Trusting Injection Drug Users With IV Antibiotics At Home: It Can Work

Two mornings a week, Arthur Jackson clears space on half of his cream-colored sofa. He sets out a few rolls of tape and some gauze, then waits for a knock on his front door.

“This is Brenda’s desk,” Jackson said with a chuckle.

Brenda Mastricola is his visiting nurse. After she arrives at Jackson’s home in Boston, she joins him on the couch and starts by taking his blood pressure. Then she changes the bandages on Jackson’s right foot. His big toe was amputated at Brigham and Women’s Hospital in November. A bacterial infection, osteomyelitis, had destroyed the bone.

Jackson is still taking intravenous penicillin to stop the infection. He came home from the hospital wearing a small medication pump that delivers a steady dose of penicillin via a PICC line. PICC stands for a “peripherally inserted” or “percutaneous indwelling” central catheter, and it resembles a flexible IV tube, inserted into Jackson’s chest.

“This all looks good,” Mastricola said, after making sure the line was clean and in place. “You don’t need me.”

When patients need weeks or months of IV antibiotic treatment but otherwise don’t need to be hospitalized, the standard protocol is to discharge them with a PICC line and allow them to finish the medication at home. It saves money and is much more convenient for patients.

But this arrangement is almost never offered to patients with a history of addiction. The fear is that such patients might be tempted to use the PICC line as a fast and easy way to inject drugs like heroin, cocaine or methamphetamine.

Jackson, 69, was addicted to heroin for 40 years. Although he’s been sober for years, most U.S. hospitals would force patients like Jackson to stay in the hospital, sometimes for eight weeks or more. But Brigham and Women’s in Boston, along with a few others in the U.S., is challenging that protocol, allowing some patients with a history of addiction to go home.

Supporters of the change argue that doing so boosts the chances these patients will stay on their antibiotics and beat the infection.

A Path To Safe At-Home Treatment

A small team of Brigham doctors and nurses started planning this unusual option shortly after opening the Bridge Clinic, a walk-in health center in Boston for patients seeking treatment for a substance use disorder. Dr. Christin Price, one of the clinic’s directors, said virtually every patient who injects drugs develops some kind of infection. It’s difficult to avoid injecting bacteria into the bloodstream when using drugs in an alley or a public bathroom. The national opioid epidemic has led, in many cases, to a parallel increase in diseases related to injection drug use, such as HIV, hepatitis C and bacterial infections of the heart and bones. A study of North Carolina hospitals found a twelvefold increase in cases of bacterial endocarditis, a heart infection, from 2010 to 2015.

“Every time someone uses injection drugs, they’re putting themselves at risk for a very complicated infection,” Price said.

Treatment options for endocarditis patients with a history of drug use are limited. Some skilled nursing facilities, home care agencies and antibiotic infusion companies decline to work with these patients once they’re released from a hospital. And, Price said, some of her patients aren’t willing to remain in a hospital for weeks on end just to finish a round of IV antibiotics.

“They kind of get stir crazy,” she said. “You can imagine it’s almost like being held captive for six weeks, especially when you’re feeling fine now because the infection is clearing. A huge problem is that some of them can’t last — and so they leave before the six weeks are over.”

Patients who don’t complete their course of antibiotics can end up with a recurring infection and a repeat trip to the hospital.

Doctors and nurses affiliated with the Bridge Clinic wondered if there was a way to send patients with a history of drug use home — safely. They mapped out three requirements: First, patients would have to be taking an addiction treatment medication such as buprenorphine, or be willing to start one. Second, patients would have to check in weekly at the Bridge Clinic. Third, patients would need to have stable housing, and live with a sober friend or loved one. Price and colleagues began months of discussions with specialists in heart, bone and joint conditions, seeking buy-in from surgeons and nurses, so their patients could participate.

“A lot of people did sort of look aghast,” Price said. “It was just their policy that people with a history of injection drug use would not go home.”

When Dr. Daniel Solomon, who is also with Brigham and Women’s, encountered those looks, he said, he’d remind colleagues that “the alternatives aren’t that good either.”

Holding patients for weeks in a hospital room is hard on both the patients and medical providers, he said. And if patients want to use drugs, they’ll find a way to do it, even in a hospital bed.

In spring 2018, Price, Solomon and others enrolled a few of the first qualified patients, then a few more — intentionally cherry-picking those who wanted to be in treatment and had a sober, stable home.

Brenda Mastricola checks on the PICC line through which Arthur Jackson, a former drug user, is receiving penicillin to treat a bone infection.(Jesse Costa/WBUR)

‘I’m Not Going Back’

Arthur Jackson met the requirement that at-home PICC line candidates take addiction treatment medication. He had been on methadone for 10 years, used heroin again, then switched to Suboxone, a combination medication containing buprenorphine and naloxone, which he has been taking for two years. And, in fact, Jackson said he was insulted when one of the doctors presented the home treatment option to him but said she was worried the PICC line might entice him to inject heroin.

