Sunday, January 23, 2011

Health - Patient Money: How to Plan For and Handle the Cost of Braces

Health - Patient Money: How to Plan For and Handle the Cost of Braces

Patient Money: How to Plan For and Handle the Cost of Braces

Posted: 21 Jan 2011 09:40 PM PST

BRACES. Few words strike more fear into a parent’s heart.

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Dr. Lee Graber shows patient Jiro Nakazaki how his teeth will be realigned during his orthodontic treatment.

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You can see that your child’s bite is misaligned or that his teeth are sticking out in all the wrong places. You know what’s coming: months of treatment and an orthodontist bill anywhere from $3,000 to $7,000. That’s a lot of money.

“The price of braces is outrageous,” said Tina Sigman, who, interestingly, is an orthodontist’s assistant in Norton, Mass. Ms. Sigman took her 13-year-old daughter, Victoria, to the orthodontist she works for, Dr. Jess Kane, last year to see if something could be done about the slightly protruding teeth crowding her daughter’s mouth.

“It wasn’t a major case,” Ms. Sigman said, “but it was still going to cost $3,500.”

When Ms. Sigman told Dr. Kane she couldn’t afford to pay that much, he told her about Smiles Change Lives, a nonprofit organization that, for a low fee, connects children whose families cannot afford braces with orthodontists willing to provide the service free. Ms. Sigman’s daughter was accepted to the program and is about halfway through treatment with Dr. Kane.

Victoria is already feeling more confident. “She was worried that her teeth stuck out,” Ms. Sigman said. “It’s a great relief to know I could do this for her.”

Getting good orthodontic care is more than just an aesthetic issue. Severe crowding or crooked teeth can inhibit good brushing and flossing, making it harder to keep teeth and gums healthy. In addition, crooked teeth or a bite that doesn’t align may strain jaw muscles and wear down teeth over time.

But paying for orthodontics can be difficult. Dental insurance rarely covers more than a small percentage of orthodontic treatment. Few patients find or qualify for programs like the one Ms. Sigman used.

Moreover, a push for earlier detection of problems in children may mean parents will be facing these bills much sooner than they may think. And the costs are rising with the introduction of new technologies, like three-dimensional imaging, that help with diagnosis and more precise treatments.

Smart planning and budgeting can offset some costs and make the expense easier to handle, said Dr. Lee Graber, an orthodontist in Vernon Hills, Ill., and president of the American Association of Orthodontists. These tips may help.

PROVIDERS AND FEES Orthodontists’ fees can vary widely from one area to another and from one doctor to the next. Be sure to get several recommendations from your dentist, friends and family.

Consult with at least three orthodontists to get an idea of what treatment is involved and what the price will be. Often both are negotiable, or at least up for discussion.

“We have to take the individual into account,” Dr. Kane said. “If what I think is an ideal result would make the treatment more complex and in my eyes this should be a high priority, if in the patient’s eyes it isn’t, I have to deal with that. The orthodontist has to tailor a treatment plan accordingly.”

Choose an orthodontist your child likes and trusts. The average treatment time is 23 months. That’s a lot of office visits, and they will be much easier if patient and doctor have a good rapport.

A PAYMENT PLAN Most orthodontists offer monthly payment plans extended over the time of treatment with no interest or other charges. If you intend to use a plan, discuss the terms — how much per month over how many months — before treatment starts.

Many orthodontists are willing to extend the length of payment and make other adjustments to help ease the burden. But you need to ask.

Some orthodontists offer discounts for upfront payments. If you can afford it, this is probably the best option for an uncomplicated treatment plan. That way you won’t unwittingly pay for treatment your child ends up not needing.

Use caution with third-party extended payment programs, sometimes through orthodontists’ offices. These programs extend your payments over five to seven years, but you’ll often end up paying hefty interest charges.

AFFORDABLE ALTERNATIVES If shopping around and payment plans don’t offer enough relief, look for a college or university near you with an orthodontics program.

Much as you can at dental schools, you can get high-quality care from residents supervised by experienced orthodontists for about two-thirds the cost of care in private practice. To find a school near you, check the list of accredited schools on the Web site of the American Association of Orthodontists: www.aaomembers.org/Education/Accredited-schools.cfm.

Ask your orthodontist about other programs in your area that may offer assistance. In addition to Smiles Change Lives, the Smiles for Life Foundation also provides help to needy families, as do many state programs.

“Orthodontists are aware that access to care is an important issue,” said Dr. Kane, adding that more doctors are getting involved in pro bono programs.

INSURANCE COVERAGE If you have dental insurance through work, check the policy or your benefits department to see what orthodontics, if any, are covered.

Most policies that offer orthodontic coverage pay only 25 percent, at most 50 percent, according to LeAnn Smith, chief operating officer of Smiles Change Lives. Still, every bit helps.

If you don’t have dental insurance, try searching for a policy at www.dentalplans.com that covers orthodontics. For an annual fee of $100 to $200, you’ll receive discounts at participating orthodontists.

Be sure to read the fine print. These plans can be severely limited, especially when it comes to braces. Make sure any discount adds up to more than the annual fee.

Keep in mind you can also save pretax dollars to help pay for these treatments in a flexible spending account or health savings account, if you have one.

UNEXPECTED EXPENSES Keep in mind the orthodontist’s bill may not be the only cost you incur with braces.

For adult patients particularly, getting braces may also mean a deep cleaning and the replacement of old fillings before treatment begins. For adults and children, removing teeth is sometimes part of the pretreatment plan.

In addition, clear, invisible or colored braces often cost more, but for obvious reasons can be more appealing than the less expensive traditional metal braces. Weigh the pros and cons against your budget to determine what’s best for you.

France Seeks to Let Icons Light Up Once More

Posted: 21 Jan 2011 10:15 PM PST

PARIS — France may count more than its share of iconic chain-smokers — from Jean-Paul Sartre to Alain Delon — but for two decades the country has been systematically removing cigarettes from their fingertips or lips in any advertisements that use their likenesses. This week, though, a parliamentary committee approved a bill that would give back the tobacco products those celebrities held so dear, and by which they came to be known.

The Cultural Affairs and Education Committee of the National Assembly, the lower house of Parliament, voted Wednesday to exempt “artistic or cultural works” from a 1991 law that prohibits tobacco advertisements, but that also prevents the presence of tobacco in advertisements for goods of any kind. The full National Assembly is expected to approve the bill this month.

“In the name of a preoccupation with health, paved with good intentions, we’re ending up changing works of art and, more concerning, history,” a Socialist member of Parliament, Didier Mathus, told the committee, according to an official transcript. The bill cited several examples of artwork that was tampered with:

¶In 1996, the French postal service issued a commemorative stamp featuring the portrait of André Malraux, a writer and a former minister of culture, but without the cigarette that hung from his lips in the well-known photograph on which it was based.

¶In 2005, in advertisements and catalog covers for a Sartre exhibit at the National Library of France, held in honor of the centennial of the philosopher’s birth, a cigarette butt was erased from between the index and middle finger of his right hand.

¶In advertisements for a 2009 retrospective on the work of the filmmaker Jacques Tati, the management of Paris’s public transportation system replaced the iconic pipe of M. Hulot, one of Mr. Tati’s best-loved characters, with a yellow pinwheel.

“It was ridiculous,” said Cécile Husson, a gravelly-voiced, 37-year-old schoolteacher, as she puffed on a cigarette on the Place Gambetta in the 20th Arrondissement. “It didn’t have any impact on whether people smoked or not.”

But she added, “We’re so bombarded by ads, I’m not even sure people noticed.”

States Face Shortage of Key Lethal Injection Drug

Posted: 21 Jan 2011 10:57 PM PST

The sole American manufacturer of an anesthetic widely used in lethal injections said Friday that it would no longer produce the drug, a move likely to delay more executions and force states to adopt new drug combinations.

The manufacturer, Hospira Inc., of Lake Forest, Ill., had originally planned to resume production of the drug, sodium thiopental, this winter at a plant in Italy, giving state corrections departments hope that the scarcity that began last fall would ease.

But the Italian authorities said they would not permit export of the drug if it might be used for capital punishment. Hospira said in a statement Friday that its aim was to serve medical customers, but that “we could not prevent the drug from being diverted to departments of corrections” and the company did not want to expose itself to liability in Italy.

Hospira does not have domestic facilities that can make sodium thiopental, said Daniel Rosenberg, a spokesman, and has decided to “exit the market.” No other American companies manufacture the drug, which has largely been supplanted by alternatives in hospitals but is used by 34 of the 35 states that use lethal injection to carry out the death penalty. An average of 55 executions have taken place annually over the last 10 years, with 46 last year and 52 in 2009, virtually all of them by lethal injection.

During what had been described as a temporary halt to production last year, scarcity of sodium thiopental led to delays in scheduled executions in at least two states, California and Oklahoma.

The extent to which execution schedules will be further disrupted by the drug shortage is not yet clear, but it could be considerable. In many states, adopting a new protocol for lethal injections requires formal proposals, public comment and often challenges in court — a process that can take months or more, said Richard Dieter, executive director of the Death Penalty Information Center. But in others, switching drugs might be done more quickly, by administrative fiat.

Lethal injections commonly involve a sequence of three drugs that is set by state regulations: an anesthetic — sodium thiopental in every state but Oklahoma — intended to prevent pain, followed by a muscle relaxant and a drug that stops the heart.

As the shortage became acute last fall, California and Arizona obtained shipments of sodium thiopental from England, but the British government has since refused to allow exports of drugs for use in capital punishment, a policy that is under consideration by the entire European Union.

Those were two of several special shipments to corrections departments permitted by the Food and Drug Administration in 2009 and 2010, said Christopher Kelly, a spokesman for the agency. “No shipments are currently being held,” Mr. Kelly said on Friday.

Texas, which carries out more executions than any other state, has an aging stock of sodium thiopental that will expire in March, leaving it unusable.

“There currently are four executions scheduled in Texas — two in February, one in May and one in July,” said Michelle Lyons, director of public information at the Texas Department of Criminal Justice. “At this time, we have enough sodium thiopental on hand to carry out the two executions scheduled in February. In March, our supply of this particular drug is set to expire.”

“The Texas Department of Criminal Justice will explore other options, including possibly seeking an alternate drug for use in Texas’ lethal injection process,” she said in an e-mail.

Two states, Ohio and Washington, use only one drug, sodium thiopental, which is fatal at larger doses for executions.

“What I can tell you is Ohio does have enough sodium pentothal to carry out the execution scheduled in February,” said JoEllen Smith, a spokeswoman for the Ohio Department of Rehabilitation and Correction, using an alternate name for the drug. “But beyond that we are going to decline to comment on our supply of the lethal injection drug.”

Officials in Washington said that they had not had time to consider how to adapt to the news that sodium thiopental will no longer be available. The state has seven people on death row, but no executions are currently scheduled.

Officials in Arizona, where 134 people are on death row, said they had enough sodium thiopental for five executions, although none are currently scheduled.

Many states are expected to follow the lead of Oklahoma, substituting pentobarbital — another, more easily available anesthetic — in a similar three-drug sequence.

Pentobarbital is widely used in veterinary medicine and is also used in legal human euthanasia in Oregon. Death penalty opponents challenged the switch last year in Oklahoma, arguing that the effectiveness of pentobarbital in preventing pain during executions had not been proved. But a federal judge sided with the state, which has since used the new drug in three executions.

Jerry Massie, a spokesman for the Oklahoma Department of Corrections, said the department orders the drug through a “private pharmacist” but would not specify who.

Only one company, Lundbeck Inc., now markets injectable pentobarbital in the United States, according to the F.D.A., but the agency said it was not aware of any shortage.

Vital Signs: Aging: Shingles Vaccine Shows Promise for Older Adults

Posted: 21 Jan 2011 10:50 PM PST

The herpes zoster vaccine, which has already proved effective for preventing shingles in a large clinical trial, may be even more effective in broad clinical practice.

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Researchers studied 75,761 vaccinated men and women 60 and older and 227,283 unvaccinated people matched for age. All were participants in a Southern California health plan that covered the cost of the shots.

The study, published Jan. 12 in The Journal of the American Medical Association, found a 55 percent reduction in incidence of the painful condition, consistent with the 51 percent found in the clinical trial. But it also found that the vaccine was effective across all ages, while the clinical trial had found it less effective in the oldest people tested.

The observational study also found it effective in preventing infection of the eyes, a common occurrence with shingles that was not studied in the clinical trial.

The vaccine worked equally well in both sexes, across all racial groups, and in those with chronic diseases like diabetes or kidney, lung and liver conditions.

The lead author, Hung Fu Tseng, a research scientist with Kaiser Permanente, said that there were some contraindications for the vaccine, and that people over 60 should discuss them with a doctor. But he added, “Shingles is a painful condition, and any measure that might reduce the risk would be helpful.”

Vital Signs: Vision: Making Inroads in Macular Degeneration

Posted: 21 Jan 2011 10:05 AM PST

In 2004, scientists at the National Eye Institute predicted that as the population aged, the rate of macular degeneration, an incurable eye disease with no known cause, would increase substantially. They appear to have been wrong.

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An analysis of data from the 2005-8 National Health and Nutrition Examination Survey has found that since the previous survey, finished in 1994, the prevalence of the disease has decreased more than 9 percent. The scientists speculate that the change was caused by reductions in smoking and improvements in diet, physical activity and blood pressure.

In age-related macular degeneration, the macula, the center of the retina, deteriorates. Gradually, central vision may become blurred, or a completely dark area may appear in the center of the vision.

The researchers, whose report appears in the January issue of The Archives of Ophthalmology, examined retinal photographs of more than 5,500 people over 40 and graded them for severity of disease using several well-established criteria. They estimated that about 1 in 15 people over 40 — 7.2 million Americans in all — have age-related macular degeneration. Prevalence was higher among white patients than black patients. The lead author, Dr. Robert Klein, a professor of ophthalmology at the University of Wisconsin, said, “The important point is to try to understand why these trends are occurring, to help prevent future generations from developing the illness.”

Vital Signs: Regimens: Antidepressant May Help Quench Hot Flashes

Posted: 21 Jan 2011 10:50 PM PST

A new study suggests that a widely prescribed antidepressant may provide at least some relief for women with hot flashes.

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Hormone replacement therapy is now the only treatment approved by the Food and Drug Administration for menopausal symptoms, but many believe its risks outweigh its benefits.

This study, published Thursday in The Journal of the American Medical Association, was a randomized, double-blinded, placebo-controlled trial of escitalopram (brand name Lexapro) in which 97 menopausal women took the drug for eight weeks while a matched group took a placebo.

Just over half of the women in the treatment group reported a decrease of at least 50 percent in the frequency of hot flashes, compared with 36 percent in the placebo group.

Women taking escitalopram averaged 1.41 fewer hot flashes per day than in those on the placebo, and there were no serious side effects. And almost two-thirds of the treatment group wanted to continue the medication, compared with 42 percent of the others.

The lead author, Ellen W. Freeman, a professor of obstetrics and gynecology at the University of Pennsylvania, stressed that this is an off-label use of the drug not approved by the F.D.A. Still, she said, “it provides an option, and there’s not much out there that has been shown to be effective.”

Several of the authors have received research support in the past from the manufacturer of Lexapro, Forest Laboratories, which supplied the drug for this study.

Across Country, Lawmakers Push Abortion Curbs

Posted: 22 Jan 2011 08:21 AM PST

Newly energized by their success in November’s midterm elections, conservative legislators in dozens of states are mounting aggressive campaigns to limit abortions.

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The lawmakers are drafting, and some have already introduced, bills that would ban most abortions at 20 weeks after conception, push women considering abortions to view a live ultrasound of the fetus, or curb insurance coverage, among other proposals.

In Florida and Kansas, legislators plan to reintroduce measures that were vetoed by previous governors but have the support of the new chief executives, like ultrasound requirements and more stringent regulation of late-term abortions.

“I call on the Legislature to bring to my desk legislation that protects the unborn, establishing a culture of life in Kansas,” Gov. Sam Brownback said last week in his first State of the State message.

“This is the best climate for passing pro-life laws in years,” said Michael Gonidakis, executive director of Ohio Right to Life, expressing the mood in many states. “We’ve got a pro-life governor and a brand new pro-life speaker. Our government now is pro-life from top to bottom.”

Abortion opponents plan marches in Washington and elsewhere this weekend and on Monday to mark the anniversary of the 1973 Supreme Court decision, Roe v. Wade, that established a woman’s right to an abortion.

Republicans in Congress hope to strengthen measures to prevent even indirect public financing of abortions, but laws in the states have the greatest impact on access to them. Abortion opponents have been emboldened by major changes in the political landscape, with conservative Republicans making large gains.

Although social issues were often played down in the campaigns, many of the newly elected governors and legislators are also solidly anti-abortion, causing advocates of abortion rights to brace for a year of even tougher battles than usual.

The biggest shift is in the state capitols, with 29 governors now considered to be solidly anti-abortion, compared with 21 last year. “This is worrisome because the governors have been the firewall, they’ve vetoed a lot of bad anti-choice legislation,” said Ted Miller, a spokesman for Naral Pro-Choice America.

In 15 states, compared with 10 last year, both the legislature and the governor are anti-abortion, according to a new report by Naral, and those joining this category include larger states like Michigan, Ohio and Wisconsin, as well as Georgia and Oklahoma. Maine and Pennsylvania are now strongly anti-abortion as well, if not quite as solidly.

Just which measures will pass is impossible to predict, particularly because many states are bogged down by budget crises.

Elizabeth Nash, who tracks state policies on abortion for the Guttmacher Institute, a research organization, said that while states would be preoccupied with budget issues, it appeared rather likely that more measures would pass this year than in 2010, which anti-abortion advocates considered a banner year, with more than 30 restrictive laws adopted in at least nine states.

