DONALD G. McNEIL Jr.
A major study testing whether Americans would take their H.I.V. drugs every day if they were paid to do so has essentially failed, the scientists running it announced Tuesday at an AIDS conference here.
Paying patients in the Bronx and in Washington — where infection rates are high among poor blacks and Hispanics — up to $280 a year to take their pills daily improved overall adherence rates very little, the study’s authors said.
The hope was that the drugs would not only improve the health of the people taking them, but help slow the spread of H.I.V. infections. H.I.V. patients who take their medicine regularly are about 95 percent less likely to infect others than patients who do not. The Centers for Disease Control and Prevention estimates that only a quarter of all 1.1 million Americans with H.I.V. are taking their drugs regularly enough to not be infectious.
Paying patients $25 to take H.I.V. tests, and then $100 to return for the results and meet a doctor, also failed, the study found.
“We did not see a significant effect of financial incentives,” said Dr. Wafaa M. El-Sadr, an AIDS expert at Columbia University and the lead investigator. But, she said, there is “promise for using such incentives in a targeted manner.”
Cash payments might still work for some patients and some poor-performing clinics, she said.
Other H.I.V.-prevention research released here Tuesday offered good news for gay men but disappointing results for African women.
Two studies — both of gay men, one in Britain and the other in France — confirmed earlier research showing that pills to prevent infection can be extremely effective if taken daily or before and after sex. Both were stopped early because they were working so well that it would have been unethical to let them continue with men in control groups who were not given the medicine.
But a large trial involving African women of a vaginal gel containing an antiviral drug failed — apparently because 87 percent of the women in the trial were unable to use the gel regularly.
The failure of the cash-incentives trial was a surprise and a disappointment to scientists and advocates. It had paid out $2.8 million to 9,000 patients in 39 clinics over three years, but the clinics where money was distributed did only 5 percent better than those that did not — a statistically insignificant difference.
Some small clinics and those where patients had been doing poorly at the start of the study did improve as much as 13 percent, however.
People in other countries have been successfully paid to stop smoking while pregnant and to get their children to school. In Africa, paying poor teenage girls to attend school lowered their H.I.V. rates; scientists concluded that it eased the pressure on them to succumb to “sugar daddies” — older men who gave them money for food, clothes and school fees in return for sex.
One study presented here at the annual Conference on Retroviruses and Opportunistic Infections estimated that every prevented H.I.V. infection saved $230,000 to $338,000. Much of that cost is borne by taxpayers.
Mathematical modeling suggested that paying people up to $5,000 a year could be cost effective, Dr. El-Sadr said, but $280 was settled on after a long, difficult debate.
Paying more than $280 at some clinics was not an option, she said; achieving statistical relevance would have meant signing up even more clinics. The study had already involved almost every H.I.V. patient in the Bronx and Washington.
“I don’t think anyone has an answer to what amount would be sufficient without being excessive,” Dr. El-Sadr said.
One advocate suggested that more money could work — in the right setting.
“In South Africa, $280 is a lot of money,” said Mitchell Warren, the executive director of AVAC, an organization that lobbies for AIDS prevention. “For that much, you’d definitely get some behavior change.”
The two studies among gay men looked at different ways to take pills. A 2010 American study, known as iPrEx, showed that taking Truvada — a combination of two antiretroviral drugs — worked if taken daily.
The British study, known as PROUD, used that dosing schedule, and men who took the pill daily were protected 86 percent of the time.
In the French trial, known as Ipergay, men were advised to take two pills in the two days before they anticipated having sex and two in the 24 hours afterward.
Those who took them correctly also got 86 percent protection.
“The problem,” Dr. Susan P. Buchbinder, director of H.I.V. prevention research for the San Francisco health department, said in a speech here commenting on the study, “is that studies have shown that men are very good at predicting when they will not have sex and not good at predicting when they will.”
The African study, known as FACTS 001, was a follow-up to the smaller trial from 2010, which showed that South African women who used a vaginal gel containing tenofovir, an antiviral drug, before and after sex were 39 percent better protected than women who did not.
But it also found that many women failed to use the gel because it was messy or inconvenient or because partners objected.
In this trial, there was virtually no effect.
One problem, said Dr. Helen Rees, the chief investigator, was that the women were very young — the median age was 23, and most lived with their parents or siblings.
“They had no privacy for sex,” she said. “They had to go outside to use the product.”
Mr. Warren, of AVAC, said: “The women wanted a product they could use. But this particular product didn’t fit into the realities of their daily lives.”
The development means that advocates are hoping even more that other interventions for women now in trials will work. They include long-lasting injections of antiretroviral drugs and vaginal rings that can be inserted once a month and leach the drugs slowly into the vaginal wall.
Another trial in Africa, the Partners Demonstration Project, conducted among couples in which one partner had H.I.V. and the other did not, found it was extremely effective to simultaneously offer treatment to the infected partner and preventive drugs to the uninfected one until the other’s drugs took full effect.
In the group getting the treatment, there were zero infections that could be traced to partners who were in the study.
Each year more than 15,000 women under the age of 55 die of heart disease in the United States. And younger women are twice as likely to die after being hospitalized for a heart attack as men in the same age group.
