Month: January 2014

3D brain maps on iPhone guide doctors during surgeries

Many brain surgeons in developing countries look to their smartphones for guidance, and luckily for them, phones have started fulfilling this role in part, thanks to the thousands of 3D brain images, produced by Dr. Albert Rhoton at the University of Florida, that are freely available online.

“I’ve had young surgeons from Africa, Brazil and other countries tell me they’re pulling the images into the operating room, Live Science quoted Rhoton, head of the Neuro-Microanatomy Lab at the University of Florida’s McKnight Brain Institute, as saying.

As a training tool for surgical residents, Dr. Rhoton’s image library has grown into the world’s largest collection of 3D brain images. Physicians from across the globe now use the detailed anatomical images to train residents, prepare for surgeries and even guide them while performing surgeries.

Dr Rhoton said the images are their small contribution to making what is a delicate, awesome experience for neurosurgery patients more accurate, gentler and safer.

Rhoton has collected images of brain anatomy for as long as he’s been teaching surgery 50 years ago and began moving to 3D technology 25 years ago.

However, only recently did he realize how smartphones and online downloads could expand the reach of his educational tools. Two and a half years ago, Rhoton and his colleagues began working with the American Association of Neurological Surgeons (AANS) to make the brain images and videos available on iTunes University free of cost.

Even before the iTunes U venture, Rhoton had shared his brain images with hospitals and universities as a visiting instructor.

The 3D images show the detailed structure of various sections of the brain, with blood vessels and nerves color-coded in bright red and blue. The colors make the details of neural anatomy clearer than in the normal, grayish brain matter.

Rhoton and the residents he instructs have built up the library over decades, performing careful dissections and transferring the images they obtain to 3D photography and video.

The iTunes U content is engineered to be usable across device platforms, from iPhones to laptops to 3D television.

Rhoton’s work earned him the 2011 Surgeon of the Year award from the journal World Neurosurgery.

Seeing how surgeons have used the images during actual surgeries, Rhoton and AANS next hope to feed the brain maps directly into endoscope screens used in surgery

Source: Ani news

 

Daily routines may influence sleep quality, quantity

Maintaining a consistent daily routine may be linked to better sleep, according to a small new study.

Young adults who went to work and ate dinner around the same time every day typically slept better and woke up fewer times during the night. They also fell asleep more quickly at bedtime.

Yet the exact time people performed daily activities—say, eating dinner at 6 p.m. versus 8 p.m. —had little bearing on how well they slept.

“For the majority of sleep outcomes, we found that completing activities at a regular time better predicted sleep outcomes than the actual time of day that activities were completed,” Natalie Dautovich, a psychologist at the University of Alabama in Tuscaloosa, said. She led the study, which was published in the Journals of Gerontology: Series B.

“For example, people reported better sleep quality and fewer awakenings at night when they were consistent in the time they first went outside,” Dautovich told Reuters Health in an email.

On the other hand, for older adults, inconsistent daily schedules were sometimes linked with better sleep, the researchers found.

For instance, older people whose dinnertime varied tended to sleep longer at night. And those who started home activities or began work at different times each day fell asleep more quickly.

The study included 50 adults between the ages of 18 and 30 and another 50 between 60 and 95. Participants kept a diary of when they performed regular activities and how well they slept at night for two weeks.

Instead of opening the door to new recommendations or sleep treatments, the authors said the study best serves to create questions for future research.

Those questions include whether older adults who have more variation in their daily schedules are already healthier and more socially active—or whether it’s the variety in one’s everyday schedule that provides the activity and stimulation that help ensure good sleep, according to Dautovich.

“We know that good sleep at night is dependent in part on our drive to sleep, which is based on how active and alert we are during the day,” she said.

For that reason, being out and about during the day remains one of the best ways to maximize the chances of a solid night of shut-eye.

“Greater activity and levels of alertness during the day increase our need to sleep at night,” Dautovich said.

Source: GMA network

Women may skip radiation therapy over child care concerns

Child care issues may keep breast cancer patients from getting the treatments they need, a new study suggests.

Mothers with young children were more likely to skip recommended radiation treatments after breast cancer surgery because of worries about the time involved, researchers found.

In particular, women who had a breast tumor removed were less likely to undergo radiation therapy afterwards if they had kids age seven or younger at home.About 81 per cent of women surveyed in the study who had younger kids received radiation therapy. The rates of radiation therapy for women with older kids or none at all ranged between 84 and 87 per cent.

