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ByLindaA.Johnson TheAssociatedPress TRENTON, N.J. U.S. reg- ulators on Monday strengthened their warn- ing against use of a once- popular device for gyne- cologic surgery that can spread unsuspected can- cer, saying its risk is only justified in a fraction of patients. The Food and Drug Ad- ministration updated its April safety warning, say- ing doctors should not use the devices, called laparo- scopic power morcellators, for performing a hysterec- tomy or removing uterine fibroids "in the vast major- ity of women." The FDA's Dr. William Maisel said there are safer options for the procedures for most patients. But he said the device may be ap- propriate for a small num- ber of women who need to have fibroids removed, but want to protect their uterus in case they decide to have a baby in the fu- ture. Fibroids are benign, but sometimes painful, tumors in the wall of the uterus. Maisel said the FDA is recommending that mak- ers of laparoscopic power morcellators immediately include in the detailed product guide new safety information: a boxed warning on the risks and two contraindications on when the devices should never be used, which would cover most patient cases. "The FDA's primary concern is the safety of pa- tients," Maisel told report- ers during a teleconfer- ence. "We want all women with uterine fibroids to be aware of this risk." Fibroids are relatively common in older women, but generally don't have to be removed if they're not causing problems such as excessive men- strual bleeding, pain and anemia. Power morcellators had become popular be- cause they enable re- moval of fibroids, or the entire uterus, with less- invasive surgery. They function something like a hand blender, chopping tissue inside the abdomen into tiny pieces that can be removed through keyhole incisions, rather than hav- ing to cut open the abdo- men or remove the uterus through the vagina. But the procedure can free cancer cells lurking in the uterus or in fibroids, spreading them to multi- ple parts of the abdomen. Maisel said the FDA does not have firm figures on how often this has hap- pened, but the agency has received about two dozen reports of such cases since last December. It now es- timates that in about one of 350 procedures using power morcellators, tissue considered benign turned out to be cancerous. Maisel said about 50,000 procedures a year were done using the de- vices in this country, but that's likely declined in recent months due to the risks. The American College of Obstetricians and Gy- necologists said in a statement it was pleased the FDA is enhancing pa- tient safety while allow- ing use of the device for some women, "sparing them the longer recovery time and higher mortal- ity rates associated with a total abdominal proce- dure." Johnson & Johnson, which had been the top manufacturer of the de- vices in the U.S., directed surgeons to stop using its device for the proce- dures in April, when con- cerns about inadvertently spreading cancer inside women's abdomens first arose. The New Bruns- wick, New Jersey-based company wouldn't dis- close sales figures for its product. In July, its Ethi- con subsidiary started a voluntary worldwide re- call. The FDA could not im- mediately identify other manufacturers who have approval to sell such de- vices in the U.S. Meanwhile, law firms specializing in medical injury cases have been fil- ing lawsuits on behalf of patients allegedly harmed. The new boxed warn- ing is to state that uterine tissue may contain unde- tected cancer cells, so use of morcellators can spread the cancer and reduce the woman's chances of sur- vival. GYNECOLOGIC SURGERY FDAstrengthens warning on device linked to cancer By Jonathan Paye- Layleh The Associated Press MONROVIA, LIBERIA Li- beria's president on Mon- day urged her country- men to double their efforts to reach the government's goal of having zero new Eb- ola cases by Dec. 25, a tar- get some experts have de- scribed as highly ambitious. "We've set a pretty tough target. But when you set a target it means that you stay focused on that target and on that goal and then you double your efforts," Sirleaf said during a cere- mony marking the docking of a Dutch aid ship in the capital, Monrovia. "When you're running a race, as you get closer and closer to the finish line you pick up the speed because you want to make sure that that last mile you will give it your best bet," Sirleaf added. Liberia has recorded nearly 3,000 confirmed, probable and suspected Ebola deaths since the out- break began — far more than any other country, ac- cording to the latest World Health Organization fig- ures. The number of new cases in Liberia has declined re- cently, however, prompting the U.S. to scale back the size and number of treat- ment facilities it is building. Still, officials have warned against compla- cency. Anthony Banbury, who heads the U.N. fight against Ebola in West Af- rica, said Friday that while achieving a decline in cases is difficult, reaching the point of zero cases in the region will be "much, much harder." The arrival of the Dutch naval vessel, the Karel Door- man, in Monrovia marked the end of its tour of the three countries hardest hit by the Ebola epidemic. The ship visited the capitals of Sierra