Health - Daily Pill Greatly Lowers AIDS Risk, Study Finds

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• Daily Pill Greatly Lowers AIDS Risk, Study Finds
• Vital Signs: Exercise: For Type 2 Diabetes, 2 Types of Training
• U.N. Reports Decrease in New H.I.V. Infections
• Privacy Groups Fault Online Health Sites for Sharing User Data With Marketers
• Medtronic Posts Profit but Cuts Its Full-Year Forecast
• Radiation Worries for Children in Dentists’ Chairs
• Patient Voices: Behind the Facade, Post-Traumatic Stress
• Well: A Vegetarian Thanksgiving, Even for Carnivores
• 18 and Under: A Prescription for Abdominal Pain: Due Diligence
• Scientist at Work: Dr. W. Ian Lipkin: A Man From Whom Viruses Can’t Hide
• Recipes for Health: Pumpkin Cornbread
• In Cybertherapy, Avatars Assist With Healing
• Wired Up at Home to Monitor Illnesses
• Global Update: Flu: Bird Flu Falls Off the Radar, but Cases Show It’s Still a Threat
• Well: A Post-Thanksgiving Breakfast
• Well: The Benefits of Weight Training for Kids
• Well: A Doctor Goes to Cancer Camp
• Well: Appetizers From America's Test Kitchen
• Well: Radiation in the Dentist Chair
• Personal Health: It’s Time for Recess: Just Keep on Moving
• Really?: The Claim: Cellphones Can Cause an Allergic Reaction.
• Economic Scene: Life Expectancy in China Rising Slowly, Despite Economic Surge
• The New Old Age: Ask an Elder Law Attorney
• The New Old Age: Heartache in the I.C.U.
• The New Old Age: Housecalls of Another Sort
• Prescriptions: Tackling Mini-Med Policies
• Prescriptions: Higher Deductibles, Lower Spending
• Prescriptions: This Week's Health Industry News
• Recipes for Health : Pumpkin Gelato
• Recipes for Health: Indian Pumpkin Pudding
• Recipes for Health: Pumpkin: The Flavor of Late Fall
• New Trade Group’s Focus Will Be Marijuana Industry
• New Rules Tell Insurers: Spend More on Care
• 2 Treatments for Retinas Make Gains
• Consumer Risks Feared as Health Law Spurs Mergers
• Vital Signs: Behavior: Young Marijuana Users Pay Cognitive Price

Daily Pill Greatly Lowers AIDS Risk, Study Finds Posted: 24 Nov 2010 10:28 AM PST Healthy gay men who took an anti-AIDS pill every day were well protected against contracting H.I.V. in a study suggesting that a new weapon against the epidemic has emerged. Enlarge This Image Paul Sakuma/Associated Press Truvada, a combination of antiretroviral drugs made by Gilead Sciences, costs around $13,000 a year in the United States. Related U.N. Reports Decrease in New H.I.V. Infections (November 24, 2010) In the study, published Tuesday by the New England Journal of Medicine, researchers found that the men taking Truvada, a common combination of two antiretroviral drugs, were 44 percent less likely to get infected with the virus that causes AIDS than an equal number taking a placebo. But when only the men whose blood tests showed that they had taken their pill faithfully every day were considered, the pill was more than 90 percent effective, said Dr. Anthony S. Fauci, head of the infectious diseases division of the National Institutes of Health, which paid for the study along with the Bill and Melinda Gates Foundation. “That’s huge,” Dr. Fauci said. “That says it all for me.” The large study, nicknamed iPrEx, included nearly 2,500 men and was coordinated by the Gladstone Institutes of the University of California, San Francisco. The results are the best news in the AIDS field in years, even better than this summer’s revelation that a vaginal microbicide protected 39 percent of all the women testing it and 54 percent of those who used it faithfully. Also, Truvada, a combination of tenofovir and emtricitabine that prevents the virus from replicating, is available by prescription in many countries right now, while the microbicide gel is made in only small amounts for clinical trials. The protection, known as pre-exposure prophylaxis, is also the first new form available to men, especially men who cannot use condoms because they sell sex, are in danger of prison rape, are under pressure from partners or lose their inhibitions when drunk or high. It “does not involve getting permission from the other partner, and that’s important,” said Phill Wilson, president of the Black AIDS Institute, which focuses on the epidemic among blacks. Michel Sidibé, the head of the United Nations agency that fights AIDS, called it “a breakthrough that will accelerate the prevention revolution.” AIDS experts and the researchers issued several caveats about the study’s limitations, emphasizing that it looked only at gay men and Truvada. More studies, now under way, are needed to see whether the results can be duplicated, whether other antiretroviral drugs will work and whether they will protect heterosexual men and women, prostitutes and drug users who share needles. There is no medical reason to think the pill would not work in other groups, since it attacks the virus in the blood, not in the vaginal wall as a microbicide does. Pre-exposure prophylaxis became possible only in recent years as newer, less-toxic antiretroviral drugs were developed. Some scientists fear that putting more people on the drugs will speed the evolution of drug-resistant strains, though that did not occur in the study. Because Truvada is available now, some clinicians already prescribe it for prophylaxis, Dr. Fauci said, but whether doing so becomes official policy will depend on discussions by the Centers for Disease Control and Prevention, the Food and Drug Administration, medical societies and others, which could take months. Although the C.D.C. would prefer that doctors wait for further studies, more will probably prescribe the drugs now that this study is out, said Dr. Kevin Fenton, chief of the agency’s AIDS division, so the C.D.C. will soon release suggested guidelines. The agency will suggest that the drug be prescribed only with close medical supervision and used only with other safe-sex practices. “The results are encouraging, but it’s not time for gay men to throw away their condoms,” Dr. Fenton said. AIDS advocacy groups were very excited by the results. “If you comply with it, this works really well,” said Chris Collins, policy director of amfAR, the Foundation for AIDS Research. “This is too big to walk away from.” Mitchell Warren, executive director of AVAC, an organization that lobbies for AIDS prevention, called the study “a great day for the fight against AIDS” and said gay men and others at risk needed to be consulted on the next steps. In the study, 2,499 men in six countries — Brazil, Ecuador, Peru, South Africa, Thailand and the United States — were randomly assigned to take either Truvada or a placebo and were followed for up to three years. For ethical reasons, they were also given condoms, treatment for venereal diseases and advice on safe sex. There were 64 infections in the placebo group and 36 in the group that took Truvada, a 44 percent risk reduction. Two in the Truvada group turned out to have been infected before the study began. When the remaining 34 were tested, only 3 had any drug in their blood — suggesting that the other 31 had not taken their pills. Different regimens, like taking the pills not daily but only when sex is anticipated, also need testing. Also, many men in the study failed to take all of their pills, and some clearly lied about it. For example, some who claimed to take them 50 percent or 90 percent of the time had little or no drug in their bloodstreams. The pills caused no major side effects, though men who began to show signs of liver problems were taken off them quickly. Some men stopped taking the pills because they disliked relatively minor side effects like nausea and headaches. Also, some stopped bothering once they suspected that they might be taking a placebo. “People have their own reasons,” Mr. Collins said. “People don’t take their Lipitor every day either.” A major question now is who will pay for the drug. In the United States, Truvada, made by Gilead Sciences, costs $12,000 to $14,000 a year. In very poor countries, generic versions cost as little as 40 cents a pill. Globally, only about 5 million of the 33 million people infected with the AIDS virus are on antiretroviral drugs, and in an era of tight foreign-aid budgets, that number is not expected to rise quickly. Hundreds of millions of Africans, Eastern Europeans and Asians are at risk and could benefit from prophylaxis, but that would cost tens of billions of dollars. In this country, insurers and Medicare normally pay for the drugs, and the Ryan White Act covers the cost for the poor, but none of these payers yet have policies on supplying the drugs to healthy people. No participant in the study developed resistance to tenofovir. Three were found to have strains resistant to emtricitabine, but investigators believe that all three were infected before the study began at levels low enough to have been missed by their first H.I.V. tests. Another concern was that the participants would become so fearless that they would stop using condoms, but the opposite effect was seen — they used condoms more often and had fewer sex partners. But that can also be a result of simply being enrolled in a study and getting a steady diet of advice on safe sex and free condoms, the investigators said. Other trials of pre-exposure prophylaxis have about 20,000 volunteers enrolled around the world. Their results are expected over the next two years.

Vital Signs: Exercise: For Type 2 Diabetes, 2 Types of Training Posted: 24 Nov 2010 07:19 AM PST Type 2 diabetics can significantly lower their blood sugar — and lose body fat in the bargain — with an exercise program that combines aerobics and weight lifting, a new study reports. Multimedia Interactive Feature Patient Voices: Type 2 Diabetes Related More Vital Signs Columns While that regimen is already recommended in Type 2 diabetes, researchers say the study offers some of the best evidence to date that a combined program offers greater benefits than aerobics or weight lifting by itself, even if it does not increase total exercise time. “We can now look at individuals with diabetes right in the face and tell them, ‘This is the best exercise prescription for you,’” said the paper’s lead author, Dr. Timothy S. Church, director of preventive medicine research at Louisiana State University’s Pennington Biomedical Research Center. Such a program consists of “about 100 minutes of higher-intensity aerobics a week, and then give yourself one to two days of resistance training for 15 to 20 minutes a day,” he said. The study randomly divided 262 inactive Type 2 diabetics, average age 55.8, into four groups — 73 assigned to resistance training three days a week, 72 to aerobic exercise, 76 to the combination and 41 to a non-exercise comparison group. The study was notable in that almost half the participants were not white, and 63 percent were women. After nine months of observed exercise, participants who did the combination training lowered their blood level of the glucose marker HbA1c to 7.3 percent from 7.7 percent, on average, a drop that corresponds to a significantly reduced risk of heart disease, Dr. Church said. The improvements in the other exercise groups were not significantly different from those in the non-exercise group. Dr. Church said he was surprised but added that the findings made sense. “Diabetes is the failure to control the amount of sugar in your blood, and the biggest user of blood sugar is skeletal muscle,” he said. “The healthier your skeletal muscle, the more blood sugar it’s chewing up and taking out of the blood.”

U.N. Reports Decrease in New H.I.V. Infections Posted: 23 Nov 2010 11:10 PM PST Fewer people are being infected with the virus that causes AIDS than at the epidemic’s peak, but progress against the disease is still halting and fragile, the United Nations’ AIDS-fighting agency reported Tuesday. Multimedia Graphic Living With H.I.V. Related Daily Pill Greatly Lowers AIDS Risk, Study Finds (November 24, 2010) In its new report on the epidemic, Unaids said 2.6 million people became newly infected with H.I.V., the virus that causes AIDS, in 2009 — almost 20 percent fewer than in the late 1990s. But progress is spotty. About 25 countries are doing better at prevention, including several in southern Africa with sky-high AIDS rates. South Africa, which has the world’s worst epidemic, has benefited from the changeover from the presidency of Thabo Mbeki, which was hostile to the distribution of AIDS drugs, to that of Jacob Zuma, who has publicly taken an AIDS test and urged citizens to do the same. Still, it faces an estimated 350,000 to 500,000 new infections annually. In one area, progress has been heartening: giving mothers drugs to prevent the infection of their babies at birth or through breastfeeding. “We’ve had a 50 percent reduction of infections among young people in South Africa, which is a huge reservoir,” Michel Sidibé, executive director of Unaids, said in an interview in Manhattan last week. Mr. Sidibé gave several reasons for the change. “Relations between parents and children over discussing sexuality are changing,” he said. “Previously, no one would talk about it. Now, more people are willing to talk to their children.” Also, he said, people are sleeping around somewhat less. “In 59 countries we surveyed, only 25 percent said they had had more than one partner in the last year,” he said. “That is a big shift.” And, he said, while posters urging everyone to use condoms are not particularly effective, government health agencies have gotten better at “concentrating on hot spots” like sex workers and long-haul truckers. In countries like Senegal and Malawi, Mr. Sidibé said, “there has been a sea change in attitudes toward men who have sex with men.” In countries that jailed homosexuals or simply denied that there were any, gay men have been released from prison. Instead of driving gay men underground, some governments are trying to reach them with safe-sex education and condoms. At the same time, some countries are becoming worse, especially those in Eastern Europe and Central Asia, where the epidemic is concentrated among heroin-injectors and their sexual partners. As Afghan and southeast Asian heroin spreads along new distribution routes, more addicts are created, increasing AIDS infections in countries with little history of dealing with them. There are exceptions. In Iran, Mr. Sidibé said, he accompanied a woman in a chador who was handing out condoms in prison. “I was shocked,” he said. “In Iran, the prisons had one of the most progressive programs. There was methadone maintenance; there was condom distribution. They even had conjugal visits for prisoners — five hours in a private room every three months with your wife. With condoms.” There is also both good and bad news on the treatment front. About 5.2 million people are getting antiretroviral drugs — more than ever before, thanks to the multinational Global Fund to Fight AIDS, Tuberculosis and Malaria and its strictly American counterpart, the President’s Emergency Plan for AIDS Relief. But 10 million more still need the treatment immediately, and it seems unlikely that donors will give enough money to keep them all alive. Also, some people have developed resistance to first-line drugs, but the money for more expensive second- and third-line drugs is not there. It is now nearly 30 years since the epidemic began, and an estimated 33.3 million people are living with H.I.V. That number has never been higher, and its growth is due to a combination of new infections and the receipt of life-prolonging treatment by more of the sick. But a comparison illustrates how much progress still needs to be made before it can be said that the world is winning the war on AIDS: in its previous report, Unaids estimated that for every 100 people put on treatment each year, 250 became newly infected. Now, it estimates that for every 100 on treatment, 200 become infected.

