Friday, 31 August 2018

A Debate Over ‘Rational Suicide’


On a March morning in 1989, Robert Shoots was found dead in his garage in Weir, Kan.

He had run a tube from the tailpipe of his beloved old Chrysler to the front seat, where he sat with a bottle of untamed Turkey. He was 80.

His daughter wishes he had mentioned this plan once they spoke by phone the night before because she didn’t get to mention a satisfying goodbye. But she wouldn't have tried to dissuade him from suicide.

Years earlier, he had told her of his intentions.

“It wasn’t an enormous surprise,” she said of his death.

“I knew what he was getting to do and the way he was getting to roll in the hay .”

(Wary of harassment in her conservative upstate NY town, she has asked me to withhold her name.)

Mr. Shoots, a retired painter, was happily remarried and enjoyed healthiness.

He still went fishing and played golf, showing no signs of depression or other mental the illness that afflicts most of the people who take their own lives.

Nevertheless, he had explained why he someday planned to require his life.

“All the people he knew were dying in hospitals, filled with tubes, lying there for weeks, and he was just horrified by it,” his daughter said. He decided to avoid that sort of death.

Is suicide by older adults ever a rational choice? It’s a subject many older people discuss among themselves, quietly or loudly — and one that physicians increasingly encounter, too.

Yet most have scant training or experience in the way to respond, said Dr. Meera Balasubramaniam, a geriatric psychiatrist at the NY University School of drugs.

“I found myself seeing individuals who were very old, doing well, and shared that they wanted to finish their lives at some point,” said Dr. Balasubramaniam.

“So many of our patients are confronting this in their heads.”

She has not taken an edge on whether suicide is often rational — her views are “evolving,” she said.

But hoping to get more medical discussion, she and a co-editor explored the difficulty during a 2017 anthology, “Rational Suicide within the Elderly,” and she or he revisited it recently in a piece of writing within the Journal of the American Geriatrics Society.

The Hastings Center, the ethics institute in Garrison, N.Y., also devoted much of its latest Hastings Center report back to a debate over “voluntary death” to forestall dementia.

Every a part of this concept, including the very phrase “rational suicide,” remains intensely controversial.

(Let’s leave aside the related but separate issue of physician aid in dying, currently legal in seven states and therefore the District of Columbia, which applies only to mentally competent people likely to die of a terminal illness within six months.)

“The suicidal state isn't fixed. It’s a teeter-totter.”

Dr. Yeates Conwell Suicide has already become a pressing public health concern for older adults, more than 8,200 of whom took their lives in 2016, consistent with the Centers for Disease Control and Prevention.

“Older people generally, and older men specifically, have the very best rates” said Dr. Yeates Conwell, a geriatric psychiatrist at the University of Rochester School of drugs and a longtime suicide researcher.

That’s true albeit research consistently shows older adults feeling happier than younger ones, with an improved psychological state.

A complex web of conditions contributes to late-life suicide, including physical illness and functional decline, personality traits, and coping styles, and social disconnection.

But the overwhelming majority of older people that kill themselves even have a diagnosable mental illness, primarily depression, Dr. Conwell acknowledged.

Suicide often also involves impulsivity, instead of careful consideration.

That doesn’t fit anybody’s definition of a rational act.

“The suicidal state isn't fixed,” Dr. Conwell said. “It’s a teeter-totter. There’s a will to measure and a will to die, and it goes back and forth.”

When health care providers aggressively treat seniors’ depression and work to enhance their health, function and relationships, he said, “it can change the equation.”

Failing to require action to stop suicide, some ethicists and clinicians argue, reflects an ageist assumption — one older people themselves aren’t resistant to — that the lives of old or disabled people lack value.

A tolerant approach also overlooks the very fact that folks often change their minds, declaring certain conditions unendurable within the abstract but choosing to measure if when the worst actually happens.

Slippery-slope arguments factor into the talk, too.

“We worry that we could shift from a right to die to a requirement to die if we make suicide seem desirable or justifiable,” Dr. Balasubramaniam said.

But the dimensions of the boomer cohort, with the drive for the autonomy that has characterized its members, means doctors expect more of their older patients to contemplate controlling the time and manner of their deaths.

Not all of them are depressed or otherwise impaired in judgment.

“Perhaps you are feeling your life is on a downhill course,” said Dena Davis, a bioethicist at Lehigh University who has written about what she calls “pre-emptive suicide.”

“You’ve completed the items you wanted to try to to. You see life’s satisfactions getting smaller and therefore the burdens getting larger — that’s true for tons folks as our bodies start breaking down.”

At that time, “it could be rational to finish your life,” Dr. Davis continued.

“Unfortunately, in the world, we currently sleep in, if you don’t take hold of life’s end, it’s likely to travel in ways that are inimical to your wishes.”

Dr. Davis cared for her mother as she slowly succumbed to Alzheimer’s disease. She intends to avoid an identical death, a choice she has discussed together with her son, her friends and her doctor.

From 0 to 10 Million: Vaping Takes Off


From 0 to 10 Million: Vaping flies within the U.S.

Some experts have suggested that e-cigarettes can help wean people off regular cigarettes; others believe that they reinforce the smoking habit and increase the user’s exposure to nicotine.

But there’s no dispute that e-cigarettes have grown popular since their introduction in 2004. Now a nationwide survey has found that 10.8 million adults within us are vaping.

The analysis, published within the Annals of general medicine found that 54.6 percent of the e cigarette users were also smoking cigarettes.

About 15 percent of vapers had never smoked cigarettes and 30.4 percent had quit smoking them.

The study is predicated on data from the Behavioral Risk Factor closed-circuit television, A national survey conducted by the Centers for Disease Control and Prevention.

In 2016, the researchers surveyed 486,000 people 18 and older by telephone in every state and the District of Columbia, also as Guam, Puerto Rico, and therefore the Virgin Islands.

More than half of e-cigarette users were younger than 35, and therefore the prevalence decreased with increasing age.

it had been highest among people ages 18 to 24, both occasional and daily users.

Overall, almost 6 percent of men and three .7 percent of girls were vaping. But there have been sharp differences among particular demographic groups.

The prevalence was 9 percent among bisexuals, for instance, and seven percent among lesbians and gay men, compared with 4.6 percent among heterosexuals.

Almost 9 percent of transgender people were vapers.

People with disorder, cancer, asthma, and depression were also more likely than others to be using e-cigarettes, and therefore the rate was 10.2 percent among people with chronic obstructive pulmonary disease. Almost 2 percent of pregnant women were vaping.

E-cigarettes were most ordinarily utilized in Oklahoma and within the Southeast, and least often utilized in North Dakota and California.

“The use of e-cigarettes within the U.S. may be a complicated picture” said the study’s senior author, Dr. Michael J. Blaha, a professor of drugs and epidemiology at Johns Hopkins.

“People who try e-cigs are in danger of a spread of health conditions. But you've got former smokers, daily smokers, occasional smokers — it’s getting to be difficult to map out the health effects.”

Dr. Blaha added, “Almost everyone would agree that the utilization of e-cigarettes among people who haven't smoked — we’re up to almost 2 million people — are some things we have to observe very carefully.”

He and his colleagues acknowledge that the study depends on self-reports and demonstrates only associations, not cause and effect. Moreover, the researchers had no data on the sort of e-cigarette device used, the flavors added or the dimensions of the nicotine dose.

