Ibuprofen linked to male infertility, study says

(CNN)Ibuprofen has a negative impact on the testicles of young men, a study published Monday in the journal Proceedings of the National Academy of Sciences found. When taking ibuprofen in doses commonly used by athletes, a small sample of young men developed a hormonal condition that typically begins, if at all, during middle age. This condition is linked to reduced fertility.

Advil and Motrin are two brand names for ibuprofen, an over-the-counter pain reliever. CNN has contacted Pfizer and Johnson & Johnson, the makers of both brands, for comment.
The Consumer Healthcare Products Association, a trade group that represents manufacturers of over-the-counter medications and supplements, “supports and encourages continued research and promotes ongoing consumer education to help ensure safe use of OTC medicines,” said Mike Tringale, a spokesman for the association. “The safety and efficacy of active ingredients in these products has been well documented and supported by decades of scientific study and real-world use.”
    The new study is a continuation of research that began with pregnant women, explained Bernard Jégou, co-author and director of the Institute of Research in Environmental and Occupational Health in France.
    Jégou and a team of French and Danish researchers had been exploring the health effects when a mother-to-be took any one of three mild pain relievers found in medicine chests around the globe: aspirin, acetaminophen (also known as paracetamol and sold under the brand name Tylenol) and ibuprofen.
    Their early experiments, published in several papers, showed that when taken during pregnancy, all three of these mild medicines affected the testicles of male babies.

    Testicles and testosterone

    Testicles not only produce sperm, they secrete testosterone, the primary male sex hormone.
    All three drugs then are “anti-androgenic,” meaning they disrupt male hormones, explained David M. Kristensen, study co-author and a senior scientist in the Department of Neurology at Copenhagen University Hospital.
    The three drugs even increased the likelihood that male babies would be born with congenital malformations, Kristensen noted.
    Tringale noted that pregnant and nursing women should always ask a health professional before using medicines.
    Knowing this, “we wondered what would happen in the adult,” he said. They focused their investigation on ibuprofen, which had the strongest effects.
    A non-steroidal anti-inflammatory drug, ibuprofen is often taken by athletes, including Olympians and professional soccer players for example, before an event to prevent pain, Jégou said. Are there health consequences for the athletes who routinely use this NSAID?
    The research team recruited 31 male volunteers between the ages of 18 and 35. Of these, 14 were given a daily dosage of ibuprofen that many professional and amateur athletes take: 600 milligrams twice a day, explained Jégou. (This 1200-mg-per-day dose is the maximum limit as directed by the labels of generic ibuprofen products.) The remaining 17 volunteers were given a placebo.
    For the men taking ibuprofen, within 14 days, their luteinizing hormones — which are secreted by the pituitary gland and stimulate the testicles to produce testosterone — became coordinated with the level of ibuprofen circulating in their blood. At the same time, the ratio of testosterone to luteinizing hormones decreased, a sign of dysfunctional testicles.
    This hormonal imbalance produced compensated hypogonadism, a condition associated with impaired fertility, depression and increased risk for cardiovascular events, including heart failure and stroke.
    For the small group of young study participants who used ibuprofen for only a short time, “it is sure that these effects are reversible,” Jégou said. However, it’s unknown whether the health effects of long-term ibuprofen use are reversible, he said.
    After this randomized, controlled clinical trial, the research team experimented with “little bits of human testes” provided by organ donors and then conducted test tube experiments on the endocrine cells, called Leydig and Sertoli cells, which produce testosterone, explained Jégou.
    The point was to articulate “in vivo, ex vivo and in vitro” — in the living body, outside the living body and in the test tube — that ibuprofen has a direct effect on the testicles and so testosterone.
    “We wanted to understand what happened after exposure (to ibuprofen) going from the global human physiology over to the specific organ (the testis) down to the endocrine cells producing testosterone,” Kristensen said.
    More than idle curiosity prompted such an extensive investigation.

    Questions around male fertility

    The World Health Organization estimates that one in every four couples of reproductive age in developing countries experiences childlessness despite five years of attempting pregnancy.
    A separate study estimated that more than 45 million couples, or about 15% of all couples worldwide, were infertile in 2010, while another unrelated study suggested that men were solely responsible for up to 30% and contribute up to 50% of cases overall.
    Meanwhile, a recent analysis published in the journal Human Reproduction Update found that sperm counts of men in North America, Europe, Australia and New Zealand are plunging. Researchers recorded a 52% decline in sperm concentration and a 59% decline in total sperm count over a nearly 40-year period ending in 2011.
    Erma Z. Drobnis, an associate professional practice professor of reproductive medicine and fertility at the University of Missouri, Columbia, noted that most drugs are not evaluated for their effects on human male fertility before marketing. Drobnis, who was not involved in the new study, has done extensive research into sperm biology and fertility.
    “There is evidence that some medications are particularly harmful to the male reproductive system, including testosterone, opioids, antidepressants, antipsychotics, immune modulators and even the over-the-counter antacid cimetidine (Tagamet),” she said. “However, prescribing providers rarely mention these adverse effects with patients when prescribing these medications. 
    She believes the new study, though small, is “important” because ibuprofen is among the most commonly used medications.
    Though the new research indicates that ibuprofen disrupts the reproductive hormones in healthy young men, she thinks it’s possible there’s an even greater negative effect in men with low fertility. The other OTC drugs concerning for potential fathers are cimetidine and acetaminophen. She recommends that men who are planning to father a child avoid drugs for several months.
    “Larger clinical trials are warranted,” she said. “This is timely work that should raise awareness of medication effects on men and potentially their offspring.”
    Jégou agrees that more study is needed to answer many questions, including whether ibuprofen’s effects on male hormones are seen at low doses and whether long-term effects are reversible.

    See the latest news and share your comments with CNN Health on Facebook and Twitter.

    “But the alarm has been raised now,” he said. “if this serves to remind people that we are really dealing with medical drugs — not with things which are not dangerous — this would be a good thing.”
    “We need to remember that it is a pharmaceutical compound that helps a lot of people worldwide,” Kristensen said. He noted, though, that of the three mild analgesics examined, ibuprofen had “the broadest endocrine-disturbing properties identified so far in men.”

    Read more: http://www.cnn.com/2018/01/08/health/ibuprofen-male-fertility-study/index.html

    How an ‘ugly,’ unwanted weapon became the most popular rifle in America

    (CNN)Larry Hyatt had never seen such a frenzy.

    The lines at Hyatt Guns, his shop in Charlotte, North Carolina, snaked out the door. The deep, green-walled warehouse bills itself as the largest gun shop in America, but even then Hyatt had to stretch to meet the demand.
    At one point, he dispatched 37 salespeople to man the cash registers. He put up velvet ropes and hired a police officer. He even put a hot dog stand outside.
    It was just after the Sandy Hook massacre — and customers were lined up to buy AR-15 semi-automatic rifles, like the one the shooter Adam Lanza used.
    Mass shootings, rather than temper gun sales, only feed the hunger.

    That the boom in business happened after one of the most heinous mass shootings in American history was no coincidence. Mass shootings, rather than temper gun sales, only feed the hunger.
    And AR-15 style rifles have become a favorite among mass shooters, used in some of the most notorious and deadly mass killings in recent history: Aurora, Vegas, Texas, San Bernardino.
    This is the story of how media hysteria and failed policy; industry pressures and consumer demand; blood and money helped turn an ugly, unwanted semi-automatic rifle into the most popular rifle in America.

    How a weapon of war was born

      History of the modern assault-style rifle

    The AR-15’s journey into the hands of gun enthusiasts and mass murderers alike started in the jungles of Vietnam. It was the 1960s, and the landscape of warfare had changed. In Vietnam, rather than clear-cut enemy lines, combatants were fighting in close combat in city streets and dense forests. Viet Cong guerillas and North Vietnamese soldiers carried AK-47s. The US Army needed its own answer.
    Enter the AR-15, developed for military use by Armalite, an arms company from which the gun takes its name (“AR” stands for “Armalite Rifle“).
    The rifle combined rapid fire with a lighter weight. It replaced higher-caliber bullets with lighter ammunition that made up in speed what it lacked in size.

    Rather than relying on marksmanship, the AR-15 used rapid fire. The lightweight rifle maximized its kill rate by raking enemy soldiers with high-velocity rounds. As the original designers explained, the speed of the impact causes the bullet to tumble after it penetrates tissue, creating catastrophic injuries.
    Armalite didn’t manage to sell the gun to the military. Faced with money woes, it instead sold the rights to Colt Industries in 1959.
    Colt was more successful in its efforts, and in 1962, Congress authorized an initial purchase of 8,500 AR-15s for testing. The fully automatic version–capable of being set to semi-automatic–was given a new name for military use: the M-16.
    It became the standard-issue rifle during the Vietnam War.

    How it was marketed to civilians

    Not long after it started selling M-16s to the military, Colt began marketing the semi-automatic AR-15 to civilians. The company gave it the gentler name of the “Sporter,” and described it as a hunting rifle.
    But the gun, designed for close, confusing combat, was not an immediate hit. In the eyes of many gun enthusiasts, the “black rifle” — as it was nicknamed — was ugly and expensive.
    “To its champions, the AR-15 was an embodiment of fresh thinking. Critics saw it as an ugly little toy,” wrote C.J. Chivers in his book, “The Gun.”
    In July 1981, the fan magazine Guns and Ammo waxed eloquent about the Sporter’s unappealing reputation.
    “Most shooters and veteran riflemen look down their noses at these steel-stamped rifles as remnants from an erector set. The turn-bolt aficionado looks with a great deal of disdain at anybody toting one of these space-age rifles with plastic stocks and fore-ends. The dyed-in-the-wool deer hunter watching his domain being infiltrated by these black and gray guns assumes that these ‘new generation’ hunters are merely fantasizing ‘war games’ and are playing ‘soldier.'”
    Instead, the gun was mainly sold to law enforcement and other narrower demographics — notably, “survivalists” who imagined they would one day face combat situations in an apocalyptic future, according to Tom Diaz, a gun expert and author of “Making a Killing: The Business of Guns in America.”

    How a mass shooting made it a celebrity

    On a dark day in 1989, the public awoke to the notion that civilians could own semi-automatic rifles.
    On January 17 of that year, a 24-year-old drifter wearing combat clothes and a flak jacket walked up to his old grade-school playground in Stockton, California, and pumped bullets on a crowd of children with his AK-47 rifle, a semi-automatic version that had been imported from China.
    Within minutes, Patrick Edward Purdy squeezed the trigger at least 106 times. He then aimed a pistol to his head and pulled the trigger one last time. Five children lay dead; 29 other children and one teacher were wounded.
    The massacre was so horrifying, Colt Industries, then the manufacturer of the competing AR-15, did something unfathomable today. It suspended civilian sales of the AR-15 for a year while the Bush administration weighed whether to ban the weapon.
    Before Stockton, most people didn’t even know you could buy those guns.
    Chris Bartocci, a former Colt’s employee and author of Black Rifle II

    Chris Bartocci, a former Colt employee and author of the book “Black Rifle II,’ says it was the first time many in the general public had heard about the availability of such weapons.
    “Before Stockton, most people didn’t even know you could buy those guns,” he said. The media coverage, he said, helped glamorize semi-automatic rifles to the buying public. “This stuff has been around forever; this is not new technology.”
    The term “AR-15” is now considered a style of rifle, rather than a specific brand of one.