It doesn't help that women tend to delay seeking emergency care for symptoms of a heart attack such as pain and dizziness, says Judith Lichtman, an associate professor of epidemiology at the Yale School of Public Health. "We've known that for a while," she says.
In a small study published Tuesday in Circulation: Cardiovascular Quality and Outcomes, Lichtman and her colleagues looked into why women delay getting help. The researchers conducted in-depth interviews with 30 women, ages 30 to 55, who had been hospitalized after a heart attack.
It turned out that many had trouble recognizing that they were having symptoms of a heart attack. "A lot of them talk about not really experiencing the Hollywood heart attack," Lichtman tells Shots.
A heart attack doesn't necessarily feel like a sudden painful episode that ends in collapse, she notes. And women are more likely than men to experience vague symptoms like nausea or pain down their arms.
"Women may experience a combination of things they don't always associate with a heart attack," Lichtman says. "Maybe we need to do a better job of explaining and describing to the public what a heart attack looks and feels like."
But even when women suspected that they were having a heart attack, many said they were hesitant to bring it up because they didn't want to look like hypochondriacs.
"We need to do a better job of empowering women to share their concerns and symptoms," Lichtman says.
And medical professionals may need to do a better job of listening, she adds. Several women reported that their doctors initially misdiagnosed the pain, assuming that the women were suffering from acid reflux or gas.
Doctors should pay special attention to women who have high blood pressure or cholesterol, as well as those with a family history of heart disease, Lichtman says.
This is just a preliminary study. Lichtman has already started working on a much larger study investigating why women have a higher risk of dying from heart disease than men.
But the findings aren't too surprising, says Dr. Nisha Parikh, a cardiologist at the University of California, San Francisco who wasn't involved in the research.
"I take care of young women who have heart disease, and this story is very common," she says.
Part of the issue is that most of the research on heart disease has focused on men, since the condition is more common among men. As a result, the diagnostic tools that doctors use to identify heart disease aren't always well suited for female patients.
Cardiologists are just beginning to rethink how to best recognize and treat heart attacks in women, Parikh notes.
Heart disease is the third leading cause of death for women ages 35 to 44, and it's the second leading cause of death for women 45 to 54, according to the Centers for Disease Control and Prevention. (Cancer is the No. 1 cause.)
"Historically we thought of heart disease as sort of a man's disease," Parikh says. "But that's not the case."
This study also highlights the importance of empowering women to speak up about their worries, says. Dr. Jennifer Tremmel, a cardiologist at Stanford University.
"It's interesting because the whole idea of female hysteria dates back to ancient times," Tremmel says. "This is an ongoing issue in the medical field, and we all have to empower women patients, so they know that they need to not be so worried about going to the hospital if they're afraid there's something wrong."
For Tabitha Waugh, it was another typical day of chaos on the sixth-floor cancer ward.
The fire alarm was blaring for the second time that afternoon, prompting patients to stumble out of their rooms. One confused elderly man approached Ms. Waugh, a registered nurse at St. Mary’s Medical Center here, but she had no time to console him. An aide was shouting from another room, where a patient sat dazed on the edge of his bed, blood pooling on the floor from the IV he had yanked from his vein.
“Hey, big guy, can you lay back in bed?” she asked, as she cleaned the patient before inserting a new line. He winced. “Hold my hand, O.K.?” she said.
Ms. Waugh, who is 30 and the main breadwinner in her family of four, still had three hours to go before the end of a 12-hour shift. But despite the stresses and constant demands, all the hard work was paying off.
Her wage of nearly $27 an hour provides for a comfortable life that includes a three-bedroom home, a pickup truck and a new sport utility vehicle, tumbling classes for her 3-year-old, Piper, and dozens of brightly colored Thomas the Tank Engine cars heaped under the double bed of her 6-year-old, Collin.
The daughter of a teacher’s aide and a gas station manager, Ms. Waugh, like many other hard-working and often overlooked Americans, has secured a spot in a profoundly transformed middle class. While the group continues to include large numbers of people sitting at desks, far fewer middle-income workers of the 21st century are donning overalls. Instead, reflecting the biggest change in recent years, millions more are in scrubs.
“We used to think about the men going out with their lunch bucket to their factory, and those were good jobs,” said Jane Waldfogel, a professor at Columbia University who studies work and family issues. “What’s the corresponding job today? It’s in the health care sector.”
In 1980, 1.4 million jobs in health care paid a middle-class wage: $40,000 to $80,000 a year in today’s money. Now, the figure is 4.5 million.
The pay of registered nurses — now the third-largest middle-income occupation and one that continues to be overwhelmingly female — has risen strongly along with the increasing demands of the job. The median salary of $61,000 a year in 2012 was 55 percent greater, adjusted for inflation, than it was three decades earlier.
And it was about $9,000 more than the shriveled wages of, say, a phone company repairman, who would have been more likely to head a middle-class family in the 1980s. Back then, more than a quarter of middle-income jobs were in manufacturing, a sector long dominated by men. Today, it is just 13 percent.
