many potential changes would need to be phased in and would not bring savings for years. Other policy changes, like tax increases, can have a quicker effect on the deficit.

On the other hand, fixing Medicare is never going to be easy. Every budget negotiation between Congress and the president is an opportunity for them to make progress on a fiscal problem that is growing every year.

13 December 2012

Study: Holiday suicide myth persists

originally appeared in USA Today:

Suicides spiking during the holidays is a myth that comes back to haunt us every year.

The months of November, December and January actually have the lowest number of suicides per day, according to the University of Pennsylvania's Annenberg Public Policy Center, which analyzed 1999-2010 data from the Centers for Disease Control and Prevention (CDC). It found that averages were highest in the spring and summer.

There is still this sort of ironic thought that maybe there are people not happy at this time, according to the Public Policy Center.  Songs and movies focused on the "holiday blues" -- including the perennial favorite It's a Wonderful Life -- also perpetuate the myth.

The center, which has tracked the media's reporting of suicides since 2000, looked at stories that linked suicides and the holidays. In 1999, 77% of those stories said, erroneously, that suicides increased over the holidays. The proportion of stories that supported that myth dropped after the center's analysis came out, but rose again last year to 76%.

The Public Policy Center tells us the return of the holiday-suicide connection may be related to the fact that the adult (ages 25 and older) suicide rate has increased in recent years in step with the Great Recession. With more people affected by suicide, news stories about suicide may be more common over the holidays, bringing the myth back to our attention.

In 2010, there were 38,364 suicides in the USA, an average of 105 a day. The month with the highest daily average in 2010 was July, with 111.3. The lowest, 98.2, was December. The CDC says suicide was the 10th leading cause of death in 2010.

Suicide-prevention experts say stories perpetuating the myth are not only wrong but dangerous.

The National Action Alliance for Suicide Prevention says that it's normal for people in their situation to end their life may be just that little nudge that puts them over.

They say anyone contemplating suicide should call the National Suicide Prevention Lifeline at 800-273-8255. Those who know someone in distress can call as well.

Media coverage needs to be more balanced. Coverage should include ways to prevent suicide, such as recognizing warning signs, as well as stories about people who got through those dark times. The number of people who positively adapt to life stresses far outweighs the number of people who do not, according to the National Action Alliance.

They conclude that those success stories may give hope to people with suicidal thoughts. The majority of people in their situation find a way to live. That might give them the courage to go on and keep looking for that way.

Women Notch Progress in Legal, Medical Fields

originally appeared in The Wall Street Journal:

In a major shift from a generation ago, women now account for a third of the nation's lawyers and doctors when those professions were occupied almost exclusively by men, new Census figures show.

Women's share of jobs in the legal and medical fields climbed during the past decade even as their share of the overall workforce stalled at slightly less than half. Women held 33.4% of legal jobs—including lawyers, judges, magistrates and other judicial workers—in 2010, up from 29.2% in 2000. The share of female physicians and surgeons increased to 32.4% from 26.8% during that time.

According to the president of the Institute for Women's Policy Research, a nonprofit group in Washington, that's very significant progress, in the midst of a lot of evidence that women's progress has plateaued, nevertheless we can see that women are still making progress in some very professional, high-wage fields.

Women's gains in these fields follow the rise in their professional school enrollments over time. Harvard Law School, for example, was closed to women until 1950, and the Washington and Lee University School of Law was the last U.S. law school to open its admissions to women in 1972, according to research by Hannah Brenner and Renee Newman Knake of Michigan State University's College of Law. Today, women graduate from law school in roughly the same numbers as men. They make up just under half—45.4%—of medical residents and fellows, or medical-school graduates in training, according to the American Medical Association.

A 26-year-old Miami resident said earlier generations in her family of Greek heritage believed women were meant to stay at home and raise children. While she was growing up, her mother didn't work.

But her parents emphasized the importance of getting an education to achieve a middle-class lifestyle. She earned a bachelor's degree in American history at Columbia University. During school, she worked part-time at a Manhattan law firm feeding off the energy of assisting on big cases, she said.

She graduated from the University of Miami School of Law last year and now is a commercial litigator. Two partners in the Florida firm where she works are mothers raising children, she said that for her, and for other women we're kind of just trying to get a start on our careers and focus on that.

Despite women's greater presence in law and medicine, wage gaps between men and women persist in both fields. In 2007, the median income—the point at which half earn more and half earn less—of female lawyers was $90,000, compared with $122,000 for male lawyers, according to research by Harvard economists.

The median income of female physicians was $112,128, compared with $186,916 for male physicians. Those differences are largely explained by individual choices, including women taking off time to raise children or opting for less-demanding career tracks or positions that pay less. But a small portion of the gap exists for unclear reasons. Discrimination could also be a factor, though it isn't clear how much, according to the economists.

One of the economists said women's gains in medicine have coincided with the rise of corporate-owned hospitals and medical practices, in many cases making it easier for women to balance work and family. Health-care companies have bought up many small, previously male-owned independent practices and raised women's wages closer to men's, while offering more flexible work schedules.

While women have made strides in the legal profession, at law firms few are taking management positions. Some leave for jobs as counsel to corporations, where hours can be more predictable. At large law firms, women make up just 15% of equity partners, according to a survey released in October by the National Association of Women Lawyers. Of the 200 firms surveyed, just 4% had a woman at the helm in the role of firm-wide managing partner.

A lawyer in Oakland, Calif., said biases against women were overt in 1975, when she graduated from the University of California Hastings College of the Law and started looking for jobs.

People would say directly, 'You can't be a lawyer because you're a woman, women are too emotional, their voices are too high,... they aren't tough enough,' she said women still face barriers to leadership jobs at firms, because advancement is largely based on hours worked. You're really trying to break into an established network, coming at it from the perspective of the woman, when most of the structures are designed by men.

A Michigan State University associate law professor, said while women graduate from law school in roughly the same numbers as men, many women leave the field for careers that offer more flexibility in hours and location.

The professor stated, as much as it's good to see the progress, she still remains troubled that we don't see a lot of our law graduates staying in the profession.

Frankie Muniz, 26, tweets about his 'mini stroke'

originally appeared in USA Today:

Twenty-somethings having strokes? Yet that's what former Malcolm in the Middle star Frankie Muniz, 27 on Wednesday, says happened to him.

The young actor tweeted that he was in the hospital last Friday and suffered a "Mini Stroke", which he described as not fun at all. He said he’ll have to start taking care of his body! (he’s) getting old!

A lot of very specific information related to health, strokes, mini-strokes, and southfield stroke is also available online.

He did not explain why, and according to TMZ, doctors are still stumped, awaiting test results. TMZ says Muniz was taken to an Arizona emergency room after his friends became alarmed when they noticed he was acting strange, and having trouble speaking and understanding.

Specific explanations and information relevant to stroke and care for strokes is also at detroit stroke online resource.

What exactly is the difference between a "mini" stroke and major stroke? According to the Mayo Clinic, a mini-stroke is "transient ischemic attack (TIA)," a temporary interruption of blood flow to part of the brain. The symptoms of both are similar but a TIA doesn't destroy brain cells or cause permanent disability.

A mini-stroke can recur and each one increases the risk of another. Medication may be needed.

12 December 2012

Colts coach Pagano finishes chemotherapy

Originally appeared in USA Today:

Chuck Pagano's return to the sideline this season remains a real possibility after the Indianapolis Colts head coach concluded a third and final round of chemotherapy Tuesday in his battle with leukemia.

I'm fully supportive, and I have my fingers crossed that he'll be there on the sideline if that's where he wants to be according to IU Health Simon Cancer Center said Tuesday evening.
That conceivably could be the regular-season finale Dec. 30 against the Houston Texans at Lucas Oil Stadium. The decision will be made jointly by Pagano and the organization.