    By 1990, Guns & Ammo reported that sales of the AR-15 were soaring, although that seems to have been a rather relative term. In 1990, Colt made only 36,000 Sporters for domestic use, according to the Hartford Courant.
    The patent on the AR-15 by then had expired, opening the door for several new competitors, which is why the term “AR-15” is now considered a style of rifle, rather than a specific brand of one.

    How a ban increased demand

    As the profile of the AR-15 rose, talk continued of banning “assault weapons,” a term used by lawmakers to denote certain types of semi-automatic firearms. President George H.W. Bush, a lifetime NRA member, proposed banning all magazines holding more than 15 rounds.
    In 1994, President Bill Clinton pushed the assault weapons ban through Congress with some bipartisan support. Presidents Reagan, Carter and Ford co-authored a letter to the House of Representatives expressing their support.

    “This is a matter of vital importance to the public safety,” it read. “We urge you to listen to the American public and to the law enforcement community and support a ban on the further manufacture of these weapons.”
    Hyatt, whose store was started by his father in 1959, recalled a surge in sales then, too.
    There’s something about human nature, he says. “You tell a man he can’t have something and suddenly he wants 12.”
    You tell a man he can’t have something and suddenly he wants 12.
    Larry Hyatt, owner of Hyatt Guns

    Ironically, the ban didn’t do much to deter the production of the now-generic AR-15.
    Clinton’s ban outlawed Colt’s AR-15 by name. But the ban didn’t cover versions of these weapons unless they had two of these purely cosmetic features: a folding stock, a bayonet mount, a “conspicuously protruding” pistol grip, a flash suppressor or a grenade launcher. Grenades aren’t even legal to own.


    of total rifles sold in 2016 were

    AR styles/modern sporting rifles.

    Source: National Shooting Sports Foundation

    “It makes no sense, banning something based on appearance,” said Bartocci. “It’s the same weapon; one just looks meaner.”
    Manufacturers quickly found a way to redesign around these constraints.
    In its August 2003 issue, while the ban was still in effect, Guns & Ammo ran a feature story titled “Stoner’s ‘Black Rifle’ Marches On,” subtitled “The basic AR platform has been refined, improved, upgraded, power-boosted and accurized.”
    Sales figures for the AR-15 aren’t made public. But as the ban was about to expire in 2004, the NRA told members “hundreds of thousands of AR-15s have been made and sold since the ban took effect.”
    In fact, the ban became a powerful tool for the NRA, both politically and for its promotion of gun manufacturers.

    Until the ban, sales of firearms had been fairly flat. In the eight years preceding the ban, gun makers produced an average of 1.1 million rifles a year, according to the Bureau of Alcohol, Tobacco, Firearms and Explosives. During the ban, production rose to 1.4 million a year.
    That increase is widely attributed to the growing popularity of semi-automatic rifles, now called “modern sporting rifles” by the industry and gun enthusiasts.

    How it became ‘king of the industry’

    Through a combination of tragedy, profit, fear, curiosity and mysterious human psychology, the AR-15 shed its early reputation as an ugly misfit and found a new place as a nimble, versatile fan favorite.
    Among sporting rifles, “AR-15 is the king of the industry, so to speak,” said Michael Weeks, owner of Georgia Gun Store, which boasts “the best selection of firearms in North Georgia.”
    Veterans returning from the wars in Iraq and Afghanistan were comfortable with the weapon. It’s also lightweight, adaptable, and relatively easy to maintain.

    More than

    15 million

    The number of AR-15s owned

    by Americans today

    Source: The National Rifle Association

    Owners can remodel the guns themselves, or they can construct one from scratch with their favorite features.
    “It’s everything you want,” said Bartocci, the “Black Rifle II” author. “You want a hunting rifle? It does it. You want a target rifle? It does it. You want a law-enforcement rifle? It does it.”
    The AR-15 is now the most popular sporting rifle in the U.S. According to the National Shooting Sports Foundation, AR-15 style rifles accounted for an estimated 61 percent of all US civilian rifle sales in 2016. The National Rifle Association reports that Americans own more than 15 million AR-15s today.
    As more AR-15 style rifles entered the market, the competition caused the price to drop. During the ban, Weeks said an AR-15 could have cost well over $1,000. But an AR-15 from his store costs as little as $400 today.

    How Obama’s election stoked sales

    By now the relationship between gun sales and anti-gun rhetoric was well-established. So after the assault-weapons ban became defunct in late 2004, rifle production numbers remained relatively flat.

    Then, in early 2009, President Barack Obama took office. Conservative gun owners feared a ban from Democrats in the White House and the Capitol, and the numbers went wild.
    According to the ATF, gun makers began cranking out 2.4 million rifles annually in Obama’s first term — a 52 percent increase from the previous four years of the Bush administration.
    In 2008, The Shooting Wire published a feature titled, “Industry Hanging on to a Single Category.”
    “For the past few weeks, it may be that we’ve given a false impression as to how well the firearms industry is really doing,” it read. “The net of all the numbers is that if you’re a company with a strong line of high-capacity pistols and AR-style rifles, you’re doing land office business. If you’re heavily dependent on hunting, you are hurting.”

    This illustrated a fundamental shift taking place among gun owners. Gun ownership has declined over the last decades, and many gun owners’ motivations have changed.
    “There are far fewer hunters now than there ever have been,” said Weeks.
    In 1999, a Pew survey asked gun owners why they owned a gun. Almost 50 percent said “hunting”, and 26 percent said “protection.” By 2017, those numbers had reversed — 67 percent said they had a gun for protection and only 38 percent said hunting.

    How history is repeating itself

    Five years ago this week, Sandy Hook devastated the nation. It was Stockton writ larger — including the threat of a new ban. The fear that had elevated gun sales during the Obama administration was now on the horizon, and so up again they went. In 2013, total rifle production exploded to nearly 4 million, according to the ATF.
    The ban never materialized. Despite strong public support for expanding background checks, President Obama failed to get even that legislation through Congress. The attack shattered the nation and raised cries for action. But the shooting that was supposed to change everything changed little.

    As gun sales kept climbing, so did the body count.
    • The shooter who killed 58 people and injured more than 500 in the Las Vegas massacre on October 1, 2017, used several AR-15 style rifles equipped with bump stocks to mimic fully-automatic rifles.
    The gun that had been created to mow down combatants in the Vietnam jungles was now a de facto calling card of some of the country’s most heinous mass shooters.

    When President Trump was elected in 2016, gun owners rejoiced and the president of the National Shooting Sports Foundation called him the “most pro-Second Amendment President in recent history.”
    So when the Las Vegas massacre happened, the deadliest shooting in modern American history, the frenzy wasn’t as great.
    The shooting that was supposed to change everything changed little.

    “When you have a president that says, ‘It’s not the gun, it’s mental illness,’ people are a lot calmer about it,” says Weeks, the Georgia gun shop owner.
    While the impact of the shooting is too recent to measure through production numbers, anecdotally, gun sales didn’t see as sharp a rise.
    But something else did: Bump stocks.
    Sellers said people who hadn’t heard of them before the Vegas shooting rushed in to get one — suspecting they would soon be banned.

    Read more: http://www.cnn.com/2017/12/14/health/ar15-rifle-history-trnd/index.html

    The embryo is just a year younger than the mother who birthed her

    (CNN)The longest known frozen human embryo to result in a successful birth was born last month in Tennessee.

    Emma Wren Gibson, delivered November 25 by Dr. Jeffrey Keenan, medical director of the National Embryo Donation Center, is the result of an embryo originally frozen on October 14, 1992.
    Emma’s parents, Tina and Benjamin Gibson of eastern Tennessee, admit feeling surprised when they were told the exact age of the embryo thawed March 13 by Carol Sommerfelt, embryology lab director at the National Embryo Donation Center.
      “Do you realize I’m only 25? This embryo and I could have been best friends,” Tina Gibson said.
      Today, Tina, now 26, explained to CNN, “I just wanted a baby. I don’t care if it’s a world record or not.”
      Sommerfelt said the birth is “pretty exciting considering how long the embryos had been frozen.” Previously, the oldest known frozen embryo that came to successful birth was 20 years old.
      Weighing 6 pounds 8 ounces and measuring 20 inches long, Emma is a healthy baby girl, and that’s the only thought on her parents’ minds.
      “We’re just so thankful and blessed. She’s a precious Christmas gift from the Lord,” Tina said. “We’re just so grateful.”
      Despite not sharing genes, Benjamin, 33, said that Emma feels completely like his own child. “As soon as she came out, I fell in love with her,” he said.
      Emma’s story begins long before the Gibsons “adopted” her (and four sibling embryos from the same egg donor). Created for in vitro fertilization by another, anonymous couple, the embryos had been left in storage so they could be used by someone unable or unwilling to conceive a child naturally.
      These are “snowbabies,” lingering in icy suspension, potential human lives waiting to be born.

      Infertility and fostering

      Seven years ago, the Gibsons married, refusing to allow a dark cloud to shadow their love. “My husband has cystic fibrosis, so infertility is common,” Tina said, adding that they had found peace with it. “We had decided that we were more than likely going to adopt, and we were fine with that.”
      Before trying to implant an embryo, they fostered several children and enjoyed doing so.
      During a break between fosters, they decided to take a week-long vacation. As they were dropping off their dog at her parents’ house, Tina’s father stopped them.
      “I saw something on the news today. It’s called embryo adoption, and they would implant an embryo in you, and you could carry a baby,” he told his daughter.
      “I was like, ‘Well, that’s nice, Dad, but we’re not interested. We’re knee-deep in foster care right now,’ ” Tina recalled with a laugh. “I kind of blew it off. I had no interest in it.”
      But during the eight-hour car trip, Tina could not stop thinking about her father’s words. “It was playing in my mind over and over and over,” she said. Hours into her journey, she turned to Benjamin and asked what he thought about “this embryo adoption.” He too had been thinking about it “the whole time.”
      Tina started researching on her phone, sharing information with Benjamin as he drove. “I knew everything about it before I got off that vacation,” she said. She knew, for instance, that the National Embryo Donation Center was based in Knoxville, Tennessee, and could facilitate a frozen embryo transfer.
      Still, she was not immediately ready. Weeks passed.
      “During August of last year, I just came home one day; I looked at Benjamin, and I said, ‘I think we need to submit an application for embryo adoption,’ ” she explained. “On a whim, we filled out an application and submitted that night.”

      ”It’s a world record!’

