Health - Down the Hatch and Straight Into Medical History

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• Down the Hatch and Straight Into Medical History
• 18 and Under: Lifting a Veil of Fear to See a Few Benefits of Fever
• Cancer Can Develop in Catastrophic Burst
• Q & A: Chilling Out
• Treating an Injured Brain Is a Long, Uncertain Process
• U.S. Backs Drug Firms in Lawsuit Over Prices
• Recipes for Health: Soups With Grains
• The Bay Citizen: Marijuana Dispensaries Are Facing New Scrutiny
• Patient Money: A Talk With the Doctor May Help Patients Afford Care
• In Battle Over Health Law, Math Cuts Both Ways
• In Wider War in Afghanistan, Survival Rate of Wounded Rises
• In Women’s Tears, a Chemical That Says, ‘Not Tonight, Dear’
• Vital Signs: Diet: Childless Couples Eat Healthier, Study Finds
• Vital Signs: Childhood: A Breast-Feeding Benefit, This One for Boys
• Vital Signs: Smoking for Two, and Lying About It
• The Mirror: Taking a Leap of Faith Onto the Scale
• Doctor and Patient: When Insurers Put Profits Between Doctor and Patient
• Several Warnings, Then a Soldier’s Lonely Death
• Well: The Benefits of Fever
• Well: Drinking Fluids to Conquer a Cold
• Well: Nutrition Advice From the China Study
• Well: Pasta and Seafood, Inspired by Italy
• Well: How to Haggle With Your Doctor
• Personal Health: Have a Food Allergy? It’s Time to Recheck
• Really?: The Claim: Drink Plenty of Fluids to Beat a Cold
• The New Old Age: The Tales They Tell
• The New Old Age: In Sickness and in Health
• The New Old Age: Dependent on Home Aides
• Prescriptions: This Week's Health Industry News
• Prescriptions: California Insurer's Rate Increase Draws Fire
• Prescriptions: Medicare Contractor Will Pay for Avastin During Appeal
• Recipes for Health: Wild Rice and Mushroom Soup
• Recipes for Health: Spaghetti With Mussels and Peas
• Recipes for Health: Linguine With Red Clam Sauce
• Recipes for Health: Fusilli With Swordfish or Tuna and Tomato Sauce
• The Texas Tribune: Shortfall Gives Hope to Disability Rights Advocates
• Republicans Are Given a Price Tag for Health Law Repeal, but Reject It
• Health Spending Rose in ’09, but at Low Rate
• U.S. Alters Rule on Paying for End-of-Life Planning
• Vital Signs: Patterns: When a Bumper Crop Led to a Baby Bulge
• Vital Signs: Diet: Fried Fish Is Seen as a ‘Stroke Belt’ Culprit
• Vital Signs: Behavior: Distracted Eating Adds More to Waistlines
• Studied: As for Empathy, the Haves Have Not

Down the Hatch and Straight Into Medical History Posted: 10 Jan 2011 11:38 AM PST From brain tissue to gallstones, doctors have long preserved specimens from their patients — sometimes as trophies, sometimes as teaching tools, sometimes as curiosities or even art. But Dr. Chevalier Jackson went much further than most. Enlarge This Image UNCOMPROMISING Dr. Chevalier Jackson was so intent on building his collection that he once refused to return a swallowed quarter. Enlarge This Image PIONEERING Dr. Jackson was an early and outspoken safety advocate, particularly when it came to children. He helped many children eat and drink again normally. A laryngologist who worked in the late 19th and early 20th centuries, he preserved more than 2,000 objects that people had swallowed or inhaled: nails and bolts, miniature binoculars, a radiator key, a child’s perfect-attendance pin, a medallion that says “Carry me for good luck.” Jackson retrieved these objects from people’s upper torsos, generally with little or no anesthesia. He was so intent on assembling his collection that he once refused to return a swallowed quarter, even when its owner threatened his life. “He was a fetishist, no question,” said Mary Cappello, the author of “Swallow” (New Press), a new book about Jackson and his bizarre collection. “But his obsession had the effect of saving lives. That’s kind of amazing, and lucky for us that his madness made possible forms of rescue.” Jackson was an artisan and a mechanical prodigy, a humanist and an ascetic whom colleagues sometimes described as aloof or cold. He spent hundreds of hours crushing peanuts with forceps to learn exactly how much pressure to exert. He experimented extensively on mannequins and dogs. In those days surgery was associated with high mortality, and few physicians were willing or able to peer into the air and food passages, let alone remove objects like open safety pins. Yet Ms. Cappello writes that the survival rate among patients from whom he removed objects was better than 95 percent. “If Jackson could tell us how he wished to be remembered, I’m certain he would do so by assemblage, or meaningful collage,” said Ms. Cappello, an English professor at the University of Rhode Island. For him, collecting was a form of self-portraiture as well as a clinical and scientific pursuit. Jackson viewed the world as a precarious place. Small and bookish as a child, he endured intense torment and bullying; at one point other children blindfolded him and threw him into a coal pit, and he was rescued only after a dog happened to find him unconscious. So in a sense, Ms. Cappello said, when Jackson became a physician — first in Pittsburgh, then Philadelphia — he “was saving lives, yes, but he was also saving himself.” He grew to be a pioneer of the upper body, developing new endoscopic techniques for peering into dark recesses. He attached a tiny light called a mignon lamp to the end of a rod that he inserted into his scopes. (Previously, physicians who used endoscopes had worked mainly with light held outside the body.) And he was an early and outspoken safety advocate, particularly when it came to children. As one of his assistants put it, his quest was to make the public and the medical profession “foreign-body-conscious” about swallowing. If it had been up to him, Ms. Cappello said, “parents who fed peanuts to children without molars would be drawn and quartered.” Chew everything thoroughly, he exhorted the public: “Chew your milk!” And he lobbied for passage of the Federal Caustic Poison Act of 1927, which required manufacturers to place warning labels on poisonous substances like lye, which burns the esophagus and causes severe scarring that can make it impossible to swallow. Children often ingested lye because it was present in many households (where it was used to make soap) and because it looked like sugar. A 7-year-old girl who could not swallow even a drop of water was taken to Dr. Jackson, who fed an endoscope into her esophagus and removed a grayish mass — perhaps food, perhaps dead tissue — with a forceps. Afterward, one of his assistants gave the child a glass of water. “She took a small sip expecting it to choke her and come back up,” Jackson recalled in his 1938 autobiography. “It went slowly down; she took another sip, and it went down. Then she gently moved aside the glass of water in the nurse’s hand, took hold of my hand and kissed it.” Jackson also developed a technique for dilating the esophagus in children with scarring. He taught them to swallow a long tube and to do so regularly for an extended period. He suggested they might think of themselves as sword swallowers and imagine that the feat “inspires awe in other children.” This eventually helped many of them to eat and drink again normally. To remove objects like keys and coins and pins, Jackson would insert a long, rigid tube into his patients — usually children, and usually awake, though his assistants did help to hold them still. “He must have had an exquisite gentleness and ability to calm people,” Ms. Cappello said. He also treated many poor children without pay. Still, his eccentricities marked him. “Some people might have painted him as a socially phobic, friendless loner,” she added. “He was not a warm and fuzzy doctor.” Nor would he compromise when it came to his collection. In the case of that swallowed quarter, he told the patient’s infuriated father that “all foreign bodies removed from the air and food passages were put into a scientific collection where they would be available to physicians working on the problems of relieving little children.” The father had beaten the boy as punishment, and when he didn’t get the coin back he apparently beat him again, so viciously he broke his son’s arm. At that point Jackson gave the family a half dollar. But he did not return the swallowed coin. The Jackson collection is now owned by the Mütter Museum of the College of Physicians of Philadelphia, which is refurbishing it for an exhibition that is to open Feb. 18. Ms. Cappello will help curate the exhibition; Anna Dhody, the museum’s curator, called her work a substantial contribution that “we’re very lucky to have.” Dr. V. Alin Botoman, a gastroenterologist at the University of Miami who has also done scholarly work on Jackson, called him “truly a renaissance man who made so many contributions to medicine and has been all but forgotten.” Until now. In October, Ms. Cappello gave a lecture on Jackson at the Observatory, an art and events space in Brooklyn. She also presented black-and-white films from Jackson’s family that had never been seen in public. In a series of clips, Jackson is shown on a small boat, looking out at the sky. He is riding in the back of a pickup truck, writing intently. His granddaughter, then a toddler, wobbles across a lawn holding a stuffed animal and a flower. She looks at the camera, shakes the flower and puts it in her mouth.

18 and Under: Lifting a Veil of Fear to See a Few Benefits of Fever Posted: 10 Jan 2011 12:05 PM PST Fever is common, but fever is complicated. It brings up science and emotion, comfort and calculation. Enlarge This Image Katherine Streeter Well Share your thoughts on this column at the Well blog. Go to Well » As a pediatrician, I know fever is a signal that the immune system is working well. And as a parent, I know there is something primal and frightening about a feverish child in the night. So those middle-of-the-night calls from worried parents, so frequent in every pediatric practice, can be less than straightforward. A recent paper in The Journal of the American Medical Association pointed out one reason, and a longstanding discussion about parental perceptions reminds us of the emotional context. The JAMA study looked at over-the-counter medications for children, including those marketed for treating pain and fever: how they are labeled, and whether the droppers and cups and marked spoons in the packages properly reflect the doses recommended on the labels. The article concluded that many medications are not labeled clearly, that some provide no dosing instrument, and that the instruments, if included, are not marked consistently. (A dosing chart might recommend 1.5 milliliters, but the dropper has no “1.5 ml” mark.) “Basically, the main message of the paper is that the instructions on the boxes and bottles of over-the-counter medications are really confusing,” said the lead author, Dr. H. Shonna Yin of New York University Medical Center, who is a colleague of mine and an assistant professor of pediatrics. Too small a dose of an antipyretic (fever medicine) may be ineffective; too much can be toxic. But the dose depends on the child’s weight, which of course changes over time, and on the concentration of the medicine, which depends on whether it is acetaminophen or ibuprofen, children’s liquid or infant drops. “We always make them get the bottle,” said Kathleen Martinez, a pediatric nurse practitioner who is clinical coordinator of the After Hours Telephone Care Program at the Children’s Hospital in Aurora, Colo. “What do you have at home? Is it the ibuprofen infant drops or the children’s? Have the bottle in hand and verify the concentration. “And then we have to verify the instrument, and then we give the right dose based on weight. It’s time-consuming, and then of course it changes with the weight, so the poor parents have to call back.” Concerns about fever — how worried should I be, and how much medicine should I give? — account for many of the calls that parents make at night to their children’s doctors. For me, these tricky measurement questions evoke memories of many conversations, often from a crowded, noisy place (my own child’s Little League game, the supermarket), trying to answer a question about a small child with fever. One recent night, I talked to the mother of a toddler with fever and abdominal pain. I was more worried about the pain, and about whether he was drinking enough to stay hydrated; she was more worried about the fever, and no matter what I asked she kept coming back to that number on the thermometer. Finally, I got so worried the child was dehydrated that I told her to go to the emergency room. And when she got there, she told them she was scared because the child had a high fever. Fever can indeed be scary, and any fever in an infant younger than 3 months is cause for major concern because of the risk of serious bacterial infections. But in general, in older children who do not look very distressed, fever is positive evidence of an active immune system, revved up and helping an array of immunological processes work more effectively. Of course, that may not be reassuring to a parent whose child’s temperature is spiking at midnight. (Fevers tend to go up in the late afternoon and evening, as do normal body temperatures.) In 1980, Dr. Barton D. Schmitt, a professor of pediatrics at the University of Colorado School of Medicine, published a now classic article about what he termed “fever phobia.” Many parents, he wrote, believed that untreated fevers might rise to critical levels and that even moderate and low-grade fevers could have serious neurological effects (that is, as parents we tend to suspect that our children’s brains may melt). A group at Johns Hopkins revisited Dr. Schmitt’s work in 2001, publishing a paper in the journal Pediatrics, “Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20 Years?” Their conclusion was that the fears and misconceptions persisted. In fact, fever does not harm the brain or the body, though it does increase the need for fluids. And even untreated, fevers rarely rise higher than 104 or 105 degrees. As many as 5 percent of children are at risk for seizures with fever. These seizures can be terrifying to watch but are not harmful and do not cause epilepsy. Still, a child who has a first febrile seizure should be checked by a physician. (These seizures tend to run in families, and children who have had one may well have another.) “Parents are telling us that they’re worried that fever can cause brain damage or even death in their children,” said Dr. Michael Crocetti, an assistant professor of pediatrics at Johns Hopkins and lead author of the 2001 study. “I’ve been doing this for a long time, and it seems to me that even though I do a tremendous amount of education about fever, its role in illness, its benefit in illness, it doesn’t seem to be something they keep hold of from visit to visit.” Dr. Janet Serwint, another author of the study and a professor of pediatrics at Johns Hopkins, agreed. “I personally think there should be much more education about this at well visits,” she told me, adding that parents need to understand “the helpfulness of fever — how fever actually is a well-orchestrated healthy response of our body.” Other studies have looked at attitudes among medical personnel, who can be just as worried about fever as parents. “Doctors are part of the problem,” Dr. Schmitt said. Some of the phobia “comes from doctors and nurses,” he added — “doctors and nurses who weren’t taught about fever and all the wondrous things fever does in the animal kingdom.”

