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Comment on: Maternal autoantibodies are associated with abnormal brain enlargement in a subgroup of children with autism spectrum disorder

14 Feb

In 2008 a paper opened up a new area of research in autism risk factors: Autism: maternally derived antibodies specific for fetal brain proteins. The researchers at the U.C. Davis MIND Institute found that for a subset of autistic kids, they could find antibodies in the mothers’ sera that reacted to human fetal brain tissue. Other teams have found similar results, and the MIND researchers have continued to explore this topic.

In the present study, the researchers studied 131 ASD kids and 50 non-ASD controls. 10 of the ASD kids were born to mothers with the brain specific autoantibodies detected in their serum. Autism severity, by their measure, was the same for the two ASD groups. The rate of develpmental regression is the same for the two groups, but strikes me as rather high at 40-50% . Previous studies by this team and others indicated a higher rate of regression in the ASD kids in the maternal-autoantibody group.

Brain volumes were measured via MRI. Most children were tested during sleep. 10 children (all ASD) were tested under anesthesia. Scans were corrected for instrument distortions before volumes were measured. Brain volumes were higher for the ASD kids than the typical kids, consistent with previous results. However, the kids in the maternal autoantibody group had brain volumes even higher than the rest of the ASD kids. The kids in the maternal autoantibody group had brains 12% larger on average than the non ASD kids, while the rest of the ASD group had about 4.4% larger volumes.

The volume differences were not the same over the entire brain:

Furthermore, the frontal lobe was selectively enlarged in the ASD-IgG children relative to other ASD children, and both gray and white matter were similarly affected.

Previous work by the authors indicate the possibility that the autoantibodies themselves might cause brain differences resulting in autism. Their animal model was rhesus monkeys, whose mothers were injected with the autoantibodies.

The authors note there are a number of open questions:

Obviously, several questions remain: What are the brain antigens recognized by the 37/73 kDa maternal IgG autoantibodies, and what is their role normal neurodevelopment? What induces the production of these antibodies in some women but not in others? What is the mechanism by which these maternal autoantibodies alter brain development? Are there processes that could be implemented to block the deleterious effects of the antibodies? Studies are currently underway to address each of these issues and they will undoubtedly shed more light on the role that maternal
autoantibodies may play in ASD and abnormal brain enlargement in ASD.

Another open question they raise has to do with siblings of the autoantibody ASD kids. In specific, since these autoantibodies can persist in the mother’s serum for many years, it is likely that younger siblings are exposed to them as well. If these children do not develop ASD, what is the reason?

The brain volume differences are shown in summarized in this figure:

Antibodies figure

There is a large spread for the brain volumes for the non-autoantibody ASD kids. While on average they are larger, a number are comparable to the average for non-ASD kids. Also, there is a large overlap between the ASD groups from parents positive for the autoantibodies and without the autoantibodies. The kids in the autoantibody group are almost all at the high end of the distribution for the non-ASD kids.

The main thing this paper adds to the autoantibody story is evidence that this may represent a separate group within the ASD population. The work is being performed on members of the Autism Phenome Project. If this is a separate group, so far the evidence is only in brain volume. The authors note: “There were no differences in age, height, autism severity, or DQ between the two ASD groups. Furthermore, the two groups did not differ in the rate of parent reported history of regression.” So on other physical measures, and on autism-based measures, there are no differences. Obviously it would be valuable to see diffrences in autism-specific measures so we could back track how those measures are related to etiology and brain structure. But it is also interesting that this group does not have differences as it could indicate multiple pathways are not always distinct in the end result in autism development.

Nordahl, C., Braunschweig, D., Iosif, A., Lee, A., Rogers, S., Ashwood, P., Amaral, D., & Van de Water, J. (2013). Maternal autoantibodies are associated with abnormal brain enlargement in a subgroup of children with autism spectrum disorder Brain, Behavior, and Immunity DOI: 10.1016/j.bbi.2013.01.084

ResearchBlogging.org

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By Matt Carey

Comment on: Use of Birth Certificates to Examine Maternal Occupational Exposures and Autism Spectrum Disorders in Offspring.

13 Feb

A recent hypothesis-generating study by the epidemiology team at Kaiser in California looks at whether one can use birth certificates as a starting point to identify possible maternal exposures which might increase autism risk. Birth certificates include parental occupation. So, the authors propose, one could categorize occupations by possible exposures and, if there more autistic children are born to parents with various occupation types. The study is: Use of Birth Certificates to Examine Maternal Occupational Exposures and Autism Spectrum Disorders in Offspring.