      By December, she was on medication to do a “mock transfer”: essentially a series of medical examinations to see whether her uterus would be physically capable of receiving an implanted embryo. In January, the tests were complete, and though Tina required a small procedure to remove a polyp from her uterus, she was eligible for implantation.
      Next, a home study was performed, said Mark Mellinger, marketing and development director for the National Embryo Donation Center. This part of the process, conducted by a partner organization run by a social worker, is “just the standard home study that mimics any home study that anybody would go through in a traditional adoption process.”
      Families who have been approved by the state generally pass the requirements set by the donation center. “Very rarely does a review find a red flag,” Mellinger said.
      Finally, the Gibsons were ready for the implantation procedure in March. But they had to choose an embryo, which required viewing donor “profiles” listing the basic genetic information about the genetic parents.”We literally had two weeks to go through 300 profiles,” Benjamin said.
      “It was overwhelming,” Tina said. “There was so many, and it’s like, how do you pick?”
      The couple started with one small detail just to “narrow it down in an easy way,” she said. Since she and Benjamin are physically small, they began by looking at profiles based on height and weight. “Then we started looking at some of the bigger things, like medical history.
      “Long story short, we picked our profile,” Tina said, but that embryo was not viable, so their second choice was used.
      Only when they “were fixing to go for the transfer” did her doctor and Sommerfelt explain “It’s a world record!”
      “I didn’t sign up for this,” Tina said, laughing.
      In fact, no one knows that it’s definitely a record.
      “Identifying the oldest known embryo is simply an impossibility,” said Dr. Zaher Merhi, director of IVF research and development at New Hope Fertility Center, which is not involved to the Gibson case. American companies are not required to report to the government the age of an embryo used, only the outcome of the pregnancy, so “nobody has these records.”
      Other experts, though, cited the study on a 20-year-old frozen embryo that came to successful birth.
      Sommerfelt said she had unthawed three “snowbabies,” all of them adopted from the same anonymous donor. Surprisingly, all three survived. Normally, there’s about a 75% survival rate when unthawing frozen embryos.
      Though Keenan transferred all three to Tina, only one implanted. This is normal, since successful implantation rate “normally runs about 25% to 30%,” she said.
      The transfer “worked out perfect,” Tina said. “It’s a miracle. First time.”
      Problems encountered during pregnancy were due to Tina having a short cervix, which could have prevented her from successfully carrying her baby. That did not happen, and just after Thanksgiving, Tina began 20 hours of labor. All the while, Emma’s heart beat normally.
      “So it all just fell into place,” said Tina. “It’s our new normal; it’s crazy to think about it.”

      Odds of success

      Dr. Jason Barritt, laboratory director and research scientist at the Southern California Reproductive Center, said that only about “15% to 20% of the time there are additional embryos” not used in IVF. Due to the high success rates of the IVF process, which has been scientifically explored in animals for more than half a century, fewer embryos are now created. Louise Brown, the first human resulting from an IVF procedure, was born in July 1978.
      “Usually, couples have leftover embryos because they have completed their families and no longer need additional embryos,” Barritt said. His center was not involved in the Gibson case. “They remain frozen until the patient asks for some other disposition.”
      Disposition options — what is done with the additional embryos — include simply leaving them cryopreserved in liquid nitrogen storage tanks, disposing of them in an appropriate way, donating them to research or training for the advancement of the field of reproductive medicine, or donating them to another couple.
      The final option is rare, Barritt said, “due to a variety of additional steps and guidelines that must be met,” such as infectious disease screening and meeting US Food and Drug Administration donor eligibility regulations, “and significant legal documentation that must be met.”
      Mellinger said the National Embryo Donation Center is a faith-based organization founded in 2003. “We say that our reason for existence is to protect the sanctity and dignity of the human embryo,” he said. “We are big advocates of embryo donation and embryo adoption.”
      If you want to donate an embryo, it will handle the details for free.
      “We will contact the fertility clinic where the embryos are stored, and they are happy to work with us,” Mellinger said. A special storage container is shipped, the fertility center places the embryos inside and sends it to the the donation center, and then the embryos are stored in the lab in Knoxville.
      “We will adopt out an embryo whenever,” he said. “Sometimes, embryos have been in storage for a few weeks, maybe a few months. Sometimes, it’s literally been decades.”
      The adopting couple pays all the fees, amounting to less than about $12,500 for a first try, according to Mellinger.
      Recalling the birth of her special daughter, Tina’s voice dissolves into tears.
      “We wanted to adopt, and I don’t know that that isn’t going to be in our future. We may still adopt,” she said. “This just ended up being the route that we took. I think that we would have been equally elated if were able to adopt. “

      See the latest news and share your comments with CNN Health on Facebook and Twitter.

      Asked whether they might try again with the remaining two embryos — Emma’s sisters or brothers — Tina said she absolutely would have said “yes” two months ago.
      “But after having natural childbirth, I’m like, ‘I’m never doing that again!’ ” she said. “But I’m sure in like a year, I’ll be like, ‘I want to try for another baby.’ “

      Read more: http://www.cnn.com/2017/12/19/health/snowbaby-oldest-embryo-bn/index.html

      Ten times more children and teens obese today than 40 years ago

      (CNN)The number of obese children and adolescents rose to 124 million in 2016 — more than 10 times higher than the 11 million classified as obese 40 years ago, in 1975.

      A further 213 million children and adolescents were overweight in 2016, finds a new study published Tuesday in the Lancet.
      Looking at the broader picture,this equated to roughly 5.6% of girls and 7.8% of boys being obese last year.
        Most countries within the Pacific Islands, including the Cook Islands and Nauru, had the highest rates globally, with more than 30% of their youth ages 5 to 19 estimated to be obese.
        The United States and some countries in the Caribbean, such as Puerto Rico, as well as the Middle East, including Kuwait and Qatar, came next with levels of obesity above 20% for the same age group, according to the new data, visualized by the NCD Risk Factor Collaboration.

        “Over the past four decades, obesity rates in children and adolescents have soared globally, and continue to do so in low- and middle-income countries,” said Majid Ezzati, professor of global environmental health at Imperial College London in the UK, who led the research.
        “More recently, they have plateaued in higher-income countries, although obesity levels remain unacceptably high,” he said.
        Over the same time period, the rise in obesity has particularly accelerated in East and South Asia.
        “We now have children who are gaining weight when they are 5 years old,” unlike children at the same age two generations ago, Ezzati told CNN.

          What is obesity?

        In the largest study of its kind, more than 1,000 researchers collaborated to analyze weight and height data for almost 130 million people, including more than 31 million people 5 to 19 years old, to identify obesity trends from 1975 to 2016.
        “Rates of child and adolescent obesity are accelerating in East, South and Southeast Asia, and continue to increase in other low and middle-income regions,” said James Bentham, a statistician at the University of Kent, who co-authored the paper.
        Obesity in adults is defined using a person’s body mass index, the ratio between weight and height. A BMI of 18.5 to 24.9 is classified as a healthy weight, 25 to 29.9 considered overweight and 30 and over obese. Cut-offs are lower among children and adolescents and vary based on age.
        “While average BMI among children and adolescents has recently plateaued in Europe and North America, this is not an excuse for complacency as more than one in five young people in the U,S. and one in 10 in the UK are obese,” he said.

        Greater risk as an adult

        Being obese as a child comes with a high likelihood of being obese as an adult and the many health consequences that come with it, including the increased risk of diabetes, cardiovascular disease and some cancers.
        The potential for these chronic conditions into adulthood also puts an increased burden on health systems — and financial constraints on individuals.
        “We are seeing very worrying trends with pediatricians who have children come in as young as 7 with type 2 diabetes,” said Temo Waqanivalu, programme officer for population-based prevention of non-communicable diseases at the World Health Organization. WHO co-led the research with Imperial College London.
        Type 2 diabetes is typically an adult-onset condition, he told CNN.

        Ongoing undernutrition

        The new research also revealed ongoing problems on the other end of the body mass spectrum — being underweight — with 192 million estimated to be moderately or severely underweight worldwide in 2016. In adults, being underweight is defined as a BMI under 18.5.
        Unlike the obesity trend, the number of children and adolescents who are underweight has been declining globally since 1975, the paper found, but numbers remain high.
        For example, in India and Pakistan, 50.1% and almost 41.6% of girls, respectively, were underweight in 2016 — down from 59.9% and 54% in 1975. Numbers were similar among boys in 2016, at 58.1% and 51%, respectively.

        Being underweight comes with its own health consequences among children and adolescents, including a greater risk of infectious disease and potential harm during pregnancy for adolescents and women old enough to have children.
        “We mustn’t forget that undernutrition remains a major global public health problem,” commented Dr. Frank Hu, professor of nutrition and epidemiology at the Harvard T.H. Chan School of Public Health in the United States. Hu was not involved in the research.
        “We’re experiencing this double burden of undernutrition and overnutrition at the same time,” Hu told CNN, adding that “this is nothing new.”
        When asked about the key findings from this research, Ezzati highlights three points that need the most attention — that numbers of underweight children is persisting and obesity in high-income countries is plateauing, while the increase has sped up in East Asia. “Obesity and underweight are just as important,” he said.

        Why it’s happening

        Over the past four decades, many countries underwent a “nutrition transition” as their economies grew, explained Hu. In those countries, such as India and China, people on the higher socioeconomic end of the spectrum became obese, he said, while people on the spectrum’s lower end were underweight — at first.
        “But when countries become more wealthy, the trends become reversed,” with the poorer population having access to cheaper, unhealthy foods and richer populations opting for healthier items, said Hu.
        “There is a continued need for policies that enhance food security in low-income countries and households, especially in South Asia,” said Ezzati. “But, our data also show that the transition from underweight to overweight and obesity can happen quickly in an unhealthy nutritional transition, with an increase in nutrient-poor, energy-dense foods.”
        We need a healthy transition, Ezzati said.
        Experts believe countries therefore need to prioritize both problems, which they have not done to date.
        “Our findings highlight the disconnect between the global dialogue on overweight and obesity, which has largely overlooked the remaining under-nutrition burden, and the initiatives and donors focusing on under-nutrition that have paid little attention to the looming burden of overweight and obesity,” said Ezzati.
        “If programs have always targeted getting more calories into children, they’re not prepared when obesity hits, he said.
        “Whoever is to blame for this epidemic, it’s not the children,” Waqanivalu said, adding that governments have created environments in which parents and children are surrounded by unhealthy food options and inadequate options for physical exercise.
        “(Children) don’t have much say in the environment they are brought up in,” he said. “Parents only respond to the environment being created. The government determines the environment.”

        Putting solutions in place

        “This data is stating what we have already said, but now quantifying the magnitude of the problem,” said Waqanivalu. “By releasing (the data), we hope to generate more political action from countries.”

        See the latest news and share your comments with CNN Health on Facebook and Twitter.

        Waqanivalu went on to explain there are proven measures that work to reduce obesity rates, such as sugar taxes, restricting marketing of unhealthy foods to children and policies to increase physical activity at schools.
        “It’s our hope that countries will see how big the problem is (in their population), know the solution and be able to take some steps,” said Waqanivalu.
        “This study is an important wake-up call for countries where childhood obesity if increasing rapidly, especially in parts of Asia where the economy is still developing quickly and the prevalence of childhood obesity is rising,” said Hu whose own work has explored the rise in obesity rates in China and India.
        “Dietary patterns are changing rapidly and accelerating obesity … and will lead to chronicdisease down the road,” said Hu.
        Along with undernutrition, “we should be vigilant about both problems.”

        Read more: http://www.cnn.com/2017/10/10/health/child-adolescent-obesity-global-increase/index.html

        ‘ICU Grandpa’ cradles babies when their parents can’t

        Atlanta (CNN)With the preemie cradled in his arms, the retiree glanced toward the entrance of the pediatric intensive care unit.