Privacy Groups Fault Online Health Sites for Sharing User Data With Marketers Posted: 23 Nov 2010 10:27 PM PST QualityHealth is a popular health Web site with more than 20 million registered users that offers online medical information and e-mail newsletters on a variety of topics, including diabetes, allergies, asthma and arthritis. Enlarge This Image QualityHealth.com is one of the Web sites listed in a complaint filed by privacy groups to the Federal Trade Commission. Add to Portfolio Google Inc WebMD Health Corp Go to your Portfolio » But according to a complaint filed Tuesday with the Federal Trade Commission, site visitors who provide personal details about themselves might not be aware that QualityHealth collects information about people’s medical conditions, preferred medicines and treatment plans and uses it to profile its users for prescription drug marketing. Rob Rebak, the chief executive of QualityHealth, a company also known as Marketing Technology Solutions of Delaware, did not return a request for comment. QualityHealth is one of a number of companies cited in the complaint to the F.T.C. filed by four nonprofit privacy and consumer advocacy groups. In the complaint, the Center for Digital Democracy, U.S. PIRG, Consumer Watchdog and the World Privacy Forum charged that online marketing of medications, products and medical services posed fundamental new risks to consumer privacy and health because of sophisticated data collection and patient-profiling techniques. Asserting that such techniques are unfair and deceptive, the groups asked the F.T.C. to investigate the health marketing used by some popular sites including Google, HealthCentral, Everyday Health, WebMD and Sermo, a site for medical professionals. Some sites, the complaint said, were not transparent enough about how they tracked people through users’ online heath searches and discussions or how they categorized and marketed to their conditions. Other sites may not be entirely open about how they create and use data profiles about users or blur the line between independent and sponsored content, the complaint said. The concern, said Ed Mierzwinski, the consumer program director at U.S. PIRG, is not just about data mining and marketing that could influence patients to seek drugs they do not need or to spend more money on branded drugs rather than generics. More broadly, employers or health insurers could gain access to the consumers’ data profiles, leading to potential problems or penalties against the consumer, he said. “You could be searching for health information about your cat or your neighbor and it could end up harming your health care in terms of denial or increased cost,” Mr. Mierzwinski said. “If people knew what kind of surveillance, eavesdropping and data mining were being used to collect information about you, encourage your use of prescription drugs and essentially use you as a research guinea pig, I think people would think twice.” The complaint comes at a delicate moment for online and social media marketing of medical products and services. The Food and Drug Administration, which oversees drug marketing, is developing industry guidelines for digital and social media. In a two-day agency hearing on the subject last winter, many health sites, drug makers and marketing firms promoted the idea of digital health as a tool that empowered consumers, allowing patients to easily access medical information and form supportive interactive communities with other patients. “There are clear public health benefits for health care providers and patients to be able to access truthful, scientifically accurate and F.D.A.-regulated information about medicines online from the companies that research and develop them,” said Jeffrey K. Francer, assistant general counsel of the Pharmaceutical Research and Manufacturers of America, an industry trade group. His group is still reviewing the complaint, he said. But Jeff Chester, the executive director of the Center for Digital Democracy, said that the industry had provided the F.D.A with a “fairy-tale version of digital health marketing.” Online data collection techniques give “pharmaceutical companies and health marketers a kind of digital X-ray of a health consumer’s concerns, fears and behaviors,” Mr. Chester said. “There is no meaningful disclosure of how that data is collected and used.” A notice at the bottom of QualityHealth’s member registration form, for example, provides a link to the site’s privacy policy. The policy explains that information that may or may not identify someone may be used for ads aimed at consumers. But QualityHealth provides greater detail about its methods in its pitch to business clients — like how the site uses tailored messages, informed by patient profiling, to prompt members to seek prescriptions for specific brands from their doctors. “We can reach consumers just before their next doctor visit,” the site says, “as well as follow up with reminders and relevant information, for maximum impact.” The site’s privacy policy states that the company is committed to providing consumers with clear notice and choice about its practices and that visitors are asked to opt in to the company’s data use policy. Adam Grossberg, a spokesman for WebMD, said that WebMD had always been transparent and direct with its users. “All sponsored content on our site is clearly labeled as such, he said.” He added that the company could not comment on the specifics of the complaint because it had not received it. A spokesman for Google said the company declined to comment for this article. HealthCentral, Everyday Health and Sermo did not respond to requests for comment. The groups decided to file their complaint with the F.T.C., Mr. Chester said, because it oversees consumer privacy issues and because, the groups believed that the F.D.A., which has long overseen traditional marketing of drugs in print, radio and television, lacked the staff and the expertise to oversee online and social media drug marketing. An F.D.A. spokeswoman said the agency planned to review the complaint. David Vladeck, the director of the F.T.C.’s bureau on consumer protection, said he had not yet read the complaint. But, he said, the F.T.C. plans to soon release a report about online privacy because it is concerned about sensitive personal information. Mr. Vladeck offered a hypothetical example of a core privacy question. “Suppose someone goes online to read about depression, should that person get targeted with ads for antidepressants, for counseling services or books about depression?”

Medtronic Posts Profit but Cuts Its Full-Year Forecast Posted: 23 Nov 2010 11:28 PM PST Medtronic, the maker of medical devices and a bellwether in its industry, cut its profit forecast for the year on Tuesday as it grapples with markets that have slowed while people postpone treatments. Add to Portfolio Thomson Reuters Corp JPMorgan Chase & Company Medtronic Inc Go to your Portfolio » Demand for medical devices has fallen in the downturn, and people who have lost jobs, or who face higher co-payments and deductibles in their health plans, are putting off medical care. In August, Medtronic reported a drop in first-quarter sales that caught the market by surprise and sent its shares and those of rival heart and orthopedic device makers reeling. On Tuesday, Medtronic posted a second-quarter profit slightly ahead of analyst targets, helped by lower-than-expected taxes, on revenue growth of just under 2 percent. The chief executive, William A. Hawkins, said demand for medical devices had started to stabilize since a slowdown at the beginning of the summer. Still, the company trimmed its fiscal-year outlook for a second time and projected earnings per share of $3.38 to $3.44, down from $3.40 to $3.48 in August. Net income in Medtronic’s second quarter, which ended Oct. 29, fell to $566 million, or 52 cents a share, compared with $868 million, or 78 cents a share, a year earlier. Excluding special items, Medtronic said it had earned 82 cents a share. Analysts on average had expected 81 cents, according to Thomson Reuters . “They kind of met expectations, but they see a tougher second half of the year,” a Noble Financial Capital analyst, Jan Wald, said. “My read is that the market growth they thought they’d see in the second half of the year, they’re not expecting to see.” Revenue rose to $3.90 billion, in line with analysts’ expectations, compared with $3.84 billion a year earlier. Revenue from implantable cardioverter defibrillators fell 1 percent, to $745 million, and declined 5 percent from pacemakers, to $472 million, hurt by slower market growth and pricing pressures in the United States and abroad. “Japan continues to be a major headwind, reflecting double-digit price cuts from April,” an analyst with JPMorgan, Michael Weinstein, said in a research note. Revenue from spinal products declined 1 percent in the quarter, to $850 million. Medtronic said it expected revenue growth of 2 to 4 percent for the second half of the 2011 fiscal year. It predicted the overall market would grow 2 to 3 percent. The company said its outlook omitted potential revenue from new products in the pipeline, whose introductions were delayed because of warning letters from the Food and Drug Administration.

Radiation Worries for Children in Dentists’ Chairs Posted: 23 Nov 2010 10:12 AM PST Because children and adolescents are particularly vulnerable to radiation, doctors three years ago mounted a national campaign to protect them by reducing diagnostic radiation to only those levels seen as absolutely necessary. The Radiation Boom Clarity at a Cost Articles in this series examine issues arising from the increasing use of medical radiation and the new technologies that deliver it. Previous Articles in the Series » Multimedia Multimedia Feature Dentists Embrace New Device Document Studies on Dentists and Radiation Graphic Radiation Doses in the Dentist’s Chair Post a Comment Related What Patients Might Want to Ask the Dentist About X-Rays (November 23, 2010) Enlarge This Image Andy Manis for The New York Times Practices and Promotion Dr. Edward Y. Lin, at top, uses cone-beam scanners in Green Bay, Wis. It is a message that has resonated in many clinics and hospitals. Yet there is one busy place where it has not: the dental office. Not only do most dentists continue to use outmoded X-ray film requiring higher amounts of radiation, but orthodontists and other specialists are embracing a new scanning device that emits significantly more radiation than conventional methods, an examination by The New York Times has found. Designed for dental offices, the device, called a cone-beam CT scanner, provides brilliant 3-D images of teeth, roots, jaw and even skull. This technology, its promoters say, is a safe way for orthodontists and oral surgeons to work with more precision and to identify problems that otherwise might go unnoticed. But there is little independent research to validate these claims. Instead, the cone beam’s popularity has been fueled in part by misinformation about its safety and efficacy, some of it coming from dentists paid or sponsored by manufacturers to give speeches, seminars and continuing education classes, as well as by industry-sponsored magazines and conferences, according to records and dozens of interviews with dentists and researchers. Last month, The Journal of the American Dental Association allowed one of the leading cone-beam manufacturers, Imaging Sciences International, to underwrite an issue devoted entirely to cone-beam technology. That magazine, which the association sent to 150,000 dentists, included a favorable article by an author who has equated a cone-beam CT with an airport scan. In fact, a cone beam can produce hundreds of times more radiation, experts say. Cone-beam CT scans can help dentists deal with complex cases involving implants, impacted teeth and other serious problems. But many experts in dental radiation have raised alarms about what they see as their indiscriminate use. They worry that with few guidelines or regulations, well-meaning orthodontists and other specialists are turning to a new technology they do not fully understand, putting patients at risk, particularly younger ones. Some orthodontists now use cone-beam CT scans to screen all patients, even though a number of dental groups in this country and in Europe have questioned whether the benefit of routine use justifies the added risk. “All these different cone-beam CT scanners came out to a world that was unprepared,” said Keith Horner, a professor of oral radiology at the University of Manchester in Britain, who is coordinating a study of cone-beam scanners for the European Commission. “They are just pushed out there by manufacturers with the message that a 3-D image is always going to be better than a 2-D image, and that isn’t the case.” One popular new brand of braces has helped cone-beam sales because it requires 3-D images, which doctors can obtain using either a cone-beam scanner with radiation, or a digital camera without it. Many orthodontists opt for radiation, because it is quicker. Even those troubled by the widening use of cone-beam technology acknowledge that by itself, the risk from a single scan is relatively small. But patients often get more than one scan, and the lifetime risk increases with each exposure. Without a clear benefit, they say, there is only risk. “So let me ask a question to the mother of a prospective orthodontic patient,” said Dr. Stuart C. White, former chairman of oral radiology at the UCLA School of Dentistry. “Would you like me to use a tool that is entirely safe — a camera — to record the position of your child’s teeth, or another method that may rarely cause cancer so that we can save time?” The cone-beam business is lucrative for manufacturers and dentists. According to one industry estimate, more than 3,000 scanners and about 30 different models have been sold, at prices up to $250,000. Dentists, some of whom charge several hundred dollars per scan, can profit by owning their own machines. “More profit per unit chair time,” promises Imaging Sciences, the cone-beam manufacturer. Marketers increase interest in the technology by holding drawings for free cone-beam CT scanners and other gifts. A Washington State orthodontist, who gave an online lecture sponsored by Imaging Sciences, offers dentists coupons for free scans for their patients as a way to build referrals. And then there is the “wow” factor, said Dr. Terry Sellke, an orthodontist in Illinois. “Kids love to see that 3-D image,” Dr. Sellke said in a Webcast sponsored by Imaging Sciences. “They can go into our computer and look at their skull.” Another orthodontist talked about coloring 3-D skulls in green and purple. “Fun for the kids,” he said. Dr. Allan G. Farman, president of the American Academy of Oral and Maxillofacial Radiology, cautions doctors not to become overly enamored of the new technology, citing the example of how shoe stores once took X-rays of customers’ feet to see if shoes fit. “At least the shoe merchants were ignorant of the effects of radiation,” Dr. Farman said. 1 2 3 4 5 Next Page » Sarah E. Fitzpatrick and Kristina Rebelo contributed reporting.