Cancer Can Develop in Catastrophic Burst Posted: 10 Jan 2011 12:20 PM PST New rapid methods of decoding DNA have brought to light a catastrophe that can strike human cells: a whole chromosome may suddenly shatter into pieces. Related Health Guide: Cancer If the cell survives this disaster, something worse may ensue: the cell becomes cancerous. The finding marks a striking exception to the current theory of how cancer develops. Cells are thought to become cancerous over many years as they collect, one by one, the mutations required to override the many genetic restraints on a cell’s growth. It now seems that a cell can gain all or most of these cancerous mutations in a single event. The discovery is reported in the current issue of Cell by a team led by Peter J. Campbell of the Sanger Institute near Cambridge, England. The institute is part of a consortium with the National Institutes of Health in the United States to study the genomes of different types of cancer cells, a task now brought within reach because of fast and cheap methods for decoding DNA. The hope is to identify the causative mutations that drive each type of cancer. As part of this project Dr. Campbell, a hematologist, was scanning the genome of 10 patients with a certain kind of leukemia. Cancer cells lose control of their chromosomes, and their genomes are often a chaotic hodgepodge in which the chromosomes are rearranged, with some segments duplicated and others lost. In one of his patients, Dr. Campbell noticed an unusual feature: almost all of the damage was confined to a single chromosome. By reconstructing the exact pattern of chromosomal rearrangements, he and colleagues found it could not be explained by the standard process in which one mutation is acquired after another in a protracted series. Rather, the chromosome must have shattered into pieces in a single event; the cell then knitted them together as best it could, but in the wrong order. Usually a cell that suffers this much damage will destroy itself, either immediately or after it has tried unsuccessfully to repair its chromosomes. But in certain cases, the self-destruct mechanism evidently fails, leaving a cell like Frankenstein’s monster, with badly patched-up chromosomes but a survival advantage that leads to unrestrained growth. Dr. Campbell’s group reports that about 2 percent to 3 percent of all cancers, and 25 percent of bone cancers, originate in this kind of chromosome-shattering crisis. “It’s very hard to explain why the damage is so catastrophic but so localized,” Dr. Campbell said, referring to the fact that almost all the damage occurs in a single chromosome or chromosome region. His best guess is that the damage is caused by a pulse of radiation. Bone cancer is sometimes treated with radioactive isotopes that home in on the bone, which might explain why so many cases of bone cancer arise this way. But Matthew Meyerson and David Pellman, two cancer biologists at the Harvard Medical School, say in a commentary that the chromosomes could shatter accidentally when they condense, a process that happens before the cell divides. Whatever the cause of the shattering, the finding “reveals a new way that cancer genomes can evolve,” they write. The discovery has no immediate implications for therapy. But it could explain why a few cancers, contrary to the usual rule, appear very suddenly. “There are clearly examples where someone has had a normal mammogram, then presents shortly after with an aggressive tumor,” Dr. Campbell said.

Q & A: Chilling Out Posted: 10 Jan 2011 12:13 PM PST Q. Will you burn more calories sitting at your desk if the thermostat is turned down? Enlarge This Image Victoria Roberts Related More Q & A Columns RSS Feed Get Science News From The New York Times » A. Yes, caloric expenditure will increase if one stays lightly dressed, but not much, said Wayne Askew, director of the division of nutrition at the University of Utah. A more effective way would be to walk up and down a few flights of stairs, he said. The basal metabolic rate increases slightly in colder climates, and Dr. Askew said there might be a very small increase in calories burned from the warming of cold air by the lungs and from the rewarming of skin that has been exposed to the cold. A more significant increase can be expected if it is cold enough to cause shivering, which warms the body through quick involuntary contractions and relaxations of muscles. This is not an ideal weight-loss technique, as a person insulated with plenty of body fat is usually less likely to shiver. “And it is very difficult to perform work requiring fine motor coordination, such as writing or using a computer, when shivering,” Dr. Askew said. When the core body temperature gets dangerously low and the shivering response is maximally stimulated, Dr. Askew said, energy expenditure can be as high as that from work requiring 40 percent to 50 percent of the person’s maximum aerobic capacity. But if the core temperature drops low enough, the shivering response ceases and hypothermia rapidly sets in. C. CLAIBORNE RAY Readers are invited to submit questions by mail to Question, Science Times, The New York Times, 620 8th Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com. This posting includes an audio/video/photo media file: Download Now

Treating an Injured Brain Is a Long, Uncertain Process Posted: 10 Jan 2011 11:39 AM PST WASHINGTON — The bullet that a gunman fired into Representative Gabrielle Giffords’s head on Saturday morning in Arizona went straight through the left side of her brain, entering the back of her skull and exiting the front. Enlarge This Image Samantha Sais for The New York Times Dr. G. Michael Lemole, left, and Dr. Peter Rhee were hopeful about Gabrielle Giffords's recovery. Related At Giffords’s Synagogue, Prayers for Recovery (January 10, 2011) Evidence Points to Methodical Planning (January 10, 2011) Times Topic: Gabrielle Giffords Trauma surgeons spent two hours on Saturday following an often-performed drill developed from extensive experience treating gunshot wounds in foreign wars and violence in American homes and streets. On Saturday, that drill really began outside a supermarket, with paramedics performing triage to determine the seriousness of the wounds in each of the 20 gunshot victims. Ms. Giffords, 40, was taken to the University Medical Center in Tucson, where, 38 minutes after arrival, she was whisked to an operating room. She did not speak at the hospital. As part of the two-hour operation, her surgeons said on Sunday, they removed debris from the gunshot, a small amount of dead brain tissue and nearly half of Ms. Giffords’s skull to prevent swelling that could transmit increased pressure to cause more extensive and permanent brain damage. The doctors preserved the skull bone for later replanting. Since surgery, they have used short-acting drugs to put Ms. Giffords in a medical coma that they lift periodically to check on her neurological responses. They said early signs made them cautiously optimistic that Ms. Giffords would survive the devastating wound. “Things are going very well, and we are all very happy at this stage,” Dr. Peter Rhee, the director of medical trauma at the hospital, said at a news conference. Dr. G. Michael Lemole Jr., the hospital’s chief of neurosurgery, was more cautious. “Brain swelling is the biggest threat now,” Dr. Lemole said, “because it can take a turn for the worse at any time.” Such swelling often peaks in about four or five days, then begins to disappear. The doctors said that it was far too early to know how much long-term functional brain damage, if any, Ms. Giffords would suffer. They also say they will carefully monitor her over the next few days as she faces a number of potential complications, like infections, that can hamper her recovery. Full rehabilitation could take months to years. Long-term complications could include seizures. The optimism expressed Sunday was based on Ms. Giffords’s ability to communicate by responding nonverbally to the doctors’ simple commands, like squeezing a hand, wiggling toes and holding up two fingers. The tests are part of a standard neurological examination after head injuries. In Ms. Giffords’s case, the doctors were encouraged because the simple tests showed that she could hear and respond appropriately, indicating that key brain circuits were working. “If she’s following commands, that’s great and a very big step toward recovery,” Dr. Eugene S. Flamm, chairman of neurosurgery at Montefiore Medical Center in the Bronx, said in an interview. Dr. Flamm is not involved in Ms. Giffords’s treatment. Functional neurological recovery from a gunshot wound depends on a number of factors, including the specific area of the brain that is injured, the number of bullets, their trajectory and velocity, and luck. Ms. Giffords was shot once in the head, according to Sheriff Clarence W. Dupnik of Pima County, Ariz., and the doctors who treated her said that tests showed the bullet did not cross the geometric center line dividing the brain’s left and right hemispheres. “That’s very good because bullets that affect both hemispheres have a much higher mortality because the swelling affects both sides,” said Dr. Flamm, who has treated many gunshot wounds in his career, including 25 years at Bellevue Hospital Center in Manhattan, 11 years as chief of neurosurgery at the University of Pennsylvania in Philadelphia and 11 years at Montefiore. In traversing the left side of Ms. Giffords’s brain, the bullet went through what is the dominant side in about 85 percent of people, whether they are right- or left-handed, Dr. Flamm explained. “It sounds simple to raise fingers and squeeze hands,” he said, “but the ability to do it is a very good sign in a brain-injured patient because it shows that the dominant hemisphere was not knocked out.” The doctors in Tucson did not cite the bullet’s trajectory — that is, whether it entered at the top of the back of the skull and exited at a lower point or whether it went straight through. If the bullet went through the visual area in the occipital part of the back of the brain, it could affect the right side of Ms. Giffords’s peripheral vision, Dr. Flamm said, adding, “It is hard to piece that together without more information.” Ms. Giffords is unable to speak because she is connected to a ventilator and unable to open her eyes, which doctors have covered with patches. It is usually several weeks before doctors can fully evaluate cognitive function in a patient who has suffered a gunshot wound to the brain, and the body has a significant capacity to compensate for serious injuries. Although Ms. Giffords’s ability to follow commands is encouraging, her doctors said that it would take several weeks to know what her recovery would be. That is a caveat that Dr. Flamm well understands. “I can understand the impatience of wanting to know it now,” he said. “But even if I wanted to know and examined her myself, I wouldn’t be able to answer that question at this stage.”

U.S. Backs Drug Firms in Lawsuit Over Prices Posted: 09 Jan 2011 10:53 PM PST WASHINGTON — The Obama administration, following a lengthy internal debate, has unexpectedly come down on the side of pharmaceutical companies that are accused of overcharging public hospitals and clinics that care for large numbers of poor people. 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 administration has told the Supreme Court that the hospitals and clinics cannot sue drug companies to enforce their right to deep discounts on drugs or to obtain reimbursement from companies that overcharge. It is a classic conflict: a political imperative for the administration — to ensure that inexpensive drugs are available to the poor people who need them — rubbing up against the Justice Department’s fear of an onslaught of lawsuits by clinics and hospitals if the Supreme Court allows them to sue. Sara Rosenbaum, a professor of health law and policy at George Washington University, said the case raises the question of whether the intended beneficiaries of a government program can enforce their right to assistance that is made available by Congress. “You can parse the legal issues, as the Justice Department has done,” Ms. Rosenbaum said. “But the bottom line is that a lot of poor people and a lot of safety-net providers are not getting the discounts they are supposed to receive.” The court is being asked to rule in a lawsuit brought by Santa Clara and Santa Cruz Counties in California against AstraZeneca and a number of other drug makers. The counties contend that the companies overcharged for drugs supplied to their hospitals and clinics. An AstraZeneca spokesman, Tony Jewell, said the company “believes that there is no evidence” that the overcharges occurred. Nationwide, more than 15,000 clinics and hospitals participate in the discount program, which cuts prices of prescription drugs by 30 to 50 percent. The providers spend more than $6 billion a year on drugs. Santa Clara County, which includes the city of San Jose and is home to 1.8 million people, operates a public hospital and 12 clinics. Juniper L. Downs, a lawyer for the county, said: “The intent of this program is to provide discounted drugs to eligible clinics and hospitals so we can deliver affordable medical services to individuals most in need. That would seem to be aligned with the broader health care goals of the Obama administration.” But in a friend-of-the-court brief, the Justice Department said that only the federal government has the authority to enforce the drug-discount law, and that private lawsuits would interfere with that authority. Oral arguments in the case, Astra USA v. Santa Clara County, Calif., are scheduled for Jan. 19. Asked to explain the administration’s stance, a White House spokesman said, “We will let the brief speak for itself.” Several Democratic lawmakers expressed surprise at the Justice Department’s position. “The administration had a chance to put health care reform into action by defending the discounted drug program,” said Representative Sam Farr of California. “Instead, it chose to side with the pharmaceutical companies to preserve a loophole that overcharges providers and undermines the president’s efforts to expand access to affordable health care.” A federal health official, who spoke on the condition of anonymity because he was recounting lawyer-client discussions inside the government, said: “We really wanted to stand on the sidelines of this case. The Justice Department took the lead in solidifying the government’s position because of a broader concern about the possible impact of the case beyond this one little program.” The drug-discount program was created in 1992 under the Public Health Service Act. The law directed the secretary of health and human services to sign agreements with the companies that set maximum prices for drugs sold to certain health care providers. They included community health centers; AIDS, tuberculosis and family-planning clinics; hospitals that serve large numbers of poor people; and children’s hospitals. Federal officials calculate the maximum price for each drug based on data that the manufacturers submit to the government. The Department of Health and Human Services’ inspector general found that drug manufacturers often overcharged clinics and hospitals over the last eight years but were rarely penalized by the government. “In actual practice, manufacturers have been able to overcharge covered entities with impunity,” said Ted Slafsky, executive director of Safety Net Hospitals for Pharmaceutical Access, which represents 600 hospitals in the drug-discount program. For their part, the companies said the rules for calculating prices and discounts were “exceedingly complex and technical.” They rejected the idea that there was “a single correct way” to calculate prices. The companies have signed agreements with the Department of Health and Human Services promising to provide discounts to clinics and hospitals that serve large numbers of poor and uninsured patients. In their lawsuit, the counties contend that these agreements are contracts, and that as “intended beneficiaries” the counties can sue to enforce them based on “a bedrock principle” of contract law. Such lawsuits “complement federal enforcement efforts,” the counties said. The Justice Department argues that the counties and clinics cannot sue because Congress has never given them that right. The United States Court of Appeals for the Ninth Circuit in San Francisco ruled in favor of the clinics and hospitals in December 2009. The drug companies appealed, with support from the Justice Department, which is urging the Supreme Court to reverse that decision. The administration’s position is similar to that taken by the drug manufacturers. Allowing lawsuits is “a recipe for rampant confusion and inconsistency,” the Pharmaceutical Research and Manufacturers of America said in its own friend-of-the-court brief. The U.S. Chamber of Commerce said such lawsuits could “wreak havoc” and would have “dire and sweeping consequences” for other companies that do business with the government. “The scope of federal contracting is enormous,” the chamber said.

