Sunday, February 13, 2011

Health - Personal Best: Gimmick or Not, Vibrating Platforms Have Joined the Gym

Health - Personal Best: Gimmick or Not, Vibrating Platforms Have Joined the Gym

Personal Best: Gimmick or Not, Vibrating Platforms Have Joined the Gym

Posted: 12 Feb 2011 12:00 AM PST

The idea seems sort of silly, just another exercise gimmick. Stand for a few minutes on a platform that vibrates. Get off and try to do some weight lifting — squats, for example. Or try a short sprint. Or see how high you can jump. You are somehow supposed to be able to lift heavier weights, sprint faster, jump higher.

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But maybe it’s not so silly, exercise physiologists say. Although they don’t really know why vibrations should work, researchers report that they actually seem to slightly improve performance in the few minutes after a person gets off the machine.

The problem, though, is that there is little consensus on how fast the vibrations should be or in what direction platforms are supposed to vibrate. Some studies have failed to show any effects from vibrations. And then there is the question of what exactly vibrations are doing to muscles and nerves.

“It certainly is intriguing, and a large portion of the evidence would support that something is happening,” said Lee E. Brown, director of the Center for Sports Performance at California State University, Fullerton. But he added, “We are still trying to figure out exactly what the mechanism is.”

Meanwhile, several companies make the vibrating platforms, and they are being used at gyms and by some athletes.

One company, Power Plate, proclaims that stars like Serena Williams and the Minnesota Twins’ Justin Morneau train with its device. A testimonial for another company, Wave, says the United States ski and snowboard teams used its vibrating plates in training for the 2010 Winter Olympics.

But researcher are wary.

“There is something to it,” said William J. Kraemer, a professor of kinesiology at the University of Connecticut and the editor in chief of The Journal of Strength & Conditioning Research, calling it “another tool” for athletic conditioning. But he added that other conditioning methods might yield the same or better results.

“If you think of conditioning as a toolbox, there are lots of tools,” he said. “But when companies are selling something, they want to pretend that one tool does everything.”

Experts who have tried the platforms describe them in different ways. The sensation is nothing like using a jackhammer, said Hugh Lamont, a sports biomechanist at Eastern Tennessee State University. Most vibration plates move no more than 50 times a secon and feel like the vibrations in a seat over the wheel hub on a bus, Dr. Lamont said.

Others say the vibrations remind them of downhill skiing — they get the same sort of the rattling in their legs and feet. For Jeffrey M. McBride, an associate professor of biomechanics who is director of the neuromuscular laboratory at Appalachian State University in Boone, N.C., the word that comes to mind is “weird.”

“You can feel your muscles contract,” he said. “It sort of fatigues you.”

But if there is an effect, the researchers said, it seems to be short-lived. People seem to be slightly faster sprinters immediately after standing on a platform. They also seem to be able to jump a bit higher. Vibrations also seem to help people warm up before more strenuous exercise.

“The effect wears off very quickly,” Dr. Brown said. “We are not talking about using this to play a 90-minute soccer match. One sprint and the effect would be gone. You’d play for one minute and still have 89 minutes to go.”

But it could make a difference, he said, if an athlete is about to try a penalty kick in soccer or swing a bat in baseball.

And Michael G. Bemben, chairman of exercise science at the University of Oklahoma, said that “one thought was if you were, say, a high jumper on your third trial in the Olympics and you are at 7 feet 2 inches and need to get to 7 feet 3, this might give you the power for that jump.”

Investigators say they can only guess why vibrations might improve performance. Their leading hypothesis is that it somehow mimics the effect of following a difficult task with an easier one — a simple technique that has been in use for years.

“If you pick up something heavy and then pick up something considerably lighter,” Dr. Lamont explained, “you might be able to throw the lighter weight farther.”

Or if you want to jump, he continued, you might first put a huge weight on a training rack, do a quarter squat, partway down, and then, for three to five seconds, try to push up and lift the weight. You would be doing an isometric contraction of your leg muscles. After that, you might jump higher.

But does it matter? Why not just warm up in the normal way, or do isometric contractions before jumping, or pick up a heavy weight before trying to throw a lighter one?

Or why not combine everything and do warm-ups on a vibrating platform, or try isometric contractions between periods of vibration?

Researchers have thought of that, and say they are investigating. Meanwhile, they say, people should be appropriately skeptical about the effects of standing on a vibrating platform.

“We don’t know a lot about prescribing it,” Dr. Kraemer said. “There’s the rub.”

And yet it is being used many times without an understanding of how to do it best or what the long-term training effects will be.

“Research,” Dr. Kraemer said, “is trying to catch up.”

For Some Troops, Powerful Drug Cocktails Have Deadly Results

Posted: 12 Feb 2011 11:08 PM PST

This article was reported by James Dao, Benedict Carey and Dan Frosch and written by Mr. Dao.

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Happier Days Before a Deadly Mixture

In his last months alive, Senior Airman Anthony Mena rarely left home without a backpack filled with medications.

He returned from his second deployment to Iraq complaining of back pain, insomnia, anxiety and nightmares. Doctors diagnosed post-traumatic stress disorder and prescribed powerful cocktails of psychiatric drugs and narcotics.

Yet his pain only deepened, as did his depression. “I have almost given up hope,” he told a doctor in 2008, medical records show. “I should have died in Iraq.”

Airman Mena died instead in his Albuquerque apartment, on July 21, 2009, five months after leaving the Air Force on a medical discharge. A toxicologist found eight prescription medications in his blood, including three antidepressants, a sedative, a sleeping pill and two potent painkillers.

Yet his death was no suicide, the medical examiner concluded. What killed Airman Mena was not an overdose of any one drug, but the interaction of many. He was 23.

After a decade of treating thousands of wounded troops, the military’s medical system is awash in prescription drugs — and the results have sometimes been deadly.

By some estimates, well over 300,000 troops have returned from Iraq or Afghanistan with P.T.S.D., depression, traumatic brain injury or some combination of those. The Pentagon has looked to pharmacology to treat those complex problems, following the lead of civilian medicine. As a result, psychiatric drugs have been used more widely across the military than in any previous war.

But those medications, along with narcotic painkillers, are being increasingly linked to a rising tide of other problems, among them drug dependency, suicide and fatal accidents — sometimes from the interaction of the drugs themselves. An Army report on suicide released last year documented the problem, saying one-third of the force was on at least one prescription medication.

“Prescription drug use is on the rise,” the report said, noting that medications were involved in one-third of the record 162 suicides by active-duty soldiers in 2009. An additional 101 soldiers died accidentally from the toxic mixing of prescription drugs from 2006 to 2009.

“I’m not a doctor, but there is something inside that tells me the fewer of these things we prescribe, the better off we’ll be,” Gen. Peter W. Chiarelli, the vice chief of staff of the Army who has led efforts on suicide, said in an interview.

Growing awareness of the dangers of overmedicated troops has prompted the Defense Department to improve the monitoring of prescription medications and restrict their use.

In November, the Army issued a new policy on the use of multiple medications that calls for increased training for clinicians, 30-day limits on new prescriptions and comprehensive reviews of cases where patients are receiving four or more drugs.

The Pentagon is also promoting measures to prevent troops from stockpiling medications, a common source of overdoses. For instance, the Navy, which provides medical care for Marines, has begun pill “give back” days on certain bases. At Camp Lejeune, N.C., 22,000 expired pills were returned in December.

The Army and the Navy are also offering more treatments without drugs, including acupuncture and yoga. And they have tried to expand talk therapy programs — one of which, exposure therapy, is considered by some experts to be the only proven treatment for P.T.S.D. But shortages of mental health professionals have hampered those efforts.

Still, given the depth of the medical problems facing combat veterans, as well as the medical system’s heavy reliance on drugs, few experts expect the widespread use of multiple medications to decline significantly anytime soon.

The New York Times reviewed in detail the cases of three service members who died from what coroners said were toxic interactions of prescription drugs. All were classified accidents, not suicides.

Airman Mena was part of a military police unit that conducted combat patrols alongside Army units in downtown Baghdad. He cleaned up the remains of suicide bombing victims and was nearly killed by a bomb himself, his records show.

Gunnery Sgt. Christopher Bachus had spent virtually his entire adult life in the Marine Corps, deploying to the Middle East in 1991, Iraq during the invasion of 2003 and, for a short tour, Afghanistan in 2005. He suffered from what doctors called survivor’s guilt and came back “like a ghost,” said his brother, Jerry, of Westerville, Ohio.

Cpl. Nicholas Endicott joined the Marines in 2003 after working as a coal miner in West Virginia. He deployed twice to Iraq and once to Afghanistan, where he saw heavy combat. On one mission, Corporal Endicott was blown more than eight feet in the air by a roadside bomb, medical records show. He came home plagued by nightmares and flashbacks and rarely left the house.

Given the complexity of drug interactions, it is difficult to know precisely what killed the three men, and the Pentagon declined to discuss their cases, citing confidentiality. But there were important similarities to their stories.

All the men had been deployed multiple times and eventually received diagnoses of P.T.S.D. All had five or more medications in their systems when they died, including opiate painkillers and mood-altering psychiatric drugs, but not alcohol. All had switched drugs repeatedly, hoping for better results that never arrived.

All died in their sleep.

Psychiatry and Warfare

The military medical system has struggled to meet the demand caused by two wars, and to this day it still reports shortages of therapists, psychologists and psychiatrists. But medications have always been readily available.

Across all branches, spending on psychiatric drugs has more than doubled since 2001, to $280 million in 2010, according to numbers obtained from the Defense Logistics Agency by a Cornell University psychiatrist, Dr. Richard A. Friedman.

Clinicians in the health systems of the Defense and Veterans Affairs Departments say that for most patients, those medications have proved safe. “It is important not to understate the benefit of these medications,” said Dr. Robert Kerns, the national director of pain management for the Department of Veterans Affairs.

Toby Lyles contributed research.

Stretch: The Delicate Art of Adjustments

Posted: 12 Feb 2011 02:43 PM PST

THINGS can get awkward when a group of strangers strip down to their spandex in a steamy, sweaty room. This is especially true in yoga class, where getting into a camel pose, for instance — thrusting your hips forward while kneeling — can feel, well, a bit “porny,” as Claire Dederer put it in the prologue of her memoir, “Poser: My Life in Twenty-Three Yoga Poses.”

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The self-consciousness that Ms. Dederer felt performing said porny poses is one hurdle that can get in the way of achieving inner peace. Having a teacher stand behind you and place his or her hands on your lower back or tug at your hips can be enough to turn some people away from yoga altogether.

The delicate art of hands-on adjustments is essential for many forms of yoga and their teachers, but it isn’t always welcome. As a student, I appreciate a skilled instructor’s help in realizing “the full expression of the pose,” as the yogis put it, or in making sure that my torso is at the correct angle, or that my toes are turned out properly. The touch of a hand can bring awareness to hard-to-reach places, like the lower back, or stabilize a wobbly leg.

But even a gesture meant to soothe can be misconstrued. A touch might be well-intentioned, but the line easily blurs into the sexual, said Jason Ray Brown, a longtime teacher and owner of Zenyasa Yoga and Wellness Studio in Manhattan.

“I’ve seen male teachers rubbing young women’s feet during savasana,” he said. “Would you do that to a 50-year-old man?”

Ask experienced instructors if a student has ever growled at them for touching — even with good intentions — and chances are they have a story for you. In his early teaching days, Mr. Brown approached a reasonably fit woman in her late 40s who was in a seated pose, a simple cross-legged forward bend. As he stood behind her, he reached out to put his hands on the tops of her thighs to increase the external rotation of her hips. Instead of welcoming the gesture, she shot up from the pose and told him to get lost. The woman never returned to class, and he has since been more cautious about making adjustments.