You’ll Never Guess Which Company Is

health Benefits

You’ll never guess which company is reinventing health Benefits

It’s hard to consider a corporation that seems less likely to rework healthcare. It isn’t headquartered in Silicon Valley, with all the venture-backed start-ups.

It’s not among the corporate giants—Amazon, Berkshire Hathaway, and JPMorgan Chase—that recently announced, with much fanfare, an idea to overhaul the medical-industrial complex for their employees.

And it's among the foremost hated companies within the U.S., consistent with many surveys on customer satisfaction.

The nation’s largest cable company—the $169 billion Philadelphia-based behemoths that also controls Universal Parks & Resorts, “Sunday Night Football,” and MSNBC—is among a couple of employers declaring progress in reaching a much-desired goal.

within the last five years, the corporate says, its healthcare costs have stayed nearly flat.

They're increasing by about 1% a year, well under the three average of other large employers and below general inflation.

“They’re the foremost interesting and artistic employer when it involves healthcare benefits,” said Dr. Bob Kocher, a partner at Venrock, a risk capital firm whose portfolio companies have done business with Comcast.

(The cable company declined over several months to supply executives for an interview on this subject.) Comcast, which spends roughly $1.3 billion a year on healthcare for its 225,000 employees and families, has steered far away from a number of the normal methods other companies impose to contain medical expenses.

It rejected the favored corporate tack of getting employees to shoulder more of the rising costs high-deductible plans, the mechanism that's notorious for discouraging people to hunt medical help.

Most employers now require their workers to pay a deductible before their insurance kicks in, with individuals on the hook for $1,500, on average, in upfront payouts, according to the Kaiser Family Foundation.

Instead, Comcast lowered its deductible to $250 for many of its workers.

Cable TV subscribers who have felt confused and overwhelmed when handling Comcast customer service could also be surprised to find out how nimbly the corporate has upgraded services for its employees.

While Comcast continues to figure with insurers, it has largely shunned them as a source of innovation.

Instead, it's assembled its own portfolio of companies that it contracts with and invests in a number of them through a venture capital arm, Comcast Ventures.

One such company is Accolade, during which Comcast is an investor, and which provides independent guides called navigators to assist employees to use their health benefits.

Another, called Grand Rounds, offers second opinions and help find a doctor.

Comcast was also among the primary major employers to supply workers access to a doctor via cellphone through Doctor on Demand, a telehealth company.

The corporation, of course, is controlling costs and offering these unusual benefits out of self-interest.

And these services are sometimes handed out at the expense of improving wages.

during a tight market, Comcast also must remain competitive for not one highly skilled employees but also lower-wage workers whose direct contact with customers have generated such a lot of dissatisfaction over the years.

But much of what sets Comcast apart is its willingness to directly tackle its medical costs rather than counting on others—insurers, consultants, or associations.

It’s a luxury only the largest companies can afford, and roughly a fifth of massive companies still see annual cost increases of quite 10%, consistent with Mercer, a benefits consultant.

Tuesday, 28 August 2018

S.T.D. Diagnoses Reach Record 2.3 Million New Cases in U.S.


New cases of chlamydia, gonorrhea, and venereal disease rose sharply for the fourth consecutive year in 2017, to a record high of nearly a pair of.3 million, in step with new information from the Centers for unwellness management and bar.

That variety surpassed the previous record, that was set in 2016, by quite two hundred,000 cases.

The statistics are an associate horrifying sign that the systems to forestall and treat sexually transmitted diseases are “strained to near-breaking purpose,” said Dr. Jonathan Mermin, a top C.D.C. official.

Using condoms will scale back the chance of sending all 3 diseases, that are among the foremost common S.T.D.s and may be cured with antibiotics.

However several cases go unknown, and therefore the diseases will cause serious issues down the road, together with physiological condition and hyperbolic H.I.V. risk.

“Most folks with these S.T.D.s don't understand they're infected,” said Dr. Gail Bolan, director of the C.D.C.’s division of sexually transmitted unwellness bar.

“They don’t understand that these diseases are spreading mutely through the country.”

Further complicating matters, sexually transmitted disease is more and more immune to antibiotic treatment.

Health officers expect that it'll eventually alter the last extremely effective antibiotic employed in u. s. It’s imperative for drug manufacturers to develop new antibiotics to treat it, Dr. Bolan said.

Officials declared the statistics at the National S.T.D. bar Conference in Washington, wherever they cautioned that the diagnosed cases represent a solely a little fraction of total cases.

There were quite one.7 million cases of chlamydia diagnosed in 2017, the foremost common sexually transmitted unwellness reported to the C.D.C., representing a twenty-two % increase from 2013 levels.

Nearly half those cases were among 15- to 24-year-old ladies.

Cases of sexually transmitted disease, that is additionally prevailing among adolescents, hyperbolic sixty-seven % from 2013 levels to a complete of 555,608 new diagnoses.

Chlamydia and sexually transmitted disease usually lurk while not symptoms, while they're doing harm to the genital system. each disease may also cause pain and abnormal discharge or hurt and may be passed to a baby throughout delivery.

The C.D.C. recommends that each one ladies beneath twenty-five be screened annually for each disease, thanks to the dire consequences they'll have if left untreated.

The rate of venereal disease shot up seventy-six % compared with 2013 levels, to a complete of thirty,644 new cases.

Men United Nations agency lies with men created up nearly seventy % of the cases within which the partner’s gender was famous. But Dr. Bolan noted that the rates were rising among ladies and heterosexual men.

The unwellness will cause sores and rashes weeks when infection, and heavy medicine, optical and different symptoms soon.

it's extremely infectious, and pregnant ladies ar possible to pass it on to their babies in utero, which might lead to stillbirths.

The rates of venereal disease declined considerably with the arrival of antibiotic treatment within the Nineteen Forties — most in order that several doctors don't acknowledge it, Dr. Bolan said.

There could also be no single reason for the rise in sexually transmitted diseases. Public health officers purpose to deteriorating public health services, like S.T.D. testing clinics.

The opioid epidemic has had an effect, as users have interaction in unsafe practices. Some native health departments have infernal a rise in casual sex joined to chemical analysis apps like ignitor.

Dr. Bolan aforementioned that to prevent the unfold of the diseases, health care suppliers should create S.T.D. screening a regular part of treatment.

“There’s imperative action that's required to handle these record-high S.T.D.s,” she said.

Monday, 27 August 2018

Breast-Feeding Mothers Should Avoid


Breast-Feeding Mothers Should Avoid Marijuana, Pediatricians Say

Marijuana is more widely available than ever, but what does it does to babies?

There’s no answer thereto yet, but nursing mothers are being warned to avoid it: Traces of the drug can show up in breast milk, consistent with the American Academy of Pediatrics.

Tetrahydrocannabinol, or THC, the psychoactive ingredient in marijuana that gets people high are often detected in breast milk up to 6 days after the utilization of the drug, consistent with a study published on Monday by the journal Pediatrics.

The study found that tetrahydrocannabinol was detectable in 63 percent of 54 samples of breast milk from women who said that they had used marijuana before pumping.

In response to evidence that babies are being exposed to marijuana, the A.A.P. recommends that ladies avoid the drug altogether once they are pregnant or breastfeeding.

Research into the potential effects of marijuana has become particularly relevant as more states have moved toward legalization and expectant mothers have haunted the drug in increasing numbers.