Patient Voices: Behind the Facade, Post-Traumatic Stress Posted: 22 Nov 2010 09:50 PM PST A soldier returns from war unable to get the images of battle out of his head. An earthquake survivor rides out long, anxiety-filled nights. A young woman in a pretty floral dress walks her dog along the streets of Manhattan. Well Share your thoughts on this column at the Well blog. Go to Well » Related Health Guide: Post-Traumatic Stress Disorder All three may be suffering from post-traumatic stress disorder. The woman walking her dog is Robin Hutchins, 25. She looks confident and self-assured, and few would guess that a year ago she discovered that she had the stress disorder. “When I tell people I have P.T.S.D., it’s like I have to convince them it’s a real issue,” she said. The disorder — in which a traumatic experience leaves the patient suffering from severe anxiety for months or years after the event — is often associated with battlefield combat and natural disasters. But as Dr. Frank Ochberg, a clinical professor of psychiatry at Michigan State University, noted in an interview, the typical trigger is more mundane — most commonly, a traffic accident. In Ms. Hutchins’s case, it was sexual violence. During her first year in college, on a weekend home to tend to a broken leg, she was raped by a young man she knew. She returned to college without telling her parents about it. “I just really wanted to be a freshman in college,” she said. Ms. Hutchins spoke to a counselor there and resumed her routine — attending class, hanging out with friends and trying to put the trauma behind her. “Nobody ever said, ‘You need to stop your life and deal with this — you can’t just walk through it,’ ” she said. The following year she was briefly pinned to a wall by a drunken male student. Seemingly a minor incident, but it sent Ms. Hutchins into a tailspin. Anxiety and panic began to strike her without warning. The prospect of leaving her dorm terrified her. She stopped going to class. Her reaction was not to get help, but to leave college. She traveled to Mongolia in hopes of clearing her head, but a car accident during her trip only made things worse. Friends didn’t understand why she never wanted to go out. They would play down her anxiety and say, “Oh, you’re just going to laugh at this in a couple days.” It took years of sleepless nights and paralyzing anxiety over tasks as simple as grocery shopping before she began to look for help. She sought out psychologists, but some dismissed her. “They’d say, ‘What does a pretty girl like you have to worry about?’ ” she said. Others were simply too expensive. Finally, during an initial consultation, a psychologist heard her full story and said the simple phrase that changed everything: “You have P.T.S.D.” Dr. Ochberg, the Michigan State professor, who has never met Ms. Hutchins, estimated that as many as 80 percent of rapes may lead to symptoms of post-traumatic stress. But the stigma of rape, along with a general misunderstanding of the disorder and how it can affect anyone who has suffered trauma, often gets in the way of a proper diagnosis. For Ms. Hutchins, the diagnosis came as good news. “When you can’t control your emotions at work, at home, with friends, you stop trusting yourself,” she said. “Knowing that my panic attacks came from P.T.S.D. was such a relief.” Understanding the cause of her emotional outbursts gave her tools to change them. Dr. Ochberg explained that the disorder causes violent memories to surface despite a person’s best efforts to tame them. Worse, the memory often feels more recent than it should. “There’s no sense of place in time,” Dr. Ochberg said. Studies suggest that the disorder may be associated with structural changes in the brain — in particular, a shrinking of the hippocampus, a region associated with memory. For most young professionals, a night out at a bar is routine; for Ms. Hutchins, the strange faces and crowds put her on high alert. Crossing the street calls up a swarm of terrifying possibilities: Will the bus hit me? Is that guy following me? Should I run? Should I fight back? If I do, will I put others at risk? Weekly therapy sessions helped her work through some of those irrational fears, and anxiety medications helped prevent some of the panic attacks. Still, she remained unnaturally vigilant. Then she met Dexter. After reading that “emotional support” dogs can be trained to comfort people with post-traumatic symptoms — staying by their side in overwhelming situations, for example — Ms. Hutchins adopted a small Lhasa apso from a shelter. Now, she and Dexter are training each other. Dexter keeps Ms. Hutchins calm on airplanes and forces her to go outside for long walks. People who see Dexter in his little blue service jacket smile at him — and at her, calming her further. She is still working on gaining control of her emotions, and she knows that the post-traumatic symptoms may linger. But there is less anxiety, fewer panic attacks. About Dexter she said, “He’s given me a partner in all of this.”

Well: A Vegetarian Thanksgiving, Even for Carnivores Posted: 23 Nov 2010 07:59 AM PST

18 and Under: A Prescription for Abdominal Pain: Due Diligence Posted: 23 Nov 2010 08:50 PM PST The stomachache people look with some envy at the headache people. Enlarge This Image Yarek Waszul Well Share your thoughts on this column at the Well blog. Go to Well » “For some reason people respect headaches,” said Dr. Carlo Di Lorenzo, a leading pediatric gastroenterologist and a professor of clinical pediatrics at Ohio State. “I’ve never seen a parent or a pediatrician tell a child complaining of a headache, ‘You don’t have a headache — it’s not real.’ Bellyache is just as real as headache.” Indeed it is. And recurrent abdominal pain in children is common, frustrating and often hard to explain. Consider a girl who came to the clinic for her 10-year physical exam. She gets these bellyaches, she told me. Had a bad one that week, but her stomach wasn’t hurting right at the moment. She’d been treated for constipation; she’d been tested for celiac disease and other problems. Every blood and stool test over the two years since the pain began was completely normal. One night the bellyache was so bad she went to the emergency room — and her abdominal X-rays were normal as well. The diagnostic term for this common and perplexing condition is “functional abdominal pain”: recurrent stomachaches, as the American Academy of Pediatrics put it in 2005, with no “anatomic, metabolic, infectious, inflammatory or neoplastic disorder” to explain them. When I was a resident, we often smirked when we spoke of functional abdominal pain, treating it as a code for a troublesome patient, dubious symptoms or an anxious family. But recent research suggests we were too biomedically narrow in our thinking. Scientists are coming to understand that abdominal pain is transmitted by a specialized nervous system that may be hypersensitive or hyperactive in some children. Studies in which researchers inflated balloons in children’s intestines suggested that those with functional abdominal pain might be unusually sensitive to any distension on the inside. “We think in terms of a biological-psychological-social model” for pain, said Dr. Joel R. Rosh, a pediatric gastroenterologist at Goryeb Children’s Hospital in Morristown, N.J., and an associate professor of pediatrics at New Jersey Medical School. “When a child says, ‘My belly hurts,’ what drives me crazy is people say, ‘No it, doesn’t.’ “Why would people say that? You’re feeling something! How much is biological, how much is psychological, how much is social?” The improved understanding of how such pain develops — and can be treated — has changed the ways that pediatricians look at the problem, but it hasn’t necessarily made it easier to take proper care of these children, to worry over them enough but not too much and, above all, to make them feel better. The problem may start with some initial insult, an infection or inflammation that may affect pain pathways in the child — and may also set up psychological patterns and anxieties in the child and response patterns and anxieties in the parent. And then the child continues to be extremely aware of sensations coming from the gastrointestinal tract, even when the initial illness is over. The challenge to the parents — passed on to the pediatrician — is how diligently these pains should be investigated, how many tests a child should be subjected to, how much money should be spent. “One thing fairly well established is that as soon as you make a referral to a subspecialist, cost increases by fivefold,” Dr. Di Lorenzo said. “We’re going to tend to do a lot more tests.” The more anxious the parent, he said, the more tests may be done for reassurance. With the 10-year-old girl, I was trying hard not to refer her to a subspecialist. She was growing well, she didn’t have celiac disease, she had none of the red flags that signal a need for a medical work-up. We suggested that she learn techniques to cope with her abdominal pain and maybe see a counselor to talk about anxiety. Her mother thought we meant the pain was imaginary. “The vast majority of data suggest that what helps the children is working with the brain more than working with the gut,” Dr. Di Lorenzo said. “Hypnosis is clearly more effective than medication.” And the medications that may work include those that work on the enteric nervous system (which uses serotonin as a neurotransmitter), so low doses of antidepressants are sometimes helpful with functional abdominal pain. Miranda A. L. van Tilburg, a psychologist who is assistant professor of medicine at the University of North Carolina, was the lead author of a study published a year ago in Pediatrics, which showed good effects from a treatment called guided imagery. “We would give them therapeutic suggestions,” Dr. van Tilburg said, “like imagining something in your hand that melts in your hand like butter and then you put it in your tummy and it makes it stronger, or imagine drinking your favorite drink and again the inside of your tummy is coated with this special layer.” The children were sent home with CDs and instructions to practice the imagery regularly as a prevention strategy. Our patient said she didn’t want to see any more doctors. She didn’t want any more blood tests, and she didn’t want tests she had heard about that involved tubes. Her mother didn’t really want those tests either, since as she said, they never seemed to find anything wrong. Neither was enthusiastic about seeing a counselor, but they finally agreed. It’s an appropriate strategy. “It’s very disempowering to have this alien living in your belly,” Dr. Rosh said. “How about if I learn that my belly doesn’t have to run my life?” And how do you help doctors, parents and children get past the idea that functional abdominal pain is not “real,” that a child doubled up with pain is faking it, that it’s all in his head? “If it was all in his head, he’d have a headache,” Dr. Rosh said. “Clearly there’s something happening in his belly.”