“You can’t assume that because you’re the yoga teacher you have the right to touch people,” Mr. Brown said.

Inappropriate touch or aggressive adjustments have also spawned lawsuits.

Michael O’Brien Keating, a Denver lawyer who has represented individuals in claims against yoga studios, took on a case in Colorado filed by a practitioner who alleged that an improper adjustment had led to an injury.

The matter was resolved out of court, but Mr. Keating, who dabbles in yoga himself, sees a large gray area in manipulating and adjusting students.

“The difficulty is that you have people in class who aren’t very athletic,” he said, “or who are getting into compromised positions” and may feel uncomfortable speaking up if an adjustment doesn’t feel right.

Each style of yoga also approaches adjustments differently. For instance, Mysore is more aggressive, Mr. Brown said, citing videos of Sri K. Pattabhi Jois, the Ashtanga guru, pushing a man’s head to his knee in a forward bend.

It’s impossible for a teacher — even when working with experienced and familiar students — to know a person’s complete medical history or his or her emotional state on a particular day.

However, “there’s a lot of information you can gather to gauge whether someone is open to suggestions,” said Joe Miller, who has taught at OM Yoga Center in Manhattan since 2000 and has a master’s degree in applied physiology. Mr. Miller will sometimes ask for verbal permission before reaching out — saying something like, “I’m going to move this shoulder back, is that O.K.?”

Alison West, who founded Yoga Union Center for Backcare and Scoliosis in Manhattan with Deborah Wolk, says some boundaries are clear. “It’s off-limits to approach the genitals and breasts,” she said.

Ms. West said she operated with two words in mind: “chaste” and “kind.”

“I have heard of teachers who are not beyond reproach,” she said. “The bottom line is that the teacher is responsible for what happens in the classroom.”

Risk and Reward in Utero

Posted: 12 Feb 2011 11:40 PM PST

The two mothers-to-be felt the same urgency. Told that their babies had potentially crippling spina bifida, both women hoped to receive an ambitious surgery that closes the hole in the spine while babies are in the womb.

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Their only access was through a clinical trial testing whether risky prenatal surgery was better than standard surgery after birth. Participating meant being randomly assigned to one surgery or the other.

“They take you to a room and a paper tells you what part of the trial you were randomized to,” said Jessica Thomas, 26, of Stansbury Park, Utah, assigned to prenatal surgery when pregnant with her son Tyson. “It was my only sense of hope to try to give him a better life.”

Amy Shapiro, 40, of Leander, Tex., was assigned to postnatal surgery, performed on her son Zachary the day after he was born.

“It was one of the hardest decisions I had to make to be in the study,” said Ms. Shapiro, who knew how disabling spina bifida was because her sister-in-law has it. “It was a big disappointment that we didn’t get the prenatal surgery because I knew that that was the surgery that was most likely going to help him the most, because otherwise why would they be doing the study? But at the same time, he could have died or been born prematurely from prenatal surgery. When they explained everything to us, I wanted to be in it regardless.”

Now, results are in: Fetal surgery, while increasing premature births and causing tearing at some mother’s incisions, made babies more likely to walk and less likely to have neurological problems or need shunts to drain brain fluid.

Besides the groundbreaking results, the seven-year study spotlights ethical dilemmas in research.

The surgery was becoming popular in the 1990s, even appearing on a Time magazine cover, and some experts believed that it might eventually eliminate most symptoms. But given the risks, others wanted proof that it was better than postnatal surgery.

“There were no systematic data regarding safety and efficacy,” said Dr. Jeremy Sugarman, a bioethicist at Johns Hopkins University who participated in early discussions. “Many things we believe to be true and right and appropriate ultimately are shown to be harmful and ineffective.” Spina bifida researchers believed that few women would participate if the surgery were available elsewhere, so they persuaded all but the three hospitals in the trial to stop doing the procedure, an unusual agreement.

“I frankly have a lot of problems when a group of physicians get together and in effect shut down everything so they can have a trial,” said Baruch A. Brody, director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. “For physicians who believe in it, why should they be pressured into stopping? For families who believe they should have the surgery, why should they be told they can’t?”

But several ethicists praised the pause. “It’s impressive to see that kind of collaboration,” said Dr. Jeffrey R. Botkin, a pediatric ethicist at the University of Utah. “The sophistication surgeons need to do this is so high, it makes sense to answer research questions by allowing it only at a few centers.”

The surgery proved beneficial enough that an independent monitoring board stopped the trial, not wanting to deny more women the opportunity for prenatal surgery. But stopping trials early sometimes limits the information researchers can collect that might benefit future patients.

Monitoring boards “walk a very fine line,” said Dr. Steven Goodman, an epidemiologist at Johns Hopkins and editor of the journal Clinical Trials. “At what point is the benefit of getting more information outweighed by the consequences of not releasing results and continuing to randomize patients?”

In some trials, if one treatment proves superior, other participants can then receive that treatment. But with prenatal surgery, that isn’t possible, said Jeffrey Kahn, director of the University of Minnesota’s bioethics center. “Some people are accepting risk for the benefit of those who will come after them.”

Still, regardless of therapy, “people who enroll in clinical trials, for the most part, do better than people who don’t, because care is controlled and monitored,” Dr. Goodman said. “You simply can’t go back and say, ‘In every trial people who didn’t get the winning therapy were deprived.’ ”

Tyson Thomas emerged from prenatal surgery with no need for a shunt and, at 22 months old, uses a walker but is almost walking independently. Zachary Shapiro, 6, has a shunt, walks with braces, and has some attention problems. Both boys, who received their surgery at the University of California, San Francisco, need catheters.

Ms. Shapiro, a kindergarten teacher, said of her son, “I do feel like he benefited, even though he didn’t benefit from the actual surgery.”

She added, “He benefited from the research that has happened about his disability.”

Arthur Schatzkin, Who Studied High-Fiber Diet and Polyps, Dies at 62

Posted: 12 Feb 2011 11:00 PM PST

Dr. Arthur Schatzkin, an epidemiologist whose investigations into the connections between diet and cancer yielded new analytic tools and led to the discovery that eating fiber did not prevent the recurrence of polyps in the colon, died on Jan. 20 in Chevy Chase, Md. He was 62.

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Dr. Arthur Schatzkin

The cause was brain cancer, said the National Cancer Institute, where Dr. Schatzkin was chief of the nutritional epidemiology branch in the division of cancer epidemiology.

Dr. Schatzkin attracted worldwide attention in 2000 when he reported on a large-scale experiment to see whether a high-fiber diet might curb the recurrence of polyps in the colon and rectum. Such polyps can become malignant.

Dividing 2,079 people into two groups, he put one group on a low-fat, high-fiber diet calling for lots of fruits and vegetables, and he had the other group’s members follow their usual diets. He concluded that the special diet had no effect on the recurrence of polyps.

Dr. Schatzkin’s conclusion contradicted the conventional belief that a stool made bulkier with fiber would be more thorough in eliminating cancer-causing chemicals. But other studies also found no relationship between fiber and the recurrence of polyps.

The delicacy in establishing links between food and cancer made Dr. Schatzkin cautious in offering dietary recommendations. His polyp study, he noted, showed only that eating fiber had no effect in stopping the future growth of another polyp. It did not address whether eating fiber would prevent a polyp in the first place, or whether it would have any influence on a polyp developing into a cancerous tumor.

One of Dr. Schatzkin’s later initiatives, however, did find evidence that a particular kind of fiber, from unrefined whole grains, might reduce the risk of colorectal cancer. The discovery was made through a database of more than 500,000 individuals that Dr. Schatzkin had put together in the 1990s. It has yielded more than 100 studies that have found significant relationships between body mass and mortality and between eating meat and liver cancer, among other things.

To create the database, Dr. Schatzkin enlisted AARP, the organization for older Americans, to provide volunteers. More than 560,000 men and women over 50 agreed to fill out periodic questionnaires about diet, physical activity, family health history and other information. When the data are combined with records of mortality and disease incidence, researchers can tease out correlations between diet and disease.

“Nothing like this had ever been initiated,” Dr. Rashmi Sinha, a senior investigator at the cancer institute, said of the database in an interview on Tuesday.

Arthur Gould Schatzkin was born on Feb. 11, 1948, in New York City, and graduated from Yale and the State University of New York Downstate College of Medicine. He earned master’s and doctorate degrees in public health from Columbia.

He joined the National Cancer Institute in 1984 and became the chief of nutritional epidemiology in 1999. He increased the number of scientists working in his branch to 26, from four or five.

Dr. Schatzkin is survived by his wife, Dr. Tamara Harris Schatzkin, chief of geriatric epidemiology at the National Institute on Aging; their children, Eric and Rebecca Schatzkin; a sister, Dorothy Schatzkin Higgins; and a brother, Paul.

The Boss: From Rocketry to Surgery

Posted: 13 Feb 2011 12:33 AM PST

WHEN I was about 5, I was always taking apart radios, clocks and other electronic devices. If our neighbors were tossing something out, they would give it to me. I’d open the back of the unit and look at the vacuum tubes. I knew that if they weren’t glowing, they were broken and I’d try and find replacements.

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Glenn W. Laub, M.D., Chief executive of Defibtech, a defibrillator maker in Guilford, Conn.

AGE 54

BIRTHPLACE Old Westbury, N.Y.

RECENT VACATION London

HOBBY Photography

When my parents saw how fascinated I was with learning how things work, they enrolled me in a science enrichment program at Columbia University on Saturdays. My father drove me into the city for it for the next four years.

The space program was in the news at that time, and it introduced me to rocketry. In junior high I started a club called Zertl, for Zodiac Experimental Research and Testing Labs, to build and launch model rockets.

In high school, I gravitated toward engineering. But I also liked working with people. We’d see films in science class, and there was always a guy in a white lab coat working alone in a lab. He seemed pretty lonely. By then I had also developed an interest in medicine, so I thought I’d combine engineering and medicine.

I received a B.S. degree in biochemical engineering from Yale in 1978 and a medical degree from Dartmouth Medical School in 1981. I served my surgical residency at what is now NYU Langone Medical Center. Initially, I was enamored of trauma surgery because of the challenge — you have only minutes to decide what to do. My mentor suggested that to become a great trauma surgeon I learn how to operate on the heart and lungs, and once I performed heart surgery I was hooked on that.

During my residency I invented several surgical devices. Some heart surgeries require that a heart-lung machine take over some functions for a patient. Often, it requires surgery to connect the patient to the machine. In the late 1980s I developed a catheter for the connection, which was less invasive than the surgical procedure and could be used in emergency situations.

While I was developing it, a woman arrived at the hospital who had been found in an unheated apartment and had no vital signs. I asked my boss if I could try my device on her and he agreed. I connected her to the heart-lung machine and her heart started in about 15 minutes. She was discharged a few days later with no damage to her brain or heart. Her case was published in the Annals of Thoracic Surgery.

When I became an attending physician, I invented a device for measuring blood flow in the leg. And my wife, Karen, and I started a company called Zertl Medical to market it. We developed the device in our garage and eventually sold it internationally. I now have 10 patents for medical devices.

In the late 1990s, a medical device salesperson visited me and demonstrated an automatic external defibrillator that anyone could operate. Defibrillators are important because if a patient’s heart develops deadly irregular rhythms, the only way to try to fix it is to shock the heart. It’s like rebooting a computer.

I recognized the benefit immediately, but I thought that his device was unwieldy and expensive. I contacted Gintaras Vaisnys, a fellow student from Yale. He and I started Defibtech in 1999 to develop a less-expensive model that was easier to use. I’m also chairman of cardiac surgery and director of the Heart Hospital at St. Francis Medical Center in Trenton. I spend about half my time operating and the other half helping to run the company. I sometimes wear a white lab coat, but the work is much more gratifying than the science-class films depicted.