Here is the abstract:

The continuing rise in the prevalence of autism spectrum disorders has led to heightened interest in the role of nongenetic factors, including exogenous exposures, but little research has been conducted. To explore a possible role in autism etiology, we used data available from our prior studies to examine potential occupational exposures, as these may occur at higher levels than environmental exposures. Parental occupation was obtained from birth certificates for 284 children with autism and 659 controls, born in 1994 in the San Francisco Bay Area. Self-reported occupation and industry were coded into eight exposure/chemical groups based on potential neurotoxicity or reprotoxicity by a board-certified physician in occupational medicine and an industrial hygienist blinded to case-control status. Mothers of autistic children were twice as likely to work in occupations considered exposed (14.4%) as mothers of controls (7.2%) (adjusted odds ratio [AOR] 2.3 [95% confidence interval {CI} 1.3-4.2]). The exposure categories of the greatest frequency among case mothers were exhaust and combustion products (AOR = 12.0 [95% CI 1.4-104.6]) and disinfectants (AOR = 4.0 [95% CI 1.4-12.0]). Paternal occupational exposure was not associated with autism, potentially consistent with a direct in-utero exposure effect. There are several limitations of this hypothesis-generating study, including lack of detail on workplace and job duties, leading to possible misclassification and low proportion exposed. However, this misclassification would not be biased by case-control status and is unlikely to explain the associations we did find, suggesting that further research on exogenous exposures may yield useful etiologic clues

There are a lot of limitations to this study, and the authors make that quite clear. The study is written as a “hypothesis-generating” study. I.e. they can create hypotheses of possible exposures which might increase autism risk. Taken in that context, a limited study which can generate hypotheses, this is a good study. One which takes a fairly inexpensive and straightforward route to narrow the list of possible exposures which increase autism risk.

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By Matt Carey

Texas Observer article: Autism Inc.: The Discredited Science, Shady Treatments and Rising Profits Behind Alternative Autism Treatments

12 Feb

The Texas Observer published an article two weeks ago: Autism Inc.: The Discredited Science, Shady Treatments and Rising Profits Behind Alternative Autism Treatments. In the article, author Alex Hannaford discusses the alternative-medicine/vaccine-causation community, the therapies they promote and the lack of evidence behind them. Mr. Hannaford argues that Texas, in particular, is a center for this movement:

To compound the problem, a host of celebrities act as unpaid marketing reps for these unproven treatments, touting a pervasive (but incorrect) belief that autism is caused by childhood vaccines. This misinformation campaign has led, in the last few years, to a decline in the number of children receiving lifesaving inoculations. And Texas has become a center for alternative autism treatment and the anti-vaccine crusade.

Texas, of course, is the home of Andrew Wakefield. Mr. Wakefield, as most will recall, made his name in the autism community promoting the idea that the MMR vaccine was causal not only in some autism cases, but in giving rise to the rise in autism diagnoses observed in the U.S. and the U.K.. Mr. Wakefield’s primary paper has been retracted, his license to practice medicine pulled for unethical practices, he has resigned his position at what was then called “Thoughtful House” and multiple studies have demonstrated the lack of substance in his ideas.

Mr. Hannaford discusses much of this, including extensive quotes from Michael Fitzpatrick, a U.K. autism parent who has been a long-time critic of Andrew Wakefield’s work, James Laidler, whose work with the alternative medicine movement has been documented and, while not calling him out by name, Brian Deer‘s work in the BMJ is also cited. Mr. Hannaford also cites Wakefield supporters Jane Johnson, for whom Thoughtful House is now named (the Johnson Center), filmmaker Robert Rodriguez and, of course, Jenny McCarthy.

I am unconvinced that Texas is a particular hotbed of the alt-med/vaccine-focused autism community. But perhaps this is colored by the fact that my home town is now headquarters for TACA, AutismOne, SafeMinds and more. However, the idea that a great deal of untested and scientifically unsound “therapy” is promoted to the autism parent community is something I do not contest in the least.

