Monday, November 29, 2010

Health - Fuel Lines of Tumors Are Target in Cancer Fight

Health - Fuel Lines of Tumors Are Target in Cancer Fight

Fuel Lines of Tumors Are Target in Cancer Fight

Posted: 29 Nov 2010 12:48 PM PST

For the last decade cancer drug developers have tried to jam the accelerators that cause tumors to grow. Now they want to block the fuel line.

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The University of Alberta

TACTICS Dr. Evangelos Michelakis of the University of Alberta is working on a method to encourage cell suicide.

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Cancer cells, because of their rapid growth, have a voracious appetite for glucose, the main nutrient used to generate energy. And tumors often use glucose differently from healthy cells, an observation first made by a German biochemist in the 1920s.

That observation is already used to detect tumors in the body using PET scans. A radioactive form of glucose is injected into the bloodstream and accumulates in tumors, lighting up the scans.

Now, efforts are turning from diagnosis to treating the disease by disrupting the special metabolism of cancer cells to deprive them of energy.

The main research strategy of the last decade has involved so-called targeted therapies, which interfere with genetic signals that act like accelerators, causing tumors to grow. But there tend to be redundant accelerators, so blocking only one with a drug is usually not enough.

In theory, however, depriving tumors of energy should render all the accelerators ineffective.

“The accelerators still need the fuel source,” said Dr. Chi Dang, a professor of medicine and oncology at Johns Hopkins University. Indeed, he said, recent discoveries show that the genetic growth signals often work by influencing cancer cells’ metabolism.

The efforts to exploit cancer’s sweet tooth are in their infancy, with few drugs in clinical trials. But interest is growing among pharmaceutical companies and academic researchers.

“Nutrient supply and deprivation is becoming potentially the next big wave,” said Dr. David Schenkein, chief executive of Agios Pharmaceuticals, a company formed two years ago to develop drugs that interfere with tumor metabolism. Among its founders was Dr. Craig B. Thompson, the new president of Memorial Sloan-Kettering Cancer Center in New York City.

Other small companies, like Cornerstone Pharmaceuticals and Myrexis, are pursuing the approach, and big drug companies are also jumping in. Earlier this year, AstraZeneca agreed to work with Cancer Research UK, a British charity, on drugs that interfere with cancer metabolism.

One factor spurring interest in cancer metabolism is the intriguing interplay between cancer and diabetes, a metabolic disease marked by high levels of blood glucose. The possible link between the two great scourges has garnered so much attention that the American Cancer Society and the American Diabetes Association jointly published a consensus statement this summer summarizing the evidence.

People with Type 2 diabetes tend to have a higher risk of getting certain cancers. And preliminary evidence suggests that metformin, the most widely used diabetes pill, might be effective in treating or preventing cancer.

It is still not clear if high blood glucose is the reason diabetics have a higher cancer risk. A more likely explanation is that people with Type 2 diabetes have high levels of insulin, a hormone that is known to promote growth of certain tumors, according to the consensus statement.

Similarly, metformin might fight cancer by lowering insulin levels, not blood sugar levels. But there is some evidence that the drug works in part by inhibiting glucose metabolism in cancer cells.

Even if blood sugar levels fuel tumor growth, however, experts say that trying to lower the body’s overall level of blood sugar — like by starving oneself — would probably not be effective. That is because, at least for people without diabetes, the body is very good at maintaining a certain blood glucose level despite fluctuations in diet.

“When a patient with cancer is calorically restricted, the amount of glucose in the blood until they are almost dead is close to normal,” said Dr. Michael Pollak, professor of medicine and oncology at McGill University in Montreal. Also, Dr. Pollak said, tumors are adept at extracting glucose from the blood. So even if glucose is scarce, he said, “the last surviving cell in the body would be the tumor cell.”

So efforts are focusing not on reducing the body’s overall glucose level but on interfering specifically with how tumors use glucose.

This gets to the Warburg effect, named after Otto Warburg, the German biochemist and Nobel Prize winner who first noticed the particular metabolism of tumors in the 1920s.

Most healthy cells primarily burn glucose in the presence of oxygen to generate ATP, a chemical that serves as a cell’s energy source. But when oxygen is low, glucose can be turned into energy by another process, called glycolysis, which produces lactic acid as a byproduct. Muscles undergoing strenuous exercise use glycolysis, with the resultant buildup of lactic acid.

What Dr. Warburg noticed was that tumors tended to use glycolysis even when oxygen was present. This is puzzling because glycolysis is far less efficient at creating ATP.

One theory is that cancer cells need raw materials to build new cells as much as they need ATP. And glycolysis can help provide those building blocks.

“You can have energy that turns on the lights in your house, but that energy can’t build anything,” said Matthew G. Vander Heiden, assistant professor of biology at the Massachusetts Institute of Technology.

Still, as with everything else about cancer, metabolism is complex. Not all tumor cells use glycolysis, and some normal cells do. So it could be challenging to develop drugs that can hurt tumors but not normal cells.

Two early efforts by a company called Threshold Pharmaceuticals to interfere with glucose metabolism did not work well in clinical trials. One of Threshold’s drugs, called 2DG, is the same form of glucose used in PET imaging, but without the radioactivity. Because of a slight chemical modification, this form of glucose cannot be metabolized by cells, so it accumulates.

Personal Best: Fell Off My Bike, and Vowed Never to Get Back On

Posted: 29 Nov 2010 12:00 PM PST

I crashed on my bike on Oct. 3 and broke my collarbone, an experience so horrific that my first impulse was to say I would never ride on the road again.

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Turns out I am not alone.

“Well, you’ve joined the proud majority of serious cyclists who’ve busted a collarbone,” said Rob Coppolillo, a competitive cyclist in Boulder, Colo., who also leads rock- and ice-climbing expeditions and is a part-time ski guide.

I’ve since heard from other cyclists who broke bones or were badly bruised and shaken up in crashes. Many say they, too, vowed, at least initially, never to ride outside again. It’s not a universal response, but it is so common that cyclists nod their heads when they hear my reaction to my injury.

Yet almost no one swears off running after an injury, even though — and I speak from experience — a running injury can keep you away from your sport at least as long. And that made me wonder: is a cycling injury qualitatively different from a running injury? Is it the drama of a crash, or is it that a crash makes you realize you could actually be killed on a bike? Is it the type of injury? Or the fact that you can feel, as I did, that the accident was unfair and out of your control?

Risk-assessment experts say that it is all of the above, and that the way we respond to various sports injuries reveals a lot about how we assess risks.

My crash came 8.9 miles into a 100-mile ride (of course I knew the distance, because of course I was watching my bicycle computer). My friend Jen Davis was taking a turn leading; my husband, Bill, was drafting — riding close behind her. I was drafting Bill when a slower rider meandered into his path. Bill swerved and I hit his wheel. Down I went.

The first thing I did when I hit the ground was turn off my stopwatch — I did not want accident time to count toward our riding time. Then I sat on a curb, dazed. My head had hit the road, but my helmet saved me. My left thigh was so bruised it was hard to walk. Worst of all was a searing pain in my left shoulder. I could hardly move my arm. But since it hurt whether I rode or not, I decided, like an idiot, to finish the ride.

The next day I went to a doctor and learned, to my shock, that my collarbone was broken. Running is my sport, I thought, and no ride is worth this.

I remembered what Michael Berry, an exercise physiologist at Wake Forest University, once told me. With cycling, he said, it’s not if you crash, it’s when. He should know. He’s a competitive cyclist whose first serious injury — a broken hip — happened when he crashed taking a sharp turn riding down a mountain road.

Then, last June, he was warming up for a race when he hit a squirrel, crashed into a telephone pole and broke his arm so badly he needed surgery.

His reaction to each crash was a variant of mine. He’d taken up cycling about five years ago because he’d injured his hamstring running. “With each wreck I thought, ‘Maybe I should try running again,’ ” he said.

My running friend Claire Brown, a triathlete, crashed a few years ago when she was riding fast on wet roads, getting in one last training ride before a race. Her bike slid on a metal plate in a bridge and she went down, hitting her head and her left hip. She was badly bruised, and even though she broke no bones, she did not feel comfortable riding for the next two years. Even now, she told me, “there are bridges around here I won’t ride on, and I definitely won’t go downhill fast.”

