Health - The New Old Age: Forgetting the Gift

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• The New Old Age: Forgetting the Gift
• Recipes for Health: Cabbage With Tomatoes, Bulgur and Chickpeas
• 18 and Under: On the Left Hand, There Are No Easy Answers
• Patient Voices: Pain, Persistence, Family: Sickle Cell Disease
• Leisurely Meals Don’t Curb Snacking, Study Finds
• Defining an Illness Is Fodder for Debate
• Global Update: India: Despite Growth, Struggle Continues With Malnutrition Among Children
• A Deep Dive to Retrieve and Fortify Memories
• Diet Plan With Hormone Has Fans and Skeptics
• Vital Signs: Aging: Hearing Loss Is Common but Often Ignored
• Vital Signs: Regimens: Drugs’ Benefits Go Beyond Blood Pressure
• Vital Signs: Hazards: Misuse of Drugs Crowds Emergency Rooms
• Rising Calls to Replace Top Man at Medicare
• Doctor and Patient: When Optimism Is Unrealistic
• Well: Sex Education on ‘Glee’
• Well: When Exercise Is Too Much of a Good Thing
• Well: The Doctor’s Wife in the Chemo Chair
• Well: Back Pain Runs in Families
• Well: When Your Child Is a Lefty
• Personal Health: Revisiting Bone Drugs and Femur Fractures
• Really?: The Claim: Back Pain Runs in Families
• Q & A: Control Yourself!
• The New Old Age: Why It Takes So Long to Decide
• The New Old Age: A Better Bank Account
• The New Old Age: Elder Abuse on the Rise
• Prescriptions: Ethics Survey for Doctors
• Prescriptions: The Case of the Missing Pepcid Tablets
• Prescriptions: A Team Approach to Patient Care Falters
• Letters: The Human Touch (1 Letter)
• Letters: Anesthesia’s Mysteries (2 Letters)
• Letters: Don’t Eat That! (1 Letter)
• Recipes for Health: Fava Bean Stew With Bulgur
• Recipes for Health: Carrots and Lentils in Olive Oil
• Recipes for Health: Vegan Recipes for Lent
• Urban Athlete: Happy to Bend Over Backward
• National Briefing | Washington: U.S. Appeals Florida Health Care Ruling
• Drug Firms Face Billions in Losses in ’11 as Patents End
• In Montana, an Economic Boon Faces Repeal Effort
• Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy
• Cancer Research Before Activism, Billionaire Conservative Donor Says

The New Old Age: Forgetting the Gift Posted: 09 Mar 2011 08:57 AM PST

Recipes for Health: Cabbage With Tomatoes, Bulgur and Chickpeas Posted: 09 Mar 2011 12:50 AM PST This recipe is based on a Greek dish made with red cabbage. I’ve used both green and red cabbage, and I like it both ways. It’s a comforting vegan dish that works as an entree or a side. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Vegan Recipes for Lent (March 7, 2011) Recipes for Health: Carrots and Lentils in Olive Oil (March 8, 2011) Recipes for Health: Fava Bean Stew With Bulgur (March 10, 2011) Recipes for Health: Wheat Berries With Winter Squash and Chickpeas (March 11, 2011) 1/4 cup extra virgin olive oil 1 onion, finely chopped Salt to taste 1 tablespoon sweet paprika 1 medium head green or red cabbage, finely shredded 1 14-ounce can chopped tomatoes with juice 2 teaspoons sugar 2 teaspoons red wine vinegar, cider vinegar or sherry vinegar 1/4 cup chopped fresh dill 2 cups water 1 cup coarse bulgur 1 15-ounce can chickpeas, drained and rinsed 1. Heat the olive oil over medium heat in a large, heavy lidded skillet or Dutch oven. Add the onion, and cook, stirring often, until tender, about five minutes. Stir in a pinch of salt and the paprika. Cook, stirring, until the onion is thoroughly tender and infused with paprika, three to four minutes. 2. Add the cabbage, and cook, stirring, for three minutes or until it begins to wilt. Stir in the tomatoes, sugar and vinegar, and add salt to taste. Bring to a simmer, lower the heat, cover and simmer 15 minutes until the cabbage is thoroughly tender. 3. Stir in the dill and the water, and bring a to a boil. Add the bulgur and chickpeas. Stir to combine. When the water comes back to a boil, reduce the heat to low and cover. Simmer 10 minutes or until all of the water has been absorbed. Remove from the heat, taste and adjust seasonings, and serve hot or at room temperature. Yield: Serves six. Advance preparation: Since this is good served at room temperature, you can make it several hours ahead. Reheat if desired. It will keep for three or four days in the refrigerator. Nutritional information per serving: 281 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 7 grams monounsaturated fat; 0 milligrams cholesterol; 42 grams carbohydrates; 12 grams dietary fiber; 311 milligrams sodium (does not include salt to taste); 9 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

