Wednesday, March 2, 2011

Health - Fewer Patients in I.C.U. Getting Blood Infections

Health - Fewer Patients in I.C.U. Getting Blood Infections

Fewer Patients in I.C.U. Getting Blood Infections

Posted: 01 Mar 2011 11:40 PM PST

Bloodstream infections caused by tubes inserted into major blood vessels of intensive care patients showed a big drop from 2001 to 2009, government researchers said on Tuesday.

But the researchers also reported unacceptably high rates of the same type of infections in other hospital wards and in people receiving dialysis for kidney failure.

The illnesses, called central-line infections, can be serious, with death rates of 12 percent to 25 percent. Central lines are tubes that are usually placed in the large veins of the neck or chest to deliver medicines and nutrition.

Infections in these lines are common, but also largely preventable. Bacteria like staphylococcus can be warded off with simple measures like washing hands, wearing sterile gowns and drapes, and following the proper techniques for inserting and maintaining the lines.

The estimated number of central-line infections in intensive care units fell to 18,000 in 2009 from 43,000 in 2001, a 58 percent drop, according to a report published online Tuesday by the Centers for Disease Control and Prevention. Experts attributed much of the progress to campaigns aimed at improving techniques for managing the lines in intensive care units, where they are most commonly used.

The figures mean that in 2009, such measures prevented 3,000 to 6,000 deaths and saved $414 million. Assuming the decrease in central-line infections was steady from 2001 to 2009, as many as 27,000 lives might have been saved at a cost savings of $1.8 billion.

The numbers are rough estimates. The 2001 figure of 43,000 infections, for instance, could have been as low as 27,000 and as high as 67,000.

Even so, Dr. Thomas R. Frieden, director of the C.D.C., called the drop in infections in intensive care units “very substantial progress.” But, he said in a telephone news briefing, the infections still occurred far too often, affecting 80,000 patients a year and killing at least 10,000 of them.

About 350,000 patients a day receive dialysis in the United States. In 2008, about 37,000 of them suffered central-line infections, Dr. Frieden said, adding that the infections are the leading cause of hospital stays and death in people on dialysis.

He said the issue was especially important because the number of people on dialysis is expected to double in the next decade because of increased rates of kidney failure linked to diabetes and the aging of the population.

One way to cut down on infections in people with kidney failure is to avoid using a central line for dialysis. It is preferable for such patients to have an operation that connects an artery and a vein, forming a structure known as a fistula that can be used for dialysis.

Fistulas have about one-sixth the risk of infection as a central line. Needles are inserted into the fistula for each treatment and removed when the treatment is done, unlike central lines, which stay in the blood vessel and emerge through the skin, posing a constant risk of infection.

Despite the widespread recognition that fistulas are safer, about 80 percent of dialysis patients in the United States start treatment with a central line. Because the surgery to create a fistula must be completed six weeks or more before dialysis starts, doctors must anticipate kidney failure and perform the procedure well ahead of time.

Dr. Arjun Srinivasan, a medical epidemiologist at the C.D.C. and one of the authors of the new report, said that hospital wards outside of intensive care units needed to adopt hygiene techniques for inserting central lines.

Some hospitals have already made those improvements. Dr. Neil Fishman, an infectious disease specialist and the director of health care epidemiology and infection prevention at the University of Pennsylvania Health System, said that at the Hospital of the University of Pennsylvania, practices first put into place in intensive care were extended to other wards.

In 2005, there were 40 to 50 central-line bloodstream infections at the hospital every month, Dr. Fishman said. “That was our peak,” he said. “In 2011, we have zero to two every month. That took a lot of work from a lot of people, and a lot of dedication.”

Well: Research Urges Going Easy on Yourself

Posted: 01 Mar 2011 11:26 AM PST

My Unhealthy Diet? It Got Me This Far

Posted: 01 Mar 2011 09:30 PM PST

SOMETIMES I can’t believe what my 82-year-old mother has been eating. Living now in a retirement home in Durham, N.C., she told me she recently had cherry cobbler for breakfast. Apparently she’d had French toast stuffed with bananas and Nutella for lunch the day before, and after lunch had gone to dessert theater (“You know, like dinner theater, but with desserts”), where she’d gobbled down a lot of cookies. “So when they served cherry cobbler for dessert that night in the dining room, I thought, I better take this back to my room and eat it tomorrow. For breakfast.”

Enlarge This Image
Noah Berger for The New York Times

Now 75, Bobby Seale, a founder of the Black Panthers, cooks and eats barbecue 10 times a year.

Enlarge This Image
Rex C. Curry for The New York Times

Mary Pyland, 92, of Abilene, Tex., continues to eat fried chicken and caramel pie.

Nancy Cardozo shares a house with her friend Aileen Ward in New Milford, Conn.; both are writers in their 90s. “We eat everything we like,” Ms. Cardozo said. “Any kinds of eggs, blini, any good red or beluga caviar with crème fraîche, cheesecake, chocolate soufflé with whipped cream, crème brûlée, filet mignon, pasta with pesto. Aileen drinks Lillet, and I’m vodka and tonic. We drink as much as we can.”

The cartoonist Mort Gerberg, now in his late 70s, went to a bat mitzvah in Denver last year for his great-niece. “Usually at these things they have a table with desserts or chocolate, but at this one they had a sour cream table,” Mr. Gerberg said. “They had all these cockamamie things to put on the sour cream: candies, chocolate. I had heaping portions. It was thrilling. And all I could think was, where are the potatoes?”

It’s a common belief that life as we know it ends in old age. Gone are the little joys that make existence worthwhile — béarnaise sauce, pancetta, cake batter — all subsumed under a banner reading, “Doctor’s Orders.” For older people, the irony of eating is that your metabolism slows down, so you need less food, but your body needs just as many nutrients, if not more.

Declining health and the voices of authority only dampen the proceedings further. The latest dietary guidelines from the federal government recommend that people older than 51 (along with African-Americans, children and adults with hypertension, diabetes or chronic kidney disease) eat only 1,500 milligrams of salt a day. Everyone else can have 2,300.

Constantly badgered by the medical establishment, family and friends to adopt a healthier approach to food, the older gourmand soldiers on anyway. Why? For my mother, it’s the thrill of transgression.

“I’m a sneaky eater,” she told me. “Inside me is a very naughty girl. I like to eat in the privacy of my own room — sticking my spoon deep into the jar of Mrs. Richardson’s caramel sauce so it sticks straight up, maybe sprinkling a little salt on it — and not telling anyone.”

For others, eating well is a way to keep traditions alive. Mary Pyland, 92, of Abilene, Tex., was raised on a ranch. “We had a fried chicken dinner every Sunday,” said Ms. Pyland, who ran a cosmetics store until she was 84. “I lost my husband 16 years ago, and I try to keep up everything we always did. Honey, I just had fried chicken with cream gravy and biscuits and mashed potatoes for dinner last night. And I made a caramel pie that was just about the best thing you ever put your lips around.”

One trope that comes up often in conversations with older gourmands is that eating what they want is, at their age, a right or privilege. For some of these privileged or righteous folks, it’s a question of not curbing one’s impulses.

Larry Garfield, 95, of Key Biscayne, Fla., worked in the carpet industry until he was 83. Asked why he recently ate a rare calf’s liver with mashed potatoes at Joe Allen’s restaurant in Miami Beach (even though he shouldn’t have, given his diabetes), Mr. Garfield said: “You ever walked down the street and seen a pretty girl and thought, ‘Mm! That’s for me!’? Well, I looked at the menu and thought, ‘Mm! That’s for me!’ ”

For other righteous or privileged folk, eating is a reward. Barbara Hillary, who reached the South Pole in January at age 79, making her the first African-American woman on record to stand on both poles, said she ate too much milk chocolate during the trip. “If I had frozen to death down there, wouldn’t it be sad if I’d gone to hell without getting what I want?” she said.

In some cases, this same right or privilege seems to stem from having lived an exalted life. Nancy Cardozo and Aileen Ward met at Isadora Duncan’s school on Nantucket when they were 14. Ms. Cardozo said: “We did Duncan dancing. We flitted on the grass in little Greek dresses.”

Both went on to lead vivid lives. Ms. Cardozo wrote fiction and poetry for the New Yorker in the 1940s and ’50s; Ms. Ward won the National Book Award in 1964 for her biography of Keats, and used to car-pool with Vladimir Nabokov when she taught at Wellesley.

Now, despite some technical difficulties (“There are chewing problems,” Ms. Cardozo said. “That doesn’t sound very attractive, does it?”), they eat luxuriant foods, albeit in small portions. “It feels like entitlement,” Ms. Cardozo explained. “We deserve it because it’s the way we’ve always lived, and we don’t want to change.”

Recipes for Health: Savory Cornbread Muffins With Jalapeños and Corn

Posted: 02 Mar 2011 12:10 AM PST

Cornbread bakes nicely in a muffin tin. I’ve added corn, chilies and cheese to this cornbread. With soup and a salad, it makes a great lunchtime muffin.

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.

Related

1 cup yellow cornmeal, preferably organic stone-ground

1 cup whole-wheat flour

3/4 teaspoon salt

2 teaspoons baking powder

1 teaspoon baking soda

1 tablespoon finely chopped fresh sage or 1 teaspoon rubbed sage

2 eggs

1 1/2 cups buttermilk

1/4 cup canola oil

1 tablespoon honey

1 cup corn kernels

2 tablespoons minced jalapeños

1/2 cup grated Cheddar or Monterey Jack (optional)

1. Preheat the oven to 400 degrees with the rack positioned in the upper third. Oil or butter muffin tins.

2. Place the cornmeal in a bowl, and sift in the flour, salt, baking powder and baking soda. Stir in the sage. In a separate bowl, beat together the eggs, buttermilk, oil and honey. Whisk or stir the cornmeal mixture into the liquid mixture. Do not beat; a few lumps are fine, but make sure there is no flour at the bottom of the bowl. Fold in the corn kernels, minced jalapeño and optional cheese.

3. Spoon into muffin cups, filling them to just below the top (about 4/5 full). Place in the oven, and bake 20 to 25 minutes until lightly browned and well risen.

Yield: Twelve muffins, depending on the size of your muffin tins.

Advance preparation: These keep for a couple of days out of the refrigerator, for a few more days in the refrigerator, and for a few months in the freezer.

Nutritional information per muffin (based on 12-muffin yield; does not include optional cheese): 161 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 3 grams monounsaturated fat; 32 milligrams cholesterol; 23 grams carbohydrates; 2 grams dietary fiber; 362 milligrams sodium; 5 grams protein

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

Lasers Rise as Threat to Retinas

Posted: 02 Mar 2011 09:05 AM PST

So far, the reports have been scattered and anecdotal. But eye doctors around the world are warning that recent cases of teenagers who suffered eye damage while playing with high-powered green laser pointers are likely to be just the first of many.