Scientist at Work: Dr. W. Ian Lipkin: A Man From Whom Viruses Can’t Hide Posted: 22 Nov 2010 10:20 PM PST Dr. W. Ian Lipkin was spending the afternoon prowling his empire of viruses. The Center for Infection and Immunity, which he directs, occupies three floors of the Mailman School of Public Health at Columbia University. Rather than wait for the elevator, Dr. Lipkin ran up and down the back stairs to move from floor to floor, leaning into the doorways of labs and glass-walled offices to get updates from a platoon of scientists. Related More Scientist at Work Columns RSS Feed Get Science News From The New York Times » Gustavo Palacios was sequencing the genes from a new strain of Ebola virus found in a bat in Spain — a worrisome development, since the fatal virus has almost never been found outside Africa. Nick Bexfield of the University of Cambridge had flown from England with a new hepatitis virus that has just broken out in British dogs. Some researchers were examining New York flu, others African colds. The blood of patients with mysterious, nameless fevers was waiting to be analyzed. There was dried African bush meat seized by customs inspectors at Kennedy Airport. Horse viruses, clam viruses: all told, members of Dr. Lipkin’s team were working on 139 different virus projects. It was, in other words, a fairly typical day. “We get 10,000 samples a year easily,” Dr. Lipkin said. “We’ve discovered at least 400 new viruses since I came to Columbia in 2002, and the process is accelerating.” Over the past 20 years, Dr. Lipkin has built a reputation as a master virus hunter. He has developed ways to quickly identify familiar viruses and ways to search for new ones. “If scientists are lucky, they’ll identify one novel virus in their whole life,” said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. “Lipkin really stands out from the crowd.” The emergence of H.I.V. in the 1980s first drove Dr. Lipkin to search for viruses. At the time, he was a neurology resident at the University of California, San Francisco, and was watching many patients fall ill with AIDS. It took years for scientists to discover the virus responsible for the disease. Dr. Lipkin worried that in years to come, new viruses would claim more lives because of this lag. “I saw all this, and I said, ‘We have to find new and better ways to do this,’ ” Dr. Lipkin said. One reason that viruses can be so hard to find is that they’re so small — typically a few millionths of an inch across. Even the most powerful microscopes may not be able to reveal viruses if they’re lurking in a hiding place in the body. Sometimes scientists can detect viruses by rearing vast numbers of them in laboratories. It’s also possible to detect them by looking for antibodies in infected people. But these methods can be slow and unreliable. Dr. Lipkin thought it might be better to find viruses in a different way. He would go fishing for their genes. “It had never been done before, and it was an obvious thing to do,” he said. Dr. Lipkin’s first quarry was the cause of a bizarre disorder caused borna disease. Borna disease had first been discovered in horses in the late 1800s; it attacks their brains and causes them to flail uncontrollably. When scientists injected filtered brain extracts into healthy animals, they could develop the disease as well. Doctors worried that it might cross over into humans and have equally devastating effects. But no one had ever found a pathogen in an animal sick with the disease. If a virus was responsible for borna disease, Dr. Lipkin reasoned, he might be able to find its genes in an infected brain. He and his colleagues infected rats with the disease and then extracted genetic material from them. They first identified the pieces of DNA that came from the rats themselves. After they painstakingly subtracted the host genes, they were left with a small amount of genetic material present only in the sick rats. To see if these genes came from the cause of borna disease, Dr. Lipkin transplanted them into bacteria. The bacteria used them to make proteins. If these were proteins from the source of borna disease, then infected animals might have made antibodies precisely tailored to grab onto them. In 1990, Dr. Lipkin and his colleagues reported that when they mixed borna antibodies with the proteins, they embraced each other tightly. This discovery allowed Dr. Lipkin and his colleagues to isolate the virus, which came to be known as the borna virus. As Dr. Lipkin earned his reputation as a virus hunter, other researchers began to bring difficult cases to him. In 1999, for example, doctors noticed a cluster of cases of encephalitis around New York City. They shipped blood from their patients to Dr. Lipkin, who was then at the University of California, Irvine. Analyzing the genetic material, he and his colleagues concluded that the encephalitis had been caused by West Nile virus. It was the first time the virus had been identified in the Western Hemisphere. Since Dr. Lipkin made the discovery, West Nile virus has spread across the continental United States. Dr. Lipkin’s success with West Nile virus led to an invitation to come to Columbia in 2002 and set up the Center for Infection and Immunity. He and his colleagues began developing faster, more sensitive methods to find viruses. At the time, the most sophisticated technologies for identifying viruses could only compare their genetic material to one known virus at a time. Dr. Lipkin and his colleagues developed a more powerful system, known as MassTag PCR. The researchers prepare a cocktail of genetic material from 20 or more kinds of viruses. When they mix the DNA from a sample into this cocktail, the viral segments will bind to any matching DNA. Dr. Lipkin and his colleagues can then fish out these matching segments and shoot them through a mass spectrometer to determine their mass. From these clues, the scientists can often determine what kind of virus they’re dealing with. MassTag PCR is relatively cheap and fast, but it can miss viruses that are scarce or especially exotic. It failed, for example, to reveal the cause of three puzzling deaths in Australia. In 2006, three women received liver and kidney transplants from the same donor. For a month after the transplant, they were in good health, but then they all suddenly developed intense fevers and died. Dr. Lipkin and his colleagues analyzed samples from their bodies, but they couldn’t find any culprits with MassTag PCR. At the time, Dr. Lipkin and his colleagues were adapting new genome sequencing machines to virus hunting. They decided to turn the machines on this mystery. 1 2 Next Page » This posting includes an audio/video/photo media file: Download Now

Recipes for Health: Pumpkin Cornbread Posted: 23 Nov 2010 09:10 PM PST This rich cornbread is inspired by a Basque recipe that I’ve altered to resemble American cornbread. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Pumpkin: The Flavor of Late Fall (November 22, 2010) Recipes for Health: Indian Pumpkin Pudding (November 23, 2010) Recipes for Health: Pumpkin Gelato (November 25, 2010) Recipes for Health: Pumpkin and Ginger Scones (November 26, 2010) 1 cup drained pumpkin purée, canned or made from 1 pound fresh pumpkin (see below) 1 cup low-fat milk 2 tablespoons extra virgin olive oil 1 tablespoon mild honey, such as clover 2 eggs 1 1/2 cups stone ground yellow cornmeal 1/2 cup all-purpose flour 1 tablespoon baking powder 1/2 teaspoon baking soda 3/4 teaspoon salt 1 tablespoon unsalted butter 1. Heat the oven to 400 degrees, and place inside a 9-inch cast iron skillet or a 2-quart baking dish. 2. Whisk together the pumpkin purée, milk, olive oil, honey and eggs. 3. Place the cornmeal in a large bowl, and sift in the flour, baking powder, baking soda and salt. 4. Stir the dry ingredients into the wet ingredients and mix together. Do not overwork. 5. Remove the baking dish or pan from the oven, and add the butter. When it has melted completely, brush the sides of the pan with a pastry brush; tip the excess melted butter into the batter, and quickly mix it in. Scrape the batter into the hot pan, and return it to the oven. Bake for 35 to 40 minutes until a tester comes out clean. Remove from the oven, and allow to cool in the pan for at least 20 minutes before serving. To make the pumpkin purée: Preheat the oven to 425 degrees. Cover a baking sheet with foil. Place the pumpkin pieces on the baking sheet, drizzle 1 tablespoon of canola oil or olive oil on top, cover tightly with foil and place in the oven. Roast for 1 1/2 hours or until thoroughly tender. Remove from the heat, transfer to a strainer or a colander set over a bowl or in the sink, and allow to cool and drain. Peel the pieces, and purée them in a food processor fitted with the steel blade. Yield: 12 servings. Advance preparation: This will keep for a couple of days if well wrapped. It does not freeze well. Nutritional information per serving: 141 calories; 5 grams fat; 1 gram saturated fat; 39 milligrams cholesterol; 22 grams carbohydrates; 2 grams dietary fiber; 320 milligrams sodium; 4 grams protein Martha Rose Shulman can be reached at martha-rose-shulman.com. Her latest book is "The Very Best of Recipes for Health."

In Cybertherapy, Avatars Assist With Healing Posted: 23 Nov 2010 01:44 PM PST OTTAWA — His talk was going just fine until some members of the audience became noticeably restless. A ripple of impatience passed through the several dozen seated listeners, and a few seemed suddenly annoyed; then two men started to talk to each other, ignoring him altogether. RSS Feed Get Science News From The New York Times » Enlarge This Image Michal Czerwonka for The New York Times Arno Hartholt interacts with characters in a simulated Old-West saloon at U.S.C. “When I saw that, I slowed down and then stopped what I was saying,” said the speaker, a 47-year-old public servant named Gary, who last year took part in an unusual study of social anxiety treatment at the University of Quebec. The anxiety rose in his throat — What if I’m not making sense? What if I’m asked questions I can’t answer? — but subsided as his therapist, observing in the background, reminded him that the audience’s reaction might have nothing to do with him. And if a question stumped him, he could just say so: no one knows everything. He relaxed and finished the talk, and the audience seemed to settle down. Then he removed a headset that had helped create an illusion that the audience was actually there, not just figures on a screen. “I just think it’s a fantastic idea to be able to experience situations where you know that the worst cannot happen,” he said. “You know that it’s controlled and gradual and yet feels somehow real.” For more than a decade, a handful of therapists have been using virtual environments to help people to work through phobias, like a fear of heights or of public spaces. But now advances in artificial intelligence and computer modeling are allowing them to take on a wider array of complex social challenges and to gain insight into how people are affected by interactions with virtual humans — or by inhabiting avatars of themselves. Researchers are populating digital worlds with autonomous, virtual humans that can evoke the same tensions as in real-life encounters. People with social anxiety are struck dumb when asked questions by a virtual stranger. Heavy drinkers feel strong urges to order something from a virtual bartender, while gamblers are drawn to sit down and join a group playing on virtual slot machines. And therapists can advise patients at the very moment those sensations are felt. In a series of experiments, researchers have shown that people internalize these virtual experiences and their responses to them — with effects that carry over into real life. The emerging field, called cybertherapy, now has annual conferences and a growing international following of therapists, researchers and others interested improving behavior through the use of simulations. The Canadian military has invested heavily in virtual-reality research; so has the United States Army, which has been spending about $4 million annually on programs with computer-generated agents, for training officers and treating post-traumatic stress reactions. The trend has already generated a few critics, who see a possible downside along with benefits. “Even if this approach works, there will be side effects that we can’t anticipate,” said Jaron Lanier, a computer scientist and author of “You Are Not a Gadget: A Manifesto” (Knopf, 2010). “And in some scenarios I would worry about defining humans down: defining what’s normal based on what we can model in virtual environments.” But most researchers say that virtual therapy is, and will remain, no more than a therapist’s tool, to be used only when it appears effective. “There’s a real and understandable distrust of technology as a shortcut for good clinical skills,” said Albert Rizzo, a psychologist at the University of Southern California, “but I think, deep down, most therapists will want any tool that can help them do their work, and they’ll be open to using virtual approaches.” Virtual Humans, Real Therapy “My abilities are somewhat limited,” says a female voice. “For example, I can speak and listen to what you say, but I can’t do any physical activity.” In an office at the Institute for Creative Technologies at the University of Southern California, a virtual woman named Angelina is addressing a college student from a computer screen. Angelina looks to be about 30 or so, a pretty, athletic figure with an open, intelligent face framed by short black hair. Her eyes and expression, guided by video cameras and microphones, stay in sync with the student’s, as an empathetic therapist’s would. “What are some of the things you hate about yourself?” asks the voice. The student stalls for a moment. “Well,” she says, in a video of the exchange, “I don’t like that I can be really quiet in social situations. Sometimes people take that as me being rude, but it’s just me being quiet.” Angelina nods sympathetically and then asks another question, about what the student fears most. Interacting with a virtual human programmed to be socially sensitive in this way is oddly liberating. The figures are clearly not human; some are balky with language, others mute. Many have a two-dimensional graphic-arts quality. 1 2 3 Next Page » This posting includes an audio/video/photo media file: Download Now

