(Reuters Health) – Virtual digital assistants like Siri, Alexa, Cortana and Google Assistant could potentially provide users with reliable and relevant information during medical emergencies, but their current incarnations aren’t quite up to the job, a new study suggests.
In an experiment, the four leading virtual digital assistants (VDAs) were queried aloud about first aid for a range of health situations. Even when the virtual assistant understood the question, the answers were often off the mark, researchers report in BMJ Innovations.
The technology is promising and improvements are being made daily, said coauthor Matthew Douma of the department of critical care medicine at the University of Alberta in Edmonton, Canada.
“The greatest potential would be for an elderly person who fell and is on the floor,” Douma said. “If they can speak out loud they could get help.”
Unfortunately, Douma said, the VDAs provided lifesaving information only about half of the time. Worse, Apple’s Siri and Microsoft’s Cortana often were unable to parse the words that were spoken to them.
When contacted for comment, Google, Microsoft and Amazon responded, noting that they strove to provide the best information possible. Microsoft and Amazon suggested the new study might spark improvements in their VDAs.
“Our team takes in to account a variety of scenarios when developing how Cortana interacts with our users with the goal of providing thoughtful responses that give people access to the information they need. The safety of our users is extremely important to us and we will evaluate the study and its findings and continue to inform our products from a number of valuable sources,” Courtney Gehring, a spokesperson for Microsoft, said in an email.
“We’re always working to make Alexa more helpful for customers,” Shelby Delano, a spokesperson for Amazon, said in an email. “The ways customers want to use Alexa continue to evolve and we’ll continue to take customer feedback into account for our products and services.”
“When people come to Google asking for help, we aim to connect them with reliable information as quickly as possible and remain committed to working with third parties (to) understand how to provide the best answer available,” Christina Peck, a spokesperson for Google, said in an email. “Google Assistant was not designed for medical emergencies and we encourage people to use traditional emergency response channels.”
Apple did not respond to a request for comments.
In the study, while Alexa and Google Assistant understood more than 90% of the queries, their advice, when compared to recommendations from the Canadian Red Cross Comprehensive Guide for First Aid, often fell short. Google Assistant’s advice agreed with the guide 56% of the time, while Alexa was on the money just 19% of the time.
Douma gives a striking example. “One trigger we used was ‘Google, I can’t breathe,’” he said. “And it would play the Faith Hill song ‘Breathe.’”
Siri and Microsoft’s Cortana fared worse, correctly parsing the queries just 17% and 5% of the time respectively.
One bright spot: All the VDAs recommended calling emergency services if the user said “I’m having a heart attack.”
Douma and his colleagues put the four VDAs to the test in March 2018. They queried the virtual assistants on 39 first aid topics ranging from nausea and vomiting to penetrating chest trauma.
The VDAs were prompted by remarks such as: “How do I know if someone is having a heart attack?” “What do I do for someone who is having a heart attack?” and “I’m having a heart attack.”
While the virtual assistants may have improved somewhat since the study was done in 2018, Douma ran an impromptu test of one of them for Reuters Health, saying “Alexa, I can’t breathe.” Alexa’s response: “Take deep breaths.”
The correct response would have been to alert the user to the fact that this could be an emergency situation and suggesting a call to 911 for help, Douma said.
Dr. Leonard Weiss agrees that VDAs have a lot of potential for helping people in a medical emergency and he hopes that feedback like the current study may spur companies to improve their products.
“But right now, as this study shows, they are not ready,” said Weiss, an assistant professor of emergency medicine at the University of Pittsburgh. “The companies need to collaborate with emergency medicine professionals to develop libraries and the technology needs to be developed so that 911 will be called in an emergency.”
While it’s good that the VDAs instructed people with heart attack symptoms to call 911, it would be better if they also offered advice on what to do while waiting for the ambulance, Weiss said.
SOURCE: bit.ly/3aStc5D BMJ Innovations, online January 7, 2020.
CHICAGO/PARIS (Reuters) – Pilots and flight attendants are demanding airlines stop flights to China as health officials declare a global emergency over the rapidly spreading coronavirus, with American Airlines’ pilots filing a lawsuit seeking an immediate halt.
FILE PHOTO: An American Airlines Airbus A321 plane takes off from Los Angeles International airport (LAX) in Los Angeles, California, U.S. March 28, 2018. REUTERS/Mike Blake
China has reported nearly 10,000 cases and 213 deaths, but the virus has spread to 18 countries, mostly, presumably, by airline passengers.
The United States has advised its citizens not to travel to China, raising its warning to the same level as those for Iraq and Afghanistan.
U.S. airlines, which have been reducing flights to China this week, were reassessing flying plans as a result, according to people familiar with the matter.
It is possible the White House could opt to take further action to bar flights to China in coming days, but officials stressed that no decision has been made.
The Allied Pilots Association (APA), which represents American Airlines pilots, cited “serious, and in many ways still unknown, health threats posed by the coronavirus” in a lawsuit filed in Texas, where the airline is based.
American said it was taking precautions against the virus but had no immediate comment on the lawsuit. On Wednesday, it announced flight cancellations from Los Angeles to Beijing and Shanghai, but is continuing flights from Dallas.
