Health - Patient Money: Burning Calories, but Not a Hole in Your Wallet

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• Patient Money: Burning Calories, but Not a Hole in Your Wallet
• Senate Passes 9/11 Health Bill as Republicans Back Down
• Medical Schools in Region Fight Caribbean Flow
• Five Years In, Gauging Impact of Gates Grants
• Health Insurers to Be Required to Justify Rate Increases Over 10 Percent
• Vatican Adds Nuance to Pope’s Condom Remarks
• Abuses Cited in Enforcing China Policy of One Child
• The New Old Age: Elder Tech: What's Important
• Recipes for Health: Blini With Smoked Herring Topping
• Personal Best: Basking in a Workout’s Long, Mysterious Afterglow
• A Doctor’s Mammogram Mission Turns Personal
• How a Torn Aorta Can Do Lethal Damage
• National Briefing | Health: Teenage Birth Rate Falls 6 Percent
• National Briefing | Southwest: Arizona: Hospital Loses Catholic Affiliation
• In Map of Brain Junction, Avenues to Answers
• Global Update: London: Tuberculosis Cases Have Increased 50 Percent in Last Decade, Lancet Says
• Cases: It Was Benign, but Almost Killed Him
• Vital Signs: Awareness: Of Medicines and Mismeasurements
• Vital Signs: Risks: Fewer Heart Problems Among Moderate Drinkers
• Vital Signs: Childhood: A Caffeine Buzz From Soft Drinks
• Mental Health Needs Seen Growing at Colleges
• Doctor and Patient: How Does Your Hospital Room Make You Feel?
• Well: Ringing in the New Year With Blini
• Well: Saving Money on Fitness
• Well: Google’s New Body Browser
• Well: Children, Loss and the Holidays
• Well: Patient 1, Society 0
• Personal Health: What We’re Not Looking After: Our Eyes
• Really?: The Claim: Humming Can Ease Sinus Problems
• Prescriptions: The Case of the Missing o.b. Tampons
• Prescriptions: This Week's Health Industry News
• Prescriptions: Court Backs Patents for Diagnostic Tests
• The New Old Age: Over 75 and Still Working
• The New Old Age: One of Those Days
• The New Old Age: Empathy 101
• Letters: Attention Must Be Paid (3 Letters)
• Letters: Just Imagine (1 Letter)
• Urban Athlete: Colleagues More Than Happy to Go Running After the Boss
• Recipes for Health: Buckwheat or Cornmeal Blini With Radish Topping
• Recipes for Health: Blini With Mushroom Caviar
• Recipes for Health: Blini With Caviar and Yogurt Topping
• National Briefing | West: California: Setback for Marijuana Farms
• Antitrust Suit in Michigan Tests Health Law
• Fixing Error, Senate Passes Food Bill Again
• The Supreme Court and Obama’s Health Care Law
• New Estimates of Food Poisoning Cases
• With Alzheimer’s Patients Growing in Number, Congress Endorses a National Plan
• Vital Signs: Hazards: Mercury Prompts a New Call to Limit Tuna

Patient Money: Burning Calories, but Not a Hole in Your Wallet Posted: 24 Dec 2010 07:56 AM PST CLAIRE ALBA is determined to nail two New Year’s resolutions at once: staying fit and saving money. Enlarge This Image Chester Higgins Jr./The New York Times Claire Alba, with her husband, Rennie, and their daughters Coco, 9, and Cori, 5, at the Park Slope Armory that houses the Y.M.C.A. they will join. Well Share your thoughts on this column at the Well blog. Go to Well » Related More Articles in This Series Ms. Alba, a 38-year-old jewelry maker, and her husband, Rennie, 42, recently gave up their fancy membership at a Park Slope gym. Instead, the couple and their two daughters, Coco, 9, and Cori, 5 , plan to join the local Y.M.C.A., where their membership will include access to a new sports center at the Park Slope Armory. The combined membership offers quite a bit more than their current gym, including a pool, exercise classes of all kinds (and for all ages), fitness equipment, child care, karate, family yoga, art classes and an inexpensive day camp for the girls during school vacations. The cost? Membership for all four Albas will cost the same each month as the couple paid for the adults-only gym. And Ms. Alba plans to sign up the day after Christmas, when the Y will waive the $121 fee to join for new members. “We’re getting so much more, and it doesn’t change what’s coming out of our pocket every month,” said Ms. Alba. As the nation’s economic woes drag on, many people are rethinking their investments in pricey gym memberships and home exercise equipment. After all, the average health club membership is $750 annually, including sign-up fees and monthly dues. A treadmills for home use can cost upward of $1,000. Many fitness buffs are finding that less expensive alternatives can be just as invigorating. “These days people realize you can burn the same number of calories for a lot less money,” said Beth Kobliner, personal finance expert and the author of “Get a Financial Life.” She added, “All kinds of programs have popped up postrecession that offer lower-cost ways to exercise.” From exercisers who have gone low-tech, here is some help for both your wallet and waistline. NO FRILLS The Y isn’t the only affordable gym option. Often other community organizations, like schools, neighborhood clubs, temples and churches offer workout facilities and sports activities for less money. In many neighborhoods, no-frills gyms provide fewer equipment choices and no fancy amenities — but at daily, weekly or monthly rates, instead of yearly memberships, so you are not paying for gym time that is not being used using. Students or an alumni of a nearby university or community college can often can use its facilities at no cost or for as little as $20 a month. (Students also are often eligible for discounts at Y’s and other community centers, too.) Check out the hotels and motels, too. Many allow neighbors to use the fitness room and pool for a small daily or weekly fee. These arrangements may be left to the individual manager’s discretion, so it pays to make a phone call or two to see what might be available and to negotiate price. GROUP EFFORTS Studies show that when people work out together, they are far more likely to stick with it, said Cedric Bryant, chief science officer at the American Council on Exercise. Walking, running and cycling groups are usually free and provide a great way to socialize and stay motivated. To find an exercise group, do an Internet search for the type of club you want to join, along with your city or ZIP code, or check the bulletin boards at your local sporting goods, running and bike shops for groups in your area. Meetup.com lists all sorts of group fitness activities by city or ZIP code. Runners can check the Road Runners Club of America for clubs in their area: www.rrca.org/find-a-running-club. If bad weather is common in your region, visit the local mall and check bulletin boards and information booths for organized mall-walking groups. Can’t find anything organized near you? Start a group. Vicky Finney, 45, of Brooklyn, plans to start a power-walking group for mothers in her neighborhood after the holidays for those wanting to walk around Prospect Park after taking the children to school. “It takes 50 minutes to walk around the whole park, and it’s completely exhilarating,” she said. “Way better than dragging yourself to the gym and staring at a bare wall while you walk a treadmill.” YOGA, PERHAPS? Yoga studios have infiltrated just about every corner of the country. Among its other virtues, yoga can be a remarkably cost-effective form of exercise — no special equipment is required, save for perhaps a mat, and you can do it on your own practically anywhere. In most studios, you pay for each class, usually between $10 and $20. But many yoga studios offer community classes for as little as $5 or $6 as a way of reaching out to new clients and giving new teachers more experience. In addition, donation-based yoga studios are becoming popular. At Yoga for the People, which has locations in New York, San Francisco and Berkeley, Calif., a donation of $10 a class is suggested, but you can put whatever you can afford in the box. HOME SCHOOLING For a few dollars, or at no cost, you can find DVD or online instruction on just about any type of exercise for use at home, said Dr. Bryant of the council on exercise. All you need is motivation and enough strength to move the coffee table away from the television or computer. Exercise DVDs may be inexpensive, but before purchasing one, think about what your goals are — weight loss? strength training? stress relief? — and what type of instruction will work best for you. (You can find more detailed advice on picking an exercise DVD at www.collagevideo.com.) Consider borrowing DVDs from your local library or renting them before you buy one. For intense strength training, go online and check out a favorite of workout bloggers: hundredpushups.com. The free program promises to enable you to do 100 push-ups in six weeks’ time. The site offers similar programs for achieving 200 sit-ups and 200 squats. For free instruction on exercises for just about every part of the body, visit the online exercise library at the American Council of Exercise. On the Web site of Self magazine, you can create and customize your own workout video: workouts.self.com. YouTube is also full of free exercise and aerobic videos that can be done at home. One of the most popular is “8-Minute Abs.” Home exercise equipment, if you decide to use it, need not be big and expensive. An exercise ball, jump rope, set of hand weights, resistance bands or an inexpensive chin-up bar can all enhance your home workout, and can cost less than $25 each. GYM DISCOUNTS If none of these alternatives sounds appealing and you still want to join a swanky health club, at the least look for discounts, which are often plentiful this time of year. Crunch Fitness, in New York, for instance, is offering $150 off the enrollment fee and $10 off monthly dues for those joining before the end of the year. Always read health club membership contracts carefully, checking for any limitations in your agreement (not being able to use all locations, for example) and a cancellation policy that allows you to stop paying if you move or are injured. For more information on what to look out for, go to www.ftc.gov/bcp/edu/pubs/consumer/health/hea08.shtm. Don’t succumb to pressure to sign up on the spot. Instead, go home, reread the contract — and think about whether you really want to spend all that money when there are so many low-cost alternatives out there.

Senate Passes 9/11 Health Bill as Republicans Back Down Posted: 22 Dec 2010 11:50 PM PST WASHINGTON — After years of fierce lobbying and debate, Congress approved a bill on Wednesday to cover the cost of medical care for rescue workers and others who became sick from toxic fumes, dust and smoke after the 2001 attack on the World Trade Center. Related Post a Comment The House Vote The Caucus: G.O.P. Finds Itself in a Corner Over 9/11 Bill Stance (December 22, 2010) 9/11 Health Bill Wins Support From G.O.P. (December 19, 2010) Times Topic: 9/11 Health and Environmental Issues Obama Gamble Pays Off With Approval of Arms Pact (December 23, 2010) For the President, a Moment to Reflect, and Then to Depart (December 23, 2010) Obama Signs Away ‘Don’t Ask, Don’t Tell’ (December 23, 2010) The $4.3 billion bill cleared its biggest hurdle early in the afternoon when the Senate unexpectedly approved it just 12 days after Republican senators had blocked a more expensive House version from coming to the floor of the Senate for a vote. In recent days, Republican senators had been under fire for their opposition to the legislation. The House quickly passed the Senate bill a few hours later, as was widely expected. The vote was 206 to 60, breaking down largely along party lines. The White House said President Obama would sign the bill into law. After the Senate vote, a celebration broke out in a room in the Capitol that was packed with emergency workers and 9/11 families, as well as the two senators from New York, Charles E. Schumer and Kirsten E. Gillibrand, and the two senators from New Jersey, Frank R. Lautenberg and Robert Menendez. The senators, all Democrats, were greeted with a huge ovation and repeated chants of “U.S.A.! U.S.A.!” Mr. Schumer, the state’s senior senator, allowed Ms. Gillibrand to address the group first, in apparent deference to the role she took in the Senate on the 9/11 legislation. “Our Christmas miracle has arrived,” she said to applause and cheers. “To the firefighters here, the police officers here, everyone involved in the recovery, all the volunteers, the family members: Thank you!” she continued. “It was your work, it was your heroism, it was your dedication that made the difference. It was your effort, coming here week after week to tell senators and Congress members about your stories and what you went through.” The votes came after prolonged aggressive lobbying by top New York officials and lawmakers, police and firefighter groups and 9/11 families, who argued that the nation had a moral obligation to provide medical assistance to rescue workers who spent days, weeks and even months at ground zero. In a reminder of the bill’s long road to passage, Secretary of State Hillary Rodham Clinton, who sponsored the legislation when she represented New York in the Senate, was coincidentally at the Capitol on Wednesday for a Senate vote on ratification of the New Start treaty The 9/11 health measure calls for providing $1.8 billion over the next five years to monitor and treat injuries stemming from exposure to toxic dust and debris at ground zero; New York City would pay 10 percent of these costs. There are nearly 60,000 people enrolled in health-monitoring and treatment programs related to the 9/11 attack. The federal government currently provides the bulk of the financing for these programs. The legislation adopted on Wednesday also sets aside $2.5 billion to reopen the September 11th Victim Compensation Fund for five years to provide payment for job and economic losses. In a statement released by City Hall, Mayor Michael R. Bloomberg hailed the passage of the legislation, saying it “affirms our nation’s commitment to protecting those who protect us all.” The bill was adopted during a flurry of activity as lawmakers rushed to adjourn for the year. It was a major turn of events since the bill appeared to have fallen victim to partisan squabbling and rancor. In September, after years of negotiation and debate, the House passed legislation that called for providing $7.4 billion over eight years to cover the medical care of 9/11 rescue workers and others. But this month, Republicans derailed that legislation in the Senate, expressing concern about its cost. By Wednesday, Senate Republicans budged, following a barrage of criticism over the last few days — not just from Democrats, but also from allies, including former Mayor Rudolph W. Giuliani of New York and conservative news outlets like Fox News. The 9/11 health care issue also became a cause of Jon Stewart, who used the platform of his program, “The Daily Show,” to bring national attention to the bill. Before agreeing to lift their opposition, Senate Republicans managed to get Democrats to scale back the size of the original House bill. The Senate adopted the legislation by a voice vote, eliminating the need for a recorded vote, as lawmakers rushed to bring the Congressional session to a close. One of the main critics of the original House bill, Senator Tom Coburn, Republican of Oklahoma, expressed satisfaction with the legislation’s final cost. “Every American recognizes the heroism of the 9/11 first responders,” Mr. Coburn said. “But it is not compassionate to help one group while robbing future generations of opportunity.” Still, the acrimonious fight over the 9/11 legislation appeared to leave Republicans on the defensive and concerned that their party had been unfairly demonized for raising legitimate objections to the original $7.4 billion bill the House passed. “Some have tried to portray this debate as a debate between those who support 9/11 workers and those who don’t,” said Senator Mitch McConnell of Kentucky, the Republican leader. “This is a gross distortion of the facts. There was never any doubt about supporting the first responders. It was about doing it right.” In the House, there was some disappointment among Democrats over the deal cut in the Senate. But many concluded that the Senate bill was the best they could get at the moment. “This compromise isn’t everything we wanted,” Representative Carolyn B. Maloney, Democrat of New York, a chief sponsor of the original legislation, said. “But in the end we got a strong program that will save lives.” The bill is formally known as the James Zadroga 9/11 Health and Compensation Act, named after a New York police detective who took part in the rescue efforts at ground zero and later developed breathing complications. He died in January 2006. The cause of his death became a source of debate after the city’s medical examiner concluded that it was not directly related to the attack. The legislation allows for money from the Victims’ Compensation Fund to be paid to any eligible claimant who receives a payment under the settlement of lawsuits that more than 10,000 rescue and cleanup workers recently reached with the city. Currently, those who receive a settlement are limited in how much compensation they can get from the fund. In New York, a federal judge told lawyers for the 10,000 that payments from the settlement must start going out by late January. The judge, Alvin K. Hellerstein of United States District Court in Manhattan, worked out a timetable with the lawyers so that the settlement terms, which call for payments of at least $625 million, become final within the next two weeks. David M. Herszenhorn contributed reporting from Washington, and Mireya Navarro from New York.

