Sunday, January 30, 2011

Health - Earlier Hormone Therapy Elevates Breast Cancer Risk, Study Says

Health - Earlier Hormone Therapy Elevates Breast Cancer Risk, Study Says

Earlier Hormone Therapy Elevates Breast Cancer Risk, Study Says

Posted: 28 Jan 2011 11:49 PM PST

Growing evidence about the risks of breast cancer and other serious illnesses posed by hormone therapy for menopause has led many women to give up the drugs, and many doctors to stop recommending them.

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But there has been a lingering belief that for younger women in the early stages of menopause, hormone risks may be negligible, at least for a while. So those who are really suffering from hot flashes, insomnia and other symptoms are often told that it is probably all right to take the drugs, as long as they use the lowest possible dose for the shortest possible time. Some researchers are even testing an idea, called the timing hypothesis, that starting hormone treatment early in menopause may help protect women from heart disease.

Now, information from a huge study in Britain suggests that the women thought to be at the lowest risk from hormones may actually be at the highest risk, at least when it comes to breast cancer. The study found that women with the greatest risk of breast cancer from hormones were those who took them earliest — before or soon after menopause began.

The new findings, published on Friday in The Journal of the National Cancer Institute, are not the strongest type of evidence: They do not come from a randomized trial, an experiment in which people are picked at random to take either a drug or a placebo and are then studied and compared over time. Instead, the British study was observational, meaning that the women being studied had made their own decisions about whether and when to take hormones. There is always a chance, in observational studies, that there is some underlying difference between people who choose to take drugs and those who do not, and that the difference — not just the drugs they took — may help account for different health outcomes. Observational findings are sometimes disproved by randomized trials.

But this particular observational study also has a unique strength — it included more than a million postmenopausal women, one in four British women who were aged 50 to 64 during the enrollment period, from May 1996 to December 2001.

The research, called the Million Women Study, found that in women ages 50 to 59 who had never taken hormones, 0.3 percent a year developed breast cancer. The rate was higher, 0.46 percent a year, in women who started taking the most commonly used hormones — estrogens combined with progestin — five or more years after menopause began. But it was highest of all — 0.61 percent a year — in women who started taking the drugs before or less than five years after menopause began. And the risk was increased even in women who took the drugs for less than five years.

The lead investigator of the study, Prof. Dame Valerie Beral, a professor of epidemiology at the University of Oxford, said that her research group had decided to look at the interval between the start of menopause and the start of treatment because other studies had found evidence of higher risk among women who started earlier. But in the other studies, the numbers of women who had started early were relatively small, and so the evidence was not statistically significant. In the Million Women Study, 90 percent of the women taking hormones had begun them before or within five years of the start of menopause, so there was a better chance of finding an answer, Dame Valerie said.

One of the studies that had detected a possible but inconclusive link between earlier hormone use and increased cancer risk was the Women’s Health Initiative, the randomized trial that in 2002 found that combined hormones were causing small but significant increases in the risk of breast cancer, heart disease, strokes and blood clots in the lungs.

Dr. Rowan Chlebowski, an investigator in the Women’s Health Initiative and a medical oncologist at the Los Angeles Biomedical Research Institute, wrote in an editorial in the cancer journal that the Million Women Study provided “substantial support” for the findings from other studies.

He said the new findings made it harder than ever to define any safe timing or duration for hormone use. Women who believe they need the hormones for severe symptoms should try to stop taking them after a year or so, he said.

But Dr. JoAnn E. Manson, also an investigator on the Women’s Health Initiative and a professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, cautioned that the Million Women findings were not conclusive because the study was observational.

“The jury is still out,” Dr. Manson said.

Women should not take hormones unless they really need them, she said, but those who do need them should not be afraid to take a low dose for a limited time.

“It may have a favorable benefit-risk profile in many cases,” Dr. Manson said.

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Vital Signs: Behavior: Another Good Reason to Sing a Lullaby

Posted: 28 Jan 2011 11:49 PM PST

Children who sleep less than their peers may be at greater risk for abnormal blood glucose levels and other metabolic problems.

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Researchers studied the sleep patterns of 308 children ages 4 to 10, half of them overweight or obese. They used wrist monitors to measure their sleep time over seven days, and did blood tests for cardiovascular risk indicators like glucose, lipids, insulin and C-reactive protein.

The study, published in the February issue of Pediatrics, found that obesity and abnormal blood tests were four times as common in children who slept the least, and three times as common in those who used the weekend to catch up on sleep lost during school days.

“We can’t rule out that obese children first became obese and then started sleeping less,” said Dr. David Gozal, the senior author. “But it’s unlikely.”

Among all children, obese or not, shorter sleep and greater variability in sleep patterns were more likely to be associated with abnormal blood tests. The researchers conclude that irregular sleep by itself may be a risk factor for metabolic problems.

“We sacrifice sleep to whatever else we do,” said Dr. Gozal, a professor of pediatrics at the University of Chicago. “But as parents we should be very attentive to preserving the treasure that is sleep — it means health for children’s brains and their bodies, their happiness and their well-being.”

Vital Signs: Disparities: Racial Gaps Seen in Chlamydia Screening

Posted: 28 Jan 2011 11:49 PM PST

All sexually active women under 25 are supposed to be screened for chlamydia. But a new analysis finds that black and Hispanic women are screened at significantly higher rates than white women, and this could help explain why minority women have higher reported rates of the disease.