And yet, and yet. Despite how much it hurt, my collarbone fracture was nowhere near as bad as some running injuries. When I got a stress fracture — a hairline break — in a small bone in my foot, I was on crutches for eight weeks. When I finally could run again, my foot hurt because the muscles had atrophied. Running was slow and difficult. I’d lost the rhythm and the stride that make running fun.

With the collarbone fracture, I wore a sling for three weeks but could take it off and ride my bike on my trainer — a device that turns a road bike into a stationary one — and use an elliptical cross-trainer. After four weeks I could run, and running felt good.

George Loewenstein, a professor of economics and psychology at Carnegie Mellon University, says there are several factors that separate running injuries from cycling ones.

Mind: A Fate That Narcissists Will Hate: Being Ignored

Posted: 29 Nov 2010 12:30 PM PST

Narcissists, much to the surprise of many experts, are in the process of becoming an endangered species.

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Scott Menchin

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Not that they face imminent extinction — it’s a fate much worse than that. They will still be around, but they will be ignored.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition.

Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles.

Most nonprofessionals have a pretty good sense of what narcissism means, but the formal definition is more precise than the dictionary meaning of the term.

Our everyday picture of a narcissist is that of someone who is very self-involved — the conversation is always about them. While this characterization does apply to people with narcissistic personality disorder, it is too broad. There are many people who are completely self-absorbed who would not qualify for a diagnosis of N.P.D.

The central requirement for N.P.D. is a special kind of self-absorption: a grandiose sense of self, a serious miscalculation of one’s abilities and potential that is often accompanied by fantasies of greatness. It is the difference between two high school baseball players of moderate ability: one is absolutely convinced he’ll be a major-league player, the other is hoping for a college scholarship.

Of course, it would be premature to call the major-league hopeful a narcissist at such an early age, but imagine that same kind of unstoppable, unrealistic attitude 10 or 20 years later.

The second requirement for N.P.D.: since the narcissist is so convinced of his high station (most are men), he automatically expects that others will recognize his superior qualities and will tell him so. This is often referred to as “mirroring.” It’s not enough that he knows he’s great. Others must confirm it as well, and they must do so in the spirit of “vote early, and vote often.”

Finally, the narcissist, who longs for the approval and admiration of others, is often clueless about how things look from someone else’s perspective. Narcissists are very sensitive to being overlooked or slighted in the smallest fashion, but they often fail to recognize when they are doing it to others.

Most of us would agree that this is an easily recognizable profile, and it is a puzzle why the manual’s committee on personality disorders has decided to throw N.P.D. off the bus. Many experts in the field are not happy about it.

Actually, they aren’t happy about the elimination of the other four disorders either, and they’re not shy about saying so.

One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual.

Asked what he thought about the elimination of narcissistic personality disorder, he said it showed how “unenlightened” the personality disorders committee is.

“They have little appreciation for the damage they could be doing.” He said the diagnosis is important in terms of organizing and planning treatment.

“It’s draconian,” he said of the decision, “and the first of its kind, I think, that half of a group of disorders are eliminated by committee.”

He also blamed a so-called dimensional approach, which is a method of diagnosing personality disorders that is new to the DSM. It consists of making an overall, general diagnosis of personality disorder for a given patient, and then selecting particular traits from a long list in order to best describe that specific patient.

This is in contrast to the prototype approach that has been used for the past 30 years: the narcissistic syndrome is defined by a cluster of related traits, and the clinician matches patients to that profile.

The dimensional approach has the appeal of ordering à la carte — you get what you want, no more and no less. But it is precisely because of this narrow focus that it has never gained much traction with clinicians.

It is one thing to call someone a neat and careful dresser. It is another to call that person a dandy, or a clotheshorse, or a boulevardier. Each of these terms has slightly different meanings and conjures up a type.

And clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.

Jonathan Shedler, a psychologist at the University of Colorado Medical School, said: “Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.” He said the committee was stacked “with a lot of academic researchers who really don’t do a lot of clinical work. We’re seeing yet another manifestation of what’s called in psychology the science-practice schism.”

Schism is probably not an overstatement. For 30 years the DSM has been the undisputed standard that clinicians consult when diagnosing mental disorders. When a new diagnosis is introduced, or an established diagnosis is substantially modified or deleted, it is not a small deal. As Dr. Gunderson said, it will affect the way professionals think about and treat patients.

Given the stakes, the blow-back from experts in personality disorders should come as no surprise.

Dr. Gunderson has written a letter co-signed by other clinical and research leaders to the trustees of the American Psychiatric Association and the task force that governs DSM-5. And Dr. Shedler and seven colleagues published an editorial in the September issue of The American Journal of Psychiatry. In the relatively small world of mental health diagnostics, this is most certainly a battle worth watching.

Right now, this much seems clear: It is way too early for the narcissists to give up their seat on the bus.

Charles Zanor is a psychologist in West Springfield, Mass.

Charles Zanor is a psychologist in West Springfield, Mass.

Inefficiency Hurts U.S. In Ranking of Health

Posted: 29 Nov 2010 12:12 PM PST

By any measure, the United States spends more on health care than any other nation. Yet according to the World Fact Book (published by the Central Intelligence Agency), it ranks 49th in life expectancy.

Why?

Researchers writing in the November issue of the journal Health Services say they know the answer. After citing statistical evidence showing that American patterns of obesity, smoking, traffic accidents and homicide are not the cause of lower life expectancy, they conclude that the problem is the health care system.

Peter A. Muennig and Sherry A. Gleid, researchers at the Mailman School of Public Health at Columbia University, compared the performance of the United States and 12 other industrialized nations: Australia, Austria, Belgium, Britain, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden and Switzerland. In addition to health care expenditures in each country, they focused on two other important statistics: 15-year survival for people at 45 years and for those at 65 years.

The researchers say those numbers present an accurate picture of public health because they measure a country’s success in preventing and treating the most common causes of death — cardiovascular disease, stroke and diabetes — which are more likely to occur at these ages. Their data come from the World Health Organization and cover 1975 to 2005.

Life expectancy increased over those years in all 13 countries, and so did health care costs. But the United States had the lowest increase in life expectancy and the highest increase in costs.

In 1975 the United States was close to the average in health care costs, and last in 15-year survival for 45-year-old men. By 2005 its costs had more than tripled, far surpassing increases elsewhere, but the survival number was still last — a little over 90 percent, compared with more than 94 percent for Swedes, Swiss and Australians. For women, it was 94 percent in the United States, versus 97 percent in Switzerland, Australia and Japan.

The numbers for 65-year-olds in 2005 were similar: about 58 percent of American men could be expected to survive 15 years, compared with more than 65 percent of Australians, Japanese and Swiss. While more than 80 percent of 65-year-old women in France, Switzerland, and Japan would survive 15 years, only about 70 percent of American women could be expected to live that long.

In narrowing the blame to the American health care system, the researchers first eliminated several other factors. Obesity and smoking are the most important behavior-related causes of death, but obesity increased more slowly in the United States than in the other countries and smoking declined more rapidly, so neither can explain the differences in survival rates. Homicide and traffic fatality rates have remained steady over time, and social, economic and educational factors do not vary greatly among these countries.

But not all experts agree with this analysis. Samuel Preston, a demographer and a professor of sociology at the University of Pennsylvania, says the analysis is faulty.

“The basic message is correct — that measures of U.S. health, including mortality and morbidity, are very poor in comparison with other countries,” he said. But the Columbia researchers “have no direct evidence about the health care system in this article,” he continued. “Their conclusion is extremely speculative.”

That they did not find smoking at fault, Dr. Preston said, “is mysterious to me, particularly since they show high lung cancer mortality for the U.S.” Dr. Preston has published widely on mortality trends and the effects of smoking.

Dr. Muennig conceded that the study examined only life expectancy and health care spending in the 13 countries, and not the structure or economics of health care. “We did a pretty good job of showing that smoking isn’t the culprit,” he said.

“Smoking and obesity are still major risk factors for an individual’s health,” he said. “But they are sapping life expectancy in all countries. Whereas in the U.S. we have a highly inefficient health system that’s taking away financial resources from other lifesaving programs.”