ULTIMATE ASSIST: Bruce Arians steps up for Colts

According to IU Health Simon Cancer Center things are going well, he's received all of the chemotherapy he was to receive. Now it's just a matter of over the next couple of weeks recovering back to health. He can start conditioning and moving towards what he wants to do, which is return to coaching.

Perhaps as soon as Dec. 30?

The IU Health Simon Cancer Center states medically, (we) think it's very possible, and (we) think the coach will make the decision about how he's feeling and whether he's up to the task, then, the organization will make a decision.

It's feasible. It's possible. Is it definite? No. (we) definitely think that's where we're heading, and we have our fingers crossed that things go well and he's able to do it.

Pagano has been on indefinite leave since being diagnosed with leukemia Sept. 26. He endured three rounds of chemotherapy and felt well enough to attend the last two home games. It was announced Nov. 5 Pagano was in remission.

The IU Health Simon Cancer Center praised his positive approach throughout the process.
He's been amazing in terms of his focus, he's done well enough he's focused on his diet and his conditioning.  He's done very well. But knock on wood. We've still got a couple more weeks to go.

28 November 2012

Requirements of Health Care Reform Affirmed

story first appeared in Los Angeles Times

The Obama administration reaffirmed key requirements of the new healthcare law Tuesday, setting out how insurance companies will cover nearly all Americans, even if they are already ill, and provide plans with minimum benefits.

Consumer advocates, insurers and business groups were looking for signs the administration might try to modify some of the law's requirements as the federal government races to implement the legislation by the end of next year.

But the proposed rules issued Tuesday hew closely to the Affordable Care Act that President Obama signed in 2010. At the same time, administration officials restated their commitment to move rapidly ahead, despite continued resistance from some Republican governors.

Health and Human Services Secretary Kathleen Sebelius said  this means that beginning in October next year, families and small-business owners everywhere will be able to shop for affordable, quality health coverage and entrepreneurs won't have to give up their chance at affordable health coverage to start a new business.

Under the law, Americans who are not covered through work will be able to comparison shop for health insurance in online markets, also known as exchanges, designed to mimic the shopping experience of popular travel sites.

These exchanges will be run by state governments, except in states that elect to leave the job to the federal government or to partner with Washington.

More than 15 states, mostly with GOP governors, have said they will not operate an exchange. Some governors have complained the federal government has put too many requirements on the exchanges.

In state and federally run exchanges, insurance companies will be prohibited from denying coverage to sick Americans. Insurers will no longer be able to charge more from women or customers with medical conditions.

And for the first time, insurers will have to cover 10 basic benefits, including hospitalizations, emergency care, newborn and maternity care, and prescription drugs.

The Obama administration has allowed each state to detail this set of benefits, allowing for some variations of drugs that might be covered, for example.

That worries many consumer advocates who would like to see a national standard for health insurance. Carl Schmid, deputy executive director of the AIDS Institute fears that leaving the decision up to the states of which drugs insurance plans must cover, many patients, particularly those with complex medical conditions, may not have the coverage they need.

But several leading consumer groups, including AARP, which represents older residents, and the American Cancer Society's Cancer Action Network, applauded the administration for retaining key protections in the law, including a requirement that insurers charge elderly consumers no more than three times as much as they charge young customers.

Insurers had pushed for more leeway to vary rates based on age, arguing that this was necessary to keep premiums affordable for younger, healthier customers.

Gary Cohen, who oversees insurance regulations at the Department of Health and Human Services, said the administration did not believe this was necessary to attract younger consumers, who will have access to a lower-priced health plan to cover catastrophic illness and also may qualify for new subsidies to offset their premiums.

The administration adjusted several rules to accommodate industry concerns, including allowing insurance companies to institute higher deductibles in plans they sell to small businesses and setting enrollment periods to prevent consumers from signing up for insurance only when they get sick.

The proposed new rules drew cautious praise from several leading industry representatives. Karen Ignagni, head of America's Health Insurance Plans, reiterated concerns that requirements still may force consumers to purchase coverage that is more costly than they have today.

25 November 2012

BCBS Overhauled

Story first appeared on freep.com.

A proposal that would end Blue Cross Blue Shield of Michigan's tax-exempt status and transform the organization from a charitable trust of the state to a customer-owned nonprofit is making headway in Lansing, but not without critics trying to step in the path of the legislation to overhaul Michigan's largest health insurer.
Competitors and advocates for consumers and the elderly — including the state attorney general — have been attempting to change or stop the legislation, which was proposed by Gov. Rick Snyder and enjoyed widespread support in the Michigan Senate. The voices for and against it now are setting their sights on the House, which is holding committee-level hearings that continue Monday and plans to bring the measures to a full and final vote by year's end.
Supporters, including the company, say the aim is to level the regulatory playing field for all health insurers. The proposed overhaul aims to modernize but not sell Blue Cross, which is governed by a separate state law from other insurers and typically waits much longer for its rate changes to be reviewed. Streamlining regulations, they say, is particularly important, as health insurers gear up for the implementation of the federal Affordable Care Act and try to meet a March deadline for getting its products and rates ready for an online health exchange where people can compare and buy their own insurance plans.
Blue Cross' special status is no accident. The insurer has been designated the state's insurer of last resort — meaning it must provide insurance coverage regardless of a customer's health status. Because of that, Blue Cross has been exempt from paying several local and state taxes. The measures proposed by Republican Gov. Rick Snyder, endorsed by Blue Cross and passed last month by the Senate, require the company to begin to pay those taxes, which Blue Cross estimates will average $100 million annually.
By transforming, Blue Cross also would shed its charitable "social mission" and contribute up to $1.5 billion to a nonprofit foundation that would carry on that work. Broadly speaking, the foundation would work to improve public health and health care access, particularly for children and the elderly. About 60% of the money is earmarked in the first four years to subsidize Medigap, which fills the gap in Medicare coverage for seniors, to prevent rates from significantly rising.
It would join 12 other Blue Cross Blue Shield companies nationwide structured as mutual insurers, which means they are owned by members. Those companies operate in 14 states.
Critics say it all doesn't add up. For starters, the contribution isn't set in stone and neither is the size of the tax bill after credits are taken into account. They fear that the social mission will be diminished because it doesn't cover the more than $300 million it contributes to social mission work.
The $1.5 billion represents half of Blue Cross' book value — the organization's assets minus liabilities. Some have been calling for a full financial valuation, saying it would provide a more accurate picture of its worth.
Michigan Attorney General Bill Schuette has opposed various parts of the legislation during the past two months and successfully lobbied to get the extended subsidies for eligible seniors, among other things, into the Senate bills. This past week, officials from his office argued for the first time publicly that the specific language creating the foundation needs to be much tighter and it should be set up so the Internal Revenue Service doesn't see it as self-dealing when Blue Cross — a major supplier of Medigap coverage — receives subsidies from the nonprofit.
Mark Cook, Blue Cross' vice president of governmental affairs, said at a hearing Tuesday that the intention of the legislation is clear to Blue Cross, which plans to make annual payments. He said the insurer is open to more language provided it's not forced to make that $1.5 billion payment at one time.
Also, he said, what some call "social assets" paid by Blue Cross in Michigan are viewed by the organization as losses. Blue Cross reported about $300 million in losses last year related to the subsidies it pays for Medigap and money it loses on individual insurance products because they tend to get the sicker folks.
Ultimately, Cook said the legislation is not what we would have proposed, but the company supports it. He said Snyder wanted to go larger and create uniformity in the insurance system, so he called for a review of the 32-year-old public act that pertains to Blue Cross, which led to the proposal he announced in September to do away with it.
Regardless, any large internal change to an insurer with 4.4 million customers representing 70% of the market is going to raise concerns and should be scrutinized.

19 November 2012

Study Shows Health Benefits of Reflexology

story first appeared on freep.com

Reflexology -- the method of massaging the feet to stimulate parts of the body -- can help cancer patients perform daily tasks better.