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The study, published in the February issue of Pediatrics, examined the records of more than 23,000 women ages 14 to 25 who visited health care facilities in Indianapolis from 2002 to 2007.

Over all, 58 percent of the women were screened. The youngest women and those with insurance were slightly more likely to be tested than the older and the uninsured. But black women were three times as likely to be tested as white women, and Hispanic women almost 13 times as likely to be tested.

Chlamydia rates are higher among blacks and Hispanics, and this could be a reason to screen them more often than whites. But cervical cancer rates, for example, are also higher among blacks and Hispanics, yet there is no difference by race in screening for that disease. The authors say the stigma attached to a sexually transmitted infection like chlamydia may make clinicians less likely to test white women.

The lead author, Dr. Sarah E. Wiehe, an assistant professor of pediatrics at Indiana University, said these differences in screening might have a significant effect on reported rates of disease. “There is a higher prevalence of chlamydia among certain women,” she said. “We don’t know how much of that is driven by differences in screening.”

Vital Signs: Diet: Bigger Breakfast, Bigger Daily Calorie Count

Posted: 28 Jan 2011 11:49 PM PST

Dieters are sometimes told to have a substantial breakfast, because it reduces the amount of food consumed during rest of the day. Not so, a new study reports.

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German researchers studied the food intake of 280 obese adults and 100 of normal weight. The subjects kept records of everything they ate over two weeks, and were carefully instructed about the importance of writing down what they ate as soon as they ate it.

For both groups, a large breakfast simply added to the number of daily calories they consumed. Whether they ate a large breakfast, a small one or none at all, their nonbreakfast calorie intake remained the same.

The study, published in Nutrition Journal, found that the foods most often responsible for the variations in daily calories were among the morning’s favorites: bread, eggs, yogurt, cheese, sausages, marmalade and butter.

This may mean that exactly the opposite of the commonly offered advice is correct: A smaller breakfast means fewer daily calories consumed, not more.

“Whenever someone comes to me for dietary advice and says, ‘I never eat breakfast,’ I say, ‘Keep doing what you’re doing,’ ” said the senior author, Dr. Volker Schusdziarra, a professor of internal medicine at the Technical University of Munich. “Eating breakfast is just added calories. You’ll never compensate for them at subsequent meals.”

Well: How Meditation May Change the Brain

Posted: 28 Jan 2011 09:09 AM PST

Recipes for Health: Sweet Potato, Carrot and Dried Fruit Casserole

Posted: 28 Jan 2011 12:10 AM PST

This dish is inspired by several tsimmes recipes in Joan Nathan’s “Jewish Cooking in America.” Tsimmes, a Yiddish word that means “fuss,” doesn’t have to be fussy at all. Sometimes the dish contains meat (and is fussier than this one), but sometimes it’s just fruit and vegetables. Warning: You may find yourself eating this for breakfast.

Recipes for Health

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

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6 medium carrots (about 1 1/2 pounds), peeled and cut in 3/4-inch dice

3 medium sweet potatoes (about 2 1/4 pounds), peeled and cut in 3/4-inch dice

2 Granny Smith apples, peeled, cored and cut in medium dice

1/4 pound pitted prunes, cut in half

1/4 pound pitted apricots, quartered

2 tablespoons mild honey, like clover

1/2 teaspoon freshly grated nutmeg

1 teaspoon ground cinnamon

Salt to taste (about 1/2 teaspoon)

1 cup fresh orange juice

1 tablespoon unsalted butter

Note: Sweet potatoes may be labeled as yams. Look for dark orange flesh.

1. Preheat the oven to 375 degrees. Butter or oil a 3-quart baking dish.

2. Place the carrots and sweet potatoes in a steamer set above 1 inch of boiling water, and steam for five to 10 minutes, until just tender. Drain and toss with the remaining ingredients in a large bowl. Combine well, and scrape into the prepared baking dish. Place in the oven, and bake 40 to 50 minutes, stirring every 15 minutes, until the sweet potatoes and carrots are thoroughly tender. Dot the top with butter, and bake another 10 minutes until the top is lightly browned. Remove from the heat, and serve hot or warm.

Yield: Serves eight.

Advance preparation: You can assemble this dish several hours before baking. You can bake it a day or two ahead of serving; reheat it in a medium oven.

Nutritional information per serving: 245 calories; 2 grams fat; 1 gram saturated fat; 4 milligrams cholesterol; 57 grams carbohydrates; 8 grams dietary fiber; 259 milligrams sodium (does not include salt to taste); 4 grams protein

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

Eleanor Galenson, Expert on Children’s Sexual Identity, Dies at 94

Posted: 29 Jan 2011 06:47 PM PST

Dr. Eleanor Galenson, a psychoanalyst whose research demonstrated that children are aware of sexual identity in infancy, even earlier than Freud had propounded, died on Jan. 15 at her home in Manhattan. She was 94.

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Dr. Eleanor Galenson

Her son Paul Himmelstein confirmed the death.

Dr. Galenson, who in her 65-year career was a professor of psychiatry at the Albert Einstein College of Medicine in the Bronx and Mount Sinai Medical Center in Manhattan, spent thousands of hours observing and documenting the actions and reactions of infants.

In 1981, with Dr. Herman Roiphe, she published “Infantile Origins of Sexual Identity.” Considered a significant book in the field, it refined existing Freudian theory about when children begin their sexual development. Dr. Roiphe died in 2005.