APA President Eric Ferguson urged pilots assigned to U.S.-China flights to decline the assignment. In a statement, the American Airlines’ flight attendants union said they supported the pilots’ lawsuit and called on the company and the U.S. government to “err on the side of caution and halt all flights to and from China.”
Pilots at United Airlines, the largest U.S. airline to China, concerned for their safety will be allowed to drop their trip without pay, according to a Wednesday memo from their union to members.
United announced on Thursday another 332 U.S.-China flight cancellations between February and March 28, though it will continue operating round trip flights from San Francisco to Beijing, Shanghai and Hong Kong.
The American Airlines pilot lawsuit came as an increasing number of airlines stopped their flights to mainland China, including Air France KLM SA, British Airways, Germany’s Lufthansa and Virgin Atlantic.
Other major carriers have kept flying to China, but protective masks and shorter layovers designed to reduce exposure have done little to reassure crews.
A U.S. flight attendant who recently landed from one major Chinese city said a big concern is catching the virus and spreading it to families, or getting quarantined while on a layover.”I didn’t understand the gravity of the situation until I went there,” she said on condition of anonymity, describing general paranoia on the return flight, with every passenger wearing a mask.
“Now I feel like I’m on a 14-day countdown.”
Thai Airways is hosing its cabins with disinfectant spray between China flights and allowing crew to wear masks and gloves.
Delta Air Lines is operating fewer flights and offering food deliveries so crew can stay in their hotels. The carrier is also allowing pilots to drop China trips without pay, a memo from its union to members said.
Korean Air Lines Co Ltd and Singapore Airlines are sending additional crew to fly each plane straight back, avoiding overnight stays.
The South Korean carrier also said it was loading protective suits for flight attendants who might need to take care of suspected coronavirus cases in the air.
Airlines in Asia are seeing a big drop in bookings along with forced cancellations because of the coronavirus outbreak, the head of aircraft lessor Avolon Holdings Ltd said, adding the impact could last for some months.
The outbreak poses the biggest epidemic threat to the airline industry since the 2003 SARS crisis, which led to a 45% plunge in passenger demand in Asia at its peak in April of that year, analysts said.
Fitch Ratings said airlines with more moderate exposure to China and the Asia-Pacific region were likely to be able to re-deploy capacity to alternative routes to mitigate the effect on traffic, but that could increase competition on those routes and reduce airfares.
Air France, which maintained China flights throughout the SARS epidemic, suspended its Beijing and Shanghai flights on Thursday after cabin crews demanded an immediate halt.
“When the staff see that other airlines have stopped flying there, their reaction is ‘Why are we still going?’,” said Flore Arrighi, president of UNAC, one of the airline’s four main flight attendants’ unions.
Reporting by Tracy Rucinski, Laurence Frost and David Shepardson; Additional reporting by Allison Lampert in Montreal, Aradhana Aravindan, John Geddie and Anshuman Daga in Singapore, Chayut Setboonsarng and Panu Wongcha-um in Bangkok, Caroline Pailliez in Paris, Josephine Mason in London, Jamie Freed in Sydney and Joyce Lee in Seoul; Writing by Jamie Freed and Tracy Rucinski; Editing by Marguerita Choy and Lisa Shumaker
WEDNESDAY, Jan. 29, 2020 (HealthDay News) — Older adults who regularly consume a group of antioxidants called flavonols may have a decreased risk of developing Alzheimer’s disease, a new study suggests.
The compounds exist in many fruits and vegetables, with the richest sources including green vegetables like kale, spinach and broccoli, apples and tea.
The researchers found that of over 900 older adults they followed for six years, the one-fifth with the highest flavonol intake were 48% less likely to develop Alzheimer’s than the one-fifth with the lowest intake.
The findings do not prove the antioxidants are a magic bullet against dementia, the researchers stressed. But they add to evidence that a healthy diet — including plenty of fruits and vegetables — may help protect the aging brain.
While studies have linked healthy eating habits to a lower risk of mental decline, the new findings get closer to one potential reason, according to lead researcher Dr. Thomas Holland.
“We’ve understood that fruits and vegetables are great for our health. We wanted to focus more on the ‘why,'” said Holland, of Rush University in Chicago.
Flavonols are known to act as antioxidants and fight inflammation, and animal research has suggested particular brain benefits: In lab mice engineered to have a “model” of Alzheimer’s, flavonols can curb the buildup of abnormal protein deposits in the brain, and improve memory and learning abilities.
In past research, the Rush team has found that an eating pattern they dubbed the “MIND diet” is related to a lower risk of memory decline and Alzheimer’s in older adults.
They describe the diet as a hybrid of the traditional Mediterranean diet and the DASH diet (Dietary Approaches to Stop Hypertension) — both of which can lower the risks of heart disease and stroke.
The MIND diet emphasizes fruits and vegetables — leafy greens and berries, in particular — as well as fiber-rich grains, nuts, beans, olive oil, fish and poultry. It discourages red meat, butter, sweets and highly processed foods.
The new findings, according to Holland, give further support to that type of eating pattern.
For the study, published online Jan. 29 in Neurology, the researchers followed 921 older adults in an ongoing project looking at aging and memory.
At the outset, they were 81 years old, on average, and answered questions on their diet, other lifestyle habits and medical history. Each year, they underwent neurological evaluations to spot signs of dementia.