Put another way, one in five women with young kids in the study skipped potentially life-saving post-surgery treatment, said Ya-Chen Tina Shih, an economist and associate professor of medicine at the University of Chicago in Illinois who co-led the study.

“We were surprised because women in the younger age range have the longest life expectancy, so we expected to see a higher compliance rate among them,” she told Reuters Health.

“Women may think, ‘I really need to take care of the kids at home,’ and they may act on what they believe is most important at that time,” Shih said.

“But they may not be aware of how important radiation therapy is.”

Women who have “lumpectomy” surgery to remove a breast tumor – the researchers did not include patients who had mastectomies – are usually advised to follow up with radiation therapy, which requires a serious time commitment. The radiation treatments take up to an hour, five days a week, for up to seven weeks, the researchers report.

“Many have hypothesized that young children might be a barrier for younger women, but this paper is the first to demonstrate that,” wrote Dr. Nancy Keating in an email to Reuters Health.

Keating, an associate professor at Harvard Medical School’s Department of Health Care Policy in Boston, was not involved in the new study.

“It suggests there is a modifiable barrier to improving care: providing child care,” Keating said.

For their study, Shih and her team looked at 21,008 patients who filed breast cancer surgery claims between 2004 and 2009 with employer-sponsored insurance.

From the data provided by Truven Health Analytics, researchers knew how many kids – dependents – were in a woman’s household.

The team found additional barriers to radiation therapy. Patients who enrolled in HMO plans, or PPO plans with fixed reimbursement amounts, were less likely to follow through with the treatment. If a patient had to travel far for the surgery itself, then she was also less likely to get radiation.

But this study’s biggest contribution is highlighting how childcare may play a role, Keating said.

Women, like those in the study, who chose breast-conserving surgery and not a mastectomy, “may not understand that the surgery is equivalent to mastectomy in terms of outcomes if women also get the radiation,” Keating wrote.

Shih pointed out that one weakness in her team’s report, published in the Journal of the National Cancer Institute, was that they did not talk to the patients themselves to record their reasons for not getting radiation therapy.

The study shows an association between the age of a woman’s children and her likelihood of opting out of radiation, but does not prove cause and effect.

Future studies could also investigate the rates of radiation therapy among women without insurance, or with less generous benefits, Shih said.

But for now, “the person in charge of a patient’s entire cancer care needs to make sure that they know if a patient has younger kids,” Shih said.

“If friends and family can make a commitment to help with the patient’s child care needs for a month or two – that could make a big difference,” she said.

The findings “suggest that providers, like hospitals, physician groups or health systems, could potentially help by providing assistance with child care,” Keating said.

Source: Khaleej times

Young adults ‘damage DNA’ with weekend alcohol consumption

College students are renowned for partying at the weekends, and this usually involves having a drink or two. But new research has found that this level of alcohol consumption may cause damage to DNA. This is according to a study published in the journal Alcohol.

The National Institute on Alcohol Abuse and Alcoholism states that around four out of five college students in the US drink alcohol and 1,825 college students between the ages of 18 and 24 die each year as a result of unintentional alcohol-related injuries.

According to the study researchers, including co-author Jesús Velázquez of the Autonomous University of Nayarit in Mexico, previous research studying the effects of alcohol consumption has mainly been carried out in individuals who have been drinking for long periods of time.

These individuals usually have illnesses as a result of their alcohol consumption, such as liver damage, cancer or depression.

But the investigators say their study is “pioneering,” as it analyzes the effects of alcohol consumption on young people who are healthy.

Oxidative damage caused by alcohol consumption

The researchers set out to determine the level of oxidative damage caused by alcohol consumption in two groups of people between the ages of 18 and 23. Oxidative stress can cause damage to proteins, membranes and genes.

One group drank an average of 1.5 liters of alcoholic beverages every weekend, while the other group did not consume any alcohol.

All participants underwent blood tests to ensure they were healthy and were free of any diseases or addictions.

The researchers also measured the activity of dehydrogenase – an enzyme responsible for metabolizing alcohol (ethanol) into acetaldehyde – as well as acetoacetate and acetone activity.