        The child’s mother stood at the door, David Deutchman later recalled. She’d gone home to take care of her older daughter, all the while worrying about the baby boy whom she’d left the previous night at the Children’s Healthcare of Atlanta hospital. Now she was back.
        “Who are you?” the mother asked, peering at this stranger holding her swaddled son, life-sustaining wires taped to his tiny cheek.
          “I’m the ICU grandpa,” Deutchman replied.
          A photo posted Friday morning on Children’s Facebook page shows Deutchman holding Logan, the sleeping infant, who was born at 25 weeks. Within hours, the post had been shared more than 160,000 times.

          From board rooms to bear hugs

          After retiring from his job as an international marketing executive in 2000, Deutchman became a guest lecturer at Atlanta-area universities, mostly Georgia Tech and Emory, he said. But it didn’t fill enough of his time.
          As he left a rehab appointment for a leg injury, Deutchman stopped into Children’s nearby.
          “I decided to walk in there, just wondering if they had volunteer opportunities,” he told CNN. “They did, and they were happy to take me on board.”
          With experience at the helm of a classroom, Deutchman first went to work in the hospital’s school for long-term patients. Then one day, he was startled by encounters with two patients’ mothers.
          “I went to help escort a child to the school room, and the mom said she’s going into surgery,” Deutchman said. “She followed me into the hallway and proceeded to tell me every detail of the child’s condition and what’s going on.”
          Awed that the mom told a virtual stranger all about her child’s condition, he then saw another mother walking out of the pediatric intensive care unit, looking upset. Her son had been flown to the hospital the previous night, she said, and his condition was dire.
          “She comes into my arms and starts crying,” Deutchman said. “After that day, I went to the volunteer office and told them, ‘I now know what I want to do at the hospital.'”

          Comfort and warmth

          Now, twice a week, Deutchman spends the day in the pediatric and neonatal ICUs, holding babies and helping their parents.
          “Sometimes I get puked on, I get peed on. It’s great,” he says in a video posted by Children’s.
          Deutchman’s friends ask why he’d put up with that.
          “They just don’t get it, the kind of reward you can get from holding a baby like this,” he says.
          Cradling fragile babies has been shown to improve their health, said Elizabeth Mittiga, a NICU nurse at Children’s.
          “It definitely helps just feeling that comfort, that warmth,” Mittiga said in recorded remarks provided to CNN by the hospital. “It definitely helps them to, I think, grow faster and put more weight on, and feeding-wise, can help them digest their feeds better and things like that.”
          Some children Deutchman meets don’t have promising prognoses.
          “Some leave with developmental disabilities and lifelong special needs,” he told CNN. “And that’s tough. That’s a memory that’s not necessarily a positive one.”

          Newfound fame

          The best cases end with kids who go home healthy — and grow up strong.
          “The good times have been spending six months with a family, and the kid had ups and downs, and the kid came out great,” he said. “Now the kid is 4 or 5 years old and is terrific. Those are the stories I love.”
          With his new social media fame, Deutchman has been reliving those stories, as thousands of parents have commented on the photo of him with Logan, reminiscing about the times the ICU Grandpa held their child.
          “It was very worthwhile doing,” he said. “It was important doing.”

          Read more: http://www.cnn.com/2017/09/29/health/icu-grandpa-childrens-hospital-trnd/index.html

          The little red pill being pushed on the elderly

          The maker of a little red pill intended to treat a rare condition is raking in hundreds of millions of dollars a year as it aggressively targets frail and elderly nursing home residents for whom the drug may be unnecessary or even unsafe,a CNN investigation has found.

          And much of the money is coming straight from the federal government.
          The pill, called Nuedexta, is approved to treat a disorder marked by sudden and uncontrollable laughing or crying — known as pseudobulbar affect, or PBA.This condition afflicts less than 1% of all Americans, based on a calculation using the drugmaker’s own figures,and it is most commonly associated with people who have multiple sclerosis (MS) or ALS, also known as Lou Gehrig’s disease.
          Nuedexta’s financial success, however, is being propelled by a sales force focused on expanding the drug’s use among elderly patients suffering from dementia and Alzheimer’s disease, and high-volume prescribing and advocacy efforts by doctors receiving payments from the company, CNN found.
          Since 2012, more than half of all Nuedexta pills have gone to long-term care facilities. The number of pills rose to roughly 14 million in 2016, a jump of nearly 400% in just four years, according to data obtained from QuintilesIMS, which tracks pharmaceutical sales. Total sales of Nuedexta reached almost $300 million that year.
          Nuedexta is being increasingly prescribed in nursing homes even though drugmaker Avanir Pharmaceuticals acknowledges in prescribing information that the drug has not been extensively studied in elderly patients — prompting critics to liken its use to an uncontrolled experiment. The one study the company conducted solely on patients with Alzheimer’s (a type of dementia) had 194 subjects and found that those on Nuedexta experienced falls at more than twice the rate as those on a placebo.

          Avanir declined repeated requests to be interviewed for this article. In an emailed statement, the company said PBA is often “misunderstood” and that the condition can affect people with dementia and other neurological disorders, which are common among residents in long-term care facilities. A company website states PBA can afflict up to roughly 40% of dementia patients — a figure that is based on an Avanir-funded survey and was repeatedly disputed by medical experts interviewed by CNN, including some of those paid by Avanir.
          Nuedexta is approved by the Food and Drug Administration (FDA) to treat anyone with PBA, including those with a variety of neurological conditions such as dementia. But geriatric physicians, dementia researchers and other medical experts told CNN that PBA is extremely rare in dementia patients; several said it affects 5% or less. And state regulators have found doctors inappropriately diagnosing nursing home residents with PBA to justify using Nuedexta to treat patients whose confusion, agitation and unruly behavior make them difficult to manage.
          “There has to be a diagnosis for every drug prescribed, and that diagnosis has to be real … it cannot be simply made up by a doctor,” said Kathryn Locatell, a geriatric physician who helps the California Department of Justice investigate cases of elder abuse in nursing homes. “There is little to no medical literature to support the drug’s use in nursing home residents (with dementia) — the population apparently being targeted.”
          CNN identified dozens of cases across the country since 2013 in which state nursing home inspectors questioned the use of Nuedexta.
          In a Los Angeles nursing home last year, regulators found that more than a quarter of its residents — 46 of 162 — had been placed on Nuedexta, noting that a facility psychiatrist had given a talk about the drug to employees. This psychiatrist was a paid speaker for Avanir.
          At another facility in 2015, also in Southern California, an employee admitted to inspectors that a resident had been given a diagnosis of PBA to “somehow justify the use” of Nuedexta, even though its intended purpose was to control the resident’s “mood disturbances” and yelling out.
          And an Ohio doctor paid by Avanir has come under government investigation for allegedly receiving kickbacks for prescribing the drug and fraudulently diagnosing patients with PBA in order to secure Medicare coverage — though the doctor has denied any wrongdoing.
          The federal government foots the bill for a big portion of the money being spent on Nuedexta in the form of Medicare Part D prescription drug funding, for people 65 and over and the disabled. In 2015, the most recent year for which data is available, this Medicare program spent $138 million on Nuedexta — up more than 400% from just three years earlier.
          Medicare is supposed to pay for drug uses that have been proven safe and effective for the population they are intended to treat or that have been otherwise supported by a specific collection of medical research. Nuedexta is currently only approved by the FDA for patients who have PBA. So experts say that Medicare coverage of the drug, which has been crucial to its financial success, relies on the diagnosis of this single condition. So-called “off-label” prescribing, in which doctors use the drug to treat patients who have not been diagnosed with PBA, would typically not be covered.

          The Centers for Medicare & Medicaid Services (CMS) declined to comment on the growing use of Nuedexta in nursing homes.
          Thousands of the doctors prescribing Nuedexta have received money, or at least a meal, from its maker — a legal but controversial practice in the industry. Between 2013 and 2016, Avanir and its parent company, Otsuka, paid doctors nearly $14 million for Nuedexta-related consulting, promotional speaking and other services, according to government data. The companies also spent $4.6 million on travel and dining costs, both for speakers and for doctors being targeted by salespeople.
          A CNN analysis also found that nearly half the Nuedexta claims filed with Medicare in 2015 came from doctors who had received money or other perks from the company (ranging from a few dollars’ worth of food or drink to hundreds of thousands of dollars in direct payments).
          Pharmaceutical companies are allowed to pay a doctor to promote a drug to colleagues and other medical professionals. It is illegal, however, for doctors to prescribe the drug in exchange for kickback payments from a manufacturer.
          Several of these paid advocates of Nuedexta argue that PBA manifests differently depending on the person. With dementia patients, they say, the typical crying or laughing outbursts seen in multiple sclerosis patients may be absent. Instead, symptoms may include moaning, wailing, hitting a wheelchair over and over again or repeating the same phrase. And they are adamant that the medication can be life-changing for patients, touting how safe and benign it is.
          “I never hear, ‘hey doc, we put a patient on this and had really bad side effects,'” said Jason Kellogg, a geriatric psychiatrist who sees patients at nursing homes across California. Kellogg has received $612,000 in payments, meals and travel from Avanir and its parent company between 2013 and 2016, according to government data. He was a top Medicare prescriber for the drug in 2015, the most recent year for which data is available.
          Kellogg, who said he was involved in early company testing of the drug for PBA, said Nuedexta is “such a blessing in psychiatry.”
          “In our treatments, we don’t have many meds that are well tolerated, and I would hate if someone took that away from me,” he said.
          During the FDA approval process, two key doctors on the committee raised concerns about Nuedexta being used for PBA in Alzheimer’s patients. They both strongly recommended that Nuedexta only be approved for PBA in patients with MSorALS. They argued that evidence it would be effective in other conditions was “weak,” that not enough was known about the safety of the drug in the elderly, and that it was unclear that PBA even existed in Alzheimer’s patients. Despite these concerns, the agency approved Nuedexta in 2010 for treating PBA in patients who have neurological conditions such as dementia.

          Soon after Nuedexta hit the market in 2011, doctors, nurses and family members began filing reports of potential harm — ranging from rashes, dizziness and falls to comas and death. Nuedexta was listed as a “suspect” medication in nearly 1,000 so-called adverse event reports received by the FDA detailing side effects, drug interactions and other issues, CNN found. While the FDA uses these voluntary reports to monitor potential issues with a drug, a report does not mean that a suspected medication has been ruled the cause of the harm.
          The FDA declined to comment on these adverse events or the concerns raised about Nuedexta during the approval process. But it did say that after any drug is approved, the agency continues to review safety information from a variety of sources (including adverse event data) and will take action as needed — such as updating a medication’s label, restricting its use or even taking it off the market entirely.
          Lon Schneider, director of the University of Southern California’s California Alzheimer’s Disease Center, reviewed information from roughly 500 of the reports which CNN obtained through a Freedom of Information Act request. Schneider, a physician specializing in geriatric and dementia care, said he was concerned about the problems stemming from potential interactions between Nuedexta and other powerful medications intended to treat problematic behaviors.
          He warned that given how medicated the elderly typically are, adding just one more pill — especially one that hasn’t been extensively tested — could be dangerous.
          One report filed by a nurse practitioner in 2015 detailed the rapid decline of an 86-year-old Alzheimer’s patient after Nuedexta was added to the psychotropic medications she took including Zoloft (an antidepressant), Xanax (an antianxiety drug) and Risperidone (an antipsychotic). Nuedexta had been prescribed to treat PBA and “weeping with underlying Alzheimer’s dementia.”
          Almost immediately, the woman experienced weakness and fatigue to the point that she was barely able to talk and was described as being “almost unresponsive.” The dose of Nuedexta was increased, and her symptoms worsened. The drug was discontinued about a week later, but she failed to recover. She remained unable to eat or drink and her kidneys failed — ultimately leading to her death.
          “The patient seemed to be doing fine,” the nurse practitioner reported, “until she was placed on Nuedexta.”