Wired Up at Home to Monitor Illnesses Posted: 22 Nov 2010 09:40 PM PST As an aging population threatens to overwhelm the nation’s hospitals and doctors, thousands of seriously ill patients are relying on computerized health trackers to help keep them safe at home. Related The New Old Age Blog: The Nurse in the Living Room (November 22, 2010) Rachel Hofstad, 94, of Rochester, Minn., has one hooked up in her bedroom. A retired teacher with chronic lung disease, Ms. Hofstad is one of 200 patients in a randomized trial of a home monitoring system being conducted by doctors at the Mayo Clinic. The device is about the size of a coffee maker. “First thing in the morning,” she said, “a light comes on and a beeper sounds.” She touches a screen to log in and is cued to slip on a blood pressure cuff and push a button. Her pressure and pulse readings are displayed. Next, she slides a forefinger into a sensor that measures blood oxygen. Then she checks her weight on a scale linked to the machine. “The machine tells me I’m well,” she said. On the other hand, a pattern of “yes” replies to questions like “Are you coughing more than usual today?” will alert a nurse to contact her. Researchers say devices like these can help motivate elderly patients with chronic conditions like heart or lung disease, advanced diabetes or depression to follow advice from their doctors and nurses and to take part in their own care. Big multinational companies including G.E., Phillips, Intel, Honeywell and Bosch are stepping up their commitment in what some experts call “telehealth”; last month AT&T said it would offer a diabetes monitor accessible by phone to some of its 1.2 million employees, retirees and their dependents. While the goal of home monitoring is to avert costly visits to hospitals, studies so far have shown mixed results. Earlier versions of the technology did not demonstrate savings in Medicare studies, and just last week in The New England Journal of Medicine, Yale researchers reported disappointing results from a study of high-risk heart patients who had monitoring devices in their homes. Still, Dr. Douglas L. Wood, a cardiologist and health policy expert at the Mayo Clinic, said he expected remote monitoring to develop rapidly. “It is amazing to see how quickly older people are taking up the technology,” he said. Advocates for in-home care, like Dr. Steven H. Landers, head of the Cleveland Clinic’s home health care unit, say it is often less costly and produces better health results than occasional checkups and repeated hospital stays. In a New England Journal article last month, Dr. Landers listed forces driving health care into the home: the aging population, “epidemics” of chronic diseases, technological advances, health care consumerism and rapidly escalating health costs. He added that “ health care organizations that do not adapt to the home care imperative risk becoming irrelevant.” The paper in last week’s New England Journal, by Dr. Sarwat I. Chaudhry, an assistant professor at the Yale School of Medicine, and colleagues said a six-month study found no significant differences in health status between patients who were monitored at home and a control group receiving the usual care. But Dr. Gregory J. Hanson, a Mayo geriatrician who is running the trial in which Ms. Hofstad is enrolled, said there were many types of monitoring systems and devices that might vary in effectiveness. Using daily reports from patients at home is “a different way to practice,” he said. The average age of patients in the Mayo trial is 80, and most have been in a hospital frequently. “We are learning how to interact with the patient and tie in with their primary care provider,” Dr. Hanson said, “so everyone is on the same page.” Eric Dishman, head of digital health strategy for Intel, which has a different system, noted that the monitoring system in the Yale study relied on the patients to phone in their daily results. Many failed to do so. A number of other monitoring systems transmit the patient’s information automatically. Some systems provide personalized feedback that helps keep the patient in the loop. Mr. Dishman said he hoped that large-scale pilot projects under the new health law would “prove out the best options” in home monitoring. Intel and G.E. Healthcare are putting up $125 million each in a venture to develop new telehealth systems. “We found our home care patients will tell things to those telehealth units that they hesitate to tell the nurse,” said Bridget Gallagher, a senior vice president at Jewish Home Lifecare in New York. “Sometimes they don’t tell a nurse or a family member about a fall,” she said. “They are scared they will be told, ‘You can’t stay in your home.’ ” In one of the largest programs, more than 48,000 veterans are participating in home monitoring. The Department of Veterans Affairs said hospital admissions were reduced by 19 percent in a 2007 study of 17,025 patients using home monitors. The department plans to have 92,000 patients on home monitoring by 2012, said Dr. Adam Darkins, its chief consultant on coordinating care for veterans. Alere Inc., a health management company based in Waltham, Mass., has 90,000 patients using its home monitoring devices, including 45,000 who are taking blood thinner drugs, said Dr. Gordon Norman, the company’s chief innovation officer. One of them is Michael L. Johnson, 72, a retired lieutenant colonel who commanded Army medical units in Vietnam and who has congestive heart failure. He checks his own blood at home instead of driving to a V.A. lab. He e-mails the results to Alere, which relays them to his doctor. National health systems in Europe and Japan are ahead of the United States in home health monitoring, industry experts say, but the gap may narrow as pressure builds to slow the increases in Medicare costs. For one thing, the Obama administration plans to cut back on generous payments to insurance companies for the nearly 11 million members of Medicare Advantage health plans. Advocates say telehealth, if carefully focused, could help reduce costs for the 5 percent of patients in the United States who account for most of the spending. OptumHealth, a unit of UnitedHealth Group, is already monitoring more than 12,000 home-based Medicare heart patients and 7,000 more in private employer health plans. They weigh themselves twice a day and answer health status questions on a keypad. Humana plans to sign up 2,000 high-risk elderly congestive heart failure patients next year in a study using a monitoring device from Intel like the ones in the Mayo Clinic trial. Aetna has completed a trial using the Intel device with 330 Medicare members who have heart problems. It is getting ready to report results in a peer-reviewed journal, said Dr. Randall Krakauer, an Aetna national medical director. The stakes are high: 68,000 Aetna Medicare members have high blood pressure. One physician who says he is cautious about telehealth is Dr. Daniel Einhorn, medical director of the Scripps Whittier Diabetes Institute in La Jolla, Calif., and president of the American Association of Clinical Endocrinologists. Even though WellDoc, which makes devices for AT&T, has said its monitoring system significantly reduced A1C, a blood sugar indicator, in a yearlong randomized trial of patients with Type 2 diabetes, Dr. Einhorn said he would wait to read the final report in a peer-reviewed journal. Treating diabetes “depends entirely on multiple details,” he said. “We need to know: Are there patterns of glucose levels, the patient’s age, medications, other medical problems?” Dr. Suzanne Clough, a diabetes specialist who is a founder of WellDoc, said she agreed that “a physician needs to know a lot about the individual.” “A phone message cannot replace that,” she said. But it can “provide additional information, insight and contextualized data.”

Global Update: Flu: Bird Flu Falls Off the Radar, but Cases Show It’s Still a Threat Posted: 23 Nov 2010 08:28 AM PST In the wake of last year’s pandemic of H1N1 swine flu — which turned into far less of a global threat than had been feared — the world has largely forgotten about the H5N1 bird flu. Related Health Guide: Avian Influenza But that flu has not disappeared. Nor does it seem any less lethal. In contrast to the swine flu, which killed only 1 out of every 2,000 people who got it, the avian flu kills about 3 out of 5. The world was reminded last week when a 59-year-old woman returning from a vacation in China became the first Hong Kong resident with the virus in seven years. The flu was originally discovered in Hong Kong in 1997 and recurred there in 2003. She was hospitalized in stable condition. Local health authorities said on Monday that she did not appear to have infected anyone, and no virus was found in bird markets or on poultry farms. Since 2003, there have been 508 cases around the world, with 302 deaths. Only three countries — Indonesia, Egypt and Vietnam — have reported more than one or two a year recently. It is more often found in poultry flocks. The government in Indonesia recently released details of two deaths. One was a 35-year-old Jakarta man who died after 11 days despite prompt hospitalization. The second was a 40-year-old woman who died a week after falling ill. For unknown reasons, a greater percentage die of the flu in Indonesia than elsewhere.

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Personal Health: It’s Time for Recess: Just Keep on Moving Posted: 22 Nov 2010 10:00 PM PST We all know by now that we should be getting 30 minutes a day of moderate to vigorous physical activity on most days. Yet for all the proselytizing, wheedling and cajoling, only about 5 percent of the population has bought into the program. Related More Personal Health Columns “Being sedentary is the norm in America,” writes Dr. Toni Yancey, a professor of health services at the University of California, Los Angeles. Thanks to the plethora of labor-saving devices and motorized vehicles, we now “spend most of our waking time sitting, reclining or lying down.” “Even activities that we still do regularly demand less exertion,” Dr. Yancey continued. “And the less people have to do, the more quickly they get tired when they exert themselves just a little bit, which of course discourages them from exercising.” Clearly, a new approach is needed. And Dr. Yancey is offering one that has already shown great promise to counteract what she calls “sedentary behavior disorder.” She calls it “Instant Recess” — the title of her new book (University of California Press), in which she demonstrates the value of two 10-minute breaks of enjoyable communal activity as part of people’s everyday lives. The sessions can be instituted wherever people gather: day care centers, schools, workplaces, conferences, places of worship, senior centers and the like. At 6-foot-2, Dr. Yancey was a college basketball star, and she remains a staunch believer in the value of lifelong physical activity. She says the secret to motivating more Americans to make regular physical exercise a part of their lives is to incorporate enjoyable bouts of activity into their everyday behavior. Take a Break and Exercise As an alternative to a structured exercise break, she suggests “gathering groups of people to take a brisk walk around the grounds for 10 minutes twice a day.” Getting people to exercise in groups is easier because “everyone’s doing it,” and these brief exercise sessions deliver the most benefit to those who need it most. Dr. Yancey has a wealth of experience at motivating highly sedentary people to move more. She describes instant recess as “a point of entry, a calling card for national physical activity” — a way to stimulate health-promoting activity, especially among those whose lives and value systems have not caught up with the top-down prescriptions for regular physical exercise. “These short bouts of activity can spill over to the rest of a person’s life,” she said in an interview. “Once people feel more fit and better about themselves, they are more likely to engage in moderate to vigorous physical activity during their leisure time.” She calls the recess model “the aerobics of the 21st century — an updated exercise prescription for an increasingly over scheduled, ethnically diverse, multicultural, media-and-information-technology-driven global modern society.” “People want to be healthier, fitter and thinner,” she writes. “But the cost is just more than most are willing to pay, and the rewards are too far in the future.” By making instant recess the default option, she said, no one has to decide to exercise or carve out a special time to do it, and some of the rewards are immediate — among them camaraderie, social interaction with friends and co-workers, stress relief, muscle relaxation, increased energy, improved mood and better concentration. So at sites around the country, students, employees and older people, among others, are taking dancelike exercise breaks to music that have been shown to enhance achievement, productivity, self-esteem and well-being. As Dr. Yancey puts it, “What’s good for the waistline is good for the bottom line.” Companies including L. L. Bean and Replacements Ltd. have found that the kinds of breaks Dr. Yancey is promoting can increase output and decrease injuries and workers’ compensation claims. L. L. Bean employees who take part in three five-minute stretch breaks each workday have given back to the company “a 100 percent return on its investment — 30 minutes of productivity in terms of what comes off the assembly line,” Dr. Yancey reported. And within three years, she said, “work-related injuries dropped from 14 a year to essentially none.” After the introduction of 10-minute exercise breaks at Replacements Ltd., which sells replacement pieces for sets of china and silverware, fewer employees lost time from work because of problems like carpal tunnel syndrome and low back pain. Dr. Yancey is now involved in a study of recess breaks at 70 work sites in Los Angeles County. Motivating the Young Likewise, she said, 10-minute exercise breaks during the school day could do more to forward the goals of No Child Left Behind than double that amount of time spent trying to stuff math and English into students’ heads. She cited a federally financed study by the University of Kansas conducted at 24 low-income public schools. The study, which included a matched control group, found that 10-minute activity breaks, usually done to music, led to improved scores in math, spelling and composition among the participants. The students also increased their activity levels outside school, on weekdays and weekends, and gained less weight than those in the schools who did not institute fitness breaks. This study is especially telling because in schools around the country, physical education classes and outdoor recess have fallen prey to the demands to improve test scores. “Getting kids to sit shoulder to shoulder for six hours a day is not going to do it,” Dr. Yancey said. “Even in schools that still have 30-minute periods of physical education or recess, many children get only about five minutes of moderate to vigorous activity. Most just stand around texting or talking with their friends.” But studies by Dr. Yancey and colleagues at U.C.L.A. showed, for example, that athlete-led exercise breaks in school, even via DVDs or CDs, could motivate otherwise sedentary youngsters to get moving and improve their fitness levels. In a charter school in Phoenix, instant recess was tested among low-income minority students from kindergarten through sixth grade. They loved the 10-minute sessions, according to researchers, saying things like “It gave me energy throughout the day,” “It was way better than sitting down in class all the time” and “I think other schools should do it so they can become more active.” This is the first of two columns about health-promoting physical activity. This posting includes an audio/video/photo media file: Download Now