The elections brought even more gains for their side than expected, said Mary Spaulding Balch, state policy director of the National Right to Life Committee, leading her group to call in its affiliates for a special strategy session on Dec. 7.

While many anti-abortion measures have been adopted or debated over the years, including requiring parental consent for minors and waiting periods, advocates have set a few top priorities for the months ahead:

¶Banning abortions earlier in pregnancy. Most states place restrictions on later abortions, often defined as after fetal viability, or around 22 to 26 weeks after conception. But last year, Nebraska set what many advocates consider a new gold standard, banning abortions, unless there is imminent danger to the woman’s life or physical health, at 20 weeks after conception, on a disputed theory that the fetus can feel pain at that point. The measure has not been tested in court, but similar measures pushing back the permissible timing are being developed in Indiana, Iowa, New Hampshire, Oklahoma and other states.

The 20-week law in Nebraska, which took effect in October, forced a prominent doctor who performed late-term abortions to leave the state. Jill June, president of Planned Parenthood of the Heartland, said women suffering from complicated pregnancies but are not yet sick enough to qualify for an emergency abortion would be forced to travel to other states. Or, she said, doctors fearing prosecution will wait until such women become dangerously ill before considering an abortion.

¶Pressing women to view ultrasounds. While several states encourage women seeking abortions to view an ultrasound, Oklahoma last year adopted a requirement that doctors or technicians perform the procedure with the screen visible to the woman, and explain in detail what she is seeing. The measure is under court challenge, but the Kentucky Senate has passed a similar bill, and variants are expected to come up in states including Indiana, Maryland, Montana, Ohio, Texas, Virginia and Wyoming.

In Florida, former Gov. Charlie Crist vetoed an ultrasound bill. The new governor, Rick Scott, attacked him for that veto and is expected to support a new proposal.

¶Banning any abortion coverage by insurance companies in the new health insurance exchanges. Numerous states are poised to impose the ban on plans that will be offered to small businesses and individual insurance buyers under the Obama administration health plan.

The shifts to conservative governors, in particular, have opened new opportunities for abortion opponents. In Kansas, legislators said they would act quickly to adopt measures that were previously vetoed, including regulations that will make it harder to open abortion clinics or to perform abortions in the second trimester.

“There’s pent-up demand in the Legislature for these changes,” said State Representative Lance Kinzer, the chairman of the Judiciary Committee in the Kansas House. Once these long-debated steps are taken, he said, the Legislature will consider more sweeping restrictions, including banning most abortions after the 20th week.

The politics of abortion have changed profoundly in some larger states including Michigan, Pennsylvania and Wisconsin.

“We’re facing the biggest threat to reproductive rights we’ve ever faced in this state,” said Lisa Subeck, executive director for Naral Pro-Choice Wisconsin.

In Michigan, because of the switch to an anti-abortion governor, “the dominos are lined up well for us this time,” said Ed Rivet, legislative director for Right to Life of Michigan. For starters, advocates hope to pass a state ban on the procedure opponents call partial-birth abortion that had been vetoed twice. After that, he said, “We have quite a list.”

Many defenders of abortion rights argue that because the election hinged largely on the economy and the role of government, officials did not receive a mandate for sweeping new social measures. “This last election was not about these issues at all,” said Cecile Richards, president of the Planned Parenthood Federation of America. “We now are concerned about a real overreaching by some state legislators and governors that will make it very difficult for women to access reproductive health care.”

Daniel S. McConchie, vice president for government affairs with Americans United for Life, responded that laws restricting abortion have been adopted right along by the states and that while he expected large gains in the year ahead, they will be part of steady trend.

The abortion rate in the United States, which had declined steadily since a 1981 peak of more than 29 abortions per 1,000 women, stalled between 2005 and 2008, at slightly under 20 abortions per 1,000 women, according to a new report from the Guttmacher Institute.

Robbie Brown contributed reporting from Atlanta, Dan Frosch from Denver and Emma Graves Fitzsimmons from Chicago.

Beliefs: Many Choices on the Menu of Religious Fasts

Posted: 21 Jan 2011 11:10 PM PST

JACKSONVILLE, Fla. — After last Sunday night’s service at Celebration Church, where a 10-piece band played Christian rock for 1,600 worshipers, Stovall Weems, the pastor, met me in his “green room” and offered nibbles from a tray of kiwi, pineapple and melon slices.

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Laura McElroy says her water-only fast is sometimes a challenge as she prepares food for her children, Sydney, left, and Colin.

In a showbiz green room, the fruit is for waist-conscious guests. But backstage at Jacksonville’s largest church, Mr. Weems — a muscular, friendly guy you desperately want to call “dude” — stocks fruit because it is all some of his staff members are eating right now.

For the rest of January, the pastor will not eat even that.

Mr. Weems has fasted periodically over the last 20 years, ever since, as a coke-snorting Theta Xi brother at Louisiana State University, he found Jesus and joined a group that encouraged fasting as a way to draw closer to God.

Twelve years ago, believing that God called him to Jacksonville, Mr. Weems founded the evangelical, nondenominational Celebration Church. As it grew to more than 10,000 worshipers a week, at 12 campuses, he always preached a combination of fasting and prayer for spiritual growth.

And two years ago he started Awakening, a three-week campaign that he invited other churches to join. The first year, nearly 400 churches participated, and for Awakening 2011, which runs through Jan. 30, there are more than 1,000 participating churches in the United States, Poland, Zimbabwe and elsewhere.

For some pastors, participation in Awakening means simulcasting Mr. Weems’s services at their church; for others, buying bulk orders of “Awakening” (WaterBrook Press), his new book; and for all of them, at least some fasting.

Mr. Weems, an avid weightlifter, talks about fasting as if it were an extreme sport. In the green room, he says that when he first fasted, in college, it was “an energy shot” in his relationship with God.

In “Awakening,” the book — which contains sentences like “Fasting hits the reset button of your soul” and exclamations of “Wow!” — Mr. Weems argues that Christian fasting is different from Old Testament, or what we might call Jewish, fasting.

In the Old Testament, Mr. Weems writes, fasting primarily “had to do with mourning or getting God to intervene in a crisis.” But “under the New Covenant,” he explains, “fasting is a way of celebrating the goodness of God and that because of Jesus we have already received God’s mercy, forgiveness and favor.”

And such fasting, Mr. Weems believes, can take many forms. He writes of finding one’s “fast zone,” which is “the place where you feel light and spiritually true. Your mind is easily focused on God and spiritual things. You have an increased spiritual energy — you can feel the fast working.”

In the green room, Mr. Weems says some people try a water fast, giving up all food, but maybe the next year “kind of back off and do a Daniel or mixture of juices.” The “Daniel fast” is based on Chapter 1 of the Book of Daniel, in the Old Testament, in which Daniel eats only vegetables and drinks only water.

In past years, Mr. Weems has done the Daniel, but this year he is following a liquid diet that includes vegetable broth and smoothies.

Lauren F. Winner, who teaches at Duke Divinity School and wrote about fasting in “Mudhouse Sabbath,” said early Christians fasted on Wednesdays and Fridays, as well as during Lent. That practice has risen and fallen over the ages, but it “saw an uptick among evangelicals in the late 1990s.”

There are Web sites devoted to the Daniel fast, and other preachers, like Jentezen Franklin of Gainesville, Ga., sponsor three-week fasts in January, a popular time for renewal.

Dr. Winner agreed that fasting can be spiritually beneficial. But she said biblical fasting occurred in diverse contexts, from Hannah’s fasting and praying to get pregnant, in the Old Testament, to Jesus’ fasting in the wilderness, in the New.

In other words, fasting is more complex than Mr. Weems’s book suggests.

“It seems an oversimplification to say that fasting is mournful in the Hebrew Bible and celebratory in the New Testament,” Dr. Winner said. “I worry that such a description subtly plays into pernicious ideas about the Old Testament as burdensome and the New Testament as freeing.

“In both testaments, fasting is ultimately about connecting people with God.”

Mr. Weems’s followers are drinking in his gospel. All 10 worshipers I met after Sunday’s service are fasting somehow. One put me in touch with a friend, Laura McElroy, who is subsisting for three weeks on just water.

Ms. McElroy first did a water fast last year, after reading about it in “Celebration of Discipline,” by Richard J. Foster.

“I knew the minute I read it, I knew that’s what God wanted me to do,” Ms. McElroy said.

When we spoke, she was on Day 8. Saying the discipline of fasting helps clarify God’s intentions for her, she pointed to Matthew 17, where Jesus recommends prayer and fasting to his disciples.

But she does not say fasting is easy.

“I have small children,” said Ms. McElroy, 27, a preschool teacher and mother of two. “Making their dinner, serving food, being around it — if I don’t drink enough water, I get kind of weak. And in those moments when I think, ‘O.K., God, I can’t do this,’ I rely on his strength.

“I might suck on some hard candy if I need something in my mouth. But other than that, I have no temptation, because I know why I’m doing it.”

Mark.Oppenheimer@nytimes.com

Recipes for Health: Celery Root, Potato and Apple Purée

Posted: 21 Jan 2011 12:20 AM PST

Classic celery root and potato purées combine two parts potatoes with one part celery root. I’ve reversed the proportion here for a lighter purée that also incorporates apple — the “secret ingredient." Rather than milk, I usually use the broth from the celery root and apples.

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

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1 pound Yukon gold potatoes, peeled and cut into large pieces

2 large celery roots, about 2 pounds, peeled and cut into large pieces

1 large or 2 small tart apples, such as a Granny Smith, peeled, cored and quartered

1/2 cup, approximately, warm milk or broth from the celery root

2 tablespoons butter or walnut oil (or a combination)

Salt and freshly ground pepper to taste

1. Place the potatoes in one saucepan and the celery root and apples in another. Add salt to taste to each, about 1/2 teaspoon. Bring to a boil, reduce the heat and simmer until tender, 15 to 20 minutes.

2. Drain the potatoes, and return to the pot. Cover tightly, and allow to sit for five minutes to steam and dry out. Drain the celery root and apples through a strainer set over a bowl. Purée all of the produce using a food mill or a potato ricer. Stir together, and whisk in the milk or the broth until the mixture is fluffy. Add the butter or walnut oil to the hot purée, stir until the butter melts, and season to taste with salt and pepper.

Yield: Serves six.

Advance preparation: You can make this up to an hour before serving. Make sure to have some extra broth or milk on hand to thin out the purée, as it will stiffen as it cools. Reheat gently on top of the stove.

Nutritional information per serving: 185 calories; 5 grams fat; 3 grams saturated fat; 11 milligrams cholesterol; 34 grams carbohydrates; 5 grams dietary fiber; 192 milligrams sodium (does not include salt to taste); 5 grams protein

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

To Really Learn, Quit Studying and Take a Test

Posted: 20 Jan 2011 10:20 PM PST

Taking a test is not just a passive mechanism for assessing how much people know, according to new research. It actually helps people learn, and it works better than a number of other studying techniques.

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The research, published online Thursday in the journal Science, found that students who read a passage, then took a test asking them to recall what they had read, retained about 50 percent more of the information a week later than students who used two other methods.

One of those methods — repeatedly studying the material — is familiar to legions of students who cram before exams. The other — having students draw detailed diagrams documenting what they are learning — is prized by many teachers because it forces students to make connections among facts.

These other methods not only are popular, the researchers reported; they also seem to give students the illusion that they know material better than they do.

In the experiments, the students were asked to predict how much they would remember a week after using one of the methods to learn the material. Those who took the test after reading the passage predicted they would remember less than the other students predicted — but the results were just the opposite.

“I think that learning is all about retrieving, all about reconstructing our knowledge,” said the lead author, Jeffrey Karpicke, an assistant professor of psychology at Purdue University. “I think that we’re tapping into something fundamental about how the mind works when we talk about retrieval.”

Several cognitive scientists and education experts said the results were striking.

The students who took the recall tests may “recognize some gaps in their knowledge,” said Marcia Linn, an education professor at the University of California, Berkeley, “and they might revisit the ideas in the back of their mind or the front of their mind.”

When they are later asked what they have learned, she went on, they can more easily “retrieve it and organize the knowledge that they have in a way that makes sense to them.”

The researchers engaged 200 college students in two experiments, assigning them to read several paragraphs about a scientific subject — how the digestive system works, for example, or the different types of vertebrate muscle tissue.

In the first experiment, the students were divided into four groups. One did nothing more than read the text for five minutes. Another studied the passage in four consecutive five-minute sessions.

A third group engaged in “concept mapping,” in which, with the passage in front of them, they arranged information from the passage into a kind of diagram, writing details and ideas in hand-drawn bubbles and linking the bubbles in an organized way.

The final group took a “retrieval practice” test. Without the passage in front of them, they wrote what they remembered in a free-form essay for 10 minutes. Then they reread the passage and took another retrieval practice test.

A week later all four groups were given a short-answer test that assessed their ability to recall facts and draw logical conclusions based on the facts.

The second experiment focused only on concept mapping and retrieval practice testing, with each student doing an exercise using each method. In this initial phase, researchers reported, students who made diagrams while consulting the passage included more detail than students asked to recall what they had just read in an essay.

But when they were evaluated a week later, the students in the testing group did much better than the concept mappers. They even did better when they were evaluated not with a short-answer test but with a test requiring them to draw a concept map from memory.

Why retrieval testing helps is still unknown. Perhaps it is because by remembering information we are organizing it and creating cues and connections that our brains later recognize.

“When you’re retrieving something out of a computer’s memory, you don’t change anything — it’s simple playback,” said Robert Bjork, a psychologist at the University of California, Los Angeles, who was not involved with the study.

But “when we use our memories by retrieving things, we change our access” to that information, Dr. Bjork said. “What we recall becomes more recallable in the future. In a sense you are practicing what you are going to need to do later.”

It may also be that the struggle involved in recalling something helps reinforce it in our brains.

Maybe that is also why students who took retrieval practice tests were less confident about how they would perform a week later.

“The struggle helps you learn, but it makes you feel like you’re not learning,” said Nate Kornell, a psychologist at Williams College. “You feel like: ‘I don’t know it that well. This is hard and I’m having trouble coming up with this information.’ ”

By contrast, he said, when rereading texts and possibly even drawing diagrams, “you say: ‘Oh, this is easier. I read this already.’ ”

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F.D.A. Sees Promise in Alzheimer’s Imaging Drug

Posted: 21 Jan 2011 03:40 PM PST

An advisory committee to the Food and Drug Administration recommended unanimously Thursday that the agency approve the first test — a brain scan — that can show the characteristic plaques of Alzheimer’s disease in the brain of a living person. The approval was contingent on radiologists agreeing on what the scans say and doctors being trained in how to read the scans.

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The F.D.A. usually follows advice from its advisory committees, and Alzheimer’s experts anticipated that the scans would be approved. The additional requirement would not be a big hurdle, said Dr. Daniel M. Skovronsky, chief executive of the company, Avid Radiopharmaceuticals, that applied to market the scans.

“We don’t know exactly what F.D.A. will want,” Dr. Skovronsky said. “But it should take months to generate this type of data, not years.”

The committee vote is “a very positive thing,” said Maria Carrillo, senior director of medical and scientific relations for the Alzheimer’s Association. “This is nothing but a positive for our families.”

More than five million Americans have Alzheimer’s disease.

Plaques are part of the criteria for having Alzheimer’s — if a person with memory problems does not have plaques, that person does not have Alzheimer’s. But without the scan, the only way to know if plaques were present is to do an autopsy.

Alzheimer’s specialists said they expected that if the scan were approved it would come into widespread use.

“This is a big deal,” said Dr. Pierre N. Tariot, director of the memory disorders center at the Banner Alzheimer’s Institute in Phoenix. Asked if he would be using the scans, Dr. Tariot replied, “Absolutely.”

Dr. Tariot is an investigator in studies by Avid, now a subsidiary of Eli Lilly & Company, and its competitors.

The approval would be for a dye that homes in on plaque in the brain, making it visible on PET scans. Such scans would be especially valuable in a common and troubling situation — trying to make a diagnosis when it is not clear whether a patient’s memory problems are a result of Alzheimer’s disease or something else. If a scan shows no plaque, the problems are not caused by Alzheimer’s and could be from tiny strokes or other diseases.

If a person has Alzheimer’s, though, there is as yet no treatment that can slow or reverse the disease, although new drugs are being tested that are intended to reduce plaque.

Nonetheless, doctors said, having a diagnosis is important for planning and for understanding what lies ahead. It also is important for family members to know because they are at increased risk if a mother or father, sister or brother has the disease. And people, they say, often want to know what is wrong with them, even when the news is bad.

The panel’s vote “has moved us a monumental step forward,” said Dr. Reisa Sperling, adding that with the scans “we will not just be guessing clinically.”

Dr. Sperling, director of the Center for Alzheimer’s Research and Treatment at Brigham and Women’s Hospital in Boston, is an unpaid consultant to Avid Radiopharmaceuticals, which makes the dye, and said she paid her own way to speak at the F.D.A. meeting in White Oak, Md.

The question about interpreting the scans arose because in the Avid study, radiologists did not establish a firm cutoff point that would say whether a person had significant amounts of plaque. Instead they did a graded analysis. What is needed in practice is a set level that would say yes or no, and distinguish significant plaque accumulation from insignificant amounts. And the company must show that its cutoff points are accurate and that different radiologists assess the same scan in the same way.

Some people have plaque without having Alzheimer’s, so if a scan shows plaque, doctors will have to use their clinical judgment, taking into account a patient’s symptoms, in deciding what the scan results mean, noted Dr. P. Murali Doraiswamy, an Alzheimer’s researcher at Duke University and a clinical investigator in the Avid trial. But if a scan shows no plaque, the situation is simpler, Dr. Doraiswamy said. It means the doctor should focus on other causes for the symptoms.

