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Health & Wellbeing

November 17, 2018 - November 23, 2018

Science Says: Sex and gender aren’t the same

The National Center for Transgender Equality, NCTE, and the Human Rights Campaign gather on Pennsylvania Avenue in front of the White House in Washington, Monday, Oct. 22, 2018, for a #WontBeErased rally. Anatomy at birth may prompt a check in the “male” or “female” box on the birth certificate - but to doctors and scientists, sex and gender aren’t always the same thing. (AP Photo/Carolyn Kaster)

Lauran Neergaard

Washington (AP) - Anatomy at birth may prompt a check in the “male” or “female” box on the birth certificate - but to doctors and scientists, sex and gender aren’t always the same thing.

The Trump administration purportedly is considering defining gender as determined by sex organs at birth, which if adopted could deny certain civil rights protections to an estimated 1.4 million transgender Americans.

But variation in gender identity is a normal part of human diversity, the American Academy of Pediatrics, or AAP, stresses in a new policy that outlines how to provide supportive medical care for transgender youth.

Here are some questions and answers about what can be sometimes blurry lines.

Q: Aren’t sex and gender interchangeable terms?

A: Sex typically refers to anatomy while “gender goes beyond biology,” says Dr. Jason Rafferty, a pediatrician and child psychiatrist at Hasbro Children’s Hospital in Rhode Island, and lead author of the AAP’s transgender policy.

Gender identity is more an inner sense of being male, female or somewhere in between - regardless of physical anatomy, he explained. It may be influenced by genetics and other factors, but it’s more about the brain than the sex organs.

And transgender is a term accepted across science and medical groups to mean people whose gender identity doesn’t match what Rafferty calls their “sex assigned at birth.”

Q: How early can people tell if they’re transgender?

A: It’s normal for children to explore in ways that ignore stereotypes of masculinity and femininity. Rafferty says it’s whether those feelings and actions remain consistent over time that tells. Sometimes that happens at a young age, while for others it may be adolescence or beyond.

Regardless, the pediatricians’ policy calls for “gender-affirmative” care so that children have a safe, nonjudgmental and supportive avenue to explore their gender questions.

Q: What kind of care might they need?

A: Transgender people of all ages are more likely to be bullied and stigmatized, which can spur anxiety and depression and put them at increased risk for suicide attempts.

For children, medicine to suppress puberty may be considered, to buy time as the youth grapples with questions of gender identity.

Q: Can’t a genetic test settle if someone’s male or female?

A: “It’s not like we’re going to find a magic transgender gene,” Rafferty says, noting that a mix of genes, chemicals and other factors contribute but is not well understood.

Generally, people are born with two sex chromosomes that determine anatomical sex - XY for males and XX for females.

But even here there are exceptions that would confound any either-or political definition. People who are “intersex” are born with a mix of female and male anatomy, internally and externally. Sometimes they have an unusual chromosome combination, such as men who harbor an extra X or women who physically appear female but carry a Y chromosome. This is different than being transgender.

More deaths seen for less invasive cervical cancer surgery

Carla K. Johnson

New evidence about a cancer operation in women finds a higher death rate for the less invasive version, challenging standard practice and the “less is more” approach to treating cervical cancer.

The unexpected findings are prompting changes at some hospitals that perform radical hysterectomies for early-stage disease.

The more rigorous of the two studies was conducted at more than 30 sites in a dozen countries. It found women who had the less invasive surgery were four times more likely to see their cancer return compared to women who had traditional surgery. Death from cervical cancer occurred in 14 of 319 patients who had minimally invasive surgery and 2 of 312 patients who had open surgery.

Results were published online Wednesday by the  New England Journal of Medicine.

Radical hysterectomy is standard treatment for women with early-stage cervical cancer. Rates are declining because of widespread screening. The number of operations has fallen, too, to several thousand a year in the United States. Some women with early-stage cervical cancer are choosing fertility-sparing techniques, treatments not included in the new research.

In both studies, researchers compared two methods for radical hysterectomy, an operation to remove the uterus, cervix and part of the vagina. The surgery costs around $9,000 to $12,000 with the minimally invasive version at the higher end.