Really?: The Claim: Cellphones Can Cause an Allergic Reaction. Posted: 22 Nov 2010 10:20 PM PST THE FACTS Talking on a cellphone for long periods can carry certain risks, like dirty looks from those around you. But allergies? Enlarge This Image Christoph Niemann Well Share your thoughts on this column at the Well blog. Go to Well » Related More Really? Columns In recent years, dermatologists have seen a small but growing number of people with itchy rashes along their jaw lines, face and ears which go away when cellphone use is discontinued. The reason, studies suggest, is an allergy to metals in the phones, most often nickel. Nationwide, nickel allergy afflicts about 3 percent of men and nearly 20 percent of women. Women are more likely to be affected because they are often sensitized to it by ear piercings and metal jewelry, said Dr. Clifford W. Bassett a New York City allergist and fellow of the American College of Allergy, Asthma and Immunology, who has treated the condition. It’s unclear how many people develop allergic reactions to their phones. But the medical literature is rife with case studies. In a typical case, described by researchers at Brown University and published in the journal CMAJ in 2008, an 18-year-old developed a strange rash on the right side of his face. When his cellphone headset tested positive for nickel, he switched to a nickel-free phone, and the eruption cleared up. The researchers later tested 22 popular models of cellphones and found nickel in 10 of them, mostly in the headsets and menu buttons. For those who suspect a metal allergy, a patch test at an allergist’s office can provide confirmation, Dr. Bassett said, and a simple swab test can reveal the presence of nickel in a phone or other product. THE BOTTOM LINE In people with nickel allergies, cellphones can cause an allergic reaction. ANAHAD O’CONNOR scitimes@nytimes.com

Economic Scene: Life Expectancy in China Rising Slowly, Despite Economic Surge Posted: 24 Nov 2010 12:17 PM PST A quick quiz: Which of the following countries has had the smallest increase in life expectancy since 1990 — Bangladesh, China, Pakistan, South Korea or Sudan? Enlarge This Image David Gray/Reuters Nearly every other big developing country had a bigger increase in life expectancy from 1990 to 2008 than China. Related Magazine Preview: In China, Cultivating the Urge to Splurge (November 28, 2010) The answer is not war-torn Sudan or tumultuous Pakistan. It isn’t South Korea, which started from a higher level than any of the others. And it isn’t abjectly poor Bangladesh. It’s China, the great economic success story of the last two decades and the country that inspires fear and envy around the world. Yet when measured on one of most important yardsticks of all, China does not look so impressive. From 1990 to 2008, life expectancy in China rose 5.1 years, to 73.1, according to a World Bank compilation of United Nations data. Nearly every other big developing country, be it Brazil, Egypt, Ethiopia, India, Indonesia or Iran, had a bigger increase over that span, despite much slower economic growth. Since 2000, most of Western Europe, Australia and Israel, all of which started with higher life expectancy, have also outpaced China. The moral? Economic growth makes almost any societal problem easier to solve, but growth doesn’t guarantee better lives — or better health — for everyone. That’s been true for centuries. The rate of growth and the kind of growth both matter. If you scan the globe today, you may end up wondering whether any country has landed on the right mix. Europe offers a good life to many people, with generous vacations, parental leaves and health benefits, but its economies have been growing slowly, which is one reason its debts are so onerous. The United States grew more quickly than Europe in recent decades, but many of the gains flowed to a small slice of the population. Median household income, adjusted for inflation, actually fell from 2000 to 2007 — and has fallen more since the financial crisis began in 2007. China can sometimes look like the economy of the future, having grown stunningly fast for almost 30 years now, lifting hundreds of millions of people out of poverty. But it, too, has real problems. Above all, its growth has been uneven. The coast has benefited much more than the interior. Almost everywhere, some aspects of life have improved much more than others. Whether China can switch to a more balanced form of growth, as its leaders have vowed, will obviously have a big effect on the rest of the global economy. Yet it’s worth remembering that the biggest impact will be on the one-sixth of the world’s population who live in China. And arguably the best example is the fact that the country has grown vastly wealthier but only modestly healthier. There is an intriguing parallel here to the Industrial Revolution. The eminent economist Richard Easterlin has noted that longevity and health did not improve much when economic growth took off in the early 19th century. With rising incomes, people could afford better food, clothing and shelter. But they were also exposed to more disease because so many of them were moving to cities. The combined effect appears to have been “stagnation or, at best, mild improvement in life expectancy,” Mr. Easterlin has written. The Mortality Revolution, as he calls it, did not occur for almost another a century. It depended on relatively cheap investments in public health, like sanitation, and on the spread of scientific methods. Similarly, in today’s China, many more people have acquired indoor plumbing, heating, air-conditioning or other basics. Other aspects of the boom, however, have pushed in the opposite direction. As in the Industrial Revolution, many people have left the countryside and poured into crowded cities. Accidents have become common, like the Shanghai fire last week or a series of workplace tragedies in recent months. Obesity is rising. Pollution is terrible. I recently spent some time in China, and despite everything I’d heard in advance about the pollution, I was still taken aback. The tops of skyscrapers in Beijing can be hard to see from the street. Breathing the smog can feel like having a permanent low-grade sinus infection. For the Chinese, cancer has displaced strokes as the leading cause of death, partly because of pollution, notes Yang Lu of the Keck School of Medicine at the University of Southern California. Finally, there is the medical system itself. The dismantling of state-run industrial companies over the last two decades has ended the cradle-to-grave benefits system known as the iron rice bowl. In its place was a market-based medical system many Chinese could not afford. Even in emergencies, people sometimes had to bring cash to the hospital to get treatment. Early last year, the Chinese government began expanding health insurance coverage, with the goal of making it universal by 2020. The initial signs look pretty good. The World Bank does not have data past 2008, but numbers published by the C.I.A. suggest that life expectancy has risen in the last two years. In my travels, I visited a simple, clean clinic in rural northern China that seemed to be providing the kind of basic care that could make a huge difference. Of course, whatever the problems with China’s boom, it still has significantly improved the lives of its citizens. Many fewer of them live in grinding poverty, and the population is living longer, even if the gains have not been as large as in many other countries. Over any extended period, economic growth is probably necessary for higher living standards. It’s just not enough. As Tsung-Mei Cheng, a health policy expert at Princeton, argues, “Economists and the media tend to pay too much attention to the growth of G.D.P. over all, and not enough to its distribution.” There is, after all, another large country with unimpressive recent gains in life expectancy, even smaller than China’s. That’s right: the United States. Since 1990, we have been passed by Chile, Denmark, Slovenia and South Korea, among others. China is still five years behind us, but it’s gaining. E-mail: leonhardt@nytimes.com This posting includes an audio/video/photo media file: Download Now

The New Old Age: Ask an Elder Law Attorney Posted: 24 Nov 2010 08:13 AM PST

The New Old Age: Heartache in the I.C.U. Posted: 23 Nov 2010 11:16 AM PST

The New Old Age: Housecalls of Another Sort Posted: 23 Nov 2010 08:15 AM PST

Prescriptions: Tackling Mini-Med Policies Posted: 24 Nov 2010 09:57 AM PST

Prescriptions: Higher Deductibles, Lower Spending Posted: 23 Nov 2010 06:17 AM PST

Prescriptions: This Week's Health Industry News Posted: 23 Nov 2010 11:09 AM PST

Recipes for Health : Pumpkin Gelato Posted: 22 Nov 2010 02:31 PM PST This is like an ice cream version of pumpkin pie, but lighter. No eggs are required, and you can use low-fat milk. The important thing to remember here is that if you use fresh pumpkin for the purée, it must be roasted until very soft in order for the purée to be extremely fine. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Pumpkin: The Flavor of Late Fall (November 22, 2010) Recipes for Health: Indian Pumpkin Pudding (November 23, 2010) Recipes for Health: Pumpkin Cornbread (November 24, 2010) Recipes for Health: Pumpkin and Ginger Scones (November 26, 2010) 1 quart low-fat milk 1/2 cup unrefined brown (turbinado) sugar 1/4 cup honey 1 1/4 cups very finely blended pumpkin purée, canned or made from 1 1/4 pounds fresh (see below) 2 teaspoons ground ginger 1 teaspoon ground cinnamon 1/4 teaspoon freshly grated nutmeg Pinch of ground cloves (less than 1/8 teaspoon) 1 teaspoon vanilla extract 1. Combine the milk, sugar and honey in a large saucepan, and bring to a simmer. Remove from the heat, and stir until the sugar is completely dissolved. Transfer to a bowl, and whisk in the remaining ingredients. Allow to cool, then chill in the refrigerator. Alternatively, set the bowl inside a bowl of ice water to chill quickly. 2. Place a bowl or a container in your freezer. Freeze the pumpkin gelato mixture in an ice cream maker following the manufacturer’s instructions. Scrape into the chilled bowl, and freeze for at least two hours before serving. If making this dish ahead, allow to soften for 15 to 30 minutes in the refrigerator before serving. To roast the pumpkin: Preheat the oven to 425 degrees. Cover a baking sheet with foil. Place the pumpkin pieces on the baking sheet, drizzle 2 teaspoons of olive or canola oil on top, cover tightly with foil and place in the oven. Roast for 1 1/2 hours or until thoroughly tender. Remove from the heat, and transfer to a strainer or colander set over a bowl or in the sink. Allow to cool and drain. Peel the pieces, and purée in a food processor fitted with the steel blade. Yield: About five to six cups, serving 10. Advance preparation: This will keep for a couple of weeks in the freezer. Nutritional information per serving: 117 calories; 1 gram fat; 1 gram saturated fat; 5 milligrams cholesterol; 24 grams carbohydrates; 1 gram dietary fiber; 49 milligrams sodium; 4 grams protein Martha Rose Shulman can be reached at martha-rose-shulman.com. Her latest book is "The Very Best of Recipes for Health."

Recipes for Health: Indian Pumpkin Pudding Posted: 23 Nov 2010 08:33 AM PST Indian pudding is an old-fashioned American dessert made with cornmeal, milk and molasses. I added pumpkin to the mix and came up with a deeply satisfying pudding, like pumpkin pie without the crust. I enjoy it warm or cold (I’ve been eating the remains of my recipe test with yogurt for breakfast). Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Pumpkin: The Flavor of Late Fall (November 22, 2010) Recipes for Health: Pumpkin Cornbread (November 24, 2010) Recipes for Health: Pumpkin Gelato (November 25, 2010) Recipes for Health: Pumpkin and Ginger Scones (November 26, 2010) 1 quart low-fat milk 6 tablespoons stone-ground yellow cornmeal 1/3 cup molasses 1/4 cup mild honey 2 cups pumpkin purée, canned or made from 2 pounds fresh pumpkin (see below) 4 eggs 3/4 teaspoon salt 1 teaspoon ground ginger 1/2 teaspoon freshly grated nutmeg 1 tablespoon unsalted butter 1/2 cup raisins (optional) 1. Heat the oven to 325 degrees. Butter a 2-quart casserole, soufflé dish or Dutch oven. 2. Pour the milk into a 3- or 4-quart pot or saucepan, and place over medium-high heat. Bring to a simmer, and slowly stream in the cornmeal while whisking the milk. Turn the heat to low and simmer 15 minutes, stirring, until the mixture has the consistency of runny cream of wheat. Stir in the molasses and honey, and continue to simmer, stirring, for five minutes. Remove from the heat, and whisk in the pumpkin until the mixture is smooth. Whisk in the eggs, one at a time, and add the remaining ingredients. Pour into the buttered casserole, scraping in every bit with a rubber spatula. 3. Place in the oven, and bake 1 to 1 1/2 hours until set; a knife should come out clean when inserted, and the top should be just beginning to brown. Remove from the heat, and allow to cool for at least 30 minutes before serving. To make the pumpkin purée: Preheat the oven to 425 degrees. Cover a baking sheet with foil. Place the pumpkin pieces on the baking sheet, drizzle 1 tablespoon of canola oil or olive oil on top, cover tightly with foil and place in the oven. Roast for 1 1/2 hours or until thoroughly tender. Remove from the heat, transfer to a strainer or a colander set over a bowl or in the sink, and allow to cool and drain. Peel the pieces, and purée them in a food processor fitted with the steel blade. Yield: Serves eight to 10. Advance preparation: You can serve this hot, at room temperature or even cold. It keeps for several days in the refrigerator. Nutritional information per serving (eight servings): 216 calories; 6 grams fat; 3 grams saturated fat; 116 milligrams cholesterol; 35 grams carbohydrates; 3 grams dietary fiber; 315 milligrams sodium; 9 grams protein Nutritional information per serving (10 servings): 172 calories; 4 grams fat; 2 grams saturated fat; 93 milligrams cholesterol; 28 grams carbohydrates; 2 grams dietary fiber; 252 milligrams sodium; 7 grams protein Martha Rose Shulman can be reached at martha-rose-shulman.com. Her latest book is "The Very Best of Recipes for Health."