“This technique will allow family doctors to feel confident ruling out Alzheimer’s,” he said. “Until now we had to guess whether someone had plaques.”

In 2008, an advisory committee to the F.D.A. said that in order for the dye to be approved for amyloid imaging, the company would have to show that the scans were detecting the same plaques as were found on autopsy.

Avid did that, using people at the end of life who agreed to be scanned and then to have brain autopsies. The company also tested young healthy people who, presumably, would not have amyloid plaque in their brains. The scans found no plaque in those younger subjects.

At the meeting Thursday, a parade of medical experts testified about the need for the scans. Dr. Norman Foster, a professor of neurology at the University of Utah, came at his own expense even though he is a consultant to GE Healthcare, which is developing its own brain scan for plaque, to urge approval of the Avid scan.

“Physicians currently have little confidence in their ability to determine the cause of dementia, and as a result they often don’t even try,” Dr. Foster said. As a result, he said, families are left in limbo, unable to plan for the future if it is Alzheimer’s and, if it is not, delaying getting treatment.

“The preventable costs are enormous,” Dr. Foster said. “The emotional toll is incalculable.”

He told of three patients he had seen in the past two weeks who would have benefited from a scan. One is a 70-year-old man with memory problems and depression. He was given a diagnosis of depression, but only after he continued to get worse over two years did it become clear that he most likely had Alzheimer’s.

“I wish I had had the ability to do an amyloid PET scan to allow an earlier diagnosis,” Dr. Foster said. Approval of the scan, he said, “would be a historic advance in neurology and in the daily management of patients with memory complaints.”

With the committee’s vote, Dr. Doraiswamy said, “It’s a landmark day for our field.”

As U.S. Patients Await Organ Transplants, Potential Donors Struggle for Visas

Posted: 21 Jan 2011 10:13 AM PST

The clock is ticking for Dr. Gabriel Danovitch’s patient. Dr. Danovitch, a transplant surgeon at the David Geffen School of Medicine at the University of California, Los Angeles, is treating an immigrant from Mexico in his 40s whose kidneys have failed. The patient is a good candidate for a transplant and has a donor, his brother.

But there is a big problem: His brother is a Mexican citizen whose application for a visa to come to the United States was not granted.

Physicians who perform transplants say patients who need organ donations from a family member or other close match outside the United States face hurdles that are often hard to surmount. Difficulties in obtaining visas leave many potential donors frustrated and force their sick relatives in the United States to wait months or even years on a list for organs like a liver or kidney.

In other cases, poor families cannot afford to pay for the donors to travel to the United States and undergo organ-removal operations that can require hospital stays of up to three weeks. In some states, Medicaid does not cover any of a donor’s expenses, and private insurance policies vary greatly in how much they will cover.

Getting organ donations is always difficult, but medical authorities say the problems have gotten worse for immigrants with the tightening of visa policies after the terrorist attacks in 2001. And with the slowdown in the economy, some states have been cutting back financial aid to transplant patients and donors.

“If there is someone living and willing and compatible, it’s concerning that, because of so much protection, they end up not being able to help a desperate person in need,” said Bryan Stewart, a spokesman for One Legacy, a nonprofit organization that deals with organ and tissue donations in the seven-county greater Los Angeles area.

Dr. Giselle Guerra, medical director of the Living Kidney Donor Program at the University of Miami Miller School of Medicine, has similar concerns. “I wish I could get rid of all the bureaucratic red tape, and it would be nice for every donor to fit the criteria so we can stop adding to the waiting list,” she said.

More than 110,000 people were waiting for an organ as of Wednesday, according to the United Network for Organ Sharing, a private nonprofit organization that manages the nation’s organ transplant system under contract with the federal government.

Over 60,000 of those on the list are black, Hispanic, Asian, American Indian, Pacific Islander or describe themselves as multiracial, according to the organ sharing network. Of those, 6,229 are resident aliens in the United States, compared with close to 1,900 resident aliens in 2000. Illegal immigrants are prohibited from the list.

“When patients need a transplant, most of the time, the first people they turn to is their families,” said Dr. Juan Carlos Caicedo, a transplant surgeon and director of the Hispanic Transplant Program at Northwestern Memorial Hospital in Chicago. “It becomes complicated when their families are not in the U.S., which in a lot of instances, that is the case.”

The State Department does not have a medical visa category, and people traveling to the United States have to qualify for the B-1/B-2 visa, more commonly known as the tourist visa.

“Our embassies and consulates around the world do their best to assist visa applicants who are dealing with life or death situations in order to expedite their cases,” a department official wrote in an e-mail.

An individual applying for a visa for a medical reason can fill out a form requesting that the application be expedited.

But some doctors say that they have contacted State Department officials on behalf of patients and even that has not sped up the process.

“When I call the consulates or embassies, they’re not very cooperative,” Dr. Guerra said. “We try to be as concise as possible, but also explaining the urgency in the letters that we write, but it just continues to be a waiting game.”

Dr. Linda Chen, a transplant surgeon at the Miller School of Medicine, said that for about the last five years, the State Department has required foreign donor candidates to get preliminary testing done in their home country.

Blood-collection tubes are mailed to the candidates, and the filled tubes are mailed back for testing. If the donor has the same blood type, there is a possibility that he or she could be a match with the patient, and the State Department will take that into consideration, Dr. Chen said.

“But even with blood work,” Dr. Chen said, “they don’t give people visas sometimes.”

Dr. Chen said she writes letters on a monthly basis. But she cannot do that for patients whose donor relatives are in Cuba.

“Since the U.S. does not have a relationship with Cuba, we cannot help them by writing a letter or sending tests over,” Dr. Chen said.

If patients cannot get a donor into the United States, their names go on the organ network’s list to receive an organ from someone who has died. Waiting times for patients vary, and among the factors is a person’s state of residence. Patients in New York, for example, wait an average of seven to nine years, while people in Florida wait three to five years.

The No. 1 transplanted organ is the kidney. When one is needed but not readily available, patients must go through dialysis. Medicare spent $9.2 billion in 2009 on dialysis patients, according to an annual Medicare Payment Advisory Commission report due to Congress in March. Martha Escamilla-Arias, a social worker at Northwestern Memorial Hospital, said that in most cases dialysis cost the State of Illinois more than a kidney transplant in the long run.

“In Illinois, two and a half years of dialysis pays for one kidney transplant,” Ms. Escamilla-Arias said. “Some people are in dialysis for five to seven years, and if things were easier for foreign donors, it would help.”

Jean Viera, 34, a Cuban immigrant on the organ network’s list, has been going through dialysis for six years.

His left arm is disfigured with two purplish raised scars where he is connected to a dialysis machine.

“I wish I did not have to go through this,” Mr. Viera said. “This is just not the best way to live.”

House Republicans Plan Their Own Health Bills

Posted: 20 Jan 2011 09:40 PM PST

WASHINGTON — Less than 24 hours after voting to repeal the new health care law, House Republicans said Thursday that they would pass discrete bills to achieve some of the same goals, but with more restraint in the use of federal power.

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At the same time, the speaker, John A. Boehner, said House Republicans would push for much stricter limits on abortion in federal programs, including those created by the new law.

By a vote of 253 to 175, the House on Thursday directed four committees to draft legislation that would replace the health care law. The directive sets forth 13 objectives.

It says, for example, that the legislation should “lower health care premiums through increased competition and choice,” provide access to affordable coverage for people with pre-existing conditions, increase the number of Americans with insurance and provide states with “greater flexibility” to run their Medicaid programs.

Republicans did not say how they would achieve those goals, but made clear that they did not want to impose detailed federal requirements on individuals, families, employers or states.

Representative Rob Woodall, a freshman Republican from Georgia, said he was proud to have voted for repeal of the new law so Congress could “go back to the drawing board and bring things forward one at a time.”

Another freshman Republican, Representative Steve Stivers of Ohio, praised a provision of the law that allows children to stay on their parents’ insurance until they reach the age of 26.

“I am committed to working with my colleagues in a bipartisan manner to support reforms we agree on, like allowing young adults to stay on their parents’ plan,” Mr. Stivers said.

Other Republicans praised a section of the new law that helps older Americans with prescription drug costs.

President Obama said this week that he was “willing and eager” to work with members of both parties to improve the law. But aides said he would adamantly resist efforts to repeal it.

On the House floor on Thursday, Democrats said it was bizarre to see Republicans praising consumer protections in a law they had just voted to dismantle.

“It’s like Alice in Wonderland,” said Representative John Garamendi of California, a former state insurance commissioner.

Representative Lloyd Doggett, Democrat of Texas, said: “With last year’s health insurance reform law, we provided real guarantees to American families against insurance abuses. Today, Republicans tell these families, ‘Forget the binding guarantees, we have 12 platitudes for you.’ This is not a Republican prescription. It’s a placebo.”

Democrats said it would be difficult for Republicans to pick and choose among provisions of the law because the popular and unpopular parts were locked together.

Consumers like the assurance that they can obtain coverage regardless of any pre-existing condition, but dislike the requirement to carry insurance. Without such a requirement, insurers say, people could go without coverage until they needed care, driving up costs for everyone else.

In addition, Democrats said they were skeptical of Republican plans because, when Republicans controlled Congress, they did little to cover the uninsured.

Republicans recalled, however, that they secured approval of two huge changes in domestic social policy that worked much better than Democrats had predicted. They remade welfare programs in 1996 and added a prescription drug benefit to Medicare in 2003.

“The idea that Republicans are just not interested in health care and won’t do anything is belied by history,” said Stuart M. Butler, director of the Center for Policy Innovation at the conservative Heritage Foundation.

The new law will set up insurance exchanges where people can shop for coverage. Millions of low- and moderate-income people will be able to obtain federal subsidies to help defray the cost.

Mr. Boehner and other House Republican leaders on Thursday embraced a bill stipulating that — with narrow exceptions — no federal money, subsidies or tax credits could be used to pay for abortion or for any health insurance plan that includes coverage of abortion. “It’s one of our highest legislative priorities,” Mr. Boehner said, referring to the bill, offered by Representatives Christopher H. Smith, Republican of New Jersey, and Daniel Lipinski, Democrat of Illinois.

Abortion rights groups vowed to fight the proposal.

Nancy Keenan, president of Naral Pro-Choice America, said Republicans had told voters they wanted to “focus on creating jobs while limiting the role of government in our lives.” But now, she said, having taken control of the House, “they want to be able to interfere in our personal, private decisions, especially a woman’s right to choose.”

The White House said it would plow ahead with the health law, undeterred by the political uproar over it on Capitol Hill.

Kathleen Sebelius, the secretary of health and human services, offered federal money to states to help them establish insurance exchanges.

“Beginning in 2014,” Ms. Sebelius said, “these marketplaces will allow individuals and small-business owners to pool their purchasing power so the mom-and-pop shop can have the same negotiating clout as the big chain down the street.”

California and other states have begun work to set up exchanges. “It would be a huge mistake to undo this progress” by repealing the new federal law, Ms. Sebelius said.

World Briefing | EUROPE: Britain: Study Supports Virus Vaccine

Posted: 20 Jan 2011 10:48 PM PST

Countries that vaccinate babies against rotavirus, which can cause severe diarrhea and kill in days, have significantly reduced the number of children admitted to hospitals with the disease, a report showed Thursday. Data from the United States, Australia, Mexico and El Salvador, where rotavirus vaccines have recently become part of routine childhood immunizations, show steep and swift declines in the number of children under 5 who become ill with the virus, according to studies published in a supplement to The Pediatric Infectious Disease Journal. The studies also show large reductions in rotavirus disease among older, unvaccinated children, suggesting that vaccination of babies may also limit the overall amount of virus transmission in what is known as herd immunity. Rotavirus-related diarrhea kills more than 500,000 children a year and sends millions more to the hospital. Dr. John Wecker, director of the global vaccine access and delivery program at the nonprofit organization PATH, said the findings should compel policy makers and international donors to support the introduction of rotavirus vaccines in all countries as soon as possible.

House Votes for Repeal of Health Law in Symbolic Act

Posted: 20 Jan 2011 08:52 AM PST

WASHINGTON — The House voted Wednesday to repeal the Democrats’ landmark health care overhaul, marking what the new Republican majority in the chamber hailed as the fulfillment of a campaign promise and the start of an all-out effort to dismantle President Obama’s signature domestic policy achievement.

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Representatives Jean Schmidt of Ohio and Ron Paul of Texas, both Republicans, on Wednesday headed to the House floor.

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The vote was 245 to 189, with 3 Democrats joining all 242 Republicans in support of the repeal.

Leaders of the Democratic-controlled Senate have said that they will not act on the repeal measure, effectively scuttling it.

While conceding that reality, House Republicans said they would press ahead with their “repeal and replace” strategy. But the next steps will be much more difficult, as they try to forge consensus on alternatives emphasizing “free market solutions” to control health costs and expand coverage.

Even as four House committees begin drafting legislation, Republicans said they would seek other ways to stop the overhaul, by choking off money needed to carry it out and by pursuing legislation to undo specific provisions, like a requirement for most Americans to carry health insurance or face penalties. The law is also under challenge in the federal courts, with the individual coverage requirements fueling a constitutional battle likely to be decided by the Supreme Court.

The House vote was the first stage of a Republican plan to use the party’s momentum coming out of the midterm elections to keep the White House on the defensive, and will be followed by a push to scale back federal spending. In response, the administration struck a more aggressive posture than it had during the campaign to sell the health care law to the public. With many House Democrats from swing districts having lost their seats in November, the remaining Democrats held overwhelmingly together in opposition to the repeal.

On the House floor, the resulting debate was a striking reprise of the one that engulfed Capitol Hill from the spring of 2009 until March 2010, when Mr. Obama signed the health care law.

And while the tone was slightly subdued in the aftermath of the attempted assassination of Representative Gabrielle Giffords in Arizona, the debate showed that the divisions over the law remained as deep as ever.

The three Democrats who crossed the aisle to support the repeal were Representatives Dan Boren of Oklahoma, Mike McIntyre of North Carolina, and Mike Ross of Arkansas, all of whom opposed the law last year.

Ms. Giffords, who had supported the law, remains hospitalized in Arizona and was the only House member who did not vote.

Republicans denounced the law as an intrusion by the government that would prompt employers to eliminate jobs, create an unsustainable entitlement program, saddle states and the federal government with unmanageable costs, and interfere with the doctor-patient relationship. Republicans also said the law would exacerbate the steep rise in the cost of medical services.

“Repeal means paving the way for better solutions that will lower the cost without destroying jobs or bankrupting our government,” the House speaker, John A. Boehner of Ohio, said. “Repeal means keeping a promise. This is what we said we would do.”

Democrats, eager for a second chance to sell the law, trumpeted the benefits that have already taken effect. These include protections for people who would otherwise be denied insurance coverage based on a pre-existing medical condition, the ability for children to stay on their parents’ policy until age 26, and new tax breaks for small businesses that provide health coverage to their workers.

Representative John Lewis, Democrat of Georgia, said, “It is unbelievable that with so many people out of work and millions of people uninsured, the first act of this new Congress is to take health care away from people who just got coverage.”

The health care law, which Congress approved last year without a single Republican in favor, seeks to extend insurance to more than 30 million people by expanding Medicaid and providing federal subsidies to help lower and middle-income Americans buy private coverage.

Republican leaders said they had not set any timetable for the four committees drafting alternatives to the law. “I don’t know that we need artificial deadlines for the committees to act,” Mr. Boehner said. “We expect them to act in an efficient way.”

Republicans said their package would probably include proposals to allow sales of health insurance across state lines; to help small businesses band together and buy insurance; to limit damages in medical malpractice suits; and to promote the use of health savings accounts, in combination with high-deductible insurance policies.

Republicans also want to help states expand insurance pools for people with serious illnesses. The new law includes such pools, as an interim step until broader insurance coverage provisions take effect in 2014, but enrollment has fallen short of expectations.

Representative Paul Broun, Republican of Georgia, said that allowing people to buy insurance across state lines would “expand choice and competition.” And he said businesses could negotiate better insurance rates if they could join together in “association health plans,” sponsored by trade and professional groups.

But state insurance officials have resisted such proposals, on the ground that they would weaken state authority to regulate insurance and to enforce consumer protections -- a concern shared by Congressional Democrats.

Some Republicans seemed sensitive to accusations that repeal would strip away new patient protections and leave millions of Americans without insurance.

Representative Joe Heck, Republican of Nevada and a physician, said he supported some goals of the new law: “making sure people don’t lose their coverage once they get sick; letting dependent children stay on their parents’ insurance until they turn 26; making sure anyone who wants to buy insurance can purchase a policy, regardless of pre-existing conditions.”

Representative Joe L. Barton, Republican of Texas, said, “There are some things in the new law that we think are worth keeping,” including a procedure for approval of generic versions of expensive biotechnology drugs.

But Mr. Barton and other Republicans returned to a core objection to the law, which they said extends the reach of government too far.

“We believe that you shouldn’t have the federal government mandate that an individual has to have health insurance, whether he or she wants it,” Mr. Barton said. “We want to repeal today so that we can begin to replace tomorrow.”

Representative Allyson Y. Schwartz, Democrat of Pennsylvania, said she doubted that the Republican alternatives would be effective in expanding coverage or controlling costs.

“Many Republicans want to repeal the law, but are not serious about replacing it,” Ms. Schwartz said.

