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Technology can be a very good thing, and in the medical world respirators and incubators can be lifesavers, especially for premature babies. But new research shows that even when preemies survive the precarious days of their early lives, they may have health issues that continue long after they come home from intensive care.

Reporting in the Journal of the American Medical Association this week, scientists at Duke University analyzed birth-registry records of over one million Norwegians born between 1967 and 1988 (about 5% of whom were born premature); unlike birth records in the U.S, those in Norway are cross-linked to sibling and parental records across generations, offering a richer set of data. Duke's Dr. Geeta Swamy and colleagues tracked people for up to 35 years to record their death rates. They also looked at how long babies had been in the womb at the time of their birth, a factor that the authors felt was a better indicator of a baby's development and maturity than, say, birth weight — a measurement many previous studies have used.

Doctors have long documented the immediate dangers of preterm birth — weakened immunity, respiratory problems and increased risk of death — but now, as neonatal technologies have allowed more and more preemies to survive past their early years into adulthood, the long-term data is beginning to emerge. Recent findings suggest that being born too early may have lasting consequences. Studies have linked preterm birth, defined as being born before 37 weeks gestation, with cognitive differences during children's elementary and high school years, for example, when preemies tend to exhibit developmental abnormalities and learning difficulties that full-term children do not. Now the new JAMA report suggests that premature babies' elevated risk of death also follows them well into adolescence — very preterm babies, born at 22 to 27 weeks, were twice as likely to die between the ages of six and 12 than their full-term counterparts.

More surprising were the longer-term consequences that Swamy's study documented for the first time: preemies who made it to adulthood, the data showed, were less likely to have children than other people and, when they did, were more likely to have premature infants themselves. After several decades, only 25% of the preterm women had had children, compared to 68% of women whose mothers had carried them to term, while 14% of the preterm men had reproduced, compared to half of the full-term men. "I think being born preterm has some effect on your development, your biological functioning," says Swamy. "Whether it affects your fertility is something that is up for research. But for men and women who are infertile, we might start asking about their birth history; we currently don't ask their birth weight, or how far along they were when they were born. It would be an interesting avenue for infertility research."

"This study provides interesting insights because it looks beyond childhood and into the adulthood of preterm individuals, as well as even into the next generation. It's an area that we have not really look at yet," says Dr. Wanda Barfield, a neonatologist at the Centers for Disease Control.

Like previous studies on preemies, Swamy's research found that men and women who were born preterm achieved less education than their full-term peers — not a surprise, since many preterm births occur among parents of lower socioeconomic status, who are less educated, more often unmarried and have higher rates of alcohol and tobacco use. Children born into these environments, studies have suggested, are more likely to adopt the behaviors and habits they see around them and thus may decide not to pursue higher education.

Swamy's report is particularly significant given that more babies are now being born preterm — intentionally. Good prenatal care means healthier mothers and babies, but it also means that doctors are earlier to catch conditions that might jeopardize either the baby or the mother. Preliminary signs of diabetes in the mother or preeclampsia, a condition in which the mother becomes hypertensive, may lead a doctor to deliver a baby preterm. Granted, these babies are closer to reaching term, but they are still born before the ideal 37-to-41-week period and, according to Swamy's findings, still at increased risk compared with full-term babies. So, if Swamy's results are replicated, doctors may have to reconsider their practice, and focus their attention on preventing these conditions from developing in the first place.

Swamy certainly hopes that will be the case. Her findings, coupled with the growing body of evidence on the short-term health issues of preemies, argues that being born too early leads to certain basic biological consequences that even high-tech neonatal medicine cannot erase. "This study demonstrates that the issue of prematurity is a public health issue," says Barfield. "So our focus should be on the prevention of preterm delivery in the first place. Our goal should be to give women the opportunity to have healthy pregnancies where babies go to term." And that would be one less thing for anxious mothers to worry about.

As a lead scientist at the Nature Conservancy, one of the richest and most influential green groups in the U.S., Sanjayan fights for biodiversity. The concept is the backbone of the environmental movement, a recognition that the unimaginable variety of wildlife is an essential part of what makes our planet special, and worthy of protection for its own sake. But Sanjayan is worried that the conservation movement to which he has dedicated his life may be overlooking another kind of diversity: racial diversity. An American of South Asian descent (like many people from his native Sri Lanka, he generally uses one name), Sanjayan often finds himself as the only person of color at environmental meetings, in the classroom, even out in the field. Conservation in the U.S. — and the environmental movement more generally — tends to be very white and relatively well off, from the leadership down to the foot soldiers. "Right now conservation groups do miserably (in diversity)," says Sanjayan. "That needs to change."