Recipes for Health: Soups With Grains Posted: 10 Jan 2011 08:31 AM PST When I make a hearty soup, like a minestrone, I follow tradition and add pasta or rice to it — or at least I did, until it occurred to me that I could just as easily bulk up a soup with whole grains like quinoa, barley or wheat berries. 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. Whole grains have higher fiber content than pasta and white rice, and because they’re slowly digested, they have less impact on blood levels of insulin than refined grains. They also bring more nutritional value. So if you’re mulling over ways to get more grains into your diet, think soups. Even light soups can be transformed into more of a main dish with the addition of whole grains. Add quinoa to your garlic soup or bulgur to chicken broth. You can cook the grains separately and add them to the soup, or cook them right in the broth with the other ingredients. The grains will be particularly tasty, as they’ll absorb the flavors in the broth. I’ve suggested before that you cook more grains than you need for a meal, bag what you don’t use and store it in the freezer. Then, if you’re wondering what to have for dinner one night, just heat some broth or make a quick garlic soup, and thaw some quinoa or wheat berries from the freezer. After simmering a vegetable in the broth, add the grains — and voila, a meal in a bowl. Garlic Soup With Quinoa and Snap Peas Traditional garlic soup might include pasta, potatoes or toasted bread. I decided I wanted more protein and less refined grain for this last-minute dinner, so I used some leftover quinoa that I had in the refrigerator. 1 1/2 quarts chicken stock, vegetable stock or water 6 garlic cloves, minced or sliced 4 small or 2 large sage leaves Salt to taste 1 tablespoon extra virgin olive oil (optional) 2 eggs 6 ounces sugar snap peas, trimmed 1 1/3 cups cooked quinoa, warmed 1. Combine the stock or water, garlic, sage leaves and salt in a heavy saucepan or soup pot, and bring to a simmer. Cover and simmer 15 to 20 minutes until the flavor of the garlic is no longer sharp. Taste and adjust seasoning. 2. Add the snap peas to the simmering soup, and simmer two to three minutes until crisp but tender. 3. Beat the eggs in a bowl with the olive oil. Whisk in about 1/2 cup of hot soup. Take the soup off the heat, then whisk the tempered eggs into the soup. Taste and adjust seasoning. 4. Place 1/3 cup of quinoa in each soup bowl. Ladle in the soup and serve. Yield: Serves four. Advance preparation: Cooked quinoa will keep for three or four days in the refrigerator. Nutritional information per serving (does not include optional olive oil): 151 calories; 4 grams fat; 1 grams saturated fat; 106 milligrams cholesterol; 19 grams carbohydrates; 3 grams dietary fiber; 78 milligrams sodium (does not include salt added during preparation); 10 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

The Bay Citizen: Marijuana Dispensaries Are Facing New Scrutiny Posted: 08 Jan 2011 08:50 PM PST Medical marijuana dispensaries try hard to maintain the appearance that they are nonprofit health centers. Customers are referred to as “patients,” and merchandise as “medicine.” Yoga classes are often available, along with health-related literature. Enlarge This Image Adithya Sambamurthy/The Bay Citizen Harborside Health Center, which runs a marijuana dispensary in Oakland, is being audited by the I.R.S., the chief executive said. A nonprofit, nonpartisan news organization providing local coverage of the San Francisco Bay Area for The New York Times. To join the conversation about this article, go to baycitizen.org. Related Times Topic: San Francisco Bay Area Enlarge This Image Adithya Sambamurthy/The Bay Citizen Harborside Health Center is one of the largest dispensaries on the West Coast and a model for the industry. But the rivers of cash flowing in and out of these businesses are attracting scrutiny from local and federal authorities who say they are trying to distinguish between legitimate health practitioners and sellers of illegal drugs. “We’re trying to get to a point where we get we can weed out — for lack of a better word — to filter out the people that are really perverting this law just to sell drugs,” said Frank Carrubba, deputy district attorney in Santa Clara County. Last month, the four operators of New Age Healing Collective in San Jose were charged with illegal marijuana sales and money laundering after the police said they turned up two sets of books. The raid was part of a series of recent investigations into San Jose dispensaries by the Santa Clara Special Enforcement Team. One ledger, kept at the tiny dispensary, showed New Age Healing losing $123,128 since May, according to the police. Another, which the police said had been discovered inside a cash-filled shoe box in the home of the couple that operated the center, told a different story: $222,238 in profits. The couple said it was operating a legitimate marijuana dispensary and had done nothing wrong, according to one of their lawyers. In Oakland, Harborside Health Center, one of the largest dispensaries on the West Coast and a model for the medical marijuana industry, is being audited by the Internal Revenue Service, said Harborside’s chief executive, Stephen DeAngelo. An I.R.S. spokesman said the agency neither confirmed nor denied audits. Last month, officials in Oakland postponed plans to license large-scale marijuana farms in the city after the Justice Department and the city attorney warned separately that the businesses could violate state and federal marijuana laws. The medical marijuana industry has continued to flourish since a state proposition to legalize cannabis was defeated in November. Oakland finance officials estimate that the city’s three dispensaries generated $35 million to $38 million in revenue last year, up from $28 million in 2009. San Jose now boasts 98 dispensaries — four times the number of 7-Eleven convenience stories in the city. State law allows collectives to cultivate medical marijuana, but the law is less clear when it comes to selling the product, said William Panzer, a lawyer who helped write California’s seminal medical marijuana law, Proposition 215. Under guidelines issued by the state attorney general, dispensaries are advised not to profit from their activities. But the guidelines are fuzzy, Mr. Panzer said, and there is virtually no case law on the issue. “Let’s come out from under the shadows and say, ‘Here are the rules,’ ” Mr. Panzer said. “The law around distribution is very hazy, and we need the Legislature to do something. We’ve fallen behind other states on regulations for medical marijuana sales.” After staking out the New Age Healing Collective for eight months, Santa Clara County narcotics agents raided it on Oct. 7. They found marijuana and a black ledger listing sales and expenses, a police report said. The ledger stated that the collective’s $255,642 in sales from May through September were offset by $323,170 in operating expenses and $55,600 that the dispensary spent on rent and payroll. The same day, officers raided the home of Jonathan Mitchell and Sheresie Dyer, the operators of New Age Healing. In a clothes closet, according to the police report, they found a Glock pistol, a pound of marijuana and a shoe box containing $15,971 and a “cash book.” The ledger, the report stated, showed that New Age’s gross receipts were $601,008 for those five months, a $222,238 profit. “Their described activity as a collective is nothing more than a retail store,” wrote Sgt. Dean Ackemann, who is now with the San Jose district attorney’s office. “Their only actions are providing marijuana to customers at street-level prices.” The police say they also found state tax returns, listing $84,111 in gross sales for the second quarter of 2010, which the report characterized as “highly suspect.” 1 2 Next Page » zelinson@baycitizen.org

Patient Money: A Talk With the Doctor May Help Patients Afford Care Posted: 08 Jan 2011 01:10 AM PST READERS of this column have been advised more than once to negotiate prices with health care providers for things like an M.R.I. scan, surgery and office visits. With patients paying more out of pocket for their health care than ever before — in the form of higher co-payments and co-insurance, high deductibles and uncovered and out-of-network treatments — negotiating with doctors and other providers has become commonplace. Well Share your thoughts on this column at the Well blog. Go to Well » Related More Articles in This Series But how exactly should you approach these nerve-racking discussions? Do you bring it up when you book the appointment? In the examining room? And just what do you say? Dr. Jeffrey Kullgren, an internist and clinical scholar at the University of Pennsylvania, specializes in research on the impact of consumer-driven health care. Here are his answers, condensed and edited, to some common questions about negotiations with a health care provider. Q. When exactly should patients bring up price? A. There really is no right or wrong time. The most important thing is just that you do it. That said, I’m a primary care physician, and often we have a really short amount of time during office visits. So I would advise not waiting until the last minute to bring up finances. It helps to bring it up early in the visit so you have enough time to talk about it. Q. What if my physician tells me that someone else in his office handles billing and insurance, and that I should talk to that person? A. This is the case most of the time. In a smaller practice, it may be the office manager. In a large practice, the billing staff may be in a separate location and specialize in developing payment plans. In a clinic, it may be a social worker. No matter whom you end up dealing with, it shouldn’t preclude financial discussions directly with your doctor. Remember, physicians order services. Billing people work on getting those services paid for, whether it is by you or insurance. They are not the ones who can offer alternative treatments that may cost less — say, generic medicines instead of brand name, for example. Only your doctor can do that, which is why he or she needs to know your situation. Q. What can I do to prepare for these conversations? A. Your physician may be just as uncomfortable with these conversations as you are. That’s because — and I can tell you firsthand — doctors are simply not trained for this. I was trained to give the very best care for my patients, regardless of cost. And many doctors are still laboring under the illusion that most people have good insurance that pays for the bulk of their care, even though out-of-pocket health care costs have gone up for everyone, and the number of uninsured is high. With that in mind, if you can get a good handle on the tests, medicines and monitoring you will need for a health condition, as well as a clear idea of what, if anything, your insurance will cover, you’ll be able to ask your doctor and the billing staff specifics about ways you can save money. Q. Why do patients who pay the bills themselves get charged more than patients who have insurance? Can they do anything about this? A. What’s happening is that people without insurance are paying full price, while insurance companies, with their high volume of patients, can negotiate steep discounts. For patients paying for care out of their own pockets, it’s important to let everyone you encounter know that. The next step: ask for the discounted rate. The reality is, you may not have as much leverage as the big insurers. But it almost always pays to ask. Another tip: If your doctor is prescribing a test, find out if it matters where you have it done. Some physicians feel strongly that a test like, say, an echocardiogram needs to be done by a specialist whom they know and trust. Other tests are more routine. Ask your doctor how he or she feels about the specific test you are about to undergo and if shopping around for a lab with the lowest price is an option. Q. But how do I find out about prices, whether it’s for a lab, a hospital or a doctor? How do I shop for less expensive but still high-quality alternatives? A. It’s not easy, but fortunately there are resources available. First, if you have insurance, check if your company lists average prices for various treatments, tests and procedures online. A growing number of insurers are doing this. Or check your state insurance department’s Web site. Some states, like New Hampshire, publish average prices for health care treatments. In addition, private sites like healthcarebluebook.com list average prices for common health care treatments in various parts of the country. 1 2 Next Page »