          Aggressive sales force

          The combination of two generic drugs that makes up Nuedexta — a cough suppressant and heart medication — was once available from specialty pharmacists willing to combine the ingredients for less than $1 a pill, according to a US Senate report on rising prescription drug prices.
          Now the FDA-approved medication costs as much as $12.60 a pill, wholesale pricing data from First Databank shows. That can add up to more than $9,000 a year, though the amount a patient actually pays depends on factors including individual insurance coverage. Medicare Part D spending on the drug averaged $3,400 per patient in 2015.

          It is Avanir’s main product and biggest moneymaker. It has gained attention with the public through its television commercial featuring actor Danny Glover seesawing between laughter and tears. And it was this drug’s financial potential that attracted Japanese pharmaceutical giant Otsuka to the boutique California firm, purchasing Avanir for $3.5 billion several years ago. Otsuka declined to comment for this story.
          Avanir investor documents have stated that only a small fraction — 100,000 of the 1.8 million patients suffering from moderate to severe PBA — live in long-term care facilities. Yet the company has described nursing homes as key to its growth.
          On a 2013 earnings call, Rohan Palekar, a top executive who eventually became CEO but is no longer with the company, said Avanir had “just scratched the surface of its full potential” in nursing homes, according to an online transcript. He said the company aimed to get Nuedexta prescribed in far more facilities. Palekar did not respond to requests for comment.
          To rack up these prescriptions, salespeople identified doctors, nurses and pharmacists who could serve as advocates for the drug, according to interviews with former Avanir employees and internal documents and emails reviewed by CNN. Salespeople then worked closely with these advocates to identify potential patients. In one case, a salesperson worked with a doctor’s office manager to pull patients’ charts, identify those who should be screened for PBA and make sure that Nuedexta brochures were inserted in their files. The sales force also coached doctors and facility employees on how to fight for Medicare coverage of the drug if it was initially refused.
          Federal laws restrict the tactics pharmaceutical sales representatives can use to sell a medication. They can’t give favor or payments in exchange for a doctor prescribing the drug. They can’t have any contact with private patient records, without the patient’s consent. And they can’t promote use of a drug off-label, in a way that hasn’t been approved by the FDA.
          Internal company emails obtained by CNN show a culture filled with intense pressure to get the drug sold and how Avanir sales representatives were encouraged to directly target dementia and Alzheimer’s patients — a practice which is legal as long as these patients also had PBA.
          In an email from several years ago, one of the company’s regional managers, Kevin Tiffany, bluntly urged his salespeople to spend “99.9 percent” of their time focused on such patients.

          What should we investigate next?

          Email Blake Ellis and Melanie Hicken

          Devoting time to other conditions more commonly associated with PBA amounted to “diluting your chances,” wrote Tiffany, a senior sales manager in California.
          “Give yourself the best chance to win,” Tiffany added.
          Tiffany, who no longer works for Avanir, declined to comment through an attorney.
          Other emails from managers show how the government’s crackdown on dangerous antipsychotic drugs — which were once widely used to control unruly and erratic behavior in nursing home patients — created an opportunity for Avanir.
          After receiving the FDA’s most severe “black box” warning for an increased risk of death in elderly dementia patients, antipsychotics are now closely monitored by government regulators, who penalize and lower the ratings of facilities that overuse them. Internal company communications show Avanir salespeople were directed to specifically target facilities that historically used high levels of antipsychotic medications — facilities that would see Nuedexta as an attractive alternative.
          Some of these tactics employed by Avanir salespeople cross into ethical gray areas, said medical ethicists and other experts who were read the emails and sales training documents or provided with details from them.
          “It definitely feels like it is too much in the business of prescribing and not in the business of conveying information,” said Michael Santoro, a Santa Clara University professor and an expert in pharmaceutical industry ethics.”It feels like (the salespeople) are actually participating in the prescribing decision.”
          In its statement, Avanir said that the company was committed to “an ethical culture,” uses methods “that are consistent with the law” and that its goal is “to give doctors truthful, accurate and balanced information so they can decide on the proper treatment for their patients.”
          Avanir executives have long touted plans for securing FDA approval for Nuedexta’s use to treat dementia patients who don’t have PBA — setting their sights on the more widespread condition of agitation in dementia and Alzheimer’s patients, characterized by emotional and physical outbursts and restless behaviors. The company announced clinical trials for testing a version of the medication for this use in 2015, but those have not yet been completed. Without additional FDA approval for the drug’s use in those conditions, salespeople cannot promote Nuedexta for that purpose. They can only market its use for dementia patients who also have PBA.
          There are currently no FDA-approved drugs for treating dementia-related agitation, and other drug makers have been penalized for marketing drugs for this use. Abbott Laboratories Inc., for instance, pleaded guilty in 2012 to illegally marketing an anticonvulsant called Depakote in nursing homes as a way to control agitated and aggressive dementia patients. But the drug had only been approved for treating seizures, bipolar disorder and migraines. The company ultimately paid a total of $1.6 billion in civil and criminal penalties.
          Those who care for the elderly remain eager for tools to manage these behaviors, however. Some caregivers say investments in increased staffing can reduce the need for medications. But such measures are expensive and don’t always work, so some facilities opt for pharmaceutical solutions that can help make their many patients easier to treat.”Rather than taking someone off an antipsychotic” and opting to treat the patient in ways that don’t require medication, “providers search for a different ‘magic bullet,'” said Helen Kales, a geriatric psychiatrist and University of Michigan professor.
          In one case, the executive director of a California assisted living facility tried to push Nuedexta on a dementia patient to address her “aggressive” behavior, according to emails reviewed by CNN. The director at the facility, Oakmont of Mariner Point in Alameda, California, told the patient’s son, Jason Laveglia, that the medication wasn’t an antipsychotic and threatened to evict his mother if she wasn’t put on the medication.
          “(I)f her behavior cannot be muted through prescription means, I would have no choice but to pursue delivering a 30-day eviction notice,” Joan Riordan wrote to Laveglia last year.
          Laveglia turned to the state for help, and by the time officials investigated weeks later, Riordan no longer worked at the facility. Social service officials ultimately found that her eviction attempt had violated state law. A spokesperson for the facility would not comment on the state’s findings, but said it “does not endorse or recommend Nuedexta nor any other medication” and that staff should not be involved in medical decisions.
          In an interview with CNN, Riordan disputed the idea that her emails served as an official eviction notice. Riordan, who is not a doctor, said that she had recommended Nuedexta after learning about the medication from a local psychiatrist and had seen it help a number of other aggressive dementia patients without the dangers and sedative effects of an antipsychotic.
          “I’ve seen it just work wonders with people,” she said. “It was the only intervention I could come up with. We needed to do something not only for her own benefit, but also for the people around her.”
          When asked whether her residents had PBA, Riordan told CNN she had never heard of the condition and had no knowledge of whether they had received such a diagnosis.

          Red flags and questionable use

          Across the country, the use of Nuedexta in nursing homes has prompted concerns among state regulators whose job is to ensure adherence to federal guidelines and protect residents from being given unnecessary drugs — especially those used as chemical restraints. But to date, the red flags raised by these regulators have been largely left buried in nursing home inspection reports and have drawn little public attention.
          CNN identified more than 80 cases in 19 states since 2013 where inspectors cited nursing homes for inappropriate monitoring and use of Nuedexta — often because residents hadn’t exhibited any symptoms of PBA. Many of the cases — about 40% — were clustered in Southern California, where Avanir is based and where former employees said there has been aggressive marketing.
          At the Montrose Healthcare Center near Los Angeles, three nursing home residents were given Nuedextawithout a doctor’s prescription or approval, according to one inspection report. All were cognitively impaired. One was known to call out for help, while another would cry when their family left the facility. But employees acknowledged that they had never seen the residents laugh or cry involuntarily — the hallmark indicators of PBA.

            Is your doctor being paid by a drug company?

          Regulators learned of these prescriptions in 2015, after a family member discovered that her relative was receiving Nuedexta without her consent. While researching the medication, she learned it could be dangerous for her family member because of other medications she took for a serious heart condition.
          The doctors for all three residents denied ever prescribing Nuedexta. State investigators later discovered nursing staff had obtained the prescriptions without a doctor’s approval, which they are not authorized to do. They also found that at least two nurses at the facility had attended a sales seminar about Nuedexta, where they were given a doctor’s sample prescription for the medication. The facility said in a statement that it had addressed the concerns raised by the state inspection report and suggested that outside pressure had been at play.
          “Our Center does not condone the pressuring of nurses by pharmaceutical reps and physicians to favor certain medications,” the facility said. “Should they feel pressured to administer medications they do not feel are appropriate, our nurses can and should bring it to our immediate attention so we may assist them in advocating for their patients.”
          In New Jersey, St. Vincent’s Healthcare and Rehab Center was cited by regulators last year because six residents were prescribed Nuedexta even though no symptoms of PBA had been documented. A representative of the facility told CNN it takes a “close look at all medications prescribed to ensure appropriate use.”
          One resident in the report told the facility’s psychiatrist there was a legitimate reason for their sadness: “All I really want is a companion. I am lonely.” In the case of another resident given the medication, a nurse said the resident’s crying was an expression of frustration, and that this had improved with a change in routine.
          Two other residents at the facility were originally prescribed Nuedexta for “Dementia with Behaviors.”
          Those diagnoses were then crossed out or rewritten — replaced with “PBA.”