Freud postulated that awareness of genital difference does not affect children until the Oedipal stage — around 4 to 5 years old — when boys become competitive with their fathers for their mothers’ attention and girls turn more toward their fathers.

But Freud’s writing on psychosexual development was based on work with adult patients, said Dr. Nellie Thompson, a historian of psychoanalysis.

“What Galenson and Roiphe were doing was observing very young children in the nursery over time,” Dr. Thompson said. “They concluded that children make the discovery of genital difference between the ages of 15 to 19 months, and that this has an impact on their play, their relationship with their own bodies, their relationship with their parents.”

Dr. Galenson and Dr. Roiphe wrote in the book that as their research proceeded “we became increasingly convinced that we had been engaged in tracing the development of the sense of sexual identity from its vague beginnings during the earliest weeks and months to a definite conscious awareness of specific gender and genital erotic feelings and fantasies by the end of the second year.

“This definitive awareness,” they continued, “has turned out to be a critical factor in ongoing psychological development and has therefore been designated as the beginning of a new psychosexual phase.”

Later research by Dr. Galenson documented that subtle differences exhibited by children during the new psychosexual phase could indicate lasting effects. Her observations, said Dr. Patricia Nachman, a clinical psychologist at Mount Sinai Medical Center, “led to the idea that some of these children with very early sexual awareness may be more anxious children.”

Dr. Galenson was an advocate of early counseling for those children and their families — including play therapy, with the parents participating — for almost half a century “during a time when there were very few champions of this view,” Dr. Nachman said.

Eleanor Galenson was born in the Bronx on Oct. 28, 1916, one of two children of Louis and Libby Galenson. She graduated from Barnard in 1936 and was one of the first women to attend the Columbia University College of Physicians and Surgeons, from which she received a medical degree in 1940. She went on to train as a psychoanalyst at the New York Psychoanalytic Institute, graduating in 1950.

Research was only a part of Dr. Galenson’s work. For many years she directed therapeutic nurseries at Mount Sinai and the Albert Einstein Medical Center. She also helped create clinics for troubled children in East Harlem and the Bronx. She was a founder of the World Association for Infant Psychiatry, now called the World Association for Infant Mental Health.

Dr. Galenson’s husband, Leonard Weinroth, died in 1988. Her first husband, Aaron Himmelstein, died in 1959. Besides her son Paul, she is survived by another son, David Himmelstein, and two grandchildren.

The Ripped and the Righteous

Posted: 29 Jan 2011 10:00 PM PST

It is Jack LaLanne you can thank, or curse, for all the gyms: in exurban strip malls, suburban manses, downtown hotels. The health club he opened in Oakland, Calif., in 1936 was one of their seeds and templates, an endorphin emporium that pointed the way.

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Gordon Magnin

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Timeline: Trying to Whip Us Into Shape

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With “The Jack LaLanne Show,” he also had a hand in the spread — a contagion, really — of television programs exhorting viewers to rise up from their La-Z-Boys and of infomercials hawking workout equipment. An army of spandex missionaries was unleashed.

But that’s not the whole of his legacy, or the most interesting (some might say insidious) part.

That sense of failure you feel when you haven’t exercised in days? That conviction that if you could pull off better push-ups, you’d be a better person through and through? These, too, are his doing, at least in part. What he left behind when he died last week, at the toned old age of 96, was not only a sweaty culture of relentless crunching and spinning but also the notion that fitness equals character, and that self-actualization begins with the self-discipline to get and stay in shape. In the post-LaLanne landscape, it’s not the eyes but the abdominals that are windows to the soul.

“There seems to be a whole substitute morality, where your obligation is to go to the gym and not ask why,” says Mark Greif, a founding editor of the literary journal n+1 and the author of a widely discussed 2004 essay, “Against Exercise.” “If you don’t, you become a sort of villain of the culture.”

The message that perspiration is a gateway to, and reflection of, higher virtues is captured in health club slogans like ones used by the Equinox chain over recent years: “Results aren’t always measured in pounds and inches.” “My body. My biography.” “It’s not fitness. It’s life.” The same idea is encoded in the language of personal improvement. A “new you” usually means a trimmer, tauter version, not someone who has learned to speak Mandarin or picked up woodworking skills.

And the pectoral is political. The current president and his predecessor have made ostentatious points of their commitments to fitness routines. Whatever the differences in their ideologies, intellects and work habits, George W. Bush and Barack Obama both let voters know that they carve out time almost daily for cardio or weights or both. And while that devotion could be seen as evidence of distraction (Bush) or vanity (Bush and Obama), each politician safely counted on a sunnier takeaway. In this country, at this time, steadiness of exercise signals sturdiness of temperament, and physical leanness connotes mental toughness.

Bill Clinton worked out less diligently, which was freighted with its own meaning: waistline as weather vane. Americans monitored his fluctuating physique as they wondered how well he was keeping all of his appetites in check.

Some conflation of the physical and the moral spans virtually all of human history. It’s present in the writings of the ancient Greeks, for whom athleticism was much more than mere sport. Christians long ago designated sloth one of the seven deadly sins, though they meant a dearth of industry more than a deficit of treadmill time.