That's the conclusion of a new study led by Michigan State University researcher Gwen Wyatt, a professor in the College of Nursing.

The study, funded by the National Cancer Institute, is believed to be the first large-scale study to put hard science behind the benefits of reflexology as a complement to standard cancer care,

"It's always been assumed that it's a nice comfort measure, but to this point we really have not, in a rigorous way, documented the benefits," Wyatt said in a report released by the MSU today. "This is the first step toward moving a complementary therapy from fringe care to mainstream care."

People who received the reflexology treatment had significantly less shortness of breath and were able to more easily perform such tasks as climbing stairs, getting dressed and going grocery shopping, according to the MSU report.

Over an 11-week period, they compared the reflexology group with a group that had regular foot massage and a group that had neither foot massage nor reflexology. The study involved 385 women undergoing chemotherapy or hormonal therapy for advanced-stage breast cancer that had spread beyond the breast. The women were assigned randomly to three groups: Some received treatment by a certified reflexologist, others got a foot massage meant to act like a placebo, and the rest had only standard medical treatment and no foot manipulation.

Wyatt is now researching whether massage similar to reflexology performed by cancer patients' friends and family, as opposed to certified reflexologists, might be a simple and inexpensive treatment option.

Republican States Delaying Health Care Law Deadine

story first appeared on nytimes.com

The days since President Obama won re-election have been marked by tension and angst in Republican-led states like Iowa, where Gov. Terry Branstad has waited until the last minute to decide whether to create a crucial tool for people to get medical coverage under Mr. Obama’s health care law.

State Senator Jack Hatch, a Democrat who vented his frustration at a news conference here this week, said there had been a total blackout of information, and they they are behind schedule and at a disadvantage.

States are supposed to tell the Obama administration by Friday whether they want to create their own health insurance exchange — a deadline that many had bet might never come to pass, choosing to sit on their hands for months in the hope that Mitt Romney would win the presidency and the health care law would be repealed.

On Wednesday, they dug in their heels a little more. Leaders of the Republican Governors Association, gathering in Las Vegas for their annual meeting, wrote a letter to Mr. Obama requesting more time, more guidance and a meeting where the president and governors could talk.

Insurance exchanges — basically online markets where the uninsured can shop for private health insurance, often with federal subsidies to help pay — are considered critical to making the health care law work. So far, 17 states, most led by Democrats, and the District of Columbia have indicated they will create their own state-run exchanges.

The other options are setting up an exchange in partnership with the federal government, or simply letting the federal government do it.

Every state is supposed to have an exchange by Jan. 1, 2014, when the health care law will require most Americans to have insurance. The exchanges are supposed to be ready to start enrolling people in October 2013.

Despite the unhappiness, there are indications that some Republican governors may be softening their opposition to the law. Gov. Rick Scott of Florida, a Republican who had been one of its toughest critics, signaled this week that he would be open to compromising.

And Governor McDonnell of Virginia — like Florida, a state Mr. Obama carried — noted that while his state had been the first to file suit seeking to block the law, it would comply with it.

But he said that the complexity of the law, and the lack of details from Washington, meant that “my best experts in Virginia, my doctors and others that are advising me on what to do, say they still can’t make a prudent call between a state or federal exchange because we don’t have all the answers.”

Others are facing intense, sometimes conflicting pressures from state legislators and interest groups. In Wisconsin, health care providers and business groups are lobbying Gov. Scott Walker to create a state exchange, while Tea Party groups are warning him not to.

At the Republican governors meeting in Las Vegas, Mr. Walker said in an interview that he would prefer a state-based program, but that he doubted that the federal government would allow him to shape it as he saw fit.

He said that he would not disclose his decision until Friday, but added, “Why do I want to take on the potential risk to my taxpayers if I don’t really have any true authority about what’s going to happen?”

Republicans who support state-run exchanges say they are embracing a fundamental conservative belief: that states should make their own decisions rather than cede control to the federal government. But others argue that deferring to the federal government is a shrewder move; that way, they say, it will not be their fault if anything goes wrong.

Experimental Breast Cancer Treatment Proving Beneficial

story first appeared on usatoday.com

Vickie Baker did not have time for breast cancer.

The 49-year-old Hazard resident knew she needed radiation therapy, but she couldn't imagine how she could get to University Hospital in Louisville for treatments five days a week. Not when she lives more than three hours away and babysits eight grandchildren.

But a University of Louisville study allowed her to receive radiation treatment just once a week in March and April, after a lumpectomy in January.

Baker, who is doing well today, said the experimental treatment for people with early stage breast cancer made her life easier and offered hope for the future.

Dr. Anthony Dragun, a radiation oncologist at the University of Louisville's James Graham Brown Cancer Center who is overseeing the study, hopes it will make radiation treatment more accessible to women facing such obstacles as distance, transportation problems and time constraints — while also cutting treatment costs by more than half.

Research subjects get higher doses of radiation once weekly than they would receive during each daily treatment, but less radiation during the overall five-week course of treatment. Traditional daily radiation schedules are also usually five weeks, but in some cases may be six or seven weeks.

Some areas of the country have better access to this type of treatment. A Cancer Specialist Detroit procedure might be available in areas less rural than in Appalachia.

Dragun led a study two years ago showing that about a third of Kentucky women with early stage breast cancer didn't get recommended radiation treatments after lumpectomy surgeries.

Among those least likely to get radiation were the elderly, African Americans and women in rural areas, including the Appalachian region of the state.

Women who did not get recommended radiation were 60% more likely to die during the time they were studied.

Dragun said that many times studies like these are published but never followed through to the next step, but made sure that wasn't the case here.

He said he's hopeful about the new regimen. In his study and previous European studies, women getting weekly radiation report similar levels of side effects as those getting radiation five days a week.

Some outside experts say the approach seems promising, but one pointed to research that found drawbacks in terms of breast appearance after once-a-week treatments.

Baker, who is scheduled for a follow-up doctor visit later this month, said she's glad to play a part in advancing the science.

Less trips, money

Dragun's study targets women with breast cancer in Stages 0-II who have undergone lumpectomies and who may be getting chemotherapy or hormonal therapy.

He said the experimental regimen not only improves access to care, but also significantly reduces treatment costs as measured by Medicare reimbursement. Five weekly treatments total $2,901, compared with $6,884 for 25 daily treatments over five weeks.

And that doesn't count such costs as increased medical staff time for the more frequent treatments, and wear-and-tear on the linear accelerator that provides the radiation.

Dragun said it is less costly for the health care system, and added that it also saves patients money on transportation and potential expenses such as overnight stays near cancer centers.

But Dragun said the biggest benefit is improving access to care — which can potentially save lives, while also giving patients more time with their families and less time off of work.

Baker said distance was a big obstacle for her after doctors found a lump in her right breast on a mammogram in 2011 and her family physician referred her to University.

After the lumpectomy in January, she didn't hesitate to join Dragun's research.

Baker said she and family members drove to Louisville each week, returning to Hazard the same day. Noting that she frequently takes care of her grandchildren, she predicted that, if the only option were daily radiation treatments, she would simply have skipped some.

Baker is one of 90 patients who have joined the study, which opened in January 2011 and aims to enroll 250 patients.

An article on the results among the first 42 patients has been accepted for publication in the International Journal of Radiation Oncology, and it concludes that women's tolerance of the weekly radiation compares well with recent reports of daily schedules, and the new regimen appears feasible and cost-effective.

Dr. Bruce Haffty, associate director of the Cancer Institute of New Jersey and president-elect of the American Society for Radiation Oncology, said he's aware of Dragun's research, which is one of several alternatives to daily, five-week radiation regimens being studied right now.

Haffty said radiation technology has grown more sophisticated, and such pared-down treatment schedules may someday help patients with long distances to travel.

Unequal treatment

If weekly regimens do become common, Dragun said they could be particularly helpful in such places as Kentucky, a largely rural state beset by doctor shortages, high levels of poverty and cancer disparities.