          The pill pushers

          At first, Alex Carington couldn’t figure out why her 85-year-old mother, Lenore Greenfield, was on Nuedexta, a pill Carington had never heard of. A psychiatrist had prescribed the medication after visiting the elderly woman in her Los Angeles nursing home while she was sleeping, Carington said. Even when the drug appeared to do nothing to ease her mother’s sadness, confusion or emotional outbursts as she battled dementia, she said the doctor kept her on it.
          “Something about this whole thing made me think money was behind it,” Carington, who lived near her mother’s facility and visited her often, wrote at the time in an online comment on the blog of a psychiatrist who had questioned Nuedexta’s aggressive advertising.
          As she began to look into her mother’s doctor, she discovered he had received more than $100,000 from Avanir in just over a year.
          Outraged, she finally got her mother taken off Nuedexta for good. Now, around two years later, she is in a new nursing home and Carington believes she is doing much better.
          Her mother’s doctor was Romeo Isidro, a speaker for Avanir and one of the physicians paid the most by the drugmaker. Between 2013 and 2016, Isidro received more than $500,000 in payments, travel and meals from Avanir and its parent company. According to internal company documents, he was an advocate for Nuedexta as early as 2012, the year after it hit the market.
          He had more than 100 patients in 11 facilities on the drug that year.
          In Avanir training documents, a California salesperson explained how he worked to get Isidro to prescribe Nuedexta. Now a senior sales manager at the company, Chris Burch wrote in 2012 that he and his colleague saw or spoke to Isidro about twice a week — regularly calling and texting him, and visiting him at both his office and nursing homes. Burch wrote that Isidro was at first skeptical about the condition of PBA, but after he successfully used Nuedexta to treat possible symptoms of it in one patient, he became more comfortable prescribing the medication. Burch then explained how he had directly targeted facilities where Isidro worked, finding employees who could serve as “advocate(s)” to help identify potential Nuedexta candidates for Isidro.
          “He is now a speaker and I ask him to advocate in his facilities, corporate facilities, and (to) other psychiatrists, internists and pharmacies,” Burch, who did not respond to requests for comment, wrote in a form used by the company to track certain prescribers.
          CNN attempted to contact Isidro by phone and by visiting his office, where two stacks of PBA and Nuedexta pamphlets sat on a table in the waiting room. He declined to be interviewed but ultimately provided a written statement saying that he had “never prescribed medication for financial incentives” and that he prescribes Nuedexta to patients who he has properly diagnosed with PBA.
          He also wrote about the first success he had seen with the drug, and how it helped him wean an elderly patient off of dangerous psychotropic medications — noting that her inappropriate crying and screaming symptoms reminded him of a visit from a Nuedexta representative who had told him about PBA. He said Avanir approached him about becoming a speaker, and that he agreed in order to share his first-hand experience with the medication — not to promote it.
          “Since learning about PBA, I have become more skilled at recognizing it in my patients, which would in turn produce increased numbers of patients on Nuedexta,” he wrote. “I am not an advocate for a particular drug or pharmaceutical companies. I am an advocate for my patients and their families.”
          In response to questions about Carington’s mother, he said he couldn’t comment on specific patients but that memories are not “infallible.” He urged CNN to substantiate any claims with medical records about her case. Carington provided her mother’s records to CNN, which confirmed that Isidro had diagnosed her with PBA and prescribed her Nuedexta, which she remained on for months.
          A different speaker paid by Avanir, a pharmacist in northern California, appeared to suggest during a 2012 presentation that doctors could broaden the use of Nuedexta when prescribing, according to an audio recording obtained by CNN. A person in attendance, who recorded the event, identified the pharmacist as Flora Brahmbhatt.
          “I’m definitely pushing this a little bit, perhaps considered off label … but maybe it’s effective on some of the other behaviors too that we find challenging,” the pharmacist said in her presentation, which was sponsored by Avanir. “There are certain nursing home chains, specifically in Southern California, that are saying, ‘Hey, if you have somebody with dementia that has a behavior issue, try them on Nuedexta before you put them on a psychotropic (medication.)’ It’s a little aggressive, I’ll say that. But CMS isn’t making it easy for us to use antipsychotics anymore.”
          She went on to discuss how a PBA diagnosis was essential for the medication to be “covered by insurance and not be off-label,” as well as how PBA’s definition of inappropriate laughing and crying could be interpreted by physicians. At one point, she told an Avanir employee in the room that they could cover their ears.
          “We don’t have anybody from the FDA in here. I’m telling you … you can extrapolate that to mean any kind of socially inappropriate behavior when you’ve ruled out other causes,” she said. “If they have an episodic behavior and they have an underlying neurological condition, you can pretty much come up with a diagnosis.”
          When contacted by CNN about the event and asked about the recorded statements, Brahmbhatt said she hadn’t given presentations about Nuedexta for many years. She said she didn’t give permission to be recorded and didn’t recall making those statements. “I don’t know if I said this stuff,” she said. “It was five years ago, at best.” She was read several of the quotes from the recording but declined to listen to it. An attorney representing Brahmbhatt contacted CNN after publication and said that Brahmbhatt denies making the statements in the audio recording.
          Former FDA investigator Larry Stevens, who now works for the consulting firm The FDA Group, said it is a violation of federal law for a paid speaker to promote a drug for anything other than its FDA-approved use.
          Yet another paid speaker, the Ohio physician accused of accepting kickbacks in exchange for prescribing Nuedexta, has been under government investigation. Internal Avanir documents show Cleveland neurologist Deepak Raheja was a top prescriber of the drug from the beginning, in 2011. Between 2013 and 2016, he received $289,000 in payments, meals and travel.
          In addition to allegedly accepting kickbacks, Raheja is accused of fraudulently diagnosing patients with PBA in order to secure Medicare coverage for off-label use and increasing dosages of Nuedexta beyond what is recommended, according to a letter obtained by CNN. The letter, circulated by the Centers for Medicare & Medicaid Services (CMS) in January, alerted insurance providers that work with Medicare about the fraud allegations so that they could take “appropriate measures.”
          Medicare officials said the agency could not comment on pending or active investigations. When contacted by CNN, Raheja denied that he had received kickbacks or been involved in any kind of Medicare fraud in his 25 years of practice.
          He also said he no longer prescribes Nuedexta.
          Email Blake Ellis and Melanie Hicken at watchdog@cnn.com.
          This story was updated to reflect a statement from Flora Brahmbhatt’s attorney made after publication.

          Read more: http://www.cnn.com/2017/10/12/health/nuedexta-nursing-homes-invs/index.html

          Nature’s calling — for more human diversity

          (CNN)In a time of intense political polarization in the United States, experts say, we need nature more than ever. Wild spaces offer opportunities for recreation but also for healing and unity. They are places to come together to breathe deeply and reflect on where society is headed.

          “We’re at a really important moment in human history,” said Florence Williams, author of “The Nature Fix.” “We’ve never been so disconnected from nature as we are right now.”
          With omnipresent technology and rising urbanization, people are becoming less connected to the great outdoors.
            “What happens to a culture when it can no longer envision a future that is better and more beautiful than the one happening now?” asked Richard Louv, author of “The Last Child in the Woods” and the “Nature Principle.”
            Exploring natural places enables everyone to see the world in a new way — but it’s an experience that’s often restricted to specific segments of the American population.

            The healing potential of wilderness

            Green spaces bring numerous health benefits. Nancy Wells, a professor of human ecology at Cornell University, explained that experiences in nature can lead to decreased blood pressure and levels of the stress hormone cortisol, assist with direct attention fatigue, and increase cognitive function. Nature might even buffer the impact of stress, Wells said.
            “There is also evidence that nature is a social magnet,” she said. “Nature draws people together and helps to foster neighborhood social ties.”
            Some doctors are even prescribing time in nature as part of treatment plans for chronic issues like high blood pressure or attention-deficit disorder.
            “Because the outdoors provide a range of benefits that we often don’t think about, we need those spaces for us to be our better selves,” said Jose Gonzalez, founder and executive director of Latino Outdoors.
            Many advocates suggest that the decreasing connection to nature accompanying urbanization may have more drastic consequences than anticipated.
            “This is about holding on to our own humanity,” said Shelton Johnson, an African-American park ranger and storyteller in Yosemite National Park. “What it means to be ‘human’ existed within the context of wilderness for tens of thousands of years. It’s like walking into a psychologist’s office and saying, ‘I don’t know who I am anymore.’ Where can we find who we really are? By climbing a mountain or by going down a river or walking into a forest at sunrise.”

            Solving the diversity problem in the great outdoors

            Natural areas in the United States have long symbolized national heritage, protected valuable natural resources and provided areas of recreation and respite. But for whom?
            Evidence shows that white populations disproportionately access public lands for outdoor recreation. The second National Park Service Comprehensive Survey of the American Public, carried out by the University of Wyoming and published in 2011, found that only about one in five visitors to a national park site is nonwhite, and only about one in 10 is Hispanic.
            This lack of diversity in outdoor recreation extends to the leadership of the park system and the outdoor industry at large. “The outdoor sector is probably the most homogenous field that exists today,” said Angelou Ezeilo, founder and CEO of the Greening Youth Foundation.
            As the population of the United States continues to rapidly diversify, experts say, the face of the outdoor community has predominantly stayed the same: male, white and wealthy. According to the 2011 national park survey, the demographic composition of visitors to public lands hasn’t changed since the previous survey in 2000.
            “Look who is on the cover of Outside magazine,” Gonzalez said. “You can look at the history of these covers. It will predominantly be a white male doing some kind of extreme outdoor adventure. What that affirms is: This is what the outdoors is, and this is who belongs in it.”
            Teresa Baker, a leading advocate for people of color in the outdoors and founder of the African American Nature and Parks Experience, explained that the lack of diversity in the outdoor community extends beyond marketing campaigns and popular publications, into the natural spaces themselves.
            “For communities of color in general, we’ve never seen us in the outdoors. We’ve never known that we have a place in these spaces. When you don’t see other people who look like you and when you don’t see the makeup of the staff that look like you in the national parks, you don’t feel welcome,” Baker said.
            Many communities of color describe a sense of anxiety when thinking about outdoor spaces. There is some fear of the unfamiliar or unknown but also fear for safety.
            “It’s not common to look at the outdoors as a place of respite. It’s a place where we’ve lived or worked or been forced to live and work,” said Glenn Nelson, a multiracial journalist and advocate and founder of The Trail Posse.
            Rue Mapp, founder and CEO of Outdoor Afro, explained that for many people of color, the legacy of slavery continues to fuel a negative association with rural or wooded areas. Gonzalez said that for some Latino communities, time in the outdoors conjures harsh memories of migrant work.
            “You don’t have to go too far back in our history in America to see that access to nature experiences, whether it be on the coast or in some pristine park lands, have been restricted and inaccessible by law to African-Americans and other people of color,” Mapp said.
            Johnson, who’s worked in the national park system for more than 20 years, explained this discomfort: “If you’re a woman, if you’re a person of color, if you’re in a wheelchair or have a cane, if you’re elderly, if you’re of a faith that’s different from the dominant faith, there is a wind blowing against you that only you, or only people who look like you, can feel. But if you are an empowered, wealthy, European-American male, it is a calm still day, and it has been a calm still day since the day you were born.”
            There is also an economic barrier to accessing the outdoors. “Cost and transportation can also be prohibitive,” Gonzalez said. “For example, do we all own that Subaru that we can hop into to get out into these spaces? Are entry fees prohibitive?”

            Redefining ‘outdoorsy’

            To solve the diversity problem in the outdoor community, experts say, we need to redefine what it means to be outdoorsy. Advocates explained that getting outside and exploring public lands can be daunting without personal experience or community members to guide you.
            “We need to be able to promote outdoor lifestyles that are real,” said Ambreen Tariq, communications director and board member of Green Muslims. “People often view the outdoors as you’re a backpacker or you have to be extreme and minimal. But that’s not my lifestyle. The outdoors means you go outside and you enjoy nature in whatever setting you want. Maybe that’s a cookout; maybe that’s gardening; maybe that’s going to a state park that’s down the street.”
            Through her Instagram account, Brown People Camping, Tariq hopes to be increase authenticity and accessibility of the outdoor community for people of all backgrounds.
            Many nonprofit organizations, such as Outdoor Afro, Latino Outdoors, Adventures for Hopi, the Greening Youth Foundation, Big City Mountaineers and the Center for Diversity and the Environment, aim to address the barriers for traditionally underserved communities in the outdoors. These organizations often partner with outdoor retailers and reach hundreds of thousands of individuals across the country.
            “It doesn’t just happen by more people showing up,” said Queta Gonzalez, programs director for the Center for Diversity and the Environment.
            “We have to build capacity. People have to learn how to create an inclusive environment for everybody. To do that, we have to look at our own implicit bias, our own internalized superiority, our internalized oppression, and we have to work across difference,” she said
            Outdoor retailers such as REI and Patagonia are also working to attract this budding customer base and project more diverse imagery in marketing campaigns.
            “There’s been a really intentional effort to tell new stories, to show new faces and to imagine broader aperture of the stories of the outdoors,” said Laura Swapp, REI’s director of public affairs and marketing. “The question of ‘Are we relevant, and who have we been relevant for?’ is the number one thing we ask as folks who love the outdoors.”