And the philosophy that one form of self-control begets another — that careful maintenance of the body yields more than corporal benefits — has countless historical precedents. In the early 19th century, the American preacher Sylvester Graham advocated sparse, vegetarian-style eating as a hedge against impure thoughts, particularly sexual ones. He was nutritionist and moralist both.

In his own way, Mr. LaLanne was also a moralist, proselytizing about diet and exercise. To go back and look at his language is to be struck by its religious flavor.

He once compared himself to Billy Graham, saying that while Mr. Graham (no relation to Sylvester) was “for the hereafter,” he was “for the here and now.” He called what he was doing a crusade, adding, “To me, this one thing — physical culture and nutrition — is the salvation of America.”

And he admitted that exercise wasn’t always pleasurable or diverting. You did it because it was right and good and true — because it would better you. The Protestant work ethic pulsed through every one of his jumping jacks.

Breast Implants Are Linked to Rare but Treatable Cancer, F.D.A. Finds

Posted: 26 Jan 2011 10:06 PM PST

Breast implants may cause a small but significant increase in the risk of an extremely rare but treatable type of cancer, the Food and Drug Administration said on Wednesday.

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The risk applies to both saline- and silicone-filled implants, and to all women who have them, whether for reconstruction after cancer surgery or for cosmetic enlargement of the breasts.

The cancer, anaplastic large-cell lymphoma, involves the immune system. It is not breast cancer. It is usually a systemic disease, but in the cases linked to implants, the lymphoma grew in the breast, usually in the capsule of scar tissue that formed around the implant. The cases were discovered because women developed symptoms long after they had healed from the implant surgery — lumps, pain, asymmetry of the breasts, fluid buildup and swelling.

In some cases simply removing the implant and scar tissue gets rid of the disease, but some women might need chemotherapy and radiation, said Dr. William Maisel, the chief scientist and deputy director for science in the drug agency’s Center for Devices and Radiological Health. He said there was some evidence, though not conclusive, that the form of this lymphoma found in implant patients was less aggressive than the usual type.

So far, the drug agency said it knew of about 60 cases worldwide, a tiny number compared with the 5 million to 10 million women who have implants. But even that small number appears to be an excess of cases when compared with the usual incidence of the disease: This type of lymphoma in the breast is normally found in only 3 in 100 million women who do not have implants.

Because the risk appears to be so small, the drug agency said, “the existing data support the continued marketing and use of breast implants.” But it also said that women considering implants should first discuss the information with their doctors.

Women with implants who have no symptoms do not need to do anything special or change their routine health care, Dr. Maisel said. But they should pay attention to any changes and see a doctor if swelling, lumps or other symptoms develop.

Because there is very little data on the lymphoma, Dr. Maisel said, the agency “is not comfortable recommending a specific treatment.” Cases may differ, and women who have the disease need to be treated by a breast surgeon and an oncologist.

The worldwide market for breast implants is roughly $820 million a year and growing at 8 percent a year, according to industry figures.

The Food and Drug Administration said it needed more data and was asking doctors to report confirmed cases to its safety information program, MedWatch. Dr. Maisel said the agency was working with the American Society of Plastic Surgeons to create a registry of cases. He also said that information about the possible link to the cancer would be added to the labeling information sent out with implants.

Dr. Maisel said it was not yet known for sure whether the implants really increase the risk of the cancer, or how they could do so.

“We do know that both silicone and saline implants are surrounded by silicone,” he said, adding that silicone has been found in cells around breast implants and may stimulate the cells and induce lymphoma in rare cases. But he added, “Please understand that is speculative and a hypothesis.”

A spokeswoman for Allergan, which makes implants, sent a statement by e-mail saying that the company supported the drug agency’s recommendations. But the statement also said: “Reports of ALCL in patients with breast implants are extremely rare and are not to be mistaken for breast cancer. A woman is more likely to be struck by lightning than get this condition.”

Another implant maker, Mentor, did not respond to a telephone message asking for comment on the drug agency announcement.

A medical group, the American Society for Aesthetic Plastic Surgery, issued a statement saying it supported the development of a registry for the cancer cases in women with implants, but added that implants were “the most studied device in medical history” and were safe.

Record Level of Stress Found in College Freshmen

Posted: 27 Jan 2011 12:16 PM PST

The emotional health of college freshmen — who feel buffeted by the recession and stressed by the pressures of high school — has declined to the lowest level since an annual survey of incoming students started collecting data 25 years ago.

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A student activities room at Stony Brook University’s Health Services Building, where therapists meet with students.

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College Freshmen’s Emotional Health

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In the survey, “The American Freshman: National Norms Fall 2010,” involving more than 200,000 incoming full-time students at four-year colleges, the percentage of students rating themselves as “below average” in emotional health rose. Meanwhile, the percentage of students who said their emotional health was above average fell to 52 percent. It was 64 percent in 1985.

Every year, women had a less positive view of their emotional health than men, and that gap has widened.

Campus counselors say the survey results are the latest evidence of what they see every day in their offices — students who are depressed, under stress and using psychiatric medication, prescribed even before they came to college.

The economy has only added to the stress, not just because of financial pressures on their parents but also because the students are worried about their own college debt and job prospects when they graduate.

“This fits with what we’re all seeing,” said Brian Van Brunt, director of counseling at Western Kentucky University and president of the American College Counseling Association. “More students are arriving on campus with problems, needing support, and today’s economic factors are putting a lot of extra stress on college students, as they look at their loans and wonder if there will be a career waiting for them on the other side.”