In Battle Over Health Law, Math Cuts Both Ways Posted: 10 Jan 2011 10:28 AM PST WASHINGTON — With the health care fight roaring back to life on Capitol Hill, questions that seemed settled last March, when President Obama signed his top domestic priority into law, are once again front and center. Enlarge This Image Drew Angerer/The New York Times The House speaker, John A. Boehner, dismissed a report concluding that a repeal of the health care law would increase deficits. Related Republicans Are Given a Price Tag for Health Law Repeal, but Reject It (January 7, 2011) So, will the health care law cost money or save money? Will it create jobs or eliminate jobs? Will it improve outcomes for patients or make medical care more difficult to get? And, for the love of gravity and basic mathematics, how can the nonpartisan Congressional Budget Office, the official scorekeeper charged with keeping count of the nation’s fiscal condition, say that it would cost the government $230 billion over 10 years to repeal a law that would spend $930 billion to extend health insurance to 32 million people? “I don’t think anybody in this town believes that repealing Obamacare is going to increase the deficit,” the House speaker, John A. Boehner, declared at a news conference on Thursday, dismissing a report by the budget experts concluding that a repeal would add $230 billion to federal deficits from 2012 to 2021. But that is exactly what the budget office says, based on a complex thicket of calculations aimed at ascertaining the effect on the government’s bottom line of the law’s myriad tax increases, cuts in projected Medicare spending and costs of new benefits, including subsidies to help people buy insurance. House Republicans on Friday pushed ahead with a measure to repeal the law. The House, by a vote of 236 to 181, approved the terms of debate for the repeal proposal, setting up a fierce floor fight next week — the first major clash of the 112th Congress. The vote showed Republicans easily have the muscle to approve the repeal in a vote scheduled for Wednesday, but the bill is likely to go no further given the staunch opposition in the Democrat-led Senate. Much of the health care debate will center on cost — to the government and to employers. On Thursday, Republicans issued their own report, called “Obamacare: A Budget-Busting Job-Killing Law,” which concluded, “The health care law will cost the nation $2.6 trillion when fully implemented, and add $701 billion to the deficit in the first 10 years.” The Republicans’ projections were in contrast to the budget office’s analysis of the health care law, and a related budget reconciliation measure, after they were adopted last March. The budget office said those laws would reduce federal deficits by $143 billion through 2019 and even more over the next decade, perhaps by more than $1 trillion. Democrats have long registered their own complaints about the budget office projections, insisting that the law would do much more to reduce health spending, by the government and by individuals and private businesses. The Democrats said that normal budget scoring rules simply cannot account for many improvements in the way health care will be practiced and delivered in response to the law. The disparities, while big, are not as hard to understand as they might seem. There are uncertainties around all of the projections and predictions. And some questions, like whether the law will create or eliminate jobs, improve outcomes for patients or make medical care harder to obtain cannot be answered with any precision. Or at least no one on Capitol Hill seems to have the needed crystal ball. Conceptually speaking, however, the budget office’s projection that the law would spend nearly $1 trillion on benefits and yet reduce deficits is easy to understand. As long as the revenue from new taxes and the savings from reductions in projected Medicare spending exceed the new expenditures by the government, the deficits are reduced. The criticisms by House Republican leaders of those projections are also mostly straightforward. They say that the budget office should not have counted roughly $70 billion in revenue from premiums for a new long-term care insurance program, because the premiums would be used to pay benefits later and that it should not have counted $53 billion in increased revenue from Social Security taxes because that money must be used for Social Security benefits. The Republicans also say that the budget rules effectively double-count nearly $400 billion in Medicare savings as both reducing the cost of the health care law and prolonging the life of the Medicare trust fund. They also complain that the projections omitted $115 billion in spending required to administer the law as well as $208 billion needed to prevent scheduled reductions in Medicare payments to doctors. The director of the budget office, Douglas W. Elmendorf, is the first to acknowledge that there are many uncertainties around the projections. But he has also defended the agency’s numbers in public forums and numerous meetings with lawmakers and Congressional staff. Mr. Elmendorf has stressed that the budget office used the “middle distribution of likely outcomes,” meaning that the health care law is just as likely to save the government more money as it is to cost more. “Assessing the effects of making broad changes in the nation’s health care and health insurance systems — or of reversing scheduled changes — requires assumptions about a broad array of technical, behavioral and economic factors,” Mr. Elmendorf wrote in his report Thursday giving the preliminary estimate of the cost of repealing the law. 1 2 Next Page »

In Wider War in Afghanistan, Survival Rate of Wounded Rises Posted: 08 Jan 2011 10:14 AM PST KHAKREZ DISTRICT, Afghanistan — Intensified fighting and a larger troop presence in Afghanistan in 2010 led to the highest American combat casualties yet in the war, as the number of troops wounded by bullets, shrapnel and bombs approached that of the bloodiest periods of the war in Iraq. Multimedia Photographs Speeding the War Wounded to Care Enlarge This Image Tyler Hicks/The New York Times The number of medevac helicopters in service has risen sharply, meaning more of the war’s wounded are being saved. More Photos » But the available data points to advances in the treatment of the fallen, as the rate at which wounded soldiers who died reached a wartime low. More than 430 American service members died from hostile action in Afghanistan last year through Dec. 21, according to official data released by the Pentagon last week at the request of The New York Times. This was a small fraction of those struck. Nearly 5,500 American troops were wounded in action — more than double the total of 2,415 in 2009, and almost six times the number wounded in 2008. In all, fewer than 7.9 percent of the Americans wounded in 2010 died, down from more than 11 percent the previous year and 14.3 percent in 2008. The fatality rate declined even though many more troops patrolled on foot, exposing the force to greater dangers than in years past. Several doctors said the improvements came not from a single breakthrough but through a series of lessons learned over nearly a decade of fighting two wars, such as placing medevac helicopters closer to the fighting and the more extensive use of tourniquets. Although fatality rates for wounded Afghan troops are not similarly available, doctors involved in their care said hospital records showed that they trail those of Western troops by a few percentage points, but have also fallen. Several soldiers and those who care for them framed the improved survival rates as the grimmest sort of success. Many more troops — some missing multiple limbs or their genitals, or suffering brain damage — are being rescued from near death. But their wounds will be exceptionally difficult to overcome later as they try to resume work, and social and family lives. Along with interviews with medics and military doctors, and a month spent by two journalists from The Times observing the collection and immediate treatment of troops suffering from a wide range of trauma, the data shows the results, in broad terms, of an evolving contest for wounded soldiers’ fates. The contest pits a multilayered and expensive effort to keep troops alive against the sharply increased rate at which they suffer grievous injuries, some beyond what any medical system can heal. A clear decline was evident: In 2005, 19.8 percent of wounded American soldiers died from their injuries. For the past five years in Afghanistan and Iraq, the fatality rates for wounded Americans have otherwise fluctuated between 9.4 and 14.3 percent. (The data draws from a sample running into the tens of thousands; in 2006 in Iraq, for example, nearly 7,200 American troops were wounded by hostile action, more than 700 of them fatally.) The statistics further served to reinforce consistent trends in the battlefield’s array of lethal hazards, and offered glimpses of wars within the war. More soldiers in Afghanistan in 2010 were wounded by explosive devices (at least 3,615, compared to 828 troops reported to suffer gunshot wounds). But the higher fatality rates from gunshot wounds (12.9 percent versus 7.3 percent for wounds caused by bombs) made rifles and machine guns the most statistically deadly weapons. Rocket-propelled grenades, for all their ferocious reputation, proved less of a threat. They wounded 373 American soldiers, of whom 13 — 3.5 percent — died. No matter the improved odds, the data, like the field observations, illuminated that even the most determined efforts to cheat death could still be desperate — like the case of an Afghan soldier wounded on Dec. 9. He was a disoriented young man on a stretcher with his uniform cut away, revealing wounds caused by a makeshift bomb. His face was mashed. A tourniquet was cinched to his left leg, high by the hip. His abdomen swelled slightly from the bleeding within. From his torso rose the odor of burned flesh and hair. The man worked with an American Special Forces team. Medics labored over him as the helicopter lifted from the dust, counting minutes in a race against time. Medical workers attributed his improved chances to several factors, among them changes in training for soldiers who administer first aid, swifter movement of victims to hospitals made possible by more helicopters in the war, and shifts in procedures in operating rooms. 1 2 Next Page »

In Women’s Tears, a Chemical That Says, ‘Not Tonight, Dear’ Posted: 06 Jan 2011 10:30 PM PST When we cry, we may be doing more than expressing emotion. Our tears, according to striking new research, may be sending chemical signals that influence the behavior of other people. Enlarge This Image © 2005 Man Ray Trust/Artist Rights Society, New York/ADAGP, Paris “Larmes (Glass Tears)“ by Man Ray. RSS Feed Get Science News From The New York Times » Enlarge This Image Science/AAAS Tears of “really good” criers were collected and dribbled on pads that were placed under men’s noses to approximate a hug. The research, published on Thursday in the journal Science, could begin to explain something that has baffled scientists for generations: Why do humans, unlike seemingly any other species, cry emotional tears? In several experiments, researchers found that men who sniffed drops of women’s emotional tears became less sexually aroused than when they sniffed a neutral saline solution that had been dribbled down women’s cheeks. While the studies were not large, the findings showed up in a variety of ways, including testosterone levels, skin responses, brain imaging and the men’s descriptions of their arousal. “Chemical signaling is a form of language,” said one of the researchers, Dr. Noam Sobel, a professor of neurobiology at the Weizmann Institute in Israel. “Basically what we’ve found is the chemo-signaling word for ‘no’ — or at least ‘not now.’ ” The researchers are currently studying men’s emotional tears, so the scientific implications of, say, the weeping of the new House speaker, John A. Boehner, remain an open question. But Dr. Sobel said he believed that men’s tears would also turn out to transmit chemical signals, perhaps serving to reduce aggression in other men. Dr. Sobel said the researchers started with women because when they advertised for “volunteers who can cry with ease,” they could not find men who were “good criers,” readily able to fill collection vials. Fortunately, he said, “we have a male crier now.” Several experts said the findings — besides potentially adding subtext to crying songs through the ages, from Roy Orbison to the Rolling Stones — could be a first step toward a breakthrough on a mysterious subject. The discovery of a chemical signal in tears suggests “a novel functional role for crying,” said Martha K. McClintock, a professor of psychology at the University of Chicago who is known for her work on pheromones and behavior. “It really broadens the possibilities of where signals are coming from.” Robert R. Provine, a psychologist and neuroscientist at the University of Maryland, Baltimore County, who has studied crying, said the discovery was “a really big deal” because “emotional tears are a very important evolutionary development in humans as a social species,” and this “may be evidence of another human pheromone.” Many questions remain, including whether the results can be replicated by other researchers, what substance could comprise the chemical signal and whether it is perceived through the nose or another way. Why women’s tears would send a message of “not tonight, dear” is puzzling. Some experts suggested the tears could have evolved to reduce men’s aggression toward women who are weakened by emotional stress. The studies did not measure the effect on aggression, although future research might, Dr. Sobel said. Another thought, he said, is that the effect of tears evolved in part to coincide with menstrual cycles. “There’s several lines of evidence that women cry much more during menstruation, and from a biological standpoint that is not a very effective time to have sex, so reducing sexual arousal in your mate at that time is really convenient,” he said. Dr. McClintock, who reported 40 years ago that women who lived together tended to synchronize their menstruation, objected. “Oh, please,” she said. “Do we know that women cry more often during menstruation?” She said it was “premature to speculate about the evolutionary function” of chemo-signaling in tears, adding: “I have no doubt that it affected sexuality as they report, but I would be very surprised if it doesn’t turn out to affect other emotions in other contexts. Maybe it’s affecting some deeper, more fundamental psychological process that drives the effect that they’re reporting.” The researchers accidentally happened upon the evidence that women’s tears make men feel as if they have taken a cold shower. They had assumed chemical signals from tears would trigger sadness or empathy in others. But initial experiments found that sniffing women’s tears did not affect men’s mood or empathy, but “had a pronounced influence on sexual arousal, a surprise,” Dr. Sobel said. Deciding to investigate more rigorously, the researchers posted fliers on several Israeli college campuses seeking easy criers. Seventy women volunteered, along with one man. But of the 70 women, there were only six “who were really good” at bawling their eyes out, Dr. Sobel said. They became the researchers’ “bank of criers”; a stable of “backup criers” was kept in reserve. 1 2 Next Page » This posting includes an audio/video/photo media file: Download Now

Vital Signs: Diet: Childless Couples Eat Healthier, Study Finds Posted: 10 Jan 2011 07:20 AM PST It may be an exaggeration to say that your children are making you sick, but a British study has found that couples with children eat a less healthy diet than those who have none. Related More Vital Signs Columns Researchers used data from a British government survey of 7,014 families who recorded their food purchases in a diary over two-week periods in 2003 and 2004. The higher-income families ate more meat, more fresh fruit and more vegetables than others. Age influenced the consumption of fats and sugar, both of which declined among older households. But perhaps most surprising, the new study, published in the December issue of the European Review of Agricultural Economics, found that households without children were healthier eaters. Even after controlling for income, age and other factors, compared with a household with children, a childless household consumed about 4.4 pounds more fruit and vegetables per person over the two-week period. Having children in the house also reduced the demand for meat, and increased the consumption of dairy products, cereal and potatoes. “This confirms what we as parents know,” said an author of the study, Richard Tiffin, a professor of economics at the University of Reading in England. “For whatever reason, the social dynamic in a household with children makes the diet on average more unhealthy.”

Vital Signs: Childhood: A Breast-Feeding Benefit, This One for Boys Posted: 10 Jan 2011 07:20 AM PST Yet another benefit of breast-feeding: improved academic performance later in childhood, at least for some children. Related More Vital Signs Columns Researchers in Australia recorded the breast-feeding duration of 1,038 babies and then tested their academic performance at age 10 using standardized tests of mathematics, reading, writing and spelling. When they controlled for the mother’s age, education, marital status, family income and other factors, they found that breast-feeding for six months or more was associated with better performance in all four academic skills, but only in boys. The lead author, Wendy H. Oddy, an associate professor of nutrition at the University of Western Australia, said the reasons for the sex difference were unclear. “We think boys tend to be more vulnerable to stress,” she said. “Female hormones might have a protective effect.” The study, published in the January issue of Pediatrics, had a number of strengths. It followed children prospectively, and had a large sample. Data was collected close to the time the women stopped nursing. But the scientists were unable to adjust for length of maternity leave, partner support and other factors. “The results add to the strong evidence that breast-feeding as long as possible is beneficial for child health,” Dr. Oddy said, “but particularly for brain development.”