“Stop right there,” Jackson recalled telling the nurse. “When it comes to my recovery, I’m serious because I’ve done so much to lick this — this thing.”

Although the possibility did cross Jackson’s mind.

“First thing I thought was, ‘Oh, I could inject heroin in here easily,’” Jackson said. “But I dismissed that thought because I’m not going back” — back to winters on the streets and living from one heroin fix to the next.

Other Bridge patients scoff at the concerns about PICC lines.

“Everyone makes such a big deal about this PICC line,” said Stephen Connolly, 36, who went home with the open port last year, while being treated for endocarditis. “If I want to get high, I know how to do it. I’m not going to mess around with a PICC.”

Connolly said that when he first came to Brigham and Women’s Hospital he was focused on his heart, ignoring his other disease: addiction. He said he was surprised when every doctor he saw, even his cardiologist, wanted to talk about addiction.

“I’m like, ‘Listen, dude. My heart’s falling apart here, so let’s hold up with the drug talk,’” Connolly recalled. He assured the cardiologist he had his addiction under control, even though he wasn’t so sure. “Obviously, I didn’t, but my mind tells me that. It’s just crazy.”

Connolly said he realizes now that the conversation around drug use was relevant and related to his heart infection.

Connolly finished his antibiotic treatment while staying with family members in Abington, Massachusetts. Brigham doctors say the housing requirement excludes otherwise eligible patients. Recent research shows homeless patients who have HIV or hep C do take their antiviral medicines; there are no equivalent robust studies on treating homeless patients who have bacterial infections.

Nevertheless, a few other hospitals are testing ways to continue outpatient treatment for patients who don’t have a stable home. In Portland, Oregon, a medical center tried providing IV antibiotics inside addiction treatment programs. A hospital in Kentucky combines addiction treatment, counseling and outpatient IV antibiotics. In Vancouver, British Columbia, the Canadian national health program pays for small apartments, staffed with a nurse 24 hours a day, where patients can stay while they complete antibiotic treatment.

“People who use drugs deserve the same standard of care,” said Dr. Christy Sutherland, medical director at the Portland Hotel Society in Vancouver. “We can’t change what we offer as clinicians — to give people subpar treatment with the excuse that they are IV drug users.”

Promising Early Signs

Arthur Jackson lives alone in his studio apartment (he does not live with a sober friend or loved one), but he convinced doctors he’d be better off there than in the hospital, so he could visit his 93-year-old mother daily, feed his tankful of tropical fish and his cat, and attend regular Narcotics Anonymous meetings.

“I guess the best way to put it is, I have a life and I need to get back to it,” he said.

Jackson is one of 40 patients with a history of drug use the Brigham team has discharged from the hospital to complete IV antibiotic treatment at home. The team is paying particular attention to 21 patients within that group who, unlike Jackson, are active drug users. So far, these men and women have finished their antibiotic treatment via a PICC line with no complications. One had to be readmitted because he had trouble administering the antibiotics. Price said three patients relapsed into drug use, but no one used the PICC line to inject illegal drugs.

“I think we’ve shown, through this pilot, that it is safe and feasible for certain patients,” Price said.

Brigham doctors have not yet published these initial results in a medical journal, though they plan to. But already, Price said, the pilot program is helping to cut health care costs.

Taken as a group, the 21 high-risk patients who needed IV antibiotics spent 571 days at home rather than in a hospital or rehab facility. Not including the cost of home care visits by a home nurse, the savings tally more than $850,000, based on estimates of $1,500 per hospital day.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

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Trump accuses cable TV of making coronavirus look ‘as bad as possible’

WASHINGTON (Reuters) – U.S. President Donald Trump accused two cable TV news channels of presenting the danger from the coronavirus in as bad a light as possible and upsetting financial markets, as public health officials warned Americans to prepare for a likely outbreak.

Trump on Wednesday wrote on Twitter that CNN and MSNBC, both of which frequently carry criticism of him, “are doing everything possible to make (the coronavirus) look as bad as possible, including panicking markets,” adding: “USA in great shape!”

Trump, who is stepping up his re-election campaign ahead of November’s presidential election, did not specify what he did not like about the coverage. He is to hold a news conference on the coronavirus at 6 p.m. EST (2300 GM) on Wednesday.

Officials at the U.S. Centers for Disease Control and Prevention (CDC) on Tuesday said the virus’ global march had raised concern about its spread in the United States, even as it remained unclear when that might happen or how severe it might be.

Global stock markets have slumped in recent days due to worries over a prolonged disruption to supply chains and economies from the disease, which has infected about 80,000 people and killed nearly 3,000, mostly in China.

U.S. stocks turned lower in afternoon trading on Wednesday in a fresh wave of selling sparked by fears of the coronavirus spreading in the United States. The Dow Jones Industrial Average was down 116.19 points, or 0.43%.

