S&P MidCap 400 constituent ABIOMED (ABMD) will replace Wyndham Worldwide (WYN) in the S&P 500, Wyndham Worldwide will replace Microsemi Corp. (MSCC) in the S&P MidCap 400, and PRA Health Sciences Inc. (PRAH) will replace ABIOMED in the S&P MidCap 400 effective prior to the open of trading on Thursday, May 31. Wyndham Hotels & Resorts (WH) will be added to the S&P MidCap 400 effective prior to the open of trading on Friday, June 1, replacing GameStop Inc. (GME), which will be removed from the S&P MidCap 400 effective prior to the open of trading on Monday, June 4, and GameStop will replace Fred’s Inc. (FRED) in the S&P SmallCap 600 also effective prior to the open of trading on June 4. New S&P MidCap 400 constituent Wyndham Worldwide, which is changing its name to Wyndham estinations Inc. and its ticker symbol to WYND, is spinning off Wyndham Hotels & Resorts in a transaction expected to be effective on June 1. Post spin-off, Wyndham Destinations will remain in the S&P MidCap 400. GameStop has a market capitalization more representative of the small-cap market space. Fred’s is ranked near the bottom of the S&P SmallCap 600. Perspecta Inc. (PRSP) will replace Office Depot Inc. (ODP) in the S&P MidCap 400, and Office Depot will replace Roadrunner Transportation Systems Inc. (RRTS) in the S&P SmallCap 600 effective prior to the open of trading on Monday, June 4. S&P 500 constituent DXC Technology Co. (DXC) is spinning off Perspecta in a transaction expected to be effective on June 1. Post spin-off, DXC Technology will remain in the S&P 500. Office Depot has a market capitalization more representative of the small-cap market space. Roadrunner Transportation Systems is ranked near the bottom of the S&P SmallCap 600.
Saturday, May 26, 2018
Keryx med may delay dialysis need in patients with advanced kidney disease
Results from an open-label investigator-sponsored study assessing Keryx Biopharmaceuticals’ (NASDAQ:KERX) Auryxia (ferric citrate) in patients with advanced chronic kidney disease (CKD) showed its potential for delaying the need for dialysis. The data were presented at ERA/EDTA in Copenhagen.
The study evaluated ferric citrate compared to standard-of-care (SOC) treatment in late-stage non-dialysis dependent CKD patients who were not expected to start dialysis within eight weeks of study initiation. Participants were randomized 2:1 to receive either a fixed dose of Auryxia (two tablets per meal) or SOC.
In the ferric citrate group, 76 of 133 patients completed the nine months of the study. 30 initiated dialysis, 16 terminated early, eight received a transplant and three died.
In the SOC group, 29 of 66 patients completed the study. 31 initiated dialysis, four terminated early and two died (dialysis results should be based on those who completed the study but 31 > 29).
Geoffrey Block, M.D, Director of Clinical Research at Denver Nephrology says, “The data from this study suggest that administering ferric citrate to late-stage pre-dialysis patients not only improves biochemical parameters associated with chronic kidney disease, but also has the potential to delay the need for dialysis. With the impact of ferric citrate across multiple aspects of CKD, it is worth further investigation to determine which of these many factors is contributing to the reduced risk of renal replacement therapy observed in this study.”
To repel ticks this summer, try insecticide-treated clothes
Outdoor enthusiasts: Here’s a bit of good tick-fighting news just in time for Memorial Day weekend and the unofficial start of summer.
A new U.S. government study confirms that insecticide-treated clothes marketed for preventing tick-borne ills do, in fact, thwart the pests.
In lab tests of clothes bought from one manufacturer, researchers found that the garments either quickly caused ticks to fall off, or rendered them unable to bite.
The study involved three types of ticks that, in the United States, are major carriers of disease—including Lyme disease, Rocky Mountain spotted fever, and what’s known as southern tick-associated rash illness, or STARI.
The clothes were pretreated with permethrin, a synthetic form of an insect-thwarting compound from the chrysanthemum flower. It’s used in insecticide sprays and shampoos and creams that treat lice and scabies.
Several companies already market permethrin-treated shirts, pants, socks and other clothing, as a way to ward off disease-transmitting pests. The new study adds to evidence that the garments are indeed toxic to ticks, according to senior researcher Lars Eisen, of the U.S. Centers for Disease Control and Prevention.