Global Update: Sierra Leone: Outbreak of Mysterious Blisters Is Case Study in Spread of Panic

Posted: 29 Nov 2010 12:11 PM PST

An outbreak of mysterious blisters in Sierra Leone illustrates how panic can be stirred by a combination of overwrought journalism, listless government and traditional witchcraft.

The Inquirer, a Sierra Leone news site cited on ProMed, an epidemic-alert service, reported that “the wild spread of the contagious skin disease” was taking over a rural county, with 75 people affected. It quoted local residents blaming polluted water, “poisonous bacteria” or “contamination of the underground,” and said a government minister had “warned people with the disease to cease all movement.”

In fact, a careful reading of the article suggested that local doctors had identified a plausible cause and suggested a sensible solution. But that point was obscured by the purple “Fear Grips City” prose.

The blisters, the doctors said, were from “Nairobi flies,” and their advice was to just blow them off, not slap them. The “Nairobi fly” is actually a red-and-black beetle of the genus Paederus that is found from India to West Africa but hatches only rarely. It does not bite, but contains pederin, a stinging acid, to drive off predators. Smacking it on the skin releases the acid, which can leave a nasty welt; touching an eye with the acid can blind it for days. The condition is, of course, not contagious.

While this brouhaha may seem minor, others have had serious consequences. Nigeria’s polio vaccination drive, for example, was derailed by journalists spreading rumors that the vaccine was a plot to sterilize Muslim girls; polio then spread from Nigeria to more than a dozen other countries.

Vital Signs: Diet: Good-for-You Things Come in Orange

Posted: 29 Nov 2010 12:31 PM PST

Eat your carrots. And have some leftover pumpkin pie.

People with high blood levels of alpha-carotene — an antioxidant found in orange fruits and vegetables — live longer and are less likely to die of heart disease and cancer than people who have little or none of it in their bloodstream, a new study reports.

The study does not prove a cause-and-effect relationship, only an association.

Still, its results are intriguing. Researchers from the Centers for Disease Control and Prevention analyzed alpha-carotene levels in blood samples from more than 15,000 adults who participated in a follow-up study of the third National Health and Nutrition Examination Survey from 1988 to 1994. By 2006, researchers determined, 3,810 of the participants had died. Those with the highest levels of alpha-carotene were more likely to have survived, even after the scientists controlled for variables like age and smoking.

Those with the highest concentrations of the antioxidant were almost 40 percent less likely to have died than those with the lowest; those with midrange levels were 27 percent less likely to die than those with the lowest levels.

“It’s pretty dramatic,” said the lead author, Dr. Chaoyang Li, a C.D.C. epidemiologist. The study was published online Nov. 22 in Archives of Internal Medicine.

Vital Signs: Aging: Unsteady on Your Feet? Try Moving to Music

Posted: 29 Nov 2010 12:31 PM PST

Elderly people in a new study cut their risk of falling by more than half after they took classes in eurhythmics, an exercise-and-music program designed for young children.

The 12-month trial recruited 134 people, average age 75, who were unsteady on their feet. Half were randomly assigned to weekly hourlong eurhythmics classes for the first six months, and the other half took no classes until the following six months.

The program, developed by the early-20th-century Swiss composer Émile Jaques-Dalcroze, teaches movement in time to music, from Mozart minuets to jazz improvisations. Participants have to walk and turn around, stay in step with changing tempos, learn to shift their weight and balance, handle objects while walking, and make exaggerated upper-body movements while walking.

The two groups were monitored to determine how many times they fell. In the first group, there were just 24 falls over the first six months, compared with 54 among those who were not in the classes.

Even after the classes ended, the participants maintained their improvements in balance, walked with a more regular gait and were better able to walk while doing other things. The study was published online in Archives of Internal Medicine.

The paper’s lead author, Dr. Andrea Trombetti of the University Hospitals and Faculty of Medicine of Geneva, said that despite the results, it was still unclear how music affected walking.

Recipes for Health: Turkey: Not Just for Thanksgiving

Posted: 29 Nov 2010 10:10 AM PST

Too often, cooks think about what to make with turkey only when faced with a deluge of Thanksgiving leftovers. Your refrigerator may still be stuffed with them even now, well after the holiday. But there are plenty of reasons for cooks to get better acquainted with turkey.

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Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

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Above all else, turkey is versatile. Combining turkey with grains is one way to make meals high in protein and low in fat. Toss shredded turkey with grain pilaf, celery, fresh herbs, a vinaigrette and a few vegetables, and you’ve got a terrific main dish salad. You can use turkey in a risotto. Or how about a casserole? The turkey casserole I’ve chosen this week is Middle Eastern, spiced with allspice and cinnamon and topped with thick yogurt.

Turkey also can substitute for chicken in your favorite tacos and enchiladas, salads, chilaquiles and soups. A while back, I devoted a week of columns to dishes you can make with shredded poached chicken breasts; turkey will work in any of those dishes just as well.

Turkey Tacos With Green Salsa

These tacos are reason enough to keep a bottle of green salsa on hand in your pantry. They are easily thrown together, even if you choose to make your own salsa.

2 cups shredded turkey

1 cup green salsa, bottled or homemade

4 radishes, thinly sliced or cut in julienne

1/4 cup chopped cilantro

1 small ripe avocado, diced

Salt

8 corn tortillas

1 cup shredded lettuce

Juice of 1 lime

1/3 cup queso fresco

1. Combine the turkey, salsa, radishes, cilantro and avocado in a bowl. Season with salt to taste.

2. Heat the tortillas individually in a dry pan or microwave. Alternately, wrap them in a kitchen towel and place in a steamer above 1 inch of boiling water for one minute. Turn off the heat, and let sit covered for 10 minutes.

3. Place two tortillas on each plate, and top with the turkey mixture. Top the turkey mixture with shredded lettuce, squeeze on some lime juice, sprinkle with queso fresco and serve.

Yield: Four servings.

Advance preparation: This is thrown together just before serving. Homemade salsa will keep for a couple of days in the refrigerator.

Nutritional information per serving: 303 calories; 12 grams fat; 3 grams saturated fat; 60 milligrams cholesterol; 23 grams carbohydrates; 6 grams dietary fiber; 129 milligrams sodium (does not include salt added during preparation); 26 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Gates Seeking to Contain Military Health Costs

Posted: 29 Nov 2010 02:16 AM PST

WASHINGTON — Francis Brady enjoys a six-figure salary and generous benefits at the consulting firm Booz Allen Hamilton, but as a retired Marine lieutenant colonel he and his family remain on the military’s bountiful lifetime health insurance, Tricare, with fees of only $460 a year. He calls the benefit “phenomenal.”

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Brendan Smialowski for The New York Times

Francis Brady, a retired Marine lieutenant colonel, says Tricare is “phenomenal,” much cheaper than a private-sector plan.

“It is so cheap compared to what Booz Allen has,” Colonel Brady said in a recent interview, acknowledging that premiums called for by private employers can run many times greater.

Of nearly 4.5 million military retirees and their families, about three-quarters are estimated to have access to health insurance through a civilian employer or group. But more than two million of them stay on Tricare. As the costs of private health care continue to climb, their numbers are only expected to grow.

Now, as part of a broad offensive to cut Pentagon spending, that group is once again in the sights of Defense Secretary Robert M. Gates, who is seriously considering whether to ask for Tricare fee increases in next year’s budget — and perhaps start one of the last fights of his public career.

Already, he has met with the chairmen of President Obama’s bipartisan fiscal commission, which faces a deadline this week for getting an agreement on a plan to address the federal budget deficit.

The battle over Tricare pits the efforts of the Pentagon to contain the exploding cost of health care for nearly 10 million eligible beneficiaries against the pain and emotions of those who say they have already “paid up front” with service in uniform, particularly those who deployed to America’s two current wars. The 10 million figure includes active-duty personnel, retirees, members of the National Guard and Reserves and their families.

The arguments reflect the broader debate over the huge Pentagon budget that will intensify next year when Mr. Gates, who says he will step down in 2011, continues his campaign to cut off what he calls the “gusher” of defense spending. Total health care costs for the Pentagon, which is the nation’s single largest employer, top $50 billion a year, a tenth of its budget and about the same amount that it is spending this year on the war in Iraq. Ten years ago, health care cost the Pentagon $19 billion; five years from now it is projected to cost $65 billion.

But Tricare fees have not increased since 1995.