Sanjayan himself has always been the exception. Born in Sri Lanka to parents who worked for the UN and the World Bank, he spent much of his childhood in Africa, igniting a lifelong love of wildlife. It was exactly the kind of experience, he notes, that few minorities and immigrants in the U.S. — more likely to be living in urban areas isolated from nature — would ever have. Still, growing up Sanjayan says that there were few if any role models of color in the conservation movement for a young South Asian like himself. David Attenborough, Jacques Cousteau: all great conservationists, all white men. "If you don't see someone you can identify with yourself as a kid, it can be hard to imagine yourself in that role," he says. "I think that has a big impact."

Role models or not, Sanjayan pursued a career in environmentalism, and rose to become one of the Nature Conservancy's most visible faces, writing columns for the New York Times,Nature and others on conservation, in addition to teaching at the University of Montana. (His family was initially doubtful of his career choice, fearing that it was financially unstable, but they became convinced after they saw him being interviewed by the Indian actress Aishwarya Rai — one of the biggest stars in Asia.)

Sanjayan admits that being the only brown face in the room, as he puts it, has probably been as much of an advantage for his career as a detriment. People remember him from the blur of conferences and meetings. In international field work, not being white can make it easier to gain the trust of local populations — Sanjayan recalls an early field trip to an African nation in the wake of apartheid, when being white meant earning instant suspicion. But he admits to being troubled that at a time when the U.S. may finally be ready to elect an African-American to the Presidency, the country's major environmental groups have yet to be led by a non-white. "It's pretty surprising, and at the same time, not surprising at all," says Sanjayan.

The Nature Conservancy scientist would like to see green groups take more aggressive steps to diversify their workforce, identifying promising young minorities who are still in school and actively recruiting them. That's worth pursuing. As America itself grows more diverse, the environmental movement risks irrelevance if it remains largely white and elite. "We need to communicate to all of our constituents," says Sanjayan, "and we'll do a better job of that if we have a range of voices in our own organization." Diversity becomes even more important as the environmental movement tries to tackle truly global threats like climate change. If Americans remain convinced that only rich, white liberals can afford to worry about global warming, we'll never achieve the political unity needed for meaningful action.

Fortunately, there are already signs that the green movement can be more than just white. At home in the U.S., a new crop of African-American activists like New Yorker Majora Carter and Oakland-based Van Jones are adopting environmentalism, fighting for clean air and water in the inner city or green jobs for the underemployed. Around the globe, Sanjayan notes, U.S. environmental groups like the Nature Conservancy have put local staffers in positions of authority. But more can and should be done. "As a conservation community, we badly need to do this," says Sanjayan. Diversity — in all its forms — should be a green goal.

In the contentious debate over whether people have a right to die, the staunchest opponents on either side could usually agree on one point — that the terminally ill ought to be made as comfortable as possible in their final days. But a controversial procedure is now calling into question even that accord.

Terminal sedation is the decision to keep dying patients, who cannot be made comfortable in any other way, unconscious until they die. As a last resort, such drug-induced sedation is legal in most countries including the U.S., and it is widely accepted as a mainstay of end-of-life care. Opponents of terminal sedation argue, however, that some doctors misuse the practice as a substitute for euthanasia. A study published last week in the British Medical Journal (BMJ) indicates this may be the case in the Netherlands. Physician-assisted suicide has been legal there — though highly regulated — since 2001, but its use has dropped in recent years. At the same time, Dutch physicians have turned more often to terminal sedation to treat patients at the end of life — 8.2% of all deaths in 2005 involved terminal sedation, up from 5.6% of deaths in 2001. These findings suggest that "continuous deep sedation has possibly increasingly been used as a relevant alternative to euthanasia," the study's authors write. "We do not know whether such substitution is always in accordance with the patient's wishes and with legal and professional guidelines."

Palliative sedation is common practice in hospitals worldwide. Burn victims or patients in intensive-care units are often sedated while doctors perform sensitive procedures or determine the next best pain-management treatment. One thing that distinguishes routine sedation from terminal sedation is that the latter often goes hand-in-hand with cutting off other medications or removing a patient's feeding tubes. On its face, this may sound to many people as automatically hastening a patient's death. But that's not the case, says Dr. Ira Byock, chair of palliative medicine at Dartmouth Medical School, who has performed terminal sedation for his patients. "This is a practice, when used correctly, that's only done in the final stages of life," Byock says. "At that point, nutrition or antibiotics can usually do nothing to prolong life." Indeed, Dutch researchers found that in 94% of the 6,500 cases they studied, the patient was sedated for less than one week before death.