“All tested tick species and life stages experienced the ‘hot-foot’ effect after coming into contact with permethrin-treated clothing,” Eisen said.
That, he explained, made the ticks drop off of “vertically oriented” clothes—which would simulate a pair of pants when a person is standing.
In addition, Eisen said, when the ticks were in contact with the clothes for up to five minutes, they lost their ability to move normally—and to bite.
There are still questions, he noted, including what types of clothing offer the best protection in the real world.
The CDC already recommends permethrin as one tactic for avoiding tick bites. It says that people can “treat clothing and gear, such as boots, pants, socks and tents, with products containing 0.5 percent permethrin.”
The agency further says that “pretreated clothing is available and may be protective longer.”
Thomas Mather is director of the University of Rhode Island’s Center for Vector-Borne Disease and its TickEncounter Resource Center.
He said the new findings, published May 24 in the Journal of Medical Entomology, offer more support for the tick-fighting garments.
“This can be a pretty effective way to stop ticks,” said Mather, who was not involved in the study.
In his own research, Mather found there are benefits even with permethrin-treated summer clothes that leave some skin uncovered—shorts, T-shirts, socks and sneakers.
His team had a group of brave volunteers watch a movie while allowing lab-raised, disease-free ticks to crawl on their bodies. Some wore regular clothes, some wore clothes with permethrin—either pretreated or with the insecticide added using home kits. Those wearing either kind of treated clothing ended up with far fewer live ticks on their bodies by the end of the movie.
While people can use permethrin on their regular clothes, the pretreated garments hold up to many more washings, according to Mather—up to 70.
Some people may be wary of chemically treated clothes. But, Mather said, the amount of permethrin in clothing is very low: A solution containing only 0.5 percent of the pesticide is “dried into” the fabric.
According to the U.S. Environmental Protection Agency, research indicates that permethrin is “poorly absorbed” through the skin, and there’s no evidence that treated clothing could be harmful to children or pregnant women.
U.S. military members have been using permethrin-treated uniforms since the 1990s, the EPA noted. According to Mather, the garments may also be a good bet for people whose jobs keep them outdoors—or for gardeners or anyone else who spends time in places where tick exposure is a concern.
Eisen pointed to some other CDC-recommended ways to cut the risk of tick-borne ills: Avoid wooded and brushy areas with high grass and “leaf litter”; walk in the center of outdoor trails; use EPA-registered repellents containing ingredients such as DEET, picaridin or oil of lemon eucalyptus; thoroughly check your body and clothes for ticks after being outdoors; and shower within two hours of coming back indoors.
Explore further: Tick bite protection: New CDC study adds to the promise of permethrin-treated clothing
More information: Lars Eisen, Ph.D., research entomologist, U.S. Centers for Disease Control and Prevention; Thomas Mather, Ph.D., director, Center for Vector-Borne Disease, and TickEncounter Resource Center, University of Rhode Island, Kingston; May 24, 2018, Journal of Medical Entomology, online
The CDC has more advice on how to avoid tick bites.
Brain’s frontal lobe could be involved in chronic pain, and thus pain relief
A University of Toronto scientist has discovered the brain’s frontal lobe is involved in pain transmission to the spine. If his findings in animals bear out in people, the discovery could lead to a new class of non-addictive painkillers.
For 20 years, Min Zhuo, a professor of physiology in the Faculty of Medicine, has been intrigued by invisible pain, in particular chronic pain with no obvious cause. He has long suspected that the standard way of viewing spinal pain – it must come from injury or tissue inflammation – and the usual understanding of how to treat it – block it from entering the spinal cord – wasn’t telling the whole story.
Now, Zhuo has shown in mice and rats that some spinal pain actually begins in the brain’s frontal lobe, an area previously thought to be uninvolved. And he has shown how treating the pain in this area could be effective at preventing chronic pain. Zhuo published his results May 16 in the journal Nature Communications.