“Health care costs are eating the Defense Department alive,” Mr. Gates said in a much-noticed speech in May. Defense budget analysts say that rising health care costs will make less money available for new weapons, repairs to a worn-out arsenal and quality-of-life programs like schools on military bases.

“In the long run, it could actually limit our ability to field a military of sufficient size,” said Todd Harrison, a senior fellow for defense budget studies at the Center for Strategic and Budgetary Assessments in Washington.

Veterans groups and military officers’ lobbies have responded by going on high alert. One of the most powerful of them, the Military Officers Association of America, is preparing a public relations campaign that will focus on what it calls the broken promise between the nation and the people who defend it.

“Don’t ask the folks who have done so much more for this country, who have been called to act since 9/11, to be the first in line to give some more,” said Norbert R. Ryan Jr., a retired vice admiral and president of the military officers’ group. As for Tricare’s generous benefits, Admiral Ryan said that anyone “can get this good deal — go over to a recruiting office and sign up for Iraq and Afghanistan.”

Defense officials point out that Mr. Gates is weighing only whether to increase the cost of health insurance for retirees and their families, not those on active duty, who receive Tricare at no cost. Any fee increases would also not affect military retirees 65 and older, who use a free program called Tricare for Life that supplements Medicare. It is not possible to estimate the exact savings without knowing what rate increase might be proposed, but analysts say even a modest rise could recoup billions of dollars annually for the Pentagon.

If the past is any guide, veterans groups are expected to point out that any fee increases could affect those disabled by the wars in Iraq or Afghanistan who do not use the free services available to them at veterans’ hospitals, either because they choose not to or because they live too far away.

Mr. Gates has included proposals to increase Tricare fees for retirees in three of his past four Pentagon budgets. In 2008, when he held the same job under the Bush administration, Mr. Gates proposed a five-year phased increase of the annual $460 family fee for Tricare Prime, the popular H.M.O.-like option offered to military retirees, to a maximum of $1,260 to $2,460, depending on a retiree’s income, according to an analysis by the Congressional Budget Office.

Tricare refers to the $460 payment as an “enrollment fee,” not a premium. With $12 co-pays per doctor visit, some drug prescription payments and other costs, the current annual out-of-pocket expense for a family on Tricare Prime is estimated at $1,200 per year, still substantially less than what is available from private employers.

Congress, unwilling to be seen as inflicting any kind of pain on the military or veterans, rejected the increases. Mr. Gates said he got the message — “The proposals routinely die an ignominious death on Capitol Hill,” he said in May — and he did not try again in 2010. But in shaping that budget proposal, Obama administration officials also told the Pentagon not to raise it, lest it distract from Mr. Obama’s overhaul of the nation’s health care system earlier this year.

Some Pentagon officials and military advocacy groups have suggested alternatives to raising fees that could cut costs. One idea is to renegotiate the lucrative Tricare packages with the insurance companies, hospitals and drug companies that actually operate the programs. Another is to promote a cost-saving mail-order pharmacy.

Defense officials say that Mr. Gates has to make up his mind about any health care fee increases in the next weeks, in time for the Pentagon to submit its 2012 spending plans to the White House budget director in December. Defense analysts who spoke to Mr. Gates over the summer said he told them that he did not know if it was realistic to try to increase military health care costs while troops were at war.

But Defense Department officials have since said they see a window of opportunity in the growing alarm over the federal debt, the focus of two bipartisan panels that are proposing deep cuts in government spending.

Mr. Gates met in recent weeks with the leaders of one of the panels, former Senator Alan K. Simpson, a Republican, and Erskine B. Bowles, a Democrat and the former chief of staff to President Bill Clinton. They are the co-chairmen of Mr. Obama’s fiscal commission, which has proposed raising Tricare fees. The panel is trying to deliver a final report to the White House on Wednesday, if the members can reach a consensus that fast.

The panel is considering proposals to increase fees for military retirees working for civilian companies, but it would also require employers to reimburse the government for a share of the health insurance costs of those on their payroll who opt for Tricare. That measure alone, described as an effort to make civilian employers pay “a normal business expense,” could recoup $3 billion annually for the Pentagon.

In the meantime, Colonel Brady, 51, said he did not want to be overly dramatic about what was at stake. Although he spent 22 years in the Marines, six of them deployed, including to the 1991 Persian Gulf war, he said he could not buy the argument about a broken promise.

“Tricare is a very good deal for me, and if it costs some more, well, O.K.,” he said. Raising Tricare fees would be a financial burden for many retirees, he acknowledged, but he could not honestly say it would be for him.

“Not that I want to pay a ton of money,” he said.

An AIDS Advance, Hiding in the Open

Posted: 27 Nov 2010 09:20 PM PST

In the war against AIDS, a new weapon has emerged.

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It wasn’t a secret weapon. It was a well-established treatment pill that has only now been shown to be effective as a prevention pill too. Which raises a question: What took so long?

Last week, a clinical trial showed that taking Truvada, a pill combining two drugs, once a day would greatly reduce a gay man’s chances of getting infected with the dangerous virus. Although confirmatory studies are still needed, the practice — called “pre-exposure prophylaxis,” or “prep” — will, in theory, also protect sex workers, needle sharers, wives of infected men, prison inmates and anyone else at risk.

But Truvada has been sold since 2004. And the world has known since 1995 that antiretroviral drugs, used in combination, can rescue people with AIDS. As far back as at least 1990, it also knew that “post-exposure prophylaxis” (“pep”) often works in humans — that is, that a victim of a needle stick or rape or unprotected sex who begins taking a short course of antiretrovirals within 72 hours can probably avoid infection.

A few scientists even knew by 1995 that a drug in Truvada can protect monkeys from infection with the simian version of the AIDS virus.

So couldn’t “prep” have been “discovered” earlier? Why did it take until 2010?

The delay turns out to be a combination of scientific caution and the fiery politics of AIDS. While a medical advance can be made by a momentary flash of inspiration or luck — as legendarily happened with penicillin — proving that it works can take forever. And that is particularly true with AIDS, a disease surrounded by visceral fears, longstanding prejudices and the potential for huge profits.

The chief reason this advance took so long, said Dr. Robert M. Grant, a virologist at the Gladstone Institutes in San Francisco and the study’s chief author, is that the two drugs in Truvada, tenofovir and emtricitabine, were not approved for use in humans until 2001 and 2002, respectively. Older drugs, like AZT, the first AIDS drug, adopted in 1987, were too toxic.

Doctors once debated using nevirapine, approved in 1996. In poor countries, single doses for mother and baby are given at birth to prevent mother-child transmission. But taking nevirapine for even a few weeks can bring on brutal side effects. Over 10 percent of users get rashes. In rare cases, the drug can kill if not stopped in time.

Giving powerful drugs to healthy people is different from giving them to the desperately ill. No doctor would give cancer drugs to a healthy person. Prophylaxis is common with, for example, malaria drugs for travelers making brief sojourns in the tropics. But a drug to be taken all one’s life — or at least for all of one’s sex life — must be very safe.

Also, the drug must not prompt drug-resistance mutations in the virus. Tenofovir is unique that way, said Dr. Howard S. Jaffe, president of the Gilead Foundation, the philanthropic arm of Gilead Sciences, which makes Truvada. Structurally, it is so nearly identical to the bit of DNA it blocks that “the virus can’t easily outsmart it,” he said. Resistance to nevirapine, by contrast, can develop after a single dose.

Another factor is that not every drug company wants to see its best treatment drugs, on which it earns billions of dollars, tested for prevention. Dying patients accept unpleasant side effects; healthy ones might sue. And any patient who gets infected, even if taking the drug improperly, could sue. Gilead Sciences was willing to let Truvada be tested, although it has not yet decided, Dr. Jaffe said, whether to apply for F.D.A. permission to sell it as prophylaxis.

Also, several AIDS experts said, lab scientists were focused for years on the dream of an AIDS vaccine, while behaviorists assumed everyone would adopt condoms or abstinence. None of those hopes has been realized.

Health Law Faces Threat of Undercut From Courts

Posted: 29 Nov 2010 10:31 AM PST

WASHINGTON — As the Obama administration presses ahead with the health care law, officials are bracing for the possibility that a federal judge in Virginia will soon reject its central provision as unconstitutional and, in the worst case for the White House, halt its enforcement until higher courts can rule.