As told to Patricia R. Olsen.

Vital Signs: Screening: Doctors’ Group Urges Fewer Scans for Lower Back Pain

Posted: 12 Feb 2011 12:00 AM PST

Many doctors order imaging scans when patients complain of lower back pain, but they are unnecessary in most cases and may do more harm than good, the American College of Physicians stated in new practice guidelines.

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Routinely ordering X-rays and CT or M.R.I. scans drives up health care costs, and does not help resolve the problem, the college’s “best practice advice” guidelines say. On the contrary, the guidelines suggest, the scans may pick up unrelated abnormalities, leading to additional tests or procedures that are of no benefit, and some scans expose patients to high levels of radiation. The recommendations are the first in a series of papers aimed at helping doctors and patients identify misused medical treatments.

Most lower back pain is caused by strain on bones, muscles and ligaments. It can be treated with over-the-counter painkillers and usually abates within a few days, said an author of the practice guidelines, Dr. Amir Qaseem, director of clinical policy in medical education at the American College of Physicians..

“Something like that can be identified by the physician taking a good plain old medical history,” he said, adding that an X-ray or scan “should be reserved for selective high-risk patients who have serious symptoms.”

Recipes for Health: Mustard Vinaigrette

Posted: 10 Feb 2011 11:40 PM PST

A generous spoonful of Dijon mustard makes this vinaigrette creamy and tart. Use the dressing with sturdy salad greens like romaine or with softer lettuces like Bibb lettuce or oak leaf. The dressing is too strong to work with baby salad greens or mesclun. It’s also great with cooked vegetables like beets or broccoli and with grain salads.

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 rounded tablespoon Dijon mustard

1 1/2 tablespoons red wine vinegar or sherry vinegar

1 tablespoon fresh lemon juice

Salt and freshly ground pepper

1/2 cup extra virgin olive oil, or use half olive oil and half canola or grapeseed oil

1 small garlic clove

1. In a small bowl or measuring cup, combine the mustard, vinegar, lemon juice, salt and pepper. Whisk in the oil.

2. Peel the garlic clove and lightly crush, or cut down to the root end with a paring knife, keeping the garlic clove intact. Place in the dressing and allow to marinate for at least 30 minutes. Remove from the dressing before serving.

Yield: About 2/3 cup.

Advance preparation: This dressing will keep well in the refrigerator for a few days. Remove the garlic clove before storing.

Nutritional information per 2 tablespoons: 184 calories; 3 grams saturated fat; 2 grams unsaturated fat; 15 grams monounsaturated fat; 0 milligrams cholesterol; 1 gram carbohydrates; 0 grams dietary fiber; 58 milligrams sodium (does not include salt to taste); 0 grams protein

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

Novelties: Have You Charged Your Eyeglasses Today?

Posted: 13 Feb 2011 12:20 AM PST

A NEW device may be joining smartphones, iPads and music players that you have to charge overnight: electronic eyeglasses. These glasses have tiny batteries, microchips and assorted electronics to turn reading power on when you need it and off when you don’t.

Traditionally, people who hit their 40s often need extra optical help as farsightedness sets in. They may buy bifocals or no-line progressive lenses. But such glasses have a drawback: the lenses that magnify fine print also blur objects more than an arm’s length away when a wearer looks down, distorting the view when on a staircase, for example, or when swinging at a golf ball.

The new electronic spectacles, called emPower, are intended to handle that problem with an unusual insert in the bottom part of the lenses: liquid crystals, cousins to the familiar ones in television displays. The crystals change how the lenses refract or bend light, just as varying levels of thickness do in traditional glasses.

To call up reading power in the new glasses, users touch the side of the frame. Batteries in the frame send along a current that changes the orientation of molecules in the crystals. Touch the side of the frame again, and the reading power disappears. Turn it off to hit a golf ball; turn it on to read the scorecard.

The glasses, made by PixelOptics in Roanoke, Va., will be on the market this spring — first in Virginia and North Carolina, and later in the year nationally, said Dr. Ronald Blum, an optometrist and the company’s president. The estimated price, $1,000 to $1,200, will include frames, lenses, coatings and charger.

Dr. Larry Wan, a managing partner at Family EyeCare Center in Campbell, Calif., tested the glasses with 10 of his patients, all in their 50s. He said they were a hit, for example, with people who had been bothered by blur as they walked down flights of stairs while wearing their glasses. “With these,” he said, “you can turn the reading power off, so they are safer and you don’t have that distortion.”

Of course, you’ll have to remember to charge them, a nuisance required by no ordinary pair of glasses. The charge lasts two to three days, said Larry Rodriguez, an executive at PixelOptics.

But you won’t have to worry if you drop them in the water. “Wipe them off and they should be fine,” he says, although they may require recharging.

The glasses have a parts list associated more with iPods than with optics. The transparent layer of liquid crystals and its electrode array are buried beneath the front surface of the lenses. The eyeglass frames have tiny microchips, rechargeable batteries and wires that supply electricity to the lenses. There are also built-in accelerometers, devices that sense the downward bend of a head, as though to look at a page, that can switch on the reading power automatically.

Although the eyeglasses are loaded with electronics, they don’t look that way, says Jack Loeb of Fisher Island, Fla., who is trying out a pair. “They look just like ordinary, high-end glasses,” he said.

Thirty-six different frames made by Aspex Eyewear will be offered initially, Mr. Rodriguez said. The electronic lenses are being manufactured by the Panasonic Healthcare Company in Japan. The lenses can be popped out and replaced if a prescription changes, Dr. Blum said.

The market for emPower glasses isn’t likely to include the young. “About 80 percent of the people wearing reading glasses are past 40,” said Steve Kodey, director of industry research at the Vision Council, a trade group for eyewear manufacturers and suppliers in Alexandria, Va. But the market is “much bigger than most people realize,” Mr. Kodey says.

Last year, some 20.6 million pairs of progressive lenses, and about 16.2 million pairs of bifocals, were sold in the United States.

If consumers buy emPowers instead of high-end progressive lenses, they will pay a premium. Even in high-end regular glasses, progressive lenses typically go for $300 to $400, Mr. Kodey said. And the average cost of frames is $125 (though there are many higher-cost options for the fashion-conscious.)

LIQUID crystals offer a promising way to bend light in glasses, says Larry Thibos, a professor of optometry at Indiana University, Bloomington, whose research for the last 20 years has included work on electronic spectacles.

“The concept is solid,” he said. You energize the crystals and you have a lens that will then vanish when the power goes off.

Dr. Thibos evaluated prototypes of the glasses for Dr. Blum a decade ago. “The glasses worked fine even then, but they looked geeky,” he said of early versions. The process of bringing the glasses to market — in a stylish form — took 12 years and roughly 275 patents, says Dr. Blum. Financing has been provided by Delphi Ventures, the Carlyle Group, Longitude Capital, Stark Investments, Panasonic Ventures and Life Science Angels, among others.

The work on the new lenses started with the liquid crystals in computers, not in spectacles. In 1999, Dr. Blum and his group were working on ways to help aging eyes read a computer screen. Originally, they had hoped to put the extra reading power directly into the liquid crystal display on the computers, which at that time had thick screens. But as the screens grew thinner, it was no longer practical to do so.

“So we had to take what we’d put into the computer screen and put it into your lenses,” Dr. Blum said.

E-mail: novelties@nytimes.com.

Consults: Men, Women and A.D.H.D.

Posted: 11 Feb 2011 02:14 PM PST

In Montana, A Bid to End Medical Use Of Marijuana

Posted: 10 Feb 2011 10:30 PM PST

HELENA, Mont. — The Montana House of Representatives voted Thursday to repeal the state’s six-year-old medical marijuana law.

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The 63-to-37 vote, largely along party lines in the Republican-controlled chamber, pushed Montana to the front lines of a national debate about social policy, economics and health as medical marijuana use has surged in the 15 states and the District of Columbia that allow its use.

“We were duped,” said the House speaker, Mike Milburn, a Republican and sponsor of the repeal bill, who said he thought that the arguments about medical use had been a pretext for encouraging recreational use and creating a path to full legalization. He said he feared gang drug wars in Montana’s cities and debilitation of its youth.

“This bill says, Shut down everything — it’s gone way too far,” Mr. Milburn told the chamber before the vote.

The State Senate, also controlled by the Republicans, will also consider the measure, and House members will have an opportunity to vote on it again as early as Friday before sending it there. If passed by the Senate it would face an uncertain fate on the desk of Gov. Brian Schweitzer, a Democrat.

Mr. Schweitzer has said he believes the laws need to be tightened, but he has not taken a position on repeal. His spokeswoman, Sarah Elliott, said in an e-mail, “The business has gotten out ahead of the regulatory environment, and we need to build some boundaries.”

But in the voices of the lawmakers on Thursday, the weight and passion of the issue were evident.

“We tried prohibition,” said Representative Diane Sands, a Democrat. “Marijuana has been in our community for years; it is not going away,” she added. “We have to deal with that fact.”

Other states and cities are also wrestling with the question of what medical marijuana is, or should be. New Mexico’s new Republican governor, Susana Martinez, expressed interest in repeal this year. Colorado is formulating some of the most detailed rules in the nation for growing and selling. Lawmakers in New Jersey have jousted with the governor over regulation.

And although party line positions have defined the issue in Montana, with Republicans mostly lined up in favor of restriction or repeal, there is widespread agreement among legislators and residents that medical marijuana has become something very different than it was originally envisioned to be.

Sixty-two percent of voters approved the use of medical marijuana in a statewide referendum in 2004. But the real explosion of growth came only in the last year, after the federal Department of Justice said in late 2009 that medical marijuana would not be a law enforcement priority.

Since then, the numbers of patients have quadrupled to more than 27,000 — in a state of only about 975,000 people — and millions of dollars have been invested in businesses that grow or supply the product.

Here in Helena, at least 16 other bills in addition to the repeal measure have been filed or drafted since the legislative session began last month, calling for everything from a marijuana tax to another voter referendum.

“I’ve lobbied every session since ’81, and I’ve never seen an issue as fluid as this,” said Tom Daubert, an advocate for medical marijuana and an author of the 2004 ballot measure. “It changes by the minute, by the hour, by the day.”

But in a huge, mostly rural state where a libertarian, keep-government-off-my-back spirit runs deep, the debate is also different in temper and geography than in other states. Marijuana, many people here say, has intensified suspicions between the two Montanas that are zipped together by the Rocky Mountains — conservative ranching and agriculture country to the east, liberal college towns and tourist communities to the west.

The change in the pattern and scale of medical marijuana use across Montana has coincided with a seismic change in politics here, where Republicans surged from a 50-50 tie in the House before last November’s election to a 68-to-32 majority now. Republicans have a 28-to-22 majority in the Senate.

Several House members who spoke against repeal said the Legislature, by declining in past years to take up bills that would have regulated or controlled medical marijuana when its use was not so widespread, had only itself to blame.

“We had many years to regulate something that 62 percent of Montanans wanted, and we chose to do nothing,” said Representative Pat Noonan, a Democrat. “Don’t vote against the citizens.”

Hospitals Shift Smoking Bans to Smoker Ban

Posted: 10 Feb 2011 11:10 PM PST

Smokers now face another risk from their habit: it could cost them a shot at a job.

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Steve Hebert for The New York Times

Mandy Carroll, a student at the University of Kansas School of Nursing, just outside the campus.

More hospitals and medical businesses in many states are adopting strict policies that make smoking a reason to turn away job applicants, saying they want to increase worker productivity, reduce health care costs and encourage healthier living.