“I am certain that this is the beginning of a trend,” said Dr. Martin Schmid, a Swiss ophthalmologist who reported one such case last September in The New England Journal of Medicine.

The pointers, which have also been implicated in a ninefold increase over five years in reports of lasers’ being aimed at airplanes, are easier than ever to order online, doctors say — even though they are 10 to 20 times as powerful as the legal limit set by the Food and Drug Administration.

At the American Academy of Ophthalmology, a spokeswoman said the group was unaware of any increase in eye injuries caused by lasers. But doctors interviewed for this article said they were shocked by the easy availability of high-powered lasers.

Not long ago a high school student went to see Dr. Robert G. Josephberg, a retina specialist at Westchester Medical Center in Valhalla, N.Y., complaining of a blind spot in his left eye. The boy, who did not want to be identified, said the injury occurred when a friend waved a green laser pointer in front of his face.(Whether it will heal completely is uncertain.)

Dr. Josephberg said that at first he doubted the story. “I didn’t believe that a green laser was out there that could cause the damage,” he said.

But it turned out the laser put out 50 milliwatts of power, 10 times the F.D.A. limit. And as he investigated his patient’s case, Dr. Josephberg went online and bought a 100-milliwatt pointer for $28. He could hardly believe how easy it was.

“I kept waiting for the error message telling me I could not complete the purchase,” he said.

Like household lights, lasers are measured in watts, but the similarity ends there. A 100-watt incandescent bulb produces about five watts of visible light; the five-milliwatt laser is only one-thousandth as powerful. But because the light from a bulb is diffuse and a laser beam is concentrated, the effect of five milliwatts on the eye is 10,000 times as intense, according to Samuel M. Goldwasser, a laser expert and author of the online guide Sam’s Laser FAQ.

Dr. Jerald A. Bovino of the American Retina Foundation says the way the eye focuses can also intensify the laser.

“It is going to the fovea, the center of the retina,” he said. The darker pigment in the fovea absorbs the light as heat, quickly raising the temperature of the retina the same way a black car seat gets hot as it absorbs the sun.

Dr. Kimia Ziahosseini of the St. Paul’s Eye Unit at Royal Liverpool University Hospital in England says the dangers are so acute that even the F.D.A.’s five-milliwatt limit is too high.

“Laser pointers available for sale to general public should be less than one milliwatt,” she said. “Anything more than this puts people at risk by the criminally minded or those who are unaware of the risks.”

In a consumer update in December, the F.D.A. said it was aware that illegal laser pointers were being sold and warned that “a higher-powered laser gives you less time to look away before injury can occur, and as power increases, eye damage may happen in a microsecond.”

Daniel Hewett, a health promotion officer at the agency, said by e-mail, “There are many noncompliant products available for purchase from retailers, importers and, of course, via the Internet.” He noted that the agency had seized products from Wicked Lasers, an online store based in Hong Kong.

Steve Liu, chief executive of Wicked Lasers, said in an interview that its products did not violate the F.D.A. restrictions because those over the five-milliwatt limit were not called pointers.

Moreover, he added, “we make it extremely clear on our Web pages that these lasers are not only eye hazards but fire hazards.” And he said the company would begin offering laser safety lessons to its customers before online checkout.

Several laser experts say the enforcement of regulations is already insufficient and ineffective. “It’s a whole can of worms,” Dr. Goldwasser said, recalling that he recently received a 100-milliwatt laser as a gift from Wicked Lasers. To rein in all the hazardous products out there — from virtual stores to flea markets — would be impossible, he said.

And any talk of restricting availability is certain to meet resistance from the large community of laser enthusiasts, including those who use them professionally (like contractors and astronomers) and hobbyists like 18-year-old Alex Triano of Staten Island.

Since middle school, with his parents’ permission, Mr. Triano has been building lasers in his home, wearing safety goggles. “You learn so much in a hobby like this: electronics, soldering, physics,” he said. “And you learn about light, you learn about optics. You also learn a lot of mechanical things.”

The laser injuries Dr. Shepard Bryan has seen at his practice in Mesa, Ariz., involved red lasers, which laser fans like Mr. Triano consider passé. Green is more easily perceived by the eye and the beam is visible along its path.

But green lasers are also more dangerous. Green is more easily absorbed by the retina than red, so it requires less exposure to cause damage. (Dr. Bryan’s cases involved an 11-year-old girl who focused on the light as part of an endurance game and a young man who also looked directly into the pointer.)

“Right now I haven’t seen an epidemic of injuries,” Dr. Bryan said, but he added that the potential was there. “In the hands of children it’s a very scary proposition.”

City Council Earmarks Flow to Brain Scan Group

Posted: 02 Mar 2011 07:51 AM PST

Every year, the Brain Tumor Foundation bombards the City Council with stories of loved ones lost, frightening statistics about the prevalence of cancer and pledges to “literally save the lives of your constituents.”

Enlarge This Image
The Brain Tumor Foundation

Until recently, the tractor-trailer housing the Brain Tumor Foundation’s M.R.I. machine had been idle for four months. The foundation provides free brain scans to adults in New York City.

And each year, the Council responds, turning down food banks, after-school programs and arts groups in favor of the foundation, which provides free brain scans. The group has received nearly $2 million since 2005, making it one of the top recipients of discretionary funds, known as earmarks.

But in doing so, the Council has given the city’s imprimatur to a use of a medical tool that the National Institutes of Health has said “may not be ethical” and whose usefulness in fighting cancer scientists have passionately debated.

And the money has kept flowing, even though the centerpiece of the foundation’s work, a 70-foot tractor-trailer equipped with an M.R.I. machine, has until recently sat idle for four months.

The popularity of the Brain Tumor Foundation raises questions about whether the Council monitors earmarks as closely as it should after a series of fraud and abuse scandals.

For all their passion, lawmakers seem largely unaware of the potential downside of cancer screenings, and several said they did not realize the Council had devoted so much money to a single cause.

The president of the foundation, Dr. Patrick J. Kelly, a retired New York University neurosurgeon, acknowledged that the potential of his work, which focuses on the early detection of tumors, has not yet been proved. “It just makes sense,” he said in a recent interview. “Can I demonstrate that scientifically? No.”

Some cancer researchers oppose Dr. Kelly’s methods because of concerns that early treatment does not improve, and in some cases might worsen, a person’s health. But the Council does not seem worried: 21 of its 51 members provided $233,000 last year to support the foundation’s trailer, named for Bobby Murcer, the Yankees outfielder who died of complications from brain cancer in 2008.

Even Dr. Kelly was startled to learn that his group was one of the biggest recipients of Council money. “Is it as important as feeding people up in Harlem?” he said. “Well, probably not.”

“But,” he joked, “I won’t turn it down.”

Thousands of groups apply for a share of the Council’s discretionary money each year. The Council speaker, Christine C. Quinn, determines the size of each council member’s pot, ranging from $80,000 to more than $1 million. The Council gives out about $18 million annually.

A familiar list of organizations consistently wins a large share of the money: the Metropolitan Council on Jewish Poverty, the City Parks Foundation and the Doe Fund, a group that provides jobs to homeless people.

But there are also highly specialized organizations that are frequent recipients of earmarks, like Chess-in-the-Schools, an educational program. Some groups are so competitive that they hire lobbyists to corner council members on the steps of City Hall at the height of budget negotiations.

The Brain Tumor Foundation suggested in its application for financing last year that its trailer would operate 9 a.m. to 5 p.m., Monday through Friday, year-round.

But the foundation, an official said, could not afford to keep the trailer running on a regular basis — it costs about $25,000 a week. In total, it has visited each of the city’s boroughs about five times, sometimes staying for several weeks.

Some council members said that the oversight process should be more rigorous and that groups should be made to follow up with the Council in a detailed way.

“Moneys are being given out, but whether we’re being successful or not is not clearly measurable,” said Councilman Jumaane D. Williams of Brooklyn, who provided $10,000 to the Brain Tumor Foundation last year.

Politicians are eager to appear at the foundation’s screenings, which are so popular in some communities that waiting lists total in the hundreds. The foundation focuses on low-income neighborhoods where access to health care is limited.

James S. Oddo, a councilman from Staten Island who gave the foundation $20,000 last year, said its programs were crucial for residents who would not otherwise go to a doctor.

“I’m cognizant of the notion of too many scans and all the negatives that come with it, but right now I’m not convinced that people are better off avoiding them,” Mr. Oddo said.

Since 2008, the Brain Tumor Foundation has scanned 2,500 people in the city, meaning each scan has so far cost the city about $778. The group has found tumors in about 1 of every 100 people. By comparison, a 1999 study published in The Journal of the American Medical Association found two brain tumors in a sample of 1,000 people.

Dr. Kelly has presented his M.R.I. scans as a breakthrough, “the best-known method of treating deadly tumor growth.”

But some researchers warn about the risk for false positives, and others argue that treating slow-growing tumors aggressively can have harmful side effects. A division of the National Institutes of Health that specializes in brain tumors has stated that “early detection strategies have not been a priority and their use may not be ethical.”

And the American Cancer Society and the American Brain Tumor Association said they had concerns about Dr. Kelly’s methods because of those risks.

Governors Seek Help on Medicaid Costs

Posted: 02 Mar 2011 12:16 PM PST

WASHINGTON — Governors told Congress on Tuesday that President Obama had not gone far enough in proposing to let states opt out of major provisions of the new health care law in 2014, and they said they needed more immediate relief from the growing financial burden of Medicaid.

Multimedia
Interactive Feature
The Health Care Law: The Growing Legal and Political Opposition

Related

Related in Opinion

“It sounds good, but it provides very, very little actual help,” Gov. Haley Barbour of Mississippi, a Republican, said of Mr. Obama’s proposal.

The most important provisions of the federal law, including a big expansion of Medicaid eligibility and a requirement that most Americans carry health insurance, take effect in 2014. The federal government will initially pay the entire cost of coverage for the people who are newly eligible for Medicaid, but after several years, states will be required to pay some of the cost.

Gov. Gary R. Herbert of Utah, a Republican, said Medicaid had been a large and growing part of his state’s budget even before the federal law was passed.

“In this recession,” Mr. Herbert said, “Medicaid enrollment has skyrocketed. In December 2007, enrollment in Utah stood at 158,267 individuals. In December 2010, enrollment stood at 230,812 individuals, a 46 percent increase in three years.”