As the job market has shifted, women, in general, have more skillfully negotiated the twists and turns of the new economy, rushing to secure jobs in health care and other industries that demand more education and training. Men, by contrast, have been less successful at keeping up.
In many working- and middle-class households, women now earn the bigger paycheck, work longer hours and have greater opportunities for career advancement. As a result, millions of American families are being reconfigured along with the economy.
“The culture still has traditional attitudes about who does what, who brings home the bacon and who scrambles the eggs,” said Isabel Sawhill, co-director of the Center on Children and Families at the Brookings Institution. “The economy is now out of sync with the culture, and I think that’s creating tensions within marriage.”
A New Springboard
At the Waughs’ house, it is T.J. Waugh, 33, who picks up the couple’s two children from the babysitter when he leaves his afternoon shift at a small plant in Huntington.
By the time Ms. Waugh arrives home in rural Salt Rock from her shift, often far later than her 7 p.m. quitting time, the children have been bathed and fed.
The house is usually messy. The bathroom walls are covered with scribbles from bath crayons; dirty clothes pile up. Ms. Waugh often jams six 12-hour shifts into one week, leaving little time for cleaning and laundry. Mr. Waugh mows the lawn and will run the vacuum cleaner now and then, and if there are no clean towels, Ms. Waugh will do a load of laundry. Otherwise, housework waits until she has a stretch of days off.
“I’m just really tired when I get home,” Ms. Waugh said.
Ms. Waugh is the keeper of the family’s books. That she out-earns her husband — a pipe fitter who hunts deer and plays men’s softball on the weekends — is an unspoken given.
“She doesn’t rub that in,” he said.
Without missing a beat, Ms. Waugh adds, “It doesn’t matter where it comes from.”
Most of the new jobs produced by America’s sprawling economy — especially since the turn of the century — are either in highly paid occupations that often require an advanced degree, or, more predominantly, in lower-paid positions providing direct services that cannot be sent overseas and, at least for now, are difficult to automate.
But even with a hollowing out of the job market and a broad stagnation in wages, an analysis by The New York Times has found, a set of occupations has emerged that holds promise as the base of a more robust middle class.
Many are in health care, which has grown sharply over the last few decades.
Economists at the Labor Department project that by 2022, as baby boomers age, health care and social assistance will absorb nearly 20 percent of consumer spending, double the share of manufactured goods. The sector is expected to support over 21 million jobs, five million more than today. This includes half a million more registered nurses.
A Rare Green Shoot
The reordering of the economic landscape can be seen all over West Virginia’s old coal country, where billboards along the highways that run through the region advertise a new cardiac center and an orthopedic clinic; and where a strip mall houses Scrubs Unlimited, a medical outfitter, its retail floor crammed with nursing uniforms in 38 colors and Peter Pan prints.
Hugging the Ohio River as it bends around the Appalachian foothills, Cabell County, which includes Huntington, has often found itself on the wrong side of economic change. The population — about 97,000 today — has shrunk 10 percent over the last three decades, as the old have died and many of the young have left.
The railroad that helps shuttle coal to Huntington, one of the nation’s busiest inland ports, is still a source of jobs. But manufacturing employment — once clustered at the long-gone glassmaking plants and furniture makers — has dwindled to fewer than 5,000 jobs. Recently, a 1920s-era nickel alloy plant laid off dozens of workers after a bankruptcy, a corporate acquisition and weak sales.
In real terms, wages in Cabell County now are lower than in the 1970s, stumbling along well below the national average. One in five residents lives in poverty.
The health care industry — which added 3,000 jobs here over the last 10 years — is one of the few green shoots in a struggling economy.
West Virginia has been battered by the same forces that have reshaped the nation since the late 1970s, when global competition, an overvalued dollar, declining unions and advanced technology began to undercut the jobs created during America’s industrial heyday, deepening income inequality. And since 2000, the share of middle-income workers has been squeezed and wages have stagnated.
Yet many of the jobs added in medical services here and across the nation have turned out to be surprisingly good ones.
That was what motivated the only male registered nurse colleague of Ms. Waugh’s on the sixth-floor cancer unit, Johnny Dial, a former highway construction worker and heavy equipment mechanic. More men are joining nursing, but they still make up only 10 percent of the ranks, compared with 4 percent in 1980.
As Mr. Dial contemplated supporting a family, it came down to health care or the railroad if he wanted job security and benefits. He chose what he thought would be a more fulfilling career, and the same one as his wife, who is also a nurse.
“You get to help people,” Mr. Dial said.
Women Stepped Up
Similar thinking was behind the career choices of Ms. Waugh’s fellow female R.N.s. They include a former waitress, a former journalist, an ex-administrator in a metals factory and a former store clerk at Bath & Body Works. In addition to the satisfaction of the work, they all said, the wages are generally better in health care than they could find in other fields.
Ms. Waugh has urged her husband to try to move up at his company, where he earns about $40,000 in regular wages, plus pay for occasional extra shifts, or to switch to a more lucrative career, maybe even in health care as a radiology technician.
But for Mr. Waugh, the only way up at the plant is to go into sales, a promotion he already turned down because he said he did not want to “deal with people.” He could earn more in the coal mines, but that work is dirty and dangerous.