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The judge, Henry E. Hudson of Federal District Court in Richmond, has promised to rule by the end of the year on the constitutionality of the law’s requirement that most Americans obtain insurance, which takes effect in 2014.

Although administration officials remain confident that it is constitutionally valid to compel people to obtain health insurance, they also acknowledge that Judge Hudson’s preliminary opinions and comments could presage the first ruling against the law.

“He’s asked a number of questions that express skepticism,” said one administration official who is examining whether a ruling against part of the law would undermine other provisions. “We have been trying to think through that set of questions,” said the official, who insisted on anonymity because he was not authorized to discuss the case freely.

While many newly empowered Republican lawmakers have vowed to repeal the health care law in Congress, a more immediate threat may rest in the federal courts in cases brought by Republican officials in dozens of states. Not only would an adverse ruling confuse Americans and attack the law’s underpinnings, it could frustrate the steps hospitals, insurers and government agencies are taking to carry out the law.

“Any ruling against the act creates another P.R. problem for the Democrats, who need to resell the law to insured Americans,” said Jonathan Oberlander, a University of North Carolina political scientist, who wrote in The New England Journal of Medicine last week that such a ruling “could add to health care reform’s legitimacy problem.”

So far, there has been only one ruling on the merits among nearly two dozen legal challenges to the health care act. Last month, a federal district judge in Michigan upheld the law. But another judge, Roger Vinson of Federal District Court in Pensacola, Fla., has joined Judge Hudson in writing preliminary opinions that seemingly accept key arguments made by state officials challenging the law.

Unlike the judge in Michigan, who was appointed by President Bill Clinton, both Judge Hudson and Judge Vinson were appointed by Republican presidents.

“We are not operating under the assumption that those two judges are inevitably going to rule against us,” the administration official said. “But of course we’re planning for the possibility that judges will reach different conclusions.”

The novel question before the courts is whether the government can require citizens to buy a commercial product like health insurance.

Because the Supreme Court has said the commerce clause of the Constitution allows Congress to regulate “activities that substantially affect interstate commerce,” the judges must decide whether the failure to obtain insurance can be defined as an “activity.”

Lawyers on both sides expect the issue eventually to be decided by the Supreme Court. But the appellate path to that decision could take two years. In the meantime, any district court judge who rules against the law would have to decide whether to block enforcement of one or more of its provisions, potentially creating bureaucratic chaos.

Such a decision would prompt a flurry of appeals, as the Justice Department almost certainly would ask the judge and then the appellate courts to stay, or delay, the injunction pending the outcome of higher court rulings.

Administration officials, as well as some lawyers for the plaintiffs, agree that Judge Hudson seems unlikely, based on his comments from the bench, to enjoin the entire law. The judge volunteered at a hearing last month that his courtroom was “just one brief stop on the way to the Supreme Court.”

If he does not enjoin the law, the immediate impact of a finding against the insurance mandate would be limited because that provision, and others that might fall with it, do not take effect for more than three years.

Virginia’s attorney general, Kenneth T. Cuccinelli II, a Republican who filed the Richmond lawsuit, argues that if Judge Hudson rejects the insurance requirement he should instantly invalidate the entire act on a nationwide basis.

Mr. Cuccinelli and the plaintiffs in the Florida case, who include attorneys general or governors from 20 states, have emphasized that Congressional bill writers did not include a “severability clause” that would explicitly protect other parts of the sprawling law if certain provisions were struck down.

The Vanishing Mind: Children Ease Alzheimer’s in Land of Aging

Posted: 26 Nov 2010 11:49 AM PST

SEONGNAM, South Korea — They were stooped, hobbled, disoriented, fumbling around the house. They got confused in the bathtub and struggled up stairs that seemed to swim before them.

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War on Dementia

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High school students in Seoul assisted a woman with dementia at the Cheongam nursing home, part of a broader “War on Dementia” by the South Korean government.

“Oh, it hurts,” said Noh Hyun-ho, sinking to the ground.

“I thought I was going to die,” said Yook Seo-hyun.

There was surprisingly little giggling, considering that Hyun-ho, Seo-hyun and the others were actually perfectly healthy 11- to 13-year-old children. But they had strapped on splints, weighted harnesses and fogged-up glasses, and were given tasks like “Doorknob Experience” and “Bathroom Experience,” all to help them feel what it was like to be old, frail or demented.

“Even though they are smiling for us, every day, 24 hours, is difficult for them,” Jeong Jae-hee, 12, said she learned. “They lose their memory and go back to childhood.”

It is part of a remarkable South Korean campaign to cope with an exploding problem: Alzheimer’s disease and other dementias. As one of the world’s fastest-aging countries, with nearly 9 percent of its population over 65 already afflicted, South Korea has opened a “War on Dementia,” spending money and shining floodlights on a disease that is, here as in many places, riddled with shame and fear.

South Korea is training thousands of people, including children, as “dementia supporters,” to recognize symptoms and care for patients. The 11- to 13-year-olds, for instance, were in the government’s “Aging-Friendly Comprehensive Experience Hall” outside Seoul. Besides the aging simulation exercise, they viewed a PowerPoint presentation defining dementia and were trained, in the hall’s Dementia Experience Center, to perform hand massage in nursing homes.

“ ‘What did I do with my phone? It’s in the refrigerator,’ ” said one instructor, explaining memory loss. “Have you seen someone like that? They may go missing and die on the street.”

In another striking move, South Korea is also pushing to make diagnoses early, despite there being scant treatment.

“This used to be hidden” and “there is still stigma and bias,” said Kim Hye-jin, director of senior policy for the Health and Welfare Ministry. But “we want to get them out of their shells, out of their homes and diagnosed” to help families adjust and give patients “a higher chance of being taken care of at home.”

Hundreds of neighborhood dementia diagnostic centers have been created. Nursing homes have nearly tripled since 2008. Other dementia programs, providing day care and home care, have increased fivefold since 2008, to nearly 20,000. Care is heavily subsidized.

And a government dementia database allows families to register relatives and receive iron-on identification numbers. Citizens encountering wanderers with dementia report their numbers to officials, who contact families.

To finance this, South Korea created a long-term-care insurance system, paid for with 6.6 percent increases in people’s national health insurance premiums. In 2009, about $1 billion of government and public insurance money was spent on dementia patients. Still, with the over-65 population jumping from 7 percent in 2000 to 14 percent in 2018 to 20 percent in 2026, dementia is straining the country, socially and economically.

“At least one family member has to give up work” to provide caregiving, said Kwak Young-soon, social welfare director for Mapo District, one of Seoul’s 25 geographic districts. Because South Korea encourages people to work well past retirement age, families may also lose dementia sufferers’ incomes.

Most families no longer have generations living together to help with caregiving, and some facilities have long waiting lists, but “we can’t keep building nursing homes,” Mr. Kwak said. “We call it a ghost. It’s basically eating up the whole house.”

Dementia Epidemic

South Korea is at the forefront of a worldwide eruption of dementia, from about 30 million estimated cases now to an estimated 100 million in 2050. And while South Korea’s approach is unusually extensive, even in the United States, the National Alzheimer’s Project Act was introduced this year to establish a separate Alzheimer’s office to create “an integrated national plan to overcome Alzheimer’s.” Supporters of the bill, currently in committee, include Sandra Day O’Connor, whose late husband had Alzheimer’s.

South Korea also worries that dementia, previously stigmatized as “ghost-seeing” or “one’s second childhood” could “dilute respect for elders,” Mr. Kwak said. “There’s a saying that even the most filial son or daughter will not be filial if they look after a parent for more than three years.”

So the authorities promote the notion that filial piety implies doing everything possible for elders with dementia, a condition now called chimae (pronounced chee-may): disease of knowledge and the brain which makes adults become babies. But South Korea’s low birth rate will make family caregiving tougher.

“I feel as if a tsunami’s coming,” said Lee Sung-hee, the South Korean Alzheimer’s Association president, who trains nursing home staff members, but also thousands who regularly interact with the elderly: bus drivers, tellers, hairstylists, postal workers. “Sometimes I think I want to run away,” she said. “But even the highest mountain, just worrying does not move anything, but if you choose one area and move stone by stone, you pave a way to move the whole mountain.”

Su-Hyun Lee contributed reporting from Seoul, South Korea.