Recreational use is legal in eight states and Washington, and 30 states leave some sort of medical use.

recently took a step toward allowing recreational marijuana.

The move toward legalization has gained momentum in countries like Canada and Britain while attracting big dollars from investors looking to require advantage of the expansion in the industry. 

The parent company of Corona beer recently plunged $4 billion into a cannabis producer.

But the A.A.P. warned that in spite of loosening restrictions, it isn’t necessarily safe for the baby.

“The incontrovertible fact that marijuana is legal in many nations may give the impression the drug is harmless during pregnancy, especially with stories swirling on social media about using it for nausea with nausea,” said Sheryl A. Ryan, chairwoman of the A.A.P.

Committee on Substance Use and Prevention. “But actually, this is often still an enormous question.”

Preliminary research has suggested that THC can cross the placenta and reach the fetus, potentially harming brain development, cognition, and birth weight.

But studies on the effects of marijuana on pregnancy and lactation are relatively rare.

The A.A.P. study, which tested breast milk instead of the babies don't provide evidence of how or if children are affected. It also noted that the quantity ingested by infants could vary significantly.

Work on the subject is all the more important now as pot has become stronger, said Christina D. Chambers, a professor of pediatrics at the University of California, San Diego, and one among the authors of the study.

“We needed current-day use of currently available products to actually understand exposure levels and to seem at outcomes that are relevant to today,” she said in an email.

More research is required so doctors can provide evidence-based advice, Dr. Chambers added.

“This creates a dilemma for pediatricians who want their patients to be breast-fed and worry that some mothers if told to not use cannabis, might not breast-feed.”

How Much Alcohol Is Safe? None, Say These

Alcohol Is Safe to Drink

How Much Alcohol Is Safe to Drink? None, Say These Researchers

Just one alcoholic drink each day slightly increases an individual’s risk for health problems,
according to an outsized new study.

No level of alcohol consumption conferred any health benefits, the authors also
concluded — a finding that runs contrary to much previous research and public health
guidelines in many countries.

The analysis, involving 195 countries and territories from 1990 to 2016, relied on 694
sources of knowledge and analyzed 592 studies to work out the health risks of alcohol use.
While the study is among the most important of its kind, it had been also observational, linking
population-wide consumption to population-wide trends.

The methods left many experts unconvinced.

Online in Medium, David Spiegelhalter, a statistician at Cambridge University in England, wrote of the study’s conclusion: “Claiming there's no ‘safe’ the level doesn't seem an argument for abstention. there's no safe level of driving, but governments don't recommend that folks avoid driving.”

The researchers relied on sales data and surveys to estimate the prevalence of drinking in each country and calculated alcohol consumption in standard drinks daily defined as 10 grams, or about one-third of an oz, of pure ethyl alcohol — the equivalent of three .4 ounces of wine at 13 percent alcohol, 12 ounces of beer at 3.5 percent alcohol or one ounce of 80-proof whiskey.

They also devised a way for distinguishing alcohol consumption among tourists from that of resident populations, and linked consumption data to 23 health outcomes, ranging from car accidents, suicides, and tuberculosis, to liver cirrhosis, cardiovascular disease, and cancers.

In 2016, 25 percent of girls and 39 percent of men were current drinkers — about 2.4 billion people worldwide. Women consumed a mean of 0.73 drinks each day, while men had 1.7 drinks.

Rates of alcohol consumption vary widely by country but generally the upper a country’s income level, the upper the prevalence of drinking.

The study, published within the Lancet, concluded that alcohol consumption is involved in 2.8
million deaths annually worldwide, making it the seventh leading risk factor for death and disability.

Among people aged 15 to 49, alcohol use is that the single commonest risk factor for death and disability.

In 2016, alcohol accounted for six .8 percent of males and a couple of .2 percent of female deaths.

“The main difference between alcohol and smoking is that nobody is surprised that smoking is bad,” said the lead author, Emmanuela Gakidou, a professor of health metrics sciences at the University of Washington.

“But there are tons of surprises, even among experts, that alcohol is as bad for you because it is.”
Many studies and most health guidelines suggest that moderate drinking — one or two drinks each day — is safe and should even reduce the danger of heart condition, stroke or diabetes.

But Dr. Gakidou and her colleagues found that only one drink each day for one year increases alcohol-related health problems slightly, to 918 per 100,000 people from 914 per 100,000.

China Has Withheld Samples of a Dangerous

Dangerous Flu Virus

China Has Withheld Samples of a Dangerous Flu Virus

For over a year, the Chinese government has withheld lab samples of a rapidly evolving influenza virus from us — specimens needed to develop vaccines and treatments, consistent with federal health officials.

Despite persistent requests from officialdom and research institutions, China has not provided samples of the damaging virus, a kind of bird flu called H7N9. In the past, such exchanges are mostly routine under rules established by the planet Health Organization.

Now, because of we and China spar over trade, some scientists worry that the vital exchange of medical supplies and knowledge could slow, hampering preparedness for the next biological threat.

The scenario is “unlike shortages in aluminum and soybeans,” said Dr. Michael Callahan,
a communicable disease specialist at Harvard school of medicine.

“Jeopardizing U.S. access to foreign pathogens and therapies to counter them undermines our nation’s ability to guard against infections which may spread globally within days.”

Experts concur that the world’s next global pandemic will likely come from a repeat
offender: the flu. The H7N9 virus is one candidate.

Since taking root in China in 2013, the virus has spread through poultry farms, evolving into a highly pathogenic strain that will infect humans. it's killed 40 percent of its victims.

If this strain were to become highly contagious among humans, seasonal flu vaccines would provide little to no protection. Americans have virtually no immunity.

“Pandemic influenza spreads faster than anything,” said Rick A. Bright, the director of Biomedical Advanced Research and Development Authority, workplace within the Department of Health and Human Services that oversees vaccine development. “There’s nothing to carry it back or slow it down. Every minute counts.”

Under an agreement established by the planet Health The organization, participating countries must transfer influenza samples with pandemic potential to designated research centers “in a timely manner.”

That process — involving paperwork, approval through several agencies and a licensed carrier — normally takes several months, consistent with Dr. Larry Kerr, the director of pandemics and emerging threats at the Department of Health and Human Services.

But quite one year after a devastating wave of H7N9 infections in Asia — 766 cases
were reported, most in China — the Centers for Disease Control and Prevention is
still expecting several viral samples, the National Security Council and therefore the W.H.O.

Scientists at the Department of Agriculture have had such difficulty obtaining flu samples from China that they need to be stopped requesting them altogether, consistent with a government official who spoke anonymously because of he wasn't authorized to debate the matter.

At least four research institutions have relied upon the little group of H7N9 samples from cases in Taiwan and Hong Kong. (All four asked to not be identified for fear of further straining ties.)

The Chinese embassy in Washington didn't answer multiple requests for comment.

The Chinese Center For Disease Control and Prevention also didn't reply to inquiries regarding the transfer.

When the H7N9 virus first appeared in China, researchers say the Chinese government at first provided timely information. But communication has gradually worsened.

Yet a sudden spike in infections during 2016-2017 outbreak wave demands intense the research said scientists getting to understand the virus’s evolution.

Recent trade tensions could worsen the matter.

The Office of us Trade Representative in April released the proposed list of products to be targeted for tariffs — including pharmaceutical products like vaccines, medicines and medical devices.