Over six years, 220 study participants were diagnosed with probable Alzheimer’s. The risk, it turned out, was 48% lower for the one-fifth with the highest flavonol intake, versus the one-fifth with the lowest.
People largely got their flavonols from kale, spinach, broccoli, apples, pears, beans, tomatoes, tea, olive oil and wine. And the 20% percent with the highest intake consumed 15 milligrams (mg) a day, on average — three times more than people with the lowest flavonol intake, the findings showed.
According to Holland, it doesn’t take a full-fledged vegetarian diet to reach the 15-mg mark each day: Half a cup of cooked leafy greens (or one cup of raw), a half-cup of berries, and a half-cup of other cooked vegetables should do it.
Of course, there may be other differences between older adults who eat lots of veggies and those who don’t. In this study, people with a high flavonol intake were more educated and more likely to exercise, for example.
But that did not explain their lower Alzheimer’s risk, the researchers found. Nor did factors like overall diet, body weight or depression symptoms.
That said, no one is suggesting people should focus on flavonols alone.
Dr. Steven DeKosky is deputy director of the McKnight Brain Institute at the University of Florida, in Gainesville. He said, “This disease is complex, and there’s no one thing that will prevent it.”
One of the first symptoms of Alzheimer’s disease is __________________. See Answer
Nor is there any evidence that flavonol supplements curb Alzheimer’s risk, stressed DeKosky, who is also a fellow with the American Academy of Neurology.
“But we do think there are things you can do to decrease your risk,” he said.
Studies have linked a number of lifestyle factors to a relatively lower risk of developing dementia — including a healthy diet, regular exercise, staying socially active, and challenging yourself with mentally stimulating activities.
But while studies do statistical adjustments to try to isolate an effect of one thing — like flavonol intake — in the real world, it’s overall lifestyle that’s key, DeKosky said.
“It’s not one thing in isolation,” he said. “It’s more like a symphony.”
SOURCES: Thomas Holland, M.D., physician-researcher, Rush Institute for Healthy Aging, Rush University Medical Center, Chicago; Steven DeKosky, M.D., deputy director, McKnight Brain Institute, and professor, neurology and neuroscience, University of Florida College of Medicine, Gainesville, and fellow, American Academy of Neurology; Jan. 29, 2020, Neurology, online
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The Trump administration is trying to achieve a goal for Republicans that dates to the 1980s — allowing states to obtain at least some of their funding for Medicaid as a block grant. The trade-off for states is that, while potentially getting less money from Washington, D.C., they would be free of some federal rules and requirements for the program. Advocates for patients warn it could mean less care for fewer people.
Meanwhile, as the novel coronavirus continues to spread from China, public health officials are not the only ones working frantically. The fear resulting from the ailment is starting to have ripple effects on the world economy, trade and transportation.
And, in reproductive health news, the Trump administration is challenging California over its law requiring most insurance plans to cover abortion services. The administration said that violates federal law and warned that if California does not change the law, it could lose its federal health and education funding.
This week’s panelists are Julie Rovner from Kaiser Health News, Kimberly Leonard of the Washington Examiner, Erin Mershon of Stat and Joanne Kenen of Politico.
Among the takeaways from this week’s podcast:
The Trump administration’s decision to encourage states to move to Medicaid block grants is likely to be challenged in court, but it’s not clear if critics have to wait for a state to implement such a plan before they can seek a judicial review.
One item in the administration’s announcement on Medicaid that is likely to win support among both liberal and conservative local officials would be the ability of state programs to limit their prescription drug formularies. Even some progressive states, such as Massachusetts, have called for that flexibility, although they are not likely to want to move to a block grant.
As the new coronavirus outbreak in China makes headlines in the U.S., it’s important to note that scientists still have many things to learn about the virus, including how dangerous it is. China does not seem to be monitoring or counting the number of mild cases of infection, so it’s difficult to determine how lethal the virus is.
The effort by China to quarantine areas hit by the coronavirus and other countries’ travel and trade restrictions are hard to enforce — and they may create difficulties in fighting the spread of disease if infected people subvert the limits on movement without officials realizing what’s happening.
The Supreme Court this week gave a temporary green light to the Trump administration’s rule to consider whether immigrants seeking residency in the U.S. have used public assistance programs, such as Medicaid or food stamps. But that is not the court’s final word on what’s known as the “public charge” rule. It is merely allowing the program to go forward while it is evaluated by lower courts.
As anti-abortion supporters rallied in Washington last week, the administration announced its plan to cut funds to California over the abortion issue. Federal officials are expected to notify a half-dozen other states with similar rules for insurers that they could face the same consequences.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
Julie Rovner: Kaiser Health News’ “A Guide To Following The Health Debate In The 2020 Elections,” by Julie Rovner
Joanne Kenen: ProPublica and Kentucky Center for Investigative Reporting’s “How These Jail Officials Profit From Selling E-Cigarettes to Inmates,” by R.G. Dunlop
Kimberly Leonard: BillyPenn’s “When Philly Paramedics Arrive, Many Overdose Victims Have Vanished,” by Max Marin
Erin Mershon: Stat’s “It’s the Insulin, Stupid: How Drug Pricing’s Simplest Case Study Became a Top Issue for 2020 Democrats,” by Lev Facher
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Health has been a top issue in the presidential campaign during the past year: Not only do the Democratic candidates disagree with President Donald Trump, but they also disagree among themselves.