The policies reflect a frustration that softer efforts — like banning smoking on company grounds, offering cessation programs and increasing health care premiums for smokers — have not been powerful-enough incentives to quit.

The new rules essentially treat cigarettes like an illegal narcotic. Applications now explicitly warn of “tobacco-free hiring,” job seekers must submit to urine tests for nicotine and new employees caught smoking face termination.

This shift — from smoke-free to smoker-free workplaces — has prompted sharp debate, even among anti-tobacco groups, over whether the policies establish a troubling precedent of employers intruding into private lives to ban a habit that is legal.

“If enough of these companies adopt theses policies and it really becomes difficult for smokers to find jobs, there are going to be consequences,” said Dr. Michael Siegel, a professor at the Boston University School of Public Health, who has written about the trend. “Unemployment is also bad for health.”

Smokers have been turned away from jobs in the past — prompting more than half the states to pass laws rejecting bans on smokers — but the recent growth in the number of companies adopting no-smoker rules has been driven by a surge of interest among health care providers, according to academics, human resources experts and tobacco opponents.

There is no reliable data on how many businesses have adopted such policies. But people tracking the issue say there are enough examples to suggest the policies are becoming more mainstream, and in some states courts have upheld the legality of refusing to employ smokers.

For example, hospitals in Florida, Georgia, Massachusetts, Missouri, Ohio, Pennsylvania, Tennessee and Texas, among others, stopped hiring smokers in the last year and more are openly considering the option.

“We’ve had a number of inquiries over the last 6 to 12 months about how to do this,” said Paul Terpeluk, a director at the Cleveland Clinic, which stopped hiring smokers in 2007 and has championed the policy. “The trend line is getting pretty steep, and I’d guess that in the next few years you’d see a lot of major hospitals go this way.”

A number of these organizations have justified the new policies as advancing their institutional missions of promoting personal well-being and finding ways to reduce the growth in health care costs.

About 1 in 5 Americans still smoke, and smoking remains the leading cause of preventable deaths. And employees who smoke cost, on average, $3,391 more a year each for health care and lost productivity, according to federal estimates.

“We felt it was unfair for employees who maintained healthy lifestyles to have to subsidize those who do not,” Steven C. Bjelich, chief executive of St. Francis Medical Center in Cape Girardeau, Mo., which stopped hiring smokers last month. “Essentially that’s what happens.”

Two decades ago — after large companies like Alaska Airlines, Union Pacific and Turner Broadcasting adopted such policies — 29 states and the District of Columbia passed laws, with the strong backing of the tobacco lobby and the American Civil Liberties Union, that prohibit discrimination against smokers or those who use “lawful products.” Some of those states, like Missouri, make an exception for health care organizations.

A spokesman for Philip Morris said the company was no longer actively working on the issue, though it remained strongly opposed to the policies.

Meghan Finegan, a spokeswoman for the Service Employees International Union, which represents 1.2 million health care workers, said the issue was “not on our radar yet.”

One concern voiced by groups like the National Workrights Institute is that such policies are a slippery slope — that if they prove successful in driving down health care costs, employers might be emboldened to crack down on other behavior by their workers, like drinking alcohol, eating fast food and participating in risky hobbies like motorcycle riding. The head of the Cleveland Clinic was both praised and criticized when he mused in an interview two years ago that, were it not illegal, he would expand the hospital policy to refuse employment to obese people.

“There is nothing unique about smoking,” said Lewis Maltby, president of the Workrights Institute, who has lobbied vigorously against the practice. “The number of things that we all do privately that have negative impact on our health is endless. If it’s not smoking, it’s beer. If it’s not beer, it’s cheeseburgers. And what about your sex life?”

Many companies add their own wrinkle to the smoking ban. Some even prohibit nicotine patches. Some companies test urine for traces of nicotine, while others operate on the honor system.

Alain Delaquérière contributed research.

Leprosy, Plague and Other Visitors to New York

Posted: 10 Feb 2011 10:56 PM PST

When New York City’s health department revealed last weekend that three people had contracted cholera, it was a reminder that the city is not just a world capital of arts, business and the like — but also of exotic diseases.

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Rare, but Not Gone

If a disease has cropped up in the world, there is a good chance it will eventually find its way to New York City through the diverse travelers who cross the city’s borders.

For instance, several people every year are found to have a biblical disease, leprosy, though health officials say no one has to fear catching it in the subway. In 2002, bubonic plague, more commonly associated with the 14th century, found its way to New York City through two travelers who came from a ranch in New Mexico, where the disease is endemic in flea-bitten wild animals like prairie dogs.

Since the anthrax scares after the terrorist attacks of 2001, the city has sharpened its surveillance systems to pick up evidence of biological warfare. Its so-called syndromic surveillance system, which was used during the swine flu pandemic in 2009, looks for unusual patterns of disease in hospital emergency rooms. As part of a federal program to guard against bioterrorism, biosensor detectors in various large cities use a device to draw in air and analyze it for telltale pathogens.

“We definitely are a world capital,” said Dr. Don Weiss, the director of surveillance for the health department’s Bureau of Communicable Diseases. “We have a lot of tourism. We have people who live here whose birth countries are just about every country in the world. We do get some exotic diseases, but not to a point where every day my phone is ringing off the hook.”

For hypochondriacs, New York City offers EpiQuery, an interactive database of communicable diseases from amebiasis to yersiniosis on the health department’s Web site. (EpiQuery lists only diseases that are caught by New York City residents and are reportable by law.)

The city’s database memorializes seven 2001 cases of anthrax and one more, the only case since then — in 2006, Vado Diomande, a maker of African drums, got inhalation anthrax from animal skins contaminated with the anthrax spores.

Malaria is a steady presence in New York City, with about 200 cases a year — a far greater incidence than that of another mosquito-borne disease, West Nile, which infected 42 New Yorkers last year. “The mosquito that transmitted it doesn’t live in this part of the world,” Dr. Weiss said. “People going home to Africa pick it up and bring it here.”

Leprosy, he said, has a long incubation period and was believed to have been brought from other countries, not transmitted within the United States. “We don’t know a lot about how it’s transmitted,” Dr. Weiss said. “It’s not clear whether it takes skin-to-skin contact or can be transmitted through respiratory secretions.”

But he said health officials were not worried about leprosy being passed on in the subway, frightening as that might sound. “Some things can be scary until you have sort of a long period of observation,” Dr. Weiss said. “Three Mile Island, when that happened, everybody was scared out of their wits. But after three weeks, it didn’t blow up, and people said, ‘Oh, it’s probably not going to blow up.’ ”

Centuries of experience have shown that when it comes to epidemics, leprosy “is not as great a concern as tuberculosis, which has been a huge killer worldwide,” Dr. Weiss said.

More prosaically, Lyme disease is on the rise, with more than 500 cases reported in 2008, the last year for which statistics were available, up from 215 in 2000. But here, Dr. Weiss hypothesizes, the higher numbers could reflect increased testing.

Although the city has counted more than 100 rabid raccoons in the past year, there has not been a reported human case of rabies infection in New York City since 1944, according to the health department. “Raccoons are pretty smart and people are pretty smart, and they stay out of each other’s way,” Dr. Weiss said.

Salmonella, he believes, is underreported, because most people with salmonella recover without ever going to the doctor.

And then there are the natural fluctuations. By the second year of West Nile, many of the birds that carried it had acquired immunity, so the incidence fell.

As for cholera, New York City receives reports of about one case a year, almost always found in someone who has traveled abroad, so the three cases of last weekend represent a bit of an increase. All three people attended the same wedding in the Dominican Republic, where health officials said they contracted the disease, which is spread by ingesting bacteria-contaminated food or water. None were hospitalized, and they have recovered, the health department said.

“That to me is what the fascinating thing about it is,” Dr. Weiss said. “All these individual factors that have to do with ecology, population, animals, different people traveling from all over the world. There’s that perfect storm that has to happen, and then you might have something interesting.”

Doctor and Patient: When Patients Share Their Stories, Health May Improve

Posted: 10 Feb 2011 07:25 PM PST

A gifted artist in his early 60s, the patient was a liver transplant candidate who learned he had hepatitis B some 20 years earlier. Despite the worsening fatigue that accompanied his liver failure, he threw himself into preparing for his transplant. He read everything he could about the procedure and the postoperative care, drilled doctors with endless questions and continued to drag himself to the gym each day in the hopes of being better prepared to withstand the rigors of the operation.

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The only reservation that he mentioned was the same one all the other patients had — he feared that death would come before the perfect organ.

But during one visit just before he finally got the transplant, he confessed that he had been grappling with another concern, one so overwhelming he had even considered withdrawing from the waiting list. He worried that he would not be strong enough mentally and physically to survive a transplant.

In desperation, he told me, he had contacted several patients who had already undergone a transplant. “That’s what made me believe I’d be O.K.,” he said. “You doctors have answered all of my questions, but what I really needed was to hear the stories about transplant from people like me.”

Patients and doctors have long understood the power of telling and listening to personal narratives. Whether among patients in peer support groups or between doctors and patients in the exam room or even between doctors during consultations, stories are an essential part of how we communicate, interpret experiences and incorporate new information into our lives.

Despite the ubiquitousness of storytelling in medicine, research on its effects in the clinical setting has remained relatively thin. While important, a vast majority of studies have been anecdotal , offering up neither data nor statistics but rather — you guessed it — stories to back up the authors’ claims.

Now The Annals of Internal Medicine has published the results of a provocative new trial examining the effects of storytelling on patients with high blood pressure. And it appears that at least for one group of patients, listening to personal narratives helped control high blood pressure as effectively as the addition of more medications.

Monitoring the blood pressure of nearly 300 African-American patients who lived in urban areas and had known hypertension, the researchers at three-month intervals gave half the patients videos of similar patients telling stories about their own experiences. The rest of the patients received videos of more generic and impersonal health announcements on topics like dealing with stress. While all the patients who received the storytelling DVD had better blood pressure control on average, those who started out with uncontrolled hypertension were able to achieve and maintain a drop as significant as it had been for patients in previous trials testing drug regimens.

“Telling and listening to stories is the way we make sense of our lives,” said Dr. Thomas K. Houston, lead author of the study and a researcher at the University of Massachusetts Medical School in Worcester and the Veterans Affairs medical center in Bedford, Mass. “That natural tendency may have the potential to alter behavior and improve health.”

Experts in this emerging field of narrative communication say that storytelling effectively counteracts the initial denial that can arise when a patient learns of a new diagnosis or is asked to change deeply ingrained behaviors. Patients may react to this news by thinking, “This is not directly related to me,” or “My experience is different.” Stories help break down that denial by engaging the listener, often through some degree of identification with the storyteller or one of the characters.

“The magic of stories lies in the relatedness they foster,” Dr. Houston said. “Marketers have known this for a long time, which is why you see so many stories in advertisements.”

In health care, storytelling may have its greatest impact on patients who distrust the medical system or who have difficulty understanding or acting on health information because they may find personal narratives easier to digest. Stories may also help those patients who struggle with more “silent” chronic diseases, like diabetes or high blood pressure. In these cases, stories can help patients realize the importance of addressing a disease that has few obvious or immediate symptoms. “These types of patients and diseases may be a particular ‘sweet spot’ for storytelling,” Dr. Houston noted.

This particular benefit from stories comes as welcome news not only for patients but also for doctors, who are increasingly reimbursed based on patient outcomes. “There’s only so much the doctor can do, so providers are looking for innovative ways to help their patients,” Dr. Houston said. While more research still needs to be done, the possibilities for integrating storytelling into clinical practice are numerous. In one possible situation, which is not all that dissimilar from popular dating sites, doctors and patients would be able to access Web sites that would match patients to videos of similar patients recounting their own experiences with the same disease.

