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PBS NewsHour

Surgeons’ late-night work doesn’t cause patients harm, study says

Photo by Morsa Images via Getty

Photo by Morsa Images via Getty

Patients receiving common operations in the daytime fared no worse in the short-term if their attending physician worked a hospital graveyard shift the night before than patients whose doctor did not, according to a new study examining the effects of sleep deprivation on surgeons.

Patients whose physicians worked from midnight to 7 a.m. the night before a daytime operation were as likely to die, be readmitted to the hospital or suffer complications within 30 days of their procedure as other patients who had the same operations in the daytime from physicians who had not worked after midnight, researchers said. Short-term outcomes were compared for patients receiving 12 elective procedures such as knee and hip replacements, hysterectomies and spinal surgeries. The study, conducted in Ontario, Canada by researchers in Toronto, was published Wednesday in the New England Journal of Medicine. It included 38,978 patients and 1,448 physicians.

Its conclusions are at odds with previous research linking sleep deprivation in physicians to reduced performance.

In the New England Journal article, researchers said most earlier studies have focused on medical trainees, otherwise known as residents, but not on attending physicians. For example, working surgeons have more experience than trainees, which could compensate for reduced performance, they said. Nancy Baxter, one of the co-authors, said working surgeons have more control over their schedules than residents have and can schedule daytime surgeries with longer breaks between nighttime shifts.

Medical school residents once were expected to work 24- to 36-hour long shifts without scheduled breaks for sleep. New rules implemented in 2003 by the Accreditation Council for Graduate Medical Education, which set standards for medical residencies, capped all residents’ schedules at a maximum 80 hours per week or 24 consecutive hours on duty. They should not be on call more than every third night. Under rules set in 2011, first-year residents are limited to 16-hour shifts and require eight hours off between shifts.

But questions about attending surgeons’ rest persist.

A small survey study published in 2009 found that only 40 percent of surgeons — or 55 of 136 — limited their working time to no more than 30 continuous hours.

David Bates, who has previously researched the relationship between physician medical errors and their lack of sleep, said the new study should be reassuring to patients who get surgery after their doctor has worked overnight. But he cautioned the results do not address the effects of long shifts that last days without rest on patient outcomes.

Such a study would be difficult to conduct in the U.S. because data on attending surgeon hours isn’t routinely collected, he said. Canada also has a single-payer system, meaning researchers could cull massive amounts of information from one source. Doing a similar study in the U.S. would be nearly impossible because of the number of insurance companies involved in health care, Bates said.

The study reported in the New England Journal dealt only with short-term outcomes on patients, but a physician’s performance could have long-term effects on patient health too.

Jeffrey Rothschild, a hospitalist physician at Newton-Wellesley Hospital in Massachusetts, published a study in 2009 finding that post-surgical complications rose when physicians at a single hospital had less than six hours of opportunity for sleep.

More studies should be done looking at long-term effects of sleep deprivation on physicians and at the quantities of sleep to patient outcomes, he said.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. You can view the original report on its website.

The post Surgeons’ late-night work doesn’t cause patients harm, study says appeared first on PBS NewsHour.

Will reimagined New Orleans hospital meet the needs of its most vulnerable?

20150826_nola1

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GWEN IFILL: Now we turn to our weeklong series on how New Orleans is faring after Katrina 10 years later.

The floodwaters that rose after the storm trapped hundreds of patients in the city’s hospitals. More than 140 of them died in a slow-motion evacuation that took days. Things went from bad to worse when officials declared the much-loved state-run Charity Hospital unfit to reopen.

A major new hospital was dedicated in New Orleans today, a crucial part of a reimagined health care system. But worries remain that some will still be left behind.

Special correspondent Jackie Judd has our report.

JACKIE JUDD:
Hurricane Katrina and all that the winds, the rain, the flooding destroyed or disabled allowed for a reimagining of what a modern health care system in New Orleans would look like. This is the centerpiece of that reimaging.

NARRATOR: University Medical Center New Orleans is a place to heal, teach and discover for generations to come. UNC New Orleans, the future of health care is here.