Mr. Hannaford concludes his article, citing Dr. Jody Jensen, director of research of the Autism Project at the University of Texas:

“We are not doing anything special,” Jensen said. “What we are doing is providing the resources to allow these kids to be safe and to explore and experience things like every other child. That’s what’s often lacking. It’s about trying to restore some sense for them of what a typical childhood looks like.”

That is what parents of kids with autism disorders want more than anything for their children: a normal childhood. Those children just might have a fighting chance to get it—if they don’t have to undergo therapies and treatment unsupported by any scientific evidence, therapies and treatments that are time-consuming, costly, and benefits only to the people administering them.

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By Matt Carey

Via Autistic Hoya: Judge Rotenberg Center Survivor’s Letter

10 Feb

The Judge Rotenberg Center (JRC) is a school for autistic students which incorporates aversives into the program for some of their students. These aversives are electric shocks delivered via remote-control to packs the students wear 24/7.

The JRC has been the focus of a great deal of criticism. To put it mildly. JRC has repeatedly described the shocks in relatively mild terms. Autistic Hoya (whose blog I highly recommend) has an article which includes a letter from a JRC survivor. I do not have permission from the author to copy the letter here, so I will send you to her site. With the warning that this is not an easy letter to read:

Judge Rotenberg Center Survivor’s Letter

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By Matt Carey

California’s Legislative Analyst Office report on special education

8 Feb

Recently the California Legislative Analyst’s Office (LAO) released a report on special education in California, Overview of Special Education in California. The report goes over many details of special education, but I will focus on only a few here.

First, the time trend. Yes, the number of students receiving services under the autism label is going up.

LAO Figure 3

Then again, no sign that it is going down after the removal of thimerosal. Also worth noting is the fact that other health impairments as a category is also increasing. Specific Learning Disability is going down. So it’s a bit more complex than just “autism is going up”.

What interests me more is the discussion of costs and finances. On term that often bothers me is the term “encroachment”. As in, “special ed students cost more, and that is an encroachment on the funds for the regular education students”. The LAO report discusses one aspect of that misconception:

(Note: SWD are “students with disabilities”)

Misconceptions About “Encroachment” Some local educational agencies (LEAs) complain that local contributions for special education “encroach” upon their general education programs, sometimes implying that any local dollar spent towards educating a student with disabilities (SWD) imposes unfair expenditure requirements on their general purpose budgets. This argument, however, is a mischaracterization of both federal and state laws. Federal Individuals with Disabilities Education Act (IDEA) and state special education categorical funds never were intended to cover the full costs of educating a SWD—instead the bulk of the “regular” education costs are intended to be covered using local revenue limit and categorical funding, just as for nondisabled students. Moreover, federal IDEA and state special education categorical funds never were intended to fully cover the excess costs of educating a SWD—the special education funding model always has been predicated on a three–way cost–sharing model, including local sources. Despite this basic design of the funding model, LEAs sometimes express frustration that their local share of special education costs is too high. This frustration tends to increase as their local share of special education costs increases, as this leaves them with fewer resources to serve other students.

LAO figure 6

Schools are required to provide free appropriate public education (FAPE) to all students, not just students with disabilities. Some students cost more, some cost less, some cost much more. In California, on average, schools spend $9,600 per non disabled student and, on average, $22,300 per disabled student. Where does that money come from to pay for the disabled student’s costs? Well, $9,600 comes from the money the school would spend anyway. The rest is: $2,300 in federal funds, about $5,400 in state funds, and about $5,000 local funds. So, the “extra” cost for special education students is largely paid by state and federal funds. The Federal government has never paid the full amount they committed for special education. The LAO notes:

LAO figure 8

Federal Share Has Never Reached Intended Contribution Level. As shown in Figure 8, federal IDEA funds typically cover less than 20 percent of overall special education expenditures. This is notably lower than the amount the federal government originally committed to provide in support of special education services. The IDEA expresses intent to appropriate funding for each SWD up to 40 percent of the national average expenditure level per K–12 pupil, which would equate to roughly 40 percent of California’s overall special education expenditures. The federal budget, however, has never come close to providing states with this amount. We estimate that California would receive roughly $2 billion more annually if the federal government were to “fully fund” the intended level articulated in the IDEA.

If the Federal Government made good on it’s promise, it would be a great help to education. How’s that for an obvious statement. Somehow this obvious fact hasn’t made an impression on our legislators. That all said–just because the Federal Government isn’t helping as much as they should, that doesn’t mean that cost is an “encroachment” by special ed students.