Trump has been increasingly alarmed by the drop in U.S. stock markets, which he considers a barometer of the health of the American economy and sees as key to his re-election.

During his recent trip to India, the Republican president praised U.S. health officials while downplaying the virus’ potential impact on the United States.

U.S. President Donald Trump and first lady Melania Trump arrive aboard Air Force One after returning from a two-day trip to India, at Joint Base Andrews in Maryland, U.S., February 26, 2020. REUTERS/Al Drago

House of Representatives Speaker Nancy Pelosi, a Democrat, on Wednesday dismissed Trump’s assertion in India that the coronavirus was under control at home.

“I don’t think the president knows what he’s talking about, once again,” she told reporters.

U.S. Health and Human Services Secretary Alex Azar on Wednesday said the United States has 59 coronavirus cases, including 42 American passengers repatriated from the Diamond Princess cruise ship docked in Japan.

There have been just two reported cases of person-to-person transmission within the United States, both infected by people who had been to China.

Health officials in Nassau County, New York, said they were monitoring 83 people who visited China and may have come in contact with the coronavirus, but Governor Andrew Cuomo said the state has had no confirmed cases so far. Nassau County is just east of New York City.

Dr. Anthony Fauci, the head of the U.S. National Institute of Allergy and Infections Diseases, who will brief Trump, said that while the virus was contained in the United States, Americans must get ready for a potential outbreak as transmissions spread outside of China.

“If we have a pandemic, then almost certainly we are going to get impacted,” Fauci told CNN.

The CDC has advised Americans to not visit China and South Korea, and on Wednesday stepped up travel warnings for Iran, Italy and Mongolia over risks from the disease.

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It is also considering expanding airport screenings to target passengers from countries that have seen recent spikes in cases such as Italy and South Korea, NBC News reported.

Trump is seeking $2.5 billion from Congress to boost its virus response. Democrats have warned that amount falls far short of what is needed and have also urged the White House to appoint a “czar” who could coordinate a national response.

Senate Democratic Leader Chuck Schumer on Wednesday called for $8.5 billion to prepare.

Reporting by Steve Holland and Susan Heavey; additional reporting by Makini Brice and Michael Erman; Writing by Alistair Bell; Editing by Bernadette Baum, Bill Berkrot and Jonathan Oatis

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Facebook to ban misleading ads about coronavirus

FILE PHOTO: A Facebook logo is displayed on a smartphone in this illustration taken January 6, 2020. REUTERS/Dado Ruvic/Illustration/File Photo

(Reuters) – Facebook Inc said on Wednesday it would ban advertisements for products offering any cures or prevention around the coronavirus outbreak, and those that create a sense of urgency around the situation.

The disease, believed to have originated in the Chinese city of Wuhan late last year, has killed more than 2,700 people.

The announcement by the social-media giant comes as it faces increasing regulatory scrutiny over the type of content posted on its platform, specifically items reflecting extreme ideologies and fake news.

Ads with claims like ‘face masks are 100% guaranteed to prevent the spread of the virus’ will not be allowed, a company spokesperson said.

The U.S. Centers for Disease Control and Prevention (CDC) on Tuesday alerted Americans to begin preparing for the spread of coronavirus in the United States after infections surfaced in several more countries.

Last month, Facebook said that it would remove content about the virus “with false claims or conspiracy theories that have been flagged by leading global health organizations and local health authorities”, joining companies like TikTok and Pinterest.

Reporting by Ambhini Aishwarya and Ayanti Bera in Bengaluru; Editing by Bernard Orr and Shailesh Kuber

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Researchers reveal new details about how joint inflammation evolves in rheumatoid arthritis

Walter and Eliza Hall Institute researchers have revealed new details about how joint inflammation evolves in rheumatoid arthritis, and the cells that prolong the inflammatory attack.

In both laboratory models and human clinical samples, the research team pinpointed immune cells called natural killer (NK) cells as an unexpected source of the inflammatory protein GM-CSF in rheumatoid arthritis, the first clue that these cells contribute to inflammatory autoimmune diseases. The research also explained how GM-CSF signals to other immune cells to prolong joint inflammation, and how GM-CSF signaling to immune cells is kept in check in healthy joints.

These discoveries could indicate potential new therapeutic targets for reducing joint inflammation in rheumatoid arthritis, and could potentially reduce inflammation in other autoimmune disease such as multiple sclerosis.

The research was published in the Journal of Experimental Medicine by a team co-led by Professor Ian Wicks, Professor Nicholas Huntington and Dr. Cynthia Louis, with Dr. Fernando Souza-Fonseca-Guimaraes.