The governors testified at a hearing of the House Energy and Commerce Committee.

Gov. Deval Patrick of Massachusetts, a Democrat, told the committee that he was largely indifferent to the president’s proposal because his state had already overhauled its health care system so that 98 percent of residents had health insurance.

The Republican governors said they were skeptical of the president’s proposal because they would have to seek waivers, making the future of innovative state health programs subject to the discretion of the secretary of health and human services. In the past, they said, they have had difficulty obtaining permission for such initiatives.

Mr. Herbert said Utah had been trying for eight months to get federal permission to communicate with Medicaid recipients by e-mail and through a secure Web site. Only after he raised the issue with Mr. Obama at the White House on Monday did federal officials agree to the arrangement, Mr. Herbert said.

Utah estimates that the move will save more than $6 million a year. Federal officials said that Medicaid recipients had low incomes and that some might not have access to computers. So in a letter approving Utah’s request, the Obama administration said the state could use e-mail only if beneficiaries “elect to receive notices through an electronic mailing system.”

Medicaid is now an open-ended entitlement, under which anyone who meets eligibility requirements is entitled to benefits. Governors said they would accept a fixed amount of federal money, in the form of a block grant, if they had more freedom to tailor the program to their residents’ needs.

The new health care law generally prevents states from adopting more restrictive eligibility requirements for Medicaid — for example, by lowering personal income limits. The Republican Governors Association has asked Mr. Obama to lift that constraint.

Representative Joe Pitts, Republican of Pennsylvania and chairman of the Subcommittee on Health, said Congress might need to give states more latitude. “If states cannot change their eligibility criteria,” Mr. Pitts said, “governors are left with few choices but to cut payments to providers or cut other parts of the state budget, such as education and transportation.”

But Representative Gene Green, Democrat of Texas, said, “States want the federal government to write them a blank check.”

Based on his 20 years of experience as a state legislator, Mr. Green said, that is not a good idea. In the absence of federal requirements, he said, Texas might try to balance its budget by eliminating coverage for tens of thousands of children.

Mr. Barbour said: “We can save money without taking people off the rolls. In return for total flexibility in managing my Medicaid program, I would agree to a block grant, with growth capped at half the national rate of increase. We should not have to kowtow to Washington to get permission for every change.”

Jocelyn A. Guyer, co-executive director of the Center for Children and Families at Georgetown University, said the federal law also prohibited states from adopting enrollment procedures that made it more difficult for people to sign up for Medicaid.

Feeling Budget Pinch, States Cut Insurance

Posted: 02 Mar 2011 06:13 AM PST

EASTON, Pa. — Ken Kewley woke up Tuesday without health insurance for the first time in nearly nine years.

Enlarge This Image
Matt Rainey for The New York Times

Artist Ken Kewley, a single father and homeowner in Easton, Penn., was a participant in Pennsylvania’s Adult Basic Health care program and witnessed the program’s end on Feb. 28, 2011.

Related in Opinion

Enlarge This Image
Matt Rainey for The New York Times

Mr. Kewley crossed the street with his 9-year-old daughter, Clara, on Monday, the day his health insurance, through a state-funded program, ended.

So did most of the 41,467 other Pennsylvanians who had been covered by adultBasic, a state-subsidized insurance program for the working poor that Gov. Tom Corbett shut down on Monday in one of the largest disenrollments in recent memory.

Mr. Corbett, a Republican elected in November, has said the program he inherited is not sustainable with Pennsylvania facing a $4 billion budget shortfall. He blames his predecessor, Edward G. Rendell, a Democrat, for not keeping the plan solvent. His administration notified beneficiaries in late January that their coverage would expire Feb. 28.

For Mr. Kewley, 57, an abstract artist in this gritty town in the Lehigh Valley, it meant the end of the coverage that made possible an aortic valve replacement last May. While the life-saving procedure cost about $85,000, he said he had paid only $915 out of pocket.

The state has pointed Mr. Kewley toward other options, but the coverage would be less comprehensive and the premiums far higher than the $36 he had been paying each month. Now any minor symptom, like a mild pinch in his chest, prompts a devil’s calculation about whether he can afford to have it checked.

When he noticed such discomfort on Tuesday morning, he broke into a cold sweat, felt his stomach tightening and experienced “a sense of impending doom,” he said. For the moment, Mr. Kewley is trying to convince himself it is just a pulled muscle.

“It’s a worry, and it’s draining,” he said, seated in the home studio where he applies bold acrylics to landscapes of the sloping hillsides nearby. “It’s always present in my mind so it’s hard to come up here and do my work.”

Pennsylvania is one of several destitute states seeking to help balance budgets by removing adults from government health insurance programs.

Gov. Christine Gregoire of Washington, a Democrat, recently removed 17,500 adults covered under Basic Health, a state-financed plan for the working poor. In Arizona, Gov. Jan Brewer, a Republican, proposes to remove up to 250,000 childless adults who have been insured by her state’s Medicaid program under a decade-long agreement with the federal government.

Medicaid, which is financed jointly by state and federal governments, primarily covers low-income children, parents and the disabled. Most states do not now offer coverage to childless adults, but starting in 2014, the new federal health care law will require them to expand Medicaid to insure adults earning up to 133 percent of the poverty level.

Former Gov. Tom Ridge, a Republican, started Pennsylvania’s adultBasic program in 2001 to cover those who earned too much to qualify for Medicaid but too little to afford private insurance.

Originally supported with national tobacco litigation proceeds, the policies were made available to adults who earned up to twice the federal poverty level (which would be $21,780 this year).

When the tobacco money started to dwindle, Mr. Rendell negotiated a deal with the state’s four nonprofit Blue Cross/Blue Shield insurers, which had been accumulating large surpluses. The Blues agreed to contribute to the plan to show they were fulfilling the charitable obligation that accompanies their tax-exempt status. The agreement expired on Dec. 31.

Over six years, the Blues provided $542.7 million to the plan, and $356.5 million more to other state health programs. They agreed last year to add $51 million to help maintain coverage through the fiscal year, which ends in June. It was not nearly enough.

The program’s revenue streams have never met more than a fraction of its demand, which has soared in the economic downturn. When the program closed, 505,000 people were on its waiting list, nearly seven times as many as in early 2007.

In an interview, Kevin Harley, a spokesman for Governor Corbett, called the program’s closing “unfortunate,” and then quickly blamed Mr. Rendell. He said the former governor had pledged to find $56 million to sustain the plan as part of last year’s deal with the Blues, but never did.

Donna Cooper, who was Mr. Rendell’s secretary of policy and planning, and the senior official in those negotiations, called Mr. Harley’s assertion “just wild.”

“That is patently untrue,” said Ms. Cooper, now a senior fellow at the Center for American Progress. “That commitment was never made.”

Mr. Corbett met with the Blue Cross plans, but did not persuade them to make additional contributions. “My understanding is that the Blues were not willing to continue,” Mr. Harley said. “They fulfilled all their obligations under the law.”

The Obama administration rejected the state’s request to allow refugees from adultBasic to qualify immediately for the high-risk insurance pool authorized under the federal health law. Kathleen Sebelius, the secretary of health and human services, responded that she could not waive the law’s requirement that applicants be uninsured for six months.

In Harrisburg, the state capital, Democratic legislators proposed to keep the program alive by seeking $25 million each from the Blues and the state, and by nearly doubling premiums. The Republicans, who control both houses of the General Assembly, have expressed no support.

“At the end of the day, the Blues are not willing to do it,” said Senator Jay Costa Jr., the minority leader, “and the administration is not willing to put the strong arm on them to get them to participate in the way that Governor Rendell did.”

The Blue Cross/Blue Shield plans continue to run substantial surpluses, rising to a cumulative $5.6 billion in 2009 from $3.5 billion in 2002, according to the Pennsylvania Budget and Policy Center, a research group that advocates for low-income families.

But the insurers say their obligation to pay for a state program has ended. “Our support to adultBasic was always a temporary financing mechanism,” said Aaron Billger, a spokesman for Highmark Blue Cross Blue Shield, the largest of the state’s plans. “We have long told the state that it was unsustainable.”

As the program’s shutdown loomed, many enrollees scurried to schedule doctors’ appointments and procedures. Mr. Kewley had his blood checked, and asked for new prescriptions. Roseanne Davis, a mother of two from Perkasie, scheduled a hysterectomy for Monday, her final day with coverage.

Doctors had discovered a benign ovarian cyst in January, but told her it did not have to be removed immediately. “I said, let’s get this done before I roll off insurance,” Ms. Davis said. “Down to the last day.”

Cases: 18 Stethoscopes, 1 Heart Murmur and Many Missed Connections

Posted: 28 Feb 2011 09:10 PM PST

BOSTON — One by one, the medical students bent down to listen to my heart.

Grady McFerrin

Related

There were six of them, led by a bright-eyed physician with a charming Irish accent — so charming I almost didn’t care that he never called me by name. All told, 18 second-year Harvard medical students would listen to me on this darkening winter afternoon, each group of six overseen by a different cardiologist.

“Place the diaphragm of your stethoscope here,” the Irish doctor was saying. “Start at the base of the heart and move down to the apex.”

He listened quietly. “Ma’am, take a breath in, and breathe out and hold it.”

I felt like an oddly invisible prop: part artist’s model, part one-night stand, heard but not seen. At first nobody made eye contact or spoke to me, a situation that evoked the universal vulnerability of patients: exposed, invisible, dehumanized.

Amplified through a stethoscope, the human heartbeat sounds like the muffled cadences of a marching band. Thuh-rhumm. Thuh-rhumm: A low washboard rumble, signifying a poorly functioning ventricle. Thhrrum-BUM. Thhrrum-BUM: A diastolic murmur, with its bass-drum finale. PAH-da-da-PAH. PAH-da-da-PAH: The crisp roll of aortic stenosis. Flutters, skips, thunks, whooshes, crescendos, decrescendos, telltale pitches and tempos — each conveys a diagnostic meaning.

Indeed, it was my “click” that had brought me to this class in the first place. The click is a prime feature of mitral valve prolapse, a generally benign condition in which the valve separating the upper and lower chambers of the left side of the heart doesn’t close properly.

During my annual physical, my doctor at Massachusetts General Hospital had remarked how loud and distinct my click was. Would I consider volunteering as a “patient,” so fledgling medical students could listen and learn?

I was intrigued by the chance to gain perspective on the doctor-patient interaction. Make that “Patient-Doctor II,” the intentionally reversed name of this second-year course that focuses on learning the physical examination.

Now, as I sat in an open-stringed green-and-blue-print cloth gown, I began to wonder if the students realized they were examining a live human being, as opposed to a particularly sophisticated anatomical model.