In his previous study, he and his colleagues analyzed the radiation rates for 11,914 women who underwent lumpectomies for early breast cancer, and found the percentages who didn't get radiation were 47.5% for women 70 or older, compared with 28.9% for those under 50; 43.8% for Appalachian women, compared with 30.4 for non-Appalachian women, and 35.4% for black women, compared with 33.6% for white women.

The study found that women without private health insurance fared worse. Among uninsured women, 34.4% didn't get radiation, compared with 27.8% for those with insurance, 34.5% for those with Medicaid and 42.1% for those with Medicare.

Dr. LaQuandra Nesbitt, director of the Louisville Metro Department of Public Health and Wellness, said some people believe that breast-cancer disparities could be eliminated simply by making screenings more available.

But she said the problem is much more complicated, considering big issues with access to care, timeliness of care and quality of treatment for cancer.

She said even the issue of transportation isn't as simple as it seems. In rural areas, public transportation is often scarce.

Nesbitt said new treatment schedules such as the one Dragun is studying could help — not only by reducing the number of commutes but also by improving women's quality of life.

Dragun said if his results hold up, the new treatment regimen eventually could help all early stage breast cancer patients who need radiation because less frequent treatments would be a boon to any woman juggling work and child-rearing.

15 November 2012

New Affordable Care Act Has State Tense Over Deadline

Story first appeared in the New York Times.

The days since President Obama won re-election have been marked by tension and angst in Republican-led states like Iowa, where Gov. Terry Branstad has waited until the last minute to decide whether to create a crucial tool for people to get medical coverage under Mr. Obama’s health care law.
 “There has been a total blackout of information,” said State Senator Jack Hatch, a Democrat who vented his frustration at a news conference here this week. “We’re behind schedule, we’re at a disadvantage, and I don’t know what our governor’s plan is to reposition Iowa.”

States are supposed to tell the Obama administration by Friday whether they want to create their own health insurance exchange — a deadline that many had bet might never come to pass, choosing to sit on their hands for months in the hope that Mitt Romney would win the presidency and the health care law would be repealed.

On Wednesday, they dug in their heels a little more. Leaders of the Republican Governors Association, gathering in Las Vegas for their annual meeting, wrote a letter to Mr. Obama requesting more time, more guidance and a meeting where the president and governors could talk.

“States are struggling with many unanswered questions and are not able to make comprehensive, far-reaching decisions prudently,” Gov. Bob McDonnell of Virginia, the chairman of the association, and Gov. Bobby Jindal of Louisiana, its next chairman, wrote.

Insurance exchanges — basically online markets where the uninsured can shop for private health insurance, often with federal subsidies to help provide Prescription Drug Assistance pay — are considered critical to making the health care law work. So far, 17 states, most led by Democrats, and the District of Columbia have indicated they will create their own state-run exchanges.

The other options are setting up an exchange in partnership with the federal government, or simply letting the federal government do it.

Every state is supposed to have an exchange by Jan. 1, 2014, when the health care law will require most Americans to have insurance. The exchanges are supposed to be ready to start enrolling people in October 2013.

Despite the unhappiness, there are indications that some Republican governors may be softening their opposition to the law. Gov. Rick Scott of Florida, a Republican who had been one of its toughest critics, signaled this week that he would be open to compromising.

“The election is over, and President Obama won,” Mr. Scott told The Associated Press. “If I can get to yes, I want to get to yes.”

And Governor McDonnell of Virginia — like Florida, a state Mr. Obama carried — noted that while his state had been the first to file suit seeking to block the law, it would comply with it.

But he said that the complexity of the law, and the lack of details from Washington, meant that “my best experts in Virginia, my doctors and others that are advising me on what to do, say they still can’t make a prudent call between a state or federal exchange because we don’t have all the answers.”

Others are facing intense, sometimes conflicting pressures from state legislators and interest groups. In Wisconsin, health care providers and business groups are lobbying Gov. Scott Walker to create a state exchange, while Tea Party groups are warning him not to.

At the Republican governors meeting in Las Vegas, Mr. Walker said in an interview that he would prefer a state-based program, but that he doubted that the federal government would allow him to shape it as he saw fit.

“I’d much prefer control at the state level,” Mr. Walker said, “but the problem is, I don’t think they are really state-run.”

He said that he would not disclose his decision until Friday, but added, “Why do I want to take on the potential risk to my taxpayers if I don’t really have any true authority about what’s going to happen?”

Republicans who support state-run exchanges say they are embracing a fundamental conservative belief: that states should make their own decisions rather than cede control to the federal government. But others argue that deferring to the federal government is a shrewder move; that way, they say, it will not be their fault if anything goes wrong.

The Affordable Care Act is a federal program, it’s primarily designed to give federal premium tax subsidies, and it’s all tied up in federal regulations,” said Tony Keck, director of the Department of Health and Human Services in South Carolina, which has rejected the idea of running its own exchange. “So to ask states to get involved is like asking states to run the post office. It doesn’t make sense.”
Setting up an insurance exchange is no simple task. Among other things, states have to set up a governance board, decide what kinds of health plans to offer through the exchange and build sophisticated information technology systems.
lthough many Republican governors delayed planning, some have quietly prepared. Gov. Brian Sandoval of Nevada and Gov. Susana Martinez of New Mexico have spent months laying the groundwork for exchanges; so has Mike Chaney, the Mississippi insurance commissioner.

Creating a state-based exchange will “allow us to retain some flexibility,” said Matt Kennicott, a spokesman for the New Mexico Human Services Department, and allow people there to buy insurance in an exchange “developed by New Mexicans, for New Mexicans.”

Other states, like Alaska, South Carolina, South Dakota and Texas, had already decided to let the federal government run an insurance exchange for them instead of building one themselves. A handful of additional states — Alabama, Kansas, Ohio, Wyoming and Missouri, whose governor, Jay Nixon, is a Democrat — announced this week that they, too, would opt for a federally run exchange.

But most Republican-led states are somewhere in the middle — still vexing over whether to build an exchange on their own, do it in partnership with the federal government or let the federal government do it for them. In Iowa, Mr. Branstad has been consulting with officials from his administration on how to move forward and help consumers get Prescription Savings, his spokesman said.

But their discussions have been private, and unlike some other governors, Mr. Branstad has not held public hearings or meetings to gather opinions. A coalition of health care advocacy groups circulated a list of “principles for success” for a state-run exchange and sent e-mails to Mr. Branstad’s staff in the days after the election, pleading for clarity.

The best response they got was at a health care conference in Des Moines on Tuesday, when several state officials said they were trying their best to prepare but were hampered by a lack of guidance. Asked by an audience member about “the current thought in Iowa on the health exchange,” Jennifer Vermeer, the state’s Medicaid director, paused for several long seconds before saying state officials had been “focusing our energies” on planning a partnership exchange.

Even if Iowa opts for a partnership with the federal government, it will be “without a totally clear understanding of who needs to do what,” said Charles M. Palmer, director of the state’s Department of Human Services.

Walking down a hallway during the Republican governors meeting on Wednesday, Mr. Branstad said that Iowa was working on its letter to send the administration by the Friday deadline, but that officials did not feel they had gotten all the information they needed from the federal government.

“There’s a whole lot of questions we have,” he said. “We have a whole lot of questions.”

02 November 2012

Tigers' Pitcher Doug Fister Appears to Avoid Concussion

story first appeared in Detroit Free Press

The line drive Tigers pitcher Doug Fister took to the head in Thursday’s World Series game certainly looked painful. But how badly was he injured?

Dr. Daniel B. Michael, a neurosurgeon and Chief of Neurotrauma at Beaumont Hospital in Royal Oak said a hit like that would obviously be painful.

Both Michael and Dr. Sadiq Haque, a sports medicine specialist at the Detroit Medical Center, watched the game on TV Thursday night. They said it didn’t appear that Fister suffered a concussion.