Vital Signs: Smoking for Two, and Lying About It Posted: 10 Jan 2011 07:20 AM PST When pregnant women are asked if they smoke, almost a quarter of the smokers deny they have the habit. Related More Vital Signs Columns RSS Feed Get Science News From The New York Times » Using data from the National Health and Nutrition Examination Survey conducted from 1999 to 2006, researchers writing online in The American Journal of Epidemiology report that 13 percent of 994 pregnant women, and almost 30 percent of 3,203 nonpregnant women of reproductive age, were active smokers. Among pregnant smokers, 23 percent reported that they did not smoke, despite high blood levels of cotinine, a biological indicator of tobacco exposure, that showed they did. More than 9 percent of the nonpregnant smokers also lied about it. The authors acknowledge that cotinine levels can be increased by secondhand smoke, and that the exact blood level of cotinine that indicates smoking in pregnant women is not known. But pregnant women metabolize cotinine faster than nonpregnant women, so the rate may actually have been underestimated. The lead author, Patricia M. Dietz, an epidemiologist with the Centers for Disease Control and Prevention, said that the deceit probably stemmed from embarrassment. “Smoking has been stigmatized,” she said. “They feel reluctant to be chastised.” But concealing the addiction is not the answer, she said — quitting is. This posting includes an audio/video/photo media file: Download Now

The Mirror: Taking a Leap of Faith Onto the Scale Posted: 08 Jan 2011 02:50 PM PST AS we edge into the new year with too many resolutions, I can say I am at least one of the few American women who is not obsessed with her weight. Enlarge This Image Jen Hsieh This is because after spending 48 years (and 48 New Years) together, my weight and I have finally struck a deal. Yes, by necessity, we still cohabitate — we eat together, we sleep together, I still drive the two of us around town — but it doesn’t ask after me and I don’t ask after it. In the 1980s and even the ‘90s, we used to check in anxiously with each other every day, with continual dialogue. But over the decades, with our too-close relationship, my weight and I have become increasingly dissatisfied. To wit, I’ve come to the profound realization that I will never have a weight I’m going to be proud of, or that even looks nice on a page. I will never weigh 115 pounds or even 125, which for some reason has always been ingrained in me as what adult women should weigh (in the same 1950s way, I suppose, that one’s dinner table should always feature cloth napkins or that your purse should match your shoes). I don’t even weigh what it says on my driver’s license: 137. Maybe 10 pounds heavier, which I consider essentially identical, given the vagaries of differently calibrated scales and water retention. Even when I was 18, 137 was a random dart throw, and to be even anywhere close to that, three decades later, I think is amazing. That said (and I don’t want to be harsh), I believe when you are 20 pounds over the weight listed on your driver’s license, police officers should be able to pull you over and give you a ticket. Thirty pounds over (this is false representation), it’s a violation; it’s like failing to report a third leg. You may as well put down the wrong gender or a different species. Forty pounds over and you should be deported. I am kidding. Just a little. To tell you the truth, I have no idea exactly what I weigh these days, as I no longer own a bathroom scale. I banished it a few years ago as a conscious midlife protest against my post-boomer generation, that group of women whose chief contribution to the culture, as Judith Warner suggested in “Perfect Madness,” was arguably anorexia. Even though I’m almost 5-foot-8, taller than the average American woman (5-foot-4), I’m sure I easily weigh less than the average American woman (162.9 pounds). Just in case, to hold myself in check, I keep a couple of pairs of jeans around like loaded guns that I eye warily, knowing that at any moment I could disturb my equilibrium by trying to pull them on. I don’t try to pull them on, but the threat is there. Anyway, I’m not too worried because I’ve cobbled together a pretty reliable weight-control regimen based on my four-decade survival of Pritikin (briefly), Atkins, the Zone Diet, South Beach and even the marvelous ’70s diet Ed McMahon espoused called “Martinis and Whipped Cream” (where you can have all the steak, butter and gin you want, but no carb-filled carrots). The secret is to eat just one meal a day. How I do it (when I am doing it) is to ingest nothing but coffee starting from the time I get up in the morning until the clock reaches the magical number 5. (Am I sometimes tempted to sleep till noon to shrink the window until cocktail hour? Sure.) At 5 p.m., I slowly and mindfully break my fast, although as you can imagine I’m pretty hungry by 5, so before dinner along with wine and some cheeses I may enjoy some olives and two or three slices of salami and just a bit of sourdough baguette (it is eyed warily and very sternly as judicious pieces are ripped off). All well and good, but during a rare recent vacation at a fancy spa, my weight equanimity was challenged. This was supposed to be kind of a midlife meditation retreat for foodies, augmented with healthy activities like yoga and hiking. To be honest, though, while it wasn’t exactly a cruise, three days in there had so many small tasting plates, amuse bouches, edgy dark chocolate and locally sourced gourmet cocktails like prickly pear margaritas that, what with the Arizona-desert water retention, I soon found myself feeling quite bloated. Tucking into yet another arresting appetizer featuring sharp-angled prawns that appeared to be on a steeplechase across a field of jicama, I observed to my group that I was soon going to have to escape the spa and go home just to be able to fit into my pants. My foodie friend Charlie jovially agreed, drained his glass of wine, went to the bathroom in the nearby men’s lounge and — just because it was there — cheerfully leaped onto a scale. To his horrified (and yet still somewhat cheerful) amazement, the number he saw was 195. Regaining his seat at the table, waving a new glass of shiraz, Charlie breezily observed to our group of women that he really preferred to be 175, 165 was quite skinny (even for middle-aged men, the reference point always vaguely seemed to be college), and 185 feels chubby. Hence 195 seemed quite off the map. 1 2 Next Page » Sandra Tsing Loh is the author, most recently, of “Mother on Fire” (2008).

Doctor and Patient: When Insurers Put Profits Between Doctor and Patient Posted: 06 Jan 2011 10:07 PM PST Late in 2007 I found myself riveted by a case playing out at the University of California, Los Angeles, the medical center where I trained and had once worked as a transplant surgeon. A 17-year-old girl named Nataline Sarkisyan was in desperate need of a transplant after receiving aggressive treatment that cured her recurrent leukemia but caused her liver to fail. Without a new organ, she would die in a matter of a days; with one, she had a 65 percent chance of surviving. Her doctors placed her on the liver transplant waiting list. Enlarge This Image Well Share your thoughts on this column at the Well blog. Go to Well » Enlarge This Image Emily Potter Wendell Potter. Nataline’s case was not all that different from the more than 200 liver patients I had seen successfully transplanted every year at that institution. She was critically ill, as close to death as one could possibly be while technically still alive, and her fate was inextricably linked to another’s. Somewhere, someone with a compatible organ had to die in time for Nataline to live. But even when the perfect liver became available a few days after she was put on the list, doctors could not operate. What made Nataline different from most transplant patients, and what eventually brought her case to the attention of much of the country, was that her survival did not depend on the availability of an organ or her clinicians or even the quality of care she received. It rested on her health insurance company. Cigna had denied the initial request to cover the costs of the liver transplant. And the insurer persisted in its refusal, claiming that the treatment was “experimental” and unproven, and despite numerous pleas from Nataline’s physicians to the contrary. But as relatives and friends organized campaigns to draw public attention to Nataline’s plight, the insurance conglomerate found itself embroiled in a public relations nightmare, one that could jeopardize its very existence. The company reversed its decision. But the change came too late. Nataline died just a few hours after Cigna authorized the transplant. Not long afterward, I spoke with a former nursing colleague who had cared for Nataline. The anger in her voice was still palpable as she recounted the protests in which she had been involved. “This was a 17-year-old girl,” she said. “How could anyone with a conscience — anyone who is human — do this to another person?” While the public fury over Nataline’s death has abated, that question of conscience in a health care system dependent on for-profit insurers has lurked behind nearly every debate over health care reform. While few politicians have dared to openly address this inherent conflict of interest, one unlikely individual has consistently spoken up over the last year and a half to remind us of this moral dilemma. In articles, interviews, op-eds and testimony on Capitol Hill, Wendell Potter has described the dark underbelly of the health care insurance industry — unkept promises of care, canceled coverage of those who get sick and fearmongering campaigns designed to quash any change that might adversely affect profits. He should know what he is talking about. For 20 years, Mr. Potter was the head of corporate communications at two major insurers, first at Humana and then at Cigna. Now Mr. Potter has written a fascinating book that details the methods he and his colleagues used to manipulate public opinion and describes his transformation from the idealistic son of working-class parents in eastern Tennessee to top insurance company executive, to vocal critic and industry watchdog. Using little of the fiery rhetoric or lurid prose that usually marks corporate exposés or memoirs of redemption, the book, “Deadly Spin” (Bloomsbury, 2010), is an evenhanded yet riveting account of the inner workings of the health care insurance industry, a cautionary tale that doctors and patients would be wise not to miss. For a man who has spent his professional life tinkering with impressions, Mr. Potter has astartlingly straightforward narrative voice; he wastes no time cutting to the chase: “It was my job to enhance those firms’ reputations. But as one of the industry’s top public relations executives and media spokesmen, I also helped create and perpetuate myth that had no other purpose but to sustain those companies’ extraordinarily high profitability.” Mr. Potter goes on to describe the myth-making he did, interspersing descriptions of front groups, paid spies and jiggered studies with a deft retelling of the convoluted (and usually eye-glazing) history of health care insurance policies. The most moving section is devoted to Nataline Sarkisyan. We learn that executives at Cigna worried that Nataline’s situation would only add fire to the growing public discontent with a health care system anchored by private insurance. As the case drew more national attention, the threat of a legislative overhaul that would ban for-profit insurers became real, and Mr. Potter found himself working on the biggest P.R. campaign of his career. As busy as they might have felt in the days leading up to Nataline’s death, he and his staff were inundated with calls from the news media immediately afterward. To bolster what was seen as a fight for its survival, Cigna hired a large international law firm and a P.R. firm already well known to them from previous work aimed at discrediting Michael Moore and his film “Sicko.” Together with Cigna, these outside firms waged a campaign that would eventually include the aggressive placement of articles with friendly “third party” reporters, editors and producers who would “disabuse the media, politicians and the public of the notion that Nataline would have gotten the transplant if she had lived in Canada or France or England or any other developed country.” A “spy” was dispatched to Nataline’s funeral; and when the Sarkisyan family filed a lawsuit against the insurer, a team of lawyers was assigned to keep track of actions and comments by the family’s lawyer. 1 2 Next Page » This posting includes an audio/video/photo media file: Download Now

Several Warnings, Then a Soldier’s Lonely Death Posted: 04 Jan 2011 09:46 AM PST WASHINGTON — A gentle snow fell on the funeral of Staff Sgt. David Senft at Arlington National Cemetery on Dec. 16, when his bitterly divided California family came together to say goodbye. His 5-year-old son received a flag from a grateful nation. Enlarge This Image Senft Family Evidence suggests that Sargeant Senft committed suicide. But that brief moment of peace could not hide the fact that for his family and friends and the soldiers who had served with him in the wars in Iraq and Afghanistan, too many unanswered questions remained about Sergeant Senft’s lonely death in a parked sport utility vehicle on an American air base in Afghanistan, and about whether the Army could have done more to prevent it. Officially, the Army says only that Sergeant Senft, 27, a crew chief on a Black Hawk helicopter in the 101st Airborne Division’s aviation brigade, was killed as a result of “injuries sustained in a noncombat related incident” at Kandahar Air Base on Nov. 15. No specific cause of death has been announced. Army officials say three separate inquiries into the death are under way. But his father, also named David Senft, an electrician from Grass Valley, Calif., who had worked in Afghanistan for a military contractor, is convinced that his son committed suicide, as are many of his friends and family members and the soldiers who served with him. The evidence appears overwhelming. An investigator for the Army’s Criminal Investigative Division, which has been looking into the death, has told Sergeant Senft’s father by e-mail that his son was found dead with a single bullet hole in his head, a stolen M-4 automatic weapon in his hands and his body slumped over in the S.U.V., which was parked outside the air base’s ammunition supply point. By his side was his cellphone, displaying a text message with no time or date stamp, saying only, “I don’t know what to say, I’m sorry.” (Mr. Senft shared the e-mails from the C.I.D. investigator with The New York Times.) With Sergeant Senft, the warning signs were blaring. The Army declared him fit for duty and ordered him to Afghanistan after he had twice attempted suicide at Fort Campbell, Ky., and after he had been sent to a mental institution near the base, the home of the 101st. After his arrival at Kandahar early in 2010 he was so troubled that the Army took away his weapon and forced him into counseling on the air base, according to the e-mails from the Army investigator. But he was assigned a roommate who was fully armed. C.I.D. investigators have identified the M-4 with which Sergeant Senft was killed as belonging to his roommate. “I question why, if he was suicidal and they had to take away his gun, why was he allowed to stay in Afghanistan?” asked Sergeant Senft’s father. “Why did they allow him to deploy in the first place, and why did they leave him there?” Defense Department officials have frequently spoken about how suicide prevention has become a top priority, and in interviews, officials noted that the National Institute of Mental Health was now leading a major study of Army suicides. Ever since the wars in Afghanistan and Iraq began, suicides among American troops have been soaring, as military personnel become mentally exhausted and traumatized from repeated deployments to combat zones. In 2004, the Army reported that 67 soldiers on active duty committed suicide; by 2009 that number had jumped to 162. The Army has reported 144 suicides in 2010 through November, and officials say it is now beginning to see a sharp rise in suicides among nonactive duty National Guard and Reserve personnel who are not currently deployed. It is unclear how much the Army knew of Sergeant Senft’s deterioration. But Col. Chris Philbrick, deputy director of the Army’s health promotion and risk reduction task force, which handles suicide prevention programs, said that a medical determination of cause of death, a law enforcement review of the matter by Army investigators, and an internal review of both Sergeant Senft’s personnel history and the handling of his case by his chain of command were all continuing. 1 2 Next Page »