Mr. Waugh has talked about trying college again; he dropped out twice in the past. At one point, his wife even filled out application papers for him to jump-start his re-enrollment, but he did not pursue class work.
“My philosophy is he is lazy,” Ms. Waugh said, standing in the hospital’s white hallway. “That’s what makes me so mad.”
For all the troubles associated with traditionally male jobs, women have not had an easy ride through the economic turmoil, either.
“The occupational structure has not somehow become more women-friendly,” said David Autor, an economist at M.I.T. who has studied the changing American job market. In fact, he added, “the hollowing out of middle-skill jobs was larger for women than for men.” The process intensified sharply during the financial crisis and the ensuing economic downturn.
But in general women have reacted much better, climbing the educational ladder to capture more of the better jobs. Today, 38 percent of women in their late 20s and early 30s have a college degree, compared with 15 percent 40 years ago. The completion rate for young men is now 7 percentage points lower than for women — back then it was 7 points higher.
This has given women an edge in the new job market: Today, almost 58 percent of registered nurses have a bachelor’s degree or more, compared with about a third in 1980.
This is true across the range of occupations capable of supporting a middle-class life. In 1980, 55 percent of workers who earned the equivalent of $40,000 to $80,000 in today’s dollars had at most a high school diploma, according to the analysis by The Times, which reviewed census returns for employed people ages 25 to 64. Only a quarter had a college degree. Today, the share of college graduates has risen to about 41 percent, while just under 31 percent have completed no more than high school.
“The days when a very, very substantial share of the work force would be able to make good middle-class incomes from jobs that did not require post-high school training are just not the case anymore,” said Francine D. Blau, an economics professor at Cornell University.
Men still hold most of the top jobs in the economy, including seven out of 10 jobs that pay over $80,000 a year. But women are rapidly moving up the ranks. Women hold 44 percent of middle-income jobs, compared with about a quarter 30 years ago.
These trends may not hold forever. Though educational attainment continues to rise for women, their progress in the workplace — in terms of both wages and jobs — has slowed significantly. Tighter controls on the cost of health care could weaken the job growth and pay raises helping support the new American middle. And while the industry is largely immune to foreign competition, it may be affected by advances in labor-saving technology.
Even as more women get ahead, many men are struggling to grab a handhold into higher-paying jobs. After her husband was laid off from a string of auto mechanic jobs, Donna Colbey, 53, urged him to switch careers and become a radiology technician.
It was a job Ms. Colbey knew would offer a good salary and require only two years of training. She had taken the same route, which eventually led her to a nursing career at a Washington hospital.
He enrolled in the courses but dropped out after a few months.
“He got tripped up over the math and didn’t go back,” said Ms. Colbey, who regularly picks up extra shifts to support her family.
A Relentless Pursuit
Far more is expected of nurses now than even two decades ago. Medical advances have kept patients alive longer, meaning many are sicker with more complex illnesses than in the past. Nurses must master technology that helps both treat and track patients, and they are called on to coordinate not just with doctors but also social workers and physical therapists.
At St. Mary’s Medical Center, Ms. Waugh, in her navy scrubs, fed potassium on a recent day into the vein of one woman with a broken hip who was on the cancer floor because of a lack of beds. She gave anti-nausea medicine to a moaning young man with liver cancer in the midst of chemotherapy and prepared pills for a half-dozen other patients, documenting it all on a computer.
An outpatient arrived for his regular blood-drawing and, squatting alongside him in a waiting room, Ms. Waugh unbuttoned his shirt and collected blood from an access port in his chest.
Ms. Waugh’s pursuit of learning to advance her career has been relentless. By her own count, she has been out of school for no longer than two years since kindergarten.
All that education has come with a cost. The couple has amassed about $50,000 in student debt. Ms. Waugh would like to send her children to a better school, but the $10,000 annual tuition that would require is out of reach. “I can’t save for their college and send them to private school,” she said.
To her husband’s co-workers who are raising families on pipe fitters’ salaries, the Waugh family is rich. Ms. Waugh’s purchase of a new Toyota S.U.V. raised eyebrows around the plant.
“We’re not wealthy,” Mr. Waugh said, “but we’re not poor.”
It hasn’t been easy getting to this point. As she made the rounds at the hospital, Ms. Waugh explained how her family was set back in 2008 after Collin was born. She stayed home for one year with the boy, who had digestive problems and required expensive formula. Living on just Mr. Waugh’s salary, they ran through their savings and they accumulated credit card debt that they are still paying off.
“That was a horrible financial situation,” Ms. Waugh said.
But later this year, when her classes and other course work are finished, Ms. Waugh will qualify as a nurse practitioner, a job that she expects will allow her to earn at least 50 percent more than her current salary. And she will be prepared, she believes, for almost anything to come.
“I knew if I was a nurse I could be self-sufficient,” she said, “and wouldn’t have to rely on anyone to take care of me.”
It’s something each of the nation’s 3.1 million RNs understands intimately: Being a nurse is intense. The hospitals and clinics where they work are often stressful. And patient care and healthcare systems have never been more complex.