Michael said it it was good to see the ball hit him at a glancing blow, and the energy with which it went from his skull was a good sign, because that energy wasn't imparted to Fister's head.

Tigers Manager Jim Leyland, a pitching coach and a trainer immediately went to check on Fister. Michael noted that Fister was asked various questions, including where he was and which inning the game was in. Short term memory problems are among the symptoms of a concussion, an injury to the brain that results in a transient deficit in function.

Fister was able to answer the questions correctly. He went back in the game.

Dr. Sadiq Haque said the impact looked serious, but the trainer would have done the appropriate evaluations to make sure it wasn't a concussion and that Fister could safely return to play.

Michael said if Fister has any memory problems, headaches or other concerning symptoms Friday, he should get checked out again, because sometimes in a moment like that the adrenaline will compensate for a mild concussion. If Doug demonstrated symptoms of a concussion within a few days of the game, he should be taken out of harm's way and watched closely. According to Michael, a head injury can be lethal even within a week or two.

Michael said he is in favor of having additional protective headgear for pitchers. He said even more protection built into the pitcher's cap could help prevent a serious head injury.

01 November 2012

Hundreds of Patients Evacuated from New York Hospital for Hurricane Sandy

story first appeared on apnews.com

A backup generator failed at a New York City hospital Monday night, forcing it to move out more than 200 patients, including 20 babies from neonatal intensive care.

Dozens of ambulances lined up around the block outside New York University Tisch Hospital as doctors and nurses began the slow process of evacuation. They started with the sickest and youngest. Some were on respirators operating on battery power.

NYU Medical Dean Robert Grossman told WCBS-TV said this challenging situation is the kind of thing they drill for all the time.

Much of New York was plunged into darkness by superstorm Sandy, a monstrous hybrid system that swept across a huge swath of the East.

Most of the power outages in lower Manhattan, where Tisch is located, were due to an explosion at an electrical substation, officials at Consolidated Edison said. It wasn't clear whether flooding or flying debris caused the explosion, said John Miksad, senior vice president for electric operations at Con Edison.

Without power, there are no elevators, meaning patients - some of whom are being treated for cancer and other serious illnesses - must be carefully carried down staircases, Grossman said.

As the patients were evacuated, gusts of wind blew their blankets. Nurses and staff huddled around the patients, some holding IVs and other equipment.

Ambulances came from around the city to help transport the sick. Patients will be taken to other hospitals including Mount Sinai and the Memorial Sloan-Kettering Cancer.

Quality of Heath Care Varies by Region According to Study

story first appeared on usatoday.com

Where you live – and where your doctors did their training – has a lot to do with whether you'll be operated on, get an infection or have other potentially risky medical tests, a report out Tuesday said.

And we're not talking about small-town vs. big-city medicine. The report by Dartmouth Medical School's Atlas Project looked closely at 23 medical centers, including many of the top-rated hospitals for clinical excellence by U.S. News and World Report and other leading hospitals affiliated with universities. New Atlas data that include nearly all the teaching hospitals in the U.S. were also released.

The study was done to help medical students decide where to do their residencies, but it also helps consumers better understand how their local hospitals differ from the norm.

Among the findings: If you're in Salt Lake City, you're twice as likely to get knee-replacement surgery than if you're in New York City. Lubbock, Texas, had the highest rate of knee replacements -- 13.2 per 1,000 Medicare beneficiaries.

Arthritis in the knee is "not a dependably progressive disorder" that nearly always requires surgery, says David Goodman, a doctor who is co-principal investigator for the Atlas Project.

The report uses new 2010 Medicare data to update previous reports on regional variations in the treatment of patients at the end of life, trends in surgical procedures and trends in quality of care as it relates to patient experience and safety.

There is an emphasis on more aggressive treatment over preventive care at some hospitals, Goodman says. The report includes a "hospital care intensity index" when it comes to treatment of people at the "end of life."
Goodman says some hospitals may have a lot of capacity in their intensive care units and not enough in primary care.

Patients at NYU Langone Medical Center were 47 times less likely to get an infection from a urinary catheter than patients at the University of Michigan Health System, for example. Mount Sinai Medical Center had the second lowest. Goodman says such infections are "largely preventable."

David Muller, dean for medical education at the Mount Sinai School of Medicine, says the population of patients a hospital treats -- that is, whether they are low income and already in poor health -- can have a lot to do with whether a patient contracts an infection and can recover fully from it. The report's rates were adjusted for age, race and gender using the U.S. Medicare population as the standard.

Muller says the Dartmouth report can be valuable for both medical students and patients, but he notes that the Atlas Project's research is sometimes practically considered a bible, but he says any measures of quality of care in hospitals, varies widely and the subject is controversial.

This list ranks 23 teaching hospitals by the Hospital Care Intensity (HCI) index, which is a measure that combines the number of days patients spent in the hospital and the average number of inpatient physician visits during the last two years of life.

Hospital (ranked by Hospital Care Intensity (HCI) index):
  • Cedars-Sinai Medical Center 2.06
  • NYU Langone Medical Center 1.73
  • Mount Sinai Medical Center 1.50
  • Ronald Reagan UCLA Medical Center 1.48
  • New York-Presbyterian Hospital 1.37
  • University of Pittsburgh Medical Center 1.28
  • Northwestern Memorial Hospital 1.28
  • Massachusetts General Hospital 1.19
  • Cleveland Clinic 1.12
  • Hospital of the Univ. of Pennsylvania 1.08
  • University of Michigan Health System 1.07
  • Brigham and Women's Hospital 1.06
  • Johns Hopkins Hospital 1.01
  • United States average 1.00
  • Indiana Univ. Health (Clarian Health) 0.96
  • Barnes-Jewish Hospital/Washington Univ. 0.95
  • UCSF Medical Center 0.92
  • Duke University Medical Center 0.87
  • Vanderbilt Univ. Medical Center 0.80
  • University of Washington Medical Center 0.78
  • Stanford Hospital and Clinics 0.78
  • St. Mary's Hospital, Mayo Clinic 0.70
  • Scott & White Memorial Hospital 0.62
  • University of Utah Health Care 0.62

23 October 2012

Studies Show No Health Benefits of Organic Food for Kids

story first appeared on nbcnews.com

If you’re buying organic foods for your kids because you think they’re more nutritious, you might want to think again. The nation’s pediatricians have weighed in on the issue for the first time, and they say that when it comes to nutritional value, organics are virtually indistinguishable from conventionally produced foods.

 Dr. Janet Silverstein, a professor of pediatric endocrinology at the University of Florida said studies show no nutritional difference. She’s a co-author of the report published Monday by the American Academy of Pediatrics.

Silverstein and her colleagues reviewed the available studies on organic and conventionally produced foods, including produce, dairy products and meat. They considered research about issues including nutrition, hormones, antibiotics and synthetic chemical exposure, plus factors such as environmental impact and price.

Overall, the docs came to a conclusion that may surprise some parents who believe organic is best for their kids

“In the long term, there is currently no direct evidence that consuming an organic diet leads to improved health or lower risk of disease,” AAP officials said in a statement.

No large studies been conducted that address the differences, they said. That largely echoes the findings of a Stanford University review last month that analyzed 237 studies and concluded that organic foods were no more nutritious than conventional -- and ignited huge debates online and on talk shows.

When it comes to the pesky issue of pesticides, hormones and other contaminants, the pediatricians came to a similar conclusion.

No one knows yet whether those substances make foods from conventional sources less safe for growing kids, Silverstein said.

While there’s no question that conventionally grown foods have more pesticides than organic foods, the effect isn’t certain.

Lowers are level than federal governement cutoffs, Silverstein said. But she also said they have no way of knowing how these low levels effect children during the vulnerable period of time when brain growth is occurring: in utero and through the first few years of life.

Studies evaluating the long-term effects of pesticides on child development need to be conducted, she said.