18 and Under: On the Left Hand, There Are No Easy Answers Posted: 09 Mar 2011 08:00 AM PST Humans are asymmetric animals. Early in our embryonic development, the heart turns to the left. The liver develops on the right. The left and right lungs have distinct structure. Enlarge This Image From left: United Press International; Gary Cameron/Reuters; Jonathan Ernst/Reuters Recent left-handed presidents include, from left, Gerald R. Ford, Bill Clinton and Barack Obama. Well Share your thoughts on this column at the Well blog. Go to Well » There are certain rare syndromes in which the usual asymmetry of organs is reversed — I remember how disconcerting it was the first time I examined a child with dextrocardia, a heart on the right side, and heard the heart sounds in unexpected places. But when it comes to handedness, another basic human asymmetry, which reflects the structure and function of the brain, the reversed pattern is relatively common, and for all that, not easily understood. Over the centuries, left-handers have been accused of criminality and dealings with the devil, and children have been subjected to “re-education.” In recent years the stigma has largely vanished; among other things, four of our last seven presidents — Ford, the elder Bush, Clinton, Obama — have been left-handed. (Reagan is sometimes cited as ambidextrous.) But the riddle of what underlies handedness remains. Its proportions — roughly 90 percent of people are right-handed and 10 percent left-handed — stay consistent over time. “This is really still mysterious,” said Clyde Francks, a geneticist and the lead author of a 2007 study in which Oxford University researchers identified a genetic variant linked to left-handedness. Hand dominance (whether left or right) is related to brain asymmetry. And that, Dr. Francks said, “is not at all understood; we’re really at the very beginning of understanding what makes the brain asymmetrical.” Though brain asymmetries exist in our closest primate relatives, there seems to be general consensus that the human brain is more profoundly asymmetric, and that understanding that asymmetry will show us much about who we are and how our brains work. Brain lateralization, the distribution of function into right and left hemispheres, is crucial for understanding language, thought memory and perhaps even creativity. For many years, handedness has been seen as a possible proxy, an external clue to the balance in the brain between left and right. For right-handed people, language activity is predominantly on the left side. Many left-handers also have left-side language dominance, but a significant number have language either more evenly distributed in both hemispheres or else predominantly on the right side of the brain. Handedness clearly runs in families. The 2007 paper by the group at Oxford identified a gene, LRRTM1, that they discovered in the course of studying children with dyslexia, and which turned out to be associated with the development of left-handedness. Dr. Francks, who is now at the Max Planck Institute for Psycholinguistics in the Netherlands, recalls that the discovery made headlines and attracted a great deal of attention, the more so because this gene was also found disproportionately in people with schizophrenia, even though none of these connections are simple or well understood. “We’re not looking for a gene for handedness or a gene for schizophrenia,” he said. “We’re looking for subtle relationships.” The gene affects the ways that neurons communicate with one another, he said, but its mechanisms still need to be studied. Dr. Daniel Geschwind, a professor of human genetics, neurology and psychiatry at University of California, Los Angeles, School of Medicine, is interested in the connections between language and handedness, and the ways that handedness can help us understand the evolution of the human brain. “Handedness has a genetic basis, but like other complex traits — height, weight — it is complex,” he said. “It’s not a single gene that leads to it. There’s a strong environmental component, too. It’s a very tricky problem.” As with other traits that we are tempted to classify as either/or, handedness is probably better viewed as a spectrum encompassing the very strongly right-handed or left-handed, and a range of those who prefer to use one hand or the other, but have different degrees of comfort and competency with the nondominant hand. In general, said Dr. Geschwind, left-handers have less asymmetric brains, with more even distribution over the two hemispheres. “Perhaps a more accurate conceptual way to think about them is as non-right-handers,” he said. “Many of them are much more likely to be ambidextrous and have fine motor abilities with their right hands.” Because left-handedness has been seen as a key to the complex anatomy of the brain, researchers continue to look for — and debate — links to many other conditions, including immune disorders, learning disabilities and dyslexia, reduced life expectancy and schizophrenia. None of it turns out to be simple. The idea of links to schizophrenia has been particularly persistent, but schizophrenia is a complicated and probably heterogeneous disorder, and studies of different populations show different patterns; last year, a study found no increased risk with non-right-handedness for schizophrenia or poorer neurocognition. In pediatrics, we sometimes worry about children who manifest handedness too early, before their first birthday. The concern is that if a very young child seems to strongly prefer one hand, there may actually be some problem — perhaps some kind of neurological damage — on the other side. Left-handedness has sometimes been treated as pathological. Cesare Lombroso, the infamous 19th-century physician who identified various facial (and racial) features with criminal traits, also saw left-handedness as evidence of pathology, primitivism, savagery and criminality. And I was brought up with the story that a generation ago, in the bad old days (and in the old country), foolish unenlightened people tried to force left-handed children to convert and use their right hands. My father said that my uncle, his older brother, had had his left hand tied behind his back as a child. A colleague’s husband, Anthony Gentile, a fund manager who is 41 and grew up outside Cincinnati, told me that though he was always left-handed, he was taught to write with his right hand — though he can form the letters, he could never learn to hold the pencil correctly in that hand. “I can hold the pencil properly in my left hand, but I don’t have the coordination to write,” he told me. “It looks like I’m holding the pencil properly, but I am unable to make any letters.” The percentage of left-handers in the population seems to be relatively constant, at 10 percent. And this goes back to studies of cave paintings, looking at which hands hunters are using to hold their spears, and to archaeological analyses of ancient artifacts. So though there has been prejudice against left-handers, and though there may be some developmental risks, said Dr. Geschwind, “there clearly must be advantages as well. The reason why it maintains that way, nobody knows what it is.” Indeed, there seems to be a certain fascination with figuring out the areas (like the presidency) in which left-handers seem to shine. Numbers are sometimes quoted about how many architects are left-handed, or how many M.I.T. professors. On the other hand (so to speak), at a moment when we can finally hope for an end to winter, maybe we should celebrate the left-handers whose greatness truly lies in the ways they integrate motor control, strength and the highest kinds of skill and intelligence. Warren Spahn, Sandy Koufax, Whitey Ford, anyone? C. C. Sabathia, Jon Lester, Cliff Lee? This posting includes an audio/video/photo media file: Download Now

Patient Voices: Pain, Persistence, Family: Sickle Cell Disease Posted: 08 Mar 2011 08:38 AM PST HOW do you live with a disease that can cause sudden episodes of extreme pain? What do you do when the only thing that helps relieve the pain are powerful, addictive painkillers? How does a family manage the needs of a child with a chronic, untreatable illness? These are among the questions that people facing a diagnosis of sickle cell anemia have to answer. Well Share your thoughts on this column at the Well blog. Go to Well » Multimedia Multimedia Feature Patient Voices: Sickle Cell Anemia Related Health Guides: Sickle Cell Anemia | Sickle Cell Test Enlarge This Image Casey Templeton for The New York Times Tiffany Drews, 33, Richmond, Va. “Both my husband and I have the trait for sickle cell disease, and combined we have two children, Tracy and Riley, with the disease.” Enlarge This Image Andrew Spear for The New York Times Shanoah Moore, 8, Cincinnati. “Every time I have a pain episode, I either get a heating pad or they take my temperature. If it’s over 101, that means I have to go to the hospital.” Sickle cell anemia is an inherited disease that causes red blood cells to have a distinctive crescentlike, or sickle, shape. These cells are unable to properly carry oxygen throughout the body, and they tend to clump together, blocking blood flow, damaging organs and causing severe pain. Affecting about 72,000 people in the United States, sickle cell anemia is most common among people of African or South American descent, but the genetic trait is also routinely found in people with ancestry from Central America, India, Saudi Arabia and Mediterranean countries. One in every 500 African-American births results in a child with sickle cell disease, according to the Sickle Cell Disease Association of America. The challenges of living with sickle cell anemia are great, but with diligent care, the disease can be managed. Here, three people speak about the impact sickle cell anemia has had on their lives and families. Hear more: Patient Voices: Sickle Cell Anemia.  Andre Hinckson, 38 Queens “With a sickle cell crisis, there’s a lot of pain, unbelievable pain. It’s like a jackhammer on your back, basically. Imagine that kind of pain throughout your whole body. Sometimes there’s pain in your joints, in the abdominal area, in your head, in your chest. Sometimes it’s all over at one time. I wish people in the medical field would take the disease more seriously. I’ve had experiences where they’ve called me ‘drug seeker.’ It’s as if we’re going to the emergency room once a month or once a week for our drug fix. They treat us atrociously, and I’m just tired of the whole situation. Some people, they smile — that’s how they deal with their pain. Me? I’m very serious, and I know people look at my face and they wonder why I’m so serious or so sad. Maybe its just because of what I’ve experienced, you know?” Shanoah Moore, 8 Cincinnati “Every time I have a pain episode, I either get a heating pad or they take my temperature. If it’s over 101, that means I have to go to the hospital. I know when I’m getting sick because my head starts getting warm, and my mom knows because my eyes kind of turn yellow. It feels like someone is just squeezing my legs or arms. Sometimes it’s very, very painful. Normally in the middle of the night, I just go and get the heating pad and go back to my bed, but when I wake up and it feels worse, then I just go to my mom or dad. “I don’t like getting sick. I still want to be in school, so I can be there and not be absent a lot.” Tiffany Dews, 33 Richmond, Va. “When I first got pregnant, my intention was not to be a stay-at-home mom. My intention was to work and finish school, but of course, plans change. Both my husband and I have the trait for sickle cell disease, and combined we have two children, Tracy and Riley, with the disease. There’s a one in four chance each time we decide to have kids that we would pass on the disease. Years ago, [children with sickle cell disease] were not making it past the age of 20 or 21. So my hope is that they will have kids, and hopefully not have kids with the disease.”