At a glance

  • The cell signaling protein GM-CSF causes inflammation that occurs in joints during rheumatoid arthritis.
  • Our researchers have identified natural killer (NK) cells as a major source of GM-CSF in rheumatoid arthritis, the first time these cells have been implicated in an autoimmune disease.
  • The team also identified the protein CIS as a key molecular brake that dampens GM-CSF activity and inflammation, revealing a potential new therapeutic avenue for inflammatory diseases.

A surprising source of GM-CSF

Rheumatoid arthritis is a chronic inflammatory autoimmune disease in which the immune system mistakenly attacks joints and other tissues, causing inflammation, pain and long-term joint damage.

GM-CSF was originally discovered at the Walter and Eliza Hall Institute as a growth factor for blood cells, but it is increasingly recognized as a key inflammatory mediator that drives a number of autoimmune diseases.

Professor Wicks said that his team’s earlier research, together with colleagues at the University of Melbourne, had identified the signaling protein GM-CSF as an important contributor to joint inflammation in rheumatoid arthritis.

When we removed GM-CSF, we could see a reduction in inflammation. This finding underpinned the development and current clinical trials of inhibitors of GM-CSF signaling as a new approach to treating rheumatoid arthritis.

Although we knew that GM-CSF signaling was important in joint inflammation, which cells were producing GM-CSF within joints, and how this protein signaled after binding to its receptor on other immune cells, was not well understood.”

Professor Ian Wicks

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Dr. Louis said the team discovered that GM-CSF in inflamed arthritis joints was produced by immune cells called natural killer (NK) cells. “This was a surprise because, until now, NK cells were thought to primarily be important for clearing virus-infected or cancer cells,” she said. “This is the first time NK cells have been found to contribute to tissue inflammation in autoimmune diseases such as rheumatoid arthritis.

“As well as looking at our laboratory model of arthritis, we examined cells from the joints of people with rheumatoid arthritis and confirmed that NK cells are indeed a significant source of GM-CSF in patients.

“This discovery has solved one part of the puzzle about how inflammation occurs in rheumatoid arthritis,” Dr. Louis said.

Filling in the gaps

The team revealed that the protein CIS is important for ‘switching off’ GM-CSF signaling, a critical mechanism to restrain destructive inflammation in arthritis.

“In the absence of CIS, we saw hyperactivation of GM-CSF signaling and more severe arthritis,” Dr Louis said.

“This research showed that if a new drug that mimics CIS were to be developed, it may help to reduce the debilitating effects of GM-CSF in rheumatoid arthritis, but also in other inflammatory diseases driven by GM-CSF, such as multiple sclerosis.”

Professor Wicks said the research revealed new aspects of cell signaling that warranted further investigation. “We’re very excited to have progressed our understanding of rheumatoid arthritis and potentially other inflammatory diseases,” he said.

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Opioid prescription for chronic non-cancer pain increased in the last two-and-a-half decades

The number of people with chronic non-cancer pain prescribed an opioid medicine worldwide increased in the last two-and-a-half decades. But there was only a small number of studies reporting prescription data outside the United States, finds research led by the University of Sydney.

Chronic pain unrelated to cancer includes conditions such as chronic lower back pain, osteoarthritis and rheumatoid arthritis.

The researchers point to guidelines such as those from the Centres of Disease Control and Prevention in the United States that discourage the use of opioids to manage chronic non-cancer pain because of concerns about harmful effects and the lack of evidence about effectiveness. The use of opioids in the US and deaths from overdoses and addiction has been said to have reached epidemic proportions.

The systematic review of studies from across the world is the first to examine the literature about the extent opioid pain relievers are being prescribed to manage people with chronic pain conditions.

The findings are published today in the high-impact Journal of Internal Medicine.

The research spanned eight countries and evaluated 42 published studies that included 5,059,098 people with chronic pain conditions (other than cancer).

Two-thirds of the studies were from the US; one study was from Australia and the other studies were from the United Kingdom, Norway, India, Spain, Denmark and Canada.

Lead author Dr. Stephanie Mathieson from the University of Sydney’s Institute for Musculoskeletal Health says that in the period 1991-2015, prescribing of opioid medicines increased markedly.

In the early studies, opioid medicines were prescribed to about 20 percent of patients experiencing chronic pain but the later studies report rates of more than 40 percent.

Over this period, on average around 30 percent of people with chronic pain were prescribed an opioid medicine.

We noted that a higher proportion of people were prescribed a strong opioid medicine such as oxycodone compared to weak opioid pain-relieving medicines.”

Dr. Stephanie Mathieson, School of Public Health in the Faculty of Medicine and Health

The authors also discovered there was insufficient data on the dose and duration of opioids prescribed to patients with chronic non-cancer pain.