One clear difference between organics and conventionally produced food is price. Organics are typically more expensive, in some cases priced 50 percent higher than the same conventionally grown foods.

Parents should recognize the importance of providing kids with lots of fruits and vegetables whether it comes from organic or conventional farms.

Parents with limited resources should know it is important to give children a healthy diet of fruits and vegetables, whether or not they can afford organic foods.
If cost is a factor, families can be selective in choosing organic foods, Silverstein said. Some conventionally grown fruits and vegetables tend to have lower pesticide residues. The AAP cites organic shopper's guides like those provided by Consumer Reports and the Environmental Working Group as references for consumers.

If moms interviewed by NBC News are typical, the new report isn’t likely to dissuade any parents from buying organic.

For Diana Lovett, 34, of Larchmont, N.Y., the most important issue was avoiding pesticides in the foods she gives her son, Noam, 4 ½ months.

Lovett says she’d make her own baby food if she couldn’t find an organic product at the supermarket.

Gigi Lee Chang, 45, of New York, has been feeding her son, Cato, mostly organic foods since he was a baby. Now that he’s 8, she’s planning on packing organic fruits and vegetables to supplement school lunches.

“I don’t think from a mom’s perspective it was ever about the nutrition,” said Chang, chief executive of Healthy Child, Healthy World, an advocacy group that works to help parents protect children from harmful chemicals.

As far as Chang is concerned, the science just hasn’t had a chance to catch up on this issue. Chang points to the situation with bisphenol A, the estrogen-mimicking chemical known as BPA. Several years ago there wasn’t enough evidence on the impact of BPA, she said. And now it’s been banned from baby bottles and sippy cups.

That makes sense to Rachel Blumenthal, 32, of New York. She chooses organic foods for 18-month-old Griffin’s meals because she’s worried about chemicals in conventional foods.

Blumenthal figures it’s just a matter of time before scientists prove what she suspects.

Brain Imaging could Detect Early Alzheimer's Signs

Story first appeared on Bloomberg News

Glaxo Fund Looks for Early-Stage Alzheimer’s Detectors

GlaxoSmithKline Plc (GSK)’s venture- capital fund is seeking to invest in a biotechnology company that has both a brain-imaging dye to detect warning signs for Alzheimer’s disease and a drug treatment for the ailment.

Jens Eckstein, president of the Cambridge, Massachusetts-based SR One fund, said big change will come with imaging agent.

Imaging agents detect proteins called amyloid that define the disease. The illness can be identified at an early stage through routine scanning if started when patients are still healthy, Eckstein said. Recent studies of treatments to slow or stop progression of Alzheimer’s were flawed as they recruited patients with advanced forms of the disease, where  damage was already done.

The comments show Glaxo isn’t giving up on Alzheimer’s disease after recent high-profile failures of experimental treatments. Johnson & Johnson (JNJ) and Pfizer Inc. (PFE)’s bapineuzumab as well as Eli Lilly & Co. (LLY)’s solanezumab failed to help Alzheimer’s symptoms in people with advanced disease in separate study results announced over the past two months. Still, both target amyloid plaque and showed promise for use in early-stage patients.

Disease Growth

In a study of 141 healthy subjects, those with clumps of amyloid beta plaques in their brains at the start of the study had as much as a 20 percent greater decline in memory and thinking over an 18-month period than those with fewer plaques. The study, conducted by Australian researchers, was published in the journal Neurology on Oct. 16.

The number of Alzheimer’s cases globally is expected to double within 20 years as the world’s population ages, to as many as 65.7 million people in 2030 and 115 million by 2050, the Geneva- based World Health Organization said in April.

SR One invests in about 30 public and private companies, half of which have compounds in human testing, and invests $30 million to $50 million in five or six companies a year, according to Eckstein.

While Glaxo has “high interest in our portfolio,” the fund acts largely independent of the drugmaker, with a strict firewall between the two entities and no special product rights, he said.

The company’s investments include iPierian Inc., which is developing treatments for neurodegenerative diseases such as Alzheimer’s, Parkinson’s and Huntington’s diseases using induced pluripotent stem cells. Shinya Yamanaka, who won the Nobel Prize in medicine this month for his discovery of iPS cells, sits on iPierian’s scientific advisory board.

17 October 2012

Diet Drink Consumptin Increases Diabetes Risk

Story first appeared on usatoday.com

Diet drink consumption has increased over the past decade, a trend that reinforces other research showing intake of calories from sugar in regular soda has decreased, government statistics out today show.

"The data suggest that diet drinks may have replaced sugar drinks during this time," says the study's lead author Tala Fakhouri, an epidemiologist with the Centers for Disease Control and Prevention.

The new diet drink analysis shows that the change in diet drink consumption occurred for both women (up from 18% in 2000 to 21% in 2010) and men (up from 14% to 19% in the same period).

Still, only about 20% of people in the USA consume diet drinks on any given day with the majority (80%) not drinking them, the report finds. Diet drinks included calorie-free and low-calorie versions of soda, fruit drinks, energy drinks, sports drinks and carbonated water. Diet drinks did not include unsweetened teas or coffees or 100% fruit juice.

Meanwhile, the consumption of sugar found in regular soda has dropped from roughly 150 calories a day in 2000 to 91 calories a day in 2008.

But when it comes to calories from all sugary drinks, including sodas, fruit drinks, energy drinks, sports drinks and sweetened bottled waters, males consume an average of 178 calories a day; females consume 103 calories, according to other government data.

Overall, about half of the population, ages 2 and older, consume sugary drinks on any given day. Among boys 2 to 19, 70% consume these types of drinks while 40% of adult women consume them.

The statistics from the CDC's National Center for Health Statistics are based on interviews with thousands of people in the National Health and Nutrition Examination Survey. Food and beverage intake is based on in-person interviews about dietary habits.

Among the findings:

-- Diet drink consumption was similar for females and males in 2010, except among adolescents, ages 12 to 19, with 17% girls consuming them on a given day compared with only 9.5% of boys the same age.

-- 28% of white adults consume diet drinks compared with 10% of black adults and 14% of Hispanic adults.

"We know that Americans, mainly white Americans, are increasing significantly the consumption of low-calorie diet beverages," says Barry Popkin, a nutrition professor at the University of North Carolina-Chapel Hill and one of the nation's top experts on beverage consumption. Research suggests that an increased intake of these diet beverages in replacement of sugary beverages reduces weight, he says.

Kelly Brownell, director of Yale University's Rudd Center for Food Policy and Obesity, says, "Diet products are controversial because it is unclear whether they are safe and help people control weight.

"We do not recommend diet drinks, particularly for children, but one can make a case for them if they do in fact displace caloric beverages and do no harm."

Sugary drinks have been in the spotlight for years, and most recently because of news that they may magnify genetic risk of obesity and diabetes. To learn more about diabetes treatment and other research and other research that heavy teens who cut soft drink consumption slow weight gain and improve individual health characteristics.

New York City is putting a 16-ounce cap on sweetened bottled drinks and fountain beverages sold at city restaurants, delis, movie theaters, sports venues and street carts. The beverage ban, which goes into effect March 12, applies to drinks that have more than 25 calories per 8 ounces. It does not include 100% juice drinks or beverages with more than 50% milk.

12 October 2012

Nobel Prize Goes to Stem-Cell Scientists

Story first appeared on wsj.com.

Two stem-cell researchers have won this year's Nobel Prize in Physiology or Medicine for their groundbreaking work in cellular reprogramming, a technique that unleashed a wave of advances in biology, from cloning to the possible treatment of diseases using a patient's own cells.

Experiments by John B. Gurdon of the United Kingdom and Shinya Yamanaka of Japan showed that mature cells taken from the body could be changed to an embryonic-like state in a laboratory dish, a head-spinning discovery that is the biological equivalent of turning back time.

A British stem-cell pioneer stated that their work has changed the accepted dogma that mature cells are condemned to exist in a specialized state.