Medical Schools in Region Fight Caribbean Flow Posted: 23 Dec 2010 01:07 PM PST For a generation, medical schools in the Caribbean have attracted thousands of American students to their tiny island havens by promising that during their third and fourth years, the students would get crucial training in United States hospitals, especially in New York State. But in a fierce turf battle rooted in the growing pressures on the medical profession and academia, New York State’s 16 medical schools are attacking their foreign competitors. They have begun an aggressive campaign to persuade the State Board of Regents to make it harder, if not impossible, for foreign schools to use New York hospitals as extensions of their own campuses. The changes, if approved, could put at least some of the Caribbean schools in jeopardy, their deans said, because their small islands lack the hospitals to provide the hands-on training that a doctor needs to be licensed in the United States. The dispute also has far-reaching implications for medical education and the licensing of physicians across the country. More than 42,000 students apply to medical schools in the United States every year, and only about 18,600 matriculate, leaving some of those who are rejected to look to foreign schools. Graduates of foreign medical schools in the Caribbean and elsewhere constitute more than a quarter of the residents in United States hospitals. With experts predicting a shortage of 90,000 doctors in the United States by 2020, the defenders of these schools say that they fill a need because their graduates are more likely than their American-trained peers to go into primary and family care, rather than into higher-paying specialties like surgery. New York has been particularly affected by the influx because it trains more medical students and residents — fledgling doctors who have just graduated from medical school — than any other state. The New York medical school deans say that they want to expand their own enrollment to fill the looming shortage, but that their ability to do so is impeded by competition with the Caribbean schools for clinical training slots in New York hospitals. Their argument is one that has been lobbed at Caribbean schools for decades: that those schools turn out poorly trained students who undercut the quality of training for their New York peers learning alongside them at the same hospitals. And they complain that the biggest Caribbean schools, which are profit-making institutions, are essentially bribing New York hospitals by paying them millions of dollars to take their students. The American medical schools traditionally pay nothing, because hospitals like the prestige of being associated with universities. “These are designed to be for-profit education mills to train students to pass the boards, which is all they need to get a license,” said Dr. Michael J. Reichgott, a professor at the Albert Einstein College of Medicine in the Bronx. Charles Modica, chancellor of St. George’s University in Grenada, whose first class started studying in 1977, making it one of the oldest in the Caribbean, said the New York deans were simply afraid of competition. “It’s basically a situation where the New York State deans just can’t hold their noses high enough up in the air, and I think it’s disgraceful,” said Mr. Modica, who founded St. George’s after he was rejected from medical school and went on to law school. Most Americans had never heard of the school until 1983, when President Reagan sent troops into Grenada, partly, he said, to rescue St. George’s American students from unrest. The debate is so fraught that officials of Ross University, on the island of Dominica, were at first reluctant to talk about it, fearing students would be scared away from offshore schools. “If the domestic schools felt we were taking opportunities away from their students, if they can specifically tell us what location we were taking them away from — that question was never answered,” said Dr. Nancy Perri, Ross’s chief academic officer. The New York schools want the state to adopt the position of the American Medical Association, that “the core clinical curriculum of a foreign medical school should be provided by that school and that U.S. hospitals should not provide substitute core clinical experience.” 1 2 Next Page »

Five Years In, Gauging Impact of Gates Grants Posted: 22 Dec 2010 11:20 AM PST SEATTLE — Five years ago, Bill Gates made an extraordinary offer: he invited the world’s scientists to submit ideas for tackling the biggest problems in global health, including the lack of vaccines for AIDS and malaria, the fact that most vaccines must be kept refrigerated and be delivered by needles, the fact that many tropical crops like cassavas and bananas had little nutrition, and so on. Related Times Topic: Bill and Melinda Gates Foundation Dennis Kunkel/Corbis TARGET Mosquitoes were the focus of research. No idea was too radical, he said, and what he called the Grand Challenges in Global Health would pursue paths that the National Institutes of Health and other grant makers could not. About 1,600 proposals came in, and the top 43 were so promising that the Bill & Melinda Gates Foundation made $450 million in five-year grants — more than double what he originally planned to give. Now the five years are up, and the foundation recently brought all the scientists to Seattle to assess the results and decide who will get further funding. In an interview, Mr. Gates sounded somewhat chastened, saying several times, “We were naïve when we began.” As an example, he cited the pursuit of vaccines that do not need refrigeration. “Back then, I thought: ‘Wow — we’ll have a bunch of thermostable vaccines by 2010.’ But we’re not even close to that. I’d be surprised if we have even one by 2015.” He underestimated, he said, how long it takes to get a new product from the lab to clinical trials to low-cost manufacturing to acceptance in third-world countries. In 2007, instead of making more multimillion-dollar grants, he started making hundreds of $100,000 ones. “Now,” he said, only half-kidding, “you get a hundred grand if you even pretend you can cure AIDS.” That little won’t buy a breakthrough, but it lets scientists “moonlight” by adding new goals to their existing grants, which saves the foundation a lot of winnowing. “And,” he added, “a scientist in a developing country can do a lot with $100,000.” Over all, he said: “On drawing attention to ways that lives might be saved through scientific advances, I’d give us an A. “But I thought some would be saving lives by now, and it’ll be more like in 10 years from now.” Several scientists at the conference noted that Mr. Gates comes from the software industry, where computing power constantly doubles. Biology, by comparison, moves glacially — and microbes are less cooperative than electrons. Biology also has a greater tendency to create progress-hindering controversy. For example, doing clinical trials on illiterate subjects in poor countries, which was once cheap and fast but ethically dubious, has become time-consuming and expensive as ethical standards have improved. Also, poor countries lacking regulatory authorities and highly educated political and scientific elites may be nervous about being misused by Western scientists and careful about accepting new technologies. Despite discoveries on many fronts, up to two-thirds of the grants either did not get renewed or may not in the near future, Mr. Gates estimated. In some cases, it was because they were not succeeding, either scientifically or because of political obstacles, or someone else had found a better path. In others, the foundation changed the goal. What follows is a sample of the progress of a few grants. Dried Vaccines The hardest-hit inventors were those working on thermostable vaccines. Several techniques worked, but paying for all to go ahead made little sense. Billions of dollars — including hundreds of millions from the Gates Foundation — have been poured into improving the distribution of a dozen existing refrigerated vaccines, and having one or two heat-stable ones doesn’t help if rural clinics still need refrigerators and electricity for the rest. Abraham L. Sonenshein of Tufts University succeeded in splicing tetanus vaccine proteins into a bacterial spore that survives heat or cold and can be sprayed into the nose. But his grant ended before he could add diphtheria or whooping cough vaccines or start human trials. Dr. Sonenshein said he was grateful to the Gates Foundation for the seed money and now might switch to veterinary vaccines. “A lot of farmers would like to be able to vaccinate their own cows and pigs instead of calling the vet every time,” he said. Robert E. Sievers, a University of Colorado chemist, also reached his chief goal — attaching a measles vaccine to a sugar matrix that can be stored dry and then sprayed into a child’s lungs. His first sugar — based on the one that protects the “amazing sea monkeys” seen in comic books (actually dried brine shrimp) — did not work, so he found another. In his speech five years ago at a gathering of grant winners, he blew a goose call as an example of a device that vibrates air to send particles into the lungs. That didn’t work either, so he designed a puffer that lofts the sugar in a tiny plastic bag, creating a sweet cloud that a child inhales. While Dr. Sievers’s Gates grant is not being renewed, he is partnering with the Serum Institute of India — the world’s biggest vaccine maker — to test it there. The foundation is still supporting two thermostabilization techniques. The first attaches vaccines to nanoparticles that can be absorbed by the skin inside the nostrils. Dr. James R. Baker Jr., director of the University of Michigan’s nanotechnology institute, said it works with hepatitis B and flu vaccine. He won a new grant to test the respiratory syncytial virus, which causes pneumonia. The particles are in what Dr. Baker described as a “proprietary formulation of mayonnaise” based on soybean oil. The vaccine ends up inside the oil particles, which protect it from temperature changes and microbes. The immune system is “made to eat oil droplets,” Dr. Baker said, because it targets viruses, which are essentially time bombs of genetic instructions inside casings of fats. The “mayonnaise” is so safe, he said, that rats fed the equivalent of two quarts a day had only one side effect — weight gain. The emulsion by itself cures viral lesions like cold sores, he said; its surfactants harmlessly penetrate the skin but break up the herpes virus inside. The second thermostabilized vaccine the foundation is still backing is a complex one against malaria. It fuses the genes for parasite proteins onto a “genetic backbone” from vaccines against smallpox and a chimpanzee virus. Rather than being bottled, the vaccine can be dried onto a bit of filter paper. 1 2 3 Next Page »

Health Insurers to Be Required to Justify Rate Increases Over 10 Percent Posted: 21 Dec 2010 11:48 PM PST WASHINGTON — In a move to protect consumers, the Obama administration said Tuesday that it would require health insurance companies to disclose and justify any rate increases of 10 percent or more next year. Enlarge This Image Luke Sharrett/The New York Times Karen Ignagni, president of the trade group America’s Health Insurance Plans. Enlarge This Image Alex Wong/Getty Images Kathleen Sebelius, the health and human services secretary. State or federal officials will review such increases to determine if they are unreasonable, the administration said in proposing a regulation to enforce the requirement. The proposed rule represents a major expansion of federal authority in an area long regulated by states. Kathleen Sebelius, the secretary of health and human services, said the reviews would “help rein in the kind of excessive and unreasonable rate increases that have made insurance unaffordable for many families.” The new health care law, signed in March by President Obama, calls for the annual review of “unreasonable increases in premiums for health insurance coverage.” The law did not define unreasonable — a gap the administration is now trying to fill. Under the rule issued Tuesday, insurers seeking increases of 10 percent or more in the individual or small-group market next year must publicly disclose the planned increases and the justifications for them. In recent years, individual and small-group premiums have been rising more than 10 percent a year, on average, and many increases far exceed national measures of medical cost inflation, federal officials said. The 10 percent threshold may change in later years. Starting in 2012, the federal government will set a threshold for each state, reflecting trends in its insurance and medical costs. Consumer advocates welcomed the rules as a way to hold insurers accountable for skyrocketing premiums. In the last year, they noted, state officials in California and Connecticut, among other states, have denied big rate increases sought by some insurers. It was not immediately clear whether the rule would help insurers hold down costs. Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said that in their zeal to review premiums, “the administration and Congress have largely ignored factors driving up the cost of coverage.” These factors, Ms. Ignagni said, include the power of doctors and hospitals to negotiate higher reimbursement rates, new benefit mandates and the tendency of younger, healthier people to drop coverage, leaving sicker people in the insurance pool. Under the proposed regulation, the federal government will assess each state’s procedures for reviewing insurance rates. If it finds that a state has an “effective rate review system,” the state would conduct the annual reviews of premium increases. But, the administration said, “if a state lacks the resources or authority to do thorough actuarial reviews, the Department of Health and Human Services would do them.” Thus, it said, “all rate increases that meet or exceed the 10 percent threshold would be reviewed.” The department will post information about the results of all rate reviews on its Web site, and insurers must post the data prominently on their Web sites. States are beefing up their ability to review rates, with the help of $46 million in federal grants — the first installment of $250 million that will be distributed over five years. Under the new federal law, insurers that show “a pattern or practice of excessive or unjustified premium increases” can be excluded from the centralized insurance market, or exchange, to be set up in each state by 2014. Ms. Sebelius, a former Kansas insurance commissioner, said that shining a spotlight on rates would discourage exorbitant increases. State officials have repeatedly said that premiums must be not only affordable to consumers, but also adequate to guarantee the solvency of insurance companies. “From a consumer protection standpoint, the most important thing we do is ensure the solvency of companies,” said Sandy Praeger, the Kansas insurance commissioner and chairwoman of the health committee of the National Association of Insurance Commissioners. “Closer scrutiny can help hold down rates,” Ms. Praeger said, “but it will not control costs resulting from the overuse or inappropriate use of health care.” Jay Angoff, the director of the federal Office of Consumer Information and Insurance Oversight, said, “We are not setting an absolute numerical standard for whether a rate is unreasonable.” Instead, the proposed rule lays out factors to be considered. Under the proposal, a rate increase will be considered unreasonable if it is excessive, unjustified or “unfairly discriminatory.” A rate increase is defined as excessive if it “causes the premium charged for the health insurance coverage to be unreasonably high in relation to the benefits provided.” The rule envisions a two-step review process. An insurer must file a “preliminary justification” for an increase of 10 percent or more in the rates for any products sold to individuals or small groups. If state or federal officials find the increase unreasonable, the carrier must then file a final justification. To justify rate increases, insurers will have to submit data on claims experience, projected medical costs, executive compensation and many other factors. “The statute does not give us authority to disapprove rates,” Mr. Angoff said. “We do not have that authority. The regulation leaves state laws intact. It does not interfere with state law.” In some states, rates cannot be put into effect unless the state affirmatively approves them. In other states, insurers must file rates with a state agency before using them, but the state does not approve or disapprove them. Whether an insurer can carry out a particular rate increase “is entirely a matter of state law,” the rule says. Moreover, Ms. Sebelius said, “there may be rates well above 10 percent that are justified by underlying cost trends.”