Dr. Houston is currently involved in several more studies that will examine the broader use of storytelling in patient care and delineate ways in which it can best be integrated. Nonetheless, he remains certain of one thing: Sharing narratives can be a powerful tool for doctors and patients.

“Storytelling is human,” Dr. Houston said. “We learn through stories, and we use them to make sense of our lives. It’s a natural extension to think that we could use stories to improve our health.”

Join the discussion on the Well blog, “Healing Through Storytelling.”

Success of Spina Bifida Study Opens Fetal Surgery Door

Posted: 12 Feb 2011 09:30 AM PST

For years, surgeons have been trying to find ways of operating on babies in the womb, reasoning that medical abnormalities might be more easily fixed while a fetus is still developing. But with tremendous risks to babies and mothers, and a mixed record of success, fetal surgery is mostly used when babies are likely to die otherwise.

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Jeffrey D. Allred for The New York Times

Doctors say prenatal surgery made a significant difference for Tyson Thomas, with his mother, Jessica.

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Jeffrey D. Allred for The New York Times

He wears braces, but is getting close to walking, his mother says.

Now, for the first time, a rigorous clinical trial shows that fetal surgery can help babies with a condition that is not usually life-threatening. Babies with a form of spina bifida, a debilitating spinal abnormality, were more likely to walk and experience fewer neurological problems if operated on before being born rather than afterward.

The $22.5 million study, long awaited by experts and published online Wednesday in The New England Journal of Medicine, is likely to galvanize interest in trying to address problems before birth, including operating on serious heart defects and bladder blockages, and potentially using fetal bone marrow or stem cell transplants for sickle cell anemia and immune disorders.

“It’s a good start, a step in the right direction,” said Dr. Joe Leigh Simpson, an obstetrician and geneticist at Florida International University, who wrote an editorial that accompanied the research. “It showed improvement and that there’s reason to continue looking for a better mousetrap.”

Still, he said, “the improvement that was hoped for, the home run or the holy grail” of eliminating all major problems “obviously did not occur.”

And as technology increasingly allows doctors to diagnose problems in a developing fetus, the study underscores remaining risks and hurdles, including developing less-invasive techniques to avoid creating other problems for babies or mothers.

The spina bifida procedure was considered beneficial enough that an independent safety monitoring board stopped the study early so babies scheduled to receive surgery after birth could have access to prenatal surgery.

But there were medical downsides for the women and infants: greater likelihood of being born several weeks earlier than the postnatal group, related breathing problems, and thinning or tearing at women’s surgical incisions, requiring Caesarean sections for later births.

“While this is a very promising and quite exciting result,” said a study author, Dr. Diana Farmer, surgeon in chief at the Benioff Children’s Hospital at the University of California, San Francisco, “not all the patients were helped here, and there are significant risks. This procedure is not for everyone.”

Conducting the study was itself challenging. Prenatal spina bifida surgery gained attention in the late 1990s when some medical centers, like Vanderbilt University, began performing it. A photograph in which a fetus’s hand appeared to be gripping the finger of a surgeon who had lifted the hand out of the womb was circulated by opponents of abortion rights, further raising the profile.

Leading experts suggested a clinical trial to determine if prenatal surgery was better than postnatal. They insisted on an unusual agreement: that all but three hospitals, in Philadelphia, San Francisco and Nashville, stop doing the procedure.

“There were lots of places that wanted to do it” amid pressure from eager patients, said Dr. Michael Harrison, who pioneered fetal surgery at the University of California, San Francisco, and was a principal investigator for the spina bifida trial before retiring. “But we wanted to make sure it wouldn’t become a freak show. And if you offer treatment outside the trial, you’ll never have a trial because no mother would agree to flip a coin.”

Ultimately the other hospitals acceded.

One reason spina bifida researchers wanted a trial was the experience with prenatal surgery for a condition in which the diaphragm has life-threatening abnormalities.

After early efforts to repair the condition prenatally, “we thought we were heroes,” Dr. Harrison said, but realized it worked only for milder cases. Another prenatal approach, forcing the lungs to grow, worked, but caused significantly premature births, making it no better than postnatal treatment, he said. He added that prenatal techniques had improved, becoming less harmful.

The spina bifida study involved the most severe form, myelomeningocele (MY-ell-oh-men-NING-guh-seal), in which the spine does not close properly and the spinal cord protrudes. Children may experience lower-body paralysis, fluid on the brain, bladder problems and learning disabilities. About one in 3,000 children have that form, said Dr. Alan Guttmacher, director of the National Institute of Child Health and Human Development, which financed and helped conduct the study.

Many babies now receive surgery to close the spinal opening after birth, but nerve damage from the spinal cord exposure to amniotic fluid remains. Also, the brainstem may be pulled into the spinal column. Excess fluid in the brain may require draining with implanted shunts, which can lead to infection or need repeated surgical replacement.

In the study, about 80 babies were randomly selected for surgery after birth; another 80 had the spinal opening surgically closed in utero, between 19 and 26 weeks of pregnancy. Two in each group died.

Before surgery, babies in the prenatal group had more severe spinal lesions than the postnatal group, but more in the prenatal group had better results, said a co-author, Dr. Scott Adzick, chief of pediatric surgery at Children’s Hospital of Philadelphia.

Those who received prenatal surgery were half as likely to have a shunt, and eight times as likely to have a normally positioned brainstem. There was “much better motor function of the legs,” Dr. Adzick said, and at 30 months old, nearly twice as many walked without crutches or orthotics.

Although they were born at 34 weeks of pregnancy on average, compared with 37 weeks for the postnatal group, there was no difference in cognitive development, said Dr. Catherine Spong, chief of pregnancy and perinatology at the child health institute.

Dr. Adzick said prenatal surgery may “stop exposure of the developing spinal cord and perhaps avert further neurological damage” or stop the leak of spinal fluid that causes brainstem problems.

Results were dramatic for Tyson Thomas, of Stansbury Park, Utah, now 22 months old. His mother, Jessica Thomas, a study participant, said doctors had described his brain malformation as “the worst they had ever seen” and said “it would be likely that he wouldn’t be able to breathe on his own.”

Since birth at 35 weeks gestation, she said, Tyson breathes independently, shows no brainstem malformation and is starting to talk. Bladder nerve damage will require him to urinate through catheters all his life. He now uses a walker and a foot brace, but is “getting really close to walking” on his own, said Ms. Thomas, a nurse.

Researchers will follow the children from ages 6 to 9 to see if benefits continue.

Several experts said they would now mention prenatal surgery as one option for some women. But since many women were excluded from the study, including those who were severely obese or whose babies’ conditions did not fit certain specifications, many may be ineligible.

The study should not propel surgeons to “run around and start doing this” for other conditions, said Dr. Terry Buchmiller, a fetal medicine expert at Children’s Hospital Boston who was not involved in the research. “I can go in utero right now and fix a cleft lip, but I don’t think anybody is saying we ought to do that, because of the risk.”

But she called the study “a wonderful, almost several-decade journey of trying to improve the outcomes of a debilitating condition,” adding, “This looks to be potentially life-changing.”

Implications of Study on Breast Cancer

Posted: 09 Feb 2011 10:10 PM PST

An article on Wednesday described how a routine procedure for the treatment of early breast cancer — the surgical removal of cancerous lymph nodes from the armpit — has been found unnecessary for many patients. The finding turns 100 years of standard medical practice on its head. The author of the article, Denise Grady, answered questions online from readers about the finding and its implications. More at nytimes.com/science.

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Q The study findings apply to 20 percent of breast cancer patients. What about the other 80 percent?

A The figure refers to 20 percent of all the newly diagnosed cases of invasive breast cancer each year in the United States — it does not include noninvasive breast cancer, or D.C.I.S., ductal carcinoma in situ. The total is about 207,000, so 20 percent is roughly 40,000 women. That is about how many women would match those in the study, in terms of tumor status, affected lymph nodes and course of treatment.

As for the other 80 percent, we need to look at how many women get a breast cancer diagnosis at various stages. The figures from the American Cancer Society indicate that 60 percent of all patients have “localized” breast cancer. That means they do not have affected lymph nodes. They do not need extensive axillary dissection, as lymph node removal is known.

An additional 33 percent of women have “regional” disease, meaning that the cancer has reached lymph nodes. These are the patients who might match those in the study.

By the estimate of Dr. Armando E. Giuliano, the lead author of the study and the chief of surgical oncology at the John Wayne Cancer Institute at St. John’s Health center in Santa Monica, Calif., about two-thirds of these women will match the study criteria and one-third will not. So for that one-third — about 10 percent of breast cancer patients over all — node dissection might be needed. An additional 5 percent of all patients have “distant” disease at the time of diagnosis, meaning the cancer has already spread to organs or bones. I don’t know if lymph node surgery is of use or benefit to women whose disease is already advanced. In the remaining 2 percent of cases, the stage of the disease at diagnosis is not known.

Q Why are the study findings said to apply only to women who have whole-breast irradiation, and not partial breast irradiation?

A Only whole-breast irradiation hits part of the armpit, and therefore some of the lymph nodes. This is what the women in the study received, and researchers think it may have wiped out any cancer in the nodes that were left behind. They say they are also unsure about whether the findings would apply to women who have irradiation while lying prone, on their stomachs. In that position, the radiation may not reach the armpit.

Q Which women still must have their lymph nodes dissected?

A Surgeons say that the lymph nodes must come out if they are big enough to feel or show up as cancerous on imaging. Surgeons will also remove nodes if there are three or more positive sentinel lymph nodes (sentinel lymph node biopsy is described in the article).

Surprises can also turn up in the operating room, doctors say. Occasionally, the sentinel node biopsy will give a false-negative result, which means failing to find cancer even though it is present. That can happen if, for instance, the sentinel node is very cancerous and the lymphatic vessels that feed it are choked off and do not pick up the dye. Then, the dye may go to a different node, one that does not have cancer. Knowing this is possible — and knowing that the sentinel node biopsy, though highly reliable, is not infallible — surgeons look and feel around in the armpit carefully during the operation and make judgment calls about what to remove and what to leave alone.

Q How do these findings apply to women who have a genetic predisposition to breast cancer?

A Dr. Monica Morrow, an author of the study and chief of the breast service at Memorial Sloan-Kettering Cancer Center in Manhattan, replied: “Genetic breast cancer doesn’t influence how we treat the nodes. Due to the increased risk of second breast cancers, many of these women chose mastectomy. Women with mastectomy require axillary dissection if the nodes are involved.”

Q From what I understand, removing even only one or two lymph nodes can result in chronic swelling of the arm. How certain is it that taking fewer nodes will result in a measurable reduction in the risk of developing lymphedema?

A There is still a risk of lymphedema even after only a few nodes are taken for sentinel biopsy, but the risk is much lower than when many nodes are removed.

Medical Treatment, Out of Reach

Posted: 10 Feb 2011 11:59 PM PST

Late last year, Biosensors International, a medical device company, shut down its operation in Southern California, which had once housed 90 people, including the company’s top executives and researchers.

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Peter DaSilva for The New York Times

Marti Conger, a business consultant in Benicia, Calif., went to England in October 2009 to get an implant of a new artificial disk for her spine developed by Spinal Kinetics of Sunnyvale, Calif., a short distance from her home.

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Jacquelyn Martin/Associated Press

Available in Europe, a heart valve from Edwards Lifesciences of the type implanted using a catheter instead of open-heart surgery.

The reason, executives say, was that it would take too long to get its new cardiac stent approved by the Food and Drug Administration.