JACKIE JUDD: University Medical Center was a decade in the making, at a cost exceeding $1 billion, most of that from the federal government. The doors recently opened to a high-tech trauma center, expensive artwork and what’s promised to be hurricane-proof windows and internal systems. Some early reviews are in.

GLYNN JAMES, New Orleans: Much, much better place, inside, clean.

MAN: It’s what New Orleans needs. They need a good hospital here. Charity was a good hospital now. Back in the day, when I was growing up, it was a good hospital, but this is way better.

DR. PETER DEBLIEUX,
University Medical Center New Orleans: It’s actually built out for redundancy for one patient in case something…

JACKIE JUDD: In case of a storm?

DR. PETER DEBLIEUX:
In case of a storm, if you will.

JACKIE JUDD: Dr. Peter Deblieux, who worked at Charity Hospital, then in makeshift tents, a converted department store and finally the interim hospital, is proud of what the city has built. This hospital’s aim, he says, is twofold, serve the poor, as Charity did, and those who pay full freight.

DR. PETER DEBLIEUX: The vision of this hospital is not to be solely an indigent care or solely a safety net hospital. That’s a vital portion of what we do, but sustainability of this hospital will be directly linked in our ability to attract all payers. What’s new and what is exciting is building destination services, so services that allow us to compete with a Houston or a Birmingham to keep regional patients here at home.

JACKIE JUDD: From the windows of the new hospital, what came before is in clear sight. Charity Hospital holds a storied place in the city’s history, because it’s where generations of residents came for care regardless of their ability to pay, and, for many, the measure of success at the new hospital is whether that tradition will continue.

SILVINA HENRY,
New Orleans: And we took that together long before the order changed.

JACKIE JUDD:
This was in Charity?

SILVINA HENRY: This was in Charity, yes.

JACKIE JUDD:
Silvina Henry worked there as a nurse’s assistant and healed there as a patient.

SILVINA HENRY: Every time I pass there, I look at Charity, because it’s the only thing — and people in New Orleans know it’s about Charity.

JACKIE JUDD: The new hospital is run by a nonprofit private company, adding to concerns that Charity’s mission to serve the public no matter the cost will be lost.

University is required to have at least 20 percent of the uninsured in its patient mix, considerably less than what Charity saw. But officials promise to give care to those who need it.

Community activist Jacques Morial organized a lawsuit to get Charity back up and running.

JACQUES MORIAL,
Community Activist: Working poor people trusted Charity to take good care of them. And reassembling all of that intellectual capital, that understanding of patients, with teamwork and the know-how, is not like assembling LEGOs. It takes lots of time, lots of work and lots of money.

JACKIE JUDD: Dr. Deblieux, who once argued for the old hospital to reopen, now says that the quality of care at Charity has been romanticized and that concerns about the new hospital are unfounded.

If you are so convinced of the success of this model, why did you fight hard to try to keep Charity open?

DR. PETER DEBLIEUX: So, what I tried hard to do was to keep open a facility that would meet on the safety care needs of our population. And I would continue that fight today if we walked away from that mission. We’re not. That’s as strong as it’s ever been.

JACKIE JUDD:
The other half of the reimagining is an extensive network of community health centers. The clinics dot poor and working neighborhoods throughout the city and provide primary care.

Dr. Karen DeSalvo worked at a pop-up clinic here near the French Quarter. Later, as the city’s health commissioner, she drove the effort to build permanent clinics where people live.

DR. KAREN DESALVO, Former New Orleans Health Commissioner: Because the health care infrastructure went down, it caused many of us to literally stand on the street and look and say, we can do better, we can come up off our knees and build a system that’s going to meet the needs of this community.

Looking at the evidence and listening to people that what they wanted was the front-line access to preventive care, primary care in neighborhoods.

JACKIE JUDD: Charity’s emergency room had been a principal source of primary care, but habits and services are slowly changing.

Silvina Henry’s primary care doctor, Keith Winfrey, is the chief medical officer at a clinic in New Orleans East, a community of African-American and Vietnamese residents.

DR. KEITH WINFREY,
Chief Medical Officer, New Orleans East Community Health Center: Prior to Katrina, it was more the traditional physician-patient interaction and the population wasn’t different. But it was more the physician-patient interaction. Since Katrina, there has been a total transformation in primary care, where it’s more of a team-based model of primary care, the patient-centered medical home.

