health care

Blind bears and eagles dropping out of the sky

Jeff EpperlyLeave a comment

Given how successfully right-wing media and characters have sown doubts about health care, medical research and vaccines, it’s probably a given that the next pandemic will be even worse than COVID-19 and even harder to bring under control.

Which is why these stories about avian flu moving into certain sub-human species of mammals so extraordinarily frightening.

Death can come swiftly—sometimes within a day or two of the infection’s start. Birds simply keel over as if they’ve been shot, their bodies dropping like rocks. On poultry farms, outbreaks can wipe out entire flocks in just two or three days. In wilder settings, locals have spotted bald eagles plummeting out of their nests, leaving shrieking chicks behind. By the time infected birds reach Hawkins in her clinic, “they’re usually almost dead,” she told me. “And we can’t figure out how to help them except to put them out of their misery.” Hawkins estimated that in the past few months alone, her team’s euthanasia rate has gone up by about 50 percent.

Mammals so far haven’t fared much better. Last spring, the corpse of a dolphin infected with the virus was found wedged into a canal in Florida—around the same time that Wisconsin locals happened upon litters of ailing fox kits, drooling, twitching, and struggling to stand in the hours before they seized and died. In the fall, three young, flu-stricken grizzlies in Montana were euthanized after researchers noticed that the disoriented animals had begun to go blind. Wendy Puryear, a molecular virologist at Tufts University, told me that seals sick with the virus will sometimes convulse so badly that they can barely hold their bodies straight. Every seal she’s seen that tested positive has ended up dead within days. This month, researchers in Peru reported that they were picking up the virus in some of the sea lions that have died by the hundreds along the country’s coast; a similar situation may now be playing out among a number of Scotland’s seals.

It’s hard to say why this outbreak is so much worse than the ones that came before. Microbial evolution may be one culprit: Flu viruses are particularly inclined to tweak their RNA code; when two genetically distinct versions of the pathogens wind up in the same cell, they can also swap bits of their genomes. This iteration of H5N1 may be particularly adept at sparking lethal disease—something Justin Brown, a veterinary pathologist at Penn State, thinks is quite likely, given how many animals have died. It may also be more easily exiting birds’ bodies in feces, or more efficiently entering cells in the airway or gut. “This particular virus seems to be better adapted to wild birds. I think that’s the key thing,” Stallknecht told me. As climate change alters migration schedules, and pushes certain avian species into more frequent contact with one another’s contaminated scat, the risks of intermingling are only growing. The greater the number of infections, the more animals will die. “It becomes a numbers game,” Stallknecht said.

Due to my age I’m in a high-risk group for any upper respiratory infection.

I suspect that, should something else not take me out sooner, my life is going to end during the next pandemic or two. Assuming it’s a pandemic of highest risk to older people and not, as with the 1918 flu pandemic, particularly dangerous to young adults.

Avian Flu is causing a die-off of sea lions in Peru.

Preventative health care of millions hangs in the balance in TX

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Health care providers — at least the sane ones who follow the Hippocratic Oath — are anxiously awaiting a ruling from one Texas judge that could up-end the requirements vis-a-vis the Affordable Care Act which require insurers to cover basic preventative services.

From the Wall Street Journal’s Stephanie Armour:

The U.S. Preventive Services Task Force, an independent volunteer panel of health experts, is one of three entities that recommends which preventive services must be covered by health plans and Medicaid expansion. The task force’s recommendations have led to no-cost coverage of such services as mammograms and screenings for colon cancer, HIV, cervical cancer, and gestational diabetes.

Six individuals and two companies opposed the ACA requirement that they provide insurance or purchase plans covering certain preventive services. Their lawsuit argued that the services aren’t needed or violate their religious beliefs.

The plaintiffs objected to coverage of contraception, screenings for sexually transmitted diseases and drug use, and vaccination against human papillomavirus, the sexually transmitted disease known as HPV, according to the lawsuit. They also objected to coverage of pre-exposure prophylaxis, or PrEP, a medicine that helps prevent HIV infection.

Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas in September ruled the requirement that the Preventive Services Task Force’s recommendations be covered by most health plans violates the Constitution because he said the task force must be appointed as officers by the Senate or the president, rather than selected as volunteers. He rejected claims that preventive-care recommendations from the two other entities were improper.

The plaintiffs are asking Judge O’Connor to strike down all preventive-coverage requirements since 2010 that have been recommended by the task force. Both parties have prepared input for the judge before he makes a decision on how broadly the ruling will apply. Judge O’Connor could limit any relief to just the plaintiffs in the case, or he could issue a nationwide injunction that would strike down the requirement that insurers cover preventive services recommended by the task force.

We always knew that extremist religious forces were emboldened by Trump, and this is the latest play they are making to control the bodies and health care of millions of Americans.

We will never know how many lives have been saved by the requirement that insurers cover PREP drugs to prevent new HIV infections.

When a beloved cat gets a kidney transplant, where does the donor kidney come from?

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There are people out there who argue that spending $15K on a pet cat’s kidney transplant — or any pet’s surgical procedure — is morally questionable when society still has so many human beings living in abject poverty and hunger without a place to live.

That is just one of the quandaries presented by Sarah Zhang’s Atlantic article about pet health care costs. It uses cat kidney transplants as a stepping-off point, no doubt because there is a considerably more ethically messy thing about cat kidney transplants that had not crossed my mind before: the way vets get the donor kidneys from otherwise healthy cats:

In the oncology department at [U-Georgia vet school], when pets finish chemotherapy, the staff have a tradition adopted from human cancer wards of ringing a celebratory bell. Back in the ’60s, Weigner points out, your cat wouldn’t have gotten chemo. It probably wouldn’t even have been diagnosed with cancer. More likely, a sick cat would just go off by itself and die. But an owner nowadays can bring their cat in for biopsies, X-rays, and ultrasounds—followed by chemo, radiation, and immunotherapy. The list of options is long, the sums of money to spend very large. You can go to great lengths to treat an ailing pet, even if how far you should go isn’t always so easy to answer.

But among all of these treatments, cat kidney transplantation poses a unique ethical dilemma. The kidney has to come from somewhere, and that somewhere—or do we say someone?—is another cat.

Even among cat people, kidney transplants are controversial. One owner told me she was called a “kidney stealer” by fellow cat owners in a Facebook group for those with pets suffering from chronic kidney disease. In the U.K., the Royal College of Veterinary Surgeons has explicitly come out against using living donor cats in transplants, arguing that the surgery inflicts pain and discomfort on an animal that derives no benefit. A cat, after all, cannot consent to giving away a kidney.

To be clear, the donor cats are not killed. Like humans, cats can survive with one kidney. When Clare Gregory and his colleagues at UC Davis pioneered cat kidney transplants in the late ’80s, he made sure that owners adopted the donor—a policy that all three hospitals performing cat kidney transplants in the U.S. continue to uphold. No other types of organ transplants are done in cats, because they would involve killing the donor, which the vets and ethicists I talked with universally condemned. (Gregory tried doing kidney transplants in dogs first, but the canine immune system is unusually reactive, leading to kidney rejection.)

Strawberry’s donor was a one-year-old male tabby with a white chin. He was already up and about the morning after his surgery, keen to receive chin rubs; the young and healthy donor cats tend to bounce back faster than the older and sicker recipient cats. He’d be ready to go home with Strawberry’s owner in a matter of days.

As the article notes, it gets even ethically messier because the source of the donor cats is usually one of any number of companies, some of whose stock is traded on Wall Street, who provide lab animals (dogs, cats, mice, rats, etc.) to universities.

So a donor cat has, in one very narrow sense, gotten a golden ticket of sorts. Instead of spending life in a cage in a lab being injected with who-knows-what for its entire miserable life, kidney donor cats usually go on to lead normal lives in loving homes.

But I added the part about Wall Street for a reason.

As history has shown us, these publicly-traded companies will often try to get away with whatever they think they can get away with in terms of shoddy animal care standards, much to the detriment of the animals they breed in often horrific conditions. There are good reasons these companies often place their animal breeding facilities in conservative states with lax animal rights laws.

It will probably be a good day for humanity’s trajectory toward a higher level of civilization when (if?) we reach a point where it’s a settled question that since cats cannot give informed consent, they cannot be used as organ donors.