Leone and Guinea in the past two weeks, said Julius Kanubah from the Euro- pean Union's political sec- tion in Liberia. Nine European coun- tries and the United Na- tions Children's Fund do- nated 160 vehicles, 80 con- tainers and 1,200 tons of supplies for humanitarian agencies. Sirleaf thanked the E.U. for also providing aid to Guinea and Sierra Leone. "We are never totally free from Ebola until all of the affected countries... are also free from Ebola," she said. VIRUS Leader: Liberia free of Ebola by Christmas By Erika Niedowski The Associated Press PROVIDENCE, R.I. The fed- eral government shelled out billions of dollars to get health insurance mar- ketplaces going in the 14 states that opted to run their own. Now they must act like true marketplaces and start paying for them- selves. Under President Barack Obama's Affordable Care Act, state-run health insur- ance exchanges need to be financially self-sustaining starting in January. Some appear to be on that path, while others have shaky funding models or even none at all. Some states, prohibited from using state money, are imposing fees on plans sold on the marketplaces. Others are spreading costs more widely — which, in one instance, has drawn a federal lawsuit. Rhode Island received high marks for the smooth rollout of HealthSource RI amid last year's stumbles by the federal government, and the agency director says the state's health care reform "revolution" has be- gun. But the state does not have a way to pay for the ex- change's long-term opera- tions, and some lawmakers in the state General Assem- bly have suggested shifting to the federal exchange. The cost to operate Rhode Island's exchange is estimated at $17 million a year, although an earlier estimate pegged the cost at $24 million. Republican state Rep. Patricia Morgan introduced a bill last ses- sion to transfer its opera- tions to the federal govern- ment, but the legislation was held for further study. "Think of what we can do with $24 million," she said. Some states have decided to tap existing revenue. New York is relying on two agencies' general reve- nue, while Maryland is us- ing money from an existing 2 percent tax on insurance plans. Republican Dele- gate Anthony O'Donnell, a critic of Maryland's de- cision to create its own ex- change, said he continues to question its sustainabil- ity. He said last week that he is concerned "about the entire structure and that it may collapse of its own weight." To cut costs, Colorado's state-run exchange has re- duced overall spending 18 percent, including on tech- nology and marketing. It's imposing a 1.4 percent fee on monthly premiums for its plans but also approved charging a $1.25-a-month "general market" fee on all individual and small group policies, including those sold outside the state ex- change. Some lawmakers called the fee unfair, and one board member voted against it. It is expected to raise an estimated $13 mil- lion a year before it expires in 2016. In the District of Colum- bia, which also is operating its own marketplace, the exchange's budget is being funded by a new 1 percent tax on all health insurance policies. The American Council of Life Insurers is suing, arguing it unfairly taxes insurance products that cannot be purchased on the exchange. Taxing only plans offered on the exchange would have required a 17 percent tax to cover costs, officials said, reducing the benefit to low-income residents. Earlier this year, Califor- nia's exchange said it was setting aside $184 million in federal money to fight off projected budget shortfalls through 2016. About 1.1 mil- lion people enrolled in the first year, exceeding pro- jections, and officials hope to grow that to 1.7 million during the second round of open enrollment. Officials with Covered California, as the exchange is known, express confi- dence about its financial health. The agency's board has projected a $250 mil- lion reserve for the com- ing year, built partly from a $13.95 monthly surcharge on individual policies. "We do not have a defi- cit; our enrollment is suffi- cient to fund ongoing op- erations through 2015-16," Covered California spokes- man James Scullary said. "We remain committed to managing our resources prudently." The Vermont mar- ketplace, which is be- ing funded by the state's health care provider tax, is on shakier ground. Of- ficials there acknowledged it could face a $20 million shortfall by year's end. The state hopes pending federal grants will fill the gap. In Rhode Island, Health- Source's individual market enrollment of more than 26,000 heading into the second sign-up period ex- ceeded unofficial federal projections. Officials plan to continue using federal money through 2015. Be- yond that, the funding mechanism is unclear. "There's time, but there's not that much time, so these decisions need to be made," exchange Director Christine Ferguson said during a recent briefing. She has called abandon- ing HealthSource short- sighted and warned that doing so could come with its own costs. Democratic Gov.-elect Gina Raimondo wants to keep HealthSource local and has pledged to scruti- nize its budget and get "cre- ative." But the top House Democrat, Nicholas Mat- tiello, remains skeptical about its cost and value. 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