The annual survey of freshmen is considered the most comprehensive because of its size and longevity. At the same time, the question asking students to rate their own emotional health compared with that of others is hard to assess, since it requires them to come up with their own definition of emotional health, and to make judgments of how they compare with their peers.

“Most people probably think emotional health means, ‘Am I happy most of the time, and do I feel good about myself?’ so it probably correlates with mental health,” said Dr. Mark Reed, the psychiatrist who directs Dartmouth College’s counseling office.

“I don’t think students have an accurate sense of other people’s mental health,” he added. “There’s a lot of pressure to put on a perfect face, and people often think they’re the only ones having trouble.”

To some extent, students’ decline in emotional health may result from pressures they put on themselves.

While first-year students’ assessments of their emotional health were declining, their ratings of their own drive to achieve, and academic ability, have been going up, and reached a record high in 2010, with about three-quarters saying they were above average.

“Students know their generation is likely to be less successful than their parents’, so they feel more pressure to succeed than in the past,” said Jason Ebbeling, director of residential education at Southern Oregon University. “These days, students worry that even with a college degree they won’t find a job that pays more than minimum wage, so even at 15 or 16 they’re thinking they’ll need to get into an M.B.A. program or Ph.D. program.”

Other findings in the survey underscore the degree to which the economy is weighing on college students.

“Paternal unemployment is at the highest level since we started measuring,” said John Pryor, director of the Cooperative Institutional Research Program at U.C.L.A.’s Higher Education Research Institute, which does the annual freshman survey. “More students are taking out loans. And we’re seeing the impact of not being able to get a summer job, and the importance of financial aid in choosing which college they’re going to attend.”

“We don’t know exactly why students’ emotional health is declining,” he said. “But it seems the economy could be a lot of it.”

For many young people, serious stress starts before college. The share of students who said on the survey that they had been frequently overwhelmed by all they had to do during their senior year of high school rose to 29 percent from 27 percent last year.

The gender gap on that question was even larger than on emotional health, with 18 percent of the men saying they had been frequently overwhelmed, compared with 39 percent of the women.

There is also a gender gap, studies have shown, in the students who seek out college mental health services, with women making up 60 percent or more of the clients.

“Boys are socialized not to talk about their feelings or express stress, while girls are more likely to say they’re having a tough time,” said Perry C. Francis, coordinator for counseling services at Eastern Michigan University in Ypsilanti. “Guys might go out and do something destructive, or stupid, that might include property damage. Girls act out differently.”

Linda Sax, a professor of education at U.C.L.A. and former director of the freshman study who uses the data in research about college gender gaps, said the gap between men and women on emotional well-being was one of the largest in the survey.

“One aspect of it is how women and men spent their leisure time,” she said. “Men tend to find more time for leisure and activities that relieve stress, like exercise and sports, while women tend to take on more responsibilities, like volunteer work and helping out with their family, that don’t relieve stress.”

In addition, Professor Sax has explored the role of the faculty in college students’ emotional health, and found that interactions with faculty members were particularly salient for women. Negative interactions had a greater impact on their mental health.

“Women’s sense of emotional well-being was more closely tied to how they felt the faculty treated them,” she said. “It wasn’t so much the level of contact as whether they felt they were being taken seriously by the professor. If not, it was more detrimental to women than to men.”

She added: “And while men who challenged their professor’s ideas in class had a decline in stress, for women it was associated with a decline in well-being.”

Observatory: With Sleight of DNA, Pneumonia Bacterium Dodges Vaccines

Posted: 28 Jan 2011 11:49 PM PST

Researchers from seven countries have collaborated to analyze how a single strain of Streptococcus pneumoniae bacteria has morphed over 30 years and spread across the world, in an attempt to overcome the development of antibiotics and vaccines.

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The research is the first detailed genetic picture of the evolution of a specific strain of pneumonia, resulting in a family tree of sorts. The researchers analyzed samples from North and South America, Africa and Southeast Asia.

Their findings appear in the current issue of the journal Science.

In looking at more than 240 samples, they found that since 1984, when the strain was first identified in Spain, it has turned over about three-quarters of its genome.

Over time, the bacteria mutated to better resist antibiotics and vaccines. The researchers found that it underwent both recombination, in which the DNA shuffles around, and base substitutions, in which individual nucleic acids in a DNA sequence change.

That means that certain samples they tested are not treatable with existing vaccines, which target certain gene clusters that have now changed.

In the past, genomic sequencing of bacteria was time-consuming and laborious, but new technology has sped up the process, and will perhaps help speed up the development of new vaccines, said Stephen Bentley, a geneticist at the Wellcome Trust Sanger Institute and one of the study’s authors.

“I think this going to be really important going forward,” he said. “We can start to do this kind of analysis routinely; then we will be able to have really valuable information for how to introduce antibiotics and new vaccines.”

He and his colleagues are now studying several other strains of the pneumonia bacteria.

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Doctor and Patient: The Missing Ingredient in Accountable Care

Posted: 27 Jan 2011 11:28 PM PST

This past week while spending time with nonmedical friends, I found myself referring to what health care experts have been touting as the system’s best hope for the future. My friends, eager to learn more and always game for any clarification of the health care system, leaned in to hear me expound on accountable care organizations, or A.C.O.’s.