Using a thiobarbituric acid reactive substances (TBARS) test, the researchers were able to assess oxidative damage. The test allowed them to see how ethanol in the blood, and the acetaldehyde produced by dehydrogenase in reaction to ethanol, affects the lipid peroxidation that impacts cell membranes.

Results of the study revealed that the alcohol-consuming group demonstrated twice as much oxidative damage to their cell membranes, compared with the group that did not drink.

Signs of DNA damage through alcohol consumption
An additional experiment, called the comet test, was conducted to see whether the participants’ DNA was also affected by alcohol consumption. This involved taking out the nucleus of lymphocytic cells in the blood and putting it through electrophoresis.

The researchers explain that if the cells are faulty and DNA is damaged, it causes a “halo” in the electrophoresis, called “the comet tail.”

The experiment revealed that the group who consumed alcohol showed significantly bigger comet tails in the electrophoresis, compared with the group that did not drink alcohol.

In detail, 8% of cells were damaged in the control group, but 44% were damaged in the drinking group. This means the drinking group had 5.3 times more damage to their cells.

However, the investigators say that they were unable to confirm there was extensive damage to the DNA, as the comet tail was less than 20 nanometers. But the investigators say their findings still raise concern.

They explain:

“The fact is, there should not have been any damage at all because they had not been consuming alcohol for very long, they had not been exposed in a chronic way.”

Overall, they conclude that oxidative damage can be found in young adults with only 4-5 years’ alcohol drinking history, and that this is the first study to provide evidence of this damage in individuals at the early stages of alcohol abuse.

Other studies have detailed some positive effects of moderate alcohol consumption. Medical News Today recently reported on a study suggesting that drinking alcohol in small doses may boost the immune system.

Source: Medical news today

Scientists discover new way of overcoming human stem cell rejection

Human embryonic stem cells have the capacity to differentiate into a variety of cell types, making them a valuable source of transplantable tissue for the treatment of numerous diseases, such as Parkinson’s disease and diabetes.

But there’s one major issue: Embryonic stem cells are often rejected by the human immune system.

Now, researchers from the University of California San Diego may have found an effective way to prevent this rejection in humans. Utilizing a novel humanized mouse model, the scientists have revealed a unique combination of immune suppressing molecules that stop the immune system from attacking the injected stem cells – without shutting the system down completely.

This discovery could ultimately help resolve some of the major problems currently limiting the use of embryonic stem cells for certain conditions, paving the way for the development of more effective human stem cell therapies.

“This is a generic way of immune suppression, so it could potentially be applied not just for stem cells therapies, but for organ transplants as well,” Yang Xu, a professor of biology at UC San Diego and lead author of the study, told FoxNews.com. “It can be very broad.”

Embryonic stem cells are different from the other cells in a patient’s body, making them “allogenic.” This means the immune system will recognize them as foreign agents and attack them.

One way of overcoming this rejection problem is to give patients immunosuppressant drugs, which suppress the entire immune system. While short term use of immunosuppressants has been successful for many organ transplants, embryonic stem cell therapies for chronic diseases require long term use of these drugs – which can often be very toxic and increase the risk of cancer.

“In order for the patient to really use this therapy, they have to decide: Do they want a lifelong use of immunosuppressant drugs, or are they willing to live with the symptoms of their disease,” Xu said.

Source: news.nom

Woman’s tragic death witnessed by family on laptop

A nurse in a Michigan hospital kissed the patient’s forehead. More than 6,000 miles away, Sanaz Nezami’s family in Iran watched on a laptop computer and wept.

Nezami, a vibrant 27-year-old woman who could speak three languages, wanted to pursue an advanced degree in engineering at Michigan Technological University. Instead, she was brain dead just a few weeks after unpacking her bags, the victim of a fatal beating by her new husband, according to police.

Technology allowed family in Iran to watch her final hours. The family’s faith in the hospital staff led to consent for an extraordinary donation: Nezami’s heart, lungs and other life-saving organs were transplanted to seven people in the U.S., a remarkable gift that occurs in less than 1% of all cases.

“We wanted God to perform a miracle and bring Sanaz back to life,” her sister, Sara Nezami, said in a phone interview from Tehran. “But this is a miracle. Sanaz gave her life in order to give life.”

A nurse who took care of Sanaz Nezami said the experience was “eye-opening” for hospital staff.

“The family was willing to trust us to know she wasn’t coming back,” Kim Grutt said.