So far, none of these medical products have landed on the ultimate tariff lists. But lower-level
trade negotiations with China concluded on Thursday with few signs of progress, increasing the likelihood of additional tariffs.

Us relies on China not just for H7N9 influenza samples except for medical supplies, like plastic drip mechanisms for intravenous saline, also as ingredients for certain oncology and anesthesia drugs.

a number of these are delivered through a just-in-time production model; there are not any stockpiles, which could prove dangerous if the supply was disrupted, health officials said.

Scientists believe top commerce officials in both governments view the viral samples much like the other laboratory product, and perhaps unacquainted their vital role in global security.

“Countries don’t own their viral samples any longer than they own the birds in their skies,” said Andrew C. Weber, who oversaw the biological defense programs at the Pentagon during the Obama administration.

“Given that this flu virus may be a potential threat to humanity, not sharing it immediately with
the global network of W.H.O. laboratories like C.D.C. is scandalous. Many could die needlessly if China denies international access to samples.” For over a decade, epidemiological data and samples are used as trade war pawns.

China hid the 2002 outbreak of severe acute respiratory syndrome, or SARS, for four months then kept the findings of its research private. Some provinces withheld information about cases even from the central government in Beijing.

In 2005, Chinese authorities insisted H5N1 influenza the outbreak was contained, contradicting University of Hong Kong scientists who offered evidence that it had been expanding. Those authorities hesitated to share viral samples from infected wild birds with the international community, concealing the scope to avoid successful in their vast poultry industry.

Indonesia followed suit, refusing in 2007 to share specimens of H5N1 with the United States and therefore the UK, arguing that the countries would use the samples to develop a vaccine that Indonesians couldn't afford.

Those episodes led to the 2011 development of the W.H.O.’s Pandemic Influenza Preparedness Framework, which aims to market sample exchanges also as developing countries’ access to vaccines.

But for countries like China, bearing the burden of the completely unique virus is paradoxical.

Outbreaks are expensive — the wave of H7N9 infections in 2013 alone cost China more than $6 billion, consistent with the United Nations — but they will provide a head-start in developing valuable treatments.

Did Juul Lure Teenagers and Get


Did Juul Lure Teenagers and obtain ‘Customers for Life’?

SAN FRANCISCO — The leaders of a little start-up, PAX Labs, gathered at a committee meeting in early 2015 to review the marketing strategy for its sleek new electronic cigarette, called Juul. They watched video clips of hip children, posed flirtatiously holding Juuls. and that they talked about the name of the gadget, meant to suggest an object of beauty and to catch on as a verb — as in “to Juul.”
While the campaign wasn’t targeted specifically at teenagers, a former senior manager said that he et al. within the company were cognizant it could appeal to them.

After Juuls went on sale in June 2015, he said, the corporate quickly realized that teenagers were, in fact, using them because they posted images of themselves vaping Juul on social media.

The former manager said the corporate was careful to form sure the models in its original campaign where a minimum of 21, but it wasn’t until late 2016 or January 2017 that the corporate said it decided the models altogether Juul ads should be over age 35 — to be “better aligned” with a mission of that specialize in adult smokers.

Only in June of this year did the corporate again change its policy, this point to using only real people that had switched from cigarettes to Juul.

The company recently modified the names of its flavors — using creme rather than custard and cucumber rather than the cool cucumber.

Juul said it “heard the criticism” that teenagers could be interested in the flavors and “responded by simplifying the names and losing the descriptors.”

The sales campaigns for Juuls — now hugely fashionable teenagers across the state — are at the guts of a federal investigation into whether the corporate intentionally marketed its devices to youth.

The attorney general of Massachusetts, also investigating the corporate contends that Juul has been luring teenagers to undertake the merchandise and has introduced many to nicotine.

Her investigation will examine Juul’s efforts to audit its own website and other online retailers that sell its products to ascertain how effective they're at preventing minors from accessing Juul or Juul-compatible products.

(Federal law prohibits sales of e-cigarettes to anyone under 18.)
“From our perspective, this is often not about getting adults to prevent smoking,” the Massachusetts attorney general, Maura Healey, said in an interview.

“This is about getting kids to start out vaping, and make money and have them as customers for all times .”

And Cult Collective, the marketing company that created the 2015 campaign, “Vaporized,” claims on its website that the work “created ridiculous enthusiasm” for the campaign the hashtag, a part of a bigger advertising effort that included music event sponsorships and retail marketing. A spokesman for Cult Collective declined to comment.

Examples of Juul’s advertising from 2015. The company’s current marketing is way more sober-looking, with a less colorful, more adult design.

The company, now called Juul Labs, denies that it ever sought to draw in teenagers. James Monsees, one among the company’s co-founders, said selling Juuls to youth was “antithetical to the company’s mission.”

The original advertising campaign was aimed toward persuading adult smokers in their 20s and The 30s to undertake an alternate to cigarettes, but it “failed to realize traction on social media and did not gain sales” and was abandoned after five months, within the fall of 2015, said a corporation spokesman, Matt David.

Mr. David said sales didn’t begin until 2017, after Juul had improved its sales and distribution expertise, and, by then, had a more sober online marketing campaign.

The former Juul manager, who spoke to The NY Times on the condition that his name not be used, saying he worried about facing the ire of the corporate, said that within months of Juul’s 2015 introduction, it became evident that teenagers were either buying Juuls online or finding others who made the purchases for them. Some people bought more Juul kits on the company’s website than they might individually use — sometimes 10 or more devices.

“First, they only knew it had been being bought for resale,” said the previous senior manager, who was briefed on the company’s business strategy. “Then, once they saw the social media, in the fall and winter of 2015, they suspected it had been teens.”

The Food and Drug The administration announced it had been investigating Juul’s marketing efforts in April. Juuls and other e-cigarettes are regulated by the F.D.A. as tobacco products because nicotine derives from tobacco leaves.

E-cigarette users inhale far fewer toxins than do smokers of traditional cigarettes. The nicotine inhaled while vaping is a smaller amount a priority for adults than these toxins, but it remains a significant health issue for teenagers, whose brains are still developing.

The Juul story highlights a central dilemma of public health. Cigarettes remain the leading explanation for preventable death within us, killing quite 480,000 people a year. But will it's possible to urge people that are hooked into cigarettes to modify to e-cigarettes, which are less harmful, without enticing a replacement generation or non-smokers to undertake them?

The F.D.A. commissioned research, published in January, that found “limited evidence” that e-cigarettes lead smokers to quit. and a few evidence now suggests that children who use e-cigarettes are more likely to undertake cigarettes.

Juul, during a letter responding to the F.D.A.’s demand for documents said it had converted a million smokers to Juul, but the corporate data is drawn from self-reported surveys on its website and is unverifiable.

Dr. Scott Gottlieb, who heads the F.D.A., declined to discuss the agency’s investigation of Juul. But he has long been hopeful that e-cigarettes or other similar devices, properly regulated, will prove a safer alternative to smoking and help people quit the deadly habit.

Before becoming F.D.A. commissioner, he served on the board of directors of Kure, a retailer that sells e-cigarette products.

Friday, 24 August 2018

Big Tobacco’s Global Reach on Social Media

Big Tobacco’s

Big Tobacco’s Global Reach on Social Media

It’s been years since the industry promised to prevent luring children to smoke cigarettes.