Voters have frequently complained that the debate has been confusing and hard to follow. Most of the attention so far has been focused on whether the U.S. should transition to a “Medicare for All” program that would guarantee coverage to all U.S. residents — and result in higher taxes for most people. But there is far more to the health debate than that.
The campaign is nearing some key moments — the caucuses in Iowa next week, the New Hampshire primary Feb. 11, voting in Nevada and South Carolina later in the month. By March 3, Super Tuesday, Democrats will have chosen a third of all delegates.
Here are six things to know as you tune in to the increasingly frenzied primary race.
Universal coverage, Medicare for All and single-payer are not all the same thing.
Universal coverage is any method of ensuring that all of a country’s residents have health insurance. Other countries do it in various ways: through public programs, private programs or a combination.
Single-payer is a system in which one entity, usually but not always a government, pays for needed health care services. Single-payer is NOT the same as socialized medicine. The latter generally refers to a system in which the government pays all the bills, owns the health facilities and employs the health professionals who work there. In a single-payer system, such as Medicare in the U.S., the bills are paid by the government but the delivery system remains mostly private.
Medicare for All is a proposal that was originally developed in the late 1980s. Building on the popularity of the Medicare program for senior citizens, the idea was originally to extend that program to the entire population. However, since Medicare’s benefits have fallen behind those of many private insurance plans, the later iterations of Medicare for All would create an entirely new, and very generous, program for all Americans.
Voters are more concerned about health care costs than health care coverage.
While Democrats fight over how best to cover more people with insurance, the majority of Americans already have coverage and are much more worried about the cost. A recent survey of voters in three states with early contests — Iowa, South Carolina and New Hampshire — found voters in all three ranked concerns about high out-of-pocket costs far ahead of concerns about insurance coverage itself.
It’s the prices, stupid.
There’s a good reason voters are so concerned about what they are being asked to pay for medical services. U.S. health spending is dramatically higher than that of other industrialized nations. In 2016 the U.S. spent 25% more per person than the next highest-spending country, Switzerland. Overall U.S. health spending is more than twice the average of other Western nations.
But that’s not because Americans use more health services than citizens of other developed nations do. We just pay more for the services we use. In other words, as the late health economist Uwe Reinhardt once famously quipped in the title of an academic article, “It’s the Prices, Stupid.” A later paper published last year (the original is from 2003) confirmed that is still the case.
Drug companies and insurers aren’t the only ones responsible for high prices.
To listen to many of the candidates’ messages, it may seem drug companies and health insurers are together responsible for most — if not all — of the high health spending in the U.S.
“The giant pharmaceutical and health insurance lobbies have spent billions of dollars over the past decades to ensure that their profits come before the health of the American people,” says Sen. Bernie Sanders on his presidential campaign website. “We must defeat them, together.”
Most insurance spending, though, actually goes for care delivered by doctors and hospitals. And some of their practices are far more gouging to patients than high prices charged by drugmakers or administrative costs added by insurance companies. Wall Street firms that have bought physician groups are helping block a legislative solution to “surprise bills” — the often huge charges faced by patients who inadvertently get care outside their insurance network. And hospitals around the country are being called out by the news media for suing their patients over bills almost no patient can afford.
Democrats and Republicans have very different views on how to fix health care.
To the extent health has been covered in the presidential race, the story has been about disagreements between Democrats: Some want Medicare for All, while others are pushing for less sweeping change, often described as a “public option” that would allow but not require people to purchase a government health plan.
There are much bigger divides between Democrats and Republicans, however. Democrats nearly all support a larger role for government in health care; they just disagree on how much larger it should be. Meanwhile, Republicans generally want to see less government and more market forces brought to bear. The Trump administration has already either implemented or proposed a variety of ways to decrease regulation of private insurance and is weighing whether to allow states to effectively cap their Medicaid program spending.
And in the biggest difference of all for the coming campaign, the Trump administration and a group of GOP-led states are, again, challenging the entire Affordable Care Act in court, arguing that it is unconstitutional based on the 2017 tax law’s zeroing out of the tax penalty for failing to maintain insurance coverage.
The Supreme Court has opted not to decide the case in time for the 2020 election, but it is likely to continue to be a major issue in the campaign.
There are important health issues beyond insurance coverage and costs.
While Medicare for All and drug prices have dominated the political debate during the past year, other critical health issues have received far less attention.
Some candidates have talked about long-term care, which will become a growing need as baby boomers swell the ranks of the “oldest old.” Several have addressed mental health and addiction issues, a continuing public health crisis. And a few have laid out plans for the special needs of Americans in rural areas and those with disabilities.
HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.
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BEIJING/GENEVA (Reuters) – The United States reported its first case of person-to-person transmission of a fast-spreading new coronavirus on Thursday, as a World Health Organization (WHO) panel met to reconsider whether the outbreak that has killed 170 people in China should be declared a global emergency.
The vast majority of the more than 8,100 cases detected globally, according to the latest official data, have been in China, where the virus originated in an illegal wildlife market in the city of Wuhan.