Traditional surgery involves a cut in the lower abdomen. In a newer method, a surgeon makes small incisions for a camera and instruments. Patients recover faster, so laparoscopic surgery, which has been around for more than a decade, gained popularity despite a lack of rigorous long-term studies.

It’s not clear why it failed to measure up. Experts suspect there may be something about the tools or technique that spreads the cancer cells from the tumor to the abdominal cavity.

Some hospitals went back to traditional hysterectomy after the results were presented at a cancer meeting in March.

“We immediately as a department changed our practice and changed completely to the open approach,” said Dr. Pedro Ramirez of the University of Texas MD Anderson Cancer Center in Houston.

Ramirez led the more rigorous study, which randomly assigned 631 patients to one of two surgeries. After 4 years, the rate of those still living without disease was 86 percent with less invasive surgery and 96 percent with traditional surgery.

The experiment was halted early last year when the higher death and cancer recurrence rates showed up. The original plan was to enroll 740 patients in the study, which was funded in part by surgical device maker Medtronic.

The other study looked at 2,461 women with cervical cancer who had radical hysterectomies from 2010 through 2013. It found a 9.1 percent death rate after four years among women who got minimally invasive surgery compared to 5.3 percent for traditional surgery.

“We’re rethinking how we approach patients,” said study co-author Dr. Jason Wright of New York-Presbyterian Hospital. “There’s a lot of surprise around these findings.”

The research is “a great blow” to the technique and the findings are “alarming,” said Dr. Amanda Fader of Johns Hopkins Kimmel Cancer Center. She said Johns Hopkins Hospital in Baltimore has stopped doing less invasive hysterectomies for cervical cancer until there is more data.

While some patients with small tumors might do as well with minimally invasive surgery, “surgeons should proceed cautiously” and discuss the new information with patients, Fader wrote in an accompanying editorial.

November 10, 2018 - November 16, 2018

At many hospitals worldwide, you don’t pay, you can’t leave

Detained patients lie on beds in the Kenyatta National Hospital in Nairobi, Kenya on Monday, Aug. 6, 2018. At east Africa’s biggest medical institution, and at an astonishing number of other hospitals around the world, if you don’t pay up, you don’t go home. (AP Photo/Desmond Tiro)

Maria Cheng

Nairobi, Kenya (AP) - Doctors at Nairobi’s Kenyatta National Hospital have told Robert Wanyonyi there’s nothing more they can do for him. Yet more than a year after he first arrived, shot and paralyzed in a robbery, the ex-shopkeeper remains trapped in the hospital.

Because Wanyonyi cannot pay his bill of nearly 4 million Kenyan shillings ($39,570), administrators are refusing to let him leave his fourth-floor bed.

At Kenyatta National Hospital and at an astonishing number of hospitals around the world, if you don’t pay up, you don’t go home.

Around the world, many hospitals detain patients if they cannot pay their bills.

The hospitals often illegally detain patients long after they should be medically discharged, using armed guards, locked doors and even chains to hold those who have not settled their accounts. Even death does not guarantee release: Kenyan hospitals and morgues are holding hundreds of bodies until families can pay their loved ones’ bills, government officials say.

An Associated Press investigation has found evidence of hospital imprisonments in more than 30 countries worldwide, according to hospital records, patient lists and interviews with dozens of doctors, nurses, health academics, patients and administrators. The detentions were found in countries including the Philippines, India, China, Thailand, Lithuania, Bulgaria, Bolivia and Iran. Of more than 20 hospitals visited by the AP in Congo, only one did not detain patients.

“What’s striking about this issue is that the more we look for this, the more we find it,” said Dr. Ashish Jha, director of the Harvard Global Health Institute. “It’s probably hundreds of thousands, if not millions of people, that this affects worldwide.”

During several August visits to Kenyatta National Hospital - a major medical institution designated a Center of Excellence by the U.S. Centers for Disease Control and Prevention - the AP witnessed armed guards in military fatigues standing watch over patients. Detainees slept on bedsheets on the floor in cordoned-off rooms. Guards prevented one worried father from seeing his detained toddler.