Now, how does the state decide how much to give to each school district? It isn’t based on “your expenses are $XX, so we will give you a fraction of that.” It isn’t based on, “You have so many special ed students, so we will give you $YY per special ed student.” No, it’s, “your student population is ZZZ, so we give you money based on that number.”

In other words, if a school district has 100% special students, they get the same funding as if they have 0%. If the costs are high or low, they get the same amount from the State and Federal Governments. This isn’t the full story, but it is close:

Two Distribution Models Exist. Across the nation, states generally use one of two approaches to distribute special education funding to the local level. Some use a “cost–based” model, with funding allocations driven by how many SWDs are served or the magnitude of special education costs incurred. In contrast, other states rely primarily on a census–based funding methodology that is not linked to particular SWDs. Under this model, the state allocates special education funds based on the total number of students enrolled, regardless of students’ disability status. This funding model implicitly assumes that SWDs—and associated special education costs—are relatively equally distributed among the general student population and across the state. While the majority of federal special education funds are distributed using a census–based model, the IDEA formula does allocate a small portion (typically around 10 percent) of funds based on counts of economically disadvantaged students, on the assumption that this group contains a greater proportion of SWDs.

A district (or SELPA or LEA) gets paid the same amount whether a student is receiving services for special education or not. Whether a student’s special education services cost a little or a lot. And some districts feel that some or all dollars spent on special education are “encroachment”. We can complain, but in the end we’ve built a system which strongly disincentivises schools from taking a true “cost blind” approach to finding an appropriate education.

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By Matt Carey

The Next Vaccine-Autism Newsmaker…5 years later

6 Feb

Years back, much focus in online autism parent community discussions focused on the Omnibus Autism Proceeding (OAP). This was the large “vaccine court” proceeding to explore if people could be compensated for autism as a vaccine injury. Those hearings were held in 2008, and the decisions went against the families.

A year ago I wrote (The Omnibus Autism Proceeding: effectively over), and while, yes, as an “Omnibus” it is effectively over, there is still activity for those who filed claims and were included in the Omnibus Autism Proceeding. Statistics as of today show there were 5,635 claims included in the Omnibus, and 4,564 have been dismissed. 2 claimants have been compensated, with the caveat given that “**HHS has never concluded in any case that autism was caused by vaccination.” This leaves 1,069 cases still pending. A relatively small fraction of the original Omnibus, but a large number nonetheless.

Another way to look at this is the Omnibus proceedings are over, the docket hasn’t been updated for quite some time but there are still individual cases to be decided. Including one case that was rather prominent in the Omnibus: that of A. Krakow. He was intended to be one of the test cases for the thimerosal but was pulled out to pursue another argument: that metabolic dysfunction is involved. David Kirby referred to him as “The Next Vaccine-Autism Newsmaker”, following the supposed game-changer of Hannah Poling.

That was in 2008. As it’s been nearly 5 years, I checked the status of the case. It turns out the first hearing was held in December (a hearing on fact) and a second hearing is set for expert witnesses to testify in April of this year. One way to explore the arguments the family may be taking is to review the experts that are testifying. For example, the family has chosen Richard Deth as an expert. His work has not focused on mitochondria. On the other hand, Yuval Shafir is also listed as an expert and has listed many articles on mitochondria with his report. Richard Frye’s CV was submitted (he also has some work on mitochondria and autism), but I don’t see that an expert report from him has been submitted.

Other experts date from 2008 (from when he was going to be an Omnibus test case) include: Elizabeth A. Mumper, Robert S. Rust, Richard Deth and Sander Greenland.

(edit to add, I see a report in the docket from Marcel Kinsbourne in 2010).

So, is this going ahead as a “mitochondrial autism” case? The “Next Hannah Poling” as David Kirby claimed in Spectrum Magazine? Well, even Hannah Poling wasn’t the game-changer some people predicted. Probably the most we can say is that is 10 years old, with a docket 16 pages long, will finally be heard.

edit to add: For the curious, here is the docket.
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By Matt Carey

A correction

5 Feb

Last year, following the autism hearing in the Oversight and Government Reform Committee, I wrote a piece Mr. Wright, is autism an epidemic or not? Why not give real examples of how to make a financial impact? In the article I used an example of how getting more autistics employed could make a real impact financially in our country.