Commercial animal breeding facilities often keep animals in deplorable conditions.

Did you know doctors used to give blacks higher doses of radiation during X-rays?

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Did you know they used to give blacks higher doses of radiation for X-rays because the medical profession thought they had thicker skin, muscle and bone that required it?

I didn’t know this until I read this piece from Harvard Medicine:

Until the late 1960s, X-ray machine operators were trained to give Black people higher doses of radiation than they did for white people.

When this fact came to light during 1968 U.S. congressional hearings on radiation safety, amid heightened racial tensions in the weeks following the assassination of Martin Luther King Jr., the practice drew considerable attention from the news media and caused an outcry from the general public.

The controversy ignited an investigation by the U.S. Public Health Service’s National Center for Radiological Health (a forerunner of today’s Center for Devices and Radiological Health in the FDA), which quickly concluded that there was no scientific evidence to suggest that Black people and white people required different doses of X-rays for successful medical imaging.

Following the center’s report, issued in June 1968, federal and state guidelines were rewritten, textbooks updated, and X-ray machine training manuals revised to remove race from the imaging protocols.

“Race and racism remain pervasive problems in health care,” said David Jones, the A. Bernard Ackerman Professor of the Culture of Medicine at Harvard Medical School, co-author of a recent New England Journal of Medicine article. “By documenting the misuse of race in medicine in the past, we can help protect patients from medical racism today.”

Keep in mind that under guidelines being proposed (and passed) by Republicans in conservative states, you couldn’t teach about racist X-rays in publicly funded schools because it would be considered critical race theory.

Which is just as ridiculous as rules saying you can’t teach the plainly evident fact that Christopher Columbus didn’t “discover” North America because there were people living here for at least 16,000 years before Columbus was even born.

It’s just that those people who were here 16,000 years before Columbus weren’t white, so whites like to teach kids that Columbus did something for which he has never deserved credit. And many whites get upset if you point all of this out because they equate pointing this out with making white kids feel bad about themselves.

It’s enough to give me a permanent headache.

Meanwhile, you can read more about blacks and X-rays in this article in the NEJM.

Untreated hearing loss is a major risk factor for later developing dementia

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The evidence is already pretty clear that moderate -to-severe untreated hearing problems in the elderly contribute toward the development of dementia. Exactly how, and on what progression timeline, is not clear.

But treating hearing loss issues in the elderly will likely save a lot of money down the road on dementia-related care and housing, according to this article in today’s Washington Post:

Hearing loss in middle age — ages 45 to 65 — is the most significant risk factor for dementia, accounting for more than 8 percent of all dementia cases, research suggests. A 2020 Lancet report calculated that hearing loss approximately doubles the risk of dementia, akin to the increased risk caused by a traumatic brain injury. In addition, because hearing ability exists on a continuum, even subclinical hearing loss can mean a greater risk for dementia.

As a way of reducing the occurrence of dementia, addressing hearing loss is a win-win, said Frank Lin, the director of the Cochlear Center for Hearing and Public Health at Johns Hopkins Bloomberg School of Public Health. “It’s really common, it’s treatable, and there are interventions that come at no risk” that are underutilized, he said.

Preserving our ability to hear is foundational to public health “strategies that can best optimize the health of older adult population, so older adults are living a long and full life till the very, very end,” Lin said.

There are several overlapping hypotheses for why hearing loss in middle age is associated with a higher risk of dementia.

One hypothesis suggests that poor hearing increases the cognitive load on the brain, which needs to work harder, at the expense of other mental faculties, to decipher the garbled signals the ears send.

This may not be the best explanation, however, because those with hearing loss and declining cognition also struggle on tests that do not depend on hearing, said Tim Griffiths, a professor of cognitive neurology at Newcastle University in England.

Research on animals and humans has found that with the loss of hearing, the brain atrophies faster, especially in the temporal lobe — where key auditory and memory functions occur — potentially because of diminished use and stimulation.

Hearing loss may also cause aberrant activity in the temporal lobe, making it more susceptible to damage and pathologies associated with Alzheimer’s disease, Griffiths said.