Nationally, nurse turnover stands at 20 percent, but nearly 40 percent of nurses are ready to leave their job after a single year. About 14 percent leave the field altogether, and the ‘working wounded’ that remain are at best demoralized and at worst error-prone. And dealing with RN turnover is among the biggest, costliest burdens in healthcare today.
It’s why University of Virginia School of Nursing’s Compassionate Care Initiative has sponsored a new Public Radio documentary series – Resilient Nurses, now available online – which will be heard on many public radio stations starting this month and also on Sunday Feb. 22 on the NPR Channel (#122) of SiriusXM satellite radio at 4pm ET / 1pm PT.
Hosted by award-winning documentary producer David Freudberg of Humankind, the program takes a no-holds-barred look at what ails American RNs: the stress, the exhaustion, and the pressured environments that often lead to their burnout.
But beyond sourcing RNs’ biggest challenges, Freudberg offers a promising glimpse into the growing number of nurses hoping to improve their lot by harnessing well-being through resilience. Freudberg also chronicles the growing movement of resilience at a handful of American clinics and hospitals where administrators realize the very real financial and personal stake they have in helping their nurses effectively handle stress.
And the stories are inspiring. Sharing the voices of these powerful, real nurses may be an important step in healing the profession’s broken hearts, strengthening American RNs’ care and practice through a practitioner-centered approach to well-being.
The Resilient Nurses audio podcast is now available online. Editors and bloggers may download and publish graphics and a brief program description from http://www.humanmedia.org/nurse/resources.php.
We hope the program will inspire nurses, nursing professors, nursing students and others in healthcare to begin their own resilient practices.
Christine Phelan Kueter, writer
Source: U.Va. School of Nursing
By PAM BELLUCK
Conventional wisdom has it that hot flashes, which afflict up to 80 percent of middle-aged women, usually persist for just a few years. But hot flashes can continue for as long as 14 years, and the earlier they begin the longer a woman is likely to suffer, a study published on Monday in JAMA Internal Medicine found.
In a racially, ethnically and geographically diverse group of 1,449 women with frequent hot flashes or night sweats — the largest study to date — the median length of time women endured symptoms was 7.4 years. So while half of the women were affected for less than that time, half had symptoms longer — some for 14 years, researchers reported.
“It’s miserable, I’ll tell you what,” said Sharon Brown, 57, of Winston-Salem, N.C., who has endured hot flashes for six years. At her job at a tax and accounting office, she has had to stop wearing silk.
Mary Hairston found that acupuncture helped with her hot flashes. CreditKaren Tam for The New York Times
Over all, black and Hispanic women experienced hot flashes for significantly longer periods than white or Asian women. And in a particularly unfair hormonal twist, the researchers found that the earlier hot flashes started, the longer they were likely to continue.
Among women who got hot flashes before they stopped menstruating, the hot flashes were likely to continue for years after menopause, longer than for women whose symptoms began only when their periods had stopped.
“That having symptoms earlier in the transition bodes ill for your symptoms during menopause — that part is certainly new to me,” said Dr. C. Neill Epperson, director of the University of Pennsylvania’s Center for Women’s Behavioral Wellness, who was not involved in the study. Perhaps, she and others suggested, early birds are more biologically sensitive to hormonal changes.
And many women fall into the early bird category. In this study, only a fifth of cases started after menopause. One in eight women began getting hot flashes while still having regular periods. For two-thirds of women, they began in perimenopause, when periods play hide and seek but have not completely disappeared.
In numerical terms, women who started getting hot flashes when they were still having regular periods or were in early perimenopause experienced symptoms for a median of 11.8 years. About nine of those years occurred after menopause, nearly three times the median of 3.4 years for women whose hot flashes did not start until their periods stopped.
“If you don’t have hot flashes until you’ve stopped menses, then you won’t have them as long,” said Nancy Avis, a professor of social sciences and health policy at Wake Forest Baptist Medical Center and the study’s first author. “If you start later, it’s a shorter total duration and it’s shorter from the last period on.”
Hot flashes, which can seize women many times a day and night — slathering them in sweat, flushing their faces — are linked to drops in estrogen and appear to be regulated by the hypothalamus in the brain. Studies have found that women with hot flash symptoms also face increased risk of cardiovascular problems and bone loss.
Researchers followed the women in the study, who came from seven American cities, from 1996 to 2013. All of them met the researchers’ definition for having frequent symptoms: hot flashes or night sweats at least six days in the previous two weeks.
None had had a hysterectomy or both ovaries removed, and none were on hormone therapy. (If they started taking hormone therapy during the study period, their data stopped being included, Dr. Avis said.)
Although some smaller studies have also found that symptoms can last many years, the new research drew praise from experts because, among other things, it included a larger and much more diverse group of women. One-third of them were African-Americans in Pittsburgh, Boston, Chicago and Ypsilanti, Mich. It also included women of Japanese descent in Los Angeles; women of Chinese descent in Oakland, Calif.; and Hispanic women in Newark — about 100 in each group.
“It’s such a real-world study of women we are seeing day in and day out,” said Dr. Risa Kagan, an obstetrician-gynecologist at the University of California, San Francisco, and the Sutter East Bay Medical Foundation in Berkeley. “There is no other study like this.”