Key findings:

Opioid prescribing:

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Between 1991 and 2015, the researchers found in people with chronic pain (unrelated to cancer):

  • Opioid prescribing increased over time from approximately 20 percent in early years to around 40 percent in later years.
  • On average over this period approximately one in three patients (30.7 percent) were prescribed an opioid medicine.
  • 42 percent of patients with chronic lower back pain were prescribed an opioid.
  • The average age of those prescribed an opioid medicine was 55.7 years.
  • Prescribing was not associated with the geographical location or the clinical setting where the opioids were prescribed (such as GPs or medical specialists).

Types of opioid painkillers:

In 17 studies that described the type of opioid pain relievers prescribed:

  • 24.1 percent were strong combination products containing opioids (eg oxycodone plus paracetamol).
  • 18.4 percent were strong opioids (eg oxycodone, morphine, fentanyl).
  • 8.5 percent were weak opioids (eg codeine, tramadol).
  • 11 percent were weak combination products containing opioids (eg codeine plus paracetamol).

An ‘evidence’ gap in global prescription data

The study aimed to establish a baseline for how commonly opioids are prescribed for people with chronic pain conditions (other than cancer). But the authors discovered a crucial evidence gap in prescription data in countries outside of the US.

“While we have sufficient data for this purpose for the US, we have little or no data for other countries,” the authors write.

Dr. Mathieson says that studies in other countries, particularly low and middle-income countries, are needed in order to check whether these countries are at risk of the problems seen in the US, where there is liberal use of opioid medicines.

This research is a collaboration between the University of Sydney; the University of Warwick, UK; the University of Notre Dame; the University of New South Wales and Monash University.

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Needy Patients ‘Caught In The Middle’ As Insurance Titan Drops Doctors

BAYONNE, N.J. — For five years, Rasha Salama has taken her two children to Dr. Inas Wassef, a pediatrician a few blocks from her home in this blue-collar town across the bay from New York City.

Salama likes the doctor because Wassef speaks her native language — Arabic — and has office hours at convenient times for children.

“She knows my kids, answers the phone, is open on Saturdays and is everything for me,” she said.

But UnitedHealthcare is dropping Wassef — and hundreds of other doctors in its central and northern New Jersey Medicaid physician network. The move is forcing thousands of low-income patients such as Salama to forsake longtime physicians.

Across the nation, business and contractual disputes are separating patients from longtime doctors. This often occurs when doctors don’t want to accept the rates insurers are willing to pay. It sometimes occurs when insurers’ business plans require having a narrower network of doctors — doctors whose practice patterns may be easier to control.

But in this case, the cause of the exclusion goes to even deeper business connections: Wassef and other doctors say the insurer appears to be trying to shift patients to Riverside Medical Group, a 20-office physicians’ practice owned by Optum, a sister company of UnitedHealthcare, both of which are subsidiaries of UnitedHealth Group.  UnitedHealthcare is essentially forcing patients to transfer to doctors it controls, the doctors allege.

Indeed, several patients said the health plan directed them to Riverside when informing them their doctors were being dropped.

Lawrence Downs, CEO of the Medical Society of New Jersey, said he estimates UnitedHealthcare is trying to remove hundreds of doctors in central and northern New Jersey from its network. That is the same area where Riverside Medical operates, he noted.

“It seems like they are steering patients away from small, community-based doctors to large groups that they own,” he said.

Good For Profits

That raises questions about whether this type of “vertical consolidation” — the term for a practice occurring across the country — is a strategy that is good for profits but bad for patients.

UnitedHealthcare said the changes are not part of a campaign to get as many patients as possible to the Riverside practice. It points out that it is retaining the community-based doctors, like Wassef, in its networks to treat its Medicare Advantage and commercial plan members.

But, experts say, traumatic disruptions in doctor-patient relationships are an inevitable result of ongoing shifts in the complicated business of U.S. health care.

Salerno’s main office is in a three-story, 19th-century house in East Orange that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.(Phil Galewitz/KHN)

Facing a rapid consolidation of doctors’ practices and hospital systems — which have hefty negotiating power to demand high fees — insurers have limited options to control costs and maintain a positive balance sheet, said Jacob Wallace, an assistant professor of public health at Yale University. Medicaid plans are especially affected because, unlike commercial plans or even Medicare, they can’t increase premiums or demand copayments.

“Plans face a challenging landscape to keep costs down,” Wallace said. As a result, health plans have taken other approaches, including narrowing provider networks and buying their own physician practices, he said.

But further complicating matters, many Medicaid and Medicare managed-care programs are contracted out to private, for-profit insurers such as UnitedHealthcare. They are looking to create returns for shareholders. With surging enrollment in government programs, UnitedHealthcare has enjoyed rising profits and a stock price that has soared tenfold since 2010.

Wassef and about two dozen other physicians filed a federal lawsuit in September to get reinstated. Wassef, whose termination is scheduled in May, said the move could seriously affect her practice because 80% of her patients are insured by UnitedHealthcare.