“When doctors can’t see anything wrong to cause chronic pain, often they think patients are making it up,” says Zhuo. “But pain that originates in the frontal lobe would be very different from pain that comes from a physical injury, like a herniated disc. There wouldn’t necessarily be any injury to see. That’s because our personality and emotions live in this region. If the frontal lobe can produce physical pain, that pain would be deeply tied to emotions like anxiety.”
Scientists already knew that the prefrontal cortex was in some way involved in pain because it would light up in scans of people in pain. But that activity was always thought to be symptom not cause, says Zhuo.
“When you have extreme anxiety, more neurotransmitters are released that end up causing pain in the spine,” he says. “Normal functions like walking shouldn’t be painful. But this flood of neurotransmitters sends the spine into hyper drive, and it starts treating ordinary sensations like pain. That could explain why anxiety can cause chest pain and make you think you’re having a heart attack. Or why some people experience pain when you touch them. I believe this helps to explain why emotional pain causes physical pain.”
The good news is that pain from the frontal lobe seems to be transmitted in a simple, direct way to the spine – making it relatively easy to shut down. Neurons in the frontal cortex send signals all the way down the spinal cord, says Zhuo, whereas pain signals from other areas of the brain are mediated by a complex network.
In animals, Zhuo found that pain was associated with increased neurotransmitters released from the frontal cortex. He was able to lessen pain by reducing the amount released. His next step is to test this process in people.
Those who suffer from anxiety along with neuropathic pain would likely benefit from a painkiller targeting the frontal lobe, says Zhuo.
Explore further: Four questions—chronic pain and how it affects the brain
More information: Tao Chen et al. Top-down descending facilitation of spinal sensory excitatory transmission from the anterior cingulate cortex, Nature Communications (2018). DOI: 10.1038/s41467-018-04309-2
CDC IDs outbreak trends tied to treated recreational water
Outbreaks associated with treated recreational water with confirmed infectious etiology are usually caused by Cryptosporidium, Legionella, or Pseudomonas, according to research published in the May 18 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.
Michele C. Hlavsa, M.P.H., from the CDC in Atlanta, and colleagues describe 493 outbreaks associated with treated recreational water reported during 2000 to 2014.
The researchers found that 58 percent of the 363 outbreaks with confirmed infectious etiology were caused by Cryptosporidium, 16 percent by Legionella, and 13 percent by Pseudomonas. Overall, 24,453 cases were identified in the 363 outbreaks; 89, 4, and 3 percent were caused by Cryptosporidium, Pseudomonas, and Legionella, respectively. Of the eight reported deaths, at least six occurred in persons affected by outbreaks caused by Legionella. The leading setting was hotels, which were associated with 32 percent of the 493 outbreaks. The outbreaks had a bimodal temporal distribution: 56 percent started in June to August, and 9 percent started in March.
“Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission,” the authors write. “Pathogens able to evade chlorine inactivation have become leading outbreak etiologies.”
Explore further: Outbreaks linked to drinking water mainly due to Legionella
More information: Abstract/Full Text
When is insurance not really insurance? When you need pricey dental care
This was how I learned all about the Great Divide between medicine and dentistry — especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.
For millions of Americans — blessed in some measure with good genes and good luck — dental insurance works pretty well, and they don’t think much about it. But people like me learn the hard way that dental insurance isn’t insurance at all — not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year — and that’s considered a decent plan.
Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren’t covered at all.
In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional pop-up clinics.
Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.
My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis — a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. Almost half of Americans 30 and older suffer from mild to severe forms of it.
My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries — and that was just the beginning. I’ve since had five more implants, more gum and bone grafts and many, many new crowns installed.
At least I’ve been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children’s dental services, states decide themselves on whether to offer benefits for adults. And many dentists won’t accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.
The program typically pays as little as half of what they get from patients with private insurance. For example, as Kaiser Health News reported in 2016, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared with the $150 and $800 that private patients typically pay.
“It’s really a labor of love to do it,” said Dana Lubet, a recently retired dentist in Madison, Wis., who estimated Medicaid paid only a third of his costs. Accepting too many, he said, “could easily kill your practice.”
A few years ago, while in his mid-50s, Nick DiGeronimo, a facility maintenance worker at a New Jersey sports center, obtained private insurance coverage through the Affordable Care Act, hoping to get treatment for progressive tooth decay.