Recipes for Health: Pumpkin: The Flavor of Late Fall Posted: 22 Nov 2010 02:57 PM PST I never got around to carving a jack-o’-lantern for Halloween. I bought the pumpkin, yes, but then decided to save it for cooking. The day after Halloween, I cut it into chunks — about eight pounds — put them on foil-lined baking sheets, covered the sheets and roasted them at 425 degrees until they were very soft, which took about 1 1/2 hours. Then I spent the week making pumpkin recipes. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Indian Pumpkin Pudding (November 23, 2010) Recipes for Health: Pumpkin Cornbread (November 24, 2010) Recipes for Health: Pumpkin Gelato (November 25, 2010) Recipes for Health: Pumpkin and Ginger Scones (November 26, 2010) Jack-o’-lantern pumpkins are easier to cut than other pumpkinlike squashes, like kabochas, because the skin is not as thick and hard. The flesh is also very moist, which is one of the reasons I think it works well in a savory pie. (Depending on what you’re making, it can be a good idea to drain the purée in a cheesecloth-lined strainer.) I used some of the pumpkin for a savory Greek pumpkin and leek pie, which is now in my freezer awaiting Thanksgiving; it will serve as an entree for the vegetarians at the table. I also made pumpkin cornbread, inspired by a Basque recipe but perfect for a Thanksgiving table. And if you love pumpkin pie but don’t want to bother with the crust, you’ll get some of the same wonderful flavors in this week’s Indian pudding and pumpkin gelato. But a Thanksgiving dinner needs more than just pumpkin. You can find creative dishes from famous chefs at the Well blog’s vegetarian Thanksgiving interactive. And following today’s recipe, I’ve appended a list of my holiday favorites, culled from the Recipes for Health archive. Greek Pumpkin and Leek Pie This savory Greek pie, one of my favorites, makes a great vegetarian main dish for Thanksgiving. You can make the filling days before you assemble the pie; you can also make the whole pie ahead, wrap it well and freeze it. Like all winter squash, pumpkin is an excellent source of vitamin A, in the form of beta carotene, and a very good source of vitamin C, potassium, dietary fiber and manganese. 2 1/2 pounds pumpkin, cut into large chunks 6 tablespoons extra virgin olive oil 3 large leeks (about 1 1/2 pounds), white and light green parts only, cleaned and chopped 2 large garlic cloves, minced 1/4 cup chopped fresh dill 1/4 cup chopped fresh mint 1/4 teaspoon freshly grated nutmeg 1 cup crumbled feta cheese (about 4 ounces) 3 large eggs, beaten Salt and freshly ground pepper 12 sheets phyllo dough 1. Preheat the oven to 425 degrees. Cover a baking sheet with foil. Place the pumpkin pieces on the baking sheet, drizzle 1 tablespoon of the olive oil on top and cover tightly with foil. Place in the oven, and roast for 1 1/2 hours or until thoroughly tender. Remove from the heat, transfer to a strainer or a colander set over a bowl or in the sink, and allow to cool and drain. Turn the oven down to 375 degrees. 2. Peel the cooled pumpkin, and place in a large bowl or in a food processor fitted with the steel blade. Purée coarsely or mash with a fork. Stir in the herbs, nutmeg and feta. Season to taste with salt and pepper. 3. Heat 1 tablespoon of the olive oil over medium heat in a large, heavy nonstick frying pan. Add the leeks. Cook, stirring, until tender and just beginning to color, five to 10 minutes. Add the garlic, and continue to cook until fragrant, 30 seconds to a minute. Remove from the heat, and add to the pumpkin. Beat the eggs, and stir into the pumpkin mixture. 4. Brush a 10- or 12-inch tart pan or cake pan with olive oil and layer in seven sheets of phyllo dough. Place them not quite evenly atop one another, so that the edges overlap the sides of the pan all the way around. Brush each sheet with olive oil (or a mixture of olive oil and melted butter) before adding the next sheet. Fill with the pumpkin mixture, and fold the edges over. Brush the folded-over phyllo with olive oil, then layer five more sheets of dough over the top, brushing each with olive oil (or a combination of melted butter and olive oil). Crimp the edges into the sides of the pan. Pierce the top of the pie in several places with a sharp knife. Bake in a 375-degree oven for 40 to 50 minutes until the top is golden brown. Serve warm or at room temperature. Recrisp the crust if necessary in a low oven for 10 to 20 minutes. Yield: Serves eight to 10. Advance preparation: The pumpkin can be cooked and mashed three or four days ahead of making the dish and kept in the refrigerator in a covered bowl. Drain off liquid that accumulates. The filling will keep for two or three days in the refrigerator; don’t add the eggs until you’re ready to assemble the pie. The finished tart keeps for a few days, but you must keep crisping the phyllo. This is easily done, either in a low oven (250 degrees to 300 degrees) for 10 to 20 minutes or in a hot oven that has just been turned off for 5 to 10 minutes. You can assemble the pie in its entirety, double-wrap it in plastic wrap and foil, and freeze until ready to bake. Uncover, brush the top with olive oil or melted butter, and transfer directly from the freezer to the oven. Add 15 minutes to the baking time. Nutritional information per serving (eight servings): 312 calories; 17 grams fat; 5 grams saturated fat; 96 milligrams cholesterol; 32 grams carbohydrates; 2 grams dietary fiber; 383 milligrams sodium (does not include salt added during preparation); 9 grams protein Nutritional information per serving (10 servings): 250 calories; 14 grams fat; 4 grams saturated fat; 77 milligrams cholesterol; 26 grams carbohydrates; 2 grams dietary fiber; 306 milligrams sodium (does not include salt added during preparation); 7 grams protein ...And a Few Thanksgiving Favorites Here are my favorite recipes for Thanksgiving soups, salads and sides. I like all of them so much, I always ask myself why Thanksgiving is the only time of year I make them. Soups: Carrot and Sweet Potato Soup with Mint or Tarragon Mushroom and Dried Porcini Soup Salads: Curried Waldorf Salad Beet and Endive Salad With Walnuts Endive, Apple and Walnut Salad Wild Rice and Brown Rice Salad With Walnuts and Asparagus Stuffings and Side Dishes: Sweet Potato Purée With Apples Sweet Potato Soufflé (could also be served as a dessert or a starter) Smashed Red Potatoes With Cabbage Garlic Green Beans Mashed Potatoes With KaleWinter Squash and Potato Gratin Savory Cornbread Stuffing Wild Rice, Almond and Mushroom Stuffing or Pilaf Mushroom Ragout Gravy Cranberry-Orange Relish Martha Rose Shulman can be reached at martha-rose-shulman.com. Her latest book is "The Very Best of Recipes for Health."

New Trade Group’s Focus Will Be Marijuana Industry Posted: 23 Nov 2010 02:39 PM PST DENVER — It is being called the green rush. With more states moving to legalize medical marijuana, the business of growing and dispensing it is booming, even as much of the rest of the economy struggles. Enlarge This Image Jim Wilson/The New York Times Steve DeAngelo, right, founded a marijuana dispensary in Oakland, Calif., and is on the board of an industry trade group. Now, flush with financial clout, and with their eyes on pushing Congress to further loosen laws, medical marijuana industry leaders are forming a national trade association. While there are smaller, local trade groups, organizers around the country say this will be the first business organization working on the national level. Based in Washington, the group, the National Cannabis Industry Association, will focus primarily on lobbying, but will also help medical marijuana businesses navigate a patchwork of laws that differ depending on location. “This is an industry that is emerging — from the dispensaries to the ancillary businesses that are now coming out of the shadows,” said Aaron Smith, a medical marijuana advocate in Phoenix and the group’s executive director. “While there is good work being done, there isn’t anyone out there representing the industry’s interests directly.” The group’s board members, which include some of the more prominent names in the medical marijuana industry, say the need for a national association has become increasingly apparent with the explosion of the legal marijuana business. Such businesses include dispensaries, growing facilities and equipment suppliers. J. B. Woods, a former insurance agent for Allstate who now sells property and product-liability insurance to medical marijuana businesses in Colorado and other states, is one of the 23 board members. Mr. Woods said the industry had grown so quickly and laws had changed so rapidly that it can be difficult for medical marijuana businesses — and the property owners and banks they deal with — to know if they are operating legally. “A lot of times these dispensaries can make a huge capital investment only to find out that the local municipality changed its rules, and they have to close down,” he said. “You are in an industry that is very complicated, and ultimately it’s about having a source of credible information.” The group will officially begin at a national convention in Denver next month. “This is an industry in its infancy,” said Bob Selan, a board member and chief executive of Kush magazine, a medical marijuana lifestyle publication. “But it is an industry now.”

New Rules Tell Insurers: Spend More on Care Posted: 22 Nov 2010 11:20 PM PST WASHINGTON — The Obama administration issued new federal rules on Monday that will require many health insurance companies to spend more on medical care and allocate less to profits, executive compensation, marketing and overhead expenses. Enlarge This Image Luke Sharrett/The New York Times Kathleen Sebelius, the secretary of health and human services, issued new rules for insurers. The rules, intended to benefit consumers, vastly expand federal authority to direct the use of premiums collected by companies like Aetna, Humana, UnitedHealth and WellPoint. While some states have had such requirements, Monday’s announcement is the first such mandate by the federal government and grows out of the new national health care law. “Millions of Americans will get better value for their health insurance premium dollar,” Kathleen Sebelius, the secretary of health and human services, said in issuing the rules. Ms. Sebelius said the rules would protect nearly 75 million people: 10.6 million with individual policies, 24.2 million with small-group coverage and 40 million covered by large employers. Starting next year, she said, insurers in the individual and small-group markets must spend at least 80 percent of their premium revenues on medical care and activities to improve the quality of care. Insurers in the large-group market must spend at least 85 percent of premium dollars for those purposes. Insurers that do not meet the standards next year will have to pay rebates to consumers, starting in 2012. Ms. Sebelius estimated that up to nine million people could get rebates worth up to $1.4 billion. About 45 percent of people with individually purchased insurance are in health plans that do not meet the new standards, known as medical loss ratios, federal officials said. At a news conference on Monday, administration officials repeatedly refused to respond to Republican attacks on the health care law. Nor would they discuss Republican calls to repeal the law, a centerpiece of President Obama’s domestic agenda. “We are just trying to implement this regulation,” said Jay Angoff, the rules’ chief author. He is director of the Department of Health and Human Services’ Office of Consumer Information and Insurance Oversight. He said most insurers should be able to meet the standards because “their profitability and reserves are at an all-time high.” However, state officials said the standards could destabilize insurance markets in some states. Specifically, they said they feared that some carriers would withdraw from the market in some states, resulting in fewer choices and less competition. Under the rules, federal officials can lower the standard for up to three years in states where “there is a reasonable likelihood that market destabilization, and thus harm to consumers, will occur.” Mr. Angoff said that Georgia, Iowa, Maine and South Carolina had asked for such adjustments. Joshua R. Raskin, a senior analyst at Barclays Capital, an investment bank, said, “With these rules, the federal government will, for the first time, hold health insurance companies accountable for putting a minimum amount of premiums toward medical expenses.” The rules allow special treatment for health plans that provide limited benefits at a more affordable price. At least 1.4 million people are enrolled in such “mini-med” plans, which may cap coverage for one or more benefits at $5,000 or $10,000 a year — or perhaps $25,000. Employers offering such coverage had said they might end it because they could not meet the 80 percent standard next year. Premiums are usually lower for mini-med plans than for regular insurance, and administrative costs may be high because these plans often cover employees with high turnover rates. As a result, administrative costs account for a higher share of premium revenues. In addition, some consumer groups said mini-med plans had higher profit margins than traditional insurance. “The administration has made a wise accommodation that will temporarily preserve this coverage, which is very important to many employees in the retail and restaurant industries,” said E. Neil Trautwein, a vice president of the National Retail Federation. The dispensation for mini-med plans is for one year. The government will collect data on these plans next year and decide how to proceed in 2012 and 2013. “In 2014, we anticipate that these mini-med policies will disappear and be replaced by more comprehensive health plans,” said Steven B. Larsen, a federal insurance regulator. The rules generally follow recommendations from the National Association of Insurance Commissioners, which represents state regulators. However, “we have a difference of opinion” on one point, said Jane L. Cline, the insurance commissioner of West Virginia and president of the association. State officials said Mr. Obama should allow states to phase in the requirements over several years, to avoid disruption of the individual or small-group insurance market. The White House said, “The law allows adjustments of the medical loss ratio for the individual market in a state and does not apply to the small-group market.” Consumers Union, the American Heart Association and Democratic members of Congress praised the rules. Representative George Miller, Democrat of California, said the rules showed the folly of efforts to repeal the health care law. “If Republicans succeed,” Mr. Miller said, “they will be taking money right out of the pockets of millions of average Americans.”