It was pointed out to me that the way I framed it, it read that only a fraction of the autistic population would be able to gain employment. An adult self-advocate pointed out to me that this is not the case, that real employment should be a goal for the entire population. And this self advocate is correct and I regret the way I worded that article.

It is worth noting that a self advocate was informing the parent of a child with multiple disabilities, including intellectual disability, that employment should be a goal for all. There is an important lesson in that apparent role reversal. Self-advocacy does not mean one advocates only for one’s self, nor for only other self advocates. This simple message often gets lost in the stereotyped presentations of self-advocates and parents.

The autism community is broad. No one person will advocate great change. No segment of the population will be very effective on its own. We are going to work together or we are going to fail.

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By Matt Carey

IACC to take more active role

4 Feb

The U.S. Interagency Autism Coordinating Committee (IACC) met last week. There were presentations on important subjects but for me the real event happened in the final hour, during the discussion. You can get an idea of that from two Autism Speaks articles: IACC Pledges More Assertive Role in Federal Autism Policy and IACC Tackles Healthcare Disparities and Access to Care.

If one looks at Public Law 109-416 (the law based on the Combating Autism Act)

(b) RESPONSIBILITIES.—In carrying out its duties under this section, the Committee shall—
(1) develop and annually update a summary of advances in autism spectrum disorder research related to causes, prevention, treatment, early screening, diagnosis or rule out, intervention, and access to services and supports for individuals with autism spectrum disorder;
(2) monitor Federal activities with respect to autism spectrum disorder;
(3) make recommendations to the Secretary regarding any appropriate changes to such activities, including recommendations to the Director of NIH with respect to the strategic plan developed under paragraph (5);
(4) make recommendations to the Secretary regarding public participation in decisions relating to autism spectrum disorder;
(5) develop and annually update a strategic plan for the conduct of, and support for, autism spectrum disorder research, including proposed budgetary requirements; and
(6) submit to the Congress such strategic plan and any updates to such plan.

If you look at (2) and (3), they constitute a very broad mandate to “monitor Federal activities with respect to autism spectrum disorder [and] make recommendations to the Secretary regarding any appropriate changes to such activities”

This is an area which the IACC has up until not been the primary focus of the IACC, from what I have observed. The IACC has spent much effort, and rightfully so, on developing and updating the strategic plan for autism research.

The IACC is working on a document to offer advice on how autism should be considered in the implementation of the Affordable Care Act and the insurance exchanges the Act will set up.

The meeting started with Tom Insel (chair of the IACC, director of the NIMH) discussing some recent papers in autism. These include studies on elopement, markers of maternal inflammation as a risk factor for autism, an imaging study showing microglial activation in autistic brains, studies by IACC member David Mandell and more.

A presentation was given about the CDC Minnesota Somali Autism Project. The presentation discussed the methodology (using the same system as the ADDM network) and the difficulties in building the infrastructure from scratch. No information on preliminary results.

Jose Cordero spoke about the prevalence of autism in Puerto Rico. It is one of the highest in the United States at 1.6%. This is especially noteworthy given the relatively low prevalence for autism among the Hispanic communities regularly reported. Another presentation was made on the recent “Optimal Outcomes” study, with much discussion afterwards about what “optimal” outcomes really are. Of note was the fact that the study authors never made the statement that people “grow out of autism”, that was an interpretation added by journalists. Anjali Jain of The Lewin Group and Craig Newschaffer of Drexel University spoke about health outcomes among autistics, showing that there are more health issues among autistics. Alan Guttmacher of the National Institute of Child Health and Human Development spoke about the National Children’s study which is starting and will follow 100,000 children’s health outcomes and track possible environmental risk factors.

Public comments were given both orally and written. Unfortunately, there was no time for discussing the comments, which included statements by Dena Gassner, Amy Lutz, Dawn Loughborough and Jake Crosby.

The meeting was recorded by video. (I’ll try to get the embed code to work) http://videocast.nih.gov/launch.asp?17778

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By Matt Carey

note: I serve as a public member to the IACC but all opinions here and elsewhere are my own.

Jenny McCarthy loses gig for health-related fundraiser

3 Feb

I haven’t spent much time discussing Jenny McCarthy in a while. The reason is pretty simple, aside from her annual presentation at the AutismOne parent convention (where she criticizes parents who don’t use alternative medicine), she’s basically dropped out of the public discussion on autism. Years back she stopped expressing her views on vaccines publicly. Gone are the days of shouting “bullshit” at pediatricians on national TV and leading “green our vaccines” demonstrations in Washington DC.