Doctor Is Charged in Killing of Newborns

Posted: 20 Jan 2011 07:27 AM PST

An abortion doctor who served minority and immigrant women in his clinic in Philadelphia was charged with multiple counts of murder on Wednesday in the deaths of a woman and seven newborn babies whose spinal cords had been cut with scissors, the district attorney’s office said.

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Prosecutors called Dr. Kermit Gosnell’s clinic “a baby charnel house.”

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Dr. Kermit Gosnell.

Prosecutors charged Dr. Kermit Gosnell, 69, with eight counts of murder in the deaths of Karnamaya Mongar, 41, a refugee from Nepal, who received high doses of anesthetic for an illegal late-term abortion performed in 2009 and of seven infants who were born, killed and then disposed of in Dr. Gosnell’s West Philadelphia clinic, the Women’s Medical Society.

Prosecutors laid out their case in a 281-page grand jury document that read like a grisly script. Plastic bags and mineral water bottles holding aborted fetuses were found stashed in Dr. Gosnell’s clinic. Jars containing the severed feet of babies lined a shelf, the Philadelphia district attorney, Seth Williams, said in a statement.

Dr. Gosnell, a family practitioner who was not certified in obstetrics, performed late-term abortions, after 24 weeks, which are illegal, and employed staff members who were not trained medical professionals, including a teenage girl, prosecutors said. Nine of his employees were also charged.

“It is very important to remember that Dr. Gosnell is presumed innocent,” a lawyer for Dr. Gosnell, William J. Brennan, said. “I would hope there is not a rush to judgment and that he has an opportunity to review this very lengthy charging document.”

In the grand jury document, prosecutors called Dr. Gosnell’s clinic “a baby charnel house,” riddled with fetal remains and reeking of cat urine, with furniture and blankets stained with blood. Medical equipment was broken and supplies were reused.

“The real business of the ‘Women’s Medical Society’ was not health, it was profit,” the document stated. It detailed a practice of selling prescription painkillers during the day, and at night, performing abortions for cash for women who could not get them elsewhere because they were too pregnant.

When labor was induced and a baby was born, Dr. Gosnell would kill it by cutting into its neck and severing its spinal cord in a process he referred to as “snipping.” In one case involving a 17-year-old who was 30 weeks pregnant, prosecutors said that Dr. Gosnell induced labor, severed the baby’s spine and put the body in a shoe box. “The doctor joked that the baby was so big, ‘he could walk me to the bus stop,’ ” the document said.

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Wal-Mart Shifts Strategy to Promote Healthy Foods

Posted: 20 Jan 2011 11:58 AM PST

WASHINGTON — Wal-Mart, the nation’s largest retailer, will announce a five-year plan on Thursday to make thousands of its packaged foods lower in unhealthy salts, fats and sugars, and to drop prices on fruits and vegetables.

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Dave Blaus, 41, in Deptford, N.J., stocking freezers at Wal-Mart, the nation’s biggest grocer.

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Michelle Obama, the first lady, has joined the company’s effort to get consumers to eat healthier foods.

The initiative came out of discussions the company has been having with Michelle Obama, the first lady, who will attend the announcement in Washington and has made healthy eating and reducing childhood obesity the centerpiece of her agenda. Aides say it is the first time Mrs. Obama has thrown her support behind the work of a single company.

The plan, similar to efforts by other companies and to public health initiatives by New York City, sets specific targets for lowering sodium, trans fats and added sugars in a broad array of foods — including rice, soups, canned beans, salad dressings and snacks like potato chips — packaged under the company’s house brand, Great Value.

In interviews previewing the announcement, Wal-Mart and White House officials said the company was also pledging to press its major food suppliers, like Kraft, to follow its example. Wal-Mart does not disclose how much of its sales come from its house brand. But Kraft says about 16 percent of its global sales are through Wal-Mart.

In addition, Wal-Mart will work to eliminate any extra cost to customers for healthy foods made with whole grains, said Leslie Dach, Wal-Mart’s executive vice president for corporate affairs. By lowering prices on fresh fruits and vegetables, Wal-Mart says it will cut into its own profits but hopes to make up for it in sales volume. “This is not about asking the farmers to accept less for their crops,” he said.

The changes will be introduced slowly, over a period of five years, to give the company time to overcome technical hurdles and to give consumers time to adjust to foods’ new taste, Mr. Dach said. “It doesn’t do you any good to have healthy food if people don’t eat it.”

Wal-Mart is hardly the first company to take such steps; ConAgra Foods, for example, has promised to reduce sodium content in its foods by 20 percent by 2015.

But because Wal-Mart sells more groceries than any other company in the country, and because it is such a large purchaser of foods produced by national suppliers, nutrition experts say the changes could have a big impact on the affordability of healthy food and the health of American families and children.

Some say the company has almost as much power as federal regulators to shape the marketplace.

“A number of companies have said they are going to make voluntary reductions in sodium over the next several years, and numerous companies have said they are going to try to get trans fat out of their food,” said Michael Jacobson, executive director of Center for Science in the Public Interest. “But Wal-Mart is in a position almost like the Food and Drug Administration. I think it really pushes the food industry in the right direction.”

But Wal-Mart is pushing only so far. The company’s proposed sugar reductions are “much less aggressive” than they could be, Mr. Jacobson said, noting that Wal-Mart is not proposing to tackle the problem of added sugars in soft drinks, which experts regard as a major contributor to childhood obesity. And he said it would be “nice if Wal-Mart’s timeline were speedier” than five years.

Wal-Mart has been planning the initiative for more than a year; the effort was in its early stages when Ms. Obama joined it. The first lady’s appearance with Mr. Dach and other Wal-Mart executives when they make the announcement at a community center in Washington’s Anacostia neighborhood on Thursday morning is out of the ordinary and a prominent effort by the administration to spur further moves toward healthier food.

“We’re not just aligning ourselves with one company; we’re aligning ourselves with people who are stepping up as leaders to take this country to a healthier place,” said Sam Kass, the White House chef who doubles as Mrs. Obama’s top adviser on matters of nutrition.

“There’s no qualms about that,” Mr. Kass said. “The only question that we have is do we think this is a significant step in that direction, and do we think there is a method in place to track progress, and do we think this will have the impact we are pushing for.”

Over the last year, Mr. Kass and other aides to the first lady have spent countless hours in meetings with company officials; both Mr. Kass and Mr. Dach said Mrs. Obama pushed the company to hold itself accountable by issuing public progress reports. The Partnership for a Healthier America, a nonprofit organization that works with the first lady on her Let’s Move initiative to reduce childhood obesity, will monitor the company’s progress.

William Neuman contributed reporting from New York.

Drug to Fight Melanoma Prolonged Life in Trial

Posted: 19 Jan 2011 10:10 PM PST

Advanced melanoma patients taking an experimental drug aimed at a particular mutation in their tumors lived longer than patients who did not receive the drug in a decisive clinical trial, the drug’s manufacturer, Roche, said Wednesday.

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Ángel Franco/The New York Times

Dr. Paul Chapman of Memorial Sloan-Kettering Cancer Center led the clinical trial.

Target Cancer

This 2010 series chronicled the first human trial of this drug in articles and video.

The results pave the way for Roche to seek approval to market the drug, which shrank tumors for an average of six months in earlier trials but had not yet been proven to prolong survival. Developed by Plexxikon, a small biotechnology company in Berkeley, Calif., it is based on an understanding of cancer’s most basic molecular workings that is seen as a potential key to providing more lasting treatments for melanoma and other cancers.

“In the past, with chemotherapy, we were grasping at things,” said Dr. Paul Chapman, an oncologist at Memorial Sloan-Kettering Cancer Center who led the trial. “Now we have a rational way of building on this. For the first time, we can see the path forward.”

About half of the 68,000 Americans who develop melanoma every year have a mutation in a gene, called B-RAF, that goes awry, for reasons not well understood, signaling cells to grow uncontrollably. The Roche drug works by blocking a malfunctioning protein the gene produces in cancer cells, but leaving the functioning proteins in noncancerous cells alone.

In the drug’s earliest trial, nearly every patient whose tumor cells contained the B-RAF mutation responded to the drug. That marked a radical difference from standard chemotherapies, whose reason for working in certain patients and not others is not well understood.

It also led some oncologists to assail the ethics of the trial, whose early results were disclosed on Wednesday, because it required some patients who might have been helped by the new drug to instead take a chemotherapy drug that was seen as essentially a placebo. Starting in January of last year, 338 patients were assigned to the chemotherapy arm of the trial, while another 338 received the Roche drug.

A series of articles in The New York Times last year described the early testing of the drug and the debate among oncologists over the design of the latest trial.

To measure whether the drug prolonged lives, the company was to compare survival on both arms of the trial. A Food and Drug Administration spokeswoman said Wednesday that the agency asked the company to perform that analysis sooner than originally planned. Patients on the chemotherapy arm of the trial will now be able to “cross over” and receive the drug.

Melanoma, the deadliest form of skin cancer, has been essentially untreatable after it spreads, with a median survival rate of eight months from the time of diagnosis. Roche has not yet reported how much longer patients taking its drug live, on average.

The company has opened an “expanded access” program at three cancer centers to provide the drug for melanoma patients who are not enrolled on the trial.

But even as patient advocates and oncologists welcomed the results of the Roche trial on Wednesday, they called for more expedient testing of drugs to combine with it. Research into why patients ultimately relapse after responding to the drug is pointing to other drugs similarly tailored to particular mutations that could yield more durable benefits for patients.

“Combining drugs is where the future of oncology treatment lies,” said Timothy Turnham, executive director of the Melanoma Research Foundation, a nonprofit advocacy group. “We need companies to cooperate and make this happen now.”

F.D.A. Plans to Streamline Reviews of Medical Devices

Posted: 20 Jan 2011 12:20 AM PST

Federal health officials on Wednesday unveiled steps to streamline reviews of medical devices, while deferring decisions on contentious issues that device makers had feared could slow the approval of new products.

The Food and Drug Administration said it would ask the Institute of Medicine for comment on seven proposals, including creation of a new category of devices that would require more data for approval. A report from the institute is expected this summer.

The delay on the toughest issues was a win for the device industry, which worried that the F.D.A. would impose standards that would slow development of new products currently reviewed under an abbreviated process.

“This is a more balanced approach that sends a positive signal to industry that the F.D.A. is engaged, listening and concerned,” said William A. Hawkins, chief executive of the device maker Medtronic.

The shorter approval pathway requires companies to show a product is “substantially equivalent” to one already on the market and typically does not require human testing. The process has drawn fire from critics who say it is too widely used and allows unsafe products to be marketed.

The F.D.A. said it would impose 25 changes to the device-approval process, including streamlining the reviews for some lower-risk devices. The agency also will also create an internal council to “assure timely and consistent science-based decision making.”

The steps will lead to “a smarter medical device program that supports innovation, keeps jobs here at home, and brings important, safe and effective technologies to patients quickly,” said Dr. Jeffrey Shuren, head of the F.D.A. device unit.

The Love Affair With the Fireplace Cools

Posted: 19 Jan 2011 09:30 PM PST

WINSOME BROWN, an actress and writer, and her husband, Claude Arpels, own an enviable apartment in TriBeCa worthy of a spread in an interior design magazine. The apartment — which is, in fact, being considered for an issue of Elle Décor — has maple floors, casement windows and all the character one would expect to find in a building that was once a factory.

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But one of the features that many people in the city would pay a premium for is something the owners don’t like: the fireplace.

“A wood-burning fire in the city is a ridiculous luxury — we would never have put it in ourselves,” said Mr. Arpels, grandson of one of the founders of Van Cleef & Arpels and the former managing partner of Netto Collection, a baby furniture company bought by Maclaren. “In the city, it doesn’t make sense to burn fires, because it’s inefficient and it’s polluting.”

Hard as it may be to believe, the fireplace — long considered a trophy, particularly in a city like New York — is acquiring a social stigma. Among those who aspire to be environmentally responsible, it is joining the ranks of bottled water and big houses.

“The smoke from a fire smells very nice,” said Diane Bailey, a senior scientist with the Natural Resources Defense Council in San Francisco. “But it can cause a lot of harm.” The tiny particles, she said, “can cause inflammation and illness, and can cross into the bloodstream, triggering heart attacks” as well as worsening other conditions.

Or as Starre Vartan, a 33-year-old blogger who goes by the name Eco-Chick, put it: “Any time you are burning wood or cow dung, you’ll be creating pollution. It’s like junk food: if you do it once a month, then who cares? But if it’s something you do every day, it’s important that you mitigate it somehow. It’s a hazard.”

Not surprisingly, the green community has been sounding the alarm for some time. For the last several years, TheDailyGreen.com, an online magazine, has advocated replacing all wood-burning fireplaces with electric ones; an article published in September by Shireen Qudosi, entitled “Breathe Easier With a Cleaner Fireplace,” argued that there is no such thing as an environmentally responsible fire: “Switching out one type of wood for another is still use of a natural resource that otherwise could have been spared,” Ms. Qudosi wrote. And last fall, an article on the Web site GreenBlizzard.com, “Cozy Winter Fires — Carbon Impact,” called wood-burning fires “a direct pollutant to you, your family and your community.”

Organizations like the American Lung Association are issuing warnings as well: the group recommends that consumers avoid wood fires altogether, citing research that names wood stoves and fireplaces as major contributors to particulate-matter air pollution in much of the United States.

Wood smoke contains some of the same particulates as cigarette smoke, said Dr. Norman H. Edelman, the chief medical officer for the American Lung Association, as well as known carcinogens like aldehydes; it has also been linked to respiratory problems in young children.

“We now know from lots of studies that wood smoke is very, very irritating,” Dr. Edelman said. “It contains a lot of irritating gases and it also contains damaging particulate matter. It’s probably not good for anybody, and it’s especially bad for anybody who has a chronic respiratory problem.” So the association strongly advises people not to use the traditional fireplace, he said.

Certainly, there are many who consider this eco-overkill. In Greek mythology, fire is a gift from the divine, stolen from Zeus by Prometheus and handed over to shivering humanity. What could be more natural than sitting around a crackling fire on a winter night, at a campsite in the Berkshires or in a Brooklyn brownstone?

But growing concerns about the air pollution and health problems caused by smoke from wood fires are prompting a number of areas across the country to pass laws regulating them.

“A lot of municipalities are taking action,” said Ms. Bailey, adding that the weather-based measures called burn bans are perhaps the most widespread restriction. When the weather is cold and the air is still, or pollution is high, the Bay Area in California, Puget Sound, Wash., Denver and Albuquerque are among the places with restrictions on residential wood-burning. These measures can be mandatory or voluntary, and can become more restrictive as air quality declines. So far, most of the wood-burning regulations tend to be out West. A few examples: Idaho offers tax incentives to people who replace uncertified wood stoves with “greener” ones; San Joaquin County in California forbids selling a home unless its wood stove is replaced with an E.P.A.-certified one; and Palo Alto and other municipalities in California prohibit wood-burning fireplaces or stoves in new construction.

Perhaps not coincidentally, sales of wood-burning appliances dropped to 235,000 in 2009 from 800,000 in 1999, according to the Hearth, Patio and Barbecue Association. And the Brick Industry Association, which promotes brick construction, reports that roughly 35,000 masonry fireplaces were installed in the United States in 2009, compared to 80,000 in 2005. Certainly those numbers reflect the economic slowdown, but they may also be affected by growing ambivalence to wood fires.

A Sniff of Home Cooking for Dogs and Cats

Posted: 20 Jan 2011 03:38 PM PST

ORION’S appetizer was a giant carrot.

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Jennifer May for The New York Times

Barbara Laino with her Alaskan malamute, Orion.

The Alaskan malamute, a 12-year-old who bounced into the kitchen like a puppy, followed that with a main course of ground raw chicken necks and livers, red cabbage, cucumbers, carrots, berries, garlic and parsley, formed into tidy patties. He licked it off a plate embellished in blue and green flowers.

Like nearly everything else Orion has eaten for most of his life, this meal was prepared for him by his owner, Barbara Laino. Her standard recipe, which will feed Orion along with the other dog and the three cats in her house for around 10 days, calls for grinding 40 pounds of pasture-raised chicken necks with another 20 pounds of chicken giblets. To this, she adds five pounds of carrots, a whole cabbage and several other fruits, all from the organic fields of Midsummer Farm, Ms. Laino’s farm in Warwick, N.Y. Finally, she blends the mix with herbs and supplements.

Ms. Laino, 39, demonstrated her technique at a workshop on homemade pet food that she gave in her kitchen in July. In addition to the workshop, which she has led regularly for the last four years, she also coaches human clients who want to eat seasonally and organically. And in fact, her philosophy for the two classes is not all that different. She says she wants for her pets what she wants for herself: a healthy diet of unprocessed organic foods.

“We know processed foods are wrong for us,” Ms. Laino said, scratching behind Orion’s ears as he licked his nose and paws clean. “It has to be wrong for them. If you can feed yourself healthily and your children, then you can feed your pets healthily, too. It really isn’t that hard.”

According to many veterinarians and pet food producers, it can, in fact, be quite hard to formulate an animal’s diet at home. But Ms. Laino, the students in her workshop and others say they have reasons for taking on the challenge. Many of them say they made the switch out of desperation after their animals had lingering illnesses that resisted medicine and other remedies. With home-cooked meals, they say, those health problems cleared up.

But they also say it’s hard to justify dumping a can of mystery meat for Bo while the rest of the family is sitting down to grass-fed osso buco with a side of biodynamic polenta. As people eat more sustainable seasonal produce and meat raised and butchered outside the industrial system, so do their pets. And as do-it-yourself hobbies like canning, gardening and raising backyard chickens have taken off in recent years, grinding 40 pounds of pet food starts to look like another fun weekend project.