Leisurely Meals Don’t Curb Snacking, Study Finds Posted: 07 Mar 2011 10:40 PM PST A leisurely four-course dinner at a fine restaurant can take two hours to eat, while meals eaten at home are usually over in 30 minutes. Does one leave you more satisfied — and less likely to snack afterward — than the other? Researchers in the Netherlands set out to see whether, all other things being equal — meaning people ate the exact same quantities of the exact same food — the speed of consumption had an effect on diners’ feelings of satiety and hunger and on the chemical signals, or hormones, that are involved in appetite regulation. The researchers also wanted to see how the pace of the meal affected postprandial snacking. Though people said they felt more sated and less hungry after a staggered meal that lasted two hours with breaks between courses and didn’t really want to eat more afterward, the experience didn’t change their snacking behavior, said Sofie G. Lemmens, a postdoctoral fellow at Maastricht University in the Netherlands who was the lead author of the paper, published in the March issue of The Journal of Nutrition. Two and a half hours after the beginning of the meal, when the diners were offered an array of traditional Dutch tea treats like apple cake, chocolate-covered marshmallows, peanuts, chips and waffles, they ate almost as much as they did two and a half hours after a meal that they had consumed in 30 minutes. “We didn’t see a big difference in their energy intake afterward,” Dr. Lemmens said. In fact, the slow diners ate only 10 percent fewer snack calories than when they had consumed their meal quickly, a difference that wasn’t statistically significant. About two-thirds of American adults are overweight or obese, according to the federal Centers for Disease Control and Prevention, and so far, public health efforts to curb or reverse the trend have not had major results. Overeating and physical inactivity are the primary causes of obesity, but Americans also eat a large number of meals outside the home — at least one a day, according to some estimates — and public health experts have been examining the roles played by restaurant meals and fast food in the obesity epidemic. For their study, the Dutch researchers recruited 38 young men and women and asked them to eat the same meal in a controlled test kitchen on two separate days, once as a “nonstaggered” meal consumed in 30 minutes and once as a “staggered” meal, with 20- to 25-minute breaks between courses. Dr. Lemmens said the meal was a typical Dutch dinner consisting of a salad, a macaroni dish with meat sauce followed by vegetable lasagna and raspberry pudding for dessert (14 percent protein, 54 percent carbohydrate and 32 percent fat). Blood samples were drawn before, during and after the meal to measure levels of hormones involved in appetite signaling, and participants also reported how sated or hungry they felt at points throughout the meal. When participants ate the drawn-out meal, their satiety hormones (glucagon-like peptide-1, or GLP-1, and peptide tyrosine-tyrosine, or PYY, believed to communicate satiety to the brain and curb the appetite) increased more gradually than after the nonstaggered meal, when they spiked more rapidly. Just before the snacking period, diners who had eaten a drawn-out meal rated their satiety higher and their hunger lower, and their levels of ghrelin, a hormone that increases with hunger and is believed to stimulate appetite, were lower. Yet these differences in hormone levels did not significantly affect how much participants ate of the sweet and salty tea snacks, Dr. Lemmens said, suggesting the availability of tempting foods overrides the body’s internal messages about when to stop eating. “The food environment is overriding all the biological cues,” said Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale, who blames what he calls a “toxic food environment” for the prevalence of obesity. he added, “Whatever biological safeguards there are against weight gain are being disabled, almost like someone went in and changed all the wiring.”