Still, what's troubling about the new findings, Byock says, is the implication that doctors may be issuing the treatment either too early or without the patient's consent — or that they are using it to sidestep legal requirements to perform euthanasia. Nine percent of the patients in the study had in fact asked for euthanasia before being sedated. "Sedating someone until they die is a one-size-fits-all solution, but thoughtful pain management requires time and money," Byock says, noting that plans should always be discussed with patients and families well in advance. "One shouldn't be a substitute for another."

How frequently terminal sedation is used in the United States has never been studied, but estimates range from almost never to as much as 50% of the time in hospice care. The practice has been sanctioned in the U.S. since 1997, when the Supreme Court, in a decision outlawing euthanasia, explicitly ruled terminal sedation legal under the Constitution. But the procedure didn't make big headlines until 2006, when some experts suggested that it may have played a role in the deaths of four critically ill patients trapped in a New Orleans hospital after Hurricane Katrina. (Louisiana prosecutors went further, charging the patients' doctor and two nurses with second-degree murder; a grand jury refused to indict them.) Two years prior, in a 2004 article in the New England Journal of Medicine, Dr. Timothy Quill, a professor of medicine at the University of Rochester, described using sedation to help his father die. Cases like these have fueled public unease with the practice.

Still, palliative care specialists who have administered terminal sedation say that choosing to do so is rarely a difficult decision for suffering patients or their families. Rather, the option to sedate can be a tremendous liberation, says Dr. Porter Storey, executive vice-president of the American Academy of Hospice and Palliative Medicine. It relieves patients of their "fear of dying or not getting adequate help at the end of life," Storey says, before adding, "Good doctors don't intentionally shorten life."

Why is it that when a group of soldiers share a horrific battle experience, some are able to work through it and get on with their lives while others suffer the persistent anxiety, emotional numbness and bomb-blasted nightmares of post-traumatic stress disorder (PTSD)? The answer, researchers have long believed, is that an individual's response to trauma — whether in battle, or as result of a natural disaster, a violent crime or some other horror — depends not only on the intensity of that trauma but also on a complex interplay of past experiences and genetic factors. A new paper, published in the current issue of the Journal of the American Medical Association, provides remarkable support for this explanation and identifies a specific gene that influences susceptibility to PTSD.

The study, led by a team at Emory University, looked at 900 adults — most of them low income and African American — seeking medical care at two clinics in Atlanta. A history of trauma is common in poor, urban populations, and the researchers found that 80% of the subjects had been exposed to trauma, with the great majority exposed to multiple traumatic stressors in their lives. "Over a third said they had a friend or family member murdered," says Dr. Rebekah Bradley, assistant professor of psychiatry and behavioral science at Emory. About 30% had been abused as children — a well-established risk factor for developing PTSD.

When the subjects were evaluated — with a psychiatric questionnaire — for symptoms of PTSD, 25% met the criteria for the disorder. "That's a rate almost as high as among returning combat veterans," says Bradley, who also directs a PTSD treatment team at the Atlanta Veterans Affairs Medical Center.

The research team collected saliva samples from each subject and looked at a gene known as FKBP5, which influences the body's response to the stress-related hormone cortisol. "When it's working right, it helps to down-regulate the stress response system," explains Dr. Bradley. Different individuals have slightly different versions of this gene, varying by a single nucleotide (or letter in the DNA alphabet). The researchers found that four variants of the gene were associated with an increased rate of PTSD in individuals who also had a history of child abuse. Other variants seemed to confer some protection or resilience. Between 26% and 33% of the subjects had one of the high-risk gene patterns, between 17% and 24% had a pattern associated with resilience to developing PTSD, with the largest group somewhere in the middle.

All told, these tiny differences in the genetic code seem to make the difference between whether an individual with a childhood history of abuse rises above it or struggles psychologically when exposed to traumas later in life.

The PTSD study adds to a growing body of research showing that genes influence whether or not an adult who experienced childhood abuse later develops mental illness. "What we're finding across the board is that what we've inherited makes us more or less vulnerable to the impact of childhood abuse," explains Dr. Bradley. "Certain genes can either amplify or dampen the impact of the abuse."

The study raises the question of whether soldiers going into combat or others who work in high-risk situations could some day be screened for vulnerability to PTSD. "It's possible that super high-risk groups might want to do this kind of screening — special forces for example. But right now the science isn't there yet," says Dr. Thomas Neylan, Director of the PTSD Program at the San Francisco VA Medical Center, and, he adds, it may be impossible to predict vulnerability with precision.