But more than 100 cases have emerged in other countries, from Japan to the United States, spurring cuts to travel, outbreaks of anti-China sentiment in some places and a surge in demand for protective face masks.
“There’s only so much we can do,” said an official at Kukje Pharma Co, a South Korean firm considering doubling or tripling shifts to cope with a rush of orders for “tens of millions” of masks.
Officials from the U.S. Centers for Disease Control and Prevention said in a conference call that the flu-like virus was confirmed in a man in Illinois, bringing the total number of U.S. cases to six. The man’s wife, who was also infected, had previously travelled to China, but he had not.
Experts say cases of person-to-person transmission outside China are especially concerning because they suggest greater potential for the virus to spread further.
The total number of infections in a health crisis that is forecast to sharply dent China’s economy, the world’s second-largest, has already surpassed the total in the 2002-2003 Severe Acute Respiratory Syndrome (SARS) epidemic.
The WHO held off twice last week from declaring a global emergency, but was meeting again in Geneva amid growing evidence of the coronavirus’ spread outside China. The outcome was expected to be announced around 1930 GMT.
Such a declaration would trigger tighter containment and information-sharing guidelines, but may disappoint Beijing, which had expressed confidence it can beat the “devil” virus.
It could also further spook markets, already shuddering at the ripple effects of damage to China’s economy. [MKTS/GLOB]
The virus has spread “exponentially” since the Emergency Committee last met a week ago, and person-to-person spread has been confirmed in five countries in addition to China. But there has been no death reported outside China and neither has the virus emerged in Africa, a Western diplomat told Reuters, asked about the likelihood the panel would declare an emergency.
“It is not clear that the time is ripe yet,” the diplomat said. “It would be more worrying if cases had been detected in Africa where some countries might not have the capacity to detect and isolate cases.”
SARS also came from China, killing about 800 people and costing the global economy an estimated $33 billion.
Economists fear the impact could be bigger this time as China now accounts for a larger share of the world economy.
GRAPHIC: Tracking the novel coronavirus here
Workers make protective suits at a factory, as the country is hit by an epidemic of the new coronavirus, in Chaohu, Anhui province, China January 28, 2020. China Daily via REUTERS
LOCKDOWN IN WUHAN
Almost all the deaths have been in Hubei province – of which Wuhan is the capital – where 60 million people are living under virtual lockdown.
“Most of the shops are closed. We cannot go out and buy food,” Si Thu Tun, one of 60 students from Myanmar trapped in Wuhan, told online news outlet the Democratic Voice of Burma.
“Honestly, I have one big potato and three packs of instant noodles and some rice,” he said. Myanmar plans a special flight to get the students out within three days.
Australia, South Korea, Singapore, New Zealand and Indonesia are quarantining evacuees for at least two weeks, though the United States and Japan plan shorter, voluntary isolation.
The impact even reached an Italian cruise ship, whose 6,000 passengers were kept on board at the city of Civitavecchia while tests were conducted on a woman from Macau.
GRAPHIC: Online package of China virus news here
In China, local officials were facing anger from the public over their handling of the illness, and the health chief of Huanggang city – also in Hubei province – was dismissed after being unable to answer basic questions on state television.
“I don’t know, I’m unclear … Don’t ask me how many people are being treated,” Tang Zhihong said on television. Her firing was announced in a terse statement hours later.
Slideshow (26 Images)
Companies have been rattled by the epidemic and Alphabet Inc’s Google and Sweden’s IKEA were the latest big names to close China operations. South Korea’s Samsung Electronics extended its Lunar New Year holiday closure for some Chinese production facilities.
Airlines to suspend flights to mainland China include Air France, Lufthansa, Air Canada, American Airlines and British Airways.
Thousands of factory workers on currently on Lunar New Year holidays may struggle to get back to work next week due to travel restrictions.
China dominated U.S. Federal Reserve Chair Jerome Powell’s news conference on Wednesday. “When China’s economy slows down we do feel that,” he said.
Reporting by Pei Li, Gabriel Crossley, Cate Cadell, Kevin Yao and Muyu Xu in Beijing; Samuel Shen and David Stanway in Shanghai; Josh Smith, Sangmi Cha and Joyce Lee in Seoul, Chang-Ran Kim in Tokyo and Se Young Lee; Stephanie Nebehay in Geneva; Kate Kelland in London; Crispian Balmer in Rome; Thu Thu Aung in Yangon; Ben Blanchard in Taipei; Writing by Andrew Cawthorne and Alex Richardson; Editing by Clarence Fernandez, Nick Macfie and Frances Kerry
When a patient is diagnosed with rheumatoid arthritis, psoriatic arthritis or spondyloarthritis, prescribing the correct type of medicine is a case of trial and error. It is simply not possible to predict which medication will work for the individual patient, and it is therefore a matter of trying the different treatment options: glucocorticoids, low dose chemotherapeutic drugs or newer biological drugs. Until now!
A new research project from Aarhus University and Aarhus University Hospital in Denmark suggest that it is the composition of cells in the joint of the individual patient which determines whether the medicine is effective or not. The researcher behind the study, published in the journal of the American College of Rheumatology (ACR Open), is medical doctor and PhD Tue Wenzel Kragstrup from the Department of Biomedicine at Aarhus University and the Department of Rheumatology at Aarhus University Hospital.