UnitedHealthcare gained millions of new customers after the Affordable Care Act led New Jersey and 35 other states and the District of Columbia to expand Medicaid and states turned to private insurers to handle the business. Salama and some other UnitedHealthcare customers said they like their insurance plan because it offers richer benefits than other Medicaid options and covers the medications they use.

The company operates New Jersey’s second-largest Medicaid health plan, with 418,000 members. (The state Department of Human Services has blocked UnitedHealthcare from enrolling any additional Medicaid members, a severe and rare penalty. That move — which is not related to the termination of doctors’ contracts — stems from complaints related to care management and discharge planning, the health plan’s call center and other issues.)

A company spokesperson acknowledged the health plan is dropping 2% of its Medicaid doctors, saying the move was designed to help control costs.

“As health care costs continue to rise, we are working to mitigate the impact on the customers, states and members we serve by negotiating with care providers on their behalf to keep reimbursement rates affordable,” the company said in a statement. “We understand that our members have personal relationships with their doctors and that network changes can be difficult.”

A Practice Destroyed

New Jersey Medicaid officials refused to comment on whether they are concerned about UnitedHealthcare’s actions. But patients caught up in the standoff have reason to worry, said Linda Schwimmer, CEO of the New Jersey Health Care Quality Institute, a coalition of health plans, providers and a variety of health trade groups.

“Once you have a trusted relationship with a provider, it means a lot and it goes to the quality [of your care] because if you are seeing the same providers and you trust them, you are more likely to take your medication and adhere to whatever care plan you have,” she said.

Velylia McIver switched to a new Medicaid health plan after Salerno was initially dropped by UnitedHealthcare in order to keep seeing him.(Phil Galewitz/KHN)

Dr. Alexander Salerno, an internist who runs a 17-doctor multispecialty practice in East Orange, New Jersey, another plaintiff in the lawsuit, is helping lead the court fight. Salerno’s main office is in a three-story, 19th-century house that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.

Until the dispute began last year, Salerno advised his patients to sign up for UnitedHealthcare because of its broad array of benefits, including vision and dental care, and because of the ease in referring to specialists.

And UnitedHealthcare never complained about this group’s skill. In fact, the group received a $130,000 bonus last year for its good care to patients. Salerno said Riverside Medical offered to buy his group practice in 2018, but he declined.

Since UnitedHealthcare announced it would drop his group from the network, more than 500 of his practices’ patients have already changed doctors to stay with the UnitedHealthcare plan, Salerno said.

“It’s not a bad insurance company. It just seems like they have become greedy trying to control both ends of the pendulum — wanting to be the payer and provider,” Salerno said.

A federal judge ordered the case to be heard by a neutral arbitrator, which in late November granted an emergency injunction that will keep Salerno from being removed from UnitedHealthcare’s network until an arbitrator makes a decision on a permanent injunction, which is expected in March.

But that leaves patients in limbo.

Glorida Rivera, 68, said UnitedHealthcare’s decision to drop Salerno was upsetting because she relied on him to care for her diabetes, thyroid and heart conditions. She credits Salerno for referring her to a cardiologist, who put stents in her heart to clear a blockage.

“He knows my whole story, so why do I have to change?” wondered Rivera. Nonetheless, she is sticking with UnitedHealthcare.

Velylia McIver, 83, decided in November to search for another plan so she could stay with Salerno. But it took her more than a month to get coverage for some medications.

“I feel caught in the middle of all this, and it’s the pits,” McIver said.

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Trump administration seeks $2.5 billion in funds to fight coronavirus

WASHINGTON (Reuters) – The Trump administration is asking Congress for $2.5 billion to fight the fast-spreading coronavirus, including more than $1 billion for vaccines, the White House said on Monday.

With financial markets falling on concerns that the virus will have a significant impact on the global economy, the Trump administration is eager to show it is prepared to combat the virus despite the limited number of cases so far in the United States.

The virus has spread to some 29 countries and territories beyond mainland China, with outbreaks in South Korea, Iran and Italy. [L3N2AO07M]

“The Trump administration continues to take the spread of the COVID-19 Coronavirus Disease very seriously. Today, the administration is transmitting to Congress a $2.5 billion supplemental funding plan to accelerate vaccine development, support preparedness and response activities and to procure much needed equipment and supplies,” said Rachel Semmel, a spokeswoman for the White House Office of Management and Budget.

The money will be used for therapeutics, vaccine development and the stockpiling of personal protective equipment such as masks, the White House said.

Of the $2.5 billion request, $1.5 billion represents new funding. The rest would come from funds already budgeted by Congress, such as unused money to fight the Ebola virus. The administration requires congressional approval to redirect that money to fight the coronavirus.

House of Representatives Appropriations Committee Chairwoman Nita Lowey, a Democrat, said in a statement the Trump administration’s funding request was “woefully insufficient to protect Americans from the deadly coronavirus outbreak.”