Philip Morris International says it's “designing a smoke-free future.” British American Tobacco, likewise, claims to be “transforming tobacco” into a safer product.

But while the Food and Drug Administration weighs plans to chop nicotine in cigarettes, making them less addictive, Big Tobacco has been making the foremost of the time it still has used social networks to market its brands around the world.

Most countries, just like us, imposed rules back within the 1970s against marketing tobacco to youths; many have banned cigarette commercials on television and radio.

So the industry that brought the planet the Marlboro Man, Joe Camel and slogans like “Reach for a Lucky rather than a Sweet” has latched onto the selfie generation’s screens during a highly adaptive way that skirts the advertising rules of old.

“What they're doing may be a really effective thanks to getting around existing laws to limit advertising to children,” said Robert V. Kozinets, a PR professor at the University of Southern California, who led a world team of researchers examining the tobacco industry’s use of social media.

“The most surprising thing to me was the extent of sophistication of those different global networks. You get incredible campaigns, the likes of which I’ve never seen before.”

International public health organizations are pushing back against tobacco companies around the world. Earlier this month, Bloomberg Philanthropies chose three international research centers to steer a replacement $20 million global tobacco watchdog group called Stop (Stopping Tobacco Organizations and Products), with partners within the UK, Thailand and France, which will partly specialize in social marketing.

Dr. Kozinets’s work, purchased by the Campaign for Tobacco-Free Kids, an advocacy group, analyzed social media in 10 countries by trying to find hashtags that hook up with tobacco cigarette brands.

By promising anonymity, Dr. Kozinets’s researchers were ready to interview paid and unpaid “ambassadors” and “micro-influencers” to reveal the connection between the tobacco companies, their communications agencies and social media posts on Instagram and Facebook.

The results of this study, alongside research during a total of 40 countries, led the Campaign for
Tobacco-Free Kids, the American Cancer Society Cancer Action Network, the American Lung Association, and other public health groups to file a petition on Friday with the Federal Trade Commission against four tobacco companies.

The petition claims that Philip Morris International, British American Tobacco, Japan Tobacco International, and Imperial Brands are targeting young American consumers with deceptive social media marketing in violation of federal law. The petition calls on the F.T.C. to prevent the practices.
Several of the tobacco companies didn't immediately answer requests to discuss the petition.

A spokesman for Philip Morris International said on Friday afternoon that the corporate had yet to review the documents and thus couldn't comment.

According to Caroline Renzulli, who oversaw the project for the campaign, 123 hashtags related to these companies’ tobacco products are viewed 8.8 billion times within us alone and 25 billion times around the world.

Representatives of a number of the businesses said they the market only to adult smokers and suits the laws of nations where they sell their products. Jonathan Duce, a spokesman for Japan Tobacco, said company-involved events were intended “to switch existing adult smokers to our brands from those of our competitors.”

“If smokers or vapers prefer to share their group action,” he added, “it is totally their choice.”
Simon Evans, a spokesman for Imperial Brands, acknowledged that the corporate paid “public opinion formers” to attend and post social media content about promotional events.
“Where this is often the case, however, we make it clear to them they're to not post branded content,” Mr. Evans said.

Some posts use hashtags that are closely connected to the brands: #lus or #likeus for Lucky Strikes, for instance. Other posts are more subtle, featuring cigarettes but no name, or appealing hashtags that signal autonomy or independence: #YouDecide, #DecideTonight and #RedIsHere are popular ones affiliated with Marlboro as is #FreedomMusic for Winston.

Sometimes the posts omit the cigarettes altogether but mention upcoming parties and other events where cigarettes are promoted in giant displays and given away. The party décor colors often match those of a selected brand.

The image below is from Indonesia, where a pack of Dunhill cigarettes may be a subtle prop. After a press inquiry, BAT said they might take down the post.

Lucky Strike ambassadors received these instructions last year in Italy, consistent with Dr. Kozinets, and that they included a note to hide up images “required to get on the packages by law”(presumably the warning labels).
In an email, Simon Cleverly, an executive with British American Tobacco, said the company’s team in Italy was reviewing the above documents, which researchers translated into English. the likes of Us campaign ran from 2012 through 2017, he said.

Some themes repeated in several countries were British American Tobacco’s #TasteTheCity, which promoted Dunhill and Kent brands, and Philip Morris International’s #Newland and #Neuland, and #IDecideTo/#YouDecide.

Bruno Nastari, a Brazilian business strategist, spent quite three years working for Geometry Global, in Sao Paulo, consistent with his LinkedIn page. His accounts included British American Tobacco brands Dunhill, Lucky Strike and Kent, his page noted.

Describing the strategy he used, Mr. Nastari wrote, “Our insight was that Dunhill is that the brand that transforms the town into a platform of discoveries, delivering exclusive experiences to younger audiences. Make Dunhill recognized as a contemporary, bold, and sassy brand, thus being more appealing to the typical smoker under 30 years. All this considering Brazil’s legal restrictions of cigarette advertising.”

Mr. Nastari didn't answer a reporter’s inquiry, but these notes are not any longer available on LinkedIn.

The NY Times reached bent the social media posters included during this article. Several, including tico13, vikicecarelli1, and Mr. Nastari, acknowledged receipt but declined to be interviewed.

Thursday, 23 August 2018

Russian Trolls Used Vaccine Debate to


Russian Trolls Used Vaccine Debate to Sow Discord, Study Finds

“Don’t get #vaccines. Illuminati is behind it.”

“Do you continue to treat your kids with leaves? No? And why don’t you #vaccinate them? It’s medicine!”

With messages like those, Russian internet trolls meddling within the 2016 presidential election also lashed out at Americans debating the security of vaccines, a replacement study has found.

But rather than picking a side, researchers said, the trolls and bots they programmed hurled insults at both pro- and anti-vaccine advocates. Their only intent, the study concluded, appeared to be to boost the extent of hostility.

“You see this pattern,” said David A. Broniatowski, a computer engineer at George
Washington University and lead author of the study, which was published Thursday within the American Journal of Public Health. “On guns or race, these accounts take opposite sides in many debates. They’re about sowing discord.”

With colleagues at the University of Maryland and Johns Hopkins University, Dr.
Broniatowski checked out 899 vaccine-related tweets sent from mid-2014 to late 2017.

Some came from accounts known to send spam or link to malware; more came from accounts that congressional investigators and NBC News have identified as belonging to Russian trolls.

While the spammer and malware accounts mostly disseminated anti-vaccine messages, the Russia-linked ones played each side.

Most of the anti-vaccine tweets repeated well-known but long-discredited rumors, like people who vaccines cause autism or contain dangerous amounts of mercury. Others accused pharmaceutical companies of caring only about profits, not children.

Pro-vaccine tweets from an equivalent account argued that vaccines saved lives. Some said they ought to be mandatory. Some were insulting, like “You can’t fix stupidity. allow them to die from measles, and I’m for #vaccination.”

But the Russians sometimes misread their audience, Dr. Broniatowski said, sending tweets that “didn’t quite add up, given the way Americans usually argue about vaccines.”

Some, for instance, suggested that God opposed vaccination. "I don’t believe #vaccines I think in God’s will,” one read.

Divine will is extremely rarely cited within the American debate except when HPV vaccine is discussed, then not over the notion that God ordains which children fall ill. HPV vaccine prevents cervical cancer, which is sexually transmitted, and a few Christian conservatives believe it encourages free love.