Researchers found significant differences between ethnic groups. African-Americans reported the longest-lasting symptoms, continuing for a median of 10.1 years — twice the median duration of Asian women’s symptoms. The median for Hispanic women was 8.9 years; for non-Hispanic whites, 6.5 years.
Reasons for ethnic differences are unclear. “It could be genetic, diet, reproductive factors, how many children women have,” Dr. Avis said.
The study also found that women with longer-lasting symptoms tended to have less education, greater perceived stress, and more depression and anxiety.
“I’m not at all suggesting that hot flashes are manifestations of depression, but they’re both brain-related phenomena, and depression is also more common in the same groups,” said Dr. Andrew Kaunitz, an obstetrician-gynecologist at the University of Florida who was not involved in the study. It is unclear if stress and emotional issues help cause hot flashes or result from them.
“Women with more stress in their lives may be more aware of their symptoms and perceive them to be more bothersome,” said Dr. JoAnn E. Manson, chief of preventive medicine at the Harvard-affiliated Brigham and Women’s Hospital and an author of a commentary accompanying the study. “But also having significant night sweats that interrupt sleep can lead to stress.”
Dr. Manson said the new study should help women and doctors anticipate that symptoms may continue longer, and might suggest that some women try different approaches at different times.
Women who are still menstruating, she said, “can become pregnant,” so low-dose contraceptives, which also tame hot flashes, might be recommended until menopause. Hormone therapy might then be prescribed for several years, she said.
But hormone therapy has been linked to increased risk of breast cancer and heart disease for some women. Effective non-hormonal therapies also exist, experts said, including low-dose antidepressants.
Dr. Manson, a past president of the North American Menopause Society, has helped the society develop a free app, MenoPro, to assist women deal with hot flashes, starting with nonmedical approaches like lowering the thermostat and cutting back on spicy foods, caffeine and alcohol.
Ms. Brown and Mary Hairston, 53, tried acupuncture in another study by Dr. Avis and colleagues, and found it helped. Before that, Ms. Hairston said, “every night I would just wake up, dripping wet.”
Now, when she starts sweating at the Italian restaurant where she waitresses, “I go stand in the cooler,” she said. “I used to get cold all the time and I would say I couldn’t wait to have hot flashes. Well, I got over that real quick.”
Scientists have discovered a highly aggressive new strain of HIV in Cuba that develops into full-blown AIDS three times faster than more common strains of the virus. This finding could have serious public health implications for efforts to contain and reduce incidences of the virus worldwide.
Researchers at the University of Leuven in Belgium say the HIV strain CRF19 can progress to full blown AIDS within two to three years of exposure to virus. Typically, HIV takes approximately 10 years to develop into AIDS. Patients with CRF19 may start getting sick before they even know they've been infected, which ultimately means there's a significantly shorter time span to stop the disease's progression.
The scientists began studying the cases in Cuba when reports began coming in that a growing number of HIV-infected patients were developing AIDS just three years after diagnosis with the virus. The findings of their study were published in the journal EBioMedicine.
Having unprotected sex with multiple partners can expose a person to numerous strains of the HIV virus. Research has found that when this occurs, the different strains can combine and form a new variant of the virus.
When HIV first enters the human body it latches on to anchor points of a certain protein, known as CCR5 on the cell membranes, which then allows it to enter human cells. Eventually the virus then latches onto another protein of the cell membrane, known as CXCR4. This marks the point when asymptomatic HIV becomes AIDS. In CRF19, the virus makes this move much sooner.
For the study, the researchers analyzed blood samples of 73 recently infected patients. Among the group, 52 already had full-blown AIDS, while the remaining 21 were HIV-positive but the virus had not yet progressed. The researchers compared their findings to blood samples of 22 AIDS patients who had more common strains of the virus.
The researchers found that patients with CRF19 had higher levels of the virus in their blood compared with those who had more common strains.
They also had higher levels of the immune response molecules known as RANTES, which bond to CCR5 proteins in early stages of the virus. The abnormally high level of RANTES in patients infected with the new strain indicates that the virus runs out of CCR5 anchor points much earlier and moves directly to CXCR4 anchor points.
Thanks to advances in medical treatment and the development of highly effective antiretroviral drugs, HIV/AIDS is no longer a death sentence. But the researchers caution that patients with the new strain of the virus are more likely to be diagnosed when they already have full-blown AIDS and when damage from the disease has taken a toll.
The researchers suspect that this aggressive form of HIV occurs when fragments of other subsets of the virus cling to each other through an enzyme that makes the virus more powerful and easily replicated in the body.
There are currently 35 million people worldwide living with HIV/AIDS, according to the most recent data from the World Health Organization. Scientists have identified more than 60 different strains of the HIV 1 virus, with each type typically found predominantly in a specific region of the world.
Far from offering patients pennies for their thoughts, mental health therapists often end up billing them hundreds of dollars per month.
The cost is a growing burden as depression among US adolescents and adults rises. The US is suffering a mental health crisis, with a San Diego State University study in October finding that one in 10 Americans is depressed – and more report symptoms of depression.