“It’s available all over the world, including Mexico and Canada, but not in the United States,” said the chief executive, Jeffrey B. Jump, an American who runs the company from Switzerland. “We decided, let’s spend our money in China, Brazil, India, Europe.”

Medical device industry executives and investors are complaining vociferously these days that the industry’s competitive edge in the United States and overseas is being jeopardized by a heightened regulatory scrutiny.

The F.D.A., they and others say, appears to be reacting to criticism that its approvals for some products had been lax, leading to a spate of recalls of some unsafe medical devices, like implanted defibrillators and hip replacements.

Now, executives of device companies say the F.D.A. has gone too far in flexing its regulatory muscle, and they worry that a slower, tougher approval process in a weakened economy could chill investments and cripple innovation.

In addition, they say that American patients are being deprived of the latest technology because companies routinely seek approval for new devices in Europe first. For instance, heart valves that can be installed through a catheter instead of open-heart surgery have been available in Europe since 2007 but will not be available in the United States until late this year at the earliest.

“Ten years from now, we’ll all get on planes and fly somewhere to get treated,” said Jonathan MacQuitty, a Silicon Valley venture capitalist with Abingworth Management.

Marti Conger, a business consultant in Benicia, Calif., already has. She went to England in October 2009 to get an implant of a new artificial disk for her spine developed by Spinal Kinetics of Sunnyvale, Calif.

“Sunnyvale is 40 miles south of my house,” said Ms. Conger, who has become an advocate for faster device approvals in the United States. “I had to go to England to get my surgery.”

Stenum Spine Hospital in Germany has performed disk surgery on 1,000 Americans over the last eight years, said Jim Rider, the hospital’s American marketing agent.

Acknowledging industry concerns, the F.D.A. on Tuesday proposed creating an “innovation pathway” aimed at speeding regulatory reviews of a small number of groundbreaking devices. And last month the agency announced measures it said would make the regulatory process more predictable for the vast majority of devices.

“A consistent and predictable review process will stimulate investment here at home and keep jobs from going overseas,” Dr. Jeffery Shuren, the director of the agency’s medical device division, told reporters.

But Dr. Shuren said the F.D.A. would not relax its standards, arguing that Europe’s system might be too lax. He said that a breast implant, a lung sealant and an implant for elbow fractures were approved in Europe but not in the United States, and then had to be taken off the market in Europe for safety reasons.

“We don’t use our people as guinea pigs in the U.S.,” he said

Medical device executives said they welcomed the steps, but continued to express concerns. Consumer advocates, like Dr. Sidney Wolfe of Public Citizen, however, said that device regulation was already much less stringent than for drugs and that the F.D.A. was caving in to industry demands rather than ensuring consumer safety.

Dr. Charles Rosen, a spine surgeon who is also president of the Association for Medical Ethics, said that the newest devices were not always best. He said he had at least 50 patients who had suffered serious problems from an older artificial disk. Many of those patients, he said, had gone to Europe to get them before they were available in the United States.

Just since November, three reports — two sponsored by device industry trade groups and one conducted by the consulting firm PricewaterhouseCoopers — have raised concerns about the F.D.A. approval process. One report found that the rate of recalls in Europe was similar to that in the United States, suggesting faster approvals overseas were not hurting patients.

Condom Rule Sought for Sex-Film Sets

Posted: 09 Feb 2011 10:20 PM PST

LOS ANGELES — The clinic that for the last decade had monitored the health of those working in the multibillion-dollar pornography industry abruptly shut its doors in December.

Now Los Angeles has moved to fill that role.

Last week, city lawmakers voted unanimously to draft an ordinance that would require condoms to be used on the set of every pornographic movie made here.

The sudden closing of the clinic, coming after a performer tested positive for H.I.V., sent pornography actors to clinics around the San Fernando Valley, north of downtown, where the industry is based. And though the clinic recently reopened, its uncertain status again raised the question of who, if anyone, should be ensuring their safety.

“We can’t keep our heads in the sand any longer,” City Councilman Bill Rosendahl said. “These people should be using condoms. Period.”

The city law would be the first to impose safety standards specifically on the pornographic film industry, which has largely been allowed to police itself.

Until the late 1990s, the industry was unregulated. But after a string of actresses contracted H.I.V. and filed lawsuits against production companies, the industry created the Adult Industry Medical Healthcare Foundation.

Since 1998, the nonprofit clinic, financed by contributions from production companies, has offered health tests to sex-film performers. Producers agreed not to hire performers who had not been tested in the last 30 days, and the clinic investigated the sources of infections, coordinated halts in filming when actors tested positive for H.I.V., and hounded performers who had been exposed to get tested.

Over the years, county health officials had clashed with the clinic, accusing it of failing to cooperate with investigators and of failing to protect industry workers and their sexual partners.

Those in the industry, however, assert that the self-regulating system has worked well, pointing to just five cases of H.I.V. infection among its performers — none of them definitively tied to on-set exposure — since a 2004 outbreak shut down the industry for a month.

“This has been working for years,” said Steven Hirsch, founder of Vivid Entertainment. “If we saw people getting sick, we would go to mandatory condoms.”

Filmmakers also oppose any new regulations because they say that sales drop when performers use condoms and that regulations are difficult to enforce on the set.

Adult Industry Medical, which the county health department shut down because it was not properly licensed, reopened last week under a new name and as a profit-making clinic, now under the oversight of the California Medical Association. On its Web site, the clinic vowed to resume all its services, “relieved from pointless harassment that came with oversight from the county health department.”

Even while testing at the clinic ceased for two months, the foundation continued to operate a database that allows producers and talent agents with passwords to see performers’ test results from other clinics.

Sexually transmitted infections, however, remain rampant among pornographic film performers. Sexually transmitted disease is diagnosed in a quarter of all performers each year, according to the Los Angeles County Department of Public Health. Rates of chlamydia and gonorrhea infection are seven times higher than those in the general population.

Jan Meza, a performer who contracted herpes and chlamydia before she left the industry in 2007, said the self-regulatory testing system often left her weighing financial needs against concerns for her safety.

“At first, I would ask about condoms, and they told me I’d never be able to find work,” Ms. Meza said. “You do worry about the risk, but any girl desperate for money, like I was, is still going to do it.”

Health care advocates have long argued that the prevalence of these sexually transmitted diseases highlights the need for government to step in.

“Testing just acts as a fig leaf for producers, who suggest that it is a reasonable substitute for condoms, which it is not,” said Michael Weinstein, president of the AIDS Healthcare Foundation. “Syphilis and gonorrhea pose significant health risks, not only to the performers but to the rest of the community.”

So far, though, government efforts to impose safety standards have met with little success.

Since 2004, the state Division of Occupational Safety and Health has maintained that existing state workplace safety laws require condoms and other protections for performers in the pornographic film industry. But the agency has issued just a handful of fines for allowing unprotected sex, and they have failed to significantly alter practices.

“It’s slow going,” said Deborah Gold, a senior safety engineer with the division. “We have a limited number of resources.”

Previous efforts to pass legislation that would specifically require condom use — and make enforcement of the mandate easier — have also stalled. Los Angeles County health officials say the county lacks the resources to enforce such a requirement. State health regulators have convened a committee to consider a condom mandate, but have not yet drafted a law.

The Los Angeles law would tie the issuing of film permits to on-set condom use. But it is unclear whether the city has jurisdiction over public health issues.

Even if the law is enacted, city regulators may face similar problems of enforcement that have dogged state occupational safety and health officials. And some filmmakers have grumbled about moving their operations, which bring in as much as $13 billion annually, to other states.

“I tried many years ago to get everybody to go to condoms,” said Jim South, a longtime talent agent for sex-film performers. “Quite a few companies did, but sales fell severely. The switch would be very difficult.”

Apps to Share Your Pride at the Gym

Posted: 10 Feb 2011 12:00 AM PST

About four years ago, when I started working at home, I plugged into a laptop to write about Silicon Valley. I made thousands of new friends on Facebook and Twitter, and, thanks to the proximity of my refrigerator, put an additional 35 pounds on an already rotund body.

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With so many people anxious to hear the most trivial updates on my life, could I use the friends I added to shed the weight I gained? Eighty-three pounds lighter, I’d say yes.

For 315 days straight, I logged into a Web site or popped out my phone and confessed what I ate, how much I exercised and what I weighed. When I went to the gym, I also checked in on Foursquare, announcing my location to friends and eventually winning the rank of “mayor” of my local gym. When I completed my food and exercise diary, the computer informed my Facebook friends; when I lost weight, it broadcast the news to the world on Twitter.

This sort of oversharing drives some people crazy. EE Times, a publication for engineers, once asked its readers why they disliked Twitter. More than half cited this reason: “I don’t really care what you had for breakfast.”

Yet in my experience, a small set of friends turned out to be intensely interested in what I had for breakfast. And lunch. And dinner. Moreover, they wanted to know whether that added up to my caloric target for the day.

And it seems their sustained obsession with my obsession has helped me stay on track. Since last March, when I first got an iPhone, downloaded a host of helpful apps and hooked them up to my Twitter and Facebook accounts, I’ve lost 63 pounds. In the year before, when I dieted and exercised in digital isolation, recording my calories in and out in a so-last-century Moleskine notebook, I lost only 20 pounds.

It’s a limited experiment, without a control set. But Mike and Albert Lee, the developers of MyFitnessPal, the calorie-tracking app I depend upon, say I’m not an isolated case.

By analyzing a sample of 500,000 users’ recorded weights, and tracking that against how many friends they had on the service, the Lees (who are brothers) found that the more friends people had, the more weight they lost. People who added friends on MyFitnessPal, giving them access to their calorie counts, lost 50 percent more weight than the typical user, they say. People with at least 10 friends lost an average of 20.5 pounds.

Other apps and Web sites that can assist you in losing weight or in sticking to an exercise plan with the help of your friends include DailyBurn, Gain Fitness, LoseIt and Social Workout. I depended mostly on MyFitnessPal, which has fine-tuned controls for broadcasting updates and sharing food diaries.

I post my exercise calories and announce the completion of my daily food diary on Facebook, while limiting Twitter posts to weight-loss milestones. I share the details only with other MyFitnessPal users, taking those engineers at their word that they don’t care what I had for breakfast. Other users make their food intake completely public, or use Twitter to announce they’ve completed their daily diaries.

The responses have varied from heartwarming to hilarious. In response to a 1,000-calorie exercise binge posted on Facebook, my friend Jennifer cracked that she “burned 20 calories going through photos.” Another friend, formerly quite athletic, confided to me privately that he’d put on weight but had been inspired to do something about it by my updates. He’s since dropped four pounds.

About a half-dozen acquaintances have signed up to be friends with me on MyFitnessPal, and a handful more periodically comment on my updates with their own jogs, runs or gym workouts.

I’ve also attracted a virtual cheering squad who routinely click “Like” on my Facebook fitness updates, including one friend, Jennie Dal Busco, a corporate lawyer and new mom, who found solace for her limited ability to exercise during her pregnancy through the vicarious viewing of my gym exploits. Now that her daughter has arrived, my friend has taken up jogging with a stroller.

Not everything I do is broadcast on the Internet; I use another iPhone app, GymGoal, to track the details of my workouts. While it’s not equipped for social networking, I do share it in a sense. When my personal trainer asks me how the last week went, I can show him what I did with precision, which makes our sessions more productive.

There are a host of new fitness services starting up that harness social networks. Nick Gammell started Gain Fitness in late December. Mr. Gammell, a former college football player, was never in particularly bad shape, but he struggled to fit exercise into 70-hour workweeks when he became a financial analyst at Google. He’s designing new features into his site, still in beta testing, to let users post public profiles, find exercise partners and share workouts.