            Diverse voices for conservation

            More and more people of color, minority communities and indigenous people are strengthening their connection with nature through outdoor experiences.
            “It is not about establishing a relationship with the land. It is about re-establishing a relationship,” said Latino Outdoors’ Jose Gonzalez.
            “Once you have that experience and you’re connected to natural places, we want to convert that into a civic voice and speak up for national parks,” said Hayley Mortimer, vice president of regional operations of the National Park Conservation Association.
            Over the next century, diverse communities will be crucial in the battle to protect the nation’s public lands from losing their designations, experts say.
            “What I understand about these spaces is, if we don’t fight for them, they’ll be taken away,” Baker said.
            Without the inclusion of all people, regardless of background, environmental groups will not have the support they need to push the conservation movement forward.

            See the latest news and share your comments with CNN Health on Facebook and Twitter.

            “Sometimes, communities of color are asked to be conservationists too soon. The truth is that people will protect what they love, but they are not going to love something that they don’t have a relationship with,” Mapp said.
            Creating a more welcoming outdoor community and dismantling barriers to access will help reconnect people with the land. The future of the planet and of our human health depend on it, experts said.
            “Nobody wants to be in the last generation where every kid, not just the kids with parents who love nature, has the chance to lie in the weeds and watch the clouds move,” Louv said. “That’s a powerful place to start.”

            Read more: http://www.cnn.com/2017/09/12/health/nature-wilderness-minorities/index.html

            Half in US choose cremation as views on death change

            (CNN)The memorial service he arranged for a local jazz musician after the cremation is a point of pride for Stephen Kemp of Haley Funeral Directors in Southfield, Michigan.

            “I cleared out half of my chapel. They brought in all their bands and friends, and they played music,” he said, recalling how the musician’s friends arranged the deceased’s alto, tenor and soprano saxophones on the wall around a photograph of the man. “The priest came in and gave a small eulogy, and they went out of the funeral home playing ‘When the Saints Go Marching In.’ ”
            Next, the mourners went to a club in downtown Detroit to host a “jazz breakout,” Kemp said. The entire day was “a wonderful tribute” to a man who had devoted his life to music.
              As a funeral director, Kemp believes, his job is to turn mourners’ wishes into reality. In many cases, today’s reality is cremation.
              In 2016, just over half (50.2%) of Americans chose cremation, while 43.5% opted for burial, according to a new report from the National Funeral Directors Association. Though the trend is new, this is not the first time the cremation rate exceeded the burial rate: 2015 was the first year these rates flipped, the report indicates, with 48.5% of Americans choosing cremation compared with 45.4% selecting burials.
              Liberated from tradition, memorial services have become more expressive and more unique.
              “It is real important for us as funeral directors to adapt to people’s wishes,” said Kemp, who is also a spokesman for the association. As he sees it, a good memorial service can create memories while reviving faded ones.

              Flames and ash

              Cremation’s growing popularity bodes ill for funeral homes. In the United States, the number of funeral homes has fallen nearly 10% over a decade, from 21,495 in 2005 to 19,391 in 2015, according to the National Funeral Directors Association report.
              Jeff Jorgenson, founder of Elemental Cremation & Burial, a green funeral home in Seattle, said that when he got into the industry 11 years ago, “it was one of those things that we talked about as the ‘cremation problem.’ “
              “There isn’t as much money in it, let’s face it,” Jorgenson said, so funeral directors tried their best to resuscitate people’s interest in burials.
              It wasn’t happening, though. The reasons people choose cremation are topped by saving money, with convenience coming in a distant second, according to the new report.
              “Whether we as an industry want to recognize that or embrace it or dance with it, that’s up to the individual funeral director,” Jorgenson said. “Things are changing.”
              Unprepared though the industry may have been, efforts have been made. Nearly 30% of funeral homes in the United States operate their own crematories, and another 9.4% intend to open a crematory within the next five years, according to the report.
              Beyond the choices of “disposition” — how a body is dealt with after death — there are also changes in what services and experiences people want, Jorgenson said. “Things like a memorial service, a visitation or a viewing — these are things that we’re trying to figure out how to tie into these minimal services. And that’s where the industry really struggles.”
              With cremation, more people have begun hosting memorial services in their backyards and homes, Kemp said: “I’ve had funeral services in parks, in bars, in sporting arenas.”
              Among the 53.6% of consumers who would choose cremation for themselves, the number who want a complete funeral with visitation has been declining over the past three years: from 26.6% in 2015 to 14.1% in 2017, according to the National Funeral Directors Association report.
              “Whatever you want to do, we’ll do it, as long as it’s within the confines of the law,” Jorgenson said.
              His Seattle-based company is and has been ahead of the curve for some time.

              Geographic differences

              Kemp said “the West Coast and some of the Northwest part of the US have always done more cremations than burials. And now it’s becoming more popular all over the US.”
              Cremation rates vary across the country, peaking in Washington state, where 76.4% of the dead were cremated during 2015, according to the report. Nevada followed with 75.6%, Oregon at 74.3%, Hawaii at 72.7% and Maine at 72.4%.
              Jorgenson said there are a few reasons why Washington, Nevada and Hawaii have high cremation rates, such as lack of religion, high education rates and transient populations.
              Educated people tend to opt for cremation, he said, and when it comes to transients, “those that die there don’t want to be buried there.” Additionally, some cultures “don’t have a religious purpose for a big ceremony.” In the end, cremation is simply a “practical way to handle your body,” he said.
              “You take out the time constraints; you take out the cost; you take out all the song and dance — I mean, to do a burial, you’re looking at one or two days just in the arrangement process,” Jorgenson said.
              The lowest rates for cremations are found in Mississippi, at 20.9%, trailed by Alabama at 25.7%, Kentucky at 27.3%, Louisiana at 29.7% and Tennessee at 31.3%.
              Kemp explains that “the South and Southeast still lag behind because they’re a little more traditional, and the gravesites are probably a little bit less expensive than what you would see in some other geographical areas.”
              High land costs combined with decreasing burial space mean cremation rates often top 70% in dense urban areas worldwide, according to the report.
              And though religion has played a role in Southern tastes in the past, it may have less impact going forward.

              Does faith matter?

              Cremation is the prevailing practice in places where the custom is ancient and most of the population adheres to Hinduism, Sikhism, Buddhism or Jainism. Many Americans of Japanese descent, for example, routinely opt for cremation just as they might in Japan, where cremation is nearly universal.
              Other nations with high cremation rates — 80% or higher — include Taiwan, Hong Kong, Switzerland, Sweden, South Korea, the Czech Republic and Thailand.
              Although nonreligious Americans are more likely than others to consider cremation, the proportion of Americans who feel that religion is an important part of a funeral has decreased from just under half in 2012 to slightly less than 40% in 2016, according to the report.
              While more than three-quarters of Americans identify themselves as faithful to one religion or another, fewer than 40% of Americans feel religion is an important part of a funeral.
              The breakdown of religion in the United States includes 22.8% who are unaffiliated, describing themselves as atheists, agnostics or “nothing in particular,” according to a Pew Research Center study. Following non-Christian faiths are 5.9% of Americans, who include Jews, Muslims, Buddhists and Hindus. The largest group is Christian: 70.6% of Americans. Of these, nearly 21% are Catholics, their large number influencing the shift toward cremation.
              The reason? In 1963, after centuries of insisting on full-body burials, the Vatican lifted the ban on cremation.
              “People still ask us if it is OK to be cremated,” said Mary Ellen Gerrity, director of the Office of Cemeteries for the Roman Catholic Diocese of Metuchen, New Jersey. Apparently, it takes time to get used to a new idea. “Actually, we have a crematory on the property, and yeah, it’s a very busy operation.”
              Scattering ashes is not permitted by the church, Gerrity said, and leaving the “cremated remains on the mantel at home, that’s not a proper burial,” either. In her diocese, and many others, people can place the cremated remains in a niche in the mausoleum.
              Along with cost, geography and religion, Jorgenson said, another important element is tradition.

              The big three options

              “Everyone in my family has been cremated,” Jorgenson said. “And I’m not gonna be any different, right?”
              Under the law in most states, he said, there are only three things you can do with your body: burial, cremation and medical donation.
              “Cryogenic is not a thing, not legally,” Jorgenson said. For example, “space burials,” touted by one company, require cremation first, and a Georgia-based company that creates an artificial reef out of your remains also relies on cremated remains.
              “Everything else is a variation on one of those three things … marketing spin,” he said.
              Some states have begun to allow alkaline hydrolosis or “resomation,” a kind of wet cremation process if you will, with a similar result where all you get back is the bone, Jorgenson said. He hopes Washington laws change in time so resomation can be his own choice.
              “You basically make an alkali solution at temperature and pressure, put the body in for a couple of hours, and it reduces the soft tissues to a liquid,” he said. The process breaks down the bones; “it’s not like you have a cartoon skeleton at the end.” Compared to cremation and burial, he said, resomation has a lower carbon footprint, is cleaner and has significantly less environmental impact. The only downside is that resomation is legal in only 10 states.
              Still, it represents a shift in thinking about death and many believe we have the baby boomers to thank for that.

              The importance of planning

              “I am no expert on death trends, but I do know from the growing popularity of death cafes and the emergence of death doulas that death is coming out of the closet, if you will,” said Ashton Applewhite, author and an anti-ageism activist.
              Applewhite believes people want to be more in touch, at the deepest level, with processes “that were once not industrialized and not hidden out of sight.” It’s like slow food, she said. As they revise their views of old age, baby boomers will also take a more clear-sighted look at disposition.
              “Because there are so many of us, we occupy a unique place in demographic history. We do have a sense of being able to shape the culture. That is arrogant, but it also is legitimate,” she said.
              Kemp, who counts himself among baby boomers, said, “A growing number of people are coming in and saying, ‘This is what I want, and I don’t want anyone to change it.’ ”
              As he sees it, families have become less nuclear, and parents would rather set things up so their kids, who may live at a distance, won’t have the burden.
              “I often caution them to please let your children know what you’re doing,” he said. “In some situations, things have been set up by a parent and then the children find out and they say, ‘What? Mom wanted to be cremated?’ “
              When it comes to disposition, Jorgenson finds that most people “leave it for their family to figure out.”
              “About 30% of people out there will prearrange some form of their disposition beforehand,” he said. This figure is based on prepayment data, he said, and it has been consistent over the past couple of decades. “They tend to be pretty uptight. I mean that in the nicest possible way,” Jorgenson said, laughing. “They’re people like engineers and attorneys and very practical people.”