JACKIE JUDD:
Henry, whose home on the banks of Lake Pontchartrain was badly damaged by Katrina, fled the city. She was cut off from her doctors, her medication, her medical records, charting chronic ailments, including high blood pressure and diabetes. She later returned to an entirely different experience, including electronic medical records that will survive a storm.

SILVINA HENRY: Every time I go, they get on the computer, and they can tell me everything that is going on. And when I go to see the doctor in the room, the doctor has a record that they can open, paper record that they can tell me what is going on.

MAN: Now, it’s my understanding that you have been sent to see me by your primary care doctor.

JACKIE JUDD: Mental health services are woven into the clinic services, and throughout the city, mobile vans offer on-the-spot support, but it is widely acknowledged here that far more is needed.

The police department’s Cecile Tebo has long worked with the mentally ill who have had run-ins with the law. She is incensed that the new hospital currently has just about a third of the psychiatric beds that Charity once held.

CECILE TEBO, New Orleans Police Department: We’re standing in front of Orleans Parish Prison. This is our largest mental health hospital in our community, which is so sad, because this is not where treatment is going to happen.

JACKIE JUDD: The great uncertainty in sustaining the new hospital and the clinics is money. Governor Bobby Jindal didn’t expand Medicaid under the Affordable Care Act, and so many uninsured patients still need free care. As part of the law, the federal government is reducing the dollars it sends states for that care.

CECILE TEBO: I think we still mostly have questions in the area of how we’re going to finance this system long-term that is going to be affordable for everyone.

JACQUES MORIAL: I think it’s going to take a lot of vigilance, a lot of advocacy and a lot of demand for accountability for all of this to work.

SILVINA HENRY: And she can get my medicines for me.

JACKIE JUDD:
Still, for people like Silvina Henry, the progress here is real. A far more robust health care system is in place to care for people than the very fragile system that Katrina washed away.

For the PBS NewsHour, this is Jackie Judd in New Orleans.

The post Will reimagined New Orleans hospital meet the needs of its most vulnerable? appeared first on PBS NewsHour.

Jimmy Carter: ‘I’ll be prepared for anything that comes’

Former U.S. President Jimmy Carter  (C) takes questions from the media during a news conference about
         his recent cancer diagnosis and treatment plans, as his grandson Jason Carter (R) listens on, at the Carter Center in Atlanta,
         Georgia August 20, 2015. Carter said on Thursday he will start radiation treatment for cancer on his brain later in the day.
         Carter, 90, said he will cut back dramatically on his schedule to receive treatment every three weeks after doctors detected
         four spots of melanoma on his brain following recent liver cancer surgery. REUTERS/John Amis - RTX1OYC8

Watch Video | Listen to the Audio

GWEN IFILL: But, first, we turn to former President Jimmy Carter’s cancer diagnosis. The 90-year-old revealed today he has spots of melanoma on his brain. He talked about life, faith and the course of the disease with reporters at the Carter Center today, just before beginning radiation treatment at Atlanta’s Emory Hospital this afternoon.

JIMMY CARTER, Former President of the United States: In May, I went down to Guyana to help monitor an election, and I had a very bad cold.

And I left down there and came back to Emory, so they could check me over. And in the process, they did a complete physical examination, and the MRI showed that there was a cancer, or a growth, a tumor on my liver.

And they did a biopsy and found that it was, indeed, cancer and it was melanoma. And they had a very high suspicion then and now that the melanoma started somewhere else on my body and spread to the — to the liver.

At first, I felt that it was confined to my liver, and that they had — the operation had completely removed it, so I — quite relieved.

And then, that same afternoon, we had an MRI of my head and neck, and it showed up that it was already in four places in my brain. So, I would say that night and the next day, until I came back up to Emory, I just thought I had a few weeks left.

But I was surprisingly at ease. Now I feel, you know, it’s in the hands of God, whom I worship. And I will be prepared for anything that comes.

I feel good. I haven’t felt any weakness or debility. The pain has been very slight.