“The dog has always been a mirror of the human style of life,” said Cesar Millan, host of the television show “The Dog Whisperer.”

“Organic has become a new fashion, a new style of living,” he said. “And if the human becomes aware, if he eats organic, he wants everyone around him to be healthy, too, especially the one that is always there for you.”

Mr. Millan was referring to the family hound, of course, but cat owners are also far from immune to the impulse.

Only a fraction of American pets are lucky enough to have a live-in cook. But millions have gone organic in recent years. Sales of organic pet food were $84 million in 2009, and have grown more than tenfold since 2002, according to the Organic Trade Association. The group reported a sales increase of 48 percent in 2008, the year after several brands of cat and dog food were recalled for melamine contamination.

“There is a general distrust in the food supply at the moment,” said Marion Nestle, a nutrition professor at New York University and the author of “Feed Your Pet Right.” In addition, people who have chosen to eat food grown on small, sustainable nearby farms, she added, want to apply their dietary choices to their pets.

Rachael Scot Lingerfelt, a 25-year-old freelance writer in Bozeman, Mont., said the only meat she eats is either raised by an organic farmer or hunted by her boyfriend. When she began cooking for her beagle, Maddie-Sue, two years ago, she researched dogs’ dietary needs before coming up with a recipe of brown rice, cooked ground beef or chicken, peas, green beans, yams, dry milk and Tums tablets for calcium. Most of the ingredients are organic. All are bought at a food co-op nearby.

“The aroma is a little interesting,” she said. “You usually wouldn’t combine those ingredients.”

But each batch lasts about three weeks and costs from $10 to $12, she said, around the same price as inexpensive commercial pet food.

Since the fall, the butcher shops Marlow & Daughters in Brooklyn and Avedano’s Holly Park Market in San Francisco have been selling pet food made from grass-fed meat raised on nearby pastures. Melanie Eisemann, an owner at Avedano’s, said the store’s custom mix of ground meats, organs, vegetables, garlic, eggs, parsley and yogurt sells for $3.25 a pound. Avedano’s also reports a robust trade in marrow bones, many of them bought as snacks for dogs.

Ms. Eisemann said customers say that they like knowing the source of their meat, whether it will ultimately be served on the table or on the floor. Entering the pet food market has also been a boon for the business, since Avedano’s, like Marlow & Daughters, is a whole-animal butcher where no part of the beast goes to waste.

Joshua Applestone, an owner at Fleisher’s, a butcher shop in Kingston, N.Y., specializing in nose-to-tail butchering and grass-fed meats, said that he started making patties of beef offal and whole ground chicken for about $2 a pound for dogs and cats in 2004. At the time, he sold about 20 to 30 pounds a week. Now, the shop has to run 250 to 300 pounds through the grinder each week to keep up with demand.

“We had to get a designated freezer chest because it sells so well,” he said. He also said more customers were asking for cuts like chicken backs and organs to make pet food at home.

Many converts said their new food choices quickly resulted in healthier animals that no longer required endless trips to the vet. Charlene Smith, a project manager in publishing who attended Ms. Laino’s workshop last year, said that one of her two cats, Polly, had been on a steady diet of antibiotics to treat urinary tract problems before the switch to home cooking. Ms. Smith said that her other cat, Esther, “was angry most of the time” when she ate commercial food, and has a much better temperament now.

Some pet owners also credited better ingredients with helping their animals live longer. Randy Klein feeds her cats and dog a mix of cooked chicken or turkey, cauliflower, broccoli, carrots and zucchini, supplemented with vitamins and minerals. She sells this preparation for $8.95 a pound at her pet store, Whiskers, in Manhattan. She believes the diet is one reason two of her cats are 25 years old.

But Ms. Nestle said that she has heard the same claim from people who feed their pets commercial food. “It’s hard to sort out because there is no research on it,” she said.

Manufacturers of store-bought pet food are skeptical of the do-it-yourself ethos. Nancy K. Cook, the vice president at the Pet Food Institute, a trade association for commercial pet food makers, cautions pet owners that it is hard to create a balanced diet at home, since dogs and cats have specific nutritional requirements.

Vocal Physicians Group Renews Health Law Fight

Posted: 18 Jan 2011 10:01 PM PST

A small professional group of doctors involved in the effort to repeal the new health care law has a history of opposing government involvement in medicine, including challenging President Bill Clinton’s attempts to overhaul health care in the 1990s.

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Luke Sharrett for The New York Times

Rand Paul made opposition to the health law central to his successful Senate bid in Kentucky.

The group, the Association of American Physicians and Surgeons, has exerted vocal influence in the country’s health care debate, despite having just 3,000 dues-paying members. Other medical groups assert that the association’s positions are unrepresentative of most of the nation’s 800,000 physicians and that its scientific views often fall outside medicine’s mainstream.

As Republicans in the House of Representatives move forward Wednesday with an expected repeal vote, the group’s executive director, Dr. Jane M. Orient, said it would start an effort to rally public support for the repeal, which faces stiff opposition in the Senate. Dr. Orient said that several congressmen who are members of the association, including Representatives Tom Price and Paul Broun, both of Georgia, and Ron Paul of Texas, are expected to be involved in the effort, which is expected to include a rally in Southern California with members of the Tea Party.

“We are going to tell Congress to repeal this monster because it really can’t be fixed,” said Dr. Orient, an internist in Tucson, where the association is based.

The group has been opposed to President Obama’s health care efforts since the beginning. Last year, it filed a lawsuit asking a federal judge to declare the new law unconstitutional; it is still pending. This fall, yet another physician member of the group, Dr. Rand Paul, an ophthalmologist and son of Representative Ron Paul, made opposition to the health care law central to his successful Senate bid in Kentucky.

A spokesman for Senator Paul said he was unavailable for an interview. In an e-mail, a spokesman, Gary Paul, said that Dr. Paul supported the groups’ stance against “government-run health care.”

There is no question that doctors differ in their view toward the new health care law, and some groups opposed its passage. Still, most of the nation’s professional medical organizations, including the American Medical Association, the country’s biggest, have supported it, saying that fundamental changes to the nation’s health care system are needed.

The heads of several medical groups supporting the health care overhaul, moreover, said they believed that the positions of the Association of American Physicians and Surgeons ignored the realities of medicine and patient needs.

“I respect their philosophical consistency,” said Dr. Ronald Goertz, the president of the American Academy of Family Physicians, which counts about 63,000 practicing doctors among its members. “But with half of all Americans receiving some sort of assistance to help them get care, I think there is a responsibility to make sure that care is of the highest quality.”

Founded in 1943, the Association of American Physicians and Surgeons opposed the creation of Medicaid and Medicare. A decade ago, it was among groups that unsuccessfully urged the United States Supreme Court to release post-mortem photographs of a former Clinton administration official, Vincent Foster. In its brief, the group argued that an independent inquiry was necessary to confirm that Mr. Foster, whose death was attributed to suicide, was not murdered.

A big moment for the organization came in the 1990s when it filed a lawsuit that helped force the Clinton administration to disclose the workings of an internal panel that drafted its health care reform proposal.

“Our organization was formed to fight socialized medicine and to fight the government takeover of medicine,” Dr. Orient said.

The association has promoted some scientific views that other medical experts have characterized as curious.

Its internal periodical has published studies arguing that abortion increases breast cancer risks, a tie rejected by an expert panel of the National Cancer Institute, as well as reports linking child vaccinations to autism, a discredited theory. Another report, “Illegal Aliens and American Medicine,” contended that illegal immigrants not only brought disease into this country but benefited if their babies were born with disabilities.

“Anchor babies are valuable,” that 2005 report stated, using a negative term for children born in America to illegal immigrants. “A disabled anchor baby is more valuable than a healthy one.”

The publication’s longtime editor, Dr. Lawrence R. Huntoon, said its articles were “peer-reviewed” or checked for accuracy by experts, a standard that is used by major medical publications. When asked, he said he could not say that what percentage of those reviewers were members of his own organization.

The National Library of Medicine, a part of the National Institutes of Health, declined requests by the group in 2004 and again in 2008 to index its journal’s articles in the national database of medical reports that the library operates.

Dr. Orient said the library did not index the publication’s reports because the content was adequately covered elsewhere. However, the library’s associate director for operations, Sheldon Kotzin, said that was only one of the reasons that a review panel turned down the group’s request. Mr. Kotzin, citing library policy, declined to identify the other reasons.

Within the courtroom, the Association of American Physicians and Surgeons has taken a stance on a variety of issues related to health care or the practice of medicine. For one, it has argued for a ban on late-term abortion and also challenged the oversight procedures of state boards that license doctors, contending that such boards abuse their power to railroad doctors out of practice. The organization has also supported physicians accused of illegally prescribing narcotics, arguing that prosecutors are imposing their views of what constitutes adequate pain treatment. The group holds that health care is not a “right” but a professional service and that doctors should treat patients based on their medical judgment, a role in which government should not interfere.

Dr. Orient added that her group favored a “free market” approach to medicine and that some members did not accept payment from government programs or private insurers. The group says it believes that such third-party payers are at the root of many problems in medicine because they interfere with the doctor-patient relationship and drive up costs.

The president of another doctors’ group, Dr. Valerie Arkoosh of the National Physicians Alliance, said the suggestion that medicine was better before government involvement was a myth.

“We have had a market-based system in this country for many years and I don’t see that it has been a very successful strategy,” said Dr. Arkoosh, who is an anesthesiologist in Philadelphia.

During the run-up to the health care law, Dr. David McKalip, a Florida neurosurgeon who is a member of the group, became the subject of controversy when it was publicly reported that he had forwarded an e-mail to Tea Party members that showed President Obama dressed as an African witch doctor with a bone through his nose. The physician subsequently apologized for doing so.

In a telephone interview, Dr. McKalip said he remained strongly opposed to the health care law, arguing that it would, among other things, provide financial incentives to doctors to take steps that would harm patients. He also said that President Obama had repeatedly been disrespectful of doctors by saying they profited by carrying out unnecessary procedures.

“Unlike President Obama, I apologized for those offensive images,” Dr. McKalip said, referring to the witch doctor e-mail. “The president never apologized for implying that doctors performed tonsillectomies and amputations for money.”

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A Pink-Ribbon Race, Years Long

Posted: 19 Jan 2011 11:27 AM PST

By the time Suzanne Hebert realized that her doctor was wrong and that the hard lump in her breast wasn’t a normal part of breast-feeding, the tumor was the size of a stopwatch and the cancer had spread to her spine.

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INCURABLE, NOT CHRONIC Elizabeth Edwards and her husband, John, announced on the campaign trail in 2007 that her cancer had returned.

Still, Dr. Hebert, an optometrist in South Windsor, Conn., went to her first support group meeting thinking that as bad as things were, at least breast cancer was not an obscure disease; she would not be alone.

But the room was filled with women who had early localized cancers. Some had completed chemotherapy years ago; they were “survivors.” When one newcomer asked Dr. Hebert for her story, she couldn’t bring herself to tell the truth.

Although great strides have been made in the treatment of breast cancer, recent events, including Elizabeth Edwards’s death last month and the government’s decision to revoke approval of Avastin as a treatment for metastatic breast cancer, have drawn attention to the limits of medical progress — and to the nearly 40,000 patients who die of the disease each year.

Of women who are given a diagnosis of breast cancer, only 4 percent to 6 percent are at Stage 4 at the time of diagnosis, meaning the cancer has already metastasized, or spread, to distant sites in the body. But about 25 percent of those with early-stage disease develop metastatic forms, with an estimated 49,000 new diagnoses each year, according to the American Cancer Society.

At least 150,000 Americans are estimated to be living with metastatic breast cancer — including Dr. Hebert, now 45, who got her diagnosis six years ago and now works with the nonprofit Metastatic Breast Cancer Network.

Stage 4 breast cancer can be treated, but it is considered incurable. Depending on the type of tumor, patients may live for many years — working, raising children, starting nonprofit foundations, doing yoga and even running half-marathons.

But theirs are not pink-ribbon lives: They live from scan to scan, in three-month gulps, grappling with pain, fatigue, depression, crippling medical costs and debilitating side effects of treatment, hoping the current therapy will keep the disease at bay until the next breakthrough drug comes along, or at least until the family trip to Disney World.

“This woman had just been diagnosed,” Dr. Hebert said of her support-group encounter, “and I couldn’t bring myself to tell her: ‘I have it in my bones. I have it in several parts of my body. My treatment is never going to end.’

“It was a horrible moment,” she went on. “I had nothing in common with them. I was what scared them.”

While perceptions of the disease may have changed in recent years, the number of deaths it causes has remained fairly static, said Dr. Eric P. Winer, director of the breast oncology center at the Dana-Farber Cancer Institute in Boston.

“All too often, when people think about breast cancer, they think about it as a problem, it’s solved, and you lead a long and normal life; it’s a blip on the curve,” he said. “While that’s true for many people, each year approximately 40,000 people die of breast cancer — and they all die of metastatic disease. You can see why patients with metastatic disease may feel invisible within the advocacy community.”

Many patients keep the spread of their disease private, and Mrs. Edwards’s 2007 announcement that her cancer had become “incurable” was an inspiration to many — it was also why her death was such a blow.

“She put a face on the disease,” Dr. Hebert said. “I could explain my situation to people.

“The day she stopped treatment was very emotional,” she added, “because I’ve been telling people, ‘I’m like Elizabeth Edwards.’ ”

Mrs. Edwards’s husband, the former senator and presidential candidate John Edwards, referred to her illness as a “chronic” disease, implying that it was manageable. In fact, however, the median life expectancy for patients with metastatic breast cancer is just 26 months, and fewer than 1 in 4 survive for more than five years.

But because breast cancer is a complex illness that encompasses many subtypes, generalizations are tricky. New drug treatments are keeping some patients alive for a decade or more, even after the disease has spread.

And they can enjoy a higher quality of life than patients did in the past, because treatments are better focused and have fewer side effects. The prognosis has especially improved for patients with certain aggressive cancers, like HER2-positive, that were considered extremely difficult to treat until recently.

“Over the past 20 years, we’ve had probably 15 new drugs approved by the F.D.A., and each of them adds an incremental amount to the length of life, “ said Dr. Gabriel N. Hortobagyi, director of the breast cancer research program at M. D. Anderson Cancer Center in Houston.

The average patient may receive eight or 10 different treatment regimens in sequence, he said.

“I would never tell a patient with a newly diagnosed metastasis that there is nothing I can do,” he said, “because there are actually dozens of things I can do — whether it is hormone therapy, whether it is Herceptin, whether it is irradiation therapy or single-agent chemotherapy — and there are many things we can do to control symptoms and prevent complications.”

Personal Best: Close Look at Orthotics Raises a Welter of Doubts

Posted: 17 Jan 2011 08:10 PM PST

Benno M. Nigg has become a leading researcher on orthotics — those shoe inserts that many athletes use to try to prevent injuries. And what he has found is not very reassuring.

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For more than 30 years Dr. Nigg, a professor of biomechanics and co-director of the Human Performance Lab at the University of Calgary in Alberta, has asked how orthotics affect motion, stress on joints and muscle activity.

Do they help or harm athletes who use them? And is the huge orthotics industry — from customized shoe inserts costing hundreds of dollars to over-the-counter ones sold at every drugstore — based on science or on wishful thinking?

His overall conclusion: Shoe inserts or orthotics may be helpful as a short-term solution, preventing injuries in some athletes. But it is not clear how to make inserts that work. The idea that they are supposed to correct mechanical-alignment problems does not hold up.

Joseph Hamill, who studies lower-limb biomechanics at the University of Massachusetts in Amherst, agrees.

“We have found many of the same results,” said Dr. Hamill, professor of kinesiology and the director of the university’s biomechanics laboratory. “I guess the main thing to note is that, as biomechanists, we really do not know how orthotics work.”

Orthotists say Dr. Nigg’s sweeping statement does not take into account the benefits their patients perceive.

The key measure of success, said Jeffrey P. Wensman, director of clinical and technical services at the Orthotics and Prosthetics Center at the University of Michigan, is that patients feel better.

“The vast majority of our patients are happier having them than not,” he said about orthotics that are inserted in shoes.

Seamus Kennedy, president and co-owner of Hersco Ortho Labs in New York, said there was an abundance of evidence — hundreds of published papers — that orthotics can treat and prevent “mechanically induced foot problems,” leading to common injuries like knee pain, shinsplints and pain along the bottom of the foot.

“Orthotics do work,” Mr. Kennedy said. “But choosing the right one requires a great deal of care.”

Yet Scott D. Cummings, president of the American Academy of Orthotists and Prosthetists, says the trade is only now moving toward becoming a science. So far, most of the focus in that direction has been on rigorously assessing orthotics and prosthetics for other conditions, like scoliosis, with less work on shoe orthotics for otherwise healthy athletes.

“Anecdotally, we know what designs work and what designs don’t work” for foot orthotics, said Mr. Cummings, who is an orthotist and prosthetist at Next Step in Manchester, N.H. But when it comes to science and rigorous studies, he added, “comparatively, there isn’t a whole lot of evidence out there.”

Dr. Nigg would agree.

In his studies, he found there was no way to predict the effect of a given orthotic. Consider, for example, an insert that pushes the foot away from a pronated position, or rotated excessively outward. You might think it would have the same effect on everyone who pronates, but it does not.

One person might respond by increasing the stress on the outside of the foot, another on the inside. Another might not respond at all, unconsciously correcting the orthotic’s correction.

“That’s the first problem we have,” Dr. Nigg said. “If you do something to a shoe, different people will react differently.”

The next problem is that there may be little agreement among orthotics makers about what sort of insert to prescribe.

In one study discussed in his new book, “Biomechanics of Sport Shoes,” Dr. Nigg sent a talented distance runner to five certified orthotics makers. Each made a different type of insert to “correct” his pronation.