In August, Nezami married Nima Nassiri in Turkey and lived with him temporarily in the Los Angeles area, where he was born and raised. Her sister said the two met over the Internet.

Nezami, a native of Tehran, had a bachelor’s degree in engineering and a master’s in French translation. She wanted a doctorate degree in environmental engineering.

On Dec. 7, she asked her sister to proofread some English-to-Persian translation she was doing on the side.

“I was shocked,” Sara Nezami said. “Sanaz was a very precise girl, but she omitted some lines. I asked, ‘Are you OK?’ She told me there was no problem.”

The next day, Sanaz Nezami was rushed to a hospital with severe head injuries and was transferred to Marquette General Hospital. Police believe she was assaulted by her husband, who has been charged with second-degree murder. His attorney, David Gemignani, declined to comment.

“Her brain was so swollen and so damaged, there was no longer any blood flow,” explained Gail Brandly, who supervises nurses at the hospital.

No one knew anything about Nezami, so Brandly ran her name through Google. Suddenly, the stranger who couldn’t speak for herself came alive through a résumé posted online.

After about 24 hours, the hospital reached relatives in Iran. Immediate travel to the U.S. was impractical due to visa requirements, so a laptop was set up so the family could see Nezami on life support and talk to nurses and doctors over Yahoo Messenger.

“It isn’t something we’ve done in the past. It’s not every day we’re dealing with family members so far-flung,” said Dave Edwards, spokesman for the hospital.

At one point, Grutt was asked to stroke Nezami’s head and kiss her forehead.

Nezami was buried Dec. 18 in a local cemetery. As a light snow fell, the hospital’s chaplain, the Rev. Leon Jarvis, read Muslim prayers over the casket while about 20 people, mostly nurses and others who cared for her, watched.

Source: detroit free press

Japan’s population declines by record 244,000 in 2013

The number of Japanese births hit a record low in 2013 while the death rate was the highest since the end of World War II, according to health ministry estimates.

Ministry officials determined the nation’s population fell by a record 244,000 for the year by deducting the number of births from the number of deaths.

“The trend of population decline will likely continue for a substantially long period of time,” a ministry official said.

It is the seventh consecutive year Japan has experienced a decrease in its population.

According to the estimates released on Dec. 31, the number of babies born in 2013 fell by 6,000 from the previous year to 1,031,000, the lowest number since such statistics became available in 1899. The ministry cited the decline in the number of women still in their childbearing years.

Meanwhile, 1,275,000 people–up 19,000 from the previous year–died in 2013, reflecting the aging of Japanese society.

The Japanese population declined for the first time in 2005. In 2006, the country saw a short-lived increase, but it has been falling steadily since 2007.

The fertility rate–the number of children a woman is expected to give birth to in her lifetime–was 1.41 in 2012. The ministry estimated that figure remains unchanged for 2013.

The statistics also showed that 663,000 couples married and 231,000 divorced in 2013.

Source: Asia and Japan watch

Relapse of ‘cured’ HIV patients spurs AIDS science on

Scientists seeking a cure for AIDS say they have been inspired, not crushed, by a major setback in which two HIV positive patients believed to have been cured found the virus re-invading their bodies once more.

True, the news hit hard last month that the so-called “Boston patients” – two men who received bone marrow transplants that appeared to rid them completely of the AIDS-causing virus – had relapsed and gone back onto antiretroviral treatment.

But experts say the disappointment could lay the basis for important leaps forward in the search for a cure.

“It’s a setback for the patients, of course, but an advance for the field because the field has now gained a lot more knowledge,” said Steven Deeks, a professor and HIV expert at the University of California, San Francisco.

He and other experts say the primary practical message is that current tests designed to detect even very low levels of HIV present in the body are simply not sensitive enough.

As well as having the human immunodeficiency virus (HIV), the Boston patients both also had a type of blood cancer called lymphoma, for which they were treated using bone marrow transplants – one man in 2008 and the other in 2010.

They continued taking the antiretroviral AIDS drugs, but eight months after each patient’s transplant, doctors found they could not detect any sign of HIV in their blood.

In the early part of 2013, both patients decided to stop taking their AIDS drugs and both appeared to remain HIV-free – prompting their doctors, Timothy Henrich and Daniel Kuritzkes from Boston’s Brigham and Women’s Hospital, to announce at a conference in July that they may have been cured.