The fourth student who strode to my chair was a guy I remembered from a cardiology lecture I’d attended at the outset, taught by Dr. Katharine Treadway. He’d sat up front and answered her toughest questions, brimming with enthusiasm and brains. I had found myself rooting for his medical career. Now he listened, smiled at me and said, “Awesome!”

That broke the ice. At last I was a person, not a prop.

The next student opened with “Hi, how are you?” When she finished, she said, “Thank you very much!”

In this class “listening” had more than one meaning, as Dr. Treadway had illustrated with a cautionary tale. About 10 years earlier a woman agreed to let students hear her heartbeat. She had an advanced condition called severe mitral regurgitation and needed a valve replacement.

One student examined her, removed the stethoscope and blurted to the instructor, “How can she live if her heart is this bad?”

“This was a student who is not uncaring or unkind,” Dr. Treadway told the class. “But in that moment she did something all of us do all the time: she was so engaged with the problem that she forgot about the person who had the problem.”

As students master the intricacies of the physical exam, “the experience of that patient’s illness will be completely invisible to you, unless you consciously look for it,” she warned, adding: “At the end of every interview, say to the patient, ‘How has it been for you, being in the hospital?’ I want to bring you back to the patient.”

Now the Irish physician’s group departed, and the second group trundled in. This doctor introduced me right away. He had an easy and personable way about him, and I admired his arty cuff links.

Again, some of the students spoke to me, while others did not. One let his hand linger too long on my shoulder as he thanked me and turned to walk away: creepy.

Another remained stony-faced as he fumblingly examined me, never saying a word: really creepy. So inept was he that I decided not to lean forward, thus making my heart more difficult for him to hear. (Doctors who don’t earn the trust of their patients, by the way, are more likely to be sued in a malpractice claim.)

I didn’t become a full-fledged person until the 10th exam, this one at the hands of a student with short combed-forward hair and rectangular wire-rims.

“Hi, my name is Ben,” he said with a warm, professional smile as he looked me in the eye and shook my hand. I was instantly at ease.

Madeline Drexler, a science journalist in Boston, is the author of “Emerging Epidemics: The Menace of New Infections.”

Essay: Life, Liberty and the Pursuit of Vaccines

Posted: 28 Feb 2011 08:49 PM PST

Recently I found myself on the outskirts of an antivaccine rally in my hometown, listening to a succession of ill-informed diatribes with a mixture of dismay and fascination.

Enlarge This Image
Collection of Ann C. Boswell

PERSONAL GHOST Benjamin Franklin’s son Franky died of smallpox.

As a pediatrician, I was baffled by scientifically baseless attacks on the substances that have tamed smallpox, polio and a host of other deadly and disfiguring diseases, at least in the developed world.

But as a historian, I found it even more bewildering to hear speakers claim that government-sponsored vaccines were a violation of the founding fathers’ design.

It is true that in their time there was no such thing as safe, standardized immunization. But even then, inoculation was used to quell smallpox, the deadliest scourge of the day. Such preventive public health measures framed the early days of our nation as tightly as the “unalienable rights” of life, liberty and the pursuit of happiness.

John Adams was inoculated in 1764. Twelve years later, while he was in Philadelphia declaring American independence, his wife and children were inoculated as an epidemic raged in Boston. Gen. George Washington ordered his soldiers to be inoculated in 1777 because more men were falling to smallpox than to Redcoat muskets. Thomas Jefferson, who avidly followed the scientific literature on the subject, inoculated himself and his children in 1782.

But the most eloquent advocate of smallpox inoculation was Benjamin Franklin.

In 1721, the Puritan minister Cotton Mather promoted inoculation in partnership with a Boston physician named Zabdiel Boylston, who risked life and limb by inoculating his children, his black servants and many of his patients.

Among those opposing Mather’s efforts was Franklin’s brother James, the contrarian publisher of The New England Courant. Aside from the inherent danger of the procedure, James Franklin argued that religious zealots had no business practicing medicine. He was hardly alone; many colonists considered inoculation a breach of the Sixth Commandment (“Thou shalt not kill”).

Inoculation involved lancing open a wound and implanting dried scabs or fresh pus containing variola (the virus that causes smallpox) under the skin of a healthy, uninfected person. Said to have originated in China, it was commonly practiced across the Far East and the Ottoman Empire.

The procedure typically caused a milder form of smallpox and conferred lifelong immunity. Still, many people became ill from it, and not a few died. Moreover, it was feared that the inoculated would infect others.

Yet after an initial silence (perhaps out of fear of enraging his older brother), Benjamin Franklin became one of the colonies’ leading proponents of inoculation, trumpeting his advocacy in the pages of his own newspaper, The Pennsylvania Gazette.

Reporting on 72 Bostonians inoculated in March 1730, for example, he noted that only two died while “the rest have recovered perfect health.

“Of those who had it in the common way,” he continued, “ ’tis computed that one in four died.”

In the following decades Franklin compiled and published quantitative studies on inoculation’s value, working with several physicians at the Pennsylvania Hospital, an institution he helped found, and with the famed British clinician William Heberden. He was also concerned that the high cost of the procedure — more than many colonists’ annual income — made it inaccessible to the poorest Americans. In 1774, to counter this inequity, Franklin established the Society for Inoculating the Poor Gratis.

Haunting these activities was a very personal ghost: that of Francis Folger Franklin, the younger of his two sons.

Franky, as his parents called him, was born in 1732 — a golden child, his smiles brighter, his babblings more telling and his tricks more magical than all the other infants in the colonies combined. Benjamin advertised for a tutor when the boy was only 2.

When he died of smallpox at age 4, the Franklins were beyond condolence. His tombstone was inscribed, “The delight of all who knew him.”

Rumors abounded that Franky had died from an inoculation gone awry. The gossip led the grieving Franklin to declare that his son had never been inoculated because he was suffering from “flux,” or protracted diarrhea. Franklin insisted that Franky “receiv’d the distemper” — smallpox — “in the common way of infection,” and that “inoculation was a safe and beneficial practice.”

Inoculation was eventually replaced by the far safer method of vaccination, which uses a milder virus to induce immunity. An English country doctor named Edward Jenner made this discovery in 1796 after noting that local milkmaids who contracted the annoying but harmless cowpox infection on their hands remained healthy during lethal smallpox epidemics.

Jenner’s vaccination soon became the major means of preventing smallpox. In 1801 President Thomas Jefferson declared vaccination one of the nation’s first public health priorities. Two years later, he instructed Meriwether Lewis and William Clark to take vaccine on their expedition to the Pacific.

Franklin died in 1790 — six years before Jenner’s discovery and 190 years before the World Health Organization announced that vaccination efforts had succeeded in eradicating smallpox from the globe. Yet while composing the final portion of his “Autobiography” in 1788, Franklin reminded his readers about the importance of immunizing their children. His advice is especially useful today when so few Americans have firsthand knowledge of the panoply of once common killers now preventable thanks to safe, reliable vaccines.

“In 1736 I lost one of my sons, a fine boy of four years old, by the small-pox, taken in the common way,” he wrote. “I long regretted bitterly, and still regret that I had not given it to him by inoculation.

“This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way and that, therefore, the safer should be chosen.”

Dr. Howard Markel, a professor of the history of medicine at the University of Michigan, is the author of “An Anatomy of Addiction,” to be published in July.

Vital Signs: Maternal Link to Alzheimer’s Makes a Gain

Posted: 28 Feb 2011 09:57 PM PST

Alzheimer’s disease is more common in people whose mothers had the illness than in those whose fathers had it — and the evidence can be found in the brains of people who are still healthy.

Multimedia
Interactive Feature
Patient Voices: Alzheimer's Disease

Related

Researchers studied 53 mentally healthy men and women over 60 years old. Ten had a father with Alzheimer’s, 11 a mother with the disease, and 32 had no family history of the illness. Each volunteer underwent an initial M.R.I. examination and was examined again two years later.

All the volunteers were still cognitively normal at the two-year point, but those with a family history of Alzheimer’s had significantly more brain atrophy than those without a family history. And even after controlling for age and sex, the deterioration was significantly greater in those with a maternal history of Alzheimer’s than in those with a paternal one.

The authors acknowledge that the study, published in Tuesday’s issue of Neurology, depended on volunteers reporting their parents’ illnesses accurately.

Still, the lead author, Robyn A. Honea of the University of Kansas, said scientists were getting closer to quantifying risk with brain scans. “The goal is to do a scan on someone before they get the disease and be able to tell if they’re at higher risk or starting to deteriorate,” she said. “Can we do that now? No. We need more and larger studies.”

Call It a Reversible Coma, Not Sleep

Posted: 28 Feb 2011 09:58 PM PST

Dr. Emery Neal Brown, 54,  is a professor of anesthesiology at Harvard Medical School, a professor of computational neuroscience at M.I.T. and  a practicing physician, seeing patients at Massachusetts General Hospital. Between all that, he heads a laboratory seeking to unravel one of medicine’s big questions: how anesthesia works.

RSS Feed

RSS Get Science News From The New York Times »

We spoke for three hours last month at his Massachusetts General office and more recently by telephone. An edited version of the two interviews follows.

Q. Anesthesia — what drew you to it?

A. I enjoyed my anesthesia rotation at medical school. I could see that it was very fast-paced and that you had to make important decisions quickly. That appealed. Plus: the regular hours. I saw myself doing research, as well as working with patients. You need a predictable schedule — which anesthesiologists have — to manage both.

It’s also a very important piece of modern medicine. If you think about what occurs when we do surgery, it’s a very traumatic insult to the body. You’re cutting people open, removing organs or possibly even transplanting them. The anesthesiologist puts people into a condition where they can tolerate such extreme assaults.

Q. Is anesthesia like a coma?

A. It’s a reversible drug-induced coma, to simplify. As with a coma that’s the result of a brain injury, the patient is unconscious, insensitive to pain, cannot move or remember. However, with anesthesia, once the drugs wear off, the coma wears off.

Q. Anesthesia was first demonstrated right here at Massachusetts General Hospital in 1846. Does that historical fact drive your research?

A. I think about it a lot. Seriously!

There’s quite a story to how that first public demonstration happened. Apparently, there was a social practice in that era called “ether follies.” People got together and they sniffed ether. At one of these, someone fell and cut himself, but felt no pain. And the story got out, which led a Boston dentist to start experimenting with ether for painless oral surgery. He brought the idea to the great surgeon John Collins Warren, and together they used it in an operation here to remove a neck tumor. “Gentlemen, this is no humbug,” Dr. Warren declared after the successful procedure, meaning that this was the real thing and that it was going to change medicine. Before that, surgery was mostly butchery. The most successful surgeon was the one who could lop off a limb quickest. To this day, most inhaled anesthetics are ether. They’ve been embellished a bit, but they are basically ether.