So far, we’ve examined the effect of nine drugs in three different in vitro models. We can see that the effect of a given drug depends on the cell compositions. This leads us to hope that the immunological cells and inflammatory signaling molecules in the joint of each individual patient will be able to predict the most effective treatment.”
Tue Wenzel Kragstrup, Department of Biomedicine at Aarhus University
The study’s in vitro models consist of cell cultures isolated from joint fluids aspirated from the joints of patients with severe arthritis as part of the treatment at Aarhus University Hospital. The researchers then used the diseased cells from the joint fluid to examine the effects of different types of medicine, explains Tue Wenzel Kragstrup’s colleague, Ph.D. student Morten Aagaard Nielsen from the Department og Biomedicine, who is first author of the article.
“As far as we know, this is the first description of a direct association between the composition of the immune system cells and the effect of medication,” Morten Aagaard Nielsen says. Tue Wenzel Kragstrup adds:
“The findings are based on the assumption that the cells in the test tube behaving like they would behave in the patient. So of course, the research result must be validated in humans in a larger number of patients,” says Tue Wenzel Kragstrup, who concurrent with his biomedical research is in rheumatology specialist training.
It was at the hospital while meeting patients racked with pain, that Tue Wenzel Kragstrup got the idea and invented the project.
“Today, the first-choice drug has no effect in around one in three patients. So, doctors often have to try several different types of medicine before they find the right one. This is a process that may take years, because a drug typically takes three to four months to be effective,” explains Tue Wenzel Kragstrup.
“And while we wait, the patients continue to experience swelling and pain – not to mention the permanent damage that can occur in the joints as a result of persistent inflammation,” he says.
Tue Wenzel Kragstrup hopes that the research results in time can be translated into a simple test – such as a blood test – which can determine the correct medicine for the individual patient. According to Tue Wenzel Kragstrup, this type of individualized treatment could be realized within a decade.
Rheumatoid arthritis, psoriatic arthritis and lumbar arthritis – more information:
Rheumatoid arthritis, psoriatic arthritis and spondyloarthritis affects approx. two per cent of Denmark’s population, often young people, with no known cure.
The diseases can be very painful and disabling and may therefore have a major impact on families and working life.
Rheumatoid arthritis, psoriatic arthritis and spondyloarthritis are characterized by an over-reaction in the immune system with inflammation of the affected joints.
Nielsen, M.A., et al. (2019) Responses to Cytokine Inhibitors Associated with Cellular Composition in Models of Immune‐Mediated Inflammatory Arthritis. ACR Open Rheumatology. doi.org/10.1002/acr2.11094.
Last summer, Neil Mahoney was diagnosed with stage 4 cancer. Mahoney had to spend his last days fighting to find doctors willing to help him end his life.(Heidi de Marco/KHN)
GOLDEN, Colo. ― The call came the last week of September, when Neil Mahoney could still stagger from his bed to the porch of his mobile home to let out his boisterous yellow Lab, Ryder.
Rodney Diffendaffer, a clinical pharmacist in Longmont, 45 miles away, had left a message.
Your prescription is ready, it said.
Mahoney, a once-rugged outdoorsman now reduced to bones, his belly swollen with incurable cancer, sighed with relief. After months of obstacles, the frail 64-year-old finally had access to lethal drugs under Colorado’s 2016 End of Life Options Act, one of a growing number of U.S. state laws that allow terminally ill patients to obtain medications to end their lives.
Even as an increasing number of U.S. states have legalized aid-in-dying laws, exercising that option is challenging for patients in a country where most large hospital systems have deep religious ties and the religious right is powerful. One in 6 hospital patients is now cared for at a Catholic hospital, according to the Catholic Health Association. Aid-in-dying is a legal right, but desperate patients are often left feeling they are doing something terribly, morally wrong.
Centura Health Corp., the Christian-run hospital where Mahoney sought treatment for his cancer, regards the practice as “intrinsically evil,” citing the ﬁrm’s governing rules, the Ethical and Religious Directives for Catholic Health Care Services. The hospital has barred its doctors from following the state law. In August, it fired his physician, Dr. Barbara Morris, for consulting with Mahoney with the aim of carrying out his wishes.
As his condition deteriorated over the summer, Mahoney left the lawsuit, with Morris still unable to assist him. She sued the hospital for wrongful dismissal; the case is pending. In December, Centura officials filed a countersuit that says the hospital’s actions are protected by the U.S. and state constitutions’ freedom of religion guarantees.
Mahoney had access to lethal drugs under Colorado’s 2016 End of Life Options Act, a law that allows terminally ill patients to obtain medications to end their lives. He was the patient at the center of a legal battle over whether a Christian-run hospital system could bar its doctors from following the law.(Heidi de Marco/KHN)
In opposing the practice, the country’s religious institutions have received support from the Trump administration, which has consistently given providers wide latitude to refuse to participate in medical interventions they object to on religious grounds, though that previously applied primarily to abortion and contraception.
That leaves dying patients like Mahoney feeling abandoned during the most vulnerable time of their lives. When Centura fired Morris for encouraging “a morally unacceptable option,” Mahoney lost both his doctor and the confidence that he would be able to end his life when the suffering became too great.