2 Treatments for Retinas Make Gains Posted: 22 Nov 2010 10:31 AM PST LOS ANGELES — Elderly people losing their vision from age-related macular degeneration might one day have a treatment option that requires fewer injections into the eye than the standard drug now used. In testing, an experimental drug being developed by Regeneron Pharmaceuticals, when injected every eight weeks, proved as effective as the standard treatment, Lucentis from Genentech, which was injected every four weeks. The findings are from two clinical trials that Regeneron is expected to announce on Monday. In a separate development, Advanced Cell Technology is expected to announce Monday that it has won regulatory approval to test a therapy derived from human embryonic stem cells in people with Stargardt’s macular dystrophy, another retina disease. It is only the second trial of a therapy derived from human embryonic stem cells to be cleared by the Food and Drug Administration. The first involves a treatment for spinal cord injury developed by Geron. Age-related macular degeneration is the leading cause of blindness in the elderly. Lucentis can restore a person’s ability to drive and read, in some cases. But the drug works best when given every four weeks, which can be inconvenient for patients and doctors. Doctors often give Lucentis less frequently, but even if that regimen produces good results, patients must still get checkups every month to make sure their vision is not deteriorating. Regeneron’s drug, which is called VEGF Trap-Eye, “gives us the opportunity to not have to see them monthly,” said Dr. Jeffrey Heier of Boston, an investigator in one of the trials and a consultant to Regeneron. That would be “very meaningful to patients and their families,” he said. Regeneron and its partner, Bayer, said they planned to apply for approval of the drug in the first half of 2011. The two similar trials involved a total of 2,457 patients who were randomly chosen to receive either Lucentis every four weeks or VEGF Trap-Eye either every four weeks or every eight weeks. In the eight-week arm, the first three doses were given every four weeks. After a year, roughly 95 percent of the patients in all the arms of the trial maintained their vision, meaning their ability to read an eye chart declined by no more than 15 letters, or three lines. VEGF Trap-Eye was also “noninferior” to Lucentis in terms of the average change in vision after one year. Lucentis recipients had a mean gain of 8.1 letters and 9.4 letters in the two trials. Those getting Regeneron’s drug every eight weeks had gains of 7.9 letters and 8.9 letters. Regeneron said the two drugs were equally safe. Both VEGF Trap-Eye and Lucentis block a protein called vascular endothelial growth factor that causes blood vessels to grow and leak into the eye. VEGF Trap-Eye could become the first big product for Regeneron, which was founded in 1988 and is based in Tarrytown, N.Y. It sells one drug for a rare disease and has garnered hundreds of millions of dollars from licensing deals with big pharmaceutical companies. Regeneron’s drug is likely to face competition from off-label use of Genentech’s cancer drug Avastin. When used in the eye, Avastin costs about $50 a dose, compared with about $2,000 for Lucentis. Still, even with such low-priced competition, Lucentis has sales exceeding $2 billion globally. Meanwhile, Advanced Cell Technology, of Marlborough, Mass., said it would test its stem cell therapy on 12 adults with severe vision loss caused by Stargardt’s, an inherited disease. The company has turned human embryonic stem cells into retinal pigment epithelial cells, which will be surgically implanted into the eye. The hope is that the implanted cells will replace those injured by the disease. Human embryonic stem cells are controversial because their creation usually entails the destruction of human embryos, although Advanced Cell Technology is working on a technique to avoid that. Embryonic cells can also form tumors if injected into the body. Dr. Robert Lanza, chief scientist at Advanced Cell, said the company had to prove to the F.D.A. that its retinal cells contained virtually no residual embryonic stem cells. It took a year for the company to get clearance for the trial from the F.D.A. It is likely to be several years before such a treatment can reach the market, if it works. Still, even starting the trial could be a boost to Advanced Cell, which often makes headlines but has struggled to raise money. Its shares closed at 5 cents on Friday. Dr. Peter J. Francis, an associate professor at the Oregon Health and Science University, which will be a site for the trial, says the eye is a good place to test stem cell therapy because it is accessible. Also, he said, there is less chance of rejection of the implanted cells because the eye is shielded somewhat from the body’s immune system. There is no treatment for Stargardt’s, which affects more than 25,000 people in the United States. The disease is usually diagnosed during childhood and it causes a loss of central vision, though not usually peripheral vision. Ryan Rapoport of Newcastle, Wash., who has the disease, “basically went from normal vision to legally blind in seven months,” said his father, Darrin. Ryan, now 10, cannot be in the trial because, for safety reasons, it is confined to adults. Still, Mr. Rapoport said, “It gives us some hope, because up until recently there was no hope.”

Consumer Risks Feared as Health Law Spurs Mergers Posted: 21 Nov 2010 10:04 PM PST WASHINGTON — When Congress passed the health care law, it envisioned doctors and hospitals joining forces, coordinating care and holding down costs, with the prospect of earning government bonuses for controlling costs. Enlarge This Image Andrew Harrer/Bloomberg News Jon Leibowitz of the Federal Trade Commission fears that competition will be stifled. Now, eight months into the new law there is a growing frenzy of mergers involving hospitals, clinics and doctor groups eager to share costs and savings, and cash in on the incentives. They, in turn, have deployed a small army of lawyers and lobbyists trying to persuade the Obama administration to relax or waive a body of older laws intended to thwart health care monopolies, and to protect against shoddy care and fraudulent billing of patients or Medicare. Consumer advocates fear that the health care law could worsen some of the very problems it was meant to solve — by reducing competition, driving up costs and creating incentives for doctors and hospitals to stint on care, in order to retain their cost-saving bonuses. “The new law is already encouraging a wave of mergers, joint ventures and alliances in the health care industry,” said Prof. Thomas L. Greaney, an expert on health and antitrust law at St. Louis University. “The risk that dominant providers and dominant insurers may exercise their market power, individually or jointly, has never been greater.” Lobbyists and industry groups are bearing down on the Federal Trade Commission and the Justice Department, which enforce the antitrust laws, and the inspector general’s office at the Department of Health and Human Services, which ferrets out Medicare fraud. Those agencies are writing regulations to govern the new entities, known as accountable care organizations. They face a delicate task: balancing the potential benefits of clinical cooperation with the need to enforce fraud, abuse and antitrust laws. “If accountable care organizations end up stifling rather than unleashing competition,” said Jon Leibowitz, the chairman of the trade commission, “we will have let one of the great opportunities for health care reform slip away.” Congress’s purpose was to foster cooperation in a health care system that is notoriously fragmented. The hope was that the new law would push doctors, hospitals and other health care providers to come together and jointly take responsibility for the cost and quality of care of patients, especially Medicare beneficiaries. Experts say patients can benefit from a network of care and greater coordination between doctors and hospitals. On Tuesday, the Obama administration established a Center for Medicare and Medicaid Innovation, to test new ways of coordinating and paying for services, in addition to the accountable care organizations. Hospitals have taken the lead in forming these new entities. Johns Hopkins Medicine, which operates a hospital in Baltimore and 25 clinics in Maryland, has just acquired Sibley Memorial Hospital in Washington, 16 months after acquiring Suburban Hospital in Bethesda, Md. “This is being driven largely by health care reform, which demands an integrated regional network,” said Gary M. Stephenson, a Johns Hopkins spokesman. In Kentucky, three of the largest hospital networks are negotiating a merger, prompted in part by the new law. In upstate New York, three regional health care systems are seeking federal permission to merge their operations, which include hospitals, clinics and nursing homes in Albany and surrounding counties. With potential efficiencies come incentives for doctors and hospitals to control costs, and a potential for abuse. Judith A. Stein, director of the nonprofit Center for Medicare Advocacy, said she was concerned that some care organizations would try to hold down costs by “cherry-picking healthier patients and denying care when it’s needed.” Under the law, Medicare can penalize organizations that avoid high-risk, high-cost patients. Peter W. Thomas, a lawyer for the Consortium for Citizens with Disabilities, a national advocacy group, expressed concern about the impact on patients. “In an environment where health care providers are financially rewarded for keeping costs down,” he said, “anyone who has a disability or a chronic condition, anyone who requires specialized or complex care, needs to worry about getting access to appropriate technology, medical devices and rehabilitation. You don’t want to save money on the backs of people with disabilities and chronic conditions.” Nearly one-fourth of Medicare beneficiaries have five or more chronic conditions. They account for two-thirds of the program’s spending. Elizabeth B. Gilbertson, chief strategist of a union health plan for hotel and restaurant employees, also worries that the consolidation of health care providers could lead to higher prices. “In some markets,” Ms. Gilbertson said, “the dominant hospital is like the sun at the center of the solar system. It owns physician groups, surgery centers, labs and pharmacies. Accountable care organizations bring more planets into the system and strengthen the bonds between them, making the whole entity more powerful, with a commensurate ability to raise prices.” She added, “That is a terrible threat.” Doctors and hospitals say the promise of these organizations cannot be fully realized unless they get broad waivers and exemptions from the government. 1 2 Next Page »

Vital Signs: Behavior: Young Marijuana Users Pay Cognitive Price Posted: 22 Nov 2010 10:40 PM PST Marijuana smoking often starts in adolescence — and the timing could not be worse, a new study suggests. Related More Vital Signs Columns Young adults who started using the drug regularly in their early teens performed significantly worse on tests assessing brain function than did subjects who were at least 16 when they started, scientists reported last week. The findings led researchers at McLean Hospital to surmise that the developing teenage brain may be particularly vulnerable to the ill effects of marijuana. “We have to understand that the developing brain is not the same as the adult brain,” said Dr. Staci A. Gruber, the paper’s senior author and director of cognitive and clinical neuroimaging at McLean, a Harvard-affiliated hospital in Belmont, Mass. The study, done in conjunction with brain scans, was small, consisting of 35 chronic marijuana smokers who were 22 years old on average. The subjects were asked to complete an assessment of executive function — the brain processes responsible for planning and abstract thinking, as well as understanding rules and inhibiting inappropriate actions. The test — in which participants were asked to sort cards with different shapes, numbers and colors — is a measure of cognitive flexibility. At 15, Dr. Gruber said, the brain is still changing, and “the part that modulates executive function is the last part to develop.”

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