Defining an Illness Is Fodder for Debate Posted: 07 Mar 2011 08:36 PM PST When reports emerged 30 years ago that young gay men were suffering from rare forms of pneumonia and cancer, public health investigators scrambled to understand what appeared to be a deadly immune disorder: What were the symptoms? Who was most susceptible? What kinds of infections were markers of the disease? Related Reporter's File: Chronic Fatigue Syndrome No Longer Seen as 'Yuppie Flu' Health Guide: Chronic Fatigue They were seeking the epidemiologist’s most essential tool — an accurate case definition, a set of criteria that simultaneously include people with the illness and exclude those without it. With AIDS, investigators soon recognized that injection-drug users, hemophiliacs and other demographic groups were also at risk, and the case definition evolved over time to incorporate lab evidence of immune dysfunction and other refinements based on scientific advances. “If you recognize something is happening, you need a case definition so you can count it,” said Andrew Moss, an emeritus professor of epidemiology at the University of California, San Francisco, and an early AIDS investigator. “You need to know whether the numbers are going up or down, or whether treatment and prevention work. And if you have a bad case definition, then it’s very difficult to figure out what’s going on.” Once a disease can be diagnosed reliably through lab tests, creating an accurate case definition becomes easier. But when an ailment has no known cause and its symptoms are subjective — as with chronic fatigue syndrome, fibromyalgia and other diseases whose characteristics and even existence have been contested — competing case definitions are almost inevitable. Now a new study of chronic fatigue syndrome has highlighted how competing case definitions can lead to an epidemiologic “Rashomon” — what you see depends on who’s doing the looking — and has stoked a fierce debate among researchers and patient advocates on both sides of the Atlantic. The study, published last month in The Lancet, reported that exercise and cognitive-behavioral therapy could help people with the illness. Advocates and some leading experts dismissed the findings and said the authors’ case definition was largely to blame. The British scientists who conducted the research identified study participants based largely on a single symptom: disabling and unexplained fatigue lasting at least six months. But many researchers, especially in the United States, say that definition takes in many patients whose real illness is not the syndrome but depression — which can often be eased with psychotherapy and exercise. The Lancet authors “have written their case definition to include both people with major depressive disorders and patients who clearly have received an insult to their immune systems and are depressed because they can no longer do things that they used to,” said Dr. Andreas Kogelnik, an infectious disease specialist in Mountain View, Calif., who treats many people with chronic fatigue syndrome. In studying the condition, he and other researchers exclude patients whose only symptom is fatigue, however disabling, and instead rely on a case definition that includes other cognitive, neurological and physiological symptoms. Those symptoms, they believe, indicate a complex immune system disorder possibly caused by a virus or another agent. Since 2009, studies have produced contradictory results over whether viruses related to mouse leukemia are associated with chronic fatigue syndrome, which is also called myalgic encephalomyelitis. A recent study found that people with the illness have distinct proteins in their spinal fluid, raising hope that a diagnostic test can someday be developed. No case definition is perfect; every disease has outliers. But whether a definition is broadly or narrowly drawn can profoundly affect the statistics vital for public health planning. A recent study of workers, for example, found that 2.5 percent to 11 percent suffered from carpal tunnel syndrome, depending on whether the case definition required reported symptoms, a physical exam, a nerve test or a combination of the three. Another study found that rates of acute gastroenteritis doubled when a looser case definition was used. If researchers filter their perceptions through different lenses — that is, case definitions that generate study populations varying in size and characteristics — it is hard to know whether they are studying the same phenomenon, overlapping ones or completely unrelated ailments. Determining whether findings from one study can be extrapolated to other patients becomes difficult at best. “You have to really define the characteristics, and everybody has to use the same criteria, because otherwise you’re calling something an apple and someone else is really looking at a peach and calling it an apple,” said Dr. Anita Belman, a neurologist at Stony Brook University who conducts research on pediatric multiple sclerosis. No one disputes that many people with chronic fatigue syndrome also suffer from depression. The question is which came first. Are patients depressed because a terrible disease has robbed them of their lives, or is the illness itself a somatic expression of an underlying depression? To researchers who believe that chronic fatigue syndrome is merely a psychological condition, that distinction may not seem important. But it matters deeply to those convinced it is a viral disease, who say the exercise therapy advised by the Lancet study can cause major relapses in people with chronic fatigue syndrome — a claim supported by some patient surveys. The single-symptom case definition used by the Lancet authors, known as the Oxford criteria, was developed in Britain in 1991. Like the team that conducted the current study, the 1991 group included prominent mental health professionals. But many scientists and clinicians view a multisymptom case definition published in 1994 by the Centers for Disease Control and Prevention in the United States as the international standard. In addition to six months of unexplained, disabling fatigue, the C.D.C. definition requires at least four of eight common symptoms: cognitive problems, sleep disorders, muscle pain, joint pain, headaches, tender lymph nodes, sore throat and what is called “postexertional malaise”— a relapse that occurs after even minimal activity. In 2005, the agency unveiled an “empirical” case definition that recommended specific screening questionnaires and cutoff scores for measuring fatigue, physical dysfunction and other symptoms. Critics challenged these newer guidelines on the same grounds as the Oxford criteria, arguing that the questionnaires and scoring methods were too ambiguous. In contrast, a 2003 case definition from Canada is considered the most restrictive and is preferred by many patients. It elevates postexertional malaise to a central role in the illness and requires a range of neurological, cognitive, endocrine or immunological symptoms. In 2009, researchers from DePaul University in Chicago reported that 38 percent of patients in a study sample suffering from depression alone were given misdiagnoses of chronic fatigue syndrome using the C.D.C. screening tools but not the narrower Canadian definition. The study suggests that the disease centers’ “empirical case definition has broadened the criteria such that some individuals with a purely psychiatric illness will be inappropriately diagnosed” with chronic fatigue syndrome, wrote Leonard A. Jason, a professor of community psychology at DePaul, and his colleagues. The authors also noted that using the new screening tools, the C.D.C. had greatly increased its estimate of the prevalence of the illness, to 2.5 percent of the population, or four million Americans. So the question remains: can therapy and exercise help patients with chronic fatigue syndrome, as the Lancet study reported? Yes, apparently — if the illness is identified with a case definition relying on fatigue alone. But does the evidence from that study prove that these strategies would help patients identified as having chronic fatigue syndrome through very different criteria? That is a much tougher argument to make. This posting includes an audio/video/photo media file: Download Now

Global Update: India: Despite Growth, Struggle Continues With Malnutrition Among Children Posted: 07 Mar 2011 08:48 PM PST There’s no evidence that India’s growing prosperity has led to less malnutrition among Indian children, according to a new study by scientists from Harvard and the University of Michigan. One plausible explanation, the authors wrote, is that India’s rapid economic growth “may have benefited only the privileged sections of society.” Technology jobs have driven the boom, but 75 percent of the population is supported by farming or manufacturing, noted S. V. Subramanian, a geographer at the Harvard School of Public Health and an author of the study. To save the children of those families, India’s government may have to use its growing tax revenues for direct aid like food or food stamps, he said. The study, published Tuesday in PLoS Medicine, looked at 77,326 children tracked in three national family health surveys conducted in 1992-93, 1998-99 and 2005-6. Among the data gathered in these huge household surveys were the heights, weights and ages of children. The study broke down malnutrition by region. It was worst in the poorest and most crowded states like Bihar, Madhya Pradesh and Uttar Pradesh. It was less common in the remote mountainous northeastern states like Mizoram and Manipur, and also in Kerala, where the state government spends more on education and health. But there was little correlation between a state’s economic growth and how much food most children got. Other studies have shown that educating women and reducing birth rates do more to keep children fed than macroeconomic growth, the authors said.

A Deep Dive to Retrieve and Fortify Memories Posted: 07 Mar 2011 09:00 PM PST For years scientists have dreamed of developing a genuine memory booster, a drug that could tune the brain’s biological search engine so that it’s better at retrieving not only recently learned facts, like last night’s dinner menu, but details that seem all but lost in the fog of time, like childhood classmates’ names and antics. Such a substance would have obvious appeal — for people at risk of dementia, to name just one group — but the search has been very slow going. Stimulants like caffeine and nicotine can sharpen the memory, but like other temporary enhancers, they need to be taken when the information is learned or retrieved to make a difference. Now, researchers in Israel and New York report that they have been able to strengthen memories formed well in the past, using a brain substance involved in anchoring and maintaining the memory in the first place. The finding, reported last week in the journal Science, is one of two recent studies in which neuroscientists used molecules active in memory formation to, in effect, goose the system and improve recall. Both studies were conducted in rats, which provide a very rough model for human memory. “The idea that an older memory can be strengthened is a novel and exciting finding,” said Jim McGaugh, a neuroscientist at the University of California, Irvine, who was not involved in the research. “But it also raises the question: How does this work? And, does it apply to all memories?” In the study published last week, researchers at the Weizmann Institute of Science in Rehovot, Israel, and the S.U.N.Y. Downstate Medical Center in Brooklyn found that giving rats an infusion of PKM-zeta, an enzyme known to be active in storing memories, strongly sharpened their aversion to drinking a sweet liquid. The animals had learned, six days earlier, that the liquid could make them sick. Six days is a long time for a rat, said Todd C. Sacktor, a neuroscientist at Downstate and an author of the paper. “For years we thought that once a memory goes into long-term storage, no one could do anything with it; it would just gradually fade. Well, apparently that’s not true.” The researchers argue that the substance they injected may act on almost any memory that the brain tries to retrieve while the drug is active. “It is unlikely that such memory, though enhanced, will not be subjected so some processes of weakening over time,” another of the authors, Yadin Dudai of the Weizmann Institute, said in an e-mail. “We do not think that we will be able to create the analogue of Funes, that famous fictional protagonist of Jorge Luis Borges who remembered forever every detail he ever encountered.” In a paper published several weeks earlier, however, researchers at Mount Sinai School of Medicine showed that they could make a specific memory last a long time — again, by using a brain substance involved in the initial learning. Rats that received an injection of the substance, called a growth factor, immediately after learning how to avoid a foot shock in their cage retained a memory of the experience that was as fresh a week or more later as on the first day. “This is a substance that’s involved in the natural regulation of memory consolidation, and an injection significantly slows down forgetting,” said Cristina M. Alberini, a neuroscientist at Mount Sinai and a co-author of the earlier study, published in the journal Nature. Turning these findings into useful drugs is another matter altogether, experts say. Researchers still have little idea of how these experimental drugs sharpen memories, whether they affect only specific memories, or what the risks are. “I’ve been working on memory enhancement since 1957, and I don’t know of a single drug that came out of work with animals that was later developed for humans,” said Dr. McGaugh. “It’s very interesting work; now let’s see where it goes.”