Other tweets promoted class hostility, saying the elite get “clean vaccines” while normal people didn't.

Yet others appeared designed to appeal to the audience for conspiracy websites like Infowars. One claimed that vaccines were a part of the planet's domination plan of the Illuminati secret sect.

More than 250 tweets had the weird hashtag #VaccinateUS. Anti-vaccination activists tend to use tags like #Vaxxed, #b1less or #CDCWhistleblower, Dr. Broniatowski said, while pro-vaccine groups use #vaccineswork, for instance.

Tweets carrying the hashtag #VaccinateUS, the study said, were “uniquely identified with Russian troll accounts linked to the web Research Agency,” a propaganda operation linked to the Kremlin.

That account, which Twitter closed, “was a failed campaign by Russian trolls,” Dr. Broniatowski said.

Anti-vaccine sentiment is lower in Russia than in many other European countries. consistent with the planet Health Organization, nearly one hundred pc of Russian children have had all their shots.

Purveyors of Juice-Box Style, Nicotine

Juice-Box Style

Purveyors of Juice-Box Style, Nicotine-Filled E-Liquids Quit Selling the Products

WASHINGTON — Makers of e-cigarette and vaping liquids like One Mad Hit Juice Box, V’Nilla Cookies & Milk, Unicorn Cakes and other products with packaging that would appeal to children have stopped selling them, consistent with the Food and Drug Administration.

The agency said on Thursday that the 17 makers, distributors and sellers of nicotine-containing e-liquids for e-cigarettes had agreed to require the products of the market, after the agency issued a warning in May.

“When companies market these products using imagery that misleads a toddler into thinking they’re things they’ve consumed before, sort of a juice box or candy, which will create an imminent risk of harm,” said Dr. Scott Gottlieb, the agency’s commissioner.

The letters, 13 of which were sent in partnership with the Federal Trade Commission, which regulates advertising, were sent to companies involved within the sale of a variety of vaping and e-cigarette products that the F.D.A. said appealed to children. Among those cited were:

• One Mad Hit Juice Box, which resembled apple juice;
• V’Nilla cookies & milk, packaged like cookies;
• Unicorn Cakes, including images and cartoons of a strawberry drink and unicorn eating pancakes, evoking the “My Little Pony” television and toy franchise.

The F.D.A. said it expected a number of the liquids would still, be sold under revised labeling and advertising.

According to the F.D.A., quite two million middle and high school students were users of e-cigarettes and related products in 2016, with flavorings given together of the highest reasons to be used.

Besides the threat of drug addiction, the agency is additionally concerned with a few rises in e-liquid poisonings of youngsters younger than six. E-liquid poisoning and other liquid nicotine exposure in young children can cause seizures, comas and even death from cardiac or respiratory arrest.

Eric Lindblom, a former F.D.A. tobacco official who is now at Georgetown school of law, called Thursday’s announcement an honest initiative.

“But,” he said, “tobacco companies know all kinds of sophisticated, under-the-radar ways to draw in kids to their products. What this is often doing is addressing the visible tip of the iceberg.”

Poetry - yeh mohabbat kitni ajeeb hai sahib

Kabhi Yeh Hi,jeer  kabhi Yeh wasaal Sahib.
Kar Diya Hai Ishq ne Jeena Mehal Sahib
Cut raha hai azeetoon  Main Mera Har Pal
In Mohabbatein Ne Diya Hai faa,qaat malal Sahib.
Kaat taa naa tha Jin Ke bagair Zindagi Ka Ek Pal.
Ba,ghair in Ke guzaar Diya Kae saal Sahib.
Yoon bhi aata hai insaan par zawaal Sahib.
Ab zamanaa Mohabbat par kuch nahi kehta.
Lagaa doo Fatwa ke Ishq Hai Halal Sahib.
Jawab Mohabbat par kyu seel Gaye Tere Hont.
Itna Mushkil To Nahi Pucha Sawal Sahib.
Chand bhi Dekhe aise toh apna aks Samjhay
Mat Pucho is ke husn ka ah e,waal Sahib.
love image
Add caption

Poetry - Tu Mujhko zaroori har daam

Tu Mujhko zaroori har daam Piyaa...
Tu Meri Amaanaat Tu Yeh Yaad Rakh Piyaa...
sad picture
Add caption

Poetry - Tujhe bhulne Ki Dua Karoon

Kabhi Yun Bhi Aa Meri Aankh Mein ke meri Nazar Ko Khabar Na Ho
Mujhe Raat Ke Nawaz De Magar uske baad Sahar Na Ho
Woh Bada Raheem ya Kareem Hai Tujhe ye saft bhi aata kare.
Tujhe bhulne Ki Dua Karoon Toh Meri Dua mein Asar Na Ho
Mere Bazoo,an Mein Thaki Thaki abhi mahu khuwab hai Chandni.
Naa Uthey Sitaron Ki Palki Abhi ahatoon ka guzaar Na Ho.
Na Mujhe kharabey Ki Roshni Kabhi bey Chirag Yeh Ghar Na Ho.
Woh farq hoo Ke wasaal Ho Teri Yaad Meheke gi Ek Din.
Wo Gulab ban kar khelega kya Jo Chirag Ban kar Jala Na Ho.
Kabhi Dukh De Kabhi badliyaan Dil wa jaan se dono Qubool Hain.
Magar is Nagar Mein Na qaid kar jahaan Zindagi Ki Hawa Na Ho.

alone girl sad image
Add caption

Wednesday, 22 August 2018

Immunotherapy Drugs Slow Skin Cancer That Has Spread to the Brain

drugs cancer
Add caption

Most skin cancers are caused by exposure to the sun. 

this might be semipermanent exposure or short periods of overexposure. 

This is as a result of ultraviolet (UV) light-weight from the sun damages the desoxyribonucleic acid (genetic material) in our skin cells.
There are 2 main forms of skin cancer: basal cell malignant neoplastic disease (BCC) and epithelial cell malignant neoplastic disease (SCC).
People with a history of sunburn or overexposure to the sun in childhood have a larger risk of developing BBC.
This won’t typically show up till a few years later. Sun exposure over your period is a lot of importance in developing SCC.

People who work outdoors have a larger risk of carcinoma as they're exposed to the sun for long periods of your time.
Fair-skinned folks have a larger risk than black- or brown-skinned folks.
This is as a result of the pigment in darker skin offers protection.

Regularly mistreatment sunbeds and sunlamps also can increase the danger of developing some skin cancers.

Other risk factors embody previous skin cancers, previous actinotherapy treatment, lowered immunity,
overexposure to chemicals at work and rare genetic conditions.

Causes and risk factors for carcinoma

Most skin cancers unit caused by exposure to the sun. this might belong to exposure or short periods of overexposure.
This is as a result of ultraviolet (UV) light-weight from the sun damages the desoxyribonucleic acid (genetic material) in our skin cells.

There unit a pair of main styles of skin cancer: basal cell malignant growth malady (BCC) and somatic cell malignant growth malady (SCC).
People with a history of sunburn or overexposure to the sun in childhood have a bigger risk of developing BBC.
This won’t generally show up until a couple of years later. Sun exposure over the amount of your time may be a ton of significant in developing SCC.