Vatican Adds Nuance to Pope’s Condom Remarks Posted: 21 Dec 2010 11:06 PM PST ROME — The Vatican on Tuesday issued its most authoritative clarification on Pope Benedict XVI’s recent remarks that condoms could sometimes be used for disease prevention, saying that the pope in no way justified their use to prevent pregnancy. The statement appeared to be a sign of the lingering confusion — and, perhaps, Vatican infighting — over the remarks. Approved by Benedict himself, it said his words had been “repeatedly manipulated” and did not “signify a change in Catholic moral teaching.” In a book published last month, Benedict said that although condoms were not “a real or moral solution,” in some cases, they might be used as “a first step in the direction of a moralization, a first assumption of responsibility.” He cited as an example a male prostitute who might use a condom so as not to spread disease. AIDS activists, especially in Africa, where H.I.V. is rampant, welcomed the pope’s comments, as did some moral theologians. But some conservative Catholics, especially in the United States, feared that it would be misinterpreted as a move to condone condom use. Tuesday’s statement did not go beyond or contradict two previous clarifications by the Vatican spokesman, the Rev. Federico Lombardi, on the same issue. But it came directly from the Congregation for the Doctrine of the Faith, the most powerful Vatican office, in what experts said could be a sign of internal Vatican tensions — or a response to criticism. “I have never seen a communiqué from the Congregation for the Doctrine of the Faith that explains the words of the pope after the fact,” said Paolo Rodari, a Vatican expert at Il Foglio, an Italian daily newspaper. “I think it’s unique. And it demonstrates how many complaints and serious criticism the Vatican has received.” By publishing “Light of the World,” a book of interviews conducted by a German journalist, Peter Seewald, Benedict effectively did an end run around the Vatican’s communications structures — and also around the Congregation for the Doctrine of the Faith, which oversees all doctrine. The Vatican’s new statement said that Benedict’s comments had been misinterpreted and manipulated by those who effectively saw them as permission for more widespread use of condoms, which like all birth control goes against church teaching. In the book’s German and English editions, the text cites the example of a male prostitute, implying homosexual sex, in which a condom would not be a form of contraception. But the Italian edition uses the feminine form of prostitute. Last month, Father Lombardi said that the Italian translation was an error, but added that the pope had specifically told him that the issue was not procreation but rather disease prevention — regardless of gender. In Tuesday’s statement, the Vatican did not touch the gender question. But it said, “The idea that anyone could deduce from the words of Benedict XVI that it is somehow legitimate, in certain situations, to use condoms to avoid an unwanted pregnancy is completely arbitrary and is in no way justified either by his words or in his thought.” Mr. Rodari said the prefect of the congregation, Cardinal William J. Levada, the highest-ranking American at the Vatican, had most likely not been shown the book before it was published since it consisted of interviews, not official church doctrine. Father Lombardi said that he could not comment on whether Cardinal Levada had seen the book before publication, but that it “went without saying” that Benedict had approved Tuesday’s statement. Issued in six languages, Tuesday’s statement, “Note of the Congregation for the Doctrine of the Faith on the Trivialization of Sexuality Regarding Certain Interpretations of ‘Light of the World,’ ” was a masterpiece of Vatican nuance. It used technical theological language, while the pope had used a conversational tone in his book. It said that condom use by a prostitute for disease prevention could not be considered a “lesser evil” because prostitution is “gravely immoral,” and that “an action which is objectively evil, even if a lesser evil, can never be licitly willed.” Yet it added that “those involved in prostitution who are H.I.V. positive and who seek to diminish the risk of contagion by the use of a condom may be taking the first step in respecting the life of another even if the evil of prostitution remains in all its gravity.”

Abuses Cited in Enforcing China Policy of One Child Posted: 21 Dec 2010 11:30 PM PST BEIJING — Thirty years after it introduced some of the world’s most sweeping population-control measures, the Chinese government continues to use a variety of coercive family planning tactics, from financial penalties for households that violate the restrictions to the forced sterilization of women who have already had one child, according to a report issued by a human rights group. The report, published Tuesday by Chinese Human Rights Defenders, documents breadwinners who lose their jobs after the birth of a second child, campaigns that reward citizens for reporting on the reproductive secrets of their neighbors and expectant mothers dragged into operating rooms for late-term abortions. Not uncommon, according to the report, are the experiences of women like Li Hongmei, 24, a factory employee from Anhui Province who was at home recovering from the birth of her daughter when a dozen men employed by the local government carried her off to a hospital for a tubal ligation. “I promised I would have the surgery when I got better but they didn’t care,” Ms. Li said in a telephone interview. “I screamed and tried to fight them off but it was no use.” Although most of the abuses documented in the report are not new, its authors are seeking to highlight the darker side of birth-control restrictions at a time when the public debate has largely focused on whether China’s family-planning policy has been too successful for its own good. This year as the nation marked the 30th anniversary of the so-called one-child policy, officials have been praising such measures for preventing 400 million births. A smaller population, they argue, has helped fuel China’s astounding economic growth by reducing the demands on food production, education and medical care. Some demographers, however, argue that plummeting fertility rates and a rapidly aging population are reasons enough to ease the rules. Sociologists fret about the surfeit of unmarried men — the result of selective abortions that favor sons — and the demands on only children forced to care for elderly parents. On Monday, the director of the National Population Family Planning Commission sought to put to rest any speculation about a change in the status quo, saying the current policies would remain in place through 2015. Groups like Chinese Human Rights Defenders say the current family-planning policies should be abolished altogether. “The state’s role in shaping the population should be through incentives and by encouraging couples to have fewer children through education,” said Wang Songlian, a researcher who worked on the report. “They should not be using coercion and violence.” As the report makes clear, China’s family-planning policies are unevenly applied and replete with exceptions. The rich simply pay the fines levied on those who ignore the restrictions, and some middle-class women have gotten around the rules by traveling overseas to give birth to a second child. Millions of couples refuse to register their newborns with the authorities, although that approach leaves such children ineligible for an array of social benefits, including a free education. The policy is also not as all encompassing as many believe. Parents who themselves were raised in single-child families are allowed to have a second baby, as are many rural residents if their first is a girl. Ethnic minorities in some places, like Tibet and Xinjiang, can have as many as four children. The worst abuses, the report says, take place in small towns and in rural areas, where a point system rewards or punishes local officials based on their ability to meet quotas. In many places, the revenues earned through fines on scofflaws, known as “social maintenance fees,” feed an entrenched bureaucracy. In Jiangsu Province, parents who give birth to an “out of quota” child can be fined four times the average annual per capita income of the area. Other fines are imposed on women who miss regular gynecological exams or fail to undergo surgery for an intrauterine device. In one city in Hunan Province, the authorities collected $1.8 million in fines between July and September, according to government figures. He Yafu, an independent demographer who has studied family-planning regulations for two decades, said one of the biggest obstacles to changes in the policy are county and township governments. “It’s become a huge vehicle for officials to collect money,” he said. “In some localities, the budget relies almost entirely on such fines.” The report cites a number of recent cases that have wiggled through the media controls that normally filter out stories about family planning excesses. Last April, more than 1,300 people in Puning city, in Guangdong Province, were held hostage in government buildings in an effort to force women who had had a second child to undergo sterilization. The detainees, it turned out, were mostly elderly people whose daughters had left town to evade family planning restrictions. The campaign was so effective, according to a government Web site, that 3,000 sterilizations had been carried out by the fall. In a case that drew widespread media coverage, Yang Zhizhu, a law lecturer at Beijing Youth Politics College, was fired after he refused to pay the $30,000 fine imposed after his wife gave birth to their second child. Last April, Mr. Yang decided to make his displeasure public by holding aloft a tongue-in-cheek sign during protests that offered himself as a slave to anyone who would pay his fine. “Why should I pay money for having my own kid?” he told China Daily at the time. “It’s not human trafficking. It’s our right as citizens.” Zhang Jing contributed research. This posting includes an audio/video/photo media file: Download Now

The New Old Age: Elder Tech: What's Important Posted: 21 Dec 2010 12:54 PM PST

Recipes for Health: Blini With Smoked Herring Topping Posted: 24 Dec 2010 12:00 AM PST Herring is a classic accompaniment for blini. A fish high in omega-3 fats, herring is sold both pickled and smoked. I use canned smoked herring for this topping. If you’ve never tasted herring preserved this way, you’re in for a treat. 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: Blini at the Buffet (December 20, 2010) Recipes for Health: Blini With Caviar and Yogurt Topping (December 21, 2010) Recipes for Health: Blini With Mushroom Caviar (December 22, 2010) Recipes for Health: Buckwheat or Cornmeal Blini With Radish Topping (December 23, 2010) 1 6.7-ounce can smoked herring in oil, drained (4.4 oz. smoked herring) 1/4 cup finely chopped celery heart (tender inner stalks) 2 teaspoons finely chopped dill 2 teaspoons fresh lemon juice 1/4 cup drained yogurt 1 batch buckwheat or cornmeal blini Thinly sliced radishes, along with chopped fresh dill and dill sprigs for garnish 1. Crumble the smoked herring into a bowl. Add the celery, dill, lemon juice and yogurt. Stir together. The herring should be finely flaked, like canned tuna. Season with freshly ground pepper. 2. Warm the blini, and top with small spoonfuls of the herring mixture. Garnish with radish slices and dill, and serve. Yield: About 1 cup topping, serving 10 as an hors d’oeuvre, four as part of a meal. Advance preparation: The smoked herring topping will keep for three or four days in the refrigerator. Nutritional information per serving (12 servings): 164 calories; 6 grams fat; 1 gram saturated fat; 55 milligrams cholesterol; 19 grams carbohydrates; 2 grams dietary fiber; 336 milligrams sodium (does not include salt added during preparation); 9 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Personal Best: Basking in a Workout’s Long, Mysterious Afterglow Posted: 20 Dec 2010 09:20 PM PST It’s a cold day and you have just finished a grueling session at the gym, sweating away on an elliptical cross-trainer. Or you had a tough workout in the swimming pool. Or in a spin class. Or you just finished a hard run or a long, fast bicycle ride. Well Share your thoughts on this column at the Well blog. Go to Well » Related More Articles in This Series Now you’ve showered and changed your clothes. You are no longer sweating, but you still feel warm. Your cold house, your chilly office does not feel so frigid anymore. Exercise researchers used to say that this was an exercise bonus — that you burn more calories not just when you work out but for hours after you stop, even for the rest of the day. Exercise, they would tell people, has a significant effect on weight loss because of this so-called excess post-exercise oxygen consumption. But then the naysayers weighed in, reporting that such an exercise effect is just a myth. Metabolic rates plunge back down to normal as soon as exercise ends, investigators reported. Still, many who exercise insist that there must be some change in their metabolism. Why else would they feel so warm? If it is not an increased metabolic rate, then what is it? Paul Laursen, a performance physiologist at the New Zealand Academy of Sport, competes in Ironman triathlons. Regular prolonged and intense exercise is part of his life. He felt the afterburn effect, he says, after a recent tough 90-mile bicycle ride. “It was an epic training session with friends, testosterone levels were high, and we were all trying to drop one another on the climbs,” Dr. Laursen wrote in an e-mail. “It was like I had a fever the rest of the day. And even into the night as well. My wife slept with the quilt, but all I wanted was the sheet. My body resembled a furnace.” It turns out that there is no easy answer to why people like Dr. Laursen feel so warm. “One thing we know for sure: your metabolism goes sky-high when you exercise,” said Nisha Charkoudian, an associate professor of physiology at the Mayo Clinic College of Medicine in Rochester, Minn. “Then, when you stop, the interesting thing we don’t understand is that your body temperature stays up for about two hours.” The effect is very dependent on how hard you exercise. “If you go out for a walk, your temperature does not go up much,” Dr. Charkoudian said, but if you run hard for an hour or so, you can have what seems like a fever, a temperature of 100 degrees or so. It’s an effect that Glenn Kenny, a professor in the School of Human Kinetics, Faculty of Health Sciences at the University of Ottawa, spent years investigating. He built a million-dollar machine — the only one in the world, he says — that can measure minute-by-minute changes in the body’s heat loss. It looks like a giant can. The subject sits inside and, if exercise is being tested, pedals a recumbent bicycle. The device can detect the amount of heat dissipated by the subject’s body at every moment of exercise and at every moment of post-exercise rest under different conditions — warmer or cooler air temperatures, more or less humidity. From experiments with the device, Dr. Kenny learned the reason for the feverlike state that arises when the body’s core temperature is elevated: not because you keep burning calories at the rate you did during exercise, but because the body has a hard time getting rid of the extra heat it generated during the exercise session. Heat dissipation is sharply reduced after exercise: for some reason the body just can’t seem to rid itself of the extra heat that it gained. Dr. Kenny thinks that the effect is linked in some way to exercise’s effects on the cardiovascular system. But even though you may feel hot, you are not burning more calories, he says, so you are not going to lose more weight. From other studies, in which he measured metabolic rates, he discounts claims that exercise might also increase the rate at which people burn calories for hours afterward. He found that any effect on metabolism after exercise was so small as to be almost immeasurable, and so fleeting it was gone within five minutes after exercise stops. His subjects, though, were not people like Dr. Laursen. Joseph LaForgia’s subjects were. Or at least they were experienced athletes. Dr. LaForgia, an exercise physiologist at the University of South Australia, says people who exercise intensely — doing repeated sprints, for example — can experience a prolonged metabolic effect. Their metabolic rates can go up and remain elevated for seven hours after the session is finished. Even so, the extra calories burned were about 10 percent of the calories burned during the intense exercise. As for people who exercised moderately, like most people do, the small increase in metabolism lasted no more than two hours and added up to only about 5 percent of the amount they burned while exercising. And since a modest exercise bout does not burn nearly as many calories as an intense one, people who exercised modestly ended up with very few extra calories burned afterward. That still leaves a question, though. If your metabolic rate increases slightly, why would you feel warmer as much as seven hours after a long, hard workout? Dr. LaForgia says he has not studied sensations of warmth, and Dr. Kenny says that if someone feels warm that long, it is not an effect of delayed heat dissipation. Instead, it might be caused by yet another exercise effect — the body’s efforts to repair subtle tissue damage from all that exercise. The immune system can kick in, and so can enzymes that repair muscles and require heat-producing energy. Maybe the heat-generating effects of damage repair are the reason Dr. Laursen kicked off the covers that night after his 90-mile ride. If so, he probably was not burning many more calories. But then again, that tough ride over the steep hills of New Zealand burned more than enough.