The athlete wore each set of orthotics for three days and then ran 10 kilometers, about 6 miles. He liked two of the orthotics and ran faster with them than with the other three. But the construction of the two he liked was completely different.

Then what, Dr. Nigg asked in series of studies, do orthotics actually do?

They turn out to have little effect on kinematics — the actual movement of the skeleton during a run. But they can have large effects on muscles and joints, often making muscles work as much as 50 percent harder for the same movement and increasing stress on joints by a similar amount.

As for “corrective” orthotics, he says, they do not correct so much as lead to a reduction in muscle strength.

In one recent review of published papers, Dr. Nigg and his colleagues analyzed studies on orthotics and injury prevention. Nearly all published studies, they report, lacked scientific rigor. For example, they did not include groups that, for comparison, did not receive orthotics. Or they discounted people who dropped out of the study, even though dropouts are often those who are not benefiting from a treatment.

Trial in a Vacuum: Study of Studies Shows Few Citations

Posted: 21 Jan 2011 11:10 PM PST

Science, so the story goes, is a meticulously built edifice. Discoveries balance on ones that preceded them. Research is stimulated by studies that went on before.

But what, then, can explain the findings by two investigators at Johns Hopkins University School of Medicine? The researchers, Karen A. Robinson and Dr. Steven N. Goodman, looked at how often published papers on clinical trials in medicine cite previous clinical trials addressing the same question.

They report in the Jan. 4 issue of Annals of Internal Medicine what Dr. Goodman describes as “a rather shocking result.” He summarizes: “No matter how many randomized clinical trials have been done on a particular topic, about half the clinical trials cite none or only one of them.”

“As cynical as I am about such things, I didn’t realize the situation was this bad,” Dr. Goodman said.

It seems, Dr. Goodman said in an e-mail, that “either everyone thinks their study is really unique (when others thought it wasn’t), or they want to unjustifiably claim originality, or they just don’t know how or want to look.”

The situation can have serious consequences for patients, said Sir Iain Chalmers, editor of the James Lind Library, which is a source of information on appropriate tests of medical treatments. He said some patients have suffered severe side effects and even died in studies because researchers were not aware of previous studies documenting a treatment’s dangers.

“That’s the tragedy,” he said. “Not only is it unscientific, it is unethical.”

Dr. Goodman said their results might help explain a troubling phenomenon in medicine: All too often, despite a multitude of clinical trials on a particular subject, the data do not supply the answers doctors need to treat patients.

“This shows part of what’s behind it,” Dr. Goodman said. Failure to cite can affect hypotheses and conclusions.

“If you are not citing the most similar studies, it is really hard to imagine that the evidence they provided played a role in the formulation of your hypothesis,” Dr. Goodman said. And, he added, if researchers do not cite other studies, they cannot play a role in formulating conclusions. “If the eighth study is positive, and the preceding seven were cold negative, is it proper to report that a treatment works?” he said. “This may not be the fire, but it’s a heck of a lot of smoke.”

Dr. Robinson, an assistant professor in the divisions of internal medicine and health sciences informatics, and Dr. Goodman, a professor of epidemiology and biostatistics and editor of the journal Clinical Trials, began their study by identifying 227 meta-analyses, which are studies that combine relevant previous studies to glean data from pooled evidence. For example, a meta-analysis might collect all studies about a drug whose effectiveness in individual studies was sometimes equivocal. The analysis would ask whether, with all results combined, the drug may seem to work.

The 227 meta-analyses cited a total of 1,523 clinical trials. For each clinical trial, the investigators asked how many of the other trials, published before it on the same topic and included with it in the meta-analysis, were cited.

They never expected so few.

“It is a pretty bad situation,” Dr. Goodman said. “There were rumblings of this before, but they did not show the phenomenon like this does.”

He adds that he and Dr. Robinson did not ask whether investigators cited prior studies in their grant applications, nor do they know for sure why so little previous research is cited.

One reason might be that investigators do not think many of the results from previous studies apply to theirs.

That is why, in a recent paper in Hepatology, Dr. Stephen Harrison of Brooke Army Medical Center in San Antonio and his colleagues did not cite any of 10 clinical trials used in a meta-analysis that followed his paper. He was studying the effects of a weight loss drug, orlistat, on liver function in overweight patients with fatty liver disease.

Explaining why he failed to cite the other studies, he said, “I limited my discussion mainly to therapies that had been studied in fatty liver disease, not just obesity or diabetes.”

There are several steps along the way to a published paper where researchers might be asked about already published papers on the same topic. Those who finance the research, the ethics committees that review some studies and the journals that publish the studies all could ask the investigators how they assured themselves they had found prior relevant results.

But, Dr. Goodman said, none of those groups feel any official responsibility.

“It’s sort of a blind spot,” he said. “People sort of assume researchers know the literature, know their own field, know the studies.”

National Briefing | SOUTH: Florida: Six More States Sue Over Health Care Law

Posted: 19 Jan 2011 11:30 AM PST

Six more states joined a lawsuit in Florida against President Obama’s health care overhaul on Tuesday, meaning more than half of the country is challenging the law. The six — Iowa, Kansas, Maine, Ohio, Wisconsin and Wyoming — all with Republican attorneys general, joined Florida and 19 others in the legal action, Attorney General Pam Bondi of Florida said. The states claim the health care law is unconstitutional and violates people’s rights by forcing them to buy health insurance by 2014 or face penalties.

Mind: When Self-Knowledge Is Only the Beginning

Posted: 17 Jan 2011 08:10 PM PST

It is practically an article of faith among many therapists that self-understanding is a prerequisite for a happy life. Insight, the thinking goes, will free you from your psychological hang-ups and promote well-being.

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Lars Leetaru

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Perhaps, but recent experience makes me wonder whether insight is all it’s cracked up to be.

Not long ago, I saw a young man in his early 30s who was sad and anxious after being dumped by his girlfriend for the second time in three years. It was clear that his symptoms were a reaction to the loss of a relationship and that he was not clinically depressed.

“I’ve been over this many times in therapy,” he said. He had trouble tolerating any separation from his girlfriends. Whether they were gone for a weekend or he was traveling for work, the result was always the same: a painful state of dysphoria and anxiety.

He could even trace this feeling back to a separation from his mother, who had been hospitalized for several months for cancer treatment when he was 4. In short, he had gained plenty of insight in therapy into the nature and origin of his anxiety, but he felt no better.

What therapy had given this young man was a coherent narrative of his life; it had demystified his feelings, but had done little to change them.

Was this because his self-knowledge was flawed or incomplete? Or is insight itself, no matter how deep, of limited value?

Psychoanalysts and other therapists have argued for years about this question, which gets to the heart of how therapy works (when it does) to relieve psychological distress.

Theoretical debates have not settled the question, but one interesting clue about the possible relevance of insight comes from comparative studies of different types of psychotherapy — only some of which emphasize insight.

In fact, when two different types of psychotherapies have been directly compared — and there are more than 100 such studies — it has often been hard to find any differences between them.

Researchers aptly call this phenomenon the Dodo effect, referring to the Dodo bird in Lewis Carroll’s “Alice in Wonderland” who, having presided over a most whimsical race, pronounces everyone a winner.

The meaning for patients is clear. If you’re depressed, for example, you are likely to feel better whether your therapist uses a cognitive-behavioral approach, which aims to correct distorted thoughts and feelings, or an insight-oriented psychodynamic therapy.

Since the common ingredient in all therapies is not insight, but a nonspecific human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better.

Not just that, but sometimes it seems that insight even adds to a person’s misery.

I recall one patient who was chronically depressed and dissatisfied. “Life is just a drag,” he told me and then went on to catalog a list of very real social and economic ills.

Of course, he was dead-on about the parlous state of the economy, even though he was affluent and not directly threatened by it. He was a very successful financial analyst, but was bored with his work, which he viewed as mechanical and personally unfulfilling.

He had been in therapy for years before I saw him and had come to the realization that he had chosen his profession to please his critical and demanding father rather than follow his passion for art. Although he was insightful about much of his behavior, he was clearly no happier for it.

When he became depressed, though, this insight added to his pain as he berated himself for failing to stand up to his father and follow his own path.

Researchers have known for years that depressed people have a selective recall bias for unhappy events in their lives; it is not that they are fabricating negative stories so much as forgetting the good ones. In that sense, their negative views and perceptions can be depressingly accurate, albeit slanted and incomplete. A lot of good their insight does them!

It even makes you wonder whether a little self-delusion is necessary for happiness.

None of this is to say that insight is without value. Far from it. If you don’t want to be a captive of your psychological conflicts, insight can be a powerful tool to loosen their grip. You’ll probably feel less emotional pain, but that’s different from happiness.

Speaking of which, my chronically depressed patient came to see me recently looking exceedingly happy. He had quit his job and taken a far less lucrative one in the art world. We got to talking about why he was feeling so good. “Simple,” he said, “I’m doing what I like.”

I realized then that I am pretty good at treating clinical misery with drugs and therapy, but that bringing about happiness is a stretch. Perhaps happiness is a bit like self-esteem: You have to work for both. So far as I know, you can’t get an infusion of either one from a therapist.

Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College in Manhattan.

Cases: When All Isn’t Enough to Foil Alzheimer’s

Posted: 17 Jan 2011 08:10 PM PST

My father knew it was coming.

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Yarek Waszul

New Old Age

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Alzheimer’s disease had been on his radar ever since his own father died of it. Witnessing the catastrophic deterioration of a man who had been sharp enough to work for Gen. Douglas MacArthur, my frightened father was inspired to become a neurologist. Perhaps the pursuit of medicine could stave off what he believed was a genetic inevitability.

As an ever-present reminder of that threat, he kept an atrophied brain in a jar on his desk. That brain, I recently discovered, belonged to his father.

As my father approached middle age he began to experiment on himself, with diet supplements. By age 60 he was taking 78 tablets a day. He tracked down anything that offered the possibility of saving brain cells and killing free radicals: Omega 3s, 6s, 9s; vitamins E and C; ginkgo biloba, rosemary and sage; folic acid; flaxseed.

After retiring from his neurology practice in Naples, Fla., he spent hours a day doing math. Even when I was visiting, he’d sit silently on his leather recliner with a calculator to verify the accuracy of calculations he did by memory.

“What are you saving your mind for, Dad?” I often wondered to myself. “I’m here now, waiting to talk with you.”

On one of these occasions, he suddenly looked up from his Sudoku game and stared at me.

“Promise me something, gal,” he said. “Anything,” I answered.

“Swear on your grandmother’s Bible that you will put a gun to my head if I wind up like my father.”

He was dead serious.

How do you answer a man who watched his father wipe feces on the walls of their Virginia farmhouse? A man who took out a second mortgage to buy the first CT scanner in Florida?

“Swear to me,” he repeated. He collected guns and kept them under lock and key. He knew I could shoot them, because he’d taught me how. I put my hand on the leather-bound King James Bible that had belonged to my great-grandmother Nannie Dunlap and my grandmother Nancy Scott.

“I swear,” I said.

He nodded in approval.

A few years later, my father arrived at my home in Vermont with a suitcase full of supplements. He parceled out his pills for the week into Dixie cups, ready for swallowing with every meal.

“Gal, you should be taking these, too.”

“Why?”

“Because you are my genetic clone.”

Our physical resemblance and character traits were uncanny: tall, big-lipped, blue-eyed, loose-jointed, freckle-skinned, angst-ridden Bercaws. Except for our male and female chromosomes, nearly everything about us was a perfect match.

My father went on to explain that everyone inherits one copy of the APOE gene from each parent. The gene can indicate a predisposing genetic risk for Alzheimer’s. APOE-2 is relatively rare and may even provide some protection against the disease. APOE-3 is the most common and appears to have a neutral role. APOE-4 indicates the highest risk factor.

“I’m only 34! Can’t I think about this later?”

He shook his head.

Back in Florida, he sent me a genetic test kit via Federal Express, instructing me to have the blood drawn at my physician’s office but to have the results sent to him. It turned out that like my father I carry the APOE-3 gene, which means I may or may not get the disease.

But unlike my father, I will have to wait to find out. In 2009, at age 71, he had an M.R.I. that showed “atrophy consistent” with Alzheimer’s disease. He looked at the film and was confused by the sight of his own brain.

I recently spent time with my father while his wife had surgery. I took him to visit her at the hospital each day, and when we got home I stopped him from calling her every five minutes. I gave him dinner and pills at the appointed hours. I cleaned up his “accidents.”

While he watched a televised baseball game one afternoon, I walked into his den and eyed the wall of supplements he used to take — bookcase after bookcase of pills with names like Memoral and Sharp Mind. Won’t be needing them anymore.

I rested my hand on his gun cabinet. Won’t need you, either.

My father walked to the coffee shop with me every morning. The only thing he’d say on these walks was, “The hibisci are in full bloom.” Every time he said it — which was dozens — I wondered whether the plural of hibiscus is, in fact, hibisci.

On the final morning of my visit, he didn’t mention the blooms. But when we passed a particularly flourishing tree, he stopped to look at me.

“Gal,” he said, then paused to find the words.

His voice quivered. “I sure appreciate you coming down to take care of me.”

I composed myself long enough to say: “It was a pleasure, especially after all you have done for me. Besides, you don’t need so much taking care of.”

As we walked on, my father would repeat this latest sentence every few minutes — the same quiver in his voice at the exact same place.

Each time, my response got shorter and shorter, until I was the one who had nothing left to say.

Nancy Stearns Bercaw is a writer in Vermont.

Well: Peppermint Oil for Irritable Bowel

Posted: 21 Jan 2011 11:30 AM PST

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Posted: 21 Jan 2011 10:40 AM PST

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Personal Health: Keep Your Voice, Even at the End of Life

Posted: 17 Jan 2011 08:20 PM PST

The specter of “death panels” was raised yet again this month, prompting the Obama administration to give in to political pressure a second time in its effort to encourage end-of-life planning.

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Yvetta Fedorova

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Of course, the goal of this effort was not to make it easier to “pull the plug on grandma” in order to save the government’s money, as some opponents would have it. The regulation in question, which was withdrawn just days after it took effect on Jan. 1, simply listed “advance care planning” as one of the services that could be offered in the “annual wellness visit” for Medicare beneficiaries.

The widespread misconceptions about the regulation were exemplified in a letter to the editor published Dec. 29 in The New York Times. “Death panels,” the writer said, would have denied her 93-year-old mother colon cancer surgery that has given her the chance to live “several more years.”

But that is not at all what the regulation would have done. Instead, “by providing Medicare coverage for end-of-life planning with a physician, it would have encouraged doctors to talk to their patients about their wishes and made it far easier and more likely for these important conversations to take place,” said Barbara Coombs Lee, president of Compassion & Choices, an organization that helps people negotiate end-of-life problems.

With payment schedules that limit doctor visits to a mere 15 minutes or so, it is unreasonable to expect physicians to spend 30 or more unreimbursed minutes discussing with patients the many decisions that can arise at the end of life.

Encouraging such conversations might indeed save money in the long run. Doctors and hospitals are paid only for treating living patients, so there is always a possibility that financial incentives, conscious or unconscious, would prompt many expensive if futile life-extending measures — efforts that many patients would veto if they could.

In a study of patients with advanced cancer published in March 2009 in Archives of Internal Medicine, the costs of care during the last week of life were 55 percent higher among those who did not have end-of-life discussions with their doctors.

At least as important, the quality of life in their final days was much worse than among those who did have such discussions. Countless studies have shown that extensive medical interventions can make the last weeks of life an excruciating experience for patients and those who care about them.

An Individual Decision

Although talk about end-of-life options has often emphasized avoiding unwanted, intrusive and futile care, that does not mean everyone would or should make that choice. Many patients, especially younger ones, might be inclined to ask that every conceivable measure be taken.

Dr. Josh Steinberg, a primary care physician in Johnson City, N.Y., routinely discusses end-of-life desires with very ill patients. He told me about an AIDS patient who was down to 77 pounds and had no strength, no appetite and failing kidneys. But the man refused hospice care, saying he wanted to go home and live as well as possible for as long as possible.

“Though we didn’t think he’d last more than a day or two, we got lucky,” Dr. Steinberg said. “We stumbled on a new treatment, he rallied, and he’s home doing well right now.”

For other patients, hospice care is the right decision. Studies have found that terminally ill patients are likely to live longer, with a better quality of life, when they choose hospice over aggressive treatment to the bitter end.

The point is that end-of-life care is an individual decision that should be thoroughly discussed with one’s family and physicians. Studies have shown that when doctors don’t know a patient’s wishes, they are inclined to use every possible procedure and medication to try to postpone the inevitable. More often than not, this shortens patients’ lives and prolongs bereavement for the survivors.

In an interview on the syndicated news program “Democracy Now!” on Jan. 5, the writer and surgeon Dr. Atul Gawande said that patients with terminal cancer who discuss end-of-life choices with their doctors “are less likely to die in the intensive care unit, more likely to have a better quality of life and less suffering at the end, do not have a shorter length of life, and six months later their family members are markedly less likely to be depressed.”

Plan While You Still Can

For many more of us these days, the end does not come swiftly via a heart attack or fatal accident, but rather after weeks, months or years battling a chronic illness like cancer, congestive heart failure, emphysema or Alzheimer’s disease. When doctors do not know how you’d want to be treated if your heart stopped, or you were unable to breathe or eat and could not speak for yourself, they are likely (some would say obliged) to do everything in their power to try to keep you alive.

A year ago, my husband was given a diagnosis of Stage 4 cancer. As his designated health care proxy, I had agreed long before he became ill to abide by the instructions in his living will. If he was terminally ill and could not speak for himself, he wanted no extraordinary measures taken to try to keep him alive longer than nature intended.