Pauline W. Chen

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Not just another pilot project or policy pipe dream, A.C.O.’s will be legal partnerships between clinicians and hospitals that will be part of Medicare by 2012. As a partnership, these providers will be responsible for all the health care needs of a specific population of patients who are assigned, but are not necessarily restricted, to them. Unlike fee-for-service, payers will give A.C.O.’s a lump sum to cover all care, but the A.C.O.’s will be able to keep any savings that result from more efficient and better care.

In this way, I concluded to my friends, A.C.O.’s will be able to stem spiraling costs, increase efficiency and improve quality. Clinicians and hospitals will have a financial motive not to do more procedures and incur more visits but to keep patients healthy and out of the hospital.

I took a deep breath then looked around. One friend had stood up and was excusing herself to go to the bathroom. The other was looking into her bag, rummaging around for her cellphone.

“Thanks for the explanation, Pauline,” she said. She pulled her phone out and quickly glanced at its screen. “I hate to break it to you,” she continued, “but whatever that care plan is called, it still sounds like an H.M.O. to me.”

For the last few years, but now with increasing frequency and intensity, health care experts and policy analysts have been preaching the virtues of accountable care organizations. While the details of these plans have yet to be worked out for Medicare, the enthusiasm for this model of payment and delivery has gone nearly viral, infecting and making strange bedfellows of third-party payers, state legislatures and politicians on both sides of the aisle. In journals, round-table discussions, blogs and most recently in the Department of Justice, the debate has focused not on whether accountable care organizations should exist but on how they might best be organized and put into action.

Without question, this payment and delivery model does hold promise. But according to a recent editorial in The New England Journal of Medicine, it also runs the risk of becoming yet another failed acronym in health care’s murky alphabet soup. One important group of individuals has yet to be convinced of its merits or to be even included in any of these high-level discussions.

The patients.

“Focusing on payment systems and thinking about incentives for providers is the right first step in making care affordable and efficient,” said Meredith B. Rosenthal, senior author and an associate professor of health economics and policy at the Harvard School of Public Health. “But you can’t just change and assume patients will go along with that.”

One risk is that patients will reject the changes, as they did in the late 1990s. “From the early days of managed care, there has always been this idea of ‘we know what is best,’ ” Dr. Rosenthal said, referring to policy makers and researchers. “And there has always been some suspicion on the part of the patient.”

One way to avert this kind of reaction is by being more transparent about the changes and results, providing patients with information on the quality and benefits of accountable care organizations, as well as using less jargon to relay this information. “We like these acronyms, so of course people are worried,” Dr. Rosenthal said. “We aren’t using plain English.”

Patients who are not engaged with their A.C.O.’s can quickly tip the savings balance. For example, the primary A.C.O. of a patient who decides to have her hip replaced at a hospital that is not part of the partnership must assume the cost of the operation, even thought it exercises no control over any clinical decisions or costs related to the operation. “There’s been a lot of thought in the A.C.O. movement about not forcing patients to get their care from a narrow group of providers,” Dr. Rosenthal said. “But that freedom will also be a huge challenge for the model.”

That challenge could be addressed by creating incentives that build patient loyalty, an idea that few experts or analysts have examined in depth. Some of the ideas that Dr. Rosenthal and her co-author suggest include having patients pay lower co-payments if they stay within their own group of providers or lower premiums if they choose a more economical A.C.O. Private health plans could also assign patients to more efficient, higher-quality groups of providers, then charge more out of pocket if patients decide to see an outside doctor.

While some of these incentives bear some resemblance to H.M.O.’s, they will allow patients to share in the cost savings of their A.C.O.’s. “Patients don’t really want to hear that you’re going to save money for the providers,” Dr. Rosenthal said. “They want to know that if they get care here, there will be some value for them.”

And that value could be enormous in terms of their health. In the current fee-for-service system, clinicians care for patients only when they present at the hospital or the doctor’s office. But accountable care organizations would encourage care beyond these medical confines. “A.C.O.’s offer what we call ‘between-visit care,’ ” Dr. Rosenthal said. “They are about outreach, making sure the right labs are checked and the right medicine is taken. They are about caring proactively for patients and not just reacting to an acute event.”

The support of patients will be crucial for the success of A.C.O.’s. “This idea makes a lot of sense,” Dr. Rosenthal said. “But if we operate in obscurity, we’ll find ourselves back in 1998, when patients really wanted nothing to do with the health care delivery system reforms that were needed to improve care.”

She added, “We can’t afford a replay of the managed-care backlash.”

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National Briefing | SOUTH: Virginia: Quick Ruling Promised on Challenge to Health Law

Posted: 26 Jan 2011 09:10 PM PST

A federal appeals court in Richmond, Va., announced Wednesday that it would expedite its consideration of a lower court ruling against a key provision of the Obama health care act. The Court of Appeals for the Fourth Circuit said it would hear arguments between May 10 and May 13 in the Obama administration’s appeal of a ruling last month by Judge Howard E. Hudson of Federal District Court in Richmond. Judge Hudson ruled that Congress had exceeded the boundaries of the Commerce Clause of the Constitution by requiring citizens to obtain commercial insurance. He allowed the law to remain in effect pending appeals, which are likely to end at the Supreme Court. Two other federal judges have upheld the insurance requirement, while a fourth judge, in Florida, is expected to rule soon.