Diet Plan With Hormone Has Fans and Skeptics Posted: 08 Mar 2011 09:31 AM PST Every morning, Kay Brown engages in a ritual similar to a heroin addict’s, or a diabetic’s: she sticks herself with a syringe. Only hers contains hCG, a pregnancy hormone. Enlarge This Image Robert Caplin for The New York Times Dr. Lionel Bissoon of Manhattan, consulting with a patient as she injects hCG. Ms. Brown, 35, is not taking hCG to help her bear a child. She believes that by combining the hormone injections with a 500-calorie-a-day diet, she will achieve a kind of weight-loss nirvana: losing fat in all the right places without feeling tired or hungry. “I had a friend who did it before her wedding,” Ms. Brown said. “She looks great.” Women like Ms. Brown are streaming into doctors’ offices and weight-loss clinics all over the country, paying upward of $1,000 a month for a consultation, a supply of the hormone and the syringes needed to deliver it. More than 50 years after a doctor at a Roman clinic began promoting hCG as a dieting aid, it is as popular as ever, even though there is scant evidence that it makes any difference. The regimen combines daily injections with a near-starvation diet, and patients, mostly women, are often enticed by promises that they can lose about a pound a day without feeling hungry. Perhaps even more seductively, they are frequently told that the hCG will prompt their bodies to carry away and metabolize fat that has been stored where they least want it — in their upper arms, bellies and thighs. In response to inquiries stirred up by the diet’s popularity, the Food and Drug Administration warned in January that “homeopathic” forms of hCG, like lozenges and sprays, sold over the Internet and in some health food stores, are fraudulent and illegal if they claim weight-loss powers. The injectable, prescription form of hCG, human chorionic gonadotropin, is approved as a treatment for infertility and other uses, and it is legal for doctors to prescribe it “off-label” for weight loss. But the F.D.A. has also reiterated a warning, first issued in the mid-1970s, that is required on hCG packaging: It has not been shown to increase weight loss, to cause a more “attractive” distribution of fat or to “decrease hunger and discomfort” from low-calorie diets. The F.D.A. recently received a report of a patient on the hCG diet who had a pulmonary embolism, said Christopher Kelly, a spokesman for the agency. He said the hormone carried risks of blood clots, depression, headaches and breast tenderness or enlargement. Dr. Pieter Cohen, an assistant professor at Harvard medical school who researches weight-loss supplements, said that aside from the issue of side effects, the use of hCG as a diet tool was “manipulating people to give them the sense that they’re receiving something that’s powerful and potent and effective, and in fact they’re receiving something that’s nothing better than a placebo.” But unlike other popular diet supplements, hCG, which is derived from the urine of pregnant women, has acquired an aura of respectability because the injections are available only by prescription. Ms. Brown’s physician, Lionel Bissoon, a well-known society doctor with an office off Central Park West, charges $1,150 for his hCG program, which covers an examination, injection training, a month’s supply of the hormone and syringes, and blood work to monitor for possible trouble. “From an anecdotal point of view,” Dr. Bissoon said, “physicians all around the country have seen people losing a tremendous amount of weight with this stuff, and you cannot afford to ignore that.” Another New York doctor, Scott M. Blyer, offers the hCG diet as an adjunct to his cosmetic surgery practice, working with Jacqueline Fulop-Goodling, an orthodontist, out of her office in Midtown. Dr. Fulop-Goodling does not prescribe hCG, but she counsels patients. They charge $800 for a 40-day course of therapy, half-price for repeat rounds; they also require an EKG to make sure the patient has no heart trouble. One of Dr. Blyer’s patients, a 30-year-old business consultant named May, who asked that her last name not be used because she was embarrassed to be considering the diet, described herself as an “emotional eater.” She is 5-foot-3 and 130 pounds, but said she hoped to shed 20 pounds in time to be a bridesmaid at an April wedding. “So I have just six weeks,” she said. Dr. Blyer looked uneasy. “Your legs are thin, your face is thin,” he told her. “You’re a very attractive woman.” But he reassured her that she would lose weight where she wanted to, in her stomach. The hCG, Dr. Blyer said, “tricks your body into a state of pregnancy; it burns off fat so the fetus can get enough calories, but it protects muscle.” May eventually decided that she did not need to lose much weight and did not go through with the diet. 1 2 Next Page » Alain Delaquérière contributed reporting.

Vital Signs: Aging: Hearing Loss Is Common but Often Ignored Posted: 07 Mar 2011 10:11 PM PST Nearly two-thirds of Americans 70 and older suffer from hearing loss that ranges from mild to severe, according to what may be the first study to gauge the prevalence of hearing impairment in a nationally representative sample of older adults. Related Health Guide: Hearing Loss More Vital Signs Columns Researchers analyzed data from about 715 elderly people whose hearing was examined as part of the National Health and Nutritional Examination Survey in 2005-6, the first time it included hearing assessments of older Americans. Sixty-three percent of those 70 and older were found to be suffering from impairment that affects their ability to hear human speech, according to the World Health Organization’s definition. Hearing loss was more common in men than in women. And it was significantly less common in black adults: just 43 percent, compared with 64 percent of whites. Yet only a minority of older people with these impairments use hearing aids, said Dr. Frank R. Lin, an assistant professor of otology at Johns Hopkins University School of Medicine, who was lead author of the paper, published Monday in The Journal of Gerontology: Medical Sciences. “There’s a general perception that hearing loss in older adults is not very important,” he said.