Kenya’s ministry of health and Kenyatta canceled several scheduled interviews with the AP and declined to respond to repeated requests for comment.

Health experts decry hospital imprisonment as a human rights violation. Yet the United Nations, U.S. and international health agencies, donors and charities have all remained silent while pumping billions of dollars into these countries to support their splintered health systems or to fight outbreaks of diseases including AIDS and malaria.

“People know patients are being held prisoner, but they probably think they have bigger battles in public health to fight, so they just have to let this go,” said Sophie Harman, a global health expert at Queen Mary University of London.

Hospitals often acknowledge detaining patients isn’t profitable, but many say it can sometimes result in a partial payment and serves as a deterrent.

Festus Njuguna, an oncologist at the Moi Teaching and Referral Hospital in Eldoret, about 300 kilometres northwest of Nairobi, said the institution regularly detains children with cancer who have finished their treatment, but whose parents cannot pay.

“It’s not a very good feeling for the doctors and nurses who have treated these patients, to see them kept like this,” Njuguna said.

Still, many officials openly defend the practice.

“We can’t just let people leave if they don’t pay,” said Leedy Nyembo-Mugalu, administrator of Congo’s Katuba Reference Hospital. He said holding patients wasn’t an issue of human rights, but simply a way to conduct business: “No one ever comes back to pay their bill a month or two later.”

Global health agencies and companies that operate where patients are held hostage often have very little to say about it.

The CDC provides about $1.5 million every year to Kenyatta National Hospital and Pumwani Maternity Hospital, helping to cover treatment costs for patients with HIV and tuberculosis, among other programs. The CDC declined to comment on whether it was aware that patients were regularly detained at the two hospitals or if it condones the practice.

Dr. Agnes Soucat of the World Health Organization said it does not support patient detentions, but has been unable to document where it happens. And while WHO has issued hundreds of health recommendations on issues from AIDS to Zika virus, the agency has never published any guidance advising countries not to imprison people in their hospitals.

Many Kenyan human rights advocates lament that hospitals continue to hold patients despite what was seen as a landmark judgment in 2015.

Back then, the High Court ruled that the detention of two women at Pumwani who couldn’t pay their delivery fees - Maimuna Omuya and Margaret Oliele - was “cruel, inhuman and degrading.” Omuya and her newborn were held for almost a month next to a flooded toilet while Oliele was handcuffed to her bed after trying to escape.

Earlier this month, the High Court ruled again that imprisoning patients “is not one of the acceptable avenues (for hospitals) to recover debt.”

Omuya said she is still psychologically scarred by her detention at Pumwani, especially after another recent run-in with a Nairobi hospital.

Several months ago, her youngest brother was treated for a suspected poisoning. When Omuya and her family were unable to pay the bill, the situation took a familiar but unwelcome turn: he was imprisoned. Her brother was only freed after his doctor intervened.

November 3, 2018 - November 9, 2018

Immunotherapy scores a first win against some breast cancers

This undated fluorescence-colored microscope image made available by the National Institutes of Health in September 2016 shows a culture of human breast cancer cells. For the first time, one of the new immunotherapy drugs has shown promise against breast cancer in a large study that combined it with chemotherapy to treat an aggressive form of the disease. (Ewa Krawczyk/National Cancer Institute via AP)

Marilynn Marchione, AP

For the first time, one of the new immunotherapy drugs has shown promise against breast cancer in a large study that combined it with chemotherapy to treat an aggressive form of the disease. But the benefit for most women was small, raising questions about whether the treatment is worth its high cost and side effects.

Results were discussed Saturday at a cancer conference in Munich and published by the <Italics> New England Journal of Medicine. <Italics>

Drugs called checkpoint inhibitors have transformed treatment of many types of cancer by removing a chemical brake that keeps the immune system from killing tumor cells. Their discovery recently earned scientists a Nobel Prize. Until now, though, they haven't proved valuable against breast cancer.

The new study tested one from Roche called Tecentriq plus chemo versus chemo alone in 902 women with advanced triple-negative breast cancer. About 15 percent of cases are this type - their growth is not fueled by the hormones estrogen or progesterone, or the gene that Herceptin targets, making them hard to treat.