Knowing this helped me and my family avoid agonizing decisions and discord. We were able to say meaningful goodbyes and spare him unnecessary physical and emotional distress in his final weeks of life.

Preparing these advance directives should not wait until someone develops a potentially fatal disease. Patients in the throes of terminal illness may resist discussions suggesting that death may be imminent, and close family members may be reluctant to imply as much.

Indeed, judging from national studies and people I know (including a 90-year-old aunt), most Americans regardless of age seem reluctant to contemplate the certainty that one day their lives will end, let alone discuss how they’d want to be treated when the end is near.

A study published in January 2009 in The Journal of the American Geriatric Society showed that 40 percent of people questioned had not yet thought about advanced-care planning and 90 percent hadn’t documented their wishes for end-of-life care.

Ideally, everybody over 18 should execute a living will and select a health care proxy — someone to represent you in medical matters.

Compassion & Choices has an excellent free guide and “tool kit” to help people prepare advanced directives. They can be downloaded from the organization’s Web site, www.compassionandchoices.org (select the “care” tab, then “planning for the future”) or call (800) 247-7421 for a free hard copy of the documents.

Really?: The Claim: Eating Ginger Helps Reduce Muscle Pain and Soreness

Posted: 17 Jan 2011 08:10 PM PST

THE FACTS

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Christoph Niemann

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Ginger’s ability to calm an upset stomach is well known. But more recently, scientists have wondered whether its soothing effects might extend to sore muscles.

Ginger, a member of the same plant family as turmeric, contains anti-inflammatory compounds and volatile oils — gingerols — that show analgesic and sedative effects in animal studies. So last year a team of researchers looked at whether ginger might do the same in humans.

In the study, published in The Journal of Pain in September, the scientists recruited 74 adults and had them do exercises meant to induce muscle pain and inflammation. Over 11 days, the subjects ate either two grams of ginger a day or a placebo. Ultimately, the ginger groups experienced roughly 25 percent reductions in exercise-induced muscle pain 24 hours after a workout.

In a similar double-blind study, scientists compared what happened when subjects consumed either two grams of ginger or a placebo one day and then two days after exercise. The ginger appeared to have no effect shortly after ingestion. But it was associated with less soreness the following day, leading the researchers to conclude that ginger may help “attenuate the day-to-day progression of muscle pain.”

Other studies have shown that consuming ginger before exercise has no impact on muscle pain, oxygen consumption and other physiological variables during or immediately after a workout, suggesting that if ginger does have any benefits, they may be limited to reductions in soreness in the days after a workout.

THE BOTTOM LINE

Ginger may help ease pain and soreness, but only a day or more after a workout.

ANAHAD O’CONNOR scitimes@nytimes.com

The New Old Age: New Lives for ‘Dead’ Malls

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Prescriptions: Insurers Reporting Healthy Profits

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Urban Athlete: Winter Swims, With Views, in New York City

Posted: 20 Jan 2011 10:00 PM PST

IT seems counterintuitive to want to jump in a pool when New York feels like a meat locker. But I do. Especially in pools under skylights, which make me feel as if I’m swimming in an urban greenhouse.

When I was eight months pregnant, I’d walk through blizzard conditions in Clinton to reach one of the most beautiful, airy and affordable swimming holes in Midtown, at the Manhattan Plaza Health Club. After a few laps in its 75-foot-long pool, surrounded by plants and below towering high-rises, I’d feel weightless and warm as I lumbered along like a manatee.

A fellow swimmer, Samantha Fox, 29, has had a similar experience at the New York Sports Club pool on the 15th floor of the Crowne Plaza Times Square. “Having that window on you makes you feel like you’re close to the outside, but not,” she said, referring to the skylight and the western-facing windows over the 54-foot pool. As a Sports Club member myself, I can vouch for how thrilling it is to swim above the bustle of Times Square.

One can also do this a few blocks away at the Manhattan at Times Square Hotel. For a $40 day pass, you can use the gym and the 50-foot pool, with its views of Broadway theaters and flashy billboards.

For those who prefer a panorama with less neon, there’s the gigantic, two-year-old Flushing Meadows-Corona Park Aquatic Center in Queens. The 164-foot-long pool — true Olympic size — not only offers lap swimmers ample space, but it also has floor-to-ceiling windows with pastoral views of trees, soccer fields and the Unisphere. Just bring your own towels, a cap and a heavy-duty lock. When I handed an attendant my dinky lock recently, she rolled her eyes and said, “They’ll clip that one immediately.”

Locks are not a problem, however, at the swanky Mandarin Oriental, New York, pool, which is open only to hotel or spa guests. If you’re fortunate enough to visit the eerily serene 75-foot pool on the 36th floor of this Columbus Circle property, you will feel as if you’re swimming in the sky.

Perhaps a more reasonable luxury hotel experience can be had a few blocks east at Le Parker Meridien, which has a smaller family-friendly pool, where $75 secures a day pass that also includes gym access. The sun-drenched space has sweeping views of Central Park and welcoming attendants who hand you fluffy towels when you leave the pool.

Another family-friendly (and less expensive) option is the Waterside Plaza Swim and Health Club, which has a jewel box of a pool (skylight, floor-to-ceiling windows) on the East Side. The night I went with my 5-year-old daughter (the same one who accompanied me in utero to Manhattan Plaza), we enjoyed our reflections in the skylight, a view of the glistening Chrysler Building and a full moon over the East River. Towels are not supplied, though, which we learned the hard way; we dried off in the sauna. At 45 feet long and mostly cordoned off for free play, though, the pool may frustrate lap swimmers.

Serious swimmers are welcome, however, at the Sports Center at Chelsea Piers. Its 75-foot pool — my personal favorite — is at the end of Pier 60, on the Hudson River. There you swim over the river and have views of it. When I visited recently, a ray of light accompanied me for about 20 minutes of my swim before the sun set over New Jersey. I then enjoyed the darkening sky and the sounds of relentless arctic gusts outside while I remained soaking wet, yet defiantly cozy, on the inside.

Recipes for Health: Root Vegetable Gratin

Posted: 20 Jan 2011 12:20 AM PST

Use turnips, rutabagas, kohlrabi or a mix of these vegetables in this delicate winter gratin.

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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1 1/2 pounds turnips, kohlrabi, rutabaga, large parsnips or a combination, peeled and sliced thin (if the rutabagas are very large, cut them in half and slice in half-moons; slice the turnips and kohlrabi into rounds; quarter and core the parsnips, then slice them)

Salt and freshly ground pepper

1/2 teaspoon fresh thyme leaves

3/4 cup grated Gruyère cheese (3 ounces)

1 1/2 cups low-fat (1 percent or 2 percent) milk

1. Preheat the oven to 400 degrees. Butter a 2-quart gratin or baking dish. Place the sliced vegetables in a large bowl, and season generously with salt and pepper. Add the thyme, and toss together.

2. Arrange the vegetables in the gratin dish. Add the milk, season with more salt and pepper if you wish, and place in the oven on the middle rack. Bake 45 minutes; every 15 minutes, press the vegetables down into the milk with the back of your spoon. Add the cheese, and stir in carefully to incorporate. Return to the oven, and bake another 30 to 45 minutes, stirring or pressing the vegetables down with the back of your spoon every 10 minutes until the gratin is nicely browned and most of the liquid is absorbed. Remove from the heat and serve, or allow to settle and serve warm.

Yield: Serves four.

Advance preparation: You can make this several hours ahead of serving, and reheat in a medium oven.

Nutritional information per serving: 200 calories; 8 grams fat; 5 grams saturated fat; 28 milligrams cholesterol; 22 grams carbohydrates; 6 grams dietary fiber; 167 milligrams sodium (does not include salt to taste); 12 grams protein

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

Recipes for Health: Grated Carrot, Kohlrabi and Radish Salad

Posted: 19 Jan 2011 12:00 AM PST

This recipe is based on the Vietnamese carrot and daikon salad that found in so many restaurants. (It also is used to fill vegetarian spring rolls.) My version is less sweet than the authentic salad and employs a mix of vegetables.

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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1 1/2 pounds mixed carrots, kohlrabi, black radish and daikon, peeled and grated on the large holes of a grater or cut in thin julienne (any combination; 4 cups total)

Kosher salt to taste (about 1/2 teaspoon)

1 1/2 cups water

1 tablespoon sugar

1/2 cup rice vinegar

2 tablespoons slivered mint leaves or chopped cilantro (optional)

1. Combine the grated or julienne vegetables in a large bowl, and toss with about 1/2 teaspoon salt. Place in a strainer or colander set over a bowl or in the sink. Let stand for about 30 minutes.

2. Meanwhile, combine the water, sugar and vinegar in a saucepan, bring to a boil and remove from the heat. Pour into the bowl in which you combined the vegetables, and allow to cool to room temperature.

3. Briefly rinse the vegetables, and squeeze dry. Add to the bowl with the vinegar mixture, and stir together. Refrigerate for one hour or longer. To serve, lift from the vinegar bath with a slotted spoon and arrange on a platter. Garnish with the mint or cilantro, and serve.

Yield: Serves six.

Advance preparation: You can keep this in the refrigerator, the vegetables marinating in the vinegar mixture, for several days.

Nutritional information per serving: 56 calories; 1 gram fat; 0 grams saturated fat; 0 milligrams cholesterol; 9 grams carbohydrates; 2 grams dietary fiber; 196 milligrams sodium (does not include salt to taste); 2 grams protein

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

Recipes for Health: Purée of Winter Vegetable Soup

Posted: 20 Jan 2011 01:52 PM PST

Living in France, I was always impressed by the bags of mixed vegetables, called soupe, sold in farmers’ markets and supermarkets alike. The bags usually included an onion, carrots and celery, a leek, a turnip or two and a bouquet garni consisting of a bay leaf, a sprig of thyme and another of parsley. I’ve added root vegetables to this ginger-scented soup, which is inspired by the many simple suppers I enjoyed in the homes of French friends.

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

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1 tablespoon extra virgin olive oil

1 medium onion, chopped

1/2 pound leeks (1 large or 2 small), white and light green parts only, cleaned well and sliced

1/2 pound carrots (2 large), peeled and sliced

1/2 pound kohlrabi, trimmed, peeled and diced

1/2 pound turnips, peeled and diced

6 ounces potatoes (2 medium), peeled and diced

1 1/2 quarts water, chicken stock or vegetable stock (see note)

2 fat slices ginger, peeled

1 bay leaf

A couple of sprigs each thyme and parsley

12 peppercorns

Salt and freshly ground pepper to taste

1. Heat the olive oil over medium heat in a large, heavy soup pot or Dutch oven. Add the onion. Cook, stirring, until it begins to soften, about three minutes. Add the leeks and a generous pinch of salt. Cook, stirring often, until tender but not browned, about five more minutes. Add the carrots, kohlrabi, turnips, potatoes and water or stock. Bring to a boil.

2. Meanwhile, wrap the ginger, bay leaf, thyme, parsley and peppercorns in cheesecloth. Tie them up to make a bouquet garni, and add to the pot. Add salt to taste (about 2 teaspoons), reduce the heat, cover and simmer one hour. Remove the cheesecloth bag, and discard.

3. Blend the soup until smooth with an immersion blender or in batches in a regular blender. (Do not put the top on tight; cover the top with a towel to prevent hot splashes.) Pour the soup through a strainer into a bowl; press the soup through the strainer with the back of a ladle or with a pestle. Return to the pot and heat through. Add lots of freshly ground pepper, taste and adjust salt, and serve.

Note: To make a quick vegetable stock, cut away the dark green outer leaves of the leeks, wash thoroughly, and simmer in a pot of water with the peelings from the carrots while you prepare your other vegetables. Strain, and use for the soup.

Yield: Serves six.

Advance preparation: The finished soup will keep for three or four days in the refrigerator. Whisk before reheating.

Nutritional information per serving: 109 calories; 3 grams fat; 0 grams saturated fat; 0 milligrams cholesterol; 21 grams carbohydrates; 5 grams dietary fiber; 76 milligrams sodium (does not include salt to taste); 3 grams protein

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

Economic View: Adding Clarity to Health Care Reform

Posted: 22 Jan 2011 10:23 AM PST

NOW that House Republicans have voted to repeal health care reform, in full knowledge that their bill has no chance of passing in the Senate, much less avoiding a presidential veto, it is time for constructive action. There is an opportunity to improve health care and reduce uncertainty, a Republican mantra.

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David G. Klein

Perhaps the most unpopular feature of the health care legislation now in place is a provision that requires nearly everyone to buy insurance. It is known as the mandate, and it is the aspect of the bill that could end up before the Supreme Court. In contrast, nearly everyone seems to approve of the provision ensuring that pre-existing medical conditions won’t prevent you from finding affordable insurance, as well as the rule that prevents insurers from dropping you if you get sick.

Unfortunately, it is hard to have the popular features without some version of the mandate. A health insurance system cannot work unless most healthy people participate.

The major source of uncertainty arises not from the bill itself, but rather from the lawsuits filed by states that object to the mandate. The legal issue is subtle, given that states have long imposed mandates of various kinds themselves, including those requiring children to go to school or requiring drivers to have liability insurance. So the states are not questioning the legality of mandates but whether it is constitutional for the federal government to foist one on state governments.

The Supreme Court may make the ultimate decision in the next year or two. If it rules the mandate unconstitutional, the viability of the rest of the plan is not clear. Until the legal issues are settled, the status of health care reform will be uncertain.

In this light, here are three thoughts about constructive steps we might take now:

SEAMLESS ENROLLMENT The first step is not really a substitute for mandates, but rather a supplement to whatever system we adopt, including the law as now written. The goal of having nearly everyone insured requires two steps. We have to get most people to enroll, and we have to keep them enrolled even if they move in and out of the labor market.

To address that second goal, we need to make it as easy as possible for people who lose jobs to remain insured. The setup I propose is that as soon as an employer submits a form notifying a laid-off worker that she has been dropped from its health insurance coverage, she would be automatically enrolled in a plan offered by her state insurance exchange, and directly billed at a rate that reflects her now-reduced income. Ideally, the default option would be an inexpensive, catastrophic policy that provides real insurance for major events.

Of course, she could choose another plan, or she could opt out of insurance altogether, but she would have to take some specific action in order to do so. And once she landed another job, she would be automatically enrolled in a plan from her new employer, again with the ability to opt out.

In a perfect world, all of this would be seamless, with one insurance ID number and no change in how claims are filed. If the Internal Revenue Service can keep track of you when you move from one job to another, the health care system should be able to do the same.

FORFEITURE, NOT FINES After 2014, when the main components of health care reform kick in, the important question will be what happens to people who do not enroll initially, or do not stay enrolled. Under the current law, they will be fined an amount that depends on their income, payable when income taxes are filed. Fines are what differentiate a mandate from a suggestion.

But fines are not the only way to give people an incentive to join. One alternative is based on a proposal by Paul Starr, the Princeton sociologist and health care expert. Instead of facing a financial penalty for not buying health insurance, people would lose some of their insurance rights. For a stretch of time — say, five years — people would no longer have the right to buy insurance at rates subsidized by the government, nor would they be protected from price discrimination based on pre-existing conditions.

Under these rules, waiting until you become sick to buy insurance would have substantial risks. If the details are set properly, this arrangement could provide as big an incentive to join as a cash penalty. And because that cash penalty is imposed only when income taxes are due, the alternative plan may be easier to enforce.

MY “REAGAN PLAN” If you don’t like that idea, here’s another. In 1984, President Ronald Reagan signed a bill encouraging all states to adopt a minimum drinking age of 21. To nudge states into going along, the plan said that any state that didn’t join would have its highway funds cut by a certain percentage. Although Mr. Reagan initially had misgivings about the plan, he would later come to embrace it, saying that the harm caused by teenage drunken drivers was “bigger than the individual states.”

All of the states ended up complying, although some were reluctant — and South Dakota, in fact, sued. But in that case, the Supreme Court ruled 7 to 2 that the law was constitutional.

Here is how the Reagan plan could apply to health care: Adopt a new bill that says that if a state doesn’t want to accept a mandate — or some alternative like the one described above — it may opt out of health care reform. But a state that chooses this course would lose a percentage — or perhaps all — of the federal funds that the health care bill would funnel to state governments. In other words, states would be permitted to turn down the health care program, but they would then give up a share of the revenue, as well as other features of the law that are popular.

BOTH political parties could benefit from a civil discussion of these issues. By creating a viable alternative to mandates, Democrats could ensure that an adverse decision by the Supreme Court would not create legal chaos. Republicans could get a seat at the table if they engaged in a constructive way — and they might try to make progress on tort reform, which has the potential to help reduce health care costs.

As the recent tax compromise has shown, negotiations between the parties offer the potential for gains. In this situation, we can learn more from Ronald Reagan than from the slogan popularized by his wife, Nancy. It is not always the best policy to “just say no.”

Richard H. Thaler is a professor of economics and behavioral science at the Booth School of Business at the University of Chicago.

Global Update: Uganda: Male Circumcision May Help Protect Sexual Partners Against Cervical Cancer

Posted: 17 Jan 2011 09:40 PM PST

Male circumcision, which has been shown to decrease a man’s risk of contracting the virus that causes AIDS, also appears to help protect his sexual partners against cervical cancer.

In an offshoot of a landmark study of 1,200 heterosexual couples in Uganda involving circumcision and AIDS, researchers reported in The Lancet this month that having a circumcised partner reduced a woman’s risk of catching human papillomaviruses by about 25 percent. Such viruses lead to genital warts and cervical cancer.

The study, led by researchers from Johns Hopkins University, did not last long enough to see how many women actually developed cancer; that can take years or decades.