He needed two implants but, to his dismay, the plan did not cover them. To pay the $10,500 bill, he had to take out loans. “Dental insurance is basically useless,” said DiGeronimo. “It’s a sham, a waste of money, and another case of the haves versus the have-nots.”
As for older Americans, many lose employer-based dental coverage when they retire even as they suffer from increasing dental problems. Among those 65 and older, 70 percent have some form of periodontal disease, according to the Centers for Disease Control and Prevention. Yet basic Medicare plans do not include dental coverage, although options exist for seniors to purchase it.
Overall, in 2015, almost 35 percent of American adults of working age did not have dental insurance. By contrast, only about 12 percent of American adults under 65 did not have medical insurance in 2016. That lack of coverage and treatment can diminish economic and social opportunities — for instance, it can be costly at work or in a job interview not to smile because of unsightly or missing teeth.
Eventually, poor prevention and treatment can become a medical problem — leading to serious, and occasionally deadly, health consequences. In an infamous 2007 case — described by Mary Otto in her book “Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America” — Deamonte Driver, a 12-year-old boy in Maryland, died after a tooth infection spread to his brain. The family’s Medicaid coverage had lapsed.
Research has demonstrated links between periodontal infections and chronic conditions like diabetes and cardiovascular disease. Studies have found associations between periodontitis and adverse pregnancy outcomes, such as premature labor and low birth weight. Tooth problems also hinder chewing and eating, affecting nutritional status.
The split between the medical and dental professions, however, has deep roots in history and tradition. For centuries, extracting teeth fell to tradesfolk like barbers and blacksmiths — doctors didn’t concern themselves with such bloody surgeries.
In the U.S., the long-standing rift between doctors and dentists was institutionalized in 1840, when the University of Maryland refused to add training in dentistry and oral surgery to its medical school curriculum — leading to the creation of the world’s first dental school.
Dentists have in some ways benefited from the separation — largely escaping the corporate consolidation of American medicine, with many making good livings in smaller practices. Patients often willingly pay out-of-pocket, at least to a point.
Some people deliberately forgo dental coverage, considering it less urgent than having insurance against medical catastrophes. “You might not get a job as hostess at the restaurant, but by the same token people that have a lot of missing teeth live to tell the tales,” Lubet said.
With fluoridation and advances in treatment, many Americans have come to take the health of their teeth for granted and shifted their attention to more cosmetic concerns. And the dental field has profited from the business.
In my experience, which includes extensive travel in other countries, Americans often seem disoriented or even horrified when confronted with imperfect dentition. During my period of intense dental care here, I hated wearing temporaries and often braved the public with missing front teeth. I found myself routinely reassuring people that, yes, I knew about the gap, and yes, I was having it dealt with.
Meanwhile, the bold line between what is covered or what is not often strikes patients as nonsensical.
Last fall, Lewis Nightingale, 68, a retired art director in San Francisco, needed surgery to deal with a benign tumor in the bone near his upper right teeth. The oral surgeon and the ear, nose and throat doctor consulted and agreed the former was best suited to handle the operation, although either one was qualified to do it.
Nightingale’s Medicare plan would have covered a procedure performed by the ear, nose and throat doctor, he said. But it did not cover the surgery in this case because it was done by an oral surgeon — a dental specialist. Nightingale had no dental insurance, so he was stuck with the $3,000 bill.
If only his tumor had placed itself just a few inches away, he thought.
“I said, what if I had nose cancer, or throat cancer?” Nightingale said. “To separate out dental problems from anything else seems arbitrary. I have great medical insurance, so why isn’t my medical insurance covering it?”
101 Americans With Over $1 Million In Student Loans
Astronomically high college tuition facilitated by a bottomless ocean of student loans has saddled Americans with a record $1.48 trillion in non-dischargeable debt – an amount which has more than doubled since the 2009 lows.
As we reported in January, nearly 40% of student loans taken out in 2004 are projected to default by 2023 according to the Brookings institute.
While in March we noted that debt-laden millennials were set back an average of $140,000 vs. their parents – a problem compounded by the fact that students aren’t just borrowing money for tuition; their student loans cover rent, food and other bills, leaving them with massive interest payments and in many cases, little prospect of getting ahead – much less saving for retirement.