Yet in December came news that one of the men had begun to show signs of an HIV rebound by August, while the second patient had a relapse in November.

Henrich said the virus’ comeback underlined how ingenious HIV can be in finding hiding places in the body to evade attack efforts by the immune system and by drug treatment.

“Through this research we have discovered the HIV reservoir is deeper and more persistent than previously known and that our current standards of probing for HIV may not be sufficient,” he said, adding that both patients were “currently in good health” and back on antiretroviral therapy.

INSPIRATION

Barely a decade ago, few HIV scientists would have dared put the words HIV and cure in the same sentence. Yet some intriguing and inspiring cases in recent years mean many now believe it is just a question of time before a cure is found.

First was the now famous case of Timothy Ray Brown, the so-called “Berlin patient,” whose HIV was eradicated by a complex treatment for leukemia in 2007 involving the destruction of his immune system and a stem cell transplant from a donor with a rare genetic mutation that resists HIV infection.

Such an elaborate, expensive and life-threatening procedure could never be used as a broad-spectrum approach for the world’s 34 million HIV patients. But the results in Brown focused scientific attention on a genetic mutation known as ‘CCR5 delta 32’ as a target for possible gene therapy treatment.

Then last March, French scientists who followed 14 HIV-positive people known as the “Visconti patients”, who were treated very swiftly with HIV drugs but then stopped treatment, said that even after seven years off therapy, they were still showing no signs of the virus rebounding.

That announcement came only weeks after news of the “functional cure” of an HIV-positive baby in Mississippi who received antiretroviral treatment for 18 months from the day she was born. By the time she was two this appeared to have stopped the virus replicating and spreading.

A “functional cure” is when HIV is reduced to such low levels that it is kept at bay even without treatment, though the virus can still be detected in the body.

Sharon Lewin, an HIV expert at Monash University in Australia, said all these developments, as well as the setback suffered by the Boston patients, inspired scientists to investigate many different approaches in the search for a cure.

“We’ve learnt many things here – and one of the most important is that a tiny, tiny amount of virus can get the whole thing going again,” she told Reuters. “It’s a clear message that we need better ways to pick up the virus.”

Scientists are now more convinced than ever that a two-pronged approach which aims to firmly suppress the virus while bolstering the immune system provides the best way forward.

“We need to attack in two ways – reduce the virus to very low levels and also to boost the immune response. We can’t do one without the other,” said Lewin.

“So we still have to think of other creative ways to control HIV. And it’s still early days… before we can say which approach is likely to be the winner.”

Source: orlando sentinel

Study Finds Texting, Dialing Dangerous While Driving, Talking Less So

A sophisticated, real-world study confirms that dialing, texting or reaching for a cellphone while driving raises the risk of a crash or near-miss, especially for younger drivers. But the research also produced a surprise: Simply talking on the phone did not prove dangerous, as it has in other studies.

This one did not distinguish between handheld and hands-free devices — a major weakness.

And even though talking doesn’t require drivers to take their eyes off the road, it’s hard to talk on a phone without first reaching for it or dialing a number —things that raise the risk of a crash, researchers note.

Earlier work with simulators, test-tracks and cellphone records suggests that risky driving increases when people are on cellphones, especially teens. The 15-to-20-year-old age group accounts for 6 percent of all drivers but 10 percent of traffic deaths and 14 percent of police-reported crashes with injuries.

For the new study, researchers at the Virginia Tech Transportation Institute installed video cameras, global positioning systems, lane trackers, gadgets to measure speed and acceleration, and other sensors in the cars of 42 newly licensed drivers 16 or 17 years old, and 109 adults with an average of 20 years behind the wheel.

The risk of a crash or near-miss among young drivers increased more than sevenfold if they were dialing or reaching for a cellphone and fourfold if they were sending or receiving a text message. The risk also rose if they were reaching for something other than a phone, looking at a roadside object or eating.

Among older drivers, only dialing a cellphone increased the chances of a crash or near miss. However, that study began before texting became more common, so researchers don’t know if it is as dangerous for them as it is for teens.

Engaging in distractions increased as time went on among novice drivers but not among experienced ones.

The National Institutes of Health and the National Highway Traffic Safety Administration paid for the research. Results are in Thursday’s New England Journal of Medicine.