Vital Signs: Regimens: Drugs’ Benefits Go Beyond Blood Pressure Posted: 08 Mar 2011 08:52 AM PST A new analysis suggests that blood pressure drugs may benefit heart disease patients even if they don’t have high blood pressure. Related Health Guide: Blood Pressure More Vital Signs Columns The paper, published in the March 2 issue of The Journal of the American Medical Association, is an analysis of 25 published studies, and the authors cautioned that randomized controlled trials must be done to confirm the results. (They reported no financial ties to drug makers.) Patients in the studies were followed for two years on average, and many had blood pressure levels that were normal or slightly above. Compared with similar patients who took dummy pills, those who took so-called antihypertensive medication cut their risk of stroke by 23 percent; heart attack by 20 percent; congestive heart failure by 29 percent; and death by 13 percent. The study’s lead author, Angela M. Thompson, said that while current guidelines call for treatment when blood pressure is 140/90 or higher, “we know from other studies that there’s a graded relationship between cardiovascular disease risk and blood pressure” — starting when the first number, the systolic reading, is as low as 115. But Ms. Thompson, a doctoral student in epidemiology at Tulane University School of Public Health and Tropical Medicine, noted that these cutoff points had changed over time. “So the question is: Is this still the best cutoff point? Or if you lower it a little bit, are people going to obtain more benefit?”

Vital Signs: Hazards: Misuse of Drugs Crowds Emergency Rooms Posted: 08 Mar 2011 08:54 AM PST Some 700,000 Americans are taken to the hospital each year after ingesting drugs, both legal and illegal, a new study reports. And the care costs nearly $1.4 billion in emergency room charges alone. Related More Vital Signs Columns The study, published in the March issue of The American Journal of Emergency Medicine, was based on data from the 2007 Nationwide Emergency Department Sample, a government database that includes information on 27 million visits to 970 emergency rooms in 27 states. Children younger than 6 had a higher rate of emergency visits for accidental drug poisoning than any other age group, but most of the visits were precautionary, said the study’s lead author, Dr. Gary Smith, director of the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio: the children did not ingest toxic levels of medication. Drug-related poisonings are increasingly a rural epidemic: the rate in rural areas was three times that of other areas. Injuries from misuse of drugs have been increasing for the past decade. A growing number involve prescription drugs, especially opioid painkillers like methadone, oxycodone and hydrocodone, which Dr. Smith says are being prescribed in record numbers. In 2007, the year covered, antidepressants and pain medications were responsible for 44 percent of emergency room visits for drug-related poisonings.

Rising Calls to Replace Top Man at Medicare Posted: 07 Mar 2011 10:16 PM PST WASHINGTON — Members of Congress, including Democrats, have urged the Obama administration to search for another Medicare chief after concluding that the Senate is unlikely to confirm President Obama’s temporary appointee, Dr. Donald M. Berwick. Drew Angerer/The New York Times Confirmation is unlikely for Dr. Donald Berwick. Related Times Topic: Donald Berwick Dr. Berwick’s principal deputy, Marilyn B. Tavenner, has emerged as a candidate to succeed him. Lawmakers of both parties said Monday that Ms. Tavenner, a former Virginia secretary of health and human resources with extensive management experience, could probably be confirmed. In a letter to the White House last week, 42 Republican senators urged Mr. Obama to withdraw the nomination of Dr. Berwick to head the Centers for Medicare and Medicaid Services, which runs insurance programs for more than 100 million people. If those senators stick together, they could block confirmation. Mr. Obama bypassed Congress and appointed Dr. Berwick while the Senate was in recess last July. The appointment allows him to serve to the end of this year. The president has nominated Dr. Berwick three times, most recently in January. No confirmation hearings have been held, and none are scheduled. Reid Cherlin, a White House spokesman, said the president would not withdraw the nomination. “The president nominated Don Berwick because he’s far and away the best person for the job, and he’s already doing stellar work at C.M.S.,” Mr. Cherlin said. It is not clear whether the White House will fight for the nomination or press the Finance Committee to hold a confirmation hearing, which could provide Republicans another opportunity to criticize the new health law. Dr. Berwick, a pediatrician and a health policy expert, was hired to run Medicare and Medicaid. In recent weeks, the White House has expanded his portfolio to include federal regulation of private insurance. As a co-founder of the Institute for Healthcare Improvement, a nonprofit organization in Cambridge, Mass., Dr. Berwick advised hospitals on how to save lives by upgrading care and reducing medical errors. He became caught up in the partisan battle over the new health law. Republicans challenged him to explain comments in which he had discussed the rationing of health care, praised the British health care system and urged health care providers to reduce the use of ineffective procedures near the end of life. At a hearing of the House Ways and Means Committee last month, Dr. Berwick said, “I abhor rationing.” Representative John Lewis, Democrat of Georgia, told Dr. Berwick, “I love your testimony, not just like it but I loved it.” Republicans were hostile. “In your testimony, I see nothing but platitudes,” Representative Charles Boustany Jr., Republican of Louisiana, told Dr. Berwick. Representative Geoff Davis, Republican of Kentucky, said Dr. Berwick’s answers bordered on equivocation. And Representative Tom Price, Republican of Georgia, told him: “You missed your calling. I think you would make a great lawyer.” Several people who work with Dr. Berwick at the Medicare agency said they were disappointed that the White House had not done more to promote him. “Everybody here admires Don and the work he’s done, but he is not going to be confirmed,” a supporter said. “That’s inevitable. The Republicans will block him. There’s not a lot of optimism that the White House can do anything about it.” Ms. Tavenner, a nurse, worked for more than two decades at the Hospital Corporation of America, first as a nursing supervisor, then as a hospital executive and eventually as president of the company’s outpatient services group.