Cervical cancer was once a major killer in wealthy countries, but because of Pap smears it is now much rarer. In poor countries, it kills almost 250,000 women a year, according to the National Cancer Institute.

Papilloma vaccines like Gardasil and Cervarix provide much greater protection than circumcision does, but they are too expensive for most poor countries.

Doctors have long suspected that having circumcised husbands protected women against cervical cancer. A 1901 study in The Lancet noted that few British Jewish women died of it (although it erroneously concluded that they were protected by avoiding bacon). Later research in Israel found that stronger protection comes from a variant gene common in Jewish women all over the world.

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Lawsuit Loans Add New Risk for the Injured

Posted: 19 Jan 2011 01:41 PM PST

Larry Long, debilitated by a stroke while using the pain medicine Vioxx, was facing eviction from his Georgia home in 2008. He could not wait for the impending settlement of a class-action lawsuit against the drug’s maker, so he borrowed $9,150 from Oasis Legal Finance, pledging to repay the Illinois company from his winnings.

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Gary Tramontina for The New York Times

Carolyn and James Williams. Ms. Williams borrowed $5,000 in 2007 from USClaims while pursuing a disability suit. Her case is unresolved and her debt to USClaims stands at $18,976.

Betting on Justice

The Lenders' Advantage

Articles in this series â€" which is a collaboration between the Center for Public Integrity, a nonprofit journalism group in Washington, and The Times â€" are looking at the growing practice of investing in lawsuits.

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Ruth Fremson/The New York Times

“It’s not for everyone, but it’s there when you need it,” said Harvey Hirschfeld of LawCash.

By the time Mr. Long received an initial settlement payment of $27,000, just 18 months later, he owed Oasis almost the entire sum: $23,588.

Ernesto Kho had pressing needs of his own. Medical bills had piled up after he was injured in a 2004 car accident. So he borrowed $10,500 from Cambridge Management Group, another company that lends money to plaintiffs in personal-injury lawsuits. Two years later, Mr. Kho, a New Jersey resident, got a $75,000 settlement — and a bill from Cambridge for $35,939.

The business of lending to plaintiffs arose over the last decade, part of a trend in which banks, hedge funds and private investors are putting money into other people’s lawsuits. But the industry, which now lends plaintiffs more than $100 million a year, remains unregulated in most states, free to ignore laws that protect people who borrow from most other kinds of lenders.

Unrestrained by laws that cap interest rates, the rates charged by lawsuit lenders often exceed 100 percent a year, according to a review by The New York Times and the Center for Public Integrity. Furthermore, companies are not required to provide clear and complete pricing information — and the details they do give are often misleading.

A growing number of lawyers, judges and regulators say that the regulatory vacuum is allowing lawsuit lenders to siphon away too much of the money won by plaintiffs.

“It takes advantage of the meek, the weak and the ignorant,” said Robert J. Genis, a personal-injury lawyer in the Bronx who said that he had warned clients against borrowing. “It is legal loan-sharking.”

Colorado filed suit in December against Oasis and LawCash, two of the largest companies, charging them with violating the state’s lending laws.

“It looks like a loan and smells like a loan and we believe that these are, in fact, high-cost loans,” John W. Suthers, the state’s attorney general, said in a recent interview. “I can see a legitimate role for it, but that doesn’t mean that they shouldn’t be subject to regulation.”

The companies, however, say that they are not lenders because plaintiffs are not required to repay the money if they lose their cases. The industry refers to the transactions as investments, advances, financing or funding. The argument has persuaded regulators in many states, including New York, that lawsuit lenders are not subject to existing lending laws. Oasis and LawCash have now filed suit against Colorado, asking the court to prevent the state from using lending laws to regulate the industry.

Companies also say that they must charge high prices because betting on lawsuits is very risky. Borrowers can lose, or win less than expected, or cases can simply drag on, delaying repayment until the profit is drained from the investment.

To fortify its position, the industry has started volunteering to be regulated — but on its own terms. The companies, and lawyers who support the industry, have lobbied state legislatures to establish rules like licensing and disclosure requirements, but also to make clear that some rules, like price caps, do not apply.

Maine and Ohio passed the first such laws in 2008, followed by Nebraska last year. Sympathetic legislators introduced bills in six other states last year; the measures passed the state Senates in New York and Illinois.

Harvey Hirschfeld, a founder of LawCash who keeps binders filled with thank-you notes from borrowers on a shelf in his Brooklyn office, said lawmakers had responded to plaintiffs’ needs.

“Sometimes people are in the wrong place at the wrong time, they get in an accident, they’re out of work, they don’t have cash sitting in the bank, their friends can’t help, and they’re faced with a terrible situation,” said Mr. Hirschfeld, who also is chairman of the industry’s trade group. “It’s not for everyone, but it’s there when you need it.”

High Rates, Low Risk

This project was initiated by the Center for Public Integrity, a nonprofit investigative journalism organization in Washington. It is based on reporting by Ben Hallman and Caitlin Ginley of the center and Binyamin Appelbaum of The Times, and was written by Mr. Appelbaum.

The Bay Citizen: Governor’s Budget Cuts Will Not Affect Those With the San Francisco’s Universal Health Care Plan

Posted: 17 Jan 2011 08:58 AM PST

Tens of thousands of San Franciscans will be insulated from state budget cuts, thanks to the Healthy San Francisco, the city’s plan to provide health care to all its residents, local officials said.

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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.

While Medi-Cal patients would see expensive new co-payments and have their coverage capped under proposals announced Monday by Gov. Jerry Brown, Jim Soos, assistant director of policy and planning for the San Francisco Department of Public Health, said the 55,000 people enrolled in the San Francisco program would see no change.

“It’s not horrible news for us,” said Mr. Soos, whose agency oversees Healthy San Francisco, the first such plan in the country. “There are no cuts to us directly.”

That is because the program, which was created in 2007, receives no state financing. Instead, it depends on a mix of city dollars, federal money, patient payments and fees on businesses that operate in the city that opt not to provide health coverage for their workers.

Patients who get care through Healthy San Francisco typically make too much to qualify for Medi-Cal but not enough to buy private insurance. Others have low incomes but do not qualify for Medi-Cal because they do not meet the eligibility criteria. Childless adults typically do not qualify for Medi-Cal unless they are elderly, disabled or pregnant.

“San Francisco is an island on its own,” said Sean South, spokesman for the California Primary Care Association, which represents more than 800 community clinics across the state.

But frontline doctors are not celebrating. “Every government program is dependent on funding streams,” said Dr. Kenneth Tai, the medical director of North East Medical Services, which sees one in six Healthy San Francisco patients at its four clinics in the city.

San Francisco is facing its own $379.8 million deficit. With the program’s chief cheerleader, Gavin Newsom, having left his post as mayor to become lieutenant governor, Dr. Tai said he was not confident about the program’s future.

In the meantime, Dr. Tai is trying to figure out how he will manage care of his Medi-Cal patients, who would be limited to six medical prescriptions a month and 10 doctors’ visits a year under Mr. Brown’s budget proposals.

At North East Medical Services’ clinic on Stockton Street, patients said they would wait longer before seeing a doctor to avoid exceeding the maximum number of doctors’ visits, and worried about $50 co-payments for emergency room visits and $100 a day for hospital stays, which could become more common if patients delay regular doctors’ visits.

Dr. Tai said he would “have to start staggering their prescriptions, giving six one month and six the next.”

But that could lead to medical complications. “Some of these patients have Alzheimer’s, and it’s already difficult to get them to take their medicine,” he said.

According to the California Department of Health Care Services, 124,000 San Franciscans receive Medi-Cal, more than double the number of city residents enrolled in Healthy San Francisco.

aglantz@baycitizen.org

Two Tests Could Aid in Risk Assessment and Early Diagnosis of Alzheimer’s

Posted: 19 Jan 2011 07:07 AM PST

Researchers are reporting major advances toward resolving two underlying problems involving Alzheimer’s disease: How do you know if someone who is demented has it? And how can you screen the general population to see who is at risk?

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One study, reported in The New York Times in June, evaluated a new type of brain scan that can detect plaques that are uniquely characteristic of Alzheimer’s disease.

On Thursday, an advisory committee to the Food and Drug Administration, which requested the study, will review it and make a recommendation on whether to approve the test for marketing.

The second study asked whether a blood test could detect beta amyloid, the protein fragment that makes up Alzheimer’s plaque, and whether blood levels of beta amyloid were associated with a risk of memory problems. The answer was yes, but the test is not ready to be used for screening.

Both studies are to published in The Journal of the American Medical Association on Wednesday.

“These are two very important papers, and I don’t always say that,” said Neil S. Buckholtz, chief of the Dementias of Aging Branch of the National Institute on Aging.

The new brain scan involved a dye developed by Avid Radiopharmaceuticals, now owned by Eli Lilly. The dye attaches to plaque in patients’ brains, making it visible on PET scans.

The study by Avid involved 152 people nearing the end of life who agreed to have a brain scan and a brain autopsy after they died. The investigators wanted to know whether the scans would show the same plaques as the autopsies.

Twenty-nine of the patients in the study died and had brain autopsies. In 28 of them, the scan matched the autopsy results. Alzheimer’s had been diagnosed in half of the 29 patients; the others had received other diagnoses.

One subject who was thought to have had Alzheimer’s did not have plaques on the scans or on the autopsy — the diagnosis was incorrect. Two other patients with dementia turned out to have had Alzheimer’s although they had received diagnoses of other diseases.

The study also included 74 younger and healthier people who underwent the scans. They were not expected to have plaques, and in fact they did not.

If the F.D.A. approves the scan, medical experts said they would use it to help determine whether a patient with dementia had Alzheimer’s. If no plaques were found, they would have to consider other diagnoses.

The Avid scan will also be used — and is being used — by companies that are testing drugs to remove amyloid from the brain. The scans can show if the drugs are working. And a large study sponsored in part by the National Institute on Aging is scanning healthy people and following them to see if the scans predict the risk of developing Alzheimer’s disease.

The other study, on a blood test for Alzheimer’s, indicates that such a test may work. But researchers agree that it is not ready for clinical use.

The study, by Dr. Kristine Yaffe of the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, included 997 subjects whose average age was 74 when the study began. They were followed for nine years and given memory tests and a blood test looking for beta amyloid.

Beta amyloid is in the brain and flows into the spinal fluid. From there, it can enter the bloodstream. When amyloid accumulates in plaque, its levels in spinal fluid go down. That indicates risk for Alzheimer’s disease.

Dr. Yaffe and her colleagues asked whether they could show similar Alzheimer’s risk by measuring beta amyloid levels in blood. It is difficult; amyloid levels in blood are much lower than in spinal fluid. And there appear to be other sources of amyloid in blood, confounding the test results.

“I was interested in the blood test because I think it’s been given a bit of a write-off,” Dr. Yaffe said. Some studies concluded that it worked, but just as many said that it did not. She wanted to try again with a large study following people for a long period and using a sensitive test for amyloid.

She divided the subjects into groups and found that those with the most amyloid had the lowest risk of a decline in their mental abilities, and those with the least had the greatest risk. But other factors also played a role. Low levels of the protein were not as useful in predicting mental decline in people who had more education and were more literate. People with a gene, APO e4, that is associated with an increased risk of Alzheimer’s, seemed to be at a greater risk of a mental decline even if their blood levels of amyloid were high.

That does not necessarily mean that the more people use their minds the more they will be protected from Alzheimer’s disease, researchers note. But, Dr. Yaffe said, that idea needs more study.

The test’s precision, said Dr. Clifford Jack of the Mayo Clinic, was “not crisp enough” to accurately predict whether an individual was likely to show an intellectual decline over the decade after the test was given.

Still, said Dr. Ronald C. Petersen, chairman of the medical and scientific advisory council of the Alzheimer’s Association, there is an increasing need for such a test. If treatments are developed to slow or stop the disease, it will be important to start them before irreversible damage is done.

Current tests of Alzheimer’s risk — spinal taps and MRI and PET scans — are not suitable to screen large numbers of people. “They are either expensive or invasive, or both,” Dr. Petersen said. “We need a cheap and safe population screening tool, like cholesterol for cardiology.”

A blood test could be ideal, and this study is an encouraging step forward, he said. The idea might be to screen with such a test and then follow up with those who test positive, giving them a PET scan, for example.

But, Dr. Petersen said, “this study is not sufficiently convincing that this is the answer.”

Pfizer in Deal With Theraclone for Antibody Drug Research

Posted: 19 Jan 2011 12:00 AM PST

Pfizer, the world’s largest drug company, has agreed to pay up to $632 million to Theraclone Sciences in a research collaboration on antibody drugs for cancer and infectious disease, the companies said Tuesday.

Pfizer, based in New York, is trying to keep up with its pharmaceutical rivals that are increasingly relying on biotechnology for products and profits.

“This fits in the big picture of us wanting to be on the leading edge of biotherapeutics and antibody discovery, and this is one company we are very excited to work with,” Jose-Carlos Gutiérrez-Ramos, Pfizer’s senior vice president and head of biotherapeutics research, said in an interview Tuesday.

Theraclone, a small company in Seattle, is receiving a jolt of new research financing.

Theraclone is led by Steven Gillis, a scientist and venture capitalist who previously co-founded the biotechnology companies Immunex and Corixa. Amgen bought Immunex for about $16 billion in 2002; GlaxoSmithKline bought Corixa for about $300 million in 2005.

“The fact that Pfizer selected our antibody discovery technology is, I think, a great endorsement of our science and the speed with which we can make discoveries,” Dr. Gillis said in an interview.

Dr. Gillis, who is also managing director of Arch Venture Partners, took over as interim chief executive of Theraclone last year after its president and chief executive, David Fanning, died unexpectedly.

Neither company would specify the amount of initial financing for the deal. The upfront money will take the form of technology access fees on two unspecified targets in oncology and two unspecified goals in infectious disease, he said.

Dr. Gillis said 30 to 40 percent of the deal, or $189 million to $252 million, was “near term money” for milestones before the Phase II clinical trials. Theraclone could also earn royalties on any developed products. Pfizer is responsible for preclinical and clinical development.

The announcement follows a similar, smaller deal earlier this month when Pfizer agreed to pay Seattle Genetics about $8 million upfront and up to $200 million over time for work on its antibody technology against cancer.

In a much larger deal in September, a Pfizer rival, Johnson & Johnson, announced that it intended to buy the antibody maker Crucell for $2.3 billion. Johnson & Johnson already owned 18 percent of the Dutch company. The final terms are still pending amid some concern about a Crucell manufacturing problem.

Theraclone has received other investments in its antibody work previously. That included financing from the International AIDS Vaccine Initiative, partly financed by the Bill & Melinda Gates Foundation, for an experimental antibody to AIDS, and money from the Tokyo-based drug maker Zenyaku Kogyo for an antibody to influenza.

Antibodies are Y-shaped proteins that can target and bind to other molecules. They form the body’s defense system against a bacteria, virus or toxin.

Theraclone specializes in screening human antibodies.

“They’re selected naturally for their lack of side effects and good expression,” Mr. Gutiérrez-Ramos of Pfizer said.

Pfizer already has 15 to 20 antibodies in clinical development, he added. Its research in the field was previously bolstered by the purchases of two antibody development companies, Boren in 2005 for an undisclosed amount, and Wyeth in 2009 for $68 billion.

Vital Signs: Aging: Mediterranean Diet as Brain Food

Posted: 18 Jan 2011 02:21 PM PST

The Mediterranean diet — heavy on vegetables, fish and olive oil, with moderate amounts of wine — may be associated with slower rates of mental decline in the elderly.

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Some previous studies have suggested that the diet has beneficial effects for the brain, but the evidence has not been strong. A new report analyzed data from a continuing study of 3,790 Chicago residents 65 and older that began in 1993. The researchers tested the subjects’ mental acuity at three-year intervals, and tracked their degree of adherence to the Mediterranean diet on a 55-point scale.

High scores for adherence to the diet were associated with slower rates of cognitive decline, even after controlling for smoking, education, obesity, hypertension and other factors.

The lead author, Christine C. Tangney, an associate professor of nutrition at Rush Medical College in Chicago, said sticking to the diet made a large difference. Those in the top third for adherence, she said in a telephone interview, were cognitively the equivalent of two years younger than those in the bottom third.

The study, published in The American Journal of Clinical Nutrition, has significant strengths in its prospective design, large sample and use of a well-validated dietary questionnaire. But the authors acknowledged that they could not account for all possible variables, and cautioned that it was an observational study that draws no conclusions about cause and effect.

Vital Signs: Behavior: They Report Abstinence, but S.T.D. Says Otherwise

Posted: 18 Jan 2011 02:20 PM PST

About 10 percent of young adults in a large study who tested positive for a sexually transmitted disease reported that they had been abstinent for the past year, and half of those said they had never had sex at all.

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Researchers writing in the January issue of Pediatrics used a nationally representative sample of 14,012 students initially recruited in 1994. The students gave urine samples and filled out sexual behavior questionnaires. The researchers interviewed and retested the subjects in 2001 and 2002.

The average age of the subjects, about half of them women, was 22. Those who reported sexual activity were only twice as likely to be infected as those who reported none, a very small difference under the circumstances.

There were no significant differences in age, sex, race or education level among those who were infected but reported abstinence.

Jessica McDermott Sales, an assistant professor of public health at Emory University and one of the study’s authors, said that dishonesty was only one possible explanation for the discrepancy. But she added, “This is a fairly sizable portion of kids who are saying they’re not sexually active when they apparently are.”

The study also found that positive tests were about a third more likely in women than men, six times as likely in African-Americans as in whites, and a third more likely in those without a high school diploma than in high school graduates.

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