Patient Money: Think Twice Before Signing Up for That Medical Credit Card

Posted: 26 Nov 2010 09:50 PM PST

IF you are like most people, you have probably used a credit card to pay some of your medical bills. With rising health costs and gaps in insurance coverage, it’s almost unavoidable.

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Mark Rukavina, executive director of the Access Project, said medical cards might not be suited to people with limited financial resources. “But it’s usually people with limited resources who sign up,” he said.

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Patients pay about $45 billion worth of health care costs with plastic, according to a report from McKinsey & Company. By 2015, that number could more than triple to an estimated $150 billion. And big finance companies and medical providers have taken note.

Companies like GE Money, Citibank and JPMorgan Chase have issued medical credit cards or lines of credit intended to be used specifically for elective health care expenses not covered by insurance, including certain dental procedures, Lasik surgery, some cosmetic surgery and even veterinary care. The cards are not used for continuing medical care or emergency room visits.

The issuers market these cards not so much to consumers but to doctors, dentists and other health care providers, who in turn offer them to patients as a payment option. Patients like medical credit cards because payments for care can be spread out over many months and the cards can be used at multiple providers. The providers have embraced them as a way of offloading billing headaches and expenses.

But even as medical credit cards become increasingly popular, they are getting more scrutiny — not much of it flattering. Critics and patient advocates claim that aggressive and misleading marketing tactics can lead to serious headaches for consumers.

In extreme cases, medical providers and associations marketing the cards have been accused of receiving financial incentives for signing up patients or of falsifying financial information to make it easier for patients to qualify for cards.

More commonly, critics say, patients may be led to assume that their providers are simply offering payment plans, not a credit card with all the potential fees, interest rate increases and the impact on credit scores that can entail.

“Ironically, these cards may be best suited to people who already have financial resources," said Mark Rukavina, executive director of the Access Project, a consumer advocacy group in Boston, and co-author of a study on medical debt. “But it’s usually people with limited resources who sign up.”

Consumer complaints concerning aggressive marketing tactics prompted the New York attorney general, Andrew M. Cuomo, to start an investigation into medical credit cards earlier this year. In Minnesota, the state attorney general, Lori Swanson, has filed lawsuits against two chiropractors whose staff is accused of signing up patients for medical credit cards without their knowledge.

A medical credit card is “one payment option among several a provider may offer and represents a very small component of health care financing for elective procedures,” said Stephen White, a spokesman for CareCredit, a medical credit card issued by GE Money. “Benefits to consumers include the ability to plan, budget and pay for certain elective health care procedures over time.”

Whether you view these cards as a convenient way to pay medical expenses or just another way for credit card companies to collect interest and fees, here are some things to consider if your provider approaches you.

ASK FOR ALTERNATIVES First, try to negotiate a lower fee with your provider; he may be more flexible than you think. Then ask about payment options. Your doctor may well offer a payment plan of his or her own, without the high interest rates often charged by a medical credit card company.

“I encourage people to negotiate with their provider, then get an extended payment plan directly from that office with a monthly payment and time period you are comfortable with,” said Mr. Rukavina. “I think most providers are willing to work for patients in this way.”

If you do opt for a payment plan, ask whether you will be paying the provider directly or a third party. If there’s a third party involved, you may well wind up with a medical credit card. If you choose to sign up for it, be sure you’ve read through the terms carefully and that you understand the interest rates and late payment fees.

If your income is low enough, be aware that you may qualify for a public assistance program, especially for dental costs.

DODGE THE HARD SELL “Some patients report feeling pressured by their clinics to use the card to pay for procedures or treatments they may not need or can’t afford,” Ms. Swanson said. That’s no surprise, since these cards are intended, at least in part, to drive more business to dentists, chiropractors, cosmetic and eye surgeons, weight loss programs, hearing aid dispensers and other providers.

But the intense marketing can lead to unethical behavior, according to Ms. Swanson.

One of the lawsuits filed by her office claims that staff members at a chiropractic office told patients they were not signing up for a credit card but rather just going through a credit check. Instead, Ms. Swanson charges, the staff members submitted applications in the patients’ names and falsified patient’s yearly income information to make sure they qualified.

If you sense you’re being pushed, that things are moving too quickly, remember that you don’t have to sign up for anything on the spot. Take a day or two to read through materials thoroughly and research your options.

BEWARE THOSE TEASER RATES Almost all medical credit cards claim zero percent financing. This is what makes them attractive: you can spread out your payments and pay no interest.

But it is important to read the fine print. As with most credit cards marketed this way, the zero percent rate lasts only for an initial promotional period, usually from six to 24 months. Once that time is up, you will start to pay interest — sometimes high interest.

For GE’s CareCredit, for instance, rates jump to 26.99 percent. (The company does offer a fixed rate of 14.9 percent for extended periods up to 60 months.)

High interest isn’t your only concern. Be sure to check your minimum payment, advised Ms. Swanson. If you pay only the minimum, your payments may extend beyond the zero percent financing period, and you’ll end up with the higher rate.

What’s more, if you make just one late payment or go over the initial promotion period, some cards will charge you a high interest rate retroactively on the original balance, Ms. Swanson noted. That can suddenly add hundreds of dollars to your bill.

PAY AS YOU GO Some providers will charge your medical card for an entire multivisit procedure, like a dental implant, all at once. If you change providers midway through, or do not go through the entire procedure for some other reason, it can be difficult and time-consuming to get a refund, warned Mr. Rukavina.

If you are entering into a treatment or procedure that will take more than one visit, make sure your provider is billing you by the visit, not in a lump sum.

You can find more background on medical credit cards from the Minnesota attorney general’s office at www.ag.state.mn.us/Consumer/Publications/HealthCareCreditCards.asp.

What Was I Thinking?

Posted: 28 Nov 2010 03:05 PM PST

In “Self Comes to Mind,” the eminent neurologist and neuroscientist Antonio Damasio gives an account of consciousness that might come naturally to a highly caffeinated professor in his study. He emphasizes wakefulness, self-awareness, reflection, rationality, “knowledge of one’s own existence and of the existence of surroundings.”

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SELF COMES TO MIND

Constructing the Conscious Brain

By Antonio Damasio

367 pp. Pantheon. $28.95

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That is certainly one kind of consciousness, what one might call self-consciousness. But there is also a different kind, as anyone who knows what it is like to have a headache, taste chocolate or see red can attest. Self-consciousness is a sophisticated and perhaps uniquely human cognitive achievement. Phenomenal consciousness by contrast — what it is like to experience — is something we share with many animals. A person who is drunk or delirious or dreaming can be excruciatingly conscious without being wakeful, self-aware or aware of his surroundings.

The term “conscious” was first introduced into academic discourse by the Cambridge philosopher Ralph Cudworth in 1678, and by 1727, John Maxwell had distinguished five senses of the term. The ambiguity has not abated. Damasio’s distinctive contributions in “Self Comes to Mind” are an account of phenomenal consciousness, a conception of self­consciousness and, most controversially, a claim that phenomenal consciousness is dependent on self-consciousness.

Phenomenally conscious content — what distinguishes the experience of blue from the taste of chocolate — is, according to Damasio, a matter of associations that are processed in different brain areas at the same time. What makes a conscious state feel like something rather than nothing is explained as a fusion of mind and body in which neurons become “extensions of the flesh.” Self-consciousness is the result of a procession of neural maps of inner and outer worlds. What’s more, he argues, phenomenal consciousness depends on self-consciousness. Without a self, he writes, “the mind would lose its orientation. . . . One’s thoughts would be freewheeling, unclaimed by an owner. . . . What would we look like? Well, we would look unconscious.”

Even fish and lizards have a kind of minimal self, one that combines sensory integration with control of information processing and action. But Damasio’s self is not minimal. It is inflated with self-awareness, reflection, rationality, deliberation and knowledge of one’s existence and the existence of one’s surroundings, and this is what he ends up arguing a ­being needs in order to have phenomenal consciousness.

You may have sensed that I think there is a problem with Damasio’s emphasis on self-consciousness: indeed, “Self Comes to Mind” is mainly about self-­consciousness rather than experiential phenomenal consciousness. And the book is not about ­geology or underwear or many other things either. So what?