Cellular reprogramming triggered the rewriting of biology textbooks and spawned thousands of new experiments in labs around the world. It led to the first cloned animal—a frog—and to the first cloned mammal, Dolly the sheep. It also paved the way for deriving embryonic-like stem cells without destroying human embryos, sidestepping an ethically contentious approach.

Once cellular reprogramming is used to turn mature cells into embryonic-like ones, those cells can be further manipulated and turned into heart, nerve, muscle and virtually all other tissues types. This freshly made tissue—from an Alzheimer's patient, for example—could be inexpensively grown and studied in a lab dish.

Drug firms have already started to test drugs on human tissue made through reprogramming. Next year, fresh retinal cells derived in this way will be transplanted into people for the first time, in a Japanese trial for patients with an eye disease known as macular degeneration.

Scientists used to believe the fate of our cells was a one-way trip. We start as a fertilized egg; become an embryo consisting of immature, undifferentiated cells; then gradually develop into a body of specialist cells, including blood, bone, muscle and skin.

In 1962, Dr. Gurdon, while trying to understand how simple, undifferentiated cells became all the other cells in the body, performed an audacious experiment. He removed the DNA from a frog egg and replaced it with the DNA of a mature cell taken from a tadpole. The egg developed into a healthy, cloned tadpole. (The same approach would be used to create Dolly the sheep in 1996.)

The frog experiment was an effort to answer a pure scientific question about how we came to be formed. There was no foreseeable therapeutic benefit.

Dr. Yamanaka, 50, was born in the year Dr. Gurdon did his frog experiment. Dr. Yamanaka would eventually ponder a related question: Could the Gurdon reprogramming trick be done without using eggs—which, in human cases, can be hard to come by?

Dr. Yamanaka had the answer a few years later. He demonstrated that by adding just four genes to a mature cell, he could turn it into an embryonic-like state. He first achieved this with mouse cells, and in 2007 he reported the same result for human cells. He transformed those cells, in turn, into heart, nerve and other human tissue in a lab.

Dr. Yamanak commented that without [Dr. Gurdon's] work they would never have started this risky project 12 years ago.

Since Dr. Yamanaka's breakthrough, many labs have altered how they do stem-cell research. Some years ago, Ian Wilmut, the scientist who created Dolly the sheep, abandoned a cloning-based approach in favor of the Yamanaka method. Last week, Japanese scientists said they used the Yamanaka technique to make mouse eggs.

Tomatoes Lower Risk of Stroke

Study shows that you could lower the chance of a stroke by eating tomatoes. A new study shows that men who had the highest levels of lycopene—an antioxidant found in tomatoes—had fewer strokes than men who had the lowest level of lycopene in their blood. Overall, the risk of strokes was reduced by 55%.

Story first appeared on wsj.com.

The study, based in Finland, will be published in the Oct. 9 issue of the medical journal Neurology. Lycopene is found in the highest concentrations in cooked tomato products like paste, puree and sauce, according to the United States Department of Agriculture's national nutrient database.
A cup of ready-to-serve marinara sauce has more than 31,000 micrograms of lycopene while the average raw tomato has about 3,165 micrograms, according to USDA. A slice of fast food pizza has 2,074 micrograms of lycopene. A tablespoon of catsup has 2,146 micrograms of lycopene.

Lycopene is also found in watermelon, grapefruit, papaya and mango.

There are no government recommendations specific to lycopene consumption, but U.S. dietary guidelines have traditionally recommended Americans consume at least five to nine servings of fruits and vegetables per day. In 2010, the U.S. updated its dietary guidelines, stating Americans should "increase" fruit and vegetable intake, noting that at least 2½ cups of fruits and vegetables per day was associated with a reduced risk of heart attacks and strokes. There have also been some studies that suggest lycopene can cut the risk of prostate and other types of cancer.

Dr. Rafael Ortiz, director of the Center for Stroke and Neuro-Endovascular Surgery at Lenox Hill Hospital in New York, who wasn't involved in the lycopene study, said it shows diet is very important for cutting stroke risk along with exercising and not smoking. He said lycopene reduces inflammation and prevents blood clots from forming.

The Finnish study involved 1,031 men who were part of a larger study looking at risk factors for the development of cardiovascular disease.
The men were between ages 42 and 61 and living in and around the city of Kuopio in Eastern Finland when they first enrolled in the study in the early 1990s. Samples of blood were taken at the study's start and seven years later for most men. The men were followed an average of 12 years.

The main goal of the study was to look at whether other substances such as retinol, or vitamin A, and alpha-tocopherol, a type of vitamin E, impacted stroke rates.

They found no association with the levels of vitamin A or E, but instead found men who had the highest level of lycopene in their bodies were 55% less likely to have a stroke than men with the lowest amount of lyocopene. They were 59% less likely to have a type of stroke called an ischemic stroke, the most common type of stroke that is caused by a blood clot.

Overall, there were 67 strokes among the 1,031 men in the study. Of those, 50 were ischemic. There were 25 strokes among 258 men who were considered to have the lowest levels of lycopene while there were 11 strokes among men with the highest lycopene levels. The men were divided into four groups by lycopene levels.

08 October 2012

Four People Have Died And Twenty-Two More People Are Sick From Rare Meningitis Outbreak In The US

original article appeared in AP News

After sickening 26 people across five states, an outbreak of a rare from of meningitis is expected to grow.  Four out of those 26 people have already died, according to health officials.

All received steroid injections, mostly for back pain, a fairly typical treatment. The drug was made by a specialty pharmacy in Massachusetts that issued a recall last week and has shut down operations.

The type of meningitis involved is not contagious like the more common forms. This type is caused by a fungus often found in leaf mold and which health officials suspect may have been in the steroid.

Eighteen of the cases are in Tennessee, where a Nashville clinic received the largest shipment of the steroid. Investigators, though, say they are still trying to confirm the source of the infection.

Three cases have been reported in Virginia, two in Maryland, two in Florida and one in North Carolina. Two of the deaths were in Tennessee, and Virginia and Maryland had one each, said officials at the Centers for Disease Control and Prevention.

More new cases are almost certain to appear in the coming days, said Tennessee Department of Health Commissioner John Dreyzehner. Five new cases were confirmed over the past 24 hours, he said Wednesday.

But federal health officials weren't clear about whether new infections are occurring. They are looking for - and increasingly finding - illnesses that occurred in the past two or three months.

Meningitis is an inflammation of the lining of the brain and spinal cord. Symptoms include severe and worsening headache, nausea, dizziness and fever. Some of the patients also experienced slurred speech, and difficulty walking and urinating, Tennessee health officials said.

The incubation period is estimated at anywhere from two to 28 days, so some people may not have fallen ill yet, Tennessee health officials said. At three clinics in Tennessee, officials are contacting the more than 900 people who received the steroid in the past three months.

Investigators also have been looking into the antiseptic and anesthetic used during the injections. Neither has been ruled out. However, the primary suspicion is on the steroid medication. Steroid shots are common for back pain, often given together with an anesthetic.

The Food and Drug Administration identified the maker of the steroid as New England Compounding Center, a specialty pharmacy in Framingham, Mass. Last week, the company issued a recall of three lots of the steroid - methylprednisolone acetate. In a statement, the company said it had voluntarily suspended operations and was working with regulators to identify the source of the infection.

Compounding pharmacies mix ingredients for customized medicines that generally aren't commercially available. They are regulated by states.

The outbreak was discovered about two weeks ago when Vanderbilt University's Dr. April Pettit was treating a patient who was not doing well for reasons doctors did not understand.

When the lab found the fungus in the patient's spinal fluid, Pettit began asking questions and learned the patient recently had steroid injections in his spine, according to Dr. William Schaffner, who chairs Vanderbilt's Department of Preventive Medicine.

Federal officials did not release condition reports or details on all the patients in the five states. Fungal meningitis is treated with high-dose antifungal medications, usually given intravenously in a hospital.