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Personal Health: Have a Food Allergy? It’s Time to Recheck Posted: 10 Jan 2011 12:13 PM PST Food allergies have generated a great deal of anxiety in recent years, with some schools going so far as to ban popular staples — especially peanut butter — after appeals from worried parents. Enlarge This Image Yvetta Fedorova Related Health Guide: Allergies, Food More Personal Health Columns Some airlines have quit serving peanut snacks, and more and more restaurants are offering dishes for diners concerned about gluten or dairy allergies. There is no question that some foods, especially peanuts and shellfish, can provoke severe reactions in a small fraction of the population. But a new analysis of the best available evidence finds that many children and adults who think they have food allergies are mistaken. According to a definitive report compiled for the National Institute of Allergy and Infectious Diseases by a 25-member panel of experts, a big part of the problem is misdiagnosis, from overreliance on two tests — a skin-prick test and a blood test for antibodies — that can produce misleading results. The mere presence of antibodies to a particular substance in food does not mean that someone would have an allergic reaction after eating that food. in And a skin-prick test can remain positive long after an allergy is gone. Sometimes a diagnosis is based on no test at all, solely on a patient’s or parent’s report of a bad reaction after a particular food was eaten. People often mistake food intolerance, like difficulty digesting the lactose in milk, for an allergy. (Allergies involve the immune system; lactose intolerance results from deficiency of an enzyme.) Facts and Fallacies The only test that can definitively establish a food allergy is a so-called oral challenge, in which the patient ingests the suspect food and waits for a reaction. This can be safely done only by an experienced health professional with emergency treatment at hand in case of a severe reaction. Understandably, doctors are often reluctant to try an oral challenge. But in challenges where a suspect food is compared with a placebo and neither doctor nor patient knows which food is which, only about a third of the foods have been found to cause allergies, the panel reported. Nonetheless, genuine food allergies seem to have risen during the last decade or two, for reasons no one knows, said Dr. Anthony S. Fauci, director of the allergy institute. The institute, a division of the National Institutes of Health, sponsored the panel’s two-year effort to establish national guidelines for the definition, diagnosis and treatment of food allergies. According to the panel’s detailed and well-documented report, about one child in 20 and one adult in 25 have a food allergy, nowhere near popular estimates that up to 30 percent of Americans are afflicted. The panel also reported that most children outgrow allergies to milk, egg, soy and wheat, but until they are properly tested they may not know it is now safe to eat the food — or, perhaps more important, to receive a vaccine prepared in eggs. Allergies to peanuts and tree nuts are relatively rare (about half of 1 percent of the population in each case, according to the panel). But they tend to be lifelong and life-threatening, and can require extreme vigilance. Some food allergies start in adulthood, and tend to last indefinitely as well. In particular, shellfish allergies, which can be life-threatening, occur in only 0.5 percent of children but 2.5 percent of adults. It is not possible to predict the severity of a food allergy reaction based on past reactions. In the case of nut allergy, for example, subsequent exposures can be much worse than what a child first experienced. There are no treatments for food allergy except to avoid the culprit food, which may require careful reading of labels and potentially embarrassing inquiries when eating away from home. Although immunotherapy has been proposed as a means of curbing an established food allergy, the panel did not recommend this outside of “highly controlled clinical settings.” Many packaged food labels now warn not only that a particular allergen is present, but also that the product was prepared where allergens like nuts, wheat or soy are present. But Mount Sinai Medical Center in Manhattan did a study of parents’ label reading and found that they were surprisingly poor at identifying foods to which their children were allergic. Symptoms of food allergies are often confusing and can be mistaken for other problems. They can affect the skin (for example, as eczema or hives), eyes, upper or lower respiratory tract, any part of the digestive tract, and the cardiovascular system. But unless a food allergy is proved, the panel does not recommend avoiding foods to control allergic dermatitis, asthma or inflammation of the esophagus. As for vaccines, the panel said that even children with an egg allergy could safely be immunized for measles, mumps, rubella and varicella (chickenpox), but the flu vaccine should not be given. When and When Not to Worry The experts found little evidence that restricting a woman’s diet during pregnancy and lactation was effective in preventing food allergies in her offspring. Nor did they find strong evidence that exclusive breast-feeding for four to six months can prevent allergic disease. The panel said substituting soy for cow’s milk infant formula did not prevent food allergies in infants thought to be at risk because of a family history of allergy. Moreover, there is danger in restricting children’s diets for fear of allergies, even real ones: They can develop nutrient deficiencies that result in retarded growth and development. Thus, the panel recommended “nutritional counseling and regular growth monitoring for all children with food allergies.” The panel devoted the last section of its lengthy report to food-induced anaphylaxis, a potentially fatal disorder that is often recognized too late for adequate treatment. The most common food causes of anaphylaxis, the panel said, are peanuts, tree nuts, milk, eggs, fish and crustacean shellfish, and a life-threatening reaction can occur even the first time a person is exposed. Symptoms that occur within minutes to several hours after exposure may involve lesions of the skin and mouth; difficulty breathing; a precipitous drop in blood pressure, dizziness or rapid heart rate; abdominal pain, vomiting or diarrhea; and anxiety, mental confusion, lethargy or seizures. Anyone with a life-threatening food allergy must always have readily available two doses of self-injectable epinephrine (commonly known by the brand EpiPen), to be injected into the thigh muscle. Treatment with an antihistamine is not an effective substitute, the panel warned. Fatalities result when the use of epinephrine is delayed or the dose given is inadequate. When in doubt, treat, the panel said; then call 911. The EpiPen is a stopgap measure to buy time until life-saving care can be administered. Parents, baby sitters, school nurses and camp counselors must have two epinephrine pens handy and know how to use them for each child at risk of anaphylaxis. The pens must be stored at 59 to 89 degrees Fahrenheit, and must be replaced annually.

Really?: The Claim: Drink Plenty of Fluids to Beat a Cold Posted: 10 Jan 2011 09:38 AM PST THE FACTS Enlarge This Image Christoph Niemann Well Share your thoughts on this column at the Well blog. Go to Well » Related Health Guide: Colds More Really? Columns The advice for conquering a cold is time-honored: Get plenty of rest and drink lots of fluids. While it’s hard to argue against getting proper rest, some scientists suspect that loading up on liquid — that is, beyond the normal amount required in a day — may not do much good. Theoretically, taking in extra beverages like water and juice helps replace fluids lost from fever and respiratory tract evaporation, and it helps loosen mucus. But when a team of scientists at the University of Queensland in Australia set out to determine whether this was indeed the case, they found a surprising dearth of data in the medical literature. For their report, published in the journal BMJ in 2004, “we examined references of relevant papers and contacted experts in the subject,” they wrote, yet were unable to find even a single clinical trial in the last four decades that specifically studied whether increased fluid intake reduced the severity of an infection. They did find some evidence that in some children with moderate to severe pneumonia, consuming extra fluids might contribute to hyponatremia, a blood-sodium deficiency. But other scientists pointed out in response that those findings should not be extrapolated to any respiratory infections besides pneumonia. Ultimately, the Australians did not argue against maintaining proper hydration during a cold or other upper respiratory infection, but they said the advice to drink more fluids than usual should be rigorously studied because it is so widespread. THE BOTTOM LINE Studies have not validated the age-old advice to drink extra fluids to help beat a cold.ANAHAD O’CONNOR scitimes@nytimes.com

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Recipes for Health: Wild Rice and Mushroom Soup Posted: 10 Jan 2011 08:43 AM PST I regretted not making a double batch of this hearty soup when I tested it over the Christmas holidays. Everybody loved the earthy, meaty flavors that the wild rice and mushrooms bring to the broth. 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: Soups With Grains (January 10, 2011) 1/2 ounce (1/2 cup) dried porcini mushrooms 2 cups boiling water 1 to 2 tablespoons extra virgin olive oil, as needed 1 large onion, chopped 2 medium carrots, diced 2 ribs celery, diced 1/2 pound cremini or button mushrooms, cleaned, trimmed, and sliced thick 2 large garlic cloves, minced Salt to taste 2/3 cup wild rice 2 quarts chicken stock, vegetable stock, or water A bouquet garni made with a few sprigs each thyme and parsley, a bay leaf and a Parmesan rind 1 cup frozen peas, thawed Freshly ground pepper to taste 1. Place the dried porcini mushrooms in a bowl or a Pyrex measuring cup, and pour on 2 cups boiling water. Let sit for 30 minutes. Set a strainer over a bowl and line it with cheesecloth. Lift the mushrooms from the water, and squeeze them over the strainer. Rinse in several changes of water, squeeze out the water and set aside. Pour the soaking water through the cheesecloth-lined strainer, and set aside. 2. Heat the oil in a large, heavy soup pot or Dutch oven over medium heat. Add the onion, carrot and celery. Cook, stirring often, until just about tender, about five minutes. Add the sliced fresh mushrooms. Cook, stirring, until the mushrooms are beginning to soften, about three minutes. Add the garlic and a generous pinch of salt. Continue to cook for about five minutes until the mixture is juicy and fragrant. Add the reconstituted dried mushrooms, the wild rice, bouquet garni, mushroom soaking liquid, stock or water, and salt to taste. Bring to a boil, reduce the heat, cover and simmer one hour. Add the peas, and simmer another 10 minutes. Remove the bouquet garni, taste and adjust salt, add a generous amount of freshly ground pepper and serve. Yield: Serves six. Advance preparation: The soup will keep for about three days in the refrigerator, but the rice will swell and absorb the liquid, so you will have to add more to the pot when you reheat. Nutritional information per serving: 158 calories; 3 grams fat; 0 grams saturated fat; 0 milligrams cholesterol; 26 grams carbohydrates; 4 grams dietary fiber; 90 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."