Neylan also points out that the research may have implications for developing drugs to treat PTSD. The role of the FKBP5 gene suggests that it might make sense to target the specific molecules that regulate the body's response to stress, he says.

Both Neylan and Bradley say the research underscores the powerful interplay between childhood trauma, genes and mental health. Childhood abuse is a risk factor for multiple mental illnesses, including depression, eating disorders and substance abuse, as well as PTSD. "If we could simply reduce childhood abuse," says Bradley, "it would have a major impact on mental health."

Here's a quick quiz: what's the world's No. 1 killer? It's not AIDS, TB or malaria. The world's deadliest disease is heart disease, which kills nearly 18 million people a year. Once considered predominantly an affliction of the wealthy, the prevalence of heart disease has been growing in the developing world — 80% of heart-disease deaths now occur in low- and middle-income countries, which has got global health workers and epidemiologists considering better ways to screen, track and treat the illness.

Now it looks like screening, at least, could get a whole lot cheaper and faster. A team of U.S. researchers publishing this week in the medical journal Lancet finds that simple, inexpensive tests for cardiovascular risk factors — performed in less than 10 minutes, using a scale, a tape measure and a blood-pressure check — are every bit as effective at determining heart-disease risk as more expensive procedures involving laboratory-based tests. It's not exactly a do-it-yourself kit, but it can help doctors screen patients more quickly, leading to potentially more effective treatment — in both the developed and developing world.

The researchers, led by Thomas Gaziano at Harvard Medical School and Brigham & Women's Hospital in Boston, trawled through data on 6,186 American adults participating in the U.S. National Health and Nutrition Examination Survey. Participants were initially examined in the early 1970s and had no prior history of cardiovascular disease; they were tracked for 21 years, during which time 1,529 of the participants suffered cardiovascular events (such as heart attacks, stroke, angina or heart failure), including 578 deaths due to heart disease.

Researchers looked at patient measurements typically used to assess heart disease risk: age, systolic blood pressure, smoking status, total cholesterol, diabetes status and any hypertension treatment. They found that they could substitute body mass index (or BMI, a ratio of height to weight), a noninvasive measure, for the lab-based blood test for cholesterol and still accurately predict patients' five-year cardiovascular disease risk.

Gaziano and his colleagues show that if simple measurements, like BMI, are thoughtfully considered, doctors with fewer resources in the developing world can screen for heart-disease risk just as effectively as their counterparts in high-income countries. There is some question about whether results from the U.S. can be applied accurately to other populations — for a given BMI, for example, Asians tend to have a higher body-fat ratio than Caucasians — but, in many ways, Americans of the 1970s may be more similar than not to populations elsewhere today. In the '70s, Americans smoked a lot more tobacco than today, and few were getting treatment for high blood pressure or high cholesterol. That's not so different from 21st-century Russians or Eastern Europeans, Gaziano suggests.

A second article in this week's Lancet shows that heart-disease risk factors are rapidly becoming more common worldwide, even in sub-Saharan Africa, where infectious disease remains a big killer. In theory, African doctors should be among those who benefit most from the new paper's findings. In resource-poor settings, saving the $1 to $3 cost of a lab blood test (in the U.S. it costs $10, according to the Lancet paper) would certainly be meaningful — but that's assuming the tests were being performed to start with. The real savings are difficult to calculate, in large part because the populations most likely to benefit from dropping lab tests are those that are least likely to have any labs or technicians available be doing them at all.

The reality is that some developing countries spend as little as $30 a year per person in health care costs; the rich world spends thousands. For patients in low- and middle-income countries, meaningful costs also include the cost of taking time off work to take the test, then traveling back to the clinic for the results. For those reasons, the World Health Organization's current guidelines for assessing cardiovascular disease risk where lab resources are scarce have already dropped the cholesterol testing.

The new findings may in the end offer more cost-saving potential — and raise more interesting questions — in developed nations, including the U.S., where medical costs have spiraled upward in the last two decades. Neither doctors nor patients may want to drop cholesterol testing altogether — more information is better, especially when the consequence of missing a diagnosis is heart attack — but there is still a practical lesson to be learned. "I think in the U.S. we might use this as an initial test," Gaziano says. "We can at least narrow the group of people for whom we need to screen cholesterol." Those with very few other heart-disease risk factors, for example, probably don't need the extra blood work, since their cholesterol profile wouldn't make a big difference to overall risk anyway. Similarly, those patients with several risk factors for heart disease probably need treatment no matter what their cholesterol levels. By giving blood tests only to those on the fence, doctors can save resources for the tests and treatments that are warranted.