A Doctor’s Mammogram Mission Turns Personal Posted: 21 Dec 2010 12:10 AM PST Dr. Marisa Weiss scheduled her mammogram this spring, just as she does every year. She had just turned 51, and after having annual scans for a decade, she knew what to expect: her dense breast tissue made reading the films difficult — “like looking for a polar bear in a blizzard” — and the technician would probably ask her to sit for a few extra views. Related Mammogram Benefit Seen for Women in Their 40s (September 30, 2010) Health Guide: Breast Cancer This year was different. After Dr. Weiss went home, she got a call from the doctor’s office. “They said, ‘Can you come back, now?’ ” she recalled. “I said I’d prefer not to, and they said, ‘Are you sure?’ And I realized at that moment that it was more serious.” Dr. Weiss, who soon learned that she had an invasive Stage 1 cancer in her left breast, is not just any physician. A radiation oncologist and a specialist in breast cancer, she founded a popular Web site, breastcancer.org, for women seeking comprehensive information about the disease, and she considers herself a woman with a mission. She sees patients three days a week, but she devotes four days a week to the site, which draws millions of visitors from 250 countries each year. She is writing her third book on breast cancer for a general audience. A year ago, when a federal task force issued new guidelines relaxing the recommendations for mammography screening, Dr. Weiss was one of their fiercest critics. Mammograms aren’t perfect, she said at the time, but they save lives. Now she says one may have saved hers. In the annals of medicine, Dr. Weiss’s story is just that: a story, an individual experience of the kind scientists dismiss as anecdotal, no reason to rethink policy. But it underscores the lingering, uncomfortable questions about when and how often to undergo breast cancer screening, and how to balance the benefits of early diagnosis with the harms of mammography — including false positive results that can lead to unnecessary biopsies and overtreatment. The new guidelines call for postponing routine screening for women at average risk to age 50, from 40, and recommend scans every other year instead of every year. If Dr. Weiss had followed them, she might have skipped this year’s scan, giving the tumor more time to grow undetected; and if she had not had a trail of scans from her 40s, doctors would not have been able to compare the images and notice the tumor’s subtle emergence. (In fact, her risk is above average, because of her dense breast tissue and a family history. But she noted, “Most women who get breast cancer don’t have a family history — that’s a huge myth.”) Yet even at the American Cancer Society, which continues to advise women to start regular mammograms at 40, experts acknowledge the limitations of screening. “Most people think mammography is much more beneficial than it actually is,” said Dr. Otis Brawley, the society’s chief medical officer. “Even if you take the most liberal, most pro-mammogram argument, we need something better.” Dr. Brawley says that on balance, mammography saves lives. But he notes that it misses some cancers, and that radiation from the scans will actually cause some cancers to develop. In addition, some women will be called back repeatedly for additional procedures, scans and biopsies that ultimately rule out cancer but can be painful and anxiety-provoking. Mammograms also find some cancers that grow very slowly but look the same as any other cancerous tumor, leading to aggressive but unnecessary treatment. The United States Preventive Services Task Force found that while mammograms saved lives over all — reducing the breast cancer death rate by 15 percent — the benefits fell off rapidly for younger women, who also bore the greatest burden of the harms. While one cancer death is prevented for every 1,339 women in their 50s and every 377 women in their 60s who undergo screening, 1,904 women in their 40s would need to be screened for 10 years to prevent a single cancer death. The panel also discouraged breast self-exams and even physicians’ breast exams. But though the recommendations received saturation coverage in the news media last year, little attention was given a month later, when the panel modified its message. Concerned that it had been misunderstood, the panel took the extraordinary step of amending the standard language of its recommendations and removed the critical word “against” as applied to routine mammography of women in their 40s. It let stand the language recommending that the decision to start screening every other year “should be an individual one” that “takes patient context into account, including the patient’s values regarding the specific benefits and harms.” “No one had read that second sentence — no one got beyond the words ‘recommend against’ routine screening in women 40 to 49,” said Dr. Bruce Ned Calonge, chairman of the task force, in a recent interview. “We didn’t say, ‘Don’t screen.’ The intent of the task force was to promote shared decision-making between physicians and women in that age interval.” There are already some indications that primary-care doctors are cutting back on mammography referrals. A recent report by the Centers for Disease Control and Prevention said a third of breast cancer cases were diagnosed at late stages, when treatment is more difficult. The trend is disturbing to Dr. Weiss, who says she fears that radical changes in the way women live — earlier puberty, rising obesity and alcohol consumption, environmental pollution, long-term use of oral contraceptives, later childbearing and less breast-feeding — could lead to more breast cancer emerging at younger ages. Her own surgery went well. She did not need radiation or chemotherapy, because the cancer had not spread. She began hormone therapy and was soon back to her crowded full-time schedule. Dr. Weiss, who lives in Wynnewood, Pa., has made some lifestyle changes since her diagnosis — filtering her tap water, no longer cooking in plastic, and buying hormone-free meat and organic fruit. She lost 15 pounds and became a Zumba dance-exercise enthusiast. She eats lots of leafy green vegetables, has cut down on wine and always tries to get a good night’s sleep. “I’m sharing my story in order to encourage women to step forward and get that mammogram,” she said. “I’m lucky to have caught this early, and I want to use my situation as an example of the value of early detection. “The thing is: every woman is at risk. And every woman needs to do everything she can to protect herself.”

How a Torn Aorta Can Do Lethal Damage Posted: 20 Dec 2010 09:30 PM PST The death of the veteran diplomat Richard C. Holbrooke last week shocked Americans and his many colleagues around the world. Mr. Holbrooke, 69, was a larger-than-life figure, a fearless and robust man who was apparently struck down without warning. Multimedia Graphic A Torn Aorta Related Richard C. Holbrooke, 1941-2010: Strong American Voice in Diplomacy and Crisis (December 14, 2010) He became ill on a Friday, and was dead by Monday. According to government officials, the cause was a tear in his aorta, the artery that carries blood from the heart to vessels that feed the rest of the body. Mr. Holbrooke underwent 21 hours of surgery from Friday to Saturday to repair the damage, and then another seven-hour operation on Sunday, all at George Washington University Medical Center in Washington. But no amount of surgery could save him. Aortic tears may be unfamiliar to most people, but they kill at least 2,000 Americans a year, and possibly more, because some of the deaths may be mistakenly attributed to heart attacks. Tears are more common in men than in women, and most likely in people from 40 to 70. Their causes include uncontrolled high blood pressure, atherosclerosis and a genetic tendency to have weak tissue or an abnormal valve in the aorta. There may be no warning signs before the tear occurs. The aorta is the biggest artery in the body, more than an inch wide in some spots. It has three layers; most tears start in the innermost one. Blood can then force its way into the tear and separate the layers, or peel them apart — a type of damage called aortic dissection. A flap and a “false channel” can form inside the aorta and impede blood flow. And the pressure from the blood can keep enlarging the tear and the flap. If the tear goes all the way through and the aorta ruptures, death can be almost immediate. That did not happen to Mr. Holbrooke, a spokeswoman said. Tears are often — but not always — associated with aneurysms, which are bulging, weakened areas in the artery wall. High blood pressure may contribute to both problems. It is not known whether Mr. Holbrooke had either of those conditions. His family has not been available for interviews, and his doctors were not given permission to speak to a reporter. Surgeons not associated with his case said Mr. Holbrooke most likely had the most common type of tear, which occurs in the ascending aorta, the beginning of the vessel where it emerges from the top of the heart. In their simplest form, such tears can be repaired “fairly easily,” said Dr. Timothy J. Gardner, a spokesman for the American Heart Association and a heart surgeon who is medical director of Christiana Care’s Center for Heart and Vascular Health in Newark, Del. Dr. Gardner did not know the details of Mr. Holbrooke’s case, but he said, “We have to infer that he had a complicated aortic dissection where one or more of the branches of his aorta were involved and/or the tissue damage and the hemorrhage were extensive and very difficult to deal with.” In that situation, he said, “it can be a really challenging surgical procedure.” Dr. Robert Michler, surgeon in chief at Montefiore Medical Center in the Bronx, said that if he is in the operating room in the middle of the night, he is very likely to be repairing a torn aorta. Patients tend to show up with symptoms at night. “Exactly why that is we don’t know,” he said. A common symptom is sudden, severe pain in the chest, back or neck. Some people even say they feel a tearing or ripping sensation. Others have no pain. Some have shortness of breath, cold legs, abnormal pulses in their limbs or stroke symptoms like weakness or paralysis. Sometimes blocked circulation causes organs to fail. The variation in symptoms can make it hard for doctors to figure out what is wrong and lead them to mistake the problem for a heart attack, collapsed lung or ulcer. Delays in diagnosis can be deadly, because tears in the ascending aorta need emergency surgery. Some people die so quickly they never even make it to the hospital. Among those who do reach the hospital, if the condition is not diagnosed and treated within 48 hours, half will die. From 80 to 90 percent survive surgery, which involves cutting out the damaged part of the aorta — several inches’ worth in most cases — and replacing it with a tube made of a synthetic material. The aortic valve may also need to be repaired or replaced, and coronary arteries may need to be bypassed. The operations are long and complicated; the heart has to be stopped and the patient must be hooked up to a heart-lung machine that takes over the jobs of pumping blood and oxygenating it. “You just operate until you’re done,” said Dr. Loren F. Hiratzka, a cardiothoracic surgeon and the medical director for cardiac surgery at Bethesda North and Good Samaritan hospitals in Cincinnati. “It’s not unusual to spend four to eight hours in there.” A 21-hour operation, like the one Mr. Holbrooke had, can only be described as “heroic,” Dr. Hiratzka said, adding: “If they were in the operating room for 21 hours, I can’t imagine what they were running into. Sometimes it’s like you’re trying to repair wet tissue paper. The layers of the aorta just get shredded. The layers themselves can become very friable and hard to put back together.” Sometimes, he and other surgeons said, the tissue is so weak that it will not hold a stitch, and they spend hours and hours sewing and trying to stop the bleeding. In some cases it may be a genetic disorder that makes the tissue fragile and the aorta prone to tearing. Certain genetic conditions, like Marfan’s syndrome, are known to predispose people to these problems, but researchers think there are other mutations, not yet identified, that may also play a part. Abnormalities in the aortic valve can also lead to tears. In most people, the valve has three leaflets that open and close to regulate blood flow, but in some it has only two — which can cause blood to squirt at the wall of the aorta in a jet spray, like water from a partly blocked hose. The spray can gouge pits in the artery wall. “I have some extraordinary pictures of an aortic wall I removed from a patient with an aneurysm that showed moonlike craters in the wall of the aorta, where the aorta had been injured and tried to heal itself,” said Dr. Michler, the surgeon in chief at Montefiore. “It had happened in half a dozen places.” CT scans and X-rays can detect aneurysms and identify people who are at risk for tears or ruptures, Dr. Michler said. If an aneurysm is developing, doctors can monitor it and operate if it gets too big. But it is not known whether Mr. Holbrooke had had X-rays or CT scans, or any reason to have had them. Some experts believe that anyone with an aortic aneurysm or tear is likely to have some underlying genetic disorder. So whenever a patient has an aortic aneurysm, Dr. Hiratzka said, it is important for the immediate family — siblings, children and parents — to be tested for similar problems.

National Briefing | Health: Teenage Birth Rate Falls 6 Percent Posted: 21 Dec 2010 10:40 PM PST The country’s teenage birth rate hit an all-time low in 2009, a decline that experts say is partly because of the economy. The rate fell to 39 births per 1,000 girls, ages 15 through 19, according to a report released Tuesday by the Centers for Disease Control and Prevention. It was a 6 percent decline from the previous year, and the lowest since officials started tracking the rate in 1940. Experts say that the recent recession drove down births over all and that there is reason to think it affected would-be teenage mothers, too.

National Briefing | Southwest: Arizona: Hospital Loses Catholic Affiliation Posted: 22 Dec 2010 12:00 AM PST Bishop Thomas J. Olmsted of Phoenix announced on Tuesday that St. Joseph’s Hospital and Medical Center could no longer identify itself as Roman Catholic because it violated church teachings by ending a woman’s pregnancy in 2009. Hospital administrators said the procedure was necessary to save her life, and stood by their decision even after Bishop Olmsted excommunicated a nun on the hospital ethics committee. The hospital, which receives no money from the Phoenix diocese, can no longer hold Masses. But Catholics can continue to work and be treated there.

In Map of Brain Junction, Avenues to Answers Posted: 20 Dec 2010 09:10 PM PST Working with human brain tissue removed in surgery, researchers have identified the components of a critical part of the brain’s architecture: the synapse, or junction where one neuron makes a connection with another. RSS Feed Get Science News From The New York Times » The work should help in understanding how the synapse works in laying down memories, as well as the basis of the many diseases that turn out to be caused by defects in the synapse’s delicate machinery. The research team, led by Seth Grant of the Sanger Institute near Cambridge, England, compiled the first exact inventory of all the protein components of the synaptic information-processing machinery. No fewer than 1,461 proteins are involved in this biological machinery, they report in the current issue of Nature Neuroscience. They have tied their catalog into the human genome sequence, connecting each protein to the gene that contains instructions for making it. This has allowed them to compare their findings in humans with other species whose genomes have been sequenced, such as the Neanderthals, who “would have suffered from the same range of psychiatric disease as humans,” Dr. Grant said. Each neuron in the human brain makes an average 1,000 or so connections with other neurons. There are 100 billion neurons, so the brain probably contains 100 trillion synapses, its most critical working part. At the side of a synapse that belongs to the transmitting neuron, an electrical signal arrives and releases packets of chemicals. The chemicals diffuse quickly across the minute gap between the neurons and dock with receptors on the surface of the receiving neuron. These receptors feed the signals they receive to a delicate complex of protein-based machines that process and store the information. The complex of proteins involved in this information processing is known to neuroanatomists as the post-synaptic density, because the proteins stick together as a visible blob, but the name does scant justice to its critical function. The 1,461 genes that specify these synaptic proteins constitute more than 7 percent of the human genome’s 20,000 protein-coding genes, an indication of the synapse’s complexity and importance. Dr. Grant believes that the proteins are probably linked together to form several biological machines that process the information and change the physical properties of the neuron as a way of laying down a memory. The tolerances of these machines seem to be very fine because almost any mutation in the underlying genes leads to a misshapen protein and, consequently, to disease. Looking through a standard list of Mendelian diseases, which are those caused by alterations in a single gene, the Sanger team found that mutations in 169 of the synaptic genes led to 269 different human diseases. The new catalog of synaptic proteins “should open a major new window in mental disease,” said Jeffrey Noebels, an expert on the genetics of epilepsy at the Baylor College of Medicine. “We can go in there and systematically look for disease pathways and therefore druggable targets.” Mendelian diseases, the ones that Dr. Grant has linked to his set of synaptic genes, are mostly rare and obscure, but they may turn out to overlap with the common mental diseases in terms of their symptoms and causative pathways, in which case some treatments might overlap too. The brain tissue analyzed by Dr. Grant’s team was extracted by a surgeon, Ian Whittle of Edinburgh University. To reach certain regions deep in the brain he had to remove a thin tube of tissue which, with the patients’ consent, he froze immediately and sent to Dr. Grant. This posting includes an audio/video/photo media file: Download Now

Global Update: London: Tuberculosis Cases Have Increased 50 Percent in Last Decade, Lancet Says Posted: 21 Dec 2010 09:17 AM PST London is the tuberculosis capital of Western Europe, according to a recent article in the medical journal Lancet, which said that cases there increased 50 percent in the last decade. Related Health Guide: Pulmonary Tuberculosis The situation is “reminiscent of the unexpected outbreaks of multidrug-resistant tuberculosis in New York and California prisons in the early 1990s,” wrote Dr. Alimuddin Zumla, an infectious-disease specialist at the University College London Medical School. In the 17th century, tuberculosis — called “the white plague” for its victims’ pallor — is thought to have killed 1 percent of London’s population each year, a far higher death rate than in Africa now, where the epidemic has soared along with AIDS. By 1980, it was considered conquered in Britain by antibiotics, the BCG vaccine and better housing, and the National Health Service cut back on surveillance. Now, most of the new cases are in immigrants. Last year, 28 percent were in people who arrived from Africa, and 27 percent in people from India. As in Victorian London, it is more common in districts with poor housing. But it is also very common among the estimated 3,600 homeless who sleep in London’s streets and parks nightly, who are also at higher risk because they more often have drug and alcohol problems, mental illness and AIDS. And it is becoming more common in prisons, where drug-resistant strains are being diagnosed among both prisoners and guards.