Mr. Gammell said the ability to show friends your workouts offers “social proof,” a phenomenon in which people take cues from others’ behavior.

“It’s something I’ve experienced in my own life,” he said. “Once you start working out, and your friends start knowing about it, that’s the biggest factor in their starting to work out.”

I’ve reached my desired weight, so now I need new goals. And that’s where most apps and services fall short.

Foursquare, which offers badges to reward activities as well as check-ins, is no help; I earned its Gym Rat badge for frequent gym attendance in my first month. MyFitnessPal’s broadcasts are geared around losing weight, not maintaining it or adding fitness.

And each new app or Web site adds more time to the routine. MyFitnessPal and Social Workout both let me share my activities on Facebook, as will Gain Fitness, but they don’t integrate with each other or with tracking tools like GymGoal. I’m confident that Mr. Gammell or another clever entrepreneur will solve that technical challenge.

The far more interesting question is how we’ll navigate the changing etiquette of sharing such formerly private details of our lives. Breaking bread together used to be the symbol of an intimate friendship. Will the future require that we disclose how we plan to burn off those carbs?

Delay of State Money for Merger May Force a Hospital in Brooklyn to Close

Posted: 09 Feb 2011 09:28 PM PST

A struggling Brooklyn hospital is making plans to shut down in March after a decision by the Cuomo administration to delay grants to help finance a merger intended to rescue the institution, officials said on Wednesday.

The hospital, Long Island College Hospital, on the border of Cobble Hill and Brooklyn Heights, announced in October that it was merging with SUNY Downstate Medical Center, a major public university and medical center, as part of a deal put together last fall by former Gov. David A. Paterson and state health officials.

The deal included some $62 million in state grants — $22 million for Long Island College Hospital and $40 million for SUNY Downstate — under a program intended to encourage efficiencies and mergers in New York’s health care system.

But State Department of Health officials told the hospital’s owner, Continuum Health Partners, on Tuesday night that they were delaying all undistributed grants under the program — more than a hundred awards totaling $683 million — as part of a broader effort to rethink the state’s sprawling Medicaid program.

With the state in a financial hole, officials are warning of significant cuts to reimbursement rates that will probably require the closing of some health care institutions around the state.

Josh Vlasto, a spokesman for Mr. Cuomo, said the administration was reassessing the undistributed grants “as part of an overall review of health care spending in order to ensure that grant money goes to the most viable projects and mergers.”

State officials are weighing several options for money now committed to the overall grant program, like redistributing some of it to other hospitals in distress or using it to help cushion the restructuring of the Medicaid system that the administration envisions. But no final decisions have been made.

The review is expected to take two to three weeks, Mr. Vlasto said, and most grants now in the pipeline are likely to be disbursed as originally intended.

But Stanley Brezenoff, president of Continuum Health Partners, said that conversations with state officials had left “a clear implication” that the grants for Long Island College Hospital “were seriously in question.”

If the $22 million grant to LICH were rescinded, Mr. Brezenoff said, the hospital, which he said was “running on fumes,” would run out of cash by mid-March. At that point, he said, he would be forced to begin bankruptcy proceedings and move forward with closing the hospital and laying off its 2,500 employees.

Without the state money, Mr. Brezenoff said, Continuum could not complete moving the hospital under the SUNY umbrella.

Mr. Brezenoff said that he was already putting together a draft closing plan and preparing to send out termination notices. He said that because the conversation with the state was so recent, he had not yet warned the employees that the merger might be called off.

Ellen Watson, a spokeswoman for SUNY-Downstate Medical Center, said its officials knew the grants were under review.

“But absent a formal announcement from the governor’s office, it’s too early for Downstate to comment,” she said.

Long Island College Hospital operates about 300 beds, though it is certified for 506. It annually delivers more than 2,500 babies and has 55,000 emergency room visits.

The original merger, announced in October, was considered a victory for Continuum and Governor Paterson. It came after the closing of two other hospitals — St. Vincent’s in Greenwich Village and North General in Harlem— that foundered under hundreds of millions of dollars in debt, operating losses and the economic downturn.

Mr. Brezenoff said that the hospital needed an infusion of $90 million to $100 million to survive, and that he had been able to pull together the money through other sources that were contingent on getting the state grants.

He expressed frustration with the idea that Mr. Cuomo might be withdrawing a promise that had been thoroughly vetted and publicly announced.

“This is a stunner,” he said. “When is something done, done?”

Shortcuts: Tiptoeing Out of One’s Comfort Zone (and of Course, Back in)

Posted: 11 Feb 2011 11:57 PM PST

LAST week, I moved out of my comfort zone, psychologically and literally. And it didn’t feel so good.

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Mark Lennihan/Associated Press

Jesse Paloger held up a sign in December 2010 to look for a job on Wall Street.

First, I spoke to a group of middle-school students about journalism. It was a day when parents were supposed to come and talk about their work and discuss why what you learned in middle school was actually important in real life.

I am fairly self-confident about talking to a roomful of adults. But 12- and 13-year-old children made me sweat. Some looked at me intently, but others stared out the window, played with their pencils or poked their neighbors. Suddenly, I was pulled back to my middle-school years, trying to entertain the “popular” kids. I was most uncomfortable.

A few days later, we had some workers in to paint a few rooms in the house. No big deal, I thought. Except that as more rooms were draped in drop cloths and living room furniture crowded the dining room, our entire family — and two befuddled cats — retreated upstairs.

No one could find anything. Everyone was out of sorts. We were feeling decidedly uncomfortable.

Moving out of our comfort zones is supposed to be a good thing. We challenge ourselves, we grow and take on new risks. But is this always true? After all, over the last few years, many of us have been pushed out of our comfort zones, forced to seek new jobs, even careers.

First of all, I wondered, how did the term originate? In my research, I came across one theory that comfort zone was the temperature range — about 67 to 78 degrees, depending on the season — at which people were neither too hot nor too cold.

All right. I can’t test that with snow on the ground. But if we transfer that to a psychological comfort zone, it makes sense — it’s where we’re completely at home. Or as Judith M. Bardwick, author of “Danger in the Comfort Zone” (American Management Association, 1991), writes, “The comfort zone is a behavioral state within which a person operates in an anxiety-neutral position.”

She cites a famous experiment conducted by the psychologists Robert M. Yerkes and John D. Dodson, way back in 1908. Using mice, they found that stimulation improved performance, up to a certain level — what is now known as optimal anxiety. When that level is passed, and we’re under too much stress, performance deteriorates.

“We need a place of productive discomfort,” said Daniel H. Pink, author of “Drive: The Surprising Truth About What Motivates Us” (Riverhead, 2009). “If you’re too comfortable, you’re not productive. And if you’re too uncomfortable, you’re not productive. Like Goldilocks, we can’t be too hot or too cold.”

Everyone’s reaction to stress is different, of course — your comfort zone is not mine.

The objective is to reach that optimal level so that our skills increase and we become comfortable with that new level of anxiety — then we’re in an expanded comfort zone. And ideally, we will get more used to those feelings of “productive discomfort” and won’t be so scared to try new things in the future.

Brené Brown, a research professor at the University of Houston Graduate College of Social Work and author of “The Gifts of Imperfection” (Hazelden, 2010), has another definition of comfort zone: “Where our uncertainty, scarcity and vulnerability are minimized — where we believe we’ll have access to enough love, food, talent, time, admiration. Where we feel we have some control.”

The trouble is, Ms. Brown said, “When we get into times of social, political or financial instability, our comfort zones get smaller.” The more afraid we are, she said, “the more impenetrable our comfort zones buffers become.”

There was a huge shift after 9/11, she said, in just how vulnerable people were willing to be in their personal and work lives. When we feel vulnerable, she added, we often feel fear and shame.

And, “since those are some of our most difficult emotions, we want to avoid them,” she said.

E-mail: shortcuts@nytimes.com

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Recipes for Health: Lime Cumin Vinaigrette

Posted: 10 Feb 2011 12:00 AM PST

This dressing is a good match for bean salads and for roasted vegetables, and it goes well with grains and fish.

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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2 tablespoons plus 2 teaspoons fresh lime juice

1 tablespoon plus 1 teaspoon sherry vinegar or Champagne vinegar

1 small garlic clove, puréed

Salt to taste

1 teaspoon cumin seeds, lightly toasted and ground in a spice mill

1/2 to 1 teaspoon Dijon mustard, to taste

Freshly ground pepper to taste

1/4 cup canola oil or grapeseed oil

1/4 cup extra virgin olive oil

1. Combine the lime juice, vinegar, garlic, salt, cumin and Dijon mustard in a small bowl or measuring cup. Whisk in the oils. Whisk or shake in a jar before serving.

Yield: Makes 3/4 cup.

Advance preparation: Dressings with citrus juice are best shortly after they’re made. Unlike in vinegar-based dressings, the flavors change over time — and not for the better.

Nutritional information per 2 tablespoons: 168 calories; 2 grams saturated fat; 4 grams polyunsaturated fat; 13 grams monounsaturated fats; 0 milligrams cholesterol; 1 gram carbohydrates; 0 grams dietary fiber; 10 milligrams sodium (does not include salt to taste); 0 grams protein

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

National Briefing | MIDWEST: Ohio: Health Law Challenge on Fast Track

Posted: 08 Feb 2011 10:10 PM PST

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A second appellate court has set an expedited schedule for hearing a constitutional challenge to the new health care law. The United States Court of Appeals for the Sixth Circuit, in Cincinnati, announced Tuesday that it would hear oral arguments during a term that stretches from May 30 to June 10. The appeal stems from a decision upholding the law by a federal judge in Detroit. The United States Court of Appeals for the Fourth Circuit, in Richmond, Va., has already announced it will hear arguments in mid-May in the Obama administration’s appeal of a Virginia judge’s decision to strike down a central provision of the law.

Health Law Provision Raises Antitrust Concerns

Posted: 09 Feb 2011 11:13 AM PST

WASHINGTON — The new health care law encourages collaboration by doctors and hospitals for cost savings, but a split has developed here as to just how far they can go without running afoul of antitrust laws.

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Lawrence Jackson/Associated Press

David A. Balto, an antitrust lawyer, said that objections to medical collaborations amounted to “unreasonable skepticism.”

An influential Republican member of the Federal Trade Commission, J. Thomas Rosch, said that without “vigorous antitrust enforcement,” the new alliances of health care providers could reduce competition and increase costs to consumers.

Mr. Rosch set forth his concerns in private letters to the White House and the federal Medicare agency. The letters, obtained by The New York Times, reveal a struggle between the Justice Department and the commission over who should police the market.

The internal debate creates uncertainty about antitrust enforcement policy at a moment when scores of hospitals, clinics and doctor groups are eager to band together and test innovative ways of delivering care. That uncertainty threatens to slow collaboration by health care providers. President Obama and other proponents say such cooperation could cut costs and improve care for millions of people.

When competitors collaborate, economists say, they can produce enormous efficiencies, but they may also be tempted to engage in monopolistic practices. The risk tends to be greatest in small- and medium-size communities dominated by one or two hospitals or health care systems, experts say.

David A. Balto, a private antitrust lawyer with close ties to the Obama administration, said the disagreement between the Justice Department and the Federal Trade Commission was “extremely unfortunate.”

“The commission has demonstrated unreasonable skepticism toward collaboration by health care providers,” Mr. Balto said.

The antitrust division of the department, under Christine A. Varney, an assistant attorney general, is widely seen by hospitals as more sympathetic to their efforts to band together with doctors and negotiate jointly with health insurance plans.

Officials of the two agencies, which normally share responsibility for enforcing antitrust laws, are trying to devise a joint statement explaining how they will evaluate proposed collaborations by doctors and hospitals. The agencies said, in response to questions, that their goal was to have one consistent policy, but they refused to give details of their talks.