People who work outdoors have a bigger risk of malignant neoplastic disease as they are exposed to the sun for long periods of it slow.
Fair-skinned of us have a bigger risk than black- or brown-skinned of us.
This is as a result of the pigment in darker skin provides protection.

Regularly victimization sunbeds and sunlamps might increase the danger of developing some skin cancers.

Other risk factors embrace previous skin cancers, previous radiation treatment, lowered immunity,
overexposure to chemicals at work and rare genetic conditions.

Tuesday, 21 August 2018

You’re Getting Very Sleepy So Is

You’re Getting Very Sleepy

You’re Getting Very Sleepy. (So Is Everyone Else.)

Inadequate sleep causes quite $400 billion in economic losses annually within us and leads to 1.23 million lost days of labor annually, researchers have found.

The impact of chronic sleeplessness within us far exceeds the prices in other industrialized countries. The runner-up, Japan, loses the maximum amount as $138 billion annually to sleeplessness among workers, but that represents a greater share of its economy, researchers at the RAND Corporation found.

The number of people who sleep but the recommended hours is increasing within the developed world. From 20 to 30 percent of those workers complain of a scarcity of sleep on a day today.

“Inadequate sleep is just too easily accepted into the community as a part of life,” said Dr. David Hillman, a clinical professor at the University of Western Australia who studies sleep deficiency. In many work settings, “sleep is an indulgence.”

On a less quantifiable level, inadequate sleep reduces the security and productivity of workers. Researchers have linked such shattering events because of the Challenger spacecraft accident to human error caused by a scarcity of sleep.

“It’s an enormous problem that translates into enormous costs,” said Dr. Hillman. “And it’s a call to not only mitigate the suffering but also to mitigate the prices .”

As the manpower becomes more competitive, he said, employers must acknowledge inadequate sleep as a threat to company productivity. Well-rested employees are more efficient, tend to be healthier and feel more content.

More people should be educated about the importance of sleep and sleep hygiene at a young age, Dr. Hillman added. Usually, poor sleeping habits in the time of life are often traced back to sleep patterns formed in youth.

“Changing the positive mind-set around inadequate sleep as a lifestyle is important to safeguard one’s health,” said Dr. Hillman. a corporation performs well when managers are “aware of the wellness of their employees,” he added.

Monday, 20 August 2018

The Secret to Keeping Black Men Healthy

The Secret to Keeping Black Men Healthy

The Secret to Keeping Black Men Healthy? Maybe Black Doctors

Black men have rock bottom anticipation of any ethnos within us.

Much of the gap is explained by greater rates of chronic illnesses like diabetes and heart condition, which afflict poor and poorly educated black men especially.

But why is that? Lack of insurance? Lack of access to health care?

Now, a gaggle of researchers in California has demonstrated that another powerful force could also be at work: a scarcity of black physicians.

In the study, black men seeing black male doctors were far more likely to comply with certain preventive measures than were black men seeing doctors who were white or Asian.

Although 13 percent of the population is black within us , just 4 percent of doctors are black.
The study, published in June by the National Bureau for Economic Research, involved 702 black men in Oakland, Calif., who came to a clinic for a free health screening. They were randomly assigned to a black male doctor or one who was white or Asian.

Neither the lads nor the doctors knew that the aim of the study was to ask if a doctor’s race mattered when he or she advised these patients. because it clothed, the racial effects weren't subtle.

Diabetes screening was a part of the checkup, and 63 percent of the black men assigned to a black doctor agreed to the screening. But just 43 percent of these assigned to a doctor who was white or Asian consented to be screened.

Some 62 percent of black men with a black doctor agreed to cholesterol tests, compared to 36 percent assigned to a doctor who wasn't black.

“If their first reaction is, ‘No, I’m not curious about that,’ you want to explore why they said no and address those concerns.”

Dr. ChaRandle Jordan

Previous studies are observational — mostly searching earlier data for trends, a substantially weaker sort of evidence — and their results mixed.

“It changed the way I feel,” said Jonathan Skinner, a health care economist at Dartmouth
College, about the new results.

“This study convinced me that the consequences are real.”

The researchers employed minority premedical students to recruit participants by visiting 20 barbershops and two flea markets in Oakland, offering black men vouchers for a free health screening.

The screening was at a clinic found out by the investigators and staffed by 14 black and nonblack doctors. the lads were offered preventive measures like flu shots and screenings for the vital signs, cholesterol, and diabetes.

The men who came to the clinic offered equal praise for his or her black, white and Asian doctors. But the patients were much more likely to consent to preventive care — screenings and vaccinations — when their doctor was also black.

If black patients were to comply with this preventive care at these rates within the world, the gap in cardiovascular mortality between black men and therefore the remainder of the population might be reduced by 20 percent, the researchers estimated.

“I don’t think I even have ever had such a robust result, so unambiguous,” said Dr. Marcella Alsan, a professor of drugs at Stanford University and an author of the study.

Why would black doctors have such an effect? Perhaps they used more nonverbal cues to speak empathy, said Dr. Amber E. Barnato, a professor of drugs and health healthcare delivery at Dartmouth College.

In another small study, she used black and white actors to review white doctors’ interactions with patients at the top of life. Although the doctors said similar things to both black and white actors posing as patients, they stood closer to the white patients, made more eye contact, and touched them more often.

In the new study, Dr. Alsan and her colleagues didn't record patient visits. But some hints of the differences might be seen in comments the patients and doctors wrote in evaluations of their experiences.

The white and Asian doctors often wrote comments like “weight loss,” “tb test” and “anxiety” — cryptic notations that mentioned medical recommendations.

The black doctors often left more personal notes, like “needs food, shelter, clothing, job, ‘flu shot causes you to sick,’ he got one.” And “subject yelled at me, on the other hand, agreed to urge flu shot because I recommended it.” And “made patient laugh.”

Black men who saw white doctors wrote comments like, “It was an excellent and fast experience, a doctor was great also .” And “very informative, very appreciated.”

Those who saw black doctors wrote comments like, “The entire day made me feel very comfortable and relaxed” and “cool doctor” — comments that described an emotional response.

Bridging this racial divide may be a fraught matter, noted Dr. Skinner.

“It doesn’t seem so controversial if a lady requests a lady physician,” he said. “If a black patient asks for a black doctor, it’s understandable, especially given this study. But what if a white patient asks for a white doctor?”

A white doctor during this study, who asked that his name be withheld because he has black patients, said he felt his interactions with those that came to the clinic were “normal, comfortable health care visits.” Still, he wasn't surprised to listen to the study’s results.

“Anyone getting to see a doctor is going to be nervous,” he said. “If you face discrimination regularly in life, you'll enter a clinic with even more apprehensions. If you see a physician who is African-American, you'll feel some relief.”

One of the black doctors who participated in the study, Dr. ChaRandle Jordan noted that low-income black patients in Oakland tend to be guarded within the doctor’s office.

Saturday, 18 August 2018

In San Francisco, Opioid Addiction

In San Francisco

in San Francisco, Opioid Addiction Treatment Offered on the Streets

The addiction treatment program at Highland Hospital’s ER is merely a method that cities and health care providers are connecting with people in unusual settings.

Another is in San Francisco, where city doctors are taking to the streets to seek out homeless people with opioid use disorder and offering them buprenorphine prescriptions on the spot.

The city is spending $6 million on the program within the next two years, partly in response to a striking increase within the number of individuals injecting drugs on sidewalks and in other public areas. Most of the cash will go toward hiring 10 new clinicians for the city’s Street Medicine Team, which already provides medical aid for the homeless.