House Speaker Nancy Pelosi said late on Monday that the supplemental funding requested by Trump is “undersized” and “completely inadequate to the scale of this emergency”.

“The House will swiftly advance a strong, strategic funding package that fully addresses the scale and seriousness of this public health crisis,” Pelosi said in a statement.

The United States has not seen the virus spread through its communities the way that China and other countries have experienced, but health officials are preparing for the possibility even as Americans affected so far have been quarantined.

FILE PHOTO: Passengers arrive at LAX from Shanghai, China, after a positive case of the coronavirus was announced in the Orange County suburb of Los Angeles, California, U.S., January 26, 2020. REUTERS/Ringo Chiu/File Photo

There have been 53 confirmed U.S. cases of the new coronavirus so far – 14 in people diagnosed in the United States and 39 among Americans repatriated from the outbreak’s epicenter of Wuhan, China, and from the Diamond Princess cruise ship quarantined in Japan, according to the U.S. Centers for Disease Control and Prevention.

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U.S. health officials have warned that cases among repatriated citizens will likely increase.

The CDC warned Americans on Monday to avoid travel to South Korea because of the virus.

“We have aggressively worked to combat the spread of this virus, tried to prevent it as best we could from coming into this country,” White House spokesman Hogan Gidley told reporters earlier on Monday.

Trump has been at odds with his own White House advisers over China’s coronavirus response. He has sought to downplay the impact of the virus, saying it could fade in April with warmer weather – something health experts said is unknown.

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Trump has praised the work of Chinese President Xi Jinping, even as his advisers have questioned the reliability of the information Beijing has shared on the virus and expressed frustration over its reluctance to accept U.S. expertise in combating it.

The Trump administration is also grappling with where to send Americans evacuated from the Diamond Princess who tested positive for the virus after backing off plans to quarantine them in a federal facility in Alabama.

In a statement on Monday, HHS cited a “rapidly evolving situation,” but said the Alabama center was “not needed at this time” and that it was looking for alternatives.

Reporting by Jeff Mason and Susan Heavey; Additional reporting by Caroline Humer in New York, Manas Mishra and Kanishka Singh in Bengaluru and Makini Brice, Ted Hesson and Eric Beech in Washington; Editing by Peter Cooney

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Senate has time to weigh funds for U.S. coronavirus response: Republican senator

WASHINGTON (Reuters) – The Senate will weigh how much money is needed to prepare for the nation’s coronavirus response, a top Republican senator said on Tuesday, adding that short-term funding is available now and that there is time for lawmakers to consider additional, longer-term spending.

“We don’t have all the time in the world, but I think we do have time to look at what will be the right number,” Senator Roy Blunt, the party’s policy committee chair and head of the Senate Rules Committee, told reporters at a news conference.

Reporting by Patricia Zengerle and Makini Brice; Writing by Susan Heavey; Editing by Chizu Nomiyama

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A highly conserved protein contributes to sensing mechanical pain, study shows

Researchers at McGill University have discovered that a protein found in the membrane of our sensory neurons are involved in our capacity to feel mechanical pain, laying the foundation for the development of powerful new analgesic drugs.

The study, published in Cell, is the first to show that TACAN, a highly conserved protein among vertebrates whose function remained unclear, is in fact involved in detecting mechanical pain by converting mechanical pressures into electric signals.

Using molecular and cellular approaches with electrophysiology, Reza Sharif-Naeini, a professor in McGill’s Department of Physiology, and his team were able to establish that TACAN is found on the membrane of pain sensing cells where it forms tunnel like pores, a structure known as an ion channel.

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The researchers also created a mouse model where TACAN could be “turned off,” making the animals significantly less sensitive to painful mechanical stimuli.

“This demonstrates that TACAN contributes to sensing mechanical pain,” says Sharif-Naeini, who is also the study’s senior author.

A decade-long search

About 70 years ago, scientists imagined that tiny sensors might be responsible for providing our brain with useful information about our environment, explaining our sense of touch or our capacity to feel pain when pinched.

These sensors have since been discovered to be ion channels – pore like structures capable of translating mechanical pressures exerted on a cell into electrical signals that travel to the brain to be processed – a phenomenon known as mechanotransduction.

This phenomenon has been shown to be central in several physiological processes such as hearing, touch and the sensation of thirst. But the identity of the sensor responsible for mechanical pain remained elusive.

Because “most of the pain we feel – a pinch or a stubbed toe – is mechanical in nature,” Sharif-Naeini said that competition to find the newly discovered sensor was fierce.

With the rampant problem of opioid overuse, the finding has practical implications for people who suffer from chronic pain. Patients with conditions such as osteoarthritis, rheumatoid arthritis or neuropathic pain often develop mechanical allodynia, a condition where mechanical pain receptors become overly sensitive. Trivial things such as walking or a light touch thus become extremely painful, leading to a significant reduction in the quality of their lives.