David Strayer, a University of Utah scientist who has done research on this topic, said the findings that merely talking on a phone while driving was not dangerous is “completely at odds with what we found.”

The study methods and tools may have underestimated risks because video cameras capture wandering eyes but can’t measure cognitive distraction, he said.

“You don’t swerve so much when you’re talking on a cellphone; you just might run through a red light,” and sensors would not necessarily pick up anything amiss unless a crash occurred, Strayer said.

As for texting, “we all agree that things like taking your eyes off the road are dangerous,” he said.

At least 12 states ban the use of hand-held cellphones while driving and 41 ban text messaging. All cellphone use is banned by 37 states for novice or teen drivers, says the National Conference of State Legislatures, citing information from the Governor’s Highway Safety Administration.

Source: NBC Bay area

Medicaid expansion increased visits to emergency rooms

People newly enrolled in a health insurance program for the poor were more likely to visit the emergency department for care than people who remained uninsured, Boston-area researchers have found, providing the best evidence to date that the national Medicaid expansion that began this week is unlikely to lead to a decline in costly emergency services.

The study was published online Thursday by the journal Science, just as millions of Americans have become newly eligible for Medicaid coverage under the Affordable Care Act. Some politicians have suggested that people who were uninsured and didn’t have a regular doctor or put off basic treatment until their condition became serious, would, once they had coverage, get the primary care they needed to avoid trips to the emergency department.

Previous research on what happened to ER usage in Massachusetts, which expanded its Medicaid program and mandated that most residents have health insurance in 2006, have reached conflicting conclusions. But the new study, of about 25,000 low-income adults randomly selected in 2008 to enroll in Oregon’s Medicaid program, found that the newly insured increased their use of all types of medical care, including prescription drugs, hospital stays, and outpatient visits. Emergency department visits were no exception.

Over an 18-month period, about 42 percent of the new Medicaid enrollees visited the emergency department. In the same period, about 35 percent of those who did not receive Medicaid visited the emergency department.

“Basic economic theory is, if you lower the price, people use it more,” said Amy Finkelstein, a Massachusetts Institute of Technology economist and a senior author on the paper.

It was not a foregone conclusion in this case, however, that reducing the cost of an emergency room visit would increase use, she said, because the cost of a visit to a primary care doctor and of preventive services that may have helped them avoid the emergency room also decreased with insurance coverage.

Yet, emergency department use among those on Medicaid increased during businesses hours, nights, and weekends. While there was no increase in visits classified as non-preventable emergencies, there was an increase for visits deemed preventable or treatable by a primary care doctor.

A 2011 study found that overall emergency department visits increased in Massachusetts in the two years after the state expanded insurance coverage under the 2006 state health care law, though visits for “low severity” problems declined slightly. Dr. Peter Smulowitz, an emergency physician at Beth Israel Deaconess Medical Center and lead author on that study, said he and colleagues have more recently reviewed emergency department use across Massachusetts and found a small increase in pockets of the state that had seen the largest gains in insurance coverage. The study is pending publication.

Data published in the New England Journal of Medicine in 2011, however, found that ER usage was already increasing in Massachusetts and nearby states before the expansion of health insurance coverage here, and that the law did not change the trend in Massachusetts when compared to the other states.

The Oregon study is unique in that it is a randomized controlled study, considered the gold standard in medical research but rarely feasible in health policy research. The state of Oregon created a valuable study scenario when, because the state had money only for a small expansion of the program, it held a lottery for Medicaid coverage, providing insurance to some people and leaving others uninsured.

Past work by principal investigators Finkelstein and Katherine Baicker, a professor of health economics at Harvard School of Public Health, and their colleagues at the National Bureau of Economic Research in Cambridge has found that the lottery winners were more likely to report feeling better about their mental and physical health and had less financial strain, including fewer bills sent to collection. But there was no improvement in key health factors, such as blood pressure or blood sugar levels, as compared with the uninsured.

With the latest study, Baicker said, the body of research out of Oregon has disproved both the worst and best predictions for Medicaid — that it is an expensive program that does little to improve access to care and overall health, or alternatively, that it is a money-saving program that clearly improves health. The results are far more nuanced.

“Policymakers should make decisions based on this evidence that the program has real costs. It’s not free,” she said. “And, it has real benefits. Beneficiaries are clearly better off.”

Source: the boston globe