Author Archives: Karen Weintraub

Investigating High C-Section Rates, Researchers To Examine Floor Plans

A woman’s chance of having a C-section can be almost three times higher from one hospital to the next in Massachusetts. But why? No one has the definitive answer. Researchers have looked at the ratio of doctors to nurses or midwives, at payment rates, at medical malpractice policies, at on-call schedules — and still the question lingers.

Could it be the layout of the labor and delivery unit?

Dr. Neel Shah, an associate faculty member at Ariadne Labs, began asking himself this question a little more than a year ago during a tour of hospitals. He watched nurses run down long hallways, from patient to patient. He noticed walls that divided patients, but also decision makers who might benefit from collaboration. And, he was struck by all the ways a labor and delivery floor mirrored an intensive care unit: one nurse per patient for women in active labor, machines that track vital signs in real time and medicines that are titrated minute to minute.

“The only difference between an ICU and a labor floor is that on the labor floor the ORs are attached,” Shah said. “So you’ve got the most intense treatment area in the entire hospital for the healthiest patients. It doesn’t take a rocket scientist to figure out why we overdo it.”

Lighting, furniture placement and waiting areas are not typically the focus of health care quality improvement projects, but maybe they should be.

Shah, working with architects at Mass Design Group, has a one-year grant from the Robert Wood Johnson Foundation to study how the design of a maternity ward affects C-section rates at 12 hospitals around the country. Continue reading

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

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

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

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

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

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

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

Why To Exercise Today: Minimizing ‘Menopause Misery’

(pennstatelive/Flickr)

(pennstatelive/Flickr)

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

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

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

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

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

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

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

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

Anna Jaques Hospital in Newburyport is seen on Friday. (Jesse Costa/WBUR)

Anna Jaques Hospital in Newburyport is seen on Friday. (Jesse Costa/WBUR)

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

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

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

Here’s what happened:

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

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

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First Case Of Zika Virus In Boston Is Confirmed

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

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

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

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

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Landmark Gene Discovery Cracks Open ‘Black Box’ Of Schizophrenia

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

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

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

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

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

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

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

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

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

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

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

“[I]t may be like you have an over-energetic gardener who prunes back so much that the bushes die off…”

– Bruce Cuthbert, of the National Institute of Mental Health

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

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

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

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

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

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

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

Panel Recommends Depression Screening For Women During And After Pregnancy

(Chris Martino/Flickr)

(Chris Martino/Flickr)

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

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

Why?

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

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

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

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

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

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

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

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

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

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

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

By Richard Knox

Readers, a pop quiz:

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

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

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

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

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

tax dollars for U.S. health spending

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

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

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

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

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

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

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

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

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