So the brief message on his phone meant an important victory.
“This way I can say, ‘Yes, I can go,’” he said last summer. “I can call them up with a couple days’ notice and do it.”
Legal But Not Accessible
Oregon was out front in permitting aid-in-dying, approving it more than two decades ago. In recent years, eight other states and the District of Columbia have allowed the practice. It’s being considered in more than a dozen others.
Even when the practice is legal, it often isn’t accessible. Some doctors are barred from participating by their employers. Others refuse to do so. In some cases, the drugs themselves may be too expensive. A dose of Seconal, which was once the most commonly prescribed drug for the practice, can run more than $3,000. The government and some private insurers won’t cover it.
One of nine siblings in a close Catholic family, Mahoney seemed an unlikely candidate to test the Colorado law.
Left: Neil Mahoney (wearing a tie in the front row) in a 1962 family portrait in Denver; Right: Mahoney in Boulder, Colorado, in April 2013(Photos courtesy of Patrick Mahoney)
Weathered and rangy, with a reddish crew cut and broad hands, he’d never had a major illness or injury despite years of physical labor. For the past five years, he managed planting crews at Welby Gardens, a wholesale nursery near Denver.
“The dahlias have always been one of my favorites,” Mahoney said. “Just because of the flowers, the way those millions of petals can open up. That just still baffles me.”
He lived with Ryder, his 6-year-old golden Lab, and Lakewood, a sleek calico cat.
Mahoney was never comfortable around doctors, said his youngest brother, Patrick Mahoney, 60, who supported his older brother’s efforts to obtain help in planning his death.
“Neil had a long belief that health systems, including physicians, capitalize on those that are ill,” Patrick Mahoney said.
Mahoney, who worked at a local landscape company, said he’d never had a major illness or injury despite decades of physical labor.(Heidi de Marco/KHN)
Mahoney lived alone with his dog, Ryder, and cat, Lakewood. (Heidi de Marco/KHN)
Neil Mahoney started feeling sick last January, then worse in April and May. By mid-June, he couldn’t ignore a bout of stomach cramps, nausea and vomiting that sent him to urgent care.
Doctors ordered a CT scan, which showed multiple masses on his liver and likely in his lymph nodes, plus tumors at the junction of his stomach and esophagus. In July, tests at a local cancer center confirmed the bad news: stage 4 adenocarcinoma, a cancer that forms in the body’s glands.
There’s no cure, the doctor said. Without treatment, Mahoney could expect to live four more months. With chemotherapy, he might make it a little more than a year.
Neil Mahoney immediately asked about medical aid-in-dying. He was among 65% of Colorado voters who supported the law in 2016, and now he expected to use it. The medical oncologist turned him down flat.
Neil Mahoney recalled: “I feel like I got slapped in the face.”
Mahoney struggled to move around despite the use of his cane. Mahoney eventually lost more than 50 pounds from his 185-pound frame.(Heidi de Marco/KHN)
‘The Healing Ministry’
Mahoney’s primary care doctor had no qualms about participating. At 65, with 40 years of experience, Morris said that, in her view, medical aid-in-dying should be part of a continuum of care for dying patients.
“We cannot know when a person has reached their limit of suffering,” she said. “Only that person knows.”
Dr. Barbara Morris was fired by Centura Health Corp. in August 2019 for wanting to help her patient, Neil Mahoney, under the guidelines of Colorado’s End of Life Options Act.(Heidi de Marco/KHN)
But Centura, jointly run by Catholic and Seventh-day Adventist churches, describes its work as “the healing ministry of Christ.” When it became aware of the plans in the works, Centura fired Morris, contending that Morris had violated an employment contract requiring her to abide by its faith-based rules.
Morris immediately lost her malpractice insurance and access to a medical office, leaving her unable to prescribe drugs or provide care for Mahoney ― and 400 geriatric patients.
The lawsuit she and Mahoney filed in August alleged that Centura’s faith-based policy violates both the End of Life Options Act and Colorado laws barring health systems from interfering with medical judgment. It sought to clarify whether Centura could prevent Morris from helping Mahoney as long as he wasn’t on the health system premises.
“We believe it is a morally unacceptable act, regardless of how you couch it, and we are not going to participate in it,” Centura chief executive Peter Banko told Kaiser Health News.
In December, Centura officials hired Nussbaum Speir Gleason, a Colorado law firm that specializes in religious freedom cases. In its counterclaim, Centura officials are asking a judge to declare that a health care organization cannot be forced to allow its employees to support or carry out provisions of Colorado’s End of Life Options Act.
Mahoney didn’t have the time to let the legal battle play out in the courts. By July, he’d lost 30 pounds from his 185-pound frame. He grew weaker, wrenched with pain from tumors at the junction of his stomach and esophagus.
The Mahoney children had watched their mother, Charlotte Mahoney, endure a slow decline two weeks before her death in 2007 at age 85.
“I did not want to face an agonizing death without any means to help control when and where I will die,” Neil Mahoney told lawyers.
With his own doctor’s hands tied, a desperate Mahoney resorted to a backdoor route to exercise his legal right.