In any case, the government finally got around to approving over-the-counter hearing aids — thanks Sens. Warren and Grassley and to the Biden administration — so let’s hope that more elders now get the hearing help they need.

Now what is really needed it to get Medicare and private insurance to cover these new, less expensive, assisted hearing devices.

Also see: Hearing aids are now sold over-the-counter. Here’s how to pick one.

Walmart is one place that is now offering over-the-counter hearing aids.

Alzheimer’s drug has Wall Street excited, but some researchers are still skeptical

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We ought not be surprised that the Wall Street Journal went all-in with its gush-y reporting about lecanemab, the Alzheimer’s drug from Biogen that has shown promise in clinical trials where other drugs of the same class have failed. Investors are drooling.

The reversal in investor sentiment is nothing short of massive. After so many drugs targeting amyloids had failed in clinical trials in recent years, there was growing skepticism of the “amyloid hypothesis,” the idea that targeting an unusual buildup of the protein in patients’ brains should slow dementia.

The results released Tuesday were unequivocal though. The drug reduced cognitive and functional decline by 27%, compared with a placebo. The data, which haven’t yet been published in a peer-reviewed medical journal, hit all of the trial’s primary and secondary endpoints, with many analysts calling it a best-case scenario. Importantly, while the drug did show safety concerns such as brain swelling, it looked safer than other candidates now making their way through clinical trials, wrote Michael Yee of Jefferies.

The positive data make it likely that the Food and Drug Administration will grant Biogen accelerated approval in January, with full approval coming later next year. The bigger question for investors, patients and society is what the Centers for Medicare and Medicaid Services will do. Biogen’s last approved drug for the disease, Aduhelm, received the FDA nod, but CMS effectively killed its commercial prospects by restricting it due to lack of meaningful improvement in health outcomes.

Biogen’s Aduhelm is the first approved treatment for early stage Alzheimer’s patients that may be able to slow the disease. WSJ explains how the drug interacts with brain cells, and why some doctors aren’t ready to prescribe it yet.

This time will be different, with CMS unlikely to “dig in and refuse coverage” due to the highly successful clinical data, wrote Brian Skorney at Baird. With about 2 million Americans suffering from early-stage Alzheimer’s, the costs to the insurance program could be meaningful, leading to higher healthcare costs for most seniors. Just Tuesday, CMS had announced that premiums and deductibles would be declining next year due to lower-than-projected spending on Aduhelm specifically. Now, the government might find itself paying for another pricey Alzheimer’s drug instead.

Just how pricey will be another important question. Biogen has probably learned some hard lessons from the backlash it got to the Aduhelm launch at $56,000 a year, so expect it to price lecanemab at closer to $20,000.

Still, the costs—and the payoff for investors—are likely to be astronomical.

That last part really jumped out at me. They could cut the annual price by almost 2/3 and still make ungodly profits. That shows you how much money big Pharma makes when nobody is keeping tabs on the price they are charging.

And, as Caitlin Owens article in Axios notes:

Some in the research community continue to question the focus on anti-amyloid cures and say success fighting Alzheimer’s will come in combination therapies like those used for heart disease, cancer and hypertension.

“Amyloid-clearing drugs will provide an incremental benefit at best and there is still a pressing need for the next generation of drugs focused on other targets based on our knowledge of the biology of aging,” said Howard Fillit, co-founder and chief science officer of the Alzheimer’s Drug Discovery Foundation.

This is a nightmare scenario for Medicare: an expensive drug of limited benefit that will mean higher premiums for millions of Americans.

Gov’t task force recommends wide U.S. screening for anxiety disorders

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In a first, a government panel recommends all adults under 65 be screen regularly for anxiety disorders.

Adults under the age of 65 should be screened for anxiety disorders and all adults should be checked for depression, a government-backed panel said, as many Americans report symptoms of these mental-health conditions following the height of the Covid-19 pandemic.

The draft guidance released Tuesday marks the first time that the United States Preventive Services Task Force has made a recommendation on screening adults for anxiety disorders. The move comes months after the task force issued similar draft guidance for children and adolescents.