John Horan, Former Chief of Merck, Dies at 90

Posted: 27 Jan 2011 09:30 PM PST

John Horan, who led Merck as it expanded its portfolio of pharmaceuticals and became the world’s largest drug maker, died on Saturday in Princeton, N.J. He was 90 and lived in Sea Girt, N.J.

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John Horan served as chairman and chief executive officer of Merck & Co. from 1976 to 1985.

A spokesman for Merck, Ronald Rogers, announced the death.

Mr. Horan was chief executive from 1976 to 1985, a period when Merck introduced a hepatitis B vaccine, as well as new antibiotics and drugs to treat high blood pressure and heart failure. Under his watch, Merck also developed ivermectin, a drug that prevents and treats river blindness.

Through a program administered by the World Health Organization, Merck donated ivermectin to countries where millions were afflicted by the disease, which is caused when black flies living in rapidly running rivers bite a person repeatedly, releasing parasitic worms. It brings excruciating itching, creates nodules under the skin and often results in blindness.

By 1982, Mr. Horan had tripled the company’s research and development spending to $338 million, according to Fortune. He also increased the sales force and imposed what the magazine called “a new pragmatism.”

“We’ve learned it’s not enough just to discover a blockbuster,” he told the magazine. “After you’ve made a breakthrough, you have to improve upon it. It used to be that if we came up with something and then somebody else took it the next step, we tended to walk away.”

His strategy made him one of the highest-paid chief executives in the country. In 1984, U.S. News & World Report put his salary and bonuses at $931,000, more than counterparts at corporations like Philip Morris and J. P. Morgan.

John Joseph Horan was born July 9, 1920, on Staten Island. He attended Manhattan College on a scholarship, graduating in 1940. After serving in the Navy in World War II, he received a law degree from Columbia. He saw heavy combat as part of amphibious forces in several theaters of war, including North Africa and Italy. He later worked in a communications operation in Plymouth, England, and was on duty when Gen. Dwight D. Eisenhower sent word to the allied fleet that the D-Day invasion was on.

“My dad explained that there were three different shifts on the communications staff,” said John Horan Jr., “and the go-ahead from Ike happened to arrive during his shift.”

Mr. Horan joined Merck in 1952 as part of its legal department. In 1957 he became spokesman for the Merck, Sharpe & Dohme research laboratory in North Wales, Pa.

Mr. Horan is survived by his wife of 66 years, Julia Fitzgerald; a daughter, Mary Alice Ryan of Spring Lake, N.J.; three sons, Thomas, of Hoboken, John Jr., of Sea Girt, and David, of Armonk, N.Y.; two sisters, Mary Smith of Lakewood, N.J., and Florence Keating of Wall, N.J.; a brother, Eugene, of Monroe, N.J.; and nine grandchildren.

Well: New Concerns About Hormone Therapy

Posted: 29 Jan 2011 09:09 AM PST

Well: A Life Lesson Learned in Medical School

Posted: 29 Jan 2011 09:07 AM PST

Well: Sweet Potatoes With Tang, Spice and Sweetness

Posted: 28 Jan 2011 09:25 AM PST

Well: A Possible Silver Lining for Hot Flashes

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Well: Making Patients Part of Accountable Care

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The New Old Age: Strains for Hispanic Caregivers

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Prescriptions: Prospects for Private Health Insurance

Posted: 27 Jan 2011 01:19 PM PST

The Texas Tribune: Health Law Response Goes 2 Ways

Posted: 30 Jan 2011 12:40 AM PST

One House Republican wants to create the state health insurance exchange required by the federal health care overhaul law for fear that the federal government will do it for Texas otherwise. Another has filed a bill that would make his colleague’s efforts — really, those of anyone trying to carry out “Obamacare” in Texas — illegal.

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Marjorie Kamys Cotera for The Texas Tribune

John Zerwas

The Texas Tribune

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.

Meanwhile, early versions of the Republican-written state budget include cost-saving pilot programs like changes in medical payments, with little mention that they are key components of the much-maligned federal law.

It is an uncomfortable balancing act: Texas Republican lawmakers hate few things more than the federal Patient Protection and Affordable Care Act, the overhaul that became law in March. But even as the state pursues a suit attacking the law’s constitutionality, and Gov. Rick Perry and other top Republican politicians assault it with the relentless enthusiasm of 9-year-olds hitting a birthday piñata, some state officials are reluctantly laying the groundwork to carry out parts of the law.

“Playing politics is one thing. Hampering the state from moving forward is another entirely,” said Tom Banning, chief executive of the Texas Academy of Family Physicians. “When the health plans, doctors, hospitals and business community get behind them saying, ‘This is something we need to do,’ it gives lawmakers the political cover to defeat the partisan effort not to do anything that touches health care reform.”

Most of the legislation filed so far is an effort to halt the federal health care overhaul in its tracks. Representatives Wayne Christian, Republican of Center, and Ken Paxton, Republican of McKinney, are among lawmakers proposing a state constitutional amendment to preserve Texans’ right to go without health insurance, free of penalty.

Representative Leo Berman, Republican of Tyler, takes it a step further. He has filed a bill to nullify the federal overhaul entirely. Under Mr. Berman’s legislation, any state or federal government official who tries to carry out any aspect of the overhaul law could be charged with a crime — and even face jail time. Mr. Berman said the measure could even apply to Representative John M. Zerwas, the Simonton Republican who has drafted legislation to create a key element of the law, a health insurance exchange.