Cases: It Was Benign, but Almost Killed Him Posted: 21 Dec 2010 09:19 AM PST William Siewert almost died from an enlarged prostate. Related More Cases Columns Not prostate cancer, just a “benign” enlarged prostate. He is yet another example of the people who fall victim to our currently broken health care system. He agreed to share his story in the hope that someday cases like his would be rare exceptions. Mr. Siewert, a 61-year-old native of San Francisco, had been living in Idaho for the past 10 years to care for his disabled girlfriend. He had to give up his job as a truck driver — and along with it, his medical insurance — but he did so willingly so his girlfriend could remain in her home as long as possible. He had started noticing urination problems five years after he moved to Idaho. His urine stream had gotten weaker, and he had to get up frequently at night. Finally he went to see a urologist, who told him that he had benign prostatic hyperplasia and that his prostate would need to be “cut out.” Unable to come up with $10,000 for surgery, he was given a rubber tube and instructed to insert it into his penis twice a day to empty his bladder. He left the urology clinic dejected and never returned. Instead, he found a small free clinic two hours away. There he was given a drug to try to shrink his prostate. The medicine seemed to help, but because of the long drive he had trouble returning for follow-up visits. He continued to empty his bladder with the rubber tube. He was constantly nauseated, so much so that he lost 50 pounds. Finally, Mr. Siewert’s girlfriend persuaded him to return home and seek care through Healthy San Francisco, a program established in 2007 to make health services accessible to uninsured San Francisco residents. His sons helped bring him back, and he came to our county hospital’s urgent-care clinic for his first comprehensive evaluation in many years. The evening after his visit, the laboratory found that Mr. Siewert’s potassium levels were dangerously high. A series of increasingly frantic calls to his home went unanswered, and finally the police were sent over. Mr. Siewert had simply been sleeping and agreed to come in for further evaluation. His kidneys had failed. They had probably been failing over the course of months, if not years. After multiple blood tests, urine tests, imaging studies of his kidneys, and discussions with nephrologists and urologists, we concluded that the kidney failure was a direct result of the prostate enlargement. The gland had simply been too big for too long — he was unable to empty his bladder sufficiently, even with the rubber tube, and the whole system backed up until his kidneys became swollen and did not function. For those who worry about the cost of the new federal health law — an estimated $938 billion over 10 years — it may be instructive to compare the costs of Mr. Siewert’s treatment options. If the medications to shrink the prostate had been successful, they would have cost just $200 a year. If not, surgery to trim away extra prostate tissue would have cost $10,000. That sounds substantial until you contrast it with the actual cost of the medical care he received: $44,500 for his four days in the hospital, $72,000 for one year of dialysis, and $106,000 for a possible kidney transplant with lots of medicines to prevent rejection. That adds up to more than $200,000 — at least 20 times the cost of early evaluation and prevention. Furthermore, there is the cost of spending five hours in dialysis three times a week, the cost of a decreased life span with kidney failure, the cost of increased health risks with a lifetime of a suppressed immune system. The price of Mr. Siewert’s quality of life? Impossible to estimate. Dr. Jennifer S. Chang is a resident in internal medicine at the University of California, San Francisco. This essay was written as part of the university’s Partnership for Physician Advocacy Skills program. This posting includes an audio/video/photo media file: Download Now

Vital Signs: Awareness: Of Medicines and Mismeasurements Posted: 21 Dec 2010 09:21 AM PST Giving the correct dose of an over-the-counter pediatric medicine is critical, but the package labeling and dosing information can be virtually incomprehensible. And an overdose can be deadly. Related More Vital Signs Columns Over the year that ended on Nov. 1, 2009, researchers examined the directions and measuring devices in 200 nonprescription pediatric liquid medicines — drugs for allergy, cough and cold, pain or gastrointestinal problems, and medicines in combination products. Writing online on Nov. 30 in The Journal of the American Medical Association, the researchers report that 52 of the medicines had no measuring device in the package, and that 146 of the other 148 had inconsistencies between the dosing directions and the devices, including missing or superfluous markings, unfamiliar units of measurement (for example, drams or cubic centimeters), or undefined or nonstandard abbreviations. In November 2009, the Food and Drug Administration published voluntary guidelines for the labeling of dosing directions and measuring devices for over-the-counter liquid medicines. “The plan is that we can expect to see changes by next winter,” said Dr. H. Shonna Yin, the lead author. But Dr. Yin, an assistant professor of pediatrics at New York University, is not finished. “When we do the study again,” she said, “we’ll see if voluntary guidelines work, or if we need something stronger.” In the meantime, she said, parents should pay careful attention to both directions on packages and the labeling on measuring devices. “A tablespoon,” she warned, “is three times as large as a teaspoon.”

Vital Signs: Risks: Fewer Heart Problems Among Moderate Drinkers Posted: 20 Dec 2010 09:30 PM PST A new study suggests that what matters to your health is not how much alcohol you drink, but how and when you drink it. Related More Vital Signs Columns For the study, in the journal BMJ, French scientists gathered data on the drinking habits of 2,405 men in Ireland and 7,373 in France, and found that the French drank more — an average of 1.2 ounces a day, compared with about three-quarters of an ounce for the Irish. Only 12 percent of the Irish drank every day, compared with 75 percent of the French. But among the Irish the rate of binge drinking was sharply higher: 9 percent, compared with 0.5 percent in France. (A binge was defined as five drinks or more at least one day a week.) The scientists followed the men for 10 years. After controlling for smoking, cholesterol levels, blood pressure and other risks, they found that compared with regular drinkers, both binge drinkers and teetotalers were almost twice as likely to have had heart problems. There are cultural differences in drinking habits, said the study’s lead author, Dr. Jean Ferrières, a professor of medicine at Toulouse University. “In France, fruits, vegetables and wine are consumed at the same meal,” he said. “We think you can protect your heart by drinking daily with a complete meal. But we don’t know how to disentangle the effect of wine from the other things.”

Vital Signs: Childhood: A Caffeine Buzz From Soft Drinks Posted: 20 Dec 2010 09:30 PM PST A small study at an urban pediatric clinic suggests that children younger than 12 are routinely consuming so much caffeine that it could interfere with their sleep. The source, almost exclusively, is caffeinated soft drinks, like Coca-Cola. About 75 percent of 228 children in the study (published online on Thursday in The Journal of Pediatrics) consumed caffeine. Children 5 to 7 swallowed an average of 52 milligrams a day, and those 8 to 12 averaged 109 milligrams — about the same amount as a cup of drip coffee. Caffeine is a diuretic, and the study was designed to see whether the consumption was associated with bed-wetting. It was not, but sleep was another matter. Average sleep times for the caffeine drinkers were slightly less than the amount recommended for these ages by the Centers for Disease Control and Prevention. The American Beverage Association disputed the study, citing a 2002 review finding that caffeine’s effects on children “seem to be modest and typically innocuous.” “Caffeine is safe, even for children,” said Maureen Storey, the association’s senior vice president for science policy. The new study’s authors acknowledged that it did not prove a link between caffeine and sleep problems. Still, the lead author, William J. Warzak, a professor of psychology at the University of Nebraska, says that avoiding it is a good idea. “But,” he added, “you’re not a terrible parent if a kid has a Coke away from home.”

Mental Health Needs Seen Growing at Colleges Posted: 20 Dec 2010 08:29 AM PST STONY BROOK, N.Y. — Rushing a student to a psychiatric emergency room is never routine, but when Stony Brook University logged three trips in three days, it did not surprise Jenny Hwang, the director of counseling. Enlarge This Image Todd Heisler/The New York Times BALANCING ACT Demand for counseling at the Student Health Center at Stony Brook University has increased â€" 1,311 students began treatment in the past academic year, 21 percent more than a year earlier. But the budget has been cut. Related The Choice: Share Your Thoughts: The Strain on College Mental Health Centers (December 20, 2010) Enlarge This Image Todd Heisler/The New York Times CRISES AND PREVENTION Judy Esposito, a social worker with experience counseling Sept. 11 widows, started a triage unit at Stony Brook to help with mental health issues. Another program recruits students to help their peers. It was deep into the fall semester, a time of mounting stress with finals looming and the holiday break not far off, an anxiety all its own. On a Thursday afternoon, a freshman who had been scraping bottom academically posted thoughts about suicide on Facebook. If I were gone, he wrote, would anybody notice? An alarmed student told staff members in the dorm, who called Dr. Hwang after hours, who contacted the campus police. Officers escorted the student to the county psychiatric hospital. There were two more runs over that weekend, including one late Saturday night when a student grew concerned that a friend with a prescription for Xanax, the anti-anxiety drug, had swallowed a fistful. On Sunday, a supervisor of residence halls, Gina Vanacore, sent a BlackBerry update to Dr. Hwang, who has championed programs to train students and staff members to intervene to prevent suicide. “If you weren’t so good at getting this bystander stuff out there,” Ms. Vanacore wrote in mock exasperation, “we could sleep on the weekends.” Stony Brook is typical of American colleges and universities these days, where national surveys show that nearly half of the students who visit counseling centers are coping with serious mental illness, more than double the rate a decade ago. More students take psychiatric medication, and there are more emergencies requiring immediate action. “It’s so different from how people might stereotype the concept of college counseling, or back in the ’70s students coming in with existential crises: who am I?” said Dr. Hwang, whose staff of 29 includes psychiatrists, clinical psychologists and social workers. “Now they’re bringing in life stories involving extensive trauma, a history of serious mental illness, eating disorders, self-injury, alcohol and other drug use.” Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting. There is also greater awareness of traumas scarcely recognized a generation ago and a willingness to seek help for those problems, including bulimia, self-cutting and childhood sexual abuse. The need to help this troubled population has forced campus mental health centers — whose staffs, on average, have not grown in proportion to student enrollment in 15 years — to take extraordinary measures to make do. Some have hospital-style triage units to rank the acuity of students who cross their thresholds. Others have waiting lists for treatment — sometimes weeks long — and limit the number of therapy sessions. Some centers have time only to “treat students for a crisis, bandaging them up and sending them out,” said Denise Hayes, the president of the Association for University and College Counseling Center Directors and the director of counseling at the Claremont Colleges in California. “It’s very stressful for the counselors,” she said. “It doesn’t feel like why you got into college counseling.” A recent survey by the American College Counseling Association found that a majority of students seek help for normal post-adolescent trouble like romantic heartbreak and identity crises. But 44 percent in counseling have severe psychological disorders, up from 16 percent in 2000, and 24 percent are on psychiatric medication, up from 17 percent a decade ago. The most common disorders today: depression, anxiety, suicidal thoughts, alcohol abuse, attention disorders, self-injury and eating disorders. Stony Brook, an academically demanding branch of the State University of New York (its admission rate is 40 percent), faces the mental health challenges typical of a big public university. It has 9,500 resident students and 15,000 who commute from off-campus. The highly diverse student body includes many who are the first in their families to attend college and carry intense pressure to succeed, often in engineering or the sciences. A Black Women and Trauma therapy group last semester included participants from Africa, suffering post-traumatic stress disorder from violence in their youth. Stony Brook has seen a sharp increase in demand for counseling — 1,311 students began treatment during the past academic year, a rise of 21 percent from a year earlier. At the same time, budget pressures from New York State have forced a 15 percent cut in mental health services over three years. Dr. Hwang, a clinical psychologist who became director in July 2009, has dealt with the squeeze by limiting counseling sessions to 10 per student and referring some, especially those needing long-term treatment for eating disorders or schizophrenia, to off-campus providers. But she has resisted the pressure to offer only referrals. By managing counselors’ workloads, the center can accept as many as 60 new clients a week in peak demand between October and the winter break. “By this point in the semester to not lose hope or get jaded about the work, it can be a challenge,” Dr. Hwang said. “By the end of the day, I go home so adrenalized that even though I’m exhausted it will take me hours to fall asleep.” For relief, she plays with her 2-year-old daughter, and she has taken up the guitar again. Shifting to Triage Near the student union in the heart of campus, the Student Health Center building dates from the days when a serious undergraduate health problem was mononucleosis. But the hiring of Judy Esposito, a social worker with experience counseling Sept. 11 widows, to start a triage unit three years ago was a sign of the new reality in student mental health. 1 2 3 Next Page »