More Americans are seeking help, and that help can come at a financial sacrifice of thousands of dollars a year. Aside from the cost of often-weekly visits to psychologists – which may or may not be defrayed by insurance – there can be additional costs for psychiatrists and any medicine they prescribe.
The cost of therapy is especially acute for young Americans, many of whom are underemployed and burdened with college debt. This year, a record number of college freshmen reported being depressed. And while many campuses provide free mental health care, affordable help is often harder to find after students leave school.
The Guardian interviewed seven young professionals about their experiences to find out how young Americans manage to pay for therapy – and if they think it’s worth it. To protect their identities, we have kept their surnames anonymous.
Click on the titles below to read their stories:
– AK, 27
– Matt, 23
– JE, 29
– Eve, 33
- John, 27
– Alex, 27
By MICHAEL TOMSIC
In Medical Park Hospital in Winston-Salem, N.C., Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer gently jokes with her. When Koons says she's itchy under her cast, Cammer warns, "Do not stick anything down there to scratch it!" Koons smiles and says, "I know."
Koons tells me Cammer's kind attention and enthusiasm for nursing has helped make the hospital stay more comfortable.
"They've been really nice, very efficient, gave me plenty of blankets because it's really cold in this place," Koons says. Koons and her stepfather, Raymond Zwack agree they'd give Medical Park a perfect 10 on the satisfaction scale.
My poll of the family is informal, but Medicare's been taking actual surveys of patient satisfaction, and hospitals are paying strict attention. The Affordable Care Act ties a portion of the payments Medicare makes to hospitals to how patients rate the facilities.
Medical Park, for example, recently received a $22,000 bonus from Medicare in part because of its sterling results on patient satisfaction surveys.
Novant Health is Medical Park's parent company, and none of its dozen or so other hospitals even come close to rating that high on patient satisfaction. Figuring out why Medical Park does so well is complicated.
First, says Scott Berger, a staff surgeon, this isn't your typical hospital.
"It kind of feels, almost like a mom-and-pop shop," he says.
Medical Park is really small, only two floors. Doctors just do surgeries, like fixing shoulders and removing prostates, and most of their patients have insurance.
Another key is that no one at Medical Park was rushed to the hospital in an ambulance, or waited a long time in the emergency room. In fact, the hospital doesn't even have an emergency room.
The hospital doesn't tend to do emergency surgeries, says Chief Operating Officer Chad Setliff. These procedures are all elective, scheduled in advance. "So they're choosing to come here," he says. "They're choosing their physician."
These are the built-in advantages that small, specialty hospitals have in terms of patient satisfaction, says Chas Roades, chief research officer with Advisory Board Company, a global health care consulting firm.
"A lot of these metrics that the hospitals are measured on, the game is sort of rigged against [large hospitals]," Roades says.
This is the third year hospitals can get bonuses or pay cuts from Medicare (partly determined by those scores) that can add up to hundreds of thousands of dollars.
More typical hospitals that handle many more patients – often massive, noisy, hectic places – are more likely to get penalized, Roades says.
"In particular, the big teaching hospitals, urban trauma centers — those kind of facilities don't tend to do as well in patient satisfaction," he says. Not only are they busy and crowded, but they have many more caregivers interacting with each patient.
Still, Roades says, although patient surveys aren't perfect, they are fair.
"In any other part of the economy," he points out, "if you and I were getting bad service somewhere – if we weren't happy with our auto mechanic or we weren't happy with where we went to get our haircut – we'd go somewhere else." In health care, though, patients rarely have that choice. So Roades thinks the evaluation of any hospital's quality should include a measurement of what patients think.
Medical Park executives say there are ways big hospitals can seem smaller — and raise their scores. Sometimes it starts with communication – long before the patient shows up for treatment.
On my recent visit, Gennie Tedde, a nurse at Medical Park, is giving Jeremy Silkstone an idea of what to expect after his scheduled surgery – which is still a week or two away. The hospital sees these conversations as a chance to connect with patients, allay fears, and prepare them for what can be a painful process.
"It's very important that you have realistic expectations about pain after surgery," Tedde explains to Silkstone. "It's realistic to expect some versus none."
Medical Park now handles this part of surgery prep for some of the bigger hospitals in its network. Silkstone, for example, will have surgery at the huge hospital right across the street — Forsyth Medical Center.
Carol Smith, the director of Medical Park's nursing staff, says that after she and her colleagues took over these pre-surgical briefings, "Forsyth's outpatient surgical scores increased by 10 percent."
But some doctors and patients who have been to both hospitals agree that the smaller one is destined to have higher scores. It is just warmer and fuzzier, one patient says.
Up to a third of teens in the U.S. don’t get enough sleep each night, and the loss of shut-eye negatively impacts their grades, mental well-being and physical health. Biologically, adolescents need fewer hours of slumber than kids — but there’s a bigger reason for teens’ sleep loss, according to a new study in the journal Pediatrics.
Katherine Keyes, an assistant professor of epidemiology at Columbia University, looked at survey data from more than 270,000 eighth-, 10th- and 12th-grade students at 130 public and private schools across the country, gathered between 1991 and 2010. Each student was asked two questions about his or her sleep habits: how often they slept for at least seven hours a night, and how often they slept less than they should.