“We’ll just have to see which one passes,” Mr. Berman said. “The Obamacare bill is unconstitutional and must be declared null and void.”

Mr. Zerwas, a staunch conservative who is also an anesthesiologist, believes Congress exceeded its authority by passing the overhaul bill. But he said that if Texas lawmakers do not design their own health insurance exchange, the federal government would do it for them.

Plus, he said, the proposed Texas Health Insurance Connector, which could operate as a kind of Orbitz for buying health insurance and has the support of the state’s most vocal health care organizations, would be beneficial even if the federal overhaul law is repealed or overturned by the courts.

“In the spirit of our 10th Amendment rights, I don’t want to cede anything to the federal government,” Mr. Zerwas said.

eramshaw@texastribune.org

Mexico’s Universal Health Care Is Work in Progress

Posted: 29 Jan 2011 10:40 PM PST

YAUTEPEC, Mexico — When her twin girls were born seven weeks early, Azucena Mora Díaz did not have to worry about how she would pay for expensive hospital care, even though her husband has only a low-wage job as a construction worker’s assistant.

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Adriana Zehbrauskas for The New York Times

Quality varies, and people in poor Guerrero may seek care in nearby Yautepec or Cuernavaca, where Lucila Rivera Díaz, right, waited with her son.

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Yautepec, Mexico
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Adriana Zehbrauskas for The New York Times

Roque Nava and his wife, Ángela Casarrubias Crespo, went to a mobile clinic in Morelos State despite his skepticism toward the government’s health plan.

Under a government insurance plan for the poor, the girls were treated at the Women’s Hospital here and continue to receive follow-up care to monitor their development. The couple pays nothing.

“We owe everything to this,” Ms. Mora said as one of the twins, now 13 months old, squirmed in her arms, wearing a T-shirt emblazoned with a single word: “Smile.”

A decade ago, half of all Mexicans had no health insurance at all. Then the country’s Congress passed a bill to ensure health care for every Mexican without access to it. The goal was explicit: universal coverage.

By September, the government expects to have enrolled about 51 million people in the insurance plan it created six years ago — effectively reaching the target, at least on paper.

The big question, critics contend, is whether all those people actually get the health care the government has promised.

Under the plan, children with leukemia have been cured, women receive breast cancer treatment, elderly people get cataract operations and people with H.I.V. are assured their drugs. Usually at no cost.

Even critics who argue that the government is failing to live up to the promise of universal health coverage acknowledge that Mexico’s program saves lives and protects families from falling into poverty in many cases of catastrophic illness.

But the task of covering so many people’s care, with a budget of about $12 billion this year, is enormous. Still, Salomón Chertorivski, who is in charge of the government’s system of social protection for health, believes it is possible.

“It’s an ideal moment for the transformation that we’re carrying out,” he said, arguing that because only 9 percent of Mexicans are over 60, health costs for the country’s relatively youthful population are low. “Easy it isn’t. And it shouldn’t just be sufficient, but it should also have the quality that you would expect.”

In Mexico’s poorer states and among its most destitute, that quality is still lacking. A study by Mexico’s National Institute for Public Health questioned how well the plan was being carried out at the state and local levels, saying their contributions and lack of transparency “leave much to be desired.”

This month, Mexico’s health minister, José Ángel Córdova, acknowledged the gaps, noting that 8 percent of the country’s municipalities still lacked any kind of health facility. “There is still first-, second- and third-class medicine,” he said in a speech.

While the undertaking is relatively young, the Health Ministry’s own statistics show that it is behind its own targets in reducing infant and maternal mortality — key health indicators — in the poorest states.

But 10 years ago, only about half the population was covered by insurance. A small sliver at the top have private insurance, and most salaried workers are treated in a giant, but fraying, public health system known as the Mexican Social Security Institute.

Because that system links coverage to employment, much like in the United States, it leaves out tens of millions of people: workers getting by on odd jobs, farmers, the self-employed, street vendors.

A health safety net for those people did exist, with clinics and hospitals run by state governments. Treatment often came with a fee, and once patients were discharged from the hospital, they had to buy their own medication. Unable to afford it, many simply gave up.

This rickety infrastructure served as the base of the new Seguro Popular, or popular insurance, which was begun in 2004. Any Mexican can sign up. A broad package of basic medical services is guaranteed, along with medicine and coverage for some catastrophic illnesses. The program was designed to charge a yearly fee based on income, but in practice hardly anybody pays because, the government argues, most of the participants are too poor.

Dr. Julio Frenk, the former health minister who designed the effort, says it ties government spending directly to how many people enroll. “We changed the budgeting logic,” said Dr. Frenk, now dean of the faculty at the Harvard School of Public Health.

In that respect, the program has met one of its basic goals, increasing public health spending — by an additional 1.5 percent of gross domestic product, Mr. Chertorivski said.

But that still leaves it below developed nations and some other Latin American countries, like Chile and Costa Rica, according to figures from the Organization for Economic Cooperation and Development and the Pan American Health Organization.

Analysts question how the government came up with a budget of about $200 per patient, arguing that it is too low, and they ask how efficiently the money is being spent.

“It is probably true that the Seguro Popular has increased people’s access to health care,” said Jason Lakin, an expert at the International Budget Partnership in Washington.

But “the system was not efficient before,” he added. “It’s unclear whether the Seguro Popular has made it more efficient.”

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