“This is a really important step forward,” said Arthur C. Evans, chief executive at the American Psychological Association. “Screening for mental-health conditions is critical to our ability to help people at the earliest possible moment.”

The task force said that there wasn’t enough evidence on whether or not screening all adults without signs or symptoms ultimately helps prevent suicide. The group didn’t recommend for or against screening for suicide risk, but called for more research in the area.

The task force, a panel of 16 independent volunteer experts, issues guidance on preventive-care measures. Health insurers are often required to cover services recommended by the task force under a provision in the Affordable Care Act.

More than 30% of adults reported having symptoms of an anxiety disorder or depressive disorder this summer, according to estimates from the federal Household Pulse Survey. The percentage of U.S. adults who received mental-health treatment within the past 12 months increased to 22% in 2021, up from 19% in 2019, according to the Centers for Disease Control and Prevention.

Mental-health screening often occurs in doctor’s offices, where patients fill out questionnaires during routine checkups or other appointments. The goal is to spot at-risk people who might not be showing obvious signs, so that the person can get the correct diagnosis and potentially get connected to care before they reach a crisis point.

As for people over 65, the article notes that “some anxiety-disorder screening questionnaires emphasize issues with sleep, pain and fatigue, which also often increase with age.” So screening older adults for those risk factors might turn up a lot of older people who are, you know, just regular old, tired and creaky.

It does strike me that they ought to come up with different a different screening regimen for older people, rather than just deciding to not issue screening recommendations as all.

Nursing homes are tossing onto the street those patients who cut too much into their bottom line

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Have you ever heard of the term “facility-initiated discharges”?

I had not until I read this article in The Bulwark by Bill Lueders, writing about his mother:

Last fall, my then-97-year-old mother, Elaine Benz, was evicted from the senior living facility known as the Regency, in New Berlin, Wisconsin, where she had lived for ten years. My sister, Diane, was told on Thursday, October 28, that our mom would not be allowed to return the following morning, as planned, from a physical rehabilitation center to which she had been sent following a fall. The Regency had decided her needs had gotten too great.

It was a staffer at the rehab center and not someone from the Regency—officially ProHealth Regency Care Communities New Berlin—who broke this news to Diane. As she recalls, the staffer told her that the Regency would turn Elaine “away at the doors” if the center tried sending her back. We needed to find her a new place to live.

That’s it! That’s all it took. The facility looked for any excuse to get his mother out the door. Once out the door, they just refused to let her back in.

A 97-year-old woman!

Lueders has had to become an expert regarding this common practice as he fights to protect his mother:

But in general, I learned, there is nothing unusual about it. What happened to my mother happens to elderly people in America all the time. A facility will conclude that a patient has become too much work or is no longer a good deal financially and find a way to get rid of her. Often, as with Elaine, nursing homes and other senior care facilities evict residents while they are temporarily moved to another facility.

Nicole Shannon, a frontline attorney for the Michigan Elder Justice Initiative, told me how this sometimes works: “The nursing home will say, ‘Well, it sure seems like you need a psychiatric consult, we’re gonna send you to the hospital.’ The hospital turns around and says, ‘You know, this person does not require psychiatric care. You can go back to your nursing home now,’ and the nursing home says ‘Nope, no thanks, you’re no longer welcome here.’”

Shannon’s group has seen cases in which nursing home residents have had discharges approved for transfers to a homeless shelter, to the home of an unwilling relative, to a house that no longer existed because it had burned down, and to an apartment the person no longer rented.

On November 18, the day after we found a new place for Elaine to live, the Office of Inspector General for the U.S. Department of Health and Human Services released a forty-page report on problems regarding “facility-initiated discharges.” It noted that “discharge/eviction” was from 2013 to 2019 the single most frequent complaint recorded by the federal Long-Term Care Ombudsman Program, which operates in all fifty states and the District of Columbia.

The report says that several of the ombudsmen surveyed “volunteered that nursing homes have said that they would rather accept a deficiency or enforcement penalty than keep the resident.” Other ombudsmen “opined that stronger enforcement actions could help to reduce these discharges.”

I cannot imagine being 97 years old and essentially being told that, while you were at some bogus pretext appointment somewhere, we’ve locked you out of your home and, good luck, whatever the state can do to us is nothing compared to what it costs us to keep you in your home.