Now that we have identified the sensor associated with mechanical pain, we can start designing new powerful analgesic drugs that can block its action. This discovery is really exciting and brings new hope for novel pain treatment.”

Reza Sharif-Naeini, professor in McGill’s Department of Physiology

“TACAN is an ion channel involved in sensing mechanical pain” by Lou Beaulieu-Laroche et al. was published in Cell.

Source:

McGill University

Journal reference:

Beaulieu-Laroche, L., et al. (2020) TACAN Is an Ion Channel Involved in Sensing Mechanical Pain. Cell. doi.org/10.1016/j.cell.2020.01.033.

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Inflammation caused by radiation can promote survival of triple-negative breast cancer cells

While radiation is successfully used to treat breast cancer by killing cancer cells, inflammation caused as a side-effect of radiation can have a contrary effect by promoting the survival of triple-negative breast cancer cells, according to research published online in the International Journal of Radiation Biology by Jennifer Sims-Mourtada, Ph.D., director of Translational Breast Cancer Research at ChristianaCare’s Helen F. Graham Cancer Center & Research Institute.

Accounting for 15-20% of all breast cancers, triple-negative breast cancer is faster growing than other types of breast cancers.

Dr. Sims-Mourtada’s latest study, “Radiation induces an inflammatory response that results in STAT3-dependent changes in cellular plasticity and radioresistance of breast cancer stem-like cells,” brings scientists closer to understanding the mechanisms behind this aggressive and hard-to-treat cancer. It shows that inflammation caused by radiation can trigger stem-cell-like characteristics in non-stem breast cancer cells.

“This is the good and the bad of radiation,” Dr. Sims-Mourtada said. “We know radiation induced inflammation can help the immune system to kill tumor cells — that’s good — but also it can protect cancer stem cells in some cases, and that’s bad.”

She added, “What’s exciting about these findings is we’re learning more and more that the environment the tumor is in – its microenvironment – is very important. Historically, research has focused on the genetic defects in the tumor cells. We’re now also looking at the larger microenvironment and its contribution to cancer.”

The term triple-negative breast cancer refers to the fact that the cancer cells don’t have estrogen or progesterone receptors and also don’t make too much of the protein called HER2. The cells test “negative” on all 3 tests. These cancers tend to be more common in women under age 40, who are African-American, Latina or who have a BRCA1 mutation.

My work focuses on cancer stem cells and their origination. They exist in many cancers, but they’re particularly elusive in triple-negative breast cancer. Their abnormal growth capacity and survival mechanisms make them resistant to radiation and chemotherapy and help drive tumor growth.”

Jennifer Sims-Mourtada, Ph.D., director of Translational Breast Cancer Research at ChristianaCare’s Helen F. Graham Cancer Center & Research Institute

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She and her team applied radiation to triple-negative breast cancer stem cells and to non-stem cells. In both cases, they found radiation induced an inflammatory response that activated the Il-6/Stat3 pathway, which plays a significant role in the growth and survival of cancer stem cells in triple-negative breast cancers. They also found that inhibiting STAT3 blocks the creation of cancer stem cells. Still unclear is the role IL-6/STAT3 plays in transforming a non-stem cell to a stem-cell.

For women living in Delaware, Dr. Sims-Mourtada’s research is especially urgent: The rates of triple-negative breast cancer in the state are the highest nationwide.

At ChristianaCare, we are advancing cancer research to help people in our community today, while we also advance the fight against cancer nationwide. Dr. Sims-Mourtada’s research is a dramatic step toward better treatments for triple-negative breast cancer.”

Nicholas J. Petrelli, M.D., Bank of America endowed medical director of the Helen F. Graham Cancer Center & Research Institute

To advance her research on inflammation, last year Dr. Sims-Mourtada received a $659,538 grant from the Lisa Dean Moseley Foundation. The three-year grant will enable her and her team at the Cawley Center for Translational Cancer Research to continue investigating the role of cells immediately around a tumor in spurring the growth of triple-negative breast cancer and a possible therapy for this particularly difficult cancer.

“Our next step is to understand the inflammatory response and how we might inhibit it to keep new cancer stem cells from developing,” Dr. Sims-Mourtada said.

Dr. Sims-Mourtada’s research team previously identified an anti-inflammatory drug, currently used to treat rheumatoid arthritis, that has the potential to target and inhibit the growth of cancer stem cells and triple-negative breast cancer tumors. That research could set the stage for clinical investigation of the drug, alone or in combination with chemotherapy, to improve outcomes for patients with triple-negative breast cancer.

Source:

ChristianaCare’s Cawley Center for Translational Cancer Research

Journal reference:

Arnold, K.M., et al. (2020) Radiation induces an inflammatory response that results in STAT3-dependent changes in cellular plasticity and radioresistance of breast cancer stem-like cells. International Journal of Radiation Biology. doi.org/10.1080/09553002.2020.1705423.

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