She found that over the 20-year study period, adolescents got less and less sleep. Part of that had to do with the fact that biologically, teens sleep less the older they get, but Keyes and her team also teased apart a period effect — meaning there were forces affecting all the students, at every age, that contributed to their sleeping fewer hours. This led to a marked drop in the average number of adolescents reporting at least seven hours of sleep nightly between 1991–1995 and 1996–2000.
That surprised Keyes, who expected to find sharper declines in sleep in more recent years with the proliferation of cell phones, tablets and social media. “I thought we would see decreases in sleep in more recent years, because so much has been written about teens being at risk with technologies that adversely affect the sleep health of this population,” she says. “But that’s not what we found.”
Instead, the rises in the mid-1990s corresponded with another widespread trend affecting most teens — the growth of childhood obesity. Obesity has been tied to health disturbances including sleep changes like sleep apnea, and “the decreases in sleep particularly in the 1990s across all ages corresponds to a time period when we also saw increases in pediatric obesity across all ages,” says Keyes. Since then, the sleep patterns haven’t worsened, but they haven’t improved either, which is concerning given the impact that long-term sleep disturbances can have on overall health.
Keyes also uncovered another worrying trend. Students in lower-income families and those belonging to racial and ethnic minorities were more likely to report getting fewer than seven hours of sleep regularly than white teens in higher-income households. But they also said they were getting enough sleep, revealing a failure of public-health messages to adequately inform all adolescent groups about how much sleep they need: about nine hours a night.
“When we first started looking at that data, I kept saying it had to be wrong,” says Keyes. “We were seeing completely opposite patterns. So our results show that health literacy around sleep are not only critical but that those messages are not adapted universally, especially not among higher-risk groups.”
1. First of all, “Why didn’t you just become a doctor? You’re too smart to be a nurse” is a rude thing to say.
Wall Street Journal Live
Submitted by SadiaK.
2. And no, people can’t just apply for nursing licenses before being educated and rigorously trained.
20th Century Fox
Submitted by jennah4377addc7.
3. Because nursing is not about wiping butts all day.
Shironosov / Getty Images/iStockphoto
Submitted by MariliseB
4. And nurses are not just there for their ability to “nurture” and “mother” patients; they’re there to use science and critical thinking to save lives.
Submitted by hellokitty914 and edwyer94.
5. Which is why it’s annoying when people think you’re always just following a doctor’s orders.
Getty Images/iStockphoto Dana Bartekoske
Submitted by oneloveyogi.
6. But you’d never know that from TV and movies, which almost never portray nurses accurately.
NBC / Getty Images
Submitted by angry penguin.
7. The reality is that doctors rely heavily on the knowledge and observations of nurses to make decisions about patient care.
Submitted by lexia49c9c42e3.
8. And it is often the nurses who make life and death decisions.
Submitted by andreae41060b2b6.
9. Nurses are actually more like a doctor-social worker-respiratory therapist-pharmacist-phlebotomist-physiotherapist-receptionist-X-ray technician-transporter-housekeeper-caregiver hybrid.
Submitted by oneloveyogi.
10. Which is probably why they’re not actually wearing sexy nurse outfits over lingerie with stilettos on their feet.
Submitted by sandrafromparis.
11. That might also be because a huge number of nurses are men.
Submitted by preciouskittenn.
12. Who, by the way, are not all gay.
Submitted by richardd31.
So now that all that’s cleared up, there are a few more things that nurses don’t want or need to hear.
13. When nurses are “just taking blood pressure” they are simultaneously assessing a dozen things about a patient’s condition.
Submitted by shannooney.
14. It doesn’t help anyone to say that all nurses do is put on Band-Aids when they’re actually catching potentially fatal mistakes made by doctors who don’t know the patient as well.
Submitted by betty.swiecka.
15. And when people assume a home health care nurse is there to give sponge baths and clean the house, it makes it harder for them to provide care.
Submitted by kimberly.riggs.18.
16. Saying nurses are so lucky to work three days a week ignores how much recovery time and rest is needed after long shifts and demanding work.
Submitted by lydia.maria.94.
17. Patients with the “I write your check” mentality that feel justified using nurses as servants make it harder for nurses to do their jobs.
Submitted by kelly.hilker.
18. That job is not being a personal drug dealer who is totally OK with going to jail just so a patient can get some OxyContin.
Submitted by nic0lie0lie and cheries4218b4a82.
19. So if you come in and say you’re allergic to every drug except Dilaudid and that you needs lots and lotsof Dilaudid, the nurse is onto you, buddy.
Submitted by cheries4218b4a82.
20. And when a nurse clearly knows the answer to your question and you say, “Can you ask the doctor?” you’re undermining their expertise and their profession.
Submitted by lalroma.
21. But the great thing about nurses is that they don’t actually care all that much about all these misconceptions.
Submitted by jonathanr49e5c50fe.
22. Because the thing they care more about than anything is saving your life.
Submitted by jonathanr49e5c50fe.
23. But for those of us who are annoyed on their behalves, we are just going to leave this here.
Submitted by ashleym45a8b720b.