Doctor and Patient: When Optimism Is Unrealistic Posted: 04 Mar 2011 11:10 PM PST As a medical student and later during my residency, I trained for some time in a medical center known for its research and clinical trials. Every week, patients with rare diseases and cancers that had not responded to standard therapy arrived from all over the country, eager to try something new, even if the efficacy of the treatments had not yet been proven. Enlarge This Image Janos Radler/Getty Images Well Share your thoughts on this column at the Well blog. Go to Well » Related More Doctor and Patient Columns One of the patients was a woman in her late 30s, a mother of three. Known for her cheery disposition — she reminded the doctors and nurses of a brunette Cathy Rigby — she had melanoma that had spread through her body despite efforts to halt its growth. By the time I met her, she was already the veteran of two clinical trials at the center. Her tumor had responded slightly during one of those studies, but slowing the pace of its growth had come at a significant price. She had endured countless hospitalizations, serious bloating, a punctured lung, overwhelming fatigue and two nearly intractable infections. Nonetheless, when her cancer began growing again, she eagerly applied for a third study. This time she would participate in one of the earliest studies of a brand-new drug, a Phase I clinical trial, and would have to undergo major surgery before taking the experimental drug. On the evening before her operation, she joked with the surgical team and shook her head when we asked if she had any more questions. “Haven’t we talked about this enough?” she said smiling and nodding gamely as the head surgeon explained once more that because this was an early-phase trial, it would benefit research but was not likely to be of any therapeutic help to her. Like other such trials, it would test only for toxicity and the maximum safe doses of the experimental drug; generally fewer than 5 percent of patients ever benefit from such early trials. The woman nodded and waved her hand for the consent form. “I’ve been through this before,” she said to us as she signed the papers. “I know what I am getting into.” Then, voice lowered, she added: “I’m a mother. I would do anything for a little extra time with my children.” We all fell silent when she said those words. She seemed to understand the study, and it was hard not to be in awe of her courage and selflessness. But we were also hesitant to probe any further. None of us wanted to deflate her sense of hope. And knowing what we did about the extent of her disease, it was hard not to convince ourselves that optimism, even if based on somewhat false hopes, had to be helpful for someone in her position. I remembered her words a little over a year later when I heard she had died. Her tumor never responded to the experimental treatment. For almost four decades, researchers and patient advocates have debated the ethics of informed consent in early-phase clinical trials, studies that test only toxicity and dosing and offer little, if any, therapeutic benefit to those enrolled. A major part of the debate has focused on the motivations of patients who participate. Some research on patient motivations has had disturbing ethical implications, indicating that patients may never fully understand the purpose of trials, despite explanations by the researchers. Others have been more reassuring, noting that patients are driven by a sense of altruism and a desire to help others who may one day suffer from the same disease. More recently, a few studies have offered what appears to be the happiest of hypotheses. Patients may simply be optimistic and have strong needs to express hope. And because optimism has long been considered an effective coping mechanism for patients with terminal diseases, other researchers have also then assumed that optimism in this context poses few ethical issues. Now one group of ethicists has just published a study challenging that assumption. It turns out that when it comes to being hopeful, not all optimism is created equal. The ethicists surveyed 70 patients enrolled in several early-phase cancer trials and asked them about their expectations and understanding of their respective trials. A solid majority understood that the trials’ purpose was to advance research, not to treat them. But despite clearly understanding the purpose, and limits, of early-phase trials, the patients were also blinded by what researchers called an “unrealistic optimism,” or an optimistic bias, when it came to applying that knowledge to their own particular situations. A majority of patients assumed that the experimental drugs would control their cancer and that they would experience benefits but not complications. In essence, they believed they would fare better than the average patient enrolled in the same trial. “It’s the Lake Wobegon effect, ” said Dr. Daniel P. Sulmasy, senior author and a professor of medicine and ethics at the University of Chicago. “If you have more than 50 percent of patients saying their chances are better than average of avoiding some harm or obtaining some benefit, they are being unrealistically optimistic because you can’t say that most people are above average.” Such unrealistic optimism differs from so-called dispositional optimism, or a general optimistic outlook. “This is not about trying to quash hope in dying patients,” said Lynn A. Jansen, lead author and an associate director at the Center for Ethics in Health Care at Oregon Health and Science University in Portland. “It’s about distinguishing between the different kinds of optimism.” Social psychologists point to smokers who underestimate their chances of getting cancer or gamblers who believe they will beat the odds as classic examples of unrealistic optimism. But unrealistic optimism can be present in anyone, regardless of whether they have a generally optimistic outlook. “No one is immune to this kind of bias,” Dr. Jansen said. “Optimistic biases are part of human psychology.” But placed in the context of early-phase clinical cancer trials, unrealistic optimism results in a perfect ethical storm. “You have oncology, a field of medicine that is strongly evidence-based and research-intensive, and you have a population of patients who are experiencing an immediate threat to their lives,” said Dr. Neal J. Meropol, a researcher who has done extensive work on the ethics of early-phase cancer trials and chief of the division of hematology and oncology at University Hospitals Case Medical Center and Case Western Reserve University in Cleveland. “Patients almost invariably take part in early-phase clinical trials because they believe they will personally benefit.” While the study represents a breakthrough in understanding how different types of optimism affect the informed consent process, doing something about these biases presents a whole different issue. Unrealistic optimism is notoriously difficult to recognize because most individuals are completely unaware that it even exists. “We would probably be able to walk away from these types of biases,” Dr. Jansen said, “if we realized when we were operating under them.” Dr. Jansen and her colleagues are hoping next to delineate the factors involved in evoking this biased response in patients. By gaining a deeper appreciation of how unrealistic optimism develops, they believe they may be able to help patients and cancer researchers more easily recognize those optimistic biases that impair a patient’s autonomy and compromise the ethics of clinical trials. “We all need to care about this kind of research,” Dr. Jansen said. “It’s how we advance knowledge and cure disease.” She added: “We just need to realize that not all optimism is ethically benign.” This posting includes an audio/video/photo media file: Download Now