The new health care law encourages joint ventures, known as accountable care organizations, in which doctors and hospitals take collective responsibility for the care of Medicare beneficiaries.

“The creation and operation of accountable care organizations potentially conflict with the antitrust laws,” Mr. Rosch wrote. “The Supreme Court long ago prohibited competing providers from jointly contracting to provide their services, except in specified circumstances.”

Mr. Rosch, an antitrust lawyer for more than 35 years, said he was speaking only for himself. But his views on antitrust policy in the health care industry generally reflect the views of the commission’s nonpartisan professional staff, based on numerous advisory opinions issued to health care providers over the last 15 years.

Unless doctors and hospitals share some degree of financial risk, Mr. Rosch said, the new entities are unlikely to achieve the promised cost savings. In recent years, independent doctors and hospitals have often come together to coordinate care but have been reluctant to pool resources and share the risks of financial losses.

The fragmentation of the health care system, in which patients often shuttle from doctor to doctor, is widely seen as a major problem. Under the new health care law, doctors and hospitals can earn financial rewards if they improve the care of Medicare patients while holding costs below benchmarks set by the federal government.

Dr. Donald M. Berwick, the administrator of the Centers for Medicare and Medicaid Services, said he would soon issue rules for these groups of health care providers. If a group becomes so powerful in a market that it can raise prices without fear of losing business to rivals, it could be required to seek review from one of the antitrust agencies, administration officials said. The health care law does not displace the antitrust laws or provide any exemption for the new entities.

Mr. Rosch said the government must set clear goals for Medicare savings and measure the performance of accountable care organizations with respect to both Medicare and the private insurance market.

“Otherwise,” Mr. Rosch said, “there will be a real risk that the savings accruing to Medicare will just come at the expense of private insurers.” In other words, he suggested, a network of doctors and hospitals could offset a loss of Medicare revenue by charging more to privately insured patients.

In recent years, the Federal Trade Commission has taken the lead in analyzing joint ventures by health care providers. Citing this experience, Mr. Rosch said his agency should also be responsible for policing compliance with the antitrust laws by accountable care organizations. This approach, he said, would “avoid time-consuming turf battles” with the Justice Department.

Health care providers said Mr. Rosch and the Federal Trade Commission were making a power grab that could jeopardize the success of accountable care organizations. As part of the Obama administration, they said, Ms. Varney and the Justice Department have a bigger stake in the success of the new entities.

As a member of the commission in 1996, Ms. Varney said the government should be receptive to new types of collaboration among health care providers, a view she has voiced lately as assistant attorney general. In 2003, as a lawyer in private practice, she testified “on behalf of the American Hospital Association,” one of her clients, at a hearing held by the Justice Department and the commission.

In discussions between the two agencies, Mr. Rosch said, the department has taken the position that health care providers should be free to choose which agency would review their plans. Such an arrangement, he said, could lead to “a lack of regulatory consistency,” with the two agencies applying different standards. Justice Department officials declined to comment.

Mr. Balto, a senior fellow at the Center for American Progress, a liberal research and advocacy group, said: “The standards applied by the F.T.C. are out of date. For health care providers to get approval from the commission for a joint venture or other form of collaboration is an exhaustive, expensive process that typically takes more than a year.”

But another antitrust lawyer in Washington, Katherine I. Funk, said, “The commission has more experience and expertise analyzing the clinical integration of health care providers — a key goal of accountable organizations.”

Latest Hidden Video by Abortion Foes Shows Bronx Clinic of Planned Parenthood

Posted: 08 Feb 2011 10:30 PM PST

An anti-abortion group released a videotape on Tuesday of a man whom the group said was posing as a pimp and a woman who was posing as a prostitute on a visit to a Planned Parenthood clinic in the Bronx. They appear to get information from a receptionist about how to obtain abortions and treatment for sexually transmitted diseases for under-age sex workers.

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The videotape was the sixth released by the group, Live Action, of undercover visits to Planned Parenthood; the others were made at a clinic in New Jersey and four locations in Virginia. Its release comes as anti-abortion advocates and their allies in Congress are trying to cut off money for Planned Parenthood, which provides family planning, contraception and abortion.

Lila Rose, the president of Live Action, which is based in San Jose, Calif., said Tuesday that her group had gone after Planned Parenthood because “they’re the biggest abortion chain in the country.” She said the tape showed that Planned Parenthood used promises of confidentiality to cover up sex trafficking.

Planned Parenthood of New York City released a statement saying that Live Action was making “false claims” as part of a political agenda.

“These tapes are part of a nationwide campaign by this group,” the statement said. “Unlike other publicized tapes, the hoax patients in New York were not able to get beyond the reception desk for a private consultation.”

Joan Malin, president of Planned Parenthood of New York City, noted that the man and woman in the video were both adults. She said that if under-age women had come into the clinic, they would have been screened for violent or abusive relationships and referred to any necessary services.

“Under New York State law, we are not required to report criminal activity,” Ms. Malin said. “We are required to report anything we believe is child abuse or neglect by a parent or guardian, which we do.”

Roger Rathman, a spokesman for Planned Parenthood, said Tuesday that the organization believed the tape had been doctored to add the words “sex work” and “sex worker,” and that the two staff members interviewed on camera — a receptionist and a supervisor — had told the Federal Bureau of Investigation they did not hear those words.

Ms. Rose, the Live Action president, denied the doctoring claim.

The Live Action Web site shows two versions of the tape, a highly condensed version and a longer one. The short version shows what appears to be the man and woman walking toward a clinic, wearing summer clothing, even though the visit to the Bronx clinic was in the midst of a snowy January. Ms. Rose acknowledged that the introduction was shot elsewhere.

On the video, a man and a woman — their faces never visible — enter the clinic, apparently carrying a hidden camera.

A woman who appears to be a receptionist leads them through metal detectors. Standing in a hall, the man says in a whispery voice that he is wondering “about testing for the both of us.” The receptionist assumes he is talking about HIV testing. The man continues: “We’re involved in sex work. We have some other girls that we manage and work with that they’re gonna need testing as well.”

The receptionist says that everything is confidential and that “they don’t have to tell anybody what it is that they do.” She says the clinic treats people as young as 13. At this point the woman posing as a prostitute interjects that “some of them are 14 and 15.”

The man asks whether he could “sign off as a guardian,” and the receptionist explains that the clinic does not ask for a guardian’s signature. Under New York law, minors can get an abortion without parental permission.

Although Live Action describes the couple as posing as a pimp and a prostitute, they are not heard calling themselves such on the tape.

Planned Parenthood fired an office manager of a New Jersey clinic who was caught on one video encouraging the pimp to have the girls lie about their ages. The group ordered retraining for staff members across the country.

Nate Schweber contributed reporting.

Under Banner of Fiscal Restraint, Republicans Plan New Abortion Bills

Posted: 09 Feb 2011 03:34 PM PST

WASHINGTON — All but invisible during the midterm elections, the abortion debate has returned to Congress.

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Stephen Crowley/The New York Times

Representative Eric Cantor, the majority leader, on Capitol Hill Tuesday.

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The latest on President Obama, the new Congress and other news from Washington and around the nation. Join the discussion.

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Drew Angerer/The New York Times

Senators Richard Blumenthal, Kirsten Gillibrand, Patty Murray (back to camera) and Barbara Boxer oppose the House bills.

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Stephen Crowley/The New York Times

Representatives Jerrold Nadler, left, and Milke Quigley, both Democrats, on Tuesday with the president of Naral, Nancy Keenan.

Invoking the mantra of fiscal restraint that has dominated House action since lawmakers reconvened last month, Republicans began committee work this week on two bills that would greatly expand restrictions on financing for and access to abortions. Another bill, one that would cut off federal dollars to women’s health care clinics that offer abortions, is expected to surface later this year.

“This House is more pro-life than it’s ever been,” said Representative Joe Pitts, Republican of Pennsylvania and the author of one of the bills to limit money for abortions.

Democrats in both the House and Senate immediately fought back Tuesday, working closely with reproductive rights advocates. They have appropriated the Republican charge from last year that Democrats were working on a liberal policy agenda instead of on job creation and the economy, and turned it on its head.

“This election was about the economy,” said Senator Kirsten Gillibrand of New York, who joined with other Democratic senators Tuesday to decry the House bills Tuesday as needless and intrusive.

Over and over, Democrats said that by bringing up the abortion issue now, Republicans were going back on their word to focus on the budget.

Yet the bills that have surfaced on the House floor this year have been fiscal in nature, including the repeal of the health care law, which was later rejected by the Senate, and some measures designed to cut spending.

“Republicans are focused on creating a better environment for economic growth and job creation,” said Kevin Smith, a spokesman for Speaker John A. Boehner, “and that is reflected in the legislation the House is passing,”

Still, Republicans in the House are clearly energized about using their new majority to reopen debate on an important issue for conservatives, especially in the context of the health care overhaul.

On Tuesday, Representative Eric Cantor, the Republican majority leader, described the new measures as “obviously very important in terms of the priorities we set out initially in our pledge to America.”

He indicated that he expected the first version of a House bill to finance the government through the rest of the year to bar spending to carry out the health care law. That provision is likely to also be attacked by the Senate and the Obama administration.

One bill, the “No Taxpayer Funding for Abortion Act,” would eliminate tax breaks for private employers who provide health coverage if their plans offer abortion services, and would forbid women who use a flexible spending plan to use pre-tax dollars for abortions. Those restrictions would go well beyond current law prohibiting the use of federal money for abortion services.

The bill, sponsored by Representative Christopher H. Smith, Republican of New Jersey, has drawn fire over language that undercuts a longstanding exemption on the ban on using federal money for abortions in the case of rape or incest; the measure narrows the definition of rape to “forcible rape,” a term that his office has never defined. Democratic lawmakers and others repeatedly hammered on the term, saying it suggested that victims of statutory rape and other crimes could not get abortions paid for with federal money.

While Mr. Smith’s staff said last week that the term "forcible rape" would be removed from the bill, the staff of RepresentativeJerrold Nadler of New York, the top Democrat on the Judiciary Subcommittee on the Constitution, said that language remained intact as of Tuesday.

Another bill, sponsored by Mr. Pitts, addresses the health care overhaul head-on by prohibiting Americans who receive insurance through state exchanges from purchasing abortion coverage, even with their own money. The bill is essentially a resurrection of a provision in the House version of the health care law but was not in the Senate version.

The bill would also permit hospitals to refuse abortions to women, even in emergency situations, if such care would offend the conscience of the health care providers.

“Both bills are designed to drive coverage for abortion out of health insurance plans, period,” said Nancy Northup, president of the Center for Reproductive Rights.

The bills drew immediate fire from House and Senate Democrats. “We are sending a clear message to House Republicans that their agenda on women’s health is extreme,” Senator Barbara Boxer of California said at a news conference. “It breaks faith with a decades-long bipartisan compromise, and it risks the health and lives of women. It also punishes women and businesses with a tax hike if they wish to keep or buy insurance that covers a full range of reproductive health care.”

Senator Frank R. Lautenberg of New Jersey, another Democrat who joined the news conference, compared the proposals to “a Third World country that’s requiring women to wear head shawls to cover their faces even if they don’t want to do it.”

As Mr. Smith’s bill provoked a spirited back and forth at a hearing of a subcommittee of the House Judiciary Committee, it also drew praise from some outside supporters.

“The federal government should not use tax dollars to support or promote elective abortion,” Richard Doerflinger, associate director of the Secretariat of Pro-Life Activities of the United States Conference of Catholic Bishops, said in a news release.

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