Q. Is it true that we don’t really know how anesthesia works?

A. It’s viewed as a mystery, and that’s wrong. It’s not a black box. There’s a lot that is actually known, and more is developing as neuroscience moves forward. We’ve certainly known how to make anesthesia safe. We watch the patient while he or she is “under.” We know what’s normal in terms of heart rate, blood pressure, temperature, gases, etc. If things start to deviate from that, we intervene. We’ve gotten very far by creating high standards for care while under anesthesia.

Q. In your research, you’ve been trying to figure out how anesthesia actually works. How do you go about doing that?

A. Since 2004, we’ve been taking volunteers and giving them anesthesia, though not in the midst of actual surgeries.

As our subjects go under, we image their brains in functional M.R.I. scanners and measure brain activities with EEG monitors. Before this technology was available, researchers had only looked at what happened to patients before and after anesthesia. But with today’s functional M.R.I., we can watch people lose consciousness — see how the various parts of the brain change in activity. We can watch the transitions, what parts of the brain are turned on and off.

Q. Were there ethical problems in designing a study where you rendered your subjects unconscious?

A. Absolutely. Because some people felt, “This is anesthesia! You should only administer it when people need surgery.” Believe me: our study got more scrutiny than any other at this hospital.

The way we overcame potential objections was by recruiting a unique set of study subjects. They were patients who’d already had tracheostomies — surgical holes in their throat. We could place a tube into the hole and connect it to a breathing circuit. If anyone got into trouble while in the scanner, we’d immediately be able to help them breathe.

Q. Was there resistance to your doing the study?

A. There’s a large body of people in my field who feel that very little more progress needs to made because the process works well enough. My answer is that we could improve anesthesia tremendously if we knew more neuroscience. This is a golden moment in neuroscience, and anesthesiologists — who, after all, work with the brain every day — ought to be part of it. Instead, people ignore what’s happening over there and go, “It’s never been solved, people have been working on this since 1846, it’s fine as is, why bother?” There’s a strange compliancy.

Q. What has your research shown so far?

A. Under general anesthesia, the brain is not entirely shut down. Certain parts are turned off; others are quite active — not only “active,” but there is a level of activity that is quite regular.

Our observation is that it is this regular activity prevents the brain from transmitting information and contributes to a state of unconsciousness. It’s analogous to stopping communication down a phone line when transmission is blocked. You could block transmission another way: by sending a loud signal down the line so that that signal was the only thing you hear. So in some parts what we see is that activity is turned off, leading to unconsciousness. In other parts, we see activity that is more active than normal. This also leads to unconsciousness. In sum: the drugs alter the way the brain transmits information.

Q. Some years ago when I had an operation, I remember the anesthesiologist trying to soothe me by saying that she was going to put me “to sleep.” Was this right?

A. No. And I wish we’d refrain from saying that to patients. It’s inaccurate. It would be better if we explained exactly what the state of general anesthesia is and why it’s needed. Patients appreciate this intellectual honesty. Moreover, anesthesiologists should never say “put you to sleep” because it is exactly the expression used when speaking about euthanizing an animal!

Q. Why would someone like Michael Jackson take the anesthetic Propofol for insomnia?

A. I can only conjecture. But that incident is another reason why I think we need to be more precise describing what we do. If an anesthesiologist says, “We’re going to have you go to sleep,” some might think you could use these drugs for sleep. The bottom line is that when you’re undergoing anesthesia, you’re in a state akin to a coma. That always needs to be remembered.

This posting includes an audio/video/photo media file: Download Now

Bronx-Lebanon Obstetricians Face Malpractice Insurance Cutoff

Posted: 28 Feb 2011 10:20 PM PST

A malpractice insurance group has warned obstetricians at a South Bronx hospital that it is considering cutting off their insurance, which could force surrounding hospitals to absorb hundreds, and perhaps thousands, of baby deliveries a year.

The group, Medical Liability Mutual Insurance Company, sent a letter on Feb. 10 to 8 of the 13 doctors who handle births at Bronx-Lebanon Hospital Center, saying that its underwriting committee had recommended not renewing their coverage.

The letter said the “method of practice” and “practice environment” among those doctors was “predictive of future claims in excess of the norm, and makes insuring you an unreasonable burden to the other policyholders.”

Bronx-Lebanon delivers more than 2,700 babies a year, many to poor women whose pregnancies are risky because they are teenagers or have diabetes, high blood pressure or other medical problems, hospital officials said. The eight doctors all deal specifically with high-risk pregnancies. The letter did not say how many times each of the doctors had been sued for malpractice.

The hospital defended its reputation, saying that regardless of the high-risk population it treats, its services compare favorably with those at other hospitals.

State health and insurance officials were also working with the hospital to try to resolve the problem, said Claudia Hutton, a spokeswoman for the State Health Department. The letter sent a shudder through surrounding hospitals, where officials said they were bracing for an influx of patients if the insurance company made good on its threat. The doctors are entitled to appeal before the decision would become final in July.

“We don’t have the capacity currently to handle these babies,” said Dr. Gary Kalkut, senior vice president and chief medical officer of Montefiore Medical Center, another Bronx hospital. “I look at it now as a boroughwide problem. We’d have to come together with the other providers to figure out what to do.”

Hospital officials used the letter as an occasion to lobby for two malpractice insurance changes proposed by Gov. Andrew M. Cuomo’s task force on Medicaid overhaul: a cap on noneconomic damages, like pain and suffering, for malpractice suits, and an indemnity fund for neurologically damaged infants. Both measures have been vigorously opposed by trial lawyers, who argue that poor people would be most hurt by efforts to limit their ability to sue for damages.

Kenneth E. Raske, president of the Greater New York Hospital Association, said: “Without being hyperbolic, this is a potential public health crisis, and it is precipitated by the current malpractice climate, particularly related to obstetrics. We could be within a cancellation notice away from a major access problem for a large number of New Yorkers.”

Insurance premiums for obstetricians in the Bronx are among the highest in New York and among the highest in the medical profession in the state, according to Edward J. Amsler of New York State Medical Liability Mutual Insurance Company. He said the highest obstetrical premiums were $187,000 a year for $1.3 million in insurance, in Nassau and Suffolk Counties; the Bronx was second at $177,000 for the same coverage. In Manhattan, premiums were $145,000 for the same coverage.

Global Update: Parasitic Disease: Guinea Worm Takes a Step Closer to Eradication, Jimmy Carter Says

Posted: 01 Mar 2011 08:36 AM PST

The guinea worm is a spaghetti-thin parasite that has proved notoriously hard to eradicate around the world. Now former President Jimmy Carter, who has led a 25-year campaign against guinea worm disease, is reporting progress in the effort to make it only the second human disease to be eradicated, after smallpox.

Mr. Carter gave awards to two nations, Nigeria and Niger, that once had the worst caseloads but now have no worms. (A former patient in Nigeria is pictured above.) Their success in halting “this ancient and horrible affliction,” he said, “provides yet another vivid reminder of how people in even the most marginalized circumstances can thrive when given the tools and knowledge to help themselves.”

Now only three countries — Sudan, Mali and Ethiopia — still have cases, and fewer than 1,800 cases were reported in the world in 2010. More than 90 percent were in southern Sudan, where they went undetected for years.

The microscopic worm larva thrives in tiny organisms that live in pond water. When a human drinks the infested water, the larvae break out, migrate toward the skin, grow to a yard long and then escape by exuding a bubble of acid that painfully bursts the skin, forcing the person to cool it in water — into which the worm injects larvae, restarting the cycle.

An undeclared “race” has been going on for a decade between polio and guinea worm fighters. Both have suffered setbacks. The battle against polio has cost $9 billion, while that against guinea worm has cost only $300 million. But polio requires vaccination of millions of children, while guinea worm is fought with water filters and larvicides.

Well: Cooking With Coconut Oil

Posted: 02 Mar 2011 09:30 AM PST

Well: The Voices of Sickle Cell Disease

Posted: 02 Mar 2011 09:36 AM PST

Well: Exercise Seen to Reduce Signs of Aging

Posted: 01 Mar 2011 09:02 PM PST

Well: The Doctor Who Knew Too Much

Posted: 01 Mar 2011 08:17 AM PST

Well: Optimistic Heart Patients Live Longer

Posted: 28 Feb 2011 02:59 PM PST

The New Old Age: They Eat What They Want

Posted: 02 Mar 2011 09:20 AM PST

The New Old Age: How Race Complicates Care

Posted: 02 Mar 2011 09:27 AM PST

The New Old Age: When Dementia Drains the Pocketbook

Posted: 28 Feb 2011 02:42 PM PST

Personal Health: For Tendon Pain, Think Beyond the Needle

Posted: 28 Feb 2011 09:10 PM PST

Two time-honored remedies for injured tendons seem to be falling on their faces in well-designed clinical trials.

Enlarge This Image
Yvetta Fedorova

Related

The first, corticosteroid injections into the injured tendon, has been shown to provide only short-term relief, sometimes with poorer long-term results than doing nothing at all.

The second, resting the injured joint, is supposed to prevent matters from getting worse. But it may also fail to make them any better.

Rather, working the joint in a way that doesn’t aggravate the injury but strengthens supporting tissues and stimulates blood flow to the painful area may promote healing faster than “a tincture of time.”

And researchers (supported by my own experience with an injured tendon, as well as that of a friend) suggest that some counterintuitive remedies may work just as well or better.

A review of 41 “high-quality” studies involving 2,672 patients, published in November in The Lancet, revealed only short-lived benefit from corticosteroid injections. For the very common problem of tennis elbow, injections of platelet-rich plasma derived from patients’ own blood had better long-term results.

Still, the authors, from the University of Queensland and Griffith University in Australia, emphasized the need for more and better clinical research to determine which among the many suggested remedies works best for treating different tendons.

My own problem was precipitated one autumn by eight days of pulling a heavy suitcase through six airports. My shoulder hurt nearly all the time (not a happy circumstance for a daily swimmer), and trying to retrieve something even slightly behind me produced a stabbing pain. Diagnosis: tendinitis and arthritis. Treatment: rest and physical therapy.

Two months of physical therapy did help somewhat, as did avoiding motions that caused acute pain. The therapist had some useful tips on adjusting my swimming stroke to minimize stress on the tendon while the injury gradually began to heal.

The following spring, although I still had some pain and feared a relapse, I attacked my garden with a vengeance. Much to my surprise, I was able to do heavy-duty digging and lugging without shoulder pain.