Both of the — former President Bush, he called me at one time, and then George H.W. Bush, Bush Sr., called me yesterday afternoon again. I think I appreciated that very much, and their wives were there on the telephone with them.

President Obama called. The vice president called. Bill Clinton called. Hillary Clinton called. The secretary of state called, the first time they’ve called me in a long time.

(LAUGHTER)

JIMMY CARTER: For a number of years, Rosalynn and I have planned on dramatically reducing our work at Carter Center. We have not done it yet.

(LAUGHTER)

JIMMY CARTER: We talked about this when I was 80. We talked about it again when I was 85. We talked about it again I was 90.

So, this is a propitious time, I think, for us finally to carry out our long-delayed plans. So I’m going to cut back fairly dramatically on my obligations.

I think I have been as blessed as any human being in the world, becoming president of the United States of America, and governor of Georgia, and worked at the Carter Center, and a big and growing family, and thousands of friends.

So I don’t think — and living to be 91 years old 1st of October. So, I have had — everything has been a blessing for me.

QUESTION: Is there anything you wish that you had not done or that you had done differently?

JIMMY CARTER: I wish I had sent one more helicopter to get the hostages, and we would have rescued them and I would have been reelected. But that may have…

(LAUGHTER)

JIMMY CARTER: And that may have interfered with the foundation of the Carter Center. And if I had to choose between four more years and the Carter Center, I think I would choose the Carter Center.

QUESTION: In the time that you have left, what would give you the most satisfaction to see something happen?

JIMMY CARTER: Well, in international affairs, I would say peace for Israel and its neighbors. That’s been a top priority for my foreign policy projects for the last 30 years.

Right now, I think the prospects are more dismal than any time I remember in the last 50 years. It’s practically — the whole process is practically dormant.

As far as the Carter Center’s concerned, I would like to see guinea worm completely eradicated before — before I die. I would like the last guinea worm to die before I do.

(LAUGHTER)

JUDY WOODRUFF: President Carter, we will all pulling for you.

And you can watch my conversation with President Jimmy Carter from last month, before his diagnosis, where we discussed his latest book, “A Full Life.” That’s at PBS.org/NewsHour.

The post Jimmy Carter: ‘I’ll be prepared for anything that comes’ appeared first on PBS NewsHour.

Study raises questions about treatment for early breast cancer

A radiologist examines breast X-rays after a regular cancer prevention medical
         check-up at a radiology center in Nice, November 5, 2012.      REUTERS/Eric Gaillard (FRANCE - Tags: HEALTH SCIENCE TECHNOLOGY)
         - RTR3A0O1

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JUDY WOODRUFF: There was other big news today related to cancer.

A study published in “The Journal of the American Medical Association Oncology” found that women given lumpectomies and mastectomies as treatment for very early-stage breast cancer had similar survival rates to those patients who had less radical cancer treatments. Those findings may call into question some of the standard assumptions on how to treat the disease.

For a closer look at the study and its potential implications, we turn to two cancer specialists. Dr. Steven Narod is a researcher at the Women’s College Research Institute in Toronto. He was the study’s lead author. And Dr. Monica Morrow is chief breast cancer surgeon at Memorial Sloan Kettering Cancer Center in New York City.

Dr. Morrow, Dr. Narod, welcome to you both.

I’m going to start with you, Dr. Narod.

On this study, we did read that it’s the most extensive collection of data ever analyzed on this particular type of cancer. Boil down the findings for us.

DR. STEVEN NAROD, Women’s College Research Institute: We focused on 100,000 women with the earliest form of cancer. Some say it’s not even cancer. It’s a precursor lesion. We call it DCIS, or ductal carcinoma in situ.

So, this, because it’s a very good prognosis, we followed the 100,000 women for up to 20 years and we found that, at 20 years, about 3 percent of them had died of breast cancer. Roughly a third of the patients were treated with lumpectomy alone, which is removing the DCIS, the focus of cancer. One-third of the patients, probably, had a lumpectomy plus radiotherapy, and one-third of the patients approximately had the entire breast removed through mastectomy.

And what we found, that there was no difference in the survival at 20 years between women treated with any of the three ways.