Doctor and Patient: How Does Your Hospital Room Make You Feel? Posted: 16 Dec 2010 11:00 PM PST During a conversation with the wife of one of my former surgery patients, I was surprised to learn that her husband had chosen to receive his postoperative chemotherapy treatments at a hospital across town from mine. His wife assured me that he had liked the highly respected colleague I had referred him to; what had troubled him was that the doctor’s office and the hospital chemotherapy infusion suites were, well, depressing. Enlarge This Image LaCoppola-Meier/Getty Images Well Share your thoughts on this column at the Well blog. Go to Well » Related More Doctor and Patient Columns I knew those rooms well; they hadn’t been painted in at least a decade. The walls were a dull white decorated only with the occasional scuff mark; the chemotherapy rooms were crowded with 1990’s-issue blue vinyl loungers and chairs; and patients connected to medication drips had to sit in straight rows. In that rigid schoolhouse configuration, they were forced either to begin awkward conversations with their neighbors or to silently contemplate their collective fates. The other hospital, my patient’s wife recounted rather breathlessly, had a brand new cancer center. Its lobby was decorated like a hotel, and the walls were painted in soothing colors. Doctors and nurses moved about noiselessly on floors covered with wall-to-wall carpeting, and the rooms used for chemotherapy were not only private but also large enough to hold family members. “I’m embarrassed to say it,” my patient’s wife said after reeling off the list of enviable amenities, “but even the art on the wall makes us feel good.” There was great clarity to her statement, the kind of personal insight that made the disingenuousness of my own professed stance on the subject of hospital “perks” all the more obvious. Like most clinicians, I had always been quick to assert that good clinical care — the right treatment, the most appropriate technology and a strong patient-doctor relationship — was all that really mattered in health care. Nonclinical amenities just added unnecessary costs and fueled profit-driven medicine. But I also knew how meaningful a pleasant lobby, private rooms and good food could be for patients and doctors. Whenever possible I had accommodated patient requests for services that made them feel comfortable, less like a sick person, and I had offered no protests when the hospitals I worked in became embroiled in costly renovation projects. I was reminded once more of that conversation and my own profession’s discomfort with the subject while reading a recent editorial in The New England Journal of Medicine that asserted that amenities are a critical part of the patient experience and possibly even a valuable component of patient-centered care. The authors, economists at the Schaeffer Center for Health Policy and Economics at the University of Southern California in Los Angeles and the Rand Corporation in Santa Monica, go on to warn that unless we finally acknowledge the importance of the patient’s nonclinical experience, we risk losing these services altogether, as well as the clinical productivity these amenities inspire. In other words, it’s time to acknowledge the writing on the (pastel) walls. “These amenities may be important drivers of clinical outcomes and, more broadly, satisfaction with care,” said John A. Romley, senior author and a research assistant professor in Policy, Planning and Development at U.S.C. While it is has long been known that certain environments and building designs can influence patient outcomes, researcher have only begun looking at the role of hospital amenities in patient decision-making. Recent studies have shown that when choosing a hospital, patients are more likely to consider nonclinical services than their doctors’ recommendations, the distance from home or hospital-specific mortality rates. Even patients who need to go to the hospital for more critical conditions, such as a heart attack, will place great importance on hospital amenities. “At some level,” Dr. Romley observed, “people are probably willing to trade off clinical quality for a very pleasant experience.” Some of this emphasis on services may arise from the fact that many patients have difficulties finding and interpreting public reports on hospital safety and quality. Without that information, they resort to evaluating what is easiest to notice — a hospital’s appearance and the array of services offered — and then use these measures to gauge a hospital’s commitment to patient-centered care. “It’s like cars,” said economist Dana P. Goldman, a professor of Medicine and Public Policy at U.S.C. and lead author of the article. “You may not know how good the engine is; but if there’s shiny paint and it looks good and smells clean, you tend to assume that the car will work for you.” While most of us, doctor and patient, would agree that having at least a few amenities would be nice, they don’t come cheap. Improving a hospital’s nonclinical services has been shown to be more costly than similar adjustments in clinical care; and it’s unclear whether the benefits are worth the cost. Third party payers like Medicare currently underwrite a large portion of these services when they pay a fixed amount for each patient discharged with a certain diagnosis. But under the Patient Protection and Affordable Care Act, these expenditures could come under more scrutiny. Hospitals will be reimbursed according to a value-based payment system; and those “values,” which have yet to be determined, may not include the nonclinical aspects of a patient’s experience. That is unless all of us, doctors and patients, can finally acknowledge that all aspects of a patient’s hospital experience count. “Whether Medicare dollars should be used for these services is an important question,” Dr. Romley said. “But the happiness and joy that these amenities provide for patients over the course of what is otherwise a difficult experience is something we should respect.” Added Dr. Goldman: “It’s not just about patient survival anymore; it’s also about the patient experience.”

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Personal Health: What We’re Not Looking After: Our Eyes Posted: 20 Dec 2010 09:10 PM PST Joe Lovett was scared, really scared. Being able to see was critical to his work as a documentary filmmaker and, he thought, to his ability to live independently. But longstanding glaucoma threatened to rob him of this most important sense — the sense that more than 80 percent of Americans worry most about losing, according to a recent survey. Enlarge This Image Yvetta Fedorova Well Share your thoughts on this column at the Well blog. Go to Well » Related More Personal Health Columns Partly to assuage his fears, partly to learn how to cope if he becomes blind, and partly to alert Americans to the importance of regular eye care, Mr. Lovett, 65, decided to do what he does best. He produced a documentary called “Going Blind,” with the telling subtitle “Coming Out of the Dark About Vision Loss.” In addition to Mr. Lovett, the film features six people whose vision was destroyed or severely impaired by disease or injury: ¶Jessica Jones, an artist who lost her sight to diabetic retinopathy at age 32, but now teaches art to blind and disabled children. ¶Emmet Teran, a schoolboy whose vision is limited by albinism, a condition he inherited from his father, and who uses comedy to help him cope with bullies. ¶Peter D’Elia, an architect in his 80s who has continued working despite vision lost to age-related macular degeneration. ¶Ray Korman, blinded at age 40 by an incurable eye disease called retinitis pigmentosa, whose life was turned around by a guide dog and who now promotes this aid to others. ¶Patricia Williams, a fiercely independent woman legally blind because of glaucoma and a traumatic injury, who continues to work as a program support assistant for the Veterans Administration. ¶Steve Baskis, a soldier blinded at age 22 by a roadside bomb in Iraq, who now lives independently and offers encouragement to others injured at war. Sadly, the nationwide survey (conducted Sept. 8 through 12 by Harris Interactive) showed that only a small minority of those most at risk get the yearly eye exams that could detect a vision problem and prevent, delay or even reverse its progression. Fully 86 percent of those who already have an eye disease do not get routine exams, the telephone survey of 1,004 adults revealed. The survey was commissioned by Lighthouse International, the world-renowned nonprofit organization in New York that seeks to prevent vision loss and treats those affected. In an interview, Lighthouse’s president, Mark G. Ackermann, emphasized that our rapidly aging population predicts a rising prevalence of sight-robbing diseases like age-related macular degeneration and diabetic retinopathy that will leave “some 61 million Americans at high risk of serious vision loss.” The Benefits of a Checkup Low vision and blindness are costly problems in more ways than you might think. In addition to the occupational and social consequences of vision loss, there are serious medical costs, not the least of them from injuries due to falls. Poor vision accounts for 18 percent of broken hips, Mr. Ackermann said. So, why, I asked, don’t more of us get regular eye exams? For one thing, they are not covered by Medicare and many health insurers. Even the new health care law has yet to include basic eye exams and rehabilitation services for vision loss, though advocates like Mr. Ackermann are pushing hard for this coverage in regulations now being prepared. Lighthouse International is one of five regional low-vision centers participating in a Medicare demonstration project in which trained therapists teach patients how to use optical devices, how to make changes in their homes to facilitate independence and how to maintain mobility outside the home. Thus far, an interim analysis showed, the costs of providing these services are well below what had been anticipated. I can think of no good reason for excluding this coverage in the nation’s health care overhaul, any more than there are good excuses for Medicare’s failure to pay for hearing aids. A lack of coverage for such services will inevitably carry its own heavy costs in the long run. But even those who have insurance or can pay out of pocket are often reluctant to go for regular eye exams. Fear and depression are common impediments for those at risk of vision loss, said Dr. Bruce Rosenthal, low-vision specialist at Lighthouse. Patients worry that they could become totally blind and unable to work, read or drive a car, he said. Yet many people fail to realize that early detection can result in vision-preserving therapy. Those at risk include people with diabetes, high blood pressure, high cholesterol or cardiovascular disease, as well as anyone who has been a smoker or has a family history of an eye disorder like macular degeneration, diabetic retinopathy or glaucoma. Smoking raises the risk of macular degeneration two to six times, Dr. Rosenthal said. Furthermore, he said, the eyes are truly a window to the body, and a proper eye exam can often alert physicians to a serious underlying disease like diabetes, multiple sclerosis or even a brain tumor. Reasons Not to Wait He recommends that all children have “a basic professional eye exam” before they start elementary school. “Being able to read the eye chart, which tests distance vision, is not enough, since most learning occurs close up,” he said. “One in three New York City schoolchildren has a vision deficit. Learning and behavior problems can result if a child does not receive adequate vision correction.” Annual checkups are best done from age 20 on, and certainly by age 40, Dr. Rosenthal said. Waiting until you have symptoms is hardly ideal. For example, glaucoma in its early stages is a silent thief of sight. It could take 10 years to cause a noticeable problem, by which time the changes are irreversible. For those who already have serious vision loss, the range of visual aids now available is extraordinary — and increasing almost daily. There are large-picture closed-circuit televisions, devices like the Kindle that can read books aloud, computers and readers that scan documents and read them out loud, Braille and large-print music, as well as the more familiar long canes and guide dogs. On Oct. 13, President Obama signed legislation requiring that every new technological advance be made accessible to people who are blind, visually impaired or deaf. Producing “Going Blind” helped to reassure Mr. Lovett that he will be able to cope, whatever the future holds. Meanwhile, the regular checkups and treatments he has received have slowed progression of his glaucoma, allowing him to continue his professional work and ride his bicycle along the many new bike paths in New York City. This is the first of two columns on vision loss.

Really?: The Claim: Humming Can Ease Sinus Problems Posted: 20 Dec 2010 09:20 PM PST THE FACTS Enlarge This Image Christoph Niemann Related More Really? Columns Dealing with a cold is bad enough, but when it leads to a sinus infection, the misery can double. Some researchers have proposed a surprising remedy: channeling your inner Sinatra. Sinus infections — which afflict more than 37 million Americans every year — generally occur when the lining of the sinuses becomes inflamed, trapping air and pus and other secretions, and leading to pain, headaches and congestion. Because the inflammation is often caused by upper-respiratory infections, people with asthma and allergies are more vulnerable than others to chronic sinusitis. Keeping the sinuses healthy and infection-free requires ventilation — keeping air flowing smoothly between the sinus and nasal cavities. And what better way to keep air moving through the sinuses and nasal cavity than by humming a tune? In a study in The American Journal of Respiratory and Critical Care Medicine, researchers examined this by comparing airflow in people when they hummed and when they quietly exhaled. Specifically, they looked to see if humming led to greater levels of exhaled nitric oxide, a gas produced in the sinuses. Ultimately, nitric oxides during humming rose 15-fold. Another study a year later in The European Respiratory Journal found a similar effect: humming resulted in a large increase in nasal nitric oxide, “caused by a rapid gas exchange in the paranasal sinuses.” Since reduced airflow plays a major role in sinus infections, the researchers suggested that daily periods of humming might help people lower their risk of chronic problems. But further study is needed, they said. THE BOTTOM LINE Studies show that humming helps increase airflow between the sinus and nasal cavities, which could potentially help protect against sinus infections. ANAHAD O’CONNOR scitimes@nytimes.com

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The New Old Age: One of Those Days Posted: 20 Dec 2010 01:45 PM PST

The New Old Age: Empathy 101 Posted: 17 Dec 2010 09:04 AM PST

Letters: Attention Must Be Paid (3 Letters) Posted: 20 Dec 2010 09:10 PM PST To the Editor: “Untangling the Myths About Attention Disorder” (18 and Under, Dec. 14) is a modern, balanced look at attention deficit hyperactivity disorder, to counter the hyperbole available to the general public. An important factor in A.D.H.D. is the number of previously undiagnosed cases in adults. In my psychiatric practice, I’ve found that close to half of my depressed female patients proved, after careful questioning, to have attention deficit disorder without hyperactivity. These women knew that something was wrong, but they did not know exactly what, nor had anyone ever told them. Most responded vigorously to stimulant medication, and then were able to reorder their lives. Edward S. Schwartzreich Waterbury, Vt. ♦ To the Editor: Dr. Perri Klass is correct: A.D.H.D. is a real disorder. But that’s hardly the end of the story. We can’t overlook the mounting evidence that a culture of electronics and multitasking creates attention deficiencies. The brain is plastic, and all too easily reshaped by a culture that values fragmented attention and an electric pace. Certainly, multitasking, surfing and tweeting are great 21st-century skills. But they should be balanced by deeper forms of attention. We should worry when our climate of distraction begins to undermine our ability to focus, stick to a task and connect in deep ways to other humans. These are, as William James put it, “habits of mind” that we cannot afford to lose. Maggie Jackson New York The writer is the author of “Distracted: The Erosion of Attention and the Coming Dark Age.” ♦ To the Editor: In “Untangling the Myths About Attention Disorder,” Dr. Klass cites actual and fictional instances of what seems to be A.D.H.D. from a time before the condition had a name. Since her examples are both boys, I would like to point to another. In Charlotte Brontë’s “Jane Eyre,” Jane’s school friend Helen Burns is constantly in trouble, regarded by many of the teachers as a slattern and a “dirty, disagreeable girl.” In the classroom, when the subject they have been reading about interests her, she pays close attention and understands better than anyone else; but at other times her thoughts “continually rove away.” She starts daydreaming, and when called on can’t answer because she has heard nothing. “I seldom put, and never keep, things in order,” she tells Jane. “I am careless; I forget rules; I read when I should learn my lessons; I have no method.” Helen (said to be modeled on Charlotte’s sister Maria) seems to be a classic example of the predominantly inattentive type of the disorder more often found in girls. Deborah Roberts Haverford, Pa. Science Times welcomes letters from readers. Those submitted for publication must include the writer’s name, address and telephone number. E-mail should be sent to scitimes@nytimes.com. Send letters to Science Editor, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018.