Enter the million-dollar-debtors
While millions of Americans are drowning in student loans – 101 people have the ultimate albatross around their necks; student loan balances exceeding $1 million, according to the Wall St. Journal. Five years ago, there were just 14 people with loans that large.
Utah orthodontist Mike Meru, 37, is one of them. After graduating from Brigham Young University with no debt and a new marriage, Meru borrowed $601,506 debt to attend USC’s orthodontics program – while his new wife Melissa finding work as a USC administrative assistant to save on tuition. After a few years, his student loan had swelled to $1,060,94.
Mr. Meru said the dental school’s financial-aid director, Sergio Estavillo, estimated that the basic four-year program would require $400,000 to $450,000 in student debt, including interest. Mr. Estavillo said he didn’t recall the conversation but had no reason to doubt its accuracy. –WSJ
And despite Meru’s $225,000 salary in 2017 which leaves him with roughly $13,333 per month after taxes, he makes monthly payments of $1,590 by taking advantage of a government-sponsored debt repayment program. Without the program which still leaves his debt growing at $130 a day, Meru’s monthly payments would be $10,541.91 according to an email from his loan servicer. At this rate, Meru’s loan balance will exceed $2 million in 20 years.
Since refinancing his debt with the federal government in 2015, lowering the rate to 7.25%, Mr. Meru’s balance has grown by $148,948. It will keep growing through the 25-year life of the repayment plan until it reaches $2 million. -WSJ
All is not lost for Meru and many others like him, however – because thanks to the repayment program, Meru’s $2 million balance will be forgiven after 25 years.
He agreed to monthly payments at 10% of his discretionary income, defined as adjusted gross income minus 150% of the poverty level. Any balance remaining after 25 years is forgiven, effectively covered by taxpayers. The forgiven amount is then taxed as ordinary income. -WSJ
And while crushing Meru’s debt load places him in the upper echelon of those drowning in student loans, he attempted to mitigate the financial pain early on, before rates jumped and the snowball began to gather speed.
USC charged tuition of $56,757 in Mr. Meru’s first year, American Dental Association records show. To save on expenses, the couple lived with his parents. He drove a Buick inherited from his wife’s grandmother for the hour-plus trip between Newbury Park and USC, located south of downtown Los Angeles. After his first year, and with his wife’s tuition discount, he owed $43,976.By Mr. Meru’s second year, the interest rate on new student loans jumped to 6.8%, and USC raised its tuition by 6%. By the end of that school year, he had taken out a total of $115,000 in loans, which also covered a summer semester. Interest rates were roughly triple what he had planned for.
Between Mike Meru and the other 100 people with $1 million or more in student loans, US taxpayers will be on the hook for around $200 million – again, just for those 101 individuals. Unfortunately, that’s just the tip of the iceberg.
While the typical student borrower owes $17,000, the number of those who owe at least $100,000 has risen to around 2.5 million, nearly 6% of the borrowing pool, Education Department data show.…More than a third of borrowers from one of the government’s main graduate school lending programs have enrolled in some form of federal loan-forgiveness plan. -WSJ
Outraged at his situation, Meru started a national dental-student movement in order to lobby Congress for lower rates on grad students. The effort, according to the Journal, went nowhere. Some dental school educators, meanwhile, have begun to worry about prohibitively expensive tuition.
USC’s dental school is one of the costliest higher educations one can attain – at $91,000 per year, and $137,000 when living expenses are factored in.
“I don’t think you’ll find any dental school dean in the country who will not tell you they’re concerned about the cost,” said Dr. Avishai Sadan, dean of USC’s Herman Ostrow School of Dentistry. “But what’s the action?”
Sadan says USC raised tuition “to cover the cost of delivering a top education.” (aka a top-tier dental school can take maximum advantage of the student loan racket).
“You cannot decide you’re just not raising tuition,” he said. “Everything that drives the operation, from salary raises to any other additional costs, have to come, for the most part, from tuition.”
Bottom line: with so many borrowers set to default on their student loans, those who can’t make ends meet will be able to pay roughly 10% of their income for 25 years. The remainder, such as Mark Meru’s $2 million balance, will be an obligation of the United States taxpayer.
Lord knows the banks who facilitated this scheme aren’t going to cover it.
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