JUDY WOODRUFF: What is the — you said one-third, one-third, one-third. What do these findings tell you that the treatment should be?

DR. STEVEN NAROD: Well, it tells us about — something about the early stages of breast cancer.

The reason I say that is because, of those 3 percent of the women who died of breast cancer, most of them, 54 percent of them, between the time they had DCIS and the time they had a distant recurrence or a metastatic disease, never experienced another breast — cancer in the breast.

So, that leads me to think that when that DCIS was removed by the surgeon, it had already spread around the breast and it took years, up to 20 years, in order for those cells that had spread to flourish and to be metastatic and to ultimately cause the breast cancer death.

JUDY WOODRUFF: So, just to quickly interpret what you’re saying and to turn to Dr. Morrow, it sounds as if what we’re hearing and what the article says, Dr. Morrow, is that these findings would suggest that a minimal treatment is going to be just as effective as the maximal treatment. What’s your interpretation?

DR. MONICA MORROW, Memorial Sloan Kettering Cancer Center: Well, I’m not necessarily sure the article says that.

I think a critical finding of this study is how good the prognosis for DCIS is, and women should be reassured, because we know that women with DCIS estimate their risk of dying of breast cancer to be as high as 30 percent. And this study says that’s just simply not true.

I think what it does tell us is that, to date, physicians have been pretty good at selecting low-risk DCIS, which can be treated minimally with lumpectomy alone. I think it says we should think hard about expanding the indications for minimal treatment.

But I think it’s also important for women to be aware that we can only say there is nothing there but DCIS after we have removed the entire area. Thirty percent of women who are — or — sorry — 20 percent of women who are diagnosed as having DCIS on a needle biopsy will actually be found to have invasive cancer when you remove the entire area.

So the idea that you can do nothing at all for DCIS and end up with the same extremely favorable outcomes that Dr. Narod reports remains to be proven and should be the subject of future research perhaps.

JUDY WOODRUFF: And I just want to clarify again for our audience who is watching, we’re throwing around the term DCIS, which, again, most — it stands for the least advanced stage of cancer, also known as stage zero.

So, Dr. Narod, how — are you — you heard what Dr. Morrow said, that she doesn’t believe the treatment should change as a result of this study. Are you saying something different should be done, that women should wait if they have a very early-stage breast cancer?

DR. STEVEN NAROD: No, and, certainly, I defer to Dr. Morrow, who is a practicing surgeon, of which I’m not.

What I do say, though, is there are two clear goals of treatment for DCIS, and those are separate goals. The first goal, the one that we have been accustomed to and the one we have always prioritized, is to prevent a new breast cancer event or recurrence.

If the goal is to prevent the breast cancer death, then we found no benefit from the radiotherapy and no benefit from the mastectomy, from the more extensive surgery.

JUDY WOODRUFF: Now, let me just go back to Dr. Morrow.

So, Dr. Morrow, what should a woman watching this who is — you know, has to make a decision, or a woman who has had the more radical treatment in the past and is now wondering if she should have had it, what are these women to think now?

DR. MONICA MORROW: Well, I think women who have had radical treatment can be reassured that they have an extremely high probability of not dying of the DCIS that they have been treated for, and that’s a very good position to be in. We can’t always say that for radical treatment of invasive breast cancer.

For women who are looking at treatment today, though, I think they have the opportunity to ask the surgeon who is counseling them, what are my options, what are the factors that suggest I might benefit from more aggressive treatment? If you’re not given options, that’s a good time to seek a second opinion.

The other thing I say is that, although death was the primary end point of this story, for many women, recurrence in the breast, even if it’s not associated with death, is a psychologically devastating complication that they would like to seek additional treatment to avoid.

And there, I think a person’s individual values is important in deciding what is right for her to do.

JUDY WOODRUFF: Well, as you said at the outset, what every woman should do is to certainly have a very close conversation with her own physician. And we will leave it on that note.

And we want to thank both of you, Dr. Monica Morrow and Dr. Steven Narod. We appreciate it.

DR. MONICA MORROW: Thank you.

DR. STEVEN NAROD: Thank you very much.

The post Study raises questions about treatment for early breast cancer appeared first on PBS NewsHour.