Could the intense workout and perhaps the increased blood flow to my shoulder have enhanced my recovery? A friend, Richard Erde, had an instructive experience.

An avid tennis player at 70, he began having twinges in his right shoulder while playing. Soon, simple motions like slipping out of a shirt sleeve caused serious pain. The diagnosis, based on a physical exam, was injury of the tendon that attaches the biceps muscle of his upper arm to the bones of the shoulder’s rotator cuff.

He was advised to see a rheumatologist, who declined to do a corticosteroid injection and instead recommended physical therapy and rest.

“I stopped playing tennis for a month, and it didn’t help at all,” Mr. Erde told me. “The physical therapist found I had very poor range of motion and had me do a variety of exercises, which improved my flexibility and reduced the pain somewhat.” After two months, he stopped the therapy.

Then several weeks ago, after watching the Australian Open, he thought he should do more to strengthen his arm and shoulder muscles and decided to try playing tennis more vigorously. “The pain started to drop off dramatically,” he said, “and in just 10 days the pain had eased more than 90 percent.”

A Frustrating Injury

Tendinopathies, as these injuries are called, are particularly vexing orthopedic problems that remain poorly understood despite their frequency. “Tendinitis” is a misnomer: rarely are there signs of inflammation, which no doubt accounts for the lack of lasting improvement with steroid shots and anti-inflammatory drugs. They may relieve pain temporarily, but don’t cure the problem.

The underlying pathology of tendinopathies is still a mystery. Even when patients recover, their tendons may continue to look awful, say therapists who do imaging studies. Without a better understanding of the actual causes of tendon pain, it’s hard to develop rational treatments, and even the best specialists may be reduced to trial and error. What works best for one tendon — or one patient — may do little or nothing for another.

Most tendinopathies are precipitated by overuse and commonly afflict overzealous athletes, amateur and professional alike. With or without treatment, they usually take a long time to heal — many months, even a year or more. They can be frustrating and often costly, especially for professional athletes and physically active people like me and Mr. Erde.

In a commentary accompanying the Lancet report, Alexander Scott and Karim M. Khan of the University of British Columbia noted that although “corticosteroid injection does not impair recovery of shoulder tendinopathy, patients should be advised that evidence for even short-term benefits at the shoulder is limited.” Like the Australian reviewers, the commentators concluded that “specific exercise therapy might produce more cures at 6 and 12 months than one or more corticosteroid injections.”

Treatments to Try

Now the question is: What kind of physical therapy gives the best results? Most therapists prescribe eccentric exercises, which involve muscle contractions as the muscle fibers lengthen (for example, when a hand-held weight is lowered from the waist to the thigh). Eccentric exercises must be performed in a controlled manner; uncontrolled eccentric contractions are a common cause of injuries like groin pulls or hamstring strains.

Marilyn Moffat, professor of physical therapy at New York University and president of the World Confederation for Physical Therapy, prefers “very protective” isometric exercises, at least at the outset of treatment until the tendon injury begins to heal. These exercises involve no movement at all, allowing muscles to contract without producing pain. For example, in treating shoulder tendinopathy, she said in an interview, the patient would push the fists against a wall with upper arms against the body and elbows bent at 90 degrees.

In another exercise, the patient sits holding one end of a dense elastic Thera-Band in each hand and, with thumbs up, upper arms at the sides and elbows bent at 90 degrees, tries to pull the hands apart.

“The stronger the shoulder muscles are when the tendinopathy calms down, the better shape the shoulder is in to take over movement without further injury,” Dr. Moffat said. “You don’t want the muscles to weaken, which is what happens when you rest and do nothing. That leaves you vulnerable to further injury.”

Really?: The Claim: Side Stitches? Change Your Posture

Posted: 01 Mar 2011 08:45 AM PST

THE FACTS

Enlarge This Image
Christoph Niemann

Well

Share your thoughts on this column at the Well blog.

Go to Well »

Multimedia
Interactive Feature
Running Voices

Related

For many avid runners, side stitches can be a maddening problem: the cramplike spasms set in suddenly and can ruin a good workout. While no one knows their precise cause, many experts believe a side stitch occurs when the diaphragm — which is vital to breathing — is overworked during a vigorous run and begins to spasm. Runners who develop stitches are commonly advised to slow down and take deep, controlled breaths.

But a new theory suggests that it may not be the diaphragm that’s responsible for the pain, and that poor posture could be a culprit. In one recent study, researchers used a device to measure muscle activity as people were experiencing side stitches. They found no evidence of increased activity or spasms in the diaphragm area during the onset of stitches.

Last year, the same team published a separate study in The Journal of Science and Medicine in Sport. They found that those who regularly slouched or hunched their backs were more likely to experience side stitches, and the poorer their posture, the more severe their stitches in exercise.

One explanation is that poor running form may affect nerves that run from the upper back to the abdomen. Another is that hunching increases friction on the peritoneum, a membrane that surrounds the abdominal cavity. This could also explain why controlled breathing seems to help relieve stitches: drawing deep breaths fills the lungs and improves posture.

THE BOTTOM LINE

Improving running posture may help relieve stitches.

ANAHAD O’CONNOR scitimes@nytimes.com

Prescriptions: New Site for Consumers on the Health Care Law

Posted: 02 Mar 2011 11:06 AM PST

Prescriptions: F.D.A. Orders Prescription Cold Drugs Pulled From Market

Posted: 02 Mar 2011 09:11 AM PST

Prescriptions: This Week's Health Industry News

Posted: 28 Feb 2011 09:30 AM PST

The Radiation Boom

Posted: 09 Sep 2010 08:40 AM PDT

Letters: Taking the Long View (1 Letter)

Posted: 28 Feb 2011 08:50 PM PST

To the Editor:

“Tackling Care as Chronic Ailments Pile Up” (Personal Health, Feb. 22) aptly points out the need for a holistic approach to care — something that rehabilitation nurses practice each day.

Rehabilitation nursing is a philosophy of care that manages complex medical issues, collaborates with specialists, provides education, sets goals for maximum independence and establishes wellness plans. It fosters the long-term goals and needs of patients and caregivers while reducing complications, hospitalizations and the associated costs.

Kathy Doeschot

Glenview, Ill.

The writer is president, Association of Rehabilitation Nurses.

Science Times welcomes letters from readers. Those submitted for publication must include the writer’s name, address and telephone number. E-mail should be sent to scitimes@nytimes.com. Send letters to Science Editor, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018.

Letters: Before We Look for Cures (1 Letter)

Posted: 28 Feb 2011 08:50 PM PST

To the Editor:

“Studying Aging, and Fearing Budget Cuts” (Feb. 22) points out that research on aging is seriously underfinanced, but overlooks the reasons.

A major factor is the overemphasis on so-called translational research, which seeks to translate laboratory findings into clinical applications, at the expense of basic research. The push for translational studies by the National Institutes of Health, Congress and our universities is shortsighted and damaging.

We do not even know the normal function of proteins that cause neurodegenerative diseases like Alzheimer’s. Moreover, several recent clinical trials to test drugs for dementia are not based on solid scientific evidence. Before we can find rational treatments for these diseases, more resources must be directed to basic studies.

Moses V. Chao

New York

The writer is a professor in the molecular neurobiology program at New York University School of Medicine.

Science Times welcomes letters from readers. Those submitted for publication must include the writer’s name, address and telephone number. E-mail should be sent to scitimes@nytimes.com. Send letters to Science Editor, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018.

Recipes for Health: Rye and Cornmeal Muffins With Caraway

Posted: 01 Mar 2011 02:20 PM PST

I like to serve these savory muffins, whose flavors are reminiscent of black bread and pumpernickel, with hearty borscht-type soups, smoked fish or cheese.

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.

Related

1 cup rye flour

1 cup whole-wheat flour

2 teaspoons baking powder

1 teaspoon baking soda

3/4 teaspoon salt

1/3 cup cornmeal

2 teaspoons caraway seeds

2 eggs

1/4 cup canola oil

2 tablespoons blackstrap molasses

1 1/2 cups buttermilk

1. Preheat the oven to 375 degrees with the rack positioned in the upper third. Oil or butter muffin tins.

2. Sift together the rye and whole-wheat pastry flours, baking powder, baking soda and salt. Stir in the cornmeal and the caraway seeds.

3. In a separate bowl, beat together the eggs, oil, blackstrap molasses and buttermilk. Using a whisk or a spatula, stir in the dry ingredients, and mix until well combined. Do not beat; a few lumps are fine, but make sure there is no flour at the bottom of the bowl.

4. Spoon into muffin cups, filling them to just below the top (about 4/5 full). Place in the oven, and bake 25 minutes until lightly browned and well risen.

Yield: Twelve muffins, depending on the size of your muffin tins.

Advance preparation: These keep for a couple of days out of the refrigerator, for a few more days in the refrigerator, and for a few months in the freezer.

Nutritional information per muffin (based on 12-muffin yield): 152 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 3 grams monounsaturated fat; 32 milligrams cholesterol; 21 grams carbohydrates; 2 grams dietary fiber; 323 milligrams sodium; 5 grams protein

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

Recipes for Health: Carrot Cake Muffins

Posted: 01 Mar 2011 02:10 PM PST

These spicy whole-grain muffins are just sweet enough, unlike most cloying carrot cakes. And these are packed with carrots.

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.

Related

2 1/2 cups whole-wheat pastry flour

2 teaspoons baking powder

1 teaspoon baking soda

2 teaspoons ground cinnamon

1 teaspoon freshly grated nutmeg

1/2 teaspoon ground allspice

1/2 teaspoon ground cloves

1/2 teaspoon salt

2 eggs

1/2 cup raw brown (turbinado) sugar

1/3 cup canola oil

1 1/3 cups buttermilk

1 teaspoon vanilla extract

2/3 cup golden raisins tossed with 1 teaspoon unbleached all-purpose flour, or 2/3 cup chopped pecans

1 1/2 cups grated carrots

1. Preheat the oven to 375 degrees with the rack in the upper third of the space. Oil or butter muffin tins.

2. Sift together the whole-wheat pastry flour, baking powder, baking soda, spices and salt.

3. In a separate bowl, beat together the eggs, sugar, oil, buttermilk and vanilla. Using a whisk or a spatula, stir in the dry ingredients and mix until well combined. Do not beat; a few lumps are fine, but make sure there is no flour at the bottom of the bowl. Fold in the raisins or pecans and the carrots.

4. Spoon into muffin cups, filling them to just below the top (about 4/5 full). Place in the oven, and bake 25 minutes until lightly browned and well risen.