Letters: Just Imagine (1 Letter) Posted: 20 Dec 2010 09:10 PM PST RSS Feed Get Science News From The New York Times » To the Editor: John Tierney’s column “Real Evidence for Diets That Are Just Imaginary” (Findings, Dec. 14) suggests that people will eat less of something if they first imagine themselves eating it. Thirty years ago I “smoked” imaginary cigarettes. It helped me stop smoking. Shirley Dunn Perry Tucson Science Times welcomes letters from readers. Those submitted for publication must include the writer’s name, address and telephone number. E-mail should be sent to scitimes@nytimes.com. Send letters to Science Editor, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018. This posting includes an audio/video/photo media file: Download Now

Urban Athlete: Colleagues More Than Happy to Go Running After the Boss Posted: 23 Dec 2010 10:10 PM PST GETTING into shape is a popular New Year’s resolution, but for many people the motivation to keep up with a fitness routine wanes within weeks or months. One strategy for sticking with it is to follow the example set by active friends or co-workers. Enlarge This Image Jermaine Miles Mr. Bastianich, second from left, at the restaurant after the 2010 New York City marathon, with some of the employees and friends who joined him in the race. For guidance consider the exercise collective on the staff of Becco, a popular restaurant run by Joseph Bastianich in the Manhattan theater district, where the Italian food is a constant source of temptation. A few years ago nary an exerciser was working at the restaurant. But six employees ran the ING New York City Marathon in November, and several others have also taken up running. The effort began with Mr. Bastianich, who also owns several other food outposts in the city, including the Italian megastore Eataly. About three years ago he was overweight and had received a diagnosis of sleep apnea. “I got scared by the fact that if I didn’t lose weight, I would have to sleep with a machine to help me breathe,” he said recently. “My doctor told me to start running a mile a day, so that’s what I did.” One mile turned into five, which led to longer runs. And as he starting shedding pounds, he signed up and completed the New York City marathon in 2008. Becco already had a relationship with the New York Road Runners club, which organizes the marathon. Club officials bring in runners for prerace carbohydrate fueling on the restaurant’s unlimited tasting of three daily pastas and for postrace celebrations. Yet it wasn’t until Mr. Bastianich started dropping weight — around 50 pounds in all — that staff members considered taking up the sport themselves. “After that first marathon, running spread virally among the Becco family,” he recalled. The employees who ran the marathon in November included the executive chef, the maître d’hôtel and a bartender. The staff members interviewed for this article said they were inspired by the others to set healthy lifestyle goals and work toward them even when their motivation lagged, or they were surrounded by rich food. Dani Zylberberg, 26, recently left Becco to help open a wine shop for Mr. Bastianich. He started running in 2008 when he heard his boss was putting in some serious weekly mileage in training for the marathon. “It put the idea in my head as something I wanted to do,” he said. At a party at the restaurant after the race, more employees vowed to join them the following year. William Gallagher, 47, the executive chef for the past 12 years, first ran the marathon in 2009. He said that cooking for the Road Runners events made him consider the sport as a way to trim his 6-foot-1, 290-pound frame. He looked to Mr. Bastianich and Mr. Zylberberg for motivation. “They were so excited about running and encouraged all of us to join them that it was hard to not do it,” Mr. Gallagher said. He set a goal to participate in the race the following year and came up with a training schedule with Mr. Zylberberg’s help. Carolina Erazo, 27, Becco’s wine director, said she wanted more balance in her work-heavy life. “I was inspired by them and by the idea that I can work in a restaurant and still be good to myself,” she said. Though most of the group members ran at different paces and primarily trained separately, they sometimes met before work or on their days off to run in Central Park. They also enjoyed simply being on the same journey together. “We were accountable, so there was no way we were going to skip our workouts,” Ms. Erazo said. Given the food-and-wine environment at Becco, diet also played a role in the training. Becco is known for Mr. Gallagher’s pastas — linguine with clams, pumpkin ravioli and fettuccini Bolognese, to name a few — but the menu also has lighter choices like fish and vegetables. Mr. Gallagher said he cooked those for himself and for his new running friends. Becco’s runners have lost more than 130 pounds combined, in recent years, and they aren’t stopping there. They’re gearing up for other races and setting new goals. Mr. Gallagher wants to lose 20 more pounds, while Mr. Zylberberg and Mr. Bastianich want to reduce their finishing times. Ms. Erazo said that she hadn’t decided whether to participate in another race, but that running and being more aware of her diet would stay with her. “I know I have other people to answer to who will always ask me if I ran and how much,” she said. “Having them will make it pretty hard to slack off and help me keep at it during these cold and dark winter months.”

Recipes for Health: Buckwheat or Cornmeal Blini With Radish Topping Posted: 23 Dec 2010 12:30 AM PST In Russia, this topping traditionally is made with cream cheese and served on black bread canapés. I use labne — drained yogurt — in this version and love the results. This topping also makes a nice snack by itself. 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: Blini at the Buffet (December 20, 2010) Recipes for Health: Blini With Caviar and Yogurt Topping (December 21, 2010) Recipes for Health: Blini With Mushroom Caviar (December 22, 2010) Recipes for Health: Blini With Smoked Herring Topping (December 24, 2010) 1 batch buckwheat or cornmeal blini 1 bunch radishes, cleaned, trimmed and finely chopped 3/4 cup drained yogurt, or 1/2 cup low-fat cottage cheese blended with 1/4 cup drained yogurt or Greek-style yogurt until smooth Salt and freshly ground pepper 1 teaspoon fresh lemon juice 1 teaspoon minced dill Very thinly sliced radishes for garnish 1. In a medium bowl, mix together the finely chopped radishes, drained yogurt or blended cottage cheese and yogurt, salt, pepper, lemon juice and dill. 2. Warm the blini. Top with a spoonful of the radish mixture, garnish with a radish slice and serve. Yield: Makes 1 cup topping, serving 12 to 15 as an appetizer, four to six as a side dish. Advance preparation: The radish mixture will keep for a day in the refrigerator. Nutritional information per serving (12 servings): 121 calories; 4 grams fat; 1 gram saturated fat; 37 milligrams cholesterol; 17 grams carbohydrates; 1 gram dietary fiber; 192 milligrams sodium (does not include salt added during preparation); 5 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Blini With Mushroom Caviar Posted: 22 Dec 2010 12:30 AM PST In Russian kitchens, mushroom caviar is made with cooked mushrooms and lots of sour cream. I use canned tomatoes in this version, and the result makes a savory topping for blini (and for latke, I found, as I tested the recipe during Chanukah). Make sure to finely chop the mushrooms. 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: Blini at the Buffet (December 20, 2010) Recipes for Health: Blini With Caviar and Yogurt Topping (December 21, 2010) Recipes for Health: Buckwheat or Cornmeal Blini With Radish Topping (December 23, 2010) Recipes for Health: Blini With Smoked Herring Topping (December 24, 2010) 2 tablespoons extra virgin olive oil 2 shallots, minced 1 pound mushrooms, trimmed and finely chopped 2 garlic cloves, minced Salt and freshly ground pepper 1 14-ounce can chopped tomatoes, with juice 2 tablespoons fresh lemon juice 1 tablespoon chopped fresh dill 1 batch buckwheat or cornmeal blini 1. Heat the olive oil in a large, heavy nonstick skillet over medium heat. Add the shallot. Cook, stirring, until tender, three to five minutes. Add the mushrooms. Cook, stirring, until they begin to sweat, and add the garlic, salt and pepper. Cook, stirring often over medium heat, for five minutes until the mushrooms are tender and fragrant. Add the tomatoes, and bring to a simmer. Cover, reduce the heat and simmer for 30 minutes. Stir in the lemon juice, and taste and adjust the seasonings. There should be very little liquid in the pan. If there is, continue to simmer uncovered until most of the liquid has evaporated. Stir in the dill, and serve. Yield: Enough to serve 12 as a topping for blini, four to six as a side dish. Advance preparation: The mushroom caviar keeps for about four days in the refrigerator, and it’s even better the day after you make it. Nutritional information per serving (12 servings): 148 calories; 6 grams fat; 1 gram saturated fat; 37 milligrams cholesterol; 19 grams carbohydrates; 2 grams dietary fiber; 234 milligrams sodium (does not include salt added during preparation); 6 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Blini With Caviar and Yogurt Topping Posted: 21 Dec 2010 09:24 AM PST After making these blini, I always have a little of the topping left over; I use it for sandwiches. Don’t use expensive caviar here -- lumpfish is 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: Blini at the Buffet (December 20, 2010) Recipes for Health: Blini With Mushroom Caviar (December 22, 2010) Recipes for Health: Buckwheat or Cornmeal Blini With Radish Topping (December 23, 2010) Recipes for Health: Blini With Smoked Herring Topping (December 24, 2010) 1/4 cup finely chopped red onion 1 1/4 cups drained yogurt 2 hard-boiled eggs, finely chopped 1 tablespoon minced chives 3 tablespoons black or red lumpfish caviar Salt and freshly ground pepper 1 batch buckwheat blini 1. Place the onion in a bowl and cover with cold water. Let sit for five minutes, then drain and rinse with cold water. Drain on paper towels. 2. Place the yogurt in a bowl, and stir in the onion, chopped eggs, chives and caviar. Season with salt and pepper. Refrigerate until ready to use. 3. Warm the blini in a low oven or in a microwave. Top each with a spoonful of the yogurt mixture and serve. Yield: Enough to top one batch of blini. Advance preparation: You can make this topping a day ahead and keep it in the refrigerator. Nutritional information per serving (12 servings): 151 calories; 5 grams fat; 1 gram saturated fat; 96 milligrams cholesterol; 18 grams carbohydrates; 1 gram dietary fiber; 269 milligrams sodium (does not include salt added during preparation); 8 grams protein Nutritional information per serving (15 servings): 121 calories; 4 grams fat; 1 gram saturated fat; 77 milligrams cholesterol; 14 grams carbohydrates; 1 gram dietary fiber; 215 milligrams sodium (does not include salt added during preparation); 7 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

National Briefing | West: California: Setback for Marijuana Farms Posted: 22 Dec 2010 10:57 PM PST The city of Oakland’s plan to license large medical marijuana growing operations was put on hold after a warning from the district attorney that city officials could face prosecution. The City Council voted 7 to 1 in a closed session on Tuesday night to suspend the application process for permits that would have let recipients set up four industrial-scale indoor marijuana farms. Applications were to have been due Wednesday. The decision came after the Alameda County district attorney, Nancy O’Malley, warned that the growing operations could be illegal, and that people associated with such operations, including city officials who approved them, could face prosecution.

Antitrust Suit in Michigan Tests Health Law Posted: 22 Dec 2010 12:58 PM PST DETROIT — When the Justice Department filed an antitrust lawsuit against Blue Cross Blue Shield of Michigan in October, the unusual action was widely seen as a warning shot to dominant health insurance carriers in many other states. Enlarge This Image Fabrizio Costantini for The New York Times Daniel Loepp, chief executive of Blue Cross Blue Shield of Michigan, with Sue Barkell, another senior executive. Enlarge This Image Fabrizio Costantini for The New York Times “I’m trying to figure out what is wrong with what we’re doing,” said Mr. Loepp, chief of Blue Cross Blue Shield of Michigan. The case is viewed as a test for the Obama administration’s introduction of the federal health care law, which is aimed at spurring competition and driving down costs. About half the states in the country, including Alabama, Rhode Island and Iowa, share circumstances similar to Michigan’s, in their relationships with a big single insurance carrier. Proponents of the new legislation have long argued that these dominant companies could subvert the competitive goals of the exchanges planned for 2014, which are intended to foster new business and cheaper coverage. Officials “have been struggling for a while with the fact that in health insurance markets, small players are not able to enter and expand in a way to make them significant competitors,” said Jonathan M. Grossman, an antitrust lawyer at Cozen O’Connor. “Nobody can look at the suit against Michigan and say they didn’t put everybody on notice.” Regulators worry that this prevailing dominance in markets across the country is a formidable obstacle. “Once you have a health plan that is that large, it’s really hard to change the dynamics of the market,” said Robert W. McCann, a health care lawyer in Washington at Drinker Biddle & Reath. Blue Cross and others paint a far more complex picture, involving intertwined economic and demographic layers. Michigan might also become a proving ground for whether a federal overhaul of the markets would attract any new insurer, especially in tough economic times and with unabated health care costs. It may become increasingly apparent, some argue, that the battle to change the health care system will play out state by state, especially with the separate constitutional challenges mounted by nearly a dozen states against the law itself. In Michigan, economic conditions alone pose steep challenges for Blue Cross, which still employs 7,100 people in the state. The recession further crippled an already deteriorating manufacturing base. Unemployment is well above the nation’s average, at 12.4 percent to the country’s 9.8 percent. Its population is declining, growing older and getting sicker. While it remained profitable through investment and other income last year, with $22 billion in revenue, Blue Cross lost money from operations, including nearly a hundred million dollars because of its status in the state as the insurer of last resort. Federal prosecutors contend that Blue Cross in Michigan thwarts competitors by pressuring hospitals to charge rival insurers more to provide care, a practice prosecutors say has made health care extremely expensive in a state that can’t afford it. “It is deeply disturbing that Blue Cross, a nonprofit created to help Michigan citizens, would strong-arm hospitals at the expense of hard-working families,” said Mike Cox, the state’s attorney general. This past Friday in its court response, Blue Cross fired back at the antitrust charges, relying mainly on states’ rights arguments to contend that the federal government was usurping the state’s ability to provide affordable health care coverage to its residents. The Justice Department says it continues to believe the insurer is stifling competition. In a recent interview, Daniel J. Loepp, the insurer’s chief executive, said Blue Cross, which provides coverage for 4.3 million people, had done nothing wrong. “Our size is a benefit to the hospitals, and it is a benefit to our customers,” he said. Many Blue Cross plans, which are frequently run as not-for-profits and operate in highly regulated states like New York and Michigan, argue that they are exactly the kind of insurer envisioned under the new law. Blue Cross Blue Shield of Michigan says it is required to offer a policy for the same price to anyone who asks, regardless of whether that person has an expensive pre-existing condition. “It’s as close as you can come to a privately run public plan,” said Mr. Loepp. The federal lawsuit is not the first attempt to curtail Blue Cross’s position in Michigan. Last year, state regulators blocked the insurer’s request for a 56 percent increase on some individual policies, and the Justice Department recently prevented Blue Cross from swallowing one of its rivals. Its main competitors are large hospital systems like Henry Ford and Spectrum Health, which largely offer H.M.O. plans. A few national carriers like Aetna and Humana also offer coverage. Some state officials argue that the market is healthy enough. “Consumers have a variety of choices,” said Ken Ross, the state insurance commissioner. “They can buy high-quality affordable products other than Blue Cross.” 1 2 Next Page » This posting includes an audio/video/photo media file: Download Now

Fixing Error, Senate Passes Food Bill Again Posted: 19 Dec 2010 11:20 PM PST WASHINGTON (AP) — The Senate on Sunday passed a sweeping bill to make food safer, sending it to the House in the waning days of the Congressional session. Blogs The Caucus The latest on President Obama, the new Congress and other news from Washington and around the nation. Join the discussion. FiveThirtyEight: Nate Silver's Political Calculus More Politics News It was the second time the Senate passed the bill, which would give the government broad new powers to increase inspections of food-processing plants and force companies to recall tainted food. The first time, three weeks ago, it was caught in a snag when senators mistakenly included tax provisions that by law must originate in the House. The version passed Sunday was amended to avoid another such problem. The bill would place stricter standards on imported foods and require larger producers to follow tougher rules for keeping food safe. The legislation has bipartisan support, and supporters say passage is crucial in the wake of E. coli and salmonella outbreaks in peanuts, eggs and produce. Recent domestic outbreaks have exposed a lack of resources and authority at the Food and Drug Administration as it struggled to contain and trace the contaminated products. The agency rarely inspects many processors or farms, visiting some every decade or so and others not at all. The bill emphasizes prevention so the agency could try to stop outbreaks before they begin. Farmers and food processors would have to tell the agency how they are working to keep their food safe at different stages of production. Congress is rushing to wrap up for the year, and many people thought the bill was dead until it was resurrected by majority leader, Senator Harry Reid of Nevada. who said it was necessary because the food safety system had not been updated in almost a century. Caroline Smith DeWaal, director of food safety at the Center for Science in the Public Interest, called it “a huge victory for consumers following a weekend cliffhanger as both consumer and industry supporters prepared for bad news.”