I can explain the problem by a brief detour into a different book, “The Origins of Consciousness in the Breakdown of the Bicameral Mind” (1976), by the American psychologist Julian Jaynes. Jaynes held that consciousness was invented by the ancient Greeks between 1400 and 600 B.C. He argued that there was a dramatic appearance of introspection in large parts of the “Odyssey,” as compared with large parts of the “Iliad,” which he claimed were composed at least a hundred years earlier. The philosopher W. V. Quine once told me that he thought Jaynes might be on to something until he asked Jaynes what it was like to perceive before consciousness was invented. According to Quine, Jaynes said it was like nothing at all — exactly what it is like to be a table or a chair. Jaynes was denying that people had experiential phenomenal consciousness based on a claim about inflated self-consciousness.

Damasio also denies phenomenal consciousness because of the demand of a sophisticated self-consciousness. You may have noticed an exciting report a few years ago of a patient in a persistent vegetative state (defined behaviorally) studied by the neuroscientists Adrian Owen and Steven Laureys. On some trials, the two instructed the patient to imagine standing still on a tennis court swinging at a ball, and on others to visualize walking from room to room in her home. The patient, they found, showed the same imagistic brain activations (motor areas for tennis, spatial areas for exploring the house) as normally conscious people who were used as controls.

Ned Block is the Silver professor of philosophy, psychology and neural science at New York University.

Well: Narcissism No Longer a Psychiatric Disorder

Posted: 29 Nov 2010 12:26 PM PST

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Personal Health: Head Out for a Daily Dose of Green Space

Posted: 29 Nov 2010 12:30 PM PST

First, the bad news: Americans are suffering from an acute case of “outdoor deprivation disorder,” and the effects on physical and mental health are rising fast. Children aged 8 to 18 today spend more time than ever using electronic media indoors — seven and a half hours a day, according to the Kaiser Family Foundation — and less time in outdoor unstructured activity. In response to the No Child Left Behind law, 30 percent of kindergarten classrooms have eliminated recess to make more room for academics.

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The resulting lack of physical activity and a growing disconnect with the natural environment have been linked in a host of studies to obesity and obesity-related diseases in children and adults, including Type 2 diabetes, high blood pressure, heart disease, asthma and nonalcoholic fatty liver disease, as well as vitamin D deficiency, osteoporosis, stress, depression, attention deficit disorder and myopia. Dr. Daphne Miller, a family physician affiliated with the University of California, San Francisco, calls them “diseases of indoor living.”

Now, the good news: There’s a simple remedy — get outside and start moving around in green spaces near and far, most of which are free. A consortium of physicians, health insurers, naturalists and government agencies have banded together to help more people of all ages and economic strata engage in health-enhancing physical activity in parks and other natural environments.

This grass-roots movement has already reached the White House. This year President Obama started the America’s Great Outdoors Initiative, proclaiming June “Great Outdoors Month.” The initiative aims not just to counter sedentary lifestyles but also to reacquaint Americans with the farms, ranches, rivers, forests, national and local parks, fishing holes and beaches that provide opportunities for people “to stay active and healthy.”

The goals dovetail with Michelle Obama’s battle against childhood obesity and her initiative Let’s Move Outside, a program that’s part of her Let’s Move campaign. Dr. Miller said that the aim was to “turn our public lands into public health resources. Doctors around the country are beginning to realize that getting patients out of doors has benefits even beyond getting people to exercise.

“It’s a lot cheaper to go outside and move than it is to build gyms and a lot of hospitals,” she said.

Doctor’s Orders: Be Active

Accordingly, Dr. Miller and a growing number of like-minded doctors have begun writing specific prescriptions for outdoor activity, providing patients with maps, guidelines and programs of gradually increased activity based on their abilities. She said that such prescriptions are necessary because many people “are unfamiliar with the outdoors — they’re scared to walk through a park, and they don’t know what to do when they get there.”

Among possible sources of help: volunteer health guides in parks who can tell people where to go and what to do and park rangers who are trained to advise people who may have health issues. “Our parks provide a huge opportunity,” Dr. Miller said. “Currently, fewer than 40 percent of visitors use them for any form of exercise.”

Some health insurers have come on board as well. SeeChange Health in California and the Blue Cross and Blue Shield Foundation in North Carolina are supporting outdoor programs in their areas, like the Kids in Parks Initiative of the Blue Ridge Parkway Foundation. SeeChange Health this year announced a pilot project to reimburse members for visits to California state parks.

Other movers and shakers include the National Wildlife Federation, which established the “Be Out There” public-education campaign to foster a daily “green hour” during which every child could enjoy 60 minutes of unstructured play and interaction with the natural world. On its Web site, www.nwf.org, the federation has posted the rationale and specific suggestions for schools and families to counter the physical, emotional and educational drain of an “indoor childhood.”

The campaign’s mission “is to return to the nation’s children what they don’t even know they’ve lost: their connection to the natural world,” with activities suitable for all children, whether rural, suburban or urban.

As for its health and educational benefits, the federation cites scientific findings that outdoor play enhances fitness, raises blood levels of vitamin D (which in turn protects against bone loss, heart disease, diabetes and other health problems), improves distance vision, lowers the risk of nearsightedness, reduces symptoms of stress and attention deficit hyperactivity disorder, raises scores on standardized tests and improves students’ critical-thinking skills.

The National Environmental Education Foundation is now training pediatric health care providers to serve as nature champions in their communities.

One study of children living in poor urban environments found that those who relocated to greener (though not more affluent) home surroundings “tended to have the highest levels of cognitive functioning following the move.” The author of the study, Nancy M. Wells, also found in research among rural children that nearby nature can act as a buffer against stressful life events and improve children’s psychological well-being.

Lest you remain unconvinced, I urge you to read the best-selling book “The Last Child in the Woods,” by Richard Louv, who coined the phrase “nature-deficit disorder.” Mr. Louv describes dozens of studies demonstrating the benefits that wilderness outings can have on mental and physical health.

‘Park Prescriptions’

The National Park Service, too, has joined the “park prescriptions” campaign, offering free wellness services that are accessible to all, regardless of health status. (I was shocked to learn on a recent visit to Grand Canyon National Park that, despite many well-maintained trails, only 5 percent of visitors ever venture below the rim of the canyon; about half the people I encountered on the trails were from other countries.)

The park service helped Dr. Eleanor Kennedy, a cardiologist in Little Rock, Ark., create a downtown “Medical Mile,” a section of the Arkansas River Trail, and now hopes to support access to similar open spaces in communities nationwide. Dr. Kennedy reports that once she gets her patients outdoors “they are more likely to be consistent about exercise.” The Medical Mile project, which had an initial goal of $350,000, managed to raise $2.1 million in two years.

Dr. Robert Lambert, a cardiologist at the Heart Clinic of Arkansas, said: “We see too many patients who need our assistance because of their lifestyle, not because of factors beyond their control. That is why my colleagues and I decided to become involved.”

Other programs include Prescription Trails, established in Santa Fe, N.M., with the help of the Centers for Disease Control and Prevention, to counter runaway rates of diabetes in the community. Local physicians get trail guides to distribute to their patients. The Web site www.prescriptiontrailsnm.org is a guide to some of the state’s best park and trail walking and wheelchair rolling paths.

This is the second of two columns on health-promoting physical activity.

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Really?: The Claim: A Cup of Coffee can Ease the Symptoms of Asthma

Posted: 29 Nov 2010 12:06 PM PST

THE FACTS Caffeine is known more as a pick-me-up than a home remedy, but for years scientists have wondered whether it may have benefits for people with asthma.

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Christoph Niemann

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The suspicion stems in part from its chemical structure, which resembles that of theophylline, a common asthma medication that relaxes the airway muscles and relieves wheezing, shortness of breath and other respiratory problems. Indeed, when caffeine is ingested and broken down by the liver, one byproduct is small amounts of theophylline.

In a 2007 study in the Cochrane Database of Systematic Reviews, researchers pooled and analyzed the results of a half dozen clinical trials looking at the effects of caffeine on asthmatics. They found that caffeine produced small improvements in airway function for up to four hours, compared with a placebo, and that even a small dose — less than the amount in a cup of Starbucks coffee — could improve lung function for up to two hours.

In other words, in a pinch, a cup of coffee or strong tea might provide some momentary relief.