Recipes for Health: Spaghetti With Mussels and Peas Posted: 06 Jan 2011 11:20 PM PST When you think you have no vegetables in the house for dinner, remember those peas buried deep in your freezer. You can use them with mussels steamed in white wine, then tossed with pasta. The broth from the mussels makes a flavorful sauce for the spaghetti. 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 For Seafood on a Budget, Just Add Pasta (January 3, 2011) Recipes for Health: Penne With Arugula and Clams (January 4, 2011) Recipes for Health: Penne With Swordfish or Tuna and Tomato Sauce (January 5, 2011) Recipes for Health: Linguine With Red Clam Sauce (January 6, 2011) 2 pounds mussels, carefully picked over and cleaned 1 tablespoon extra virgin olive oil 1/2 small onion, or 1 medium shallot, chopped 2 large garlic cloves, sliced Pinch of red chili flakes 1/2 cup dry white wine 1 cup water 2 sprigs thyme 1 tablespoon extra virgin olive oil 1/4 cup minced flat-leaf parsley Salt and freshly ground pepper 1 pound spaghetti 1 1/2 cups thawed frozen peas or fresh peas 1. Begin heating a large pot of water for the pasta. 2. Meanwhile, heat the olive oil over medium heat in a wide, lidded pan. Add the onion or shallot. Cook, stirring, until it begins to soften, about three minutes. Add the garlic, chili flakes, wine, water and thyme, and bring to a boil. Boil for two minutes, then add the mussels, cover the pan and cook about four minutes, shaking the pan once or twice, until the mussels have all opened. Remove from the heat, and remove the mussels with tongs from the pan (do not drain the liquid from the pan). 3. Holding the mussels over the pan to catch the liquid, remove them from their shells. Discard the shells. Strain the liquid in the pot, and return it to the pan with the mussels. Stir in the parsley. Keep warm. 4. When the pasta water has reached a rolling boil, add the spaghetti. Cook five minutes. Add the peas. Continue to cook until the pasta is al dente (about five more minutes). Drain and toss with the mussels and the parsley, and serve. Yield: Serves six. Advance preparation: You can make this through Step 3 an hour or two before you cook the pasta. Remove from the heat and set aside. Reheat the mussels gently, and then proceed with the recipe. Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Linguine With Red Clam Sauce Posted: 05 Jan 2011 11:40 PM PST A classic dish that has been popular in Italian-American restaurants for decades, this dish can be made with a light hand, as it is here. 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 For Seafood on a Budget, Just Add Pasta (January 3, 2011) Recipes for Health: Penne With Arugula and Clams (January 4, 2011) Recipes for Health: Penne With Swordfish or Tuna and Tomato Sauce (January 5, 2011) Recipes for Health: Spaghetti With Mussels and Peas (January 7, 2011) 32 Littleneck or Cherrystone clams, or 40 Manila clams, cleaned and rinsed 2 fat garlic cloves, minced, plus 1 clove, crushed 1/2 cup dry white wine 1 dried chili pepper 2 tablespoons extra virgin olive oil 1/4 teaspoon red chili flakes 1 (14-ounce) can chopped tomatoes, with juice Salt and freshly ground pepper 3/4 pound linguine 1/4 cup chopped flat-leaf parsley 1. Bring a large pot of generously salted water to a boil for the pasta. Meanwhile, in a wide skillet over high heat, combine the crushed garlic clove, the white wine and the chili. Bring to a boil, and add the clams. Cover and cook four to six minutes, shaking the pan from time to time, until the clams open up. Remove from the heat, and remove the clams from the pan with tongs. Allow them to cool, then remove them from their shells, holding them over the pan to catch the juices. Rinse briefly to rid them of any lingering sand, then cut in half or chop coarsely and set aside. Strain the liquid in the pan into a bowl through a cheesecloth-lined strainer. 2. Heat the olive oil over medium-high heat in the pan in which you cooked the clams. Add the minced garlic and the red chili flakes. Cook, stirring, just until fragrant, about 30 seconds to a minute. Add the tomatoes and their juice. Cook, stirring often, for 5 to 10 minutes until the tomatoes have slightly cooked down. Add the broth from the clams, and bring to a simmer. Taste, and add salt and freshly ground pepper as needed. Keep at a simmer while you cook the linguine. 3. When the pasta water comes to a rolling boil, add the pasta. Cook al dente following the timing directions on the package but checking about a minute before the indicated time. Drain the pasta, and add to the pan with the clams and parsley. Toss together and serve. Yield: Serves four. Advance preparation: You can make this through Step 2 an hour or two before you cook the pasta. Reheat gently, and proceed with the recipe. Nutritional information per serving: 495 calories; 9 grams fat; 1 gram saturated fat; 39 milligrams cholesterol; 72 grams carbohydrates; 4 grams dietary fiber; 232 milligrams sodium (does not include salt added during preparation); 27 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Fusilli With Swordfish or Tuna and Tomato Sauce Posted: 07 Jan 2011 01:22 PM PST The sauce here is a sort of fish ragù common throughout Sicily and Southern Italy. In summer, use fresh tomatoes, but you can make it now with canned. 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 For Seafood on a Budget, Just Add Pasta (January 3, 2011) Recipes for Health: Penne With Arugula and Clams (January 4, 2011) Recipes for Health: Linguine With Red Clam Sauce (January 6, 2011) Recipes for Health: Spaghetti With Mussels and Peas (January 7, 2011) 2 tablespoons extra virgin olive oil 1 pound swordfish or tuna steaks, skinned and cut in approximately 1/2-inch dice Salt and freshly ground pepper 1/2 cup dry white wine (optional) 1 small onion, finely chopped 2 to 4 garlic cloves (to taste), minced 1/4 teaspoon red chili flakes (optional) 2 anchovy fillets, finely chopped 1 (28-ounce) can diced tomatoes, with juice, or 2 pounds fresh tomatoes, peeled, seeded and diced or grated 1/4 cup chopped flat-leaf parsley 1 pound penne or fusilli 1. Begin heating a large pot of water for the pasta. 2. Heat the olive oil over medium heat in a large, heavy nonstick skillet, and add the onion. Cook, stirring, until tender, about five minutes. Turn the heat to medium-high. Add the garlic, red chili flakes, anchovies and diced swordfish or tuna. Season with salt and pepper. Cook, stirring, until the fish changes color slightly, about two minutes. Add the wine, bring to a boil and continue to cook for two minutes while stirring. Then, using a slotted spoon, remove the fish and transfer to a bowl. Continue to boil the liquid in the pan until it has reduced to a couple of tablespoons. 3. Add the tomatoes to the pan, and bring to a simmer. Cook, stirring often, for 15 minutes, until they have cooked down slightly and smell fragrant. Stir the fish back into the pan, add the parsley and season the mixture to taste with salt and pepper. Bring to a simmer, and simmer 10 minutes until the sauce is thick and fragrant. Taste, and adjust seasonings. 4. Bring the pasta water to a boil, and salt generously. Add the penne or fusilli and cook al dente, eight to nine minutes or according to the timing directions on the package. Add 1/4 to 1/2 cup of the pasta cooking water to the fish ragù, and stir well. Drain the pasta, toss with the sauce in the pan or in a pasta bowl, and serve. Yield: Serves six. Advance preparation: The fish ragù can be made a few hours before you’re ready to cook the pasta. Refrigerate, then reheat gently. Nutritional information per serving: 445 calories; 9 grams fat; 2 grams saturated fat; 29 milligrams cholesterol; 65 grams carbohydrates; 4 grams dietary fiber; 330 milligrams sodium (does not include salt added during preparation); 26 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

The Texas Tribune: Shortfall Gives Hope to Disability Rights Advocates Posted: 06 Jan 2011 10:40 PM PST Disability rights advocates try year after year to persuade lawmakers to close Texas’ state-supported living centers, the large, institutional-care settings that the United States Justice Department has monitored for dangerous conditions. Every time, their efforts have been rebuffed — by the adamant parents who rely on the facilities to care for their loved ones and by the lawmakers who count on the centers as economic drivers in their districts. Enlarge This Image Todd Wiseman/The Texas Tribune Tamika Mays, an employee of one of Texas' state-supported living centers for the disabled, with a resident of the facility. Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org. This session, advocates say they have a big plus in their column: the state’s giant budget crunch. They hope lawmakers, facing an estimated $15 billion to $28 billion shortfall, will have to shutter some of the centers, which cost Texas $500 million a year to operate. “Does this economic reality make it easier for legislators to do it? I sure hope so,” said Amy Mizcles, governmental affairs director for The Arc of Texas, which wants people with disabilities to receive community-based care. “We keep hearing this fiscal-responsibility mantra. We have a real opportunity to provide better quality care in a much less expensive setting.” So far, there is little evidence that state officials will take this course. State Senator Steve Ogden, Republican of Bryan, the key Senate budget writer who has been most open to downsizing the state schools, declined to comment. Meanwhile, the Department of Aging and Disability Services, which operates the centers, said it was prohibited by state law from closing any of the state-supported living centers without legislative direction. “We can’t,” said Cecilia Fedorov, a spokeswoman for the department. “But that doesn’t mean the Legislature can’t.” Even with the budget shortfall, advocates for community-based care are not optimistic. Since state leaders ordered agencies to trim their budgets to help close the gap, the Department of Aging and Disability Services has recommended cutting new community-based care slots and slashing Medicaid reimbursement rates for workers at nursing homes, group homes and in-home facilities. Meanwhile, money for the state-supported living centers has grown, a requirement of the state’s five-year, $112 million settlement with the Justice Department over conditions inside them. “I’ve heard that everything will be on the table,” Ms. Mizcles said. “But every bit of action that’s been taken thus far is completely to the contrary.” Parents who rely on the centers to care for their adult children say the influx of money is having an enormous positive impact. The settlement agreement “has been a wonderful thing,” said Nancy Ward, with the Parent Association for the Retarded of Texas. “We need to give them a chance to keep on doing the improvements with the money they got.” According to advocates for community care, however, the state-supported living centers do not make financial sense. A third of the disability department’s budget for people with intellectual and developmental disabilities serves the 4,600 people living in 13 state-supported living centers — a comparable amount finances more than 17,000 people receiving care at home or in small-group settings. The annual cost per resident in a state-supported living center is roughly $120,000, compared with nearly $50,000 in community-based care. Parents of residents at state-supported living centers say that is an unfair comparison because the people currently remaining in the institutions have some of the most acute medical needs. “There are people who cannot survive without being in the state school,” Ms. Ward said. But advocates for community care say many of these people can be cared for far more efficiently in less-restrictive settings. In the wake of highly publicized abuse in Texas’ institutions for the disabled — from physical beatings and restraints to medical neglect — state health officials have had to increase payments to the centers by thousands of dollars per patient annually, a cost that opponents argue comes at the expense of community-based care. “There’s a bell curve of people, from some who want to close them to other people who think we ought to do more of them,” said State Senator Robert Deuell, Republican of Greenville. “And they’ll all use the current situation to promote their agenda.” eramshaw@texastribune.org

Republicans Are Given a Price Tag for Health Law Repeal, but Reject It Posted: 07 Jan 2011 02:20 PM PST WASHINGTON — The nonpartisan budget scorekeepers in Congress said on Thursday that the Republican plan to repeal President Obama’s health care law would add $230 billion to federal budget deficits over the next decade, intensifying the first legislative fight of the new session and highlighting the challenge Republicans face in pursuing their agenda. Enlarge This Image Stephen Crowley/The New York Times Representative David Dreier, left, chairman of the Rules Committee, before a hearing Thursday on repealing the health care law. Multimedia Document Reading Between the Battle Lines: An Annotated Guide to the Constitution Related Constitution Has Its Day (More or Less) in House (January 7, 2011) 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 new House speaker, John A. Boehner, flatly rejected the report, saying it was based largely on chicanery by Democrats. Mr. Boehner’s dismissal of the report by the Congressional Budget Office, at his first formal news conference as speaker, was the latest salvo in the battle over the health care law. White House officials on Thursday said they were stepping up efforts to defend the law, with a new rapid-response operation to rebut Republican claims and to deploy supporters to talk about the benefits of the law. But Mr. Boehner’s remarks held wider implications, effectively putting him on a war footing with the independent analysts whose calculations generally guide discussions about the projected cost or savings of any legislation. “I do not believe that repealing the job-killing health care law will increase the deficit,” he said. “C.B.O. is entitled to their opinion,” he said, but he said Democrats had manipulated the rules established for determining the cost of a program under the 1974 Budget Act. “C.B.O. can only provide a score based on the assumptions that are given to them,” Mr. Boehner said. “And if you go back and look at the health care bill and the assumptions that were given to them, you see all of the double-counting that went on.” But the analysis released by the budget office on Thursday was based on the health care repeal bill that House Republicans introduced on Wednesday. And it highlighted the difficult position that Republicans are in as they try to address what they insist are the top two priorities of voters who elected them in November: cutting the deficit and undoing the health care law. According to the budget office, those goals are contradictory. The budget office estimated that the health care law, including education provisions, would reduce deficits over 10 years by $143 billion. Tax increases and cuts in projected Medicare spending would more than offset the cost of extending health insurance to millions of Americans. The budget office projected that the law would result in even bigger savings beyond 2019. Republicans have said they do not believe that many of the Medicare cuts will ever take hold. They say that government subsidies to help people buy health insurance will prove far costlier than the budget office has predicted, and that the Democrats wrote the law to mask the steep future costs of some provisions, like a new long-term-care insurance program. The budget office did not comment on Mr. Boehner’s remarks. Douglas W. Elmendorf, its director, has frequently said his office applies the longstanding budget rules. He says it uses its own professional expertise, as well as consulting with outside experts, to derive its projections, which represent the “middle of the distribution of likely outcomes.” Mr. Elmendorf has warned that Congress may find it difficult to follow through with parts of the health care law, particularly the cuts to Medicare. The law’s cost would rise if the cuts were not enacted. In the report on Thursday, Mr. Elmendorf, a former Clinton administration official appointed in 2008 when Democrats controlled both chambers of Congress, said that a preliminary analysis showed that repealing the law would increase federal budget deficits by a total of $145 billion from 2012 to 2019 and by $230 billion between 2012 and 2021. Moreover, he said, if the law is repealed, 32 million fewer people will have health insurance in 2019, compared with estimates of coverage under the existing law. As a result, he said, the number of uninsured would be 54 million, rather than 23 million, in 2019. At Mr. Boehner’s news conference, reporters peppered him with questions about repealing the law — including the cost analysis and a plan by Republicans not to allow amendments on the repeal measure even though the party had promised to maintain a more open legislative process. “Well, listen, I promised a more open process,” Mr. Boehner said. “I didn’t promise that every single bill was going to be an open bill.” Mr. Boehner grew testy when a reporter noted that Democrats who controlled the Senate were unlikely to bring up the repeal measure, let alone support it, and that Mr. Obama could veto it. “Don’t you think it’s a waste of time?” Mr. Boehner was asked. “No, I do not,” he said, raising his voice. “I believe it’s our responsibility to do what we said we were going to do. And I think it’s pretty clear to the American people that the best health care system in the world is going to go down the drain if we don’t act.” In their own report on Thursday, intended to illustrate how the law would lead to job losses, Republican leaders put the cost of the health care law “when fully implemented” at $2.6 trillion and said it would “add $701 billion to the deficit in its first 10 years.” Michael D. Shear contributed reporting. This posting includes an audio/video/photo media file: Download Now