You might also want to see this article from last April detailing how Wall Street private equity has been gobbling up the nursing home industry.

We are all going to end up living in a Wall Street-owned dystopian society because, while the rest of us are wasting our time fighting about the southern border and drag queen story hours, America is being sold to the highest billionaire bidder.

Bill Lueders’ mother, Elaine Benz.

Scientists find 31,000-year-old skeleton with signs of medical amputation

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The only surgery I’ve had was after some inattentive goon in an SUV made a wide right turn in front of me at a Boston intersection, which sent me flying off my Vespa and into a fire hydrant.

Shattered right ankle, mostly. What I remember most vividly about the incident is how the city ambulance seemed to have no suspension whatsoever, so the entire time between the accident scene and Boston Medical Center we were hitting Boston’s ubiquitous potholes. Everything in the ambulance — including my shattered ankle — would bounce violently.

What a relief it was when we arrived at the emergency room and they gave me a shot of pain killer. And then put me under for emergency surgery.

I was in that hospital bed for a couple of days and nights while they gave me shots of glorious morphine every four hours — I watched the clock closely, let me tell you.

And I remember thinking, “I cannot imagine that they used to do all of this without pain killers of any kind. Surgery without being asleep.”

Life before general anesthesia must have been grim and terrifying.

On a related note, researchers in the journal Nature have revealed that they found a very old skeleton that shows signs of pre-planned amputation that had healed:

A 31,000-year-old skeleton missing its lower left leg and found in a remote Indonesian cave is believed to be the earliest known evidence of surgery, according to a peer-reviewed study that experts say rewrites understanding of human history.

An expedition team led by Australian and Indonesian archaeologists stumbled upon the skeletal remains while excavating a limestone cave in East Kalimantan, Borneo looking for ancient rock art in 2020.

The finding turned out to be evidence of the earliest known surgical amputation, pre-dating other discoveries of complex medical procedures across Eurasia by tens of thousands of years.

By measuring the ages of a tooth and burial sediment using radioisotope dating, the scientists estimated the remains to be about 31,000 years old.

Palaeopathological analysis of the remains revealed bony growths on the lower left leg indicative of healing and suggesting the leg was surgically amputated several years before burial.

Dr Tim Maloney, a research fellow at Australia’s Griffith University who oversaw the excavation, said the discovery was an “absolute dream for an archaeologist”.

The stuff of nightmares.

California legislator who championed vaccine laws in the face of death threats has been term-limited out of office

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You wanna talk about heroes? This guy is a hero.

A California lawmaker who rose to national prominence by muscling through some of the country’s strongest vaccination laws is leaving the state legislature later this year after a momentous tenure that made him a top target of the boisterous and burgeoning movement against vaccination mandates.

State Sen. Richard Pan, a bespectacled and unassuming pediatrician who continued treating low-income children during his 12 years in the state Senate and Assembly, has been physically assaulted and verbally attacked for working to tighten childhood vaccine requirements — even as Time magazine hailed him as a “hero.” Threats against him intensified in 2019, becoming so violent that he needed a restraining order and personal security detail.

“It got really vicious, and the tenor of these protests inside the Capitol building didn’t make you feel safe, yet he stood his ground,” said Karen Smith, director of the California Department of Public Health from 2015 to 2019. “Dr. Pan is unusual because he has the knowledge and belief in science, but also the conviction to act on it.”

“That takes courage,” she added. “He’s had a tremendous impact in California, and there’s going to be a hole in the legislature when he’s gone.”

The Democrat from Sacramento is leaving the Capitol because of legislative term limits that restrict state lawmakers to 12 years of service. He has overseen state budget decisions on health care and since 2018 has chaired the Senate Health Committee, a powerful position that has allowed him to shape health care coverage for millions of Californians.

Pan, 56, helped lead the charge to restore vision, dental, and other benefits to California’s Medicaid program, called Medi-Cal, after they were slashed during the Great Recession. Since then, he has pushed to expand social services to some of the most vulnerable enrollees.

You can read the rest at this link

Calif. State Sen. Richard Pan and his family.