Women in the study who received Tecentriq plus chemo went two months longer on average without their cancer worsening compared with those on chemo alone - a modest benefit. The combo did not significantly improve survival in an early look before long-term follow-up is complete.

Previous studies found that immunotherapies work best in patients with high levels of a protein that the drugs target, and the plan for the breast cancer study called for analyzing how women fared according to that factor if Tecentriq improved survival overall.

The drug failed that test, but researchers still looked at protein-level results and saw encouraging signs. Women with high levels who received the combo treatment lived roughly 25 months on average versus about 15 months for women given chemo alone.

That's a big difference, but it will take more time to see if there's a reliable way to predict benefit, said Dr. Jennifer Litton of the MD Anderson Cancer Center in Houston. She had no role in running the study but enrolled some patients in it, and oversees 14 others testing immunotherapies.

"We're really hopeful that we can identify a group of women who can get a much bigger and longer response," she said.

Another breast cancer specialist with no role in the study, Dr. Michael Hassett at Dana-Farber Cancer Institute in Boston, said he felt "cautious excitement" that immunotherapy may prove helpful for certain breast cancer patients.

Side effects need a close look, both doctors said. Nearly all study participants had typical chemo side effects such as nausea or low blood cell counts, but serious ones were more common with the combo treatment and twice as many women on it stopped treatment for that reason.

Three of the six deaths from side effects in the combo group were blamed on the treatment itself; only one of three such deaths in the chemo group was.

Cost is another concern. Tecentriq is $12,500 a month. The chemo in this study was Celgene's Abraxane, which costs about $3,000 per dose plus doctor fees for the IV treatments. Older chemo drugs cost less but require patients to use a steroid to prevent allergic reactions that might interfere with the immunotherapy. Abraxane was chosen because it avoids the need for a steroid, said one study leader, Dr. Sylvia Adams of NYU Langone Health.

The study was sponsored by Roche and many study leaders consult or work for the company or own stock in it.

EU drug agency urges approval for dengue vaccine

London (AP) - Europe's drug regulator has recommended approving the first vaccine for dengue despite concerns about the vaccine's wide use and a lawsuit in the Philippines alleging that it was linked to three deaths.

The European Medicines Agency said last Friday it had adopted a "positive opinion" of French pharmaceutical company Sanofi's Dengvaxia. The vaccine is the world's first against dengue, which sickens about 96 million people annually.

The mosquito-spread virus is found in tropical and sub-tropical climates across Latin and South America, Asia, Africa and elsewhere. It produces a flu-like disease that can cause joint pain, nausea, vomiting and a rash. In severe cases, dengue can result in breathing problems, hemorrhaging and organ failure.

There is no specific treatment for dengue and there are no other licensed vaccines on the market.

Earlier this year, the World Health Organization said the vaccine needs to be dealt with "in a much safer way" and should be given mainly to people who had dengue before. The vaccine is licensed for use in about 20 countries.

The U.N. health agency said there were "significant obstacles" in using the vaccine and that a rapid test should be developed to determine if people had previously been infected with dengue.

Sanofi previously warned that people who had never been sickened by dengue were at risk of more serious disease after receiving the vaccine. The company said it expected to take a 100 million-euro loss based on that news.

The Philippines was the first country to introduce a national dengue immunization program - which it halted after Sanofi's announcement last year. The government also demanded a refund of more than 3 billion pesos ($59 million) from Sanofi. In February, the Philippines said the vaccine was potentially linked to the deaths of three people: all of them died of dengue despite having been immunized against it.

The country imposed a symbolic fine of $2,000 on Sanofi and suspended the vaccine's approval, charging that the drugmaker broke rules on how the shot was registered and marketed.

HEADLINES [click on headline to view story]

Science Says: Sex and gender aren’t the same

More deaths seen for less invasive cervical cancer surgery

At many hospitals worldwide, you don’t pay, you can’t leave

Immunotherapy scores a first win against some breast cancers

EU drug agency urges approval for dengue vaccine