But the improvements are very slight, studies show — certainly not enough to make caffeine a replacement for medication. The other problem is that because of their chemical similarities, consuming too much caffeine can compound any side effects of theophylline. As a result, doctors advise people taking that medication to watch their consumption of coffee, tea, chocolate and other foods with caffeine.

THE BOTTOM LINE Caffeine’s benefits for asthma are real but minimal.


The New Old Age: A War on Dementia

Posted: 26 Nov 2010 08:42 AM PST

Prescriptions: Steep Rise in H.M.O. Costs

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Recipes for Health: Pumpkin and Ginger Scones

Posted: 25 Nov 2010 11:50 PM PST

Just in case you didn’t get enough pumpkin pie flavor at the Thanksgiving table, here’s a nice breakfast pastry for the day after.

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.

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3/4 cup whole-wheat flour

1 cup all purpose flour

1/2 teaspoon salt

1/4 teaspoon ground ginger

2 teaspoons baking powder

1/2 teaspoon baking soda

4 tablespoons cold unsalted butter, cut into 1/2-inch pieces

1/2 cup pumpkin purée, well drained, canned or made from 1/2 pound fresh

1/4 cup buttermilk

2 tablespoons maple syrup

1/2 cup chopped candied ginger

1. Preheat the oven to 400 degrees. Line a baking sheet with parchment. Sift together the flours, salt, ginger, baking powder and baking soda. Place in the bowl of a food processor fitted with the steel blade.

2. Add the butter to the food processor, and pulse several times until it is distributed throughout the flour. The mixture should have the consistency of coarse cornmeal.

3. Beat together the pumpkin purée, buttermilk and maple syrup in a small bowl, and scrape into the food processor. Add the ginger, and process just until the dough comes together.

4. Scrape onto a lightly floured surface, and gently shape into a rectangle about 3/4 inch thick. Cut into six squares, then cut the squares in half on the diagonal to form 12 triangular pieces. Place on the baking sheet. Bake 12 to 15 minutes until lightly browned. Cool on a rack.

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, 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 in a food processor fitted with the steel blade.

Yield: 12 scones.

Advance preparation: These will keep for a couple of days well wrapped or in a cookie tin.

Nutritional information per serving: 143 calories; 4 grams fat; 3 grams saturated fat; 10 milligrams cholesterol; 25 grams carbohydrates; 2 grams dietary fiber; 223 milligrams sodium; 3 grams protein

Martha Rose Shulman can be reached at martha-rose-shulman.com. Her latest book is "The Very Best of Recipes for Health."

Study Finds No Progress in Safety at Hospitals

Posted: 25 Nov 2010 01:14 PM PST

Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

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Little Change in Patient Safety

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

“It is unlikely that other regions of the country have fared better,” said Dr. Christopher P. Landrigan, the lead author of the study and an assistant professor at Harvard Medical School. The study is being published on Thursday in The New England Journal of Medicine.

It is one of the most rigorous efforts to collect data about patient safety since a landmark report in 1999 found that medical mistakes caused as many as 98,000 deaths and more than one million injuries a year in the United States. That report, by the Institute of Medicine, an independent group that advises the government on health matters, led to a national movement to reduce errors and make hospital stays less hazardous to patients’ health.

Among the preventable problems that Dr. Landrigan’s team identified were severe bleeding during an operation, serious breathing trouble caused by a procedure that was performed incorrectly, a fall that dislocated a patient’s hip and damaged a nerve, and vaginal cuts caused by a vacuum device used to help deliver a baby.

Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.

The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

“Until there is a more coordinated effort to implement those strategies proven beneficial, I think that progress in patient safety will be very slow,” he said.

An expert on hospital safety who was not associated with the study said the findings were a warning for the patient-safety movement. “We need to do more, and to do it more quickly,” said the expert, Dr. Robert M. Wachter, the chief of hospital medicine at the University of California, San Francisco.

A recent government report found similar results, saying that in October 2008, 13.5 percent of Medicare beneficiaries — 134,000 patients — experienced “adverse events” during hospital stays. The report said the extra treatment required as a result of the injuries could cost Medicare several billion dollars a year. And in 1.5 percent of the patients — 15,000 in the month studied — medical mistakes contributed to their deaths. That report, issued this month by the inspector general of the Department of Health and Human Services, was based on a sample of Medicare records from patients discharged from hospitals.

Dr. Landrigan’s study reviewed the records of 2,341 patients admitted to 10 hospitals — in both urban and rural areas and involving large and small medical centers. (The hospitals were not named.) The researchers used a “trigger tool,” a list of 54 red flags that indicated something could have gone wrong. They included drugs used only to reverse an overdose, the presence of bedsores or the patient’s readmission to the hospital within 30 days.

The researchers found 588 instances in which a patient was harmed by medical care, or 25.1 injuries per 100 admissions.

Not all the problems were serious. Most were temporary and treatable, like a bout with severe low blood sugar from receiving too much insulin or a urinary infection caused by a catheter. But 42.7 percent of them required extra time in the hospital for treatment of problems like an infected surgical incision.

In 2.9 percent of the cases, patients suffered a permanent injury — brain damage from a stroke that could have been prevented after an operation, for example. A little more than 8 percent of the problems were life-threatening, like severe bleeding during surgery. And 2.4 percent of them caused or contributed to a patient’s death — like bleeding and organ failure after surgery.

Medication errors caused problems in 162 cases. Computerized systems for ordering drugs can cut such mistakes by up to 80 percent, Dr. Landrigan said. But only 17 percent of hospitals have such systems.

For the most part, the reporting of medical errors or harm to patients is voluntary, and that “vastly underestimates the frequency of errors and injuries that occur,” Dr. Landrigan said.

“We need a monitoring system that is mandatory,” he said. “There has to be some mechanism for federal-level reporting, where hospitals across the country are held to it.”

Dr. Mark R. Chassin, president of the Joint Commission, which accredits hospitals, cautioned that the study was limited by its list of “triggers.” If a hospital had performed a completely unnecessary operation, but had done it well, the study would not have uncovered it, he said. Similarly, he said, the study would not have found areas where many hospitals have made progress, such as in making sure that patients who had heart attacks or heart failure were sent home with the right medicines.

The bottom line, he said, “is that preventable complications are way too frequent in American health care, and “it’s not a problem we’re going to get rid of in six months or a year.”

Dr. Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Leah Binder, the chief executive officer of the Leapfrog Group, a patient safety organization whose members include large employers trying to improve health care, said it was essential that hospitals be more open about reporting problems.

“What we know works in a general sense is a competitive open market where consumers can compare providers and services,” she said. “Right now you ought to be able to know the infection rate of every hospital in your community.”

For hospitals with poor scores, there should be consequences, Ms. Binder said: “And the consequences need to be the feet of the American public.”

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U.S. Orders Vast Review of Bioethics

Posted: 24 Nov 2010 07:12 PM PST

WASHINGTON (AP) — President Obama on Wednesday ordered a vast review to ensure the ethical treatment of people who take part in research backed by the federal government.

His action is a response to the revelation this year that American scientists intentionally infected people at a Guatemalan mental hospital with syphilis in the 1940s.

In a memorandum released by the White House, Mr. Obama announced a review of federal and international standards to guard the health and well-being of research participants, known as human subjects. He also ordered a fresh inquiry into what happened in the widely condemned experiment in Guatemala.

In that case, American scientists deliberately infected prisoners and patients in a mental hospital with syphilis from 1946 to 1948. It was apparently an effort to test if penicillin, then relatively new, could prevent some sexually transmitted infections. Secretary of State Hillary Rodham Clinton said in October that it was “reprehensible research,” and both she and Mr. Obama called Guatemala’s president, Álvaro Colom, to apologize.

“While I believe the research community has made tremendous progress in the area of human subjects protection, what took place in Guatemala is a sobering reminder of past abuses,” Mr. Obama said in the memo to Amy Gutmann, the chairwoman of the Presidential Commission for the Study of Bioethical Issues.

Mr. Obama said the commission must use its expertise across the fields of science, policy, ethics and religion to protect those who take part in medical research. The president added, “We owe it to the people of Guatemala and future generations of volunteers.”

Mr. Obama ordered Dr. Gutmann to form a panel, starting in January, to begin the reviews and to provide him with a report and recommendations within nine months. He said the members must get input from experts in Guatemala and around the world.

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