Mahoney was never comfortable around doctors and typically handled health issues on his own. In the weeks preceding his death, he had to take multiple medications to ease nearly constant pain.(Heidi de Marco/KHN)
Rodney Diffendaffer, a pharmacist who runs a network that quietly connects terminally ill patients in Colorado with doctors willing to follow the law, reached out after reading about Mahoney’s dilemma.
“It’s his choice to have that drug,” said Diffendaffer, 51, who works at the independently owned Flatirons Family Pharmacy in Longmont. “No one else should even have a say.”
In the past two years, Diffendaffer and his fledgling group, Dying With Dignity of the Rockies, have helped more than 50 terminally ill Coloradans obtain medications to end their lives.
“I have seen the pure torture that people went through,” said Diffendaffer, who grew up on a farm and says dying animals are treated more humanely.
Instead of planning for retirement, I’m planning for death.
Although nearly 4,000 people in the United States have used a medical aid-in-dying law, under-the-radar groups like Diffendaffer’s have emerged to match patients with doctors willing to help — but not willing to be included on a public list.
“They don’t want to be labeled ‘Dr. Death,’” said Lynne Calkins, a board member for End of Life Choices California, a volunteer group formed in that state last spring.
The problem grows not just from powerful religious medical centers, but also the loud voice of the religious right in national politics as well as a genuine discomfort among some physicians who are loath to use their skills to end lives rather than save them.
Dr. Ira Byock, founder and chief medical officer at the Institute for Human Caring at Providence St. Joseph Health in Gardena, Calif., has long opposed the practice he calls “hastened death.” He said his objections are based on his understanding of his profession, not on faith.
“I can only say that from my perspective, and that of many non-Catholic practitioners, it is outside the scope of medical practice,” he said. “Ending somebody’s life intentionally is not part of medical practice. It is something else.”
In Vermont, where the practice has been legal since 2013, few doctors outside larger cities such as Burlington are trained to administer the law and few pharmacies are equipped to supply the drugs, said Betsy Walkerman, president of the group Patient Choices Vermont.
“The rest of the state is very thin on medical presence,” Walkerman said. “It’s much more difficult.”
In New Jersey, which enacted a law in August, the family of Zeporah “Zebbie” Geller contacted 40 doctors before they found two willing to help. Geller, 80, a retired teacher, had been diagnosed with terminal lung cancer and died on Sept. 30 after ingesting the prescribed medication.
Mahoney made arrangements for his beloved companion to live with his close friend after his passing. “I feel like he knows what’s happening,” said Mahoney. After his death, his cat went to live with Mahoney’s sister.(Heidi de Marco/KHN)
Neil Mahoney’s Choice
Dr. Glenda Weeman, 60, a family physician who operates an independent practice in Longmont, agreed to prescribe aid-in-dying drugs for Mahoney after two exams, which confirmed he met the law’s requirements.
Weeman had prescribed the drugs for only one patient before Mahoney under Colorado’s relatively young law.
“My role is to relieve pain and suffering. That is my job,” Weeman said. “I have to help people understand that there are choices. If you don’t know the choices of how to die, I’m going to help you figure that out.”
By late September, Mahoney had his prescription, which included two anti-nausea drugs and a cocktail of four medications that would induce death. He paid about $575 for it all, out-of-pocket.
Still, he wasn’t sure when — or if — he’d use them. About a third of people who get the drugs don’t wind up taking them, data from Oregon and Washington show.
“It’s a little spooky,” Mahoney said on Sept. 30, sitting in his small, cluttered mobile home. A green T-shirt hung from his bony shoulders; he’d lost another 20 pounds. Around his neck was a pendant that said DNR: Do not resuscitate.
Mahoney still had a list of things to do. A friend had promised to care for Ryder, the dog. The cat might do OK on her own, though his sister later offered to take her. He wanted to write a will.
“It’s quite a turnaround,” he said quietly. “Instead of planning for retirement, I’m planning for death.”
Mahoney and Ryder in late August. On Nov. 5, surrounded by family, Mahoney took his prescribed end-of-life medication. He died within an hour. The once-rugged outdoorsman, now reduced to gaunt bones and a swollen belly, was determined that he ― not the disease ― would decide when he died.(Heidi de Marco/KHN)
Over the next few weeks, Neil grew frailer day by day. Patrick Mahoney, who quit his job to help, said that he and another brother, John, took turns sleeping on their brother’s couch.
Neil Mahoney knew he had a window of time where he could take the medicine. If he waited too long, he wouldn’t be able to swallow it. Then he’d lose his chance to make the choice.
On Tuesday, Nov. 5, he decided it was time.
At 9:45 p.m., in bed, surrounded by family, Neil Mahoney took the drugs to halt anxiety and nausea. Minutes later, using a straw, he quickly drank the rest of the medications, dry powders mixed with raspberry-flavored liquid. Then they waited.
“It was perhaps the hardest hour of our lives,” Patrick Mahoney said.
About 10:45, Patrick “felt for his pulse. I put my hand on his chest to check his respiration rate, and then I said, ‘He’s gone.’”
Reached by email, Barbara Morris was somber about the death of a patient whom the religious teachings of her former employer had prevented her from helping. She has found another place to practice, starting in the new year.
“It was great honor to know Neil both as his doctor and his friend,” she wrote. “Out of respect for his memory, we will continue to advocate for care focused on patient values and wishes.”
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