Health Spending Rose in ’09, but at Low Rate Posted: 05 Jan 2011 10:55 PM PST WASHINGTON — Total national health spending grew by 4 percent in 2009, the slowest rate of increase in 50 years, as people lost their jobs, lost health insurance and deferred medical care, the federal government reported on Wednesday. Enlarge This Image Matthew Staver/Bloomberg Many hospitals had fewer admissions in 2009. Kristen Mann soothed her daughter Kira at Children’s Hospital in Aurora, Colo. Multimedia Graphic Rate of Health Care Spending Still, health care accounted for a larger share of a smaller economy — a record 17.6 percent of the total economic output in 2009, the report said. The economy contracted while health spending continued to grow. The nation spent $2.5 trillion on health care in 2009, for an average of $8,086 a person, and the recession had a profound influence. “Many consumers decreased their use of health care goods and services, partly because they had lost employer-based private health insurance coverage and partly because their household income had declined,” said Anne B. Martin, an economist and principal author of the report, issued by the office of the actuary at the Centers for Medicare and Medicaid Services. In many cases, Ms. Martin said, people decided to “forgo health care services they could not afford.” The number of visits to doctors’ offices apparently declined. Many hospitals reported fewer admissions, as patients put off medical procedures. Spending on dental services declined slightly. Many hospitals and other health care providers reduced their capital investments. Spending on doctors’ services in 2009 increased at the slowest pace since 1996, according to the new federal study, being published in the journal Health Affairs. Partly offsetting the slowdown in private health spending was a rapid increase in Medicaid spending, driven by the addition of 3.5 million people to the rolls. Medicaid, created in 1965 to provide health care for low-income people, is financed jointly by the federal government and the states. The economic stimulus program approved in February 2009 temporarily increased the federal share, to help states in dire fiscal straits cope with a growing need. “Federal Medicaid spending increased 22 percent in 2009, the highest rate of growth since 1991,” Ms. Martin said, while “state spending decreased 9.8 percent, the largest decline in the program’s history.” Federal officials emphasized that none of the data reflected the impact of the new health care law, which President Obama signed in March 2010. Spending on health care by private insurance companies grew a modest 1.3 percent in 2009, as the number of people with private coverage declined by 3.2 percent, or 6.3 million people. At the same time, out-of-pocket spending by consumers rose just four-tenths of 1 percent, compared with an increase of 3.1 percent in 2008. Despite the economy’s downturn, retail spending on prescription drugs “increased more rapidly in 2009 than in 2008, as a result of more rapid growth in the prices of drugs and in the number of prescriptions dispensed,” the report said. Retail purchases of prescription drugs account for $1 of every $10 spent on health care, almost $250 billion of the $2.5 trillion total in 2009. Medicaid spending accounted for 15 percent of all health spending and totaled $373.9 billion in 2009, the report said. Many of the new Medicaid recipients are relatively healthy children and adults of working age. The new health care law calls for a major additional expansion in Medicaid eligibility, starting in 2014. The recession ran from December 2007 to June 2009. Even after it ended, the economy was sluggish, and unemployment continued to rise. So the growth of health spending outpaced the growth of the overall economy in 2009, federal officials said. The share of the economy devoted to health care rose one percentage point in 2009, the largest one-year increase in a half-century of record-keeping. Health spending, as tracked by the government, has grown at a slower rate every year since 2002, when it increased 9.5 percent. The slowdown was more pronounced in 2008 and 2009 because of the recession. Out-of-pocket spending by consumers — which includes deductibles, co-payments and the purchase of goods and services not covered by insurance — accounted for 12 percent of all health spending and totaled almost $300 billion in 2009, the report said. In addition, it said, health insurance premiums increased more slowly in 2009 than per-person spending on medical benefits under private health plans. Insurers spent more on prescription drugs and “more on benefits for existing enrollees,” it said. Republicans pounced on the new numbers. “No one should take solace in the fact that health spending grew at a lower rate in 2009,” said Senator Orrin G. Hatch of Utah, who is in line to be the senior Republican on the Finance Committee. Mr. Hatch said the new health care law could lead to “crushing increases in health costs and premiums.” By contrast, the chief Medicare actuary, Richard S. Foster, has estimated that the new law will lead to an increase of only nine-tenths of 1 percent in national health spending over 10 years. Uninsured people who gain coverage will use more health care, Mr. Foster said, but the law is also supposed to reduce the growth of Medicare payments to many health care providers. Medicare spending reached $502 billion in 2009, meaning that the program, for older Americans and the disabled, accounts for $1 of every $5 spent on health care. Enrollment in the traditional fee-for-service Medicare program declined, as some beneficiaries chose to enroll in private Medicare Advantage plans, federal officials said. Over all, Medicare spending rose 7.9 percent in 2009, the same rate as in 2008, while enrollment grew about 2 percent, the report said. Medicare spending increased an average of 2.3 percent for each person in a private Medicare Advantage plan and 6.9 percent for each person in the traditional program. The new health care law cuts Medicare payments to private plans. Many studies have found that Medicare spends more on people in such private plans than it would spend for the same beneficiaries in the original Medicare program.

U.S. Alters Rule on Paying for End-of-Life Planning Posted: 05 Jan 2011 08:57 AM PST WASHINGTON — The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday. Post a Comment Related Obama Returns to End-of-Life Plan That Caused Stir (December 26, 2010) The move is an abrupt shift, coming just days after the new policy took effect on Jan. 1. Many doctors and providers of hospice care had praised the regulation, which listed “advance care planning” as one of the services that could be offered in the “annual wellness visit” for Medicare beneficiaries. While administration officials cited procedural reasons for changing the rule, it was clear that political concerns were also a factor. The renewed debate over advance care planning threatened to become a distraction to administration officials who were gearing up to defend the health law against attack by the new Republican majority in the House. Although the health care bill signed into law in March did not mention end-of-life planning, the topic was included in a huge Medicare regulation setting payment rates for thousands of physician services. The final regulation was published in the Federal Register in late November. The proposed rule, published for public comment in July, did not include advance care planning. An administration official, authorized by the White House to explain the mix-up, said Tuesday, “We realize that this should have been included in the proposed rule, so more people could have commented on it specifically.” “We will amend the regulation to take out voluntary advance care planning,” the official said. “This should not affect beneficiaries’ ability to have these voluntary conversations with their doctors.” The November regulation was issued by Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services and a longtime advocate for better end-of-life care. White House officials who work on health care apparently did not focus on the part of the rule that dealt with advance care planning. The decision to drop the reference to end-of-life care upset some officials at the Department of Health and Human Services, who said the administration ought to promote discussions of such care. Such discussions help ensure that patients get the care they want, the officials said. During debate on the legislation, Democrats dropped a somewhat similar proposal to encourage end-of-life planning after it touched off a political storm. Republicans said inaccurately that the House version of the bill allowed a government panel to make decisions about end-of-life care for people on Medicare. Sarah Palin, the 2008 Republican vice-presidential candidate, said in the summer of 2009 that “Obama’s death panel” would decide who was worthy of health care. Representative John A. Boehner of Ohio, the House Republican leader who is to become speaker on Wednesday, said the provision could be a step “down a treacherous path toward government-encouraged euthanasia.” The health care bill passed by the House in 2009 allowed Medicare to pay doctors for discussions of end-of-life care, including advance directives, in which patients can indicate whether they want to forgo or receive aggressive life-sustaining treatment. The provision for advance care planning was not included in the final health care overhaul signed into law by President Obama. Health policy experts assumed that the proposal had been set aside — until a similar idea showed up in the final Medicare regulation in November.

Vital Signs: Patterns: When a Bumper Crop Led to a Baby Bulge Posted: 04 Jan 2011 09:25 AM PST Ministers of the Lutheran Church in 18th-century Finland kept careful records of births, deaths and marriages so they could efficiently tax their congregants, but 21st-century biologists are using the data for quite a different purpose. Related More Vital Signs Columns Matching up birth records with yearly crop yields, they conclude that poor children born in years with good harvests were more likely to go on to have children themselves. “These results suggest that food in early life can affect fertility in a human population,” said the lead researcher, Ian J. Rickard, a research fellow at the University of Sheffield in England. The study, published in the December issue of Ecology, found a strong correlation between fertility and social class. For children born to landowners, the chance of reproducing remained steady at about 80 percent, unaffected by variations in the yearly grain harvest. But 95 percent of landless women born the year of a bumper crop had babies later, while only 56 percent of those born the year of a poor harvest reproduced as adults. Dr. Rickard cautioned that the finding was specific to a time and place with a fairly rigid social structure. The strong link between early deprivation and infertility later on, he said, “is unlikely to be the case in modern industrialized societies where the availability of calories is not the issue.”

Vital Signs: Diet: Fried Fish Is Seen as a ‘Stroke Belt’ Culprit Posted: 03 Jan 2011 10:00 PM PST A wide swath of the South has long been known as the “stroke belt” because it has higher rates of stroke and other cardiovascular illnesses than the rest of the country. Now researchers are suggesting one culprit: fried fish. Related More Vital Signs Columns Fish contain omega-3 fatty acids, which help reduce the risk for stroke, and the American Heart Association recommends at least two fish meals per week. But deep-fat frying destroys these natural fatty acids and replaces them with cooking oil. Scientists writing online in the journal Neurology analyzed the diets of more than 21,000 people nationwide. They found that people in eight stroke belt states — North and South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas and Louisiana — ate a three-ounce serving of fish an average of twice a week, roughly the same as people elsewhere. But they were 32 percent more likely to have that fish fried. Nationally, African-Americans ate more fish meals than whites, and twice as much fried fish. The lead author of the study, Dr. Fadi Nahab, an assistant professor of neurology at Emory University, said fried fish was only one potential contributor to geographic and racial differences in stroke rate, but added that it stood out. “The No. 1 thing is diet,” he said. “And yet when we look at dietary differences in and out of the stroke belt, it’s hard to find any other than this one.”

Vital Signs: Behavior: Distracted Eating Adds More to Waistlines Posted: 03 Jan 2011 10:00 PM PST Catching up with e-mail while you eat lunch? Watching television? You may end the day eating more than you think. Well Share your thoughts on this column at the Well blog. Go to Well » Related More Vital Signs Columns Researchers had 22 volunteers eat a meal while playing computer solitaire and 22 others eat the same meal in the same amount of time while undistracted. They told the subjects it was a test of the effect of food on memory, but actually they were testing how full people felt after a meal, how much they ate at a “taste test” 30 minutes later, and how successfully they could recall exactly what they ate. Their results appear online in The American Journal of Clinical Nutrition. Not only were distracted eaters worse at remembering what they had eaten, but they felt significantly less full just after lunch, even after the researchers controlled for height and weight. And at the taste-test session a half-hour later, they ate about twice as many cookies as those who had lunch without playing games. “If you can avoid eating in front of a computer screen or any other activity that distracts you, that might temper the tendency to snack later in the day,” said Jeffrey M. Brunstrom, the senior author. Dr. Brunstrom, a researcher in behavioral nutrition at the University of Bristol in England, said the problem lay in recalling what one has eaten. “Memory plays an important role in the regulation of food intake,” he said, “and distractions during eating disrupt that.”

Studied: As for Empathy, the Haves Have Not Posted: 31 Dec 2010 07:30 PM PST THE GIST The rich don’t get how the other half lives. Enlarge This Image Getty Images/DeAgostini THE SOURCE “Social Class, Contextualism, and Empathic Accuracy,” by Michael W. Kraus, Stéphane Côté and Dacher Keltner, Psychological Science. ARE the upper classes really indifferent to the hopes, fears and miseries of ordinary folk? Or is it that they just don’t understand their less privileged peers? According to a paper by three psychological researchers — Michael W. Kraus, at the University of California, San Francisco; Stéphane Côté, at the University of Toronto; and Dacher Keltner, the University of California, Berkeley — members of the upper class are less adept at reading emotions. Research on psychological effects of social status is recent in this country, where the mere mention of class can set off Marxism alarms. “Only in the last seven or eight years have we tried to capture all the nuances of differences between the ways the rich and the poor experience the world psychologically,” Dr. Keltner said. “It’s a really new science.” The paper, published in October by the Association for Psychological Science, recounts three experiments conducted among students and employees of a large (unidentified) public university, some of whom had graduated from college and others who had not. In American social science, the definition of class is generally based on measures like income, occupational prestige and material wealth. In these experiments, class was determined either by educational level or by self-reported perceptions of family socioeconomic status. In the first experiment, participants were asked to look at pictures of faces and indicate which emotions were being expressed. The more upper class the judges, the less able they were to accurately identify emotions in others. In another experiment, upper-class participants had a harder time reading the emotions of strangers during simulated job interviews. In the third one — an interesting twist of an experiment — people of greater socioeconomic status were asked to compare themselves to the wealthiest, most powerful Americans, thus diminishing their own relative stature. When asked to identify emotions by looking at 36 sets of emoting eyes, they did markedly better than their upper-class peers. Here’s why: Earlier studies have suggested that those in the lower classes, unable to simply hire others, rely more on neighbors or relatives for things like a ride to work or child care. As a result, the authors propose, they have to develop more effective social skills — ones that will engender good will. “Upper-class people, in spite of all their advantages, suffer empathy deficits,” Dr. Keltner said. “And there are enormous consequences.” In other words, a high-powered lawyer or chief executive, ill equipped to pick up on more-subtle emotions, doesn’t make for a sympathetic boss. In an apocryphal but oft-cited exchange, Hemingway supposed the rich to be different only because they had more money. But, as Fitzgerald rather presciently wrote in his story “Rich Boy,” because the wealthy “possess and enjoy early, it does something to them,” surmising, “They are different from you and me.” Score one for Scott.

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