Seventeen of the Tennessee cases were treated at the Saint Thomas Outpatient Neurosurgery Center in Nashville. It had 2,000 vials of the suspect lots, the largest number. To deal with the investigation, that clinic voluntarily closed last month.

29 August 2012

My Brain Made Me Do it Defense

by Peak Positions

Original article appeared in Reuters

A once respected paediatrician, loved by patients and their parents, today Domenico Mattiello faces trial for pedophilia, accused of abusing children in his care.

Scientific experts will argue in court that his damaged brain made him do it, and his lawyers will ask for leniency.

It's the latest example of how neuroscience - the science of the brain and how it works - is taking the stand and beginning to challenge society's notions of crime and punishment.

The issue has been thrown into the spotlight by new technologies, like structural and functional magnetic resonance imaging (MRI), positron emission tomography (PET) scans and DNA analysis, that can help pinpoint the biological basis of mental disorders.

A series of recent studies has established that psychopathic rapists and murderers have distinct brain structures that show up when their heads are scanned using MRI.

And in the United States, two companies, one called No Lie MRI and another called Cephos Corp, are advertising lie-detection services using fMRI to lawyers and prosecutors.


While structural MRI scans show the structure of a brain and can highlight differences between one brain and another, PET and fMRI scans can also show the brain in action, lighting up at particular points when the brain engages in certain tasks.

But the dazzling new technologies and detailed genetic data leave unanswered the issue of whether criminal courts are the right place to use this new information.

"The worry is that the law, or at least some judges, might be so overawed by the technology that they start essentially delegating the decision about guilt to a particular form of test," commented a professor of neuroscience at Oxford University.

The lawyers for American serial killer Brian Dugan, who was facing execution in Illinois after pleading guilty to raping and killing a 10-year-old girl, used scans of his brain activity to argue he had mental malfunctions and should be spared the death penalty. In the event, Illinois abolished capital punishment while he was on death row.

In a court in the Indian city of Mumbai, a woman was convicted of murder based only on circumstantial evidence and a so-called brain electrical oscillations signature profiling (BEOS) test, the results of which prosecutors said suggested she was guilty.

The days when mental capacity for crime is argued over by psychiatrists unaided by sophisticated machinery - such as Friday's verdict that Norwegian mass killer Anders Behring Breivik was sane when he killed 77 people - look numbered.

"All sorts of types of neuroscience evidence are being used for all sorts of types of claims," said a professor of law at the University of Utah. "The question is, is this technology really ready for prime time, or is it being abused?"


In Mattiello's case, the neuroscientific evidence will come in the form of a full psychiatric and biological analysis including an MRI brain scan that shows a roughly four-centimeter tumour growing at the base of his brain.

This created pressure inside his skull and "altered his behaviour," said a molecular geneticist and psychiatrist at Italy's University of Pisa who is compiling an expert report on the 65-year-old.

"His previous behaviour was completely normal," she told Reuters. "He was a pediatrician for 30 something years and he saw tens of thousands of children and never had any problem. The question is why, at some point, did someone who has always behaved properly suddenly change so drastically?"

The doctor was arrested in Vicenza, northern Italy, more than a year ago and is undergoing cancer treatment after having the tumour removed. Pietrini is due to see him again next month to continue his assessment and see the effects of the treatment.

The case, which has yet go to court, is strikingly similar to another of "acquired pedophilia" dating back to 2002, in which a 40-year-old married American schoolteacher suddenly became obsessed with sex and began secretly to collect child pornography.

He was eventually removed from the family home for making sexual advances towards his step-daughter and convicted of paedophilia. But later medical examinations found he had an egg-sized tumour in a part of the brain involved in decision-making.

When the tumour was removed, the man recovered from his paedophilic tendencies and was able to return to his family.

Experts are generally agreed that conditions like psychopathy and paedophilia can't be "cured", but in this groundbreaking case it appeared that removing the tumour, and hence the pressure in the brain, may have re-established his ability to control impulses.

As in that case, specialists believed Mattiello's tumour "may well have played a role in altering his behaviour".

"This is what we will be arguing," they said. "But of course it will be for the judge to determine to what extent he believes this medical condition played a role."

An Oxford expert in the field, called such cases "startling."

"It makes one wonder about the notion of responsibility," he said in an interview.


And when it comes to prison, should pedophiles, psychopaths and other violent criminals be punished less severely if their behaviour can be blamed on biology? Is "my brain made me do it" a defence that warrants recognition with lighter sentences, or even no jail time at all?

"(It) raises the whole issue of what you think sentencing is for," said the Oxford expert. "Is it about punishment? Is it about retribution? Is it about remediation and rehabilitation? Is it about protecting society? Well, to some extent it's about all of those things."

Recent evidence - from both real and hypothetical cases - suggests judges are sympathetic to neurobiological evidence as mitigation.

A study published in the journal Science this month showed that criminal psychopaths in the United States whose lawyers provide biological evidence for their brain condition are more likely to be sentenced to shorter jail terms than those who are simply said to be psychopaths.

For the study, researchers at the University of Utah tweaked the real-life case of Stephen Mobley, a 39-year-old American who was sentenced to death in 1994 after robbing a Domino's pizza place in Georgia and shooting dead the restaurant's manager.

At his trial, Mobley's lawyer presented evidence in mitigation showing the accused had a variant of a gene called MAO-A that has been dubbed the "warrior" gene after scientists found it was linked to violent behavior.


In the Science study, judges were given a hypothetical case loosely based on Mobley's, where the crime was a savage beating with a gun, rather than a fatal shooting.

All the judges were told the defendant was a psychopath, but only half were given expert testimony on the genetic and neurobiological causes of his psychopathy. Those who got the neuroscientific evidence were more likely to give a shorter sentence - generally about a year less, the study found.

Pietrini worked on a similar real-life case in Italy in 2009 - thought to be one of the first criminal cases in Europe to use this type of neuroscientific evidence.

It involved Abdelmalek Bayout, an Algerian living in Italy, who was tried and convicted for fatally stabbing a man who teased him in the street.

After conducting a series of tests on the Algerian, Pietrini and colleagues said they had found abnormalities in imaging scans of his brain, and in five genes that have been linked to violent behaviour - including MAO-A.

A 2002 study led by researchers at the Institute of Psychiatry at King's College London linked low levels of MAO-A with aggressiveness and criminal behaviour in boys who were raised in abusive environments.

Bayout's lawyers got his sentence reduced by arguing that this and other bad genes had affected his brain and were partly to blame for the attack.


Experts say it's almost inevitable that neuroscience and law will become yet more intertwined. After all, while neuroscience seeks to find out how the brain functions and affects behavior, the law's main concern is with regulating behaviour.

Yet many are uneasy about the use in courts of law - and in matters of life and death - of basic science that is only just creeping out of the lab.

A professor of law at Stanford University pointed out that no scientific peer-reviewed studies have been published demonstrating that BEOS - the brain test used in the Mumbai case - actually works.

Others stress that while genes like MAO-A have been associated with violence, there are also plenty of people with similar genotypes who don't go out and kill, rape or abuse.

"Neuroscience is being used by serious scientists in real labs, but the people trying to apply it in courts are not those same people," said one expert. "So they're taking something that looks very objective, that looks like gold standard science, but then morphing it into a forensic use it wasn't developed for.

"This isn't snake-oil science. It's real science. But it's being misapplied."

A clinical senior lecturer in forensic psychiatry at Oxford University, says he's uncomfortable with the long-term implications and wonders where it will end.

There are already known biological bases for many brain disorders criminals suffer from, including drug addiction, alcoholism and antisocial personality disorder, which is thought to affect up to half of all those in prison.
"The problem here is where do we draw the line?" he asked, suggesting a slippery slope if psychopathy reduces a sentence. What other more common biological conditions might also be used in a defense?