Yield: Twelve muffins, depending on the size of the muffin tins.

Advance preparation: These keep for a couple of days out of the refrigerator, for a few more days in the refrigerator and for a few months in the freezer.

Nutritional information per muffin (based on 12-muffin yield): 239 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 4 grams monounsaturated fat; 32 milligrams cholesterol; 38 grams carbohydrates; 4 grams dietary fiber; 323 milligrams sodium; 5 grams protein

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

Recipes for Health: Whole Grain Goodness, Straight From the Oven

Posted: 01 Mar 2011 10:32 AM PST

The muffins available in most coffee shops and cafes are like oversize, unfrosted cupcakes: too sweet and too big. But muffins don’t have to be cloying — a bit of natural sweetener is all that’s required to make them taste like a treat. And they don’t have to be calorie-laden confections.

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.

This week, you’ll find it’s possible to make muffins with a number of nutritious ingredients, particularly whole grains. Muffins made with buckwheat or cornmeal offer great taste and nourishment — without the feeling that you’re chewing on rocks.

Even if you don’t think of yourself as a baker, take a stab at this week’s recipes. They’re easy and come together quickly.

Buckwheat and Amaranth Muffins

Of all the muffins I make, these have the most distinctive flavor.

3/4 cup whole-wheat flour

3/4 cup buckwheat flour

2 teaspoons baking powder

1 teaspoon baking soda

1/2 teaspoon salt

1/2 cup amaranth flour (you can make this by blending the amaranth in a spice mill; it does not have to be finely ground)

2 eggs

1/3 cup honey

1 1/2 cups buttermilk

1/3 cup canola oil

1 teaspoon vanilla extract

1 cup blackberries tossed with 1 teaspoon all-purpose flour

1. Preheat the oven to 375 degrees with the rack moved to the upper third of the oven. Oil or butter muffin tins. Sift together the whole-wheat and buckwheat flours, baking powder, baking soda and salt. Stir in the amaranth flour.

2. In a separate bowl, beat together the eggs, honey, buttermilk, canola oil and vanilla extract. Using a whisk or a spatula, stir in the dry ingredients. Mix until well combined, but do not beat -- a few lumps are fine, but make sure there is no flour at the bottom of the bowl. Fold in the blackberries.

3. Spoon into muffin cups, filling them to just below the top (about 4/5 full). Place in the oven, and bake 25 minutes until lightly browned and well risen.

Yield: Twelve muffins or so, depending on the size of your tins.

Advance preparation: These muffins keep for a couple of days out of the refrigerator, for a few more days in the refrigerator, and for a few months in the freezer.

Nutritional information per muffin (based on a 12-muffin yield): 182 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 4 grams mono-unsaturated fat; 32 milligrams cholesterol; 24 grams carbohydrates; 2 grams dietary fiber; 314 milligrams sodium; 5 grams protein

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

Oakland Plan to Cash In on Marijuana Is Blocked

Posted: 02 Mar 2011 11:57 AM PST

OAKLAND, Calif. — For a brief, smoky moment last fall, this economically challenged city seemed poised to become the nation’s most aggressive when it comes to growing and taxing medical marijuana.

Enlarge This Image
Jim Wilson/The New York Times

Gregory Kang demonstrates hydroponic growing equipment at weGrow, a marijuana supply warehouse in Oakland, Ca. The city sought to attract (and tax) large-scale growers before the Justice Department nixed the plan.

Related

Those hopes have been dimmed considerably in recent weeks, though, since an exchange of letters between the city attorney and federal law enforcement officials has made it exceedingly clear that Washington will not tolerate plans for the large-scale marijuana farms the City Council approved last July. City officials had hoped to use the massive indoor growing facilities to raise some $38 million annually in fees and taxes at a time when the city is struggling with a $31 million deficit and 17 percent unemployment.

Indeed, polls last summer had suggested that voters were likely to pass a November ballot initiative that would have legalized recreational marijuana use in California. They did not. But Oakland decided to proceed with its plans anyway.

Hundreds of well-heeled investors and would-be farmers poured in from across the country to vie for the city’s four cultivation permits. Then, in December, just weeks before the city was set to issue permits, the Council voted to stall the plan after the city’s attorney, John Russo, and a county district attorney warned the Council that the marijuana cultivation ordinance thwarted state law and that city officials could be held criminally liable.

On Jan. 14, Mr. Russo wrote a letter to the United States Department of Justice seeking guidance on the city’s legal standing. In a response, Melinda Haag, United States attorney for the Northern District of California, warned that “individuals who elect to operate ‘industrial cannabis cultivation and manufacturing facilities’ will be doing so in violation of federal law.” The letter went on to say that the Justice Department was “carefully considering civil and criminal legal remedies regarding those who seek to set up industrial marijuana growing warehouses.”

As a result, Mr. Russo has refused to provide further legal guidance to the city on the marijuana farm issue, forcing Oakland to hire a new legal team as they consider a revised version of the ordinance.

Desley Brooks, the council member who wrote the revised ordinance, said the city had little choice but to move ahead with large marijuana farms. “There are unregulated grow operations in the city, and we’re having fires, home invasions and crime as a result,” she said.

Ms. Brooks puts much of the blame for the legal hoopla over the ordinance on Mr. Russo. “Our city attorney went to the feds and invited scrutiny,” Ms. Brooks said.

State law restricts who can grow pot to medical marijuana patients and their “primary caregivers,” ruling out the type of stand-alone marijuana farms originally proposed by the city. Ms. Brooks’s revised ordinance couples the farms together with a storefront dispensary that acts as “primary caregiver.”

“Oakland is the epicenter of medical marijuana in the United States,” said Allen St. Pierre, executive director for the National Organization for the Reform of Marijuana Laws. “The Department of Justice is paying closer attention in Oakland because they’re mindful of the fact that there is enough political and commercial chutzpah to actually get this done. The only thing stopping these entrepreneurs from breaking ground tomorrow is this letter from the feds.”

When the city greenlighted industrial-scale marijuana cultivation, an eclectic group of investors stepped forward.

Among dozens of groups who spent months and hundreds of thousands of dollars on business plans, consultants and architects was Ben Bronfman, an heir to the Seagram liquor fortune and fiancé of the rapper M.I.A. Mr. Bronfman leased 11 acres of land by the airport where he and partners had hoped to install enormous greenhouses that would produce environmentally friendly pot using a massive, experimental carbon-capturing device.

“Cannabis is a more constructive thing to have in our society than alcohol,” Mr. Bronfman said.

Jeff Wilcox, a former commercial real estate developer turned medical marijuana advocate, was one of the first in line for a cultivation permit. He spent $120,000 and two years developing a $20 million plan to transform a 172,000-square-foot office park he owns into a high-tech facility capable of growing 23 pounds of medical marijuana a day, an annual crop worth up to $58 million. In accordance with city rules, much of that money would have been turned back into city coffers and into nonprofit organizations.

Many of the investors who flocked to Oakland are now taking their money and their marijuana know-how elsewhere.

“I applaud the city for pushing the envelope, but it’s frustrating for those of us who spent a lot of time and money on this process,” said Derek Peterson, a former Wall Street banker turned marijuana entrepreneur who spent some $80,000 on his permit application.

Mr. Peterson is not waiting around for the city to make a decision. Fourteen states and the District of Columbia now have medical marijuana laws on the books, providing ample opportunity to grow and distribute marijuana on a huge scale. Mr. Peterson is applying for a permit to do just that in Arizona.

“Right now Oakland is far too visible for this kind of investment,” said Scott Hawkins, who worked as a consultant on a permit application on behalf of Richard Lee, the founder of Oaksterdam University, a medical marijuana trade school here. “Investors don’t want to risk their capital in this situation unless things can get worked out between the City Council and the Department of Justice and the city attorney’s office.”

Obama Backs Easing State Health Law Mandates

Posted: 28 Feb 2011 11:00 PM PST

WASHINGTON — President Obama, who has stood by his landmark health care law through court attacks and legislative efforts to repeal it, told the nation’s governors on Monday that he was willing to amend the measure to give states the ability to opt out of its most controversial requirements right from the start, including the mandate that most people buy insurance.

Multimedia
Interactive Feature
The Growing Legal and Political Opposition

Blogs

The Caucus

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

Enlarge This Image
Luke Sharrett/The New York Times

Senators Ron Wyden, a Democrat, proposed a change in the health care law.

In remarks to the National Governors Association, Mr. Obama said he supported legislation that would allow states to obtain waivers from the mandate as soon as it took effect in 2014, as long as they could find another way to expand coverage without driving up health care costs. Under the current law, states must wait until 2017 to obtain waivers.

The announcement is the first time Mr. Obama has called for altering a central component of his signature health care law, although he has backed removing a specific tax provision that both parties regard as onerous on business.

But the prospects for the proposal appear dim. Congress would have to approve the change through legislation, and House Republican leaders said Monday that they were committed to repealing the law, not amending it. Even if the change were approved, it could be difficult for states to meet the federal requirements for the waivers.

The White House described the proposal, based on a bipartisan bill recently introduced in the Senate, as a common-sense date change that would give states the freedom to innovate and act as laboratories. Mr. Obama called it “a reasonable proposal,” telling the governors, “It will give you flexibility more quickly while still guaranteeing the American people reform.”

Political calculations, as much as policy ones, were at work in the president’s announcement. The shift comes as the health care law — and the mandate in particular — is under fierce attack in the courts, where federal judges have issued conflicting opinions on its constitutionality. The mandate is also a rallying cry for conservatives and Tea Party supporters, who regard it as a prime example of overreaching by the federal government.

Mr. Obama has been trying to reposition himself in the political center on some issues in the wake of the drubbing his party took in the November midterm elections; dropping his insistence on the mandate is one way to do that. And with governors pressing the administration to allow them to cut Medicaid rolls to ease their fiscal distress — a step Mr. Obama does not want to take — the president is trying to look flexible in other ways.

But Mr. Obama’s flexibility goes only so far. “I am not open to refighting the battles of the last two years,” he said, “or undoing the progress that we’ve made.”

Mr. Obama’s announcement did not appear to appease his Republican critics. The House majority leader, Representative Eric Cantor of Virginia, told reporters that the health law was “an impediment to job growth” and that Republicans remained committed to its repeal.

And while some Republican governors praised Mr. Obama for reaching out, they said the move did not address their underlying discomfort with the law or the major structural flaws facing state budgets. In meeting with the governors, Mr. Obama also asked them to come up with a bipartisan group to find ways to reduce Medicaid costs.