Members of the team will travel around the city offers buprenorphine prescriptions to addicted homeless people, which they will fill an equivalent day at a city-run pharmacy.

At the top of a recent yearlong pilot, about 20 of the 95 participants were still taking buprenorphine under the care of the road medicine team.

Dr. Barry Zevin, the city’s medical director for Street Medicine and Shelter Health hopes to supply buprenorphine to 250 more people through the program. That’s only a small fraction of the estimated 22,500 people in San Francisco who actively inject drugs, he said, but it’s a start.

What follows may be a condensed, edited interview with Dr. Zevin, who has been providing medical aid to the homeless in San Francisco since 1991.

Why offer buprenorphine on the streets rather than during a medical clinic?

Most health looks after the homeless happen under the model of expecting people to return to a clinic. But tons of individuals never are available. There are tons of psychological states, drug abuse and cognitive problems during this population, tons of chronic illness.

Appointments are the enemy of homeless people. On the road, there are not any appointments and no penalties or judgments for missing appointments.

Are you finding tons of enthusiasm for the buprenorphine program?

Virtually all the people we interact with have an interest. The people we approach on the streets and in encampments tend to be the longer-term users. At our needle exchange sites, it’s younger people that have maybe spent less time using.

Do you attempt to confirm that folks are taking the buprenorphine you give them, and not selling it to others who might abuse it? 

does one check to ascertain whether participants are still using illicit drugs?

We’re listening — we’re doing urine testing. But it’s not a barrier. People can still be within the program. Our pharmacist today said it seemed like one patient was still using and hadn’t had a toxicology that showed he had been in his system for a few months. So we'll give him a three-day supply, then check him again. If he’s not taking the buprenorphine, we'll offer observed dosing daily for the subsequent three days.

I do need to worry about diversion, but I would like to individualize look after everyone and not say that that worry is more important then my patient ahead of me, whose life is at stake.

What happens if a patient during this program is using other drugs besides opioids — like methamphetamine or cocaine?

It’s really, really hard to treat people with co-occurring meth and opioid use disorder. Only a couple of places have such a robust trend of individuals using both these drugs, and San Francisco is one among them. Easily 75 percent of my patients use both a day.

But a minimum of we is reducing the danger of death, albeit somebody’s only taking their bupesome of the time. It’s especially important now due to the poisoning of the heroin supply with fentanyl.

This E.R. Treats Opioid Addiction on

This E.R. Treats Opioid Addiction on Demand

This E.R. Treats Opioid Addiction on Demand. That’s Very Rare.

OAKLAND, Calif. — per annum, thousands of individuals hooked into opioids show up at hospital emergency rooms in withdrawal so agonizing it leaves them moaning and writhing on the ground. 

Usually, they’re given medicines that help with vomiting or diarrhea and sent on their way, maybe with a couple of numbers to call about treatment.

When Rhonda Hauswirth received the Highland Hospital E.R. here, retching and shaking violently after each day and a half without heroin, something very different happened. She was offered a dose of buprenorphine on the spot.

one among three medications approved within us to treat opioid addiction, it works by easing withdrawal symptoms and cravings. The tablet dissolved under her tongue while she slumped during a plastic chair, her long red hair obscuring her ashen face.

Soon, the shakes stopped. “I could focus a touch more. I could see straight,” said Ms.
Hauswirth, 40. “I’d never heard of anyone getting to an ER to try to that.”

Highland, a clattering big-city hospital where security wands constantly beep as new patients get scanned for weapons, is among little group of institutions that have started initiating opioid addiction treatment within the E.R. Their aim is to plug a gaping hole during a medical system that consistently fails to supply treatment on demand, or any evidence-based treatment in the least, whilst quite two million Americans suffer from opioid addiction.

consistent with the newest estimates, overdoses involving opioids killed nearly 50,000 people last year.

By providing buprenorphine round the clock to people in crisis — people that may never otherwise seek medical aid — these E.R.s do their best to make sure a rare opportunity isn’t lost.

“With one E.R. visit, we will provide 24 to 48 hours of withdrawal suppression, also as suppression of cravings,” said Dr. Andrew Herring, a medicine specialist at Highland who runs the buprenorphine program. “It is often this revelatory moment for people — even within the depth of the crisis, within the middle of the night. It shows them there’s a pathway back to feeling normal.”

It usually takes more steps to urge someone started on addiction medicine — if they will find it in the least, or have the time to undertake.

Locating a doctor who prescribes buprenorphine and takes insurance are often impossible in large swaths of the country, and therefore the await the initial appointment can stretch for weeks, during which individuals can easily relapse and overdose.

[Read about the national shortage of doctors who can prescribe buprenorphine.]

A 2015 study out of Yale-New Haven Hospital found that addicted patients who got buprenorphine within the ER were twice as likely to be in treatment a month later as those that were simply handed an informational pamphlets with phone numbers.

After Dr. Herring read the Yale study, he persuaded the California Health Care Foundation to offer a little grant to Highland and 7 other hospitals in Northern California last year, in both urban and rural areas, to experiment with dispensing buprenorphine in their E.R.s. Now the state is spending nearly $700,000 more to expand the concept statewide as a part of a broader, $78 million effort to line up a so-called hub-and-spoke meant to supply more access to buprenorphine and two other addiction medications, methadone, and naltrexone.

Under that system, an ER would function a portal, starting people on buprenorphine and referring them to a large-scale addiction treatment clinic (the hub), to urge adjusted to the medication, and to a medical care practice (the spoke) for ongoing care. Dr. Herring is serving because of the PI for the project referred to as E.D. Bridge.

The $78 million is most of California’s share of an initial $1 billion in federal grants that Congress approved for states to spend on addiction treatment and prevention under the 21st Century Cures Act, enacted in 2016.

“At first it seemed so alien and far-fetched,” Dr. Herring said, noting that doctors are often nervous about buprenorphine, which is more commonly-known by the name Suboxone. they have the training and a special license from the federal Drug Enforcement Administration to prescribe it for addiction (it’s also wont to treat pain), although E.R.

doctors don’t need the license to supply doses of the medication to patients in withdrawal.
But lately, Dr. Gail D’Onofrio, the lead author of the Yale the study, has been fielding calls hebdomadally from E.R. doctors curious about her hospital’s model.

Since the study was published, a couple of dozen hospital emergency departments, including in Boston, New York, Philadelphia, Brunswick, Me., Camden, N.J., and Syracuse, have also started offering buprenorphine.

“I think we’re at the stage now where emergency docs are saying, ‘I’ve needed to do something,’ ”
Dr. D’Onofrio said. “They’re beyond thinking they will just be a revolving door.”

As Dr. Herring’s shift began one Tuesday, a 30-year-old woman during a white jockey cap entered the E.R. She said she had been using heroin for the past three years but had been taking opioids since a doctor prescribed her the painkiller Norco after a softball injury when she was 12. She had overdosed twice and had never stopped using for quite two months at a time.

last, she told the doctor, she had been snorting fentanyl from a dealer who gave it to her free of charge in exchange for meth provided by her friend.

She was talking fast about how she hadn’t been ready to sleep for days. She had just moved into a sober-living house in Berkeley, about 20 minutes away, and therefore the withdrawal was kicking in. The manager of the house had sent her to Highland.