So when I heard that she was going to headline a fundraiser for a cancer charity in Ottawa, I didn’t feel any need to write about it. Sure, it was a bad decision on the charity’s part. Why spend some of their credibility on Ms. McCarthy?

We are talking a cancer charity. Cancer patients often have reduced immune systems due to treatments they receive. They are highly dependent on the rest of us providing protection from serious vaccine-preventable diseases. The efforts of Ms. McCarthy and her organization have, by their own words, reduced vaccine uptake, endangering the very population the charity seeks to serve.

The Ottowa Citizen is reporting that Ms. McCarthy has been replaced for the event. I thank the charity for that. Ms. McCarthy is tweeting that she has a conflict and had to pull out. If this is true, perhaps she could return the “financial settlement” she is reportedly still being paid. In other words, I’m finding it hard to believe her tweet. If she wants to save face, she can save the charity money at the same time.

With luck, this will be the only Jenny McCarthy article here this year. Her time came and passed. We will be feeling the damage of her efforts for years to come. I’m not feeling much sympathy that she has to accept some consenquences.

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By Matt Carey

The Geiers’ Second Home

2 Feb

Mark Geier is well known within the autism alternative medicine community (think chelation, lupron) and as a consultant and expert for the attorneys in the vaccine court. David Geier is his son and has also been associated with the alt-med treatments (much criticised research, being accused of practicing medicine without a license) and tried to break in to the vaccine-court expert/consultant business. The Geiers are currently suing the attorneys who represented the families in the Ominibus Autism Proceeding (the vaccine court hearings on vaccine causation of autism). According to court papers, the Geiers are seeking $600,000 in fees and expenses they feel are owed to them. The vaccine court denied the application for paying for their fees.

In looking over the documents I was struck by an odd fact: the address given for the Geiers is not the same one I am used to seeing. It isn’t their usual home base in Maryland. So I decided to take a look at what sort of home they are currently claiming as their residence.

Here’s a picture (click to enlarge pictures):

House 1

The home is described online as 7,800 square feet, on a 20 acre lot. The backyard comes complete with a swimming pool.

House 2

Apparently, the estate was listed for $2.6M in 2011, but pulled from the market. Eidt to add: I’ve been informed that Mark and David Geier (not Mark and his wife) purchased the property in Nov. 2011 for $2M.

the Interior is not understated:

B-Room Geier

and

B-Room Geier

If you work out where they live, please don’t post it here. It is publicly available information, but it is not relevant to this discussion. What is releavant is this: there’s a lot of money in alternative medicine and promoting the idea that vaccines cause autism. Mark Geier has 20 years experience working with, and being critcized by, the vaccine court, including for double charging and for charging for costs well outside their roles (such as trips to Europe)

A single study they assisted in preparing for the Omnibus was billed at $440k, even though it was of low quality and was not useful in the case. The special master was very clear:

Clearly, no rational “hypothetical paying client” of the PSC would have agreed to pay for the production of such a flawed study. Thus, the fact that the Young-Geier article did not add any value to the petitioners’ causation presentation in this case is a very strong reason why I should decline to compensate the PSC for the cost of producing the article.

The Special Masters of the Court of Federal Claims (the vaccine court) appear to have closed the door on payments to the Geiers. But not until nearly two decades of low quality work was compensated. Mark Geier has lost his license to practice medicine in multiple states, but, again, not until after he was able to spend decades “treating” people with and charging people for therapies which make no sense.

The Geiers may not get the $600k they believe they are owed for work on the Omnibus. Their multistate franchise of lupron treatment centers may be closed. They may not be able to charge the American taxpayer for future low quality “expert” reports for the Court. Perhaps Mark Geier will have to retire a little early (reportedly, he’s 64), to his new home. Shared with his wife and son. Except for the living out one’s retirement with David Geier, I’m not seeing this as a difficult time for him. As to David Geier, one does wonder if he will ever amount to anything. Extrapolating from existing data, I’m not betting on it. But, as with his father, I don’t see cause to worry for his future. The U.S. taxpayers, and medical consumers, have taken care of this father/son team far better than we have our disabled citizens. And with less return to show for it.

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By Matt Carey

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