“I was disappointed,” said Gov. Rick Perry of Texas, chairman of the Republican Governors Association. “Pretty much all he did was to reset the clock on what many of us consider a ticking time bomb that is absolutely going to crush our state budgets. The states need more than that.”

Some Democrats also reacted warily. Many are convinced that it is not possible to expand health care coverage and achieve deficit reductions without the federal mandate, and they worry that amending the law would be tantamount to weakening it.

Senator Max Baucus, a Montana Democrat who as chairman of the Senate Finance Committee wrote a bill that included an idea similar to the one Mr. Obama proposed, issued a tepid statement saying he would consider it.

“We want to give states as much flexibility as possible,” Mr. Baucus said, “but that flexibility shouldn’t fail to ensure that Americans in every state have access to quality, affordable health care.”

The White House said the proposal was unrelated to the challenges to the constitutionality of the mandate. But encouraging states to pursue alternative ways of expanding coverage could prove useful should the Supreme Court ultimately rule that the mandate is unconstitutional.

At the same time, the mandate, and the health care law more generally, is sure to be an issue in the president’s 2012 re-election campaign, which may be a reason he is offering the proposal now.

“It’s to his advantage to show that he wants to be more moderate on this,” said Dan Mendelson, a health policy expert who worked in the Clinton administration, “because the mandate is terribly unpopular politically and he doesn’t want to be saddled with that going into the next election.”

The bipartisan legislation that Mr. Obama is now embracing was first proposed in November, eight months after the enactment of the Affordable Care Act, by Senators Ron Wyden, Democrat of Oregon, and Scott Brown, Republican of Massachusetts. Senator Mary L. Landrieu of Louisiana, a Democrat, is now a co-sponsor.

Sheryl Gay Stolberg reported from Washington, and Kevin Sack from Atlanta. Jeff Zeleny contributed reporting from Washington.

Dr. Richard F. Daines, Former State Health Chief, Dies at 60

Posted: 01 Mar 2011 09:40 PM PST

Dr. Richard F. Daines, a former New York state health commissioner who espoused politically risky public health initiatives like closing hospitals and banning the use of food stamps to buy soda, died on Saturday at his family farm in Stanfordville, N.Y., in Dutchess County. He was 60.

Enlarge This Image
Nathaniel Brooks for The New York Times

Dr. Richard F. Daines in April 2009.

The death was confirmed by his former press secretary, Claudia Hutton.

Dr. Daines was found by the State Police in a barn on his property, where he had been taking down Christmas decorations, Ms. Hutton said. He had been in good health and appeared to have died of a heart attack or stroke, she added.

Dr. Daines was an unconventional choice when he was appointed health commissioner in 2007 by Gov. Eliot Spitzer. He was a Republican in a Democratic administration, and he came from the world of hospital practice rather than public policy.

In his first year in office, Dr. Daines rejected millions of dollars in federal grants for abstinence-only sex education, saying that he believed it did not work.

During his tenure he oversaw the consolidation and closing of hospitals and nursing homes across the state, as recommended by a state commission.

He also lobbied aggressively, though unsuccessfully, for a tax on soda and other sugary drinks, at one point recording a YouTube video, called “Soda vs. Milk,” in which he appeared in his shirtsleeves in a kitchen to argue that rising soda consumption caused obesity.

Last October, Dr. Daines and Dr. Thomas Farley, New York City’s health commissioner, asked the federal government to let the city experiment with a prohibition on using food stamps to buy soda; the request is pending.

Explaining, in an interview last year, his advocacy of a soda tax, Dr. Daines said, “We underprice this commodity that we overconsume — and I mean we, we all do it — we suffer the consequences, and then we try to buy our way back out of it, liposuction or something, bariatric surgery, some kind of pill for obesity.”

Dr. Daines fit the part of the sin-tax crusader. Standing 6-foot-1, he was lanky and folksy, a former Mormon missionary in Bolivia and a Sunday school teacher.

In 2009, he angered health care workers by ordering them to get flu vaccinations to prevent the spread of swine flu. Three nurses challenged the order in court, and Dr. Daines later relented because of a shortage of H1N1 vaccine.

Richard Frederick Daines, the son of an anesthesiologist and a homemaker, was born in Preston, Idaho, on Feb. 17, 1951, the third of five children of Newel and Jean Daines. He grew up in Logan, Utah, where his father served two terms as mayor and where he met Linda Skidmore, his wife of 36 years.

He received his medical degree from Cornell in 1978 and worked at St. Barnabas Hospital in the South Bronx during the height of the AIDS and crack epidemics, and at St. Luke’s-Roosevelt Hospital Center in Manhattan, where he became president and chief executive in 2002.

He is survived by his wife, a managing director at Goldman Sachs; his parents; his children, William, Katherine and Andrew; two sisters, Pamela Johnson and Janet Stowell; two brothers, George and Peter; and a grandchild.

His term as health commissioner ended Dec. 31 as a new governor, Andrew M. Cuomo took office, and Dr. Daines accepted an appointment as a visiting scholar at the New York Academy of Medicine in Manhattan.

Long after Dr. Daines’s sons were too old for the Boy Scouts, Dr. Daines, a former Eagle Scout himself, still invited members of Troop 525, from the Upper East Side of Manhattan, to his farm in Stanfordville, Bill Butler, the troop’s scoutmaster, said.

“Even in the dead of winter we would go up there, and he would be the most gracious host,” Mr. Butler said. “He would have a fire blazing within minutes.”

Lorillard and Reynolds Sue F.D.A.

Posted: 28 Feb 2011 11:50 PM PST

Two major tobacco companies filed a lawsuit against the Food and Drug Administration on Friday, contending that three members of an advisory committee had conflicts of interest that would taint any recommendations by the panel to the agency.

The committee is considering whether to recommend banning or restricting menthol in cigarettes. It meets next week and again in mid-March to make its recommendation by March 23.

The suit was filed in the United States District Court in Washington by Lorillard and R. J. Reynolds. Lorillard, maker of Newport cigarettes, gets an estimated 90 percent of its revenue from menthol products. R. J. Reynolds, maker of Camel cigarettes, is the nation’s third-biggest tobacco company.

The lawsuit argues that the advisory committee is improperly balanced and influenced by special interests. It contends that three members of the committee — Dr. Neal L. Benowitz, Dr. Jack E. Henningfield and Dr. Jonathan M. Samet — have received tens of thousands of dollars as expert witnesses in litigation against cigarette makers and as advisers to pharmaceutical companies that make smoking cessation products. They are all university professors, researchers and national experts in the antismoking movement. Dr. Samet is chairman of the panel.

The F.D.A. said it would not comment on pending litigation. Last year, however, agency lawyers rejected a similar complaint from Philip Morris and the Citizens for Responsibility and Ethics, a Washington nonprofit watchdog group. The F.D.A. said its advisory members would not benefit financially from any decision related to menthol and did not have to ask for agency waivers.

Prostate Guideline Causes Many Needless Biopsies, Study Says

Posted: 28 Feb 2011 09:00 PM PST

Current guidelines for the early detection of prostate cancer recommend a biopsy for men whose P.S.A. rises rapidly, no matter what the initial level. But a new study says that the practice does not help patients find aggressive cancers and results in many unnecessary biopsies.

P.S.A., or prostate-specific antigen, rises with age, and what is considered normal varies. In general, a level under 4 nanograms per milliliter is considered safe. But even with a normal reading, an increase of 0.35 nanograms per year is widely believed to be high enough to require a biopsy.

Researchers examined the records of 5,519 men with a base-line P.S.A. under 3. They followed them for seven years with yearly tests and a biopsy if the level rose above 4.

They also analyzed P.S.A. velocity — the rate of change in readings from year to year. But after adjusting for age, base-line P.S.A. and other factors, they found little evidence that ordering a biopsy for men whose velocity was greater than 0.35 helped find prostate cancer. And it was particularly useless in uncovering the most aggressive types of cancer, the ones most important to treat.

The researchers, writing in the March 16 issue of The Journal of the National Cancer Institute, concluded that using P.S.A. velocity for prostate cancer detection is ineffective, that it leads to unnecessary biopsies and that references to it should be removed from professional guidelines and policy statements.

Andrew J. Vickers, the lead author, drew an analogy: A basketball player’s height, he said, is important to his ability to play, and it correlates very closely with his shoe size. But once you know his height, his shoe size is irrelevant to judging his value as a player.

Similarly, it is easy to demonstrate a statistical relationship between sharp rises in P.S.A. and cancer, but the correlation reveals no more information than is already available with a P.S.A. reading, a digital examination and a family history. It is irrelevant in deciding whether a biopsy is needed.

Not all experts agree. Dr. Anthony V. D’Amico, a professor of radiation oncology at Harvard, said that the methodology of Dr. Vickers’s study was sound, but that the data gathered was almost certainly flawed.

The problem, Dr. D’Amico said, is that many factors that have nothing to do with prostate cancer can cause a rapid increase in prostate-specific antigen. Sexual activity, riding on a bicycle or on horseback, a recent colonoscopy, a bladder or prostate infection, even variations in the ways laboratories perform the test can radically affect the readings.

“It may well be that the high velocity in your case is not important,” he said. “But before you reach that conclusion, I would get a repeat P.S.A.” If there is still a spike after eliminating those other possible causes, he continued, a biopsy should be the next step.

Dr. Vickers, a researcher at Memorial Sloan-Kettering Cancer Center in New York, agreed that prostate cancer was only one of many reasons for a high P.S.A. “A doctor sees a high P.S.A. and says, ‘Could this be cancer or some other reason?’ ” he said. “Well, the thought was that P.S.A. velocity could help you think this through” — that measuring the rate of change would be decisive.

But in practice, Dr. Vickers said, it does not work. If he had strictly applied the guidelines to the men in his study, he said, one in every seven would have required a biopsy. This would mean millions of American men would need biopsies, he said, with almost none revealing a cancer.

Dr. Vickers and his colleagues acknowledged that there might be better methods of calculating P.S.A. velocity that could lead to more accurate predictions, and that some effect might have been found if the patients had been followed for more than seven years.

But at this point, he is firmly against biopsies on the basis of velocity alone. “If your P.S.A. is in the normal range, you shouldn’t get a biopsy,” he said. “Changes or spikes in P.S.A. are not something to worry about if your P.S.A. is still normal.”

The Science of Living a Healthy Life

Posted: 09 Sep 2010 08:40 AM PDT
Posted by at

1 comment:

Unknown said...

“Congratulations dwi! Thank you so much for taking the time to share this exciting information.”

click here

March 19, 2013 at 3:51 AM

Post a Comment

Subscribe to: Post Comments (Atom)

Enter your email address:

Delivered by FeedBurner