              Talk about it … and keep talking

              “If your mom has never said what she wanted, you might feel bad about putting her in a cardboard box and cremating her,” Applewhite said.
              Another reason to have a recurring conversation about what you think you want while dying and after death is so that “your family doesn’t have to guess,” she said.
              “There’s a Mexican saying that the appearance of the bull changes when you enter the ring,” she said. “The longer we live, the less afraid of dying — not the more afraid — we become.
              “If you think about the terribly gloomy and negative and ageist lens and youth-oriented lens through which we look at aging … we project, ‘Oh, my God, it must be awful to have to use a walker; it must be awful to be bent over,’ whatever it happens to be.
              “It’s actually the knowledge that time is short that helps people live in the moment,” Applewhite said.
              As an activist, she hopes to provoke more awareness of the “powerful and beautiful aspects to aging.” She also wants people to know that their “anxieties are way out of proportion.”

              See the latest news and share your comments with CNN Health on Facebook and Twitter.

              “We’re eventually going to die, but just looking makes it instantly less scary,” Applewhite said. “The more we talk about it, the less afraid we are and the more we can involve whoever we want — friends or family — and … orchestrate the kind of death we think might be fantastic.”

              Read more: http://www.cnn.com/2017/08/09/health/cremation-tops-burials-in-us-study/index.html

              Girl, 2, defends her choice of doll to cashier

              (CNN)When 2-year-old Sophia was told she could pick out a prize for finishing her potty training, she knew just what she wanted.

              She and her mother, Brandi Benner, visited a Target near their South Carolina home, where Sophia spent 20 minutes looking at all the dolls in the toy aisle.
              “She kept going back to the doctor doll, because in her mind, she is already a doctor,” Benner said. “She loves giving checkups, and if you come in the house, she’ll tell you that’s the first thing you need.”
                Sophia, who will be 3 in July,was so excited by her choice that she wouldn’t let go of her new doll until they reached the register to check out.
                Did we mention that the doll is black and Sophia is white?
                The issue came up right away, when a store cashier asked Sophia: Wouldn’t she rather have a doll that looked like her?
                According to her mother, Sophia had a ready answer.
                “She does (look like me)!” the toddler responded. “She’s a doctor; I’m a doctor. She is a pretty girl; I am a pretty girl. See her pretty hair? See her stethoscope?”
                Benner credits the TV cartoon “Doc McStuffins” with teaching Sophia the word “stethoscope.” But she credits Sophia for knowing what is important: The doll’s skin tone didn’t matter. To Sophia, she and the doll share the same aspirations.
                Benner was relieved she didn’t have to defend her daughter’s choice and glad that Sophia wasn’t fazed by the cashier’s question.
                “If she was another child, that could have discouraged her,” Benner said.

                Nick and I told Sophia that after 1 whole month of going poop on the potty, she could pick out a special prize at Target. She, of course, picked a new doll. The obsession is real. While we were checking out, the cashier asked Sophia if she was going to a birthday party. We both gave her a blank stare. She then pointed to the doll and asked Sophia if she picked her out for a friend. Sophia continued to stare blankly and I let the cashier know that she was a prize for Sophia being fully potty trained. The woman gave me a puzzled look and turned to Sophia and asked, "Are you sure this is the doll you want, honey?" Sophia finally found her voice and said, "Yes, please!" The cashier replied, "But she doesn't look like you. We have lots of other dolls that look more like you." I immediately became angry, but before I could say anything, Sophia responded with, "Yes, she does. She's a doctor like I'm a doctor. And I'm a pretty girl and she's a pretty girl. See her pretty hair? And see her stethoscope?" Thankfully the cashier decided to drop the issue and just answer, "Oh, that's nice." This experience just confirmed my belief that we aren't born with the idea that color matters. Skin comes in different colors just like hair and eyes and every shade is beautiful. #itswhatsontheinsidethatcounts #allskinisbeautiful #teachlove #teachdiversity #thenextgenerationiswatching

                A post shared by Brandi Benner (@leilani324) on

                Benner posted an account of their experience Friday to her personal Facebook page. It’s been shared more than 140,000 times and attracted more than 19,000 comments. Most of them have been supportive messages from other mothers or people with similar experiences.
                The few negative ones don’t bother her.
                “I just want to teach my kids love, and that’s included in my own actions,” Benner said, explaining why she doesn’t engage with negative commenters.
                Research suggests that kids aren’t born with biases about race and gender.
                But Sophia doesn’t know about all that. She just knows that everywhere she goes, she wants her doctor doll to come along.

                Read more: http://www.cnn.com/2017/04/03/health/potty-training-doll-trnd/index.html

                The remarkable history in your cereal bowl

                (CNN)This morning, more than 350 million people devoured a bowl of Kellogg’s Corn Flakes. All told, more than 128 billion bowls of Corn Flakes are consumed each year. While perusing the cereal box, peering over the bowl and gripping a spoonful of the stuff, few of these sleepy diners know that two men created those famously crispy, golden flakes of corn. John Harvey Kellogg, one of America’s most famous physicians, and Will Keith Kellogg, John’s longtime lackey and whipping boy, were brothers from the Michigan hamlet of Battle Creek. Together, they introduced and mass-marketed the concept of “wellness.”

                And in so doing, they transfigured breakfast.
                In early 1906, at the advanced age of 46, Will Keith Kellogg acrimoniously left his brother John’s employ at the famed Battle Creek Sanitarium, a medical center and grand hotel — a “university of health” that treated the wealthy ill and the worried well and promoted wellness or, as the doctor called it, “biologic living.”
                  Will marched across the street and founded the Battle Creek Toasted Corn Flake Company, the original name of the Kellogg Company, which today enjoys more than $14 billion a year in net sales of breakfast cereals, snacks and other manufactured foods in 180 nations around the globe.
                  Flaked cereals were initially developed by the Kellogg brothers as a health food for “invalids with poor digestion.” Dr. Kellogg specialized in treating people with chronic flatulence, constipation, indigestion, all from consuming of the then-typical American diet of greasy fried foods, salted or cured meats, creamed vegetables, spicy pickles and condiments, and too much caffeine and alcohol. No wonder Walt Whitman once called stomachaches “the great American evil.”
                  Will’s genius was to recognize that there were far many more people looking for a nutritious and convenient breakfast, so he substituted tasty corn for the bland wheat originally used, added some salt and sugar against the doctor’s prescription, and came up with Corn Flakes.

                  The dawn of ‘processed food’

                  Will was a serious student of the “science” of business, whether he was publishing his brother’s books and magazines, selling the foods and health products John invented, running the Battle Creek Sanitarium or manufacturing cereal. He methodically analyzed, applied and adopted efficiency techniques and business systems espoused by the best commercial gurus of the day.
                  For nearly a quarter of a century, while John enacted one scene after another of fraternal dominance, the quiet, stolid Will was doing far more than merely taking orders. He was preparing to become a renowned captain of industry. Just as Henry Ford was figuring out the economies of scale to sell the millions of automobiles rolling off his vaunted assembly line, Will Kellogg revolutionized the administration of the modern medical center and, later, the mass production and marketing of “processed food.”
                  Will tirelessly persuaded American grocers to carry his products and consumers to relish his cereals. Heralding breakfast as “the most important meal of the day,” Will made the hectic mornings of beleaguered mothers and fathers so much easier by providing a quick, convenient, healthy, nutritious breakfast they could simply pour out of a box and into a bowl. He was an early adopter of the newly created field of mass advertising and invested millions of dollars in a neverending barrage of colorful and attractive ads, slogans and jingles, cartoon characters and, when radio and later television took the nation by storm, entertaining shows and commercials. He was quick to recognize and target youngsters as the demographic group most likely to hunger for his products, as they hunted for the prizes he cleverly placed in his cereal boxes.
                  Will Kellogg, of course, benefited by creating his business at the dawn of the 20th century, when huge corporations and nationally known brands began to dominate the American landscape. He became the “Corn Flake King” during the synchronous rise of urban populations, better living and nutritional conditions, and a national system of transportation, first by rail and later by highways, which allowed for the rapid delivery of raw grain into his factories and cases of cereal out of them. He capitalized on the widespread distribution of his food products, thanks to the development and rise of self-serve grocery stores, supermarkets and, perhaps most important, clean, safe, fresh pasteurized milk — the essential accoutrement of any bowl of cereal.
                  Yet there was far more to Will Kellogg’s genius than mere timing or the willingness to adopt new business methods. As he labored to process whole grains into ready-to-eat cereals, he refused to be satisfied with the status quo. The boss’ charge was to always improve on what the company produced. He developed ever-more-sophisticated means of packaging to keep his cereals fresh and toasty, whether on the grocery shelf or in the kitchen cabinet.
                  From the start of his manufacturing career, Will announced himself to the American public with a facsimile of his signature on every box of the “original” Kellogg’s Corn Flakes. It was initially devised as a means of thwarting the dozens of copycat companies stealing ideas and sales from his cereal business.
                  Above Will’s signature was the solemn promise that the box’s contents were tasty, crisp, nutritious and, most important, genuine. This pledge, backed by better and better means of quality control, was essential to building a longstanding, trustworthy and profitable relationship with the American public. Today, an artist’s rendition of Will’s signature — the familiar red script “Kellogg’s” — appears on virtually every product his company manufactures. It is a scribble almost as famous as another iconic American scrawl, “Walt Disney.”

                  The most-consumed breakfasts in history

                  In essence, Will Kellogg inaugurated an entirely new industry centered on the transformation of foods from their natural state into cooked, shaped, chemically manipulated, mass-manufactured products. During his lifetime, his name appeared on billions of boxes of Corn Flakes, Rice Krispies, All-Bran, Bran Krumbles, Pep, Corn-Soya Shreds and similar products. After his death in 1951, his company pushed glucose-loaded concoctions such as Kellogg’s Sugar Frosted Flakes, Sugar Smacks, Froot Loops, Cocoa Krispies, Pop Tarts and a long list of other processed foods.
                  Many of these products are nutritious and convenient; others may have played a significant role in fueling the current obesity epidemic among children and adults. Regardless of the precise ingredients filling the Kellogg Company’s horn of plenty, Will’s crunchy concoctions make up the most-consumed breakfasts in the history of humankind.
                  John, the once-famous doctor, built his kingdom upon the foundation of his personality and theories on wellness and vitality. It was a realm he dreamed would last forever but one that effectively ended with his funeral. Will died a little more than eight years later, and despite their differences, he is buried only a few dozen feet away from his older brother in Battle Creek’s Oak Hill cemetery.

                  See the latest news and share your comments with CNN Health on Facebook and Twitter.

                  The company he founded remains a multinational behemoth of food production. The charitable foundation he endowed with the mountain of money he made on Corn Flakes is one of the largest in the world and continues to work for the welfare of children, families and communities. When uttering the name “Kellogg” today, it is, undoubtedly, Will’s industry we recall. As Bing Crosby crooned in the opening refrain of a song he recorded in 1968, “What’s more American than Corn Flakes?”

                  Read more: http://www.cnn.com/2017/08/13/health/kellogg-corn-flakes-wellness-history-markel/index.html