The Supreme Court and Obama’s Health Care Law Posted: 23 Dec 2010 06:34 AM PST When it comes to the future of the Obama administration’s health care plan, the judicial math can seem simple. Enlarge This Image MPI/Getty Images TRY AGAIN Chief Justice Charles Hughes, center, and his fellow justices rejected many of the early New Deal laws. Related Judge Hints He May Rule Against Health Law (December 17, 2010) Times Topic: Health Care Reform Enlarge This Image Daniel Acker/Bloomberg The new health care law isn’t necessarily doomed. So far in three lawsuits against the plan, two federal judges appointed by Democrats have upheld the law; one Republican-appointed judge has declared an important part of it unconstitutional. Use party as your measure, send the cases up the appeals ladder, and you quickly get to a 5-4 decision at the Supreme Court: the justices appointed by Republican presidents will vote to strike down the law. Game over, thanks for playing. But the votes of the Supreme Court are not that easy to divine, and while political considerations can creep into any judge’s views, deeper factors are at play, said Mark Tushnet, a professor at Harvard Law School. Supreme Court justices, for the most part, “are attuned to their reputations as individuals in history, and their overall place in the government as a whole,” he said. Supreme Court justices work differently from judges at the District Court level, noted Jack Balkin, a constitutional scholar at Yale. “Federal District Court judges do not have to deliberate with anyone else,” he said. “Multimember courts are affected by who sits with them,” and “this is especially true of a nine-person Supreme Court.” Predicting how justices will vote, and especially the reasoning they will use to get there, becomes especially dicey when questions concerning the extent of government power come up. Take this year’s decision in United States v. Comstock. A Supreme Court majority supported the power of Congress to order the confinement of “sexually dangerous” prisoners — to many observers, an enormous extension of state power. Justice Stephen Breyer, of the court’s liberal wing, was joined by Chief Justice John Roberts and Justice Samuel Alito, who are among the most conservative of the nine. In the history of Congressional power and the court, one struggle stands out: the New Deal. President Franklin Roosevelt and Congress took on a Supreme Court that was overturning their reform initiatives. Eventually, they prevailed and the fight left justices reluctant to overturn Congressional action, especially if the legislators could themselves repeal the measure, said Eric M. Freedman, a Constitutional scholar at Hofstra University Law School. Randy Barnett, a law professor at Georgetown University who opposes the health care bill, agreed that the fight over the law was best understood in the context of the Roosevelt administration. While the court retreated from its efforts to overturn New Deal legislation, Professor Barnett said, those later opinions should not be interpreted as having fully abdicated power to Congress. The power of the courts to restrict Congress never ended, he said. “The New Deal cases have been misread by wishful thinking.“ Professor Barnett acknowledges that his overall view is in the minority of legal scholars. But, he said, “we’re not refighting the New Deal here.” The Obama administration, he said, is “trying to go beyond the line drawn by the New Deal.” Opponents of the law insist that Congress has never ordered people to buy something — that is, to regulate inactivity as opposed to activity. But Congress has successfully regulated inactivity, said Professor Tushnet of Harvard. In a famous 1942 case, Wickard v. Filburn, the Supreme Court ruled in favor of federal quotas, meant to support wheat prices, that restricted how much farmers could grow. In the case, Roscoe Filburn grew more wheat than permitted; he argued that the wheat was for his own use. Professor Tushnet noted that Mr. Filburn’s actions could be described as a failure to purchase wheat in the general market — a situation similar to that of people who do not buy health insurance. “If the constitutional challenge has any legs, it is on the ground that it is unprecedented — Congress has never done it before,” he said. “Well, it turns out that Congress has done it before.” Michael McConnell, a senior fellow of the Hoover Institution and director of the Constitutional Law Center at Stanford, said the health care bill “is the first time that regulation of commerce has been taken this far.” Even so, he said, “that doesn’t make it automatically unconstitutional.” Professor McConnell said the New Deal had been misunderstood — but not necessarily in the ways that Professor Barnett argues it has. In his view, Professor McConnell said, the Supreme Court’s initial resistance to the New Deal legislation sent Congress back to the drawing board to fashion better legal approaches. 1 2 Next Page »

New Estimates of Food Poisoning Cases Posted: 17 Dec 2010 11:20 AM PST The federal government on Wednesday significantly cut its estimate of how many Americans get sick every year from tainted food. Enlarge This Image Cody Duty/Associated Press An outbreak of salmonella sickened thousands this summer and led to a recall of eggs. Multimedia Graphic A New Estimate of Foodborne Estimate But that does not mean that food poisoning is declining or that farms and factories are producing safer food. Instead, officials said, the government’s researchers are just getting better at calculating how much foodborne illness is out there. In a pair of research reports made public on Wednesday, the Centers for Disease Control and Prevention said that about 48 million people a year get sick from tainted food, down from the previous, often-cited estimate of 76 million. The number of deaths estimated to come from food poisoning also went down, to about 3,000 a year from 5,000. The revision means that one in six Americans gets sick each year from tainted food, not one in four, as the old study, conducted in 1999, projected. The estimates were part scientific detective work and part guesswork. For both studies, government statisticians extrapolated the number of nationwide illnesses from data on tens of thousands of lab-confirmed illnesses in 10 states. They also used information from telephone surveys. Some scientists said the new estimates on their own offered little new guidance on how to prevent major outbreaks, such as the outbreak of salmonella in eggs that sickened thousands of people this summer. “Knowing the number of cases of salmonella is not that valuable unless you know what food that disease is linked with,” said Dr. J. Glenn Morris, director of the Emerging Pathogens Institute of the University of Florida in Gainesville. “The real question is how much of that salmonella is coming from chickens vs. eggs vs. beef vs. pork.” The C.D.C. said it was working on a follow-up study with a range of pathogens, showing how often each is linked with a particular food. That will allow regulators to focus on the areas of greatest risk in the food system. But Dr. Morris also said that the study signals the need for better data collection in general. Today, the C.D.C., the Food and Drug Administration and the Agriculture Department all gather data on food safety in separate databases, making it hard to share data. “We are not where we need to be in terms of national data collection systems,” he said. The new estimates of foodborne illness arrived as regulators and food-safety advocates were hoping for the Senate to take a new vote on stalled food safety legislation. The Senate approved the legislation last month and the House essentially agreed to the Senate’s version, but the bill was sidetracked by a procedural snafu that imperiled its final passage. C.D.C. officials took pains to say that while their projections of the amount of foodborne illness were now lower, the problem was no less urgent. “It would be really unfortunate if there were conclusions, looking at 76 million and 48 million, that foodborne disease is no longer a problem,” said Dr. Christopher R. Braden, director of foodborne, waterborne and environmental diseases at the C.D.C. “The fact is that tens of millions of illnesses and hospitalizations and deaths of this extent tells us we need to do more.” The difference between the two estimates rests heavily on a reduced calculation of the national numbers of what researchers call acute gastroenteritis, or stomach illness. It also reflects a revised understanding, also lower, of how many of those cases are caused by foodborne pathogens, as opposed to other sources, like the flu or other viruses passed through person-to-person contact, or contaminated drinking water. But the numbers also highlight how little is known about foodborne illnesses. The new estimate, published in the journal Emerging Infectious Diseases, says that only about a fifth of all foodborne illness is the result of pathogens that scientists have been able to identify. Researchers estimated that four-fifths of the foodborne illnesses each year, or about 38 million, are caused by what they called “unspecified agents.” That includes pathogens for which there is little data and those that have not yet been discovered. It also may include chemicals in foods that scientists have not yet identified as the cause of illness. Of the remainder, a bug called norovirus is believed to cause 5.5 million cases of foodborne illness each year, making it the single most common known source of foodborne disease. Norovirus, whose symptoms include vomiting and diarrhea, is most often transferred from person to person but it can also be spread through foods. The smallest category of illnesses is made up mainly of cases caused by bacteria, including salmonella and E. coli, which were behind many prominent outbreaks in recent years. This group, which also includes parasites like toxoplasma, accounts for 3.9 million cases of illness a year. Dr. Richard Raymond, who was formerly the head of food safety at the Agriculture Department, said this group was the one where regulators could have the greatest impact. “We’ve got to keep this in perspective when we decide how much money to spend to get that number down,” said Dr. Raymond, who had criticized the earlier estimate of 76 million illnesses as being too high. The new study sheds light on the prevalence and virulence of the headline-grabbing bacteria involved in numerous outbreaks. Salmonella, the bacteria behind this summer’s extensive egg recall, is now estimated to be responsible for more than a million illnesses and 378 deaths a year. Listeria, which is less common but far more likely to be fatal, was estimated to cause 1,591 illnesses, with 255 deaths. A group of toxic forms of E. coli bacteria that have been found in hamburger meat and leafy greens were estimated to cause more than 175,000 illnesses and 20 deaths a year. Researchers said that there was a great deal of guesswork in the new estimates. The 48 million figure is near the midpoint of the range of projections in the survey, which said the number of illnesses could be as few as 29 million or as many as 71 million.

With Alzheimer’s Patients Growing in Number, Congress Endorses a National Plan Posted: 15 Dec 2010 11:48 PM PST Congress has voted unanimously to create, for the first time, a national plan to combat Alzheimer’s disease with the same intensity as the attacks on AIDS and cancer. Related Health Guide: Alzheimer's Disease Blogs The Caucus The latest on President Obama, the new Congress and other news from Washington and around the nation. Join the discussion. FiveThirtyEight: Nate Silver's Political Calculus More Politics News The bill, expected to be signed by President Obama, would establish a National Alzheimer’s Project within the Department of Health and Human Services, to coordinate the country’s approach to research, treatment and caregiving. Its goal, the legislation says, is to “accelerate the development of treatments that would prevent, halt or reverse the course of Alzheimer’s” and “improve the early diagnosis of Alzheimer’s disease and coordination of the care and treatment of citizens with Alzheimer’s.” The project would include an advisory council of representatives from agencies like the Centers for Disease Control and Prevention, the National Institutes of Health, the Department of Veterans Affairs, the Food and Drug Administration, the Indian Health Service and the Centers for Medicare and Medicaid Services. Scientific experts, health care providers and people caring for relatives with Alzheimer’s would also be included. “If you go to war, you have planning, planning, planning,” said Representative Christopher H. Smith, Republican of New Jersey, who co-sponsored the bill. “Well, this is a war on a dreaded disease. We need to bring all the disparate elements together for the greatest possible result.” While the act itself does not authorize more money, one of the recommendations of the national plan “is likely to be for an increase in research money for Alzheimer’s,” said another co-sponsor of the bill, Senator Susan Collins, Republican of Maine. “We spend one penny on research for every dollar the federal government spends on care for patients with Alzheimer’s,” she said. “That just doesn’t make sense. We really need to step up the investment.” The legislation was driven by the rapidly rising number of people with Alzheimer’s — about 5.3 million now, and expected to triple by 2050. The cost of their care to Medicare and Medicaid was about $170 billion last year. By 2050, Ms. Collins said, it will grow to $800 billion a year, more than the military budget. The House passed the bill on Wednesday, and the Senate last Thursday. The advisory council would draft an annual report on federally financed programs involving research, treatment, nursing homes and home care, recommending which to expand or eliminate. It would also ensure that members of ethnic and racial groups at higher risk for Alzheimer’s be included in research and treatment. Alzheimer’s experts said the effort could make a significant difference. “What really makes this so powerful is that it takes us from a lot of small efforts going on locally to doing something in a coordinated way,” said Dr. Kenneth Kosik, a neuroscientist at the University of California, Santa Barbara. “If there’s one thing we know in science it is that to draw conclusions we need numbers, large-size populations to study.” The national plan will reinforce efforts to detect brain changes that occur years before people develop symptoms of dementia, and to develop drugs to prevent or substantially delay symptoms. “Dealing with symptoms only after the fact is not going to solve the problem,” said Dr. Zaven Khachaturian, a former director of Alzheimer’s research for the National Institutes of Health. Delaying symptoms for just five years, he said, “we will cut down tremendously” on the number of people who live long enough to develop Alzheimer’s. Representative Edward J. Markey, a Massachusetts Democrat who co-sponsored the bill, said his mother had had Alzheimer’s. “We’re trying to create a sense of urgency so that we’re developing multiple pathways that ultimately might be successful,” he said. “We’ve done it with polio, we’ve done it with AIDS. “It’s a unique disease to the extent that patients can’t lobby for themselves, and the person close to them cannot lobby because they’re home taking care of that person. There are no Alzheimer’s survivors.”

Vital Signs: Hazards: Mercury Prompts a New Call to Limit Tuna Posted: 14 Dec 2010 11:31 AM PST Consumers Union is urging pregnant women to avoid eating tuna altogether and advising small children to limit consumption after tests on dozens of cans and pouches of tuna found mercury in every sample. The tuna was bought in the New York metropolitan area and online. Related More Vital Signs Columns “White” tuna generally contained more mercury than “light” tuna, but some light tuna contained enough that a woman of childbearing age eating less than a can a week would exceed federal recommendations for mercury consumption, the new Consumer Reports study says. The metal can affect fetal development. The average amount of mercury found by Consumer Reports in white tuna samples was 0.427 parts per million, compared with the average 0.353 p.p.m. found in F.D.A. tests in 2002-04. The average in light tuna was 0.071 p.p.m., lower than the 0.118 p.p.m. found by the F.D.A. Consumers Union urges women of childbearing age to be more careful about their tuna consumption than current F.D.A. guidelines advise, because mercury accumulates in the body over time. Children who weigh less than 45 pounds should limit intake to 4 ounces of light or 1.5 ounces of white tuna a week, and heavier children no more than 12.5 ounces of light or 4 ounces of white tuna a week, Consumers Union says. The National Fisheries Institute took issue with the report, saying the Consumer Reports recommendations were “reckless” and had “the potential to harm public health,” because fish contains omega-3 fatty acids, which may be beneficial during pregnancy.

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