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Personal Health: Revisiting Bone Drugs and Femur Fractures Posted: 07 Mar 2011 08:50 PM PST Nearly six years ago in this column, I discussed what was then a little-known problem associated with long-term use of bisphosphonates, the valuable drugs that protect against fractures caused by bone loss. The drugs, among them Fosamax, Actonel and Boniva, can slow bone loss, increase bone density and cut fracture rates in half in women with established osteoporosis. Enlarge This Image The femur of Dr. Jennifer Schneider of Tucson, an internist who after seven years on Fosamax suffered a nontraumatic femur fracture that took two years to heal. Related More Personal Health Columns Reports had begun to emerge that some women taking bisphosphonates for many years suffered an unusual fracture of the femur, the long bone of the thigh. There was little or no trauma; in most cases the women were simply standing or walking when the femur snapped in half. In some, breaks occurred in both thighs, and many of the fractures were unusually slow to heal. Experts think the fractures happened because of the way the drugs work: by slowing the rate of bone remodeling, the normal process by which injured bone heals. As a result, microfractures that occur through normal wear and tear are not repaired. Although bone density may be normal, the bone can become brittle and crack under minor stress. In the years since, hundreds of cases of atypical femur fractures have been reported among women and some men taking bisphosphonates for five or more years. A number of studies have tried to assess the risk, and last fall the Food and Drug Administration issued a “safety announcement” and required that the drugs’ labels warn physicians and patients to be alert for this potential complication. Weighing the Research But many questions remain, including who is most at risk for femur fractures and whether the risks outweigh the important benefits of taking a bisphosphonate for many years. The latest assessment was published Feb. 23 in The Journal of the American Medical Association by a team of physicians and epidemiologists in Toronto. The team, led by Laura Y. Park-Wyllie, an epidemiologist who is a doctor of pharmacology at St. Michael’s Hospital, gathered treatment and fracture data among all 205,466 women in Ontario aged 68 or older who had been treated with a bisphosphonate. They identified those who had suffered femur fractures occurring below the hip and above the knee — called subtrochanteric or femoral shaft fractures — and compared each case with those of up to five other women the same age who had been free of this injury. Those who had taken the drugs for five years or longer were more than twice as likely to have had such a fracture as those who took them only briefly. But because X-rays of the bone were not reviewed, it is not certain that the fractures were linked to the drugs. At the same time, long-term use of bisphosphonates prevented many more fractures than it might have caused; the risk of osteoporotic femur fractures, a far more common injury, was reduced by 25 percent, Dr. Park-Wyllie said in an interview. “Compared to the number of fractures prevented,” she said, “the actual risk of a subtrochanteric femur fracture is small” — 1 case in 1,000 in the sixth year of therapy and 2.2 cases in 1,000 the seventh year. A report published last year in The New England Journal of Medicine found no increase in atypical femur fractures, but that study did not include enough patients taking bisphosphonates for many years to produce a reliable result. Preliminary data from a much larger study has indicated that the risk of atypical femur fractures increased from 2 cases a year per 100,000 users after two years of bisphosphonate therapy to 78 cases a year per 100,000 after eight years on the drug. In a report from a 27-member task force of the American Society for Bone and Mineral Research (published online in September in The Journal of Bone and Mineral Research), the experts noted that the way bisphosphonates work can reduce the “toughness” of bones. “It is highly likely that case reports and case series of atypical femur fractures will continue to accumulate,” the task force wrote, noting that another 47 cases had been reported since their analysis was prepared. Many cases are not reported, and in an unknown number of cases physicians may not recognize the fractures as atypical. The task force called for an international registry of cases, including details that could help define who is most at risk. First, an Evaluation What should patients and doctors do? “Relative to the millions of fractures that occur every year in the United States, the number of atypical femur fractures should not discourage the use of these effective drugs by patients with osteoporosis who are at high risk of fracture,” a leader of the task force, Dr. Elizabeth Shane, said in an interview. (Dr. Shane is a bone specialist at Columbia University Medical Center.) Initial excitement about bone-protecting drugs led to prescriptions for millions of women who were not necessarily at high fracture risk, and many experts now urge a thorough evaluation before a bisphosphonate is prescribed. In addition to bone density test results, the evaluation should take into account a patient’s smoking and drinking habits, thinness, family history of osteoporosis, previous osteoporotic fractures, drug prescriptions and weight-bearing exercise regimen. An online evaluation tool developed by the World Health Organization is at www.shef.ac.uk/FRAX, though some experts have criticized it as incomplete. The task force said a decision to treat should be “based on an assessment of benefits and risks,” and added, “patients who are deemed to be at low risk of osteoporotic-related fractures should not be started on bisphosphonates.” Even those with osteoporosis in the spine but little or no problem in their hips, the experts concluded, should consider alternative remedies. While no one knows what the optimal length of drug treatment should be, five years on a bisphosphonate seems to confer an adequate benefit; after that, patients should consider taking a “drug holiday.” Before resuming therapy, the patient’s risk factors for fracture should be reassessed. The task force noted that half of currently known patients with atypical fractures had been on bisphosphonates for seven years. Furthermore, in 70 percent of cases, patients reported experiencing pain or discomfort in the thigh or groin for weeks or months before the femur fractured. Anyone on a bone drug who develops such a pain should be carefully evaluated, first with an X-ray and, if nothing is seen but the cause is uncertain, by a bone scan or M.R.I. When a problem like a defect in the shell of the femur is found and the patient has pain, a fracture is highly likely, Dr. Shane said, and the task force recommended inserting a rod in the bone to keep it from breaking. Furthermore, Dr. Jennifer Schneider of Tucson, an internist who after seven years on Fosamax suffered a nontraumatic femur fracture that took two years to heal, notes that the damage is often bilateral — so when a problem is found in one leg, the other leg should be thoroughly examined. Among patients in an online support and information group she established, some reported suffering a second atypical fracture in the other thigh. Dr. Schneider invites patients who have had such a fracture to write to her at jennifer@jenniferschneider.com.

Really?: The Claim: Back Pain Runs in Families Posted: 08 Mar 2011 08:57 AM PST THE FACTS Enlarge This Image Christoph Niemann Well Share your thoughts on this column at the Well blog. Go to Well » Related More Really? Columns Health Guides: Nonspecific Back Pain | Low Back Pain - Chronic Heavy lifting, overuse and middle age are some of the most familiar risk factors for lower back pain. But for many people, predicting a lifetime of lumbar trouble could be as simple as consulting the family tree. A growing number of studies are finding that chronic back pain has a strong genetic component. In the past, researchers who looked at families with multiple back patients had trouble ruling out the environmental factors that relatives often share, like similar lifestyles and careers, or habits like smoking and lack of exercise. Now, however, studies have shown a clear connection. In one large analysis published in February in The Journal of Bone and Joint Surgery, researchers at the University of Utah used records from a large health and genealogic database to study more than a million Utah residents. As they scoured the data, they focused on people with herniated or degenerating disks — diagnoses that commonly result in chronic pain. The data showed that having a second-degree relative (aunt, uncle or grandparent) or third-degree relative (cousin) with the condition increased a person’s risk, regardless of environmental factors. And having an immediate family member raised a person’s risk more than four times. Other studies have strengthened the hypothesis by identifying at least two versions of a gene that produces a collagen protein and appears closely linked to sciatica and disk herniation. THE BOTTOM LINE Development of lower back pain appears to have a genetic component. ANAHAD O’CONNOR scitimes@nytimes.com

Q & A: Control Yourself! Posted: 07 Mar 2011 08:20 PM PST Q. Is there evidence that Kegel exercises really strengthen bladder control? Enlarge This Image Victoria Roberts Related More Q & A Columns RSS Feed Get Science News From The New York Times » A. Several studies have found that Kegel exercises, in which the muscles that cut off urinary flow are tensed and then relaxed, can help many people control stress-related urinary incontinence, if the exercises are properly done. In some studies, surgery was found to be more effective, but it has risks not associated with exercise. In stress incontinence, pelvic floor muscles that support the bladder are weak and the sphincter muscles around the urethra are not strong enough to prevent leakage during movement. A simple Kegel exercise involves cutting off urine flow for six seconds and resuming urination for six seconds. Urologists recommend doing several cycles several times daily. In a study published in the journal Gerontology, half of a group of incontinent women in a nursing home were treated with both exercises and bladder training, to increase the interval between urinations. “A significant increase in pelvic floor strength was observed in the treatment group compared to the control group,” with improvement in symptoms, the study reported. Kegel exercises have also been used effectively by men and children. In other studies, Kegel success rates were higher with supervision and biofeedback, and a studyfound that when exercise treatment was initially successful, there was a 66 percent chance that the results would last for 10 years. C. CLAIBORNE RAY Readers are invited to submit questions by mail to Question, Science Times, The New York Times, 620 8th Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com. This posting includes an audio/video/photo media file: Download Now

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Prescriptions: The Case of the Missing Pepcid Tablets Posted: 08 Mar 2011 10:50 AM PST

Prescriptions: A Team Approach to Patient Care Falters Posted: 08 Mar 2011 04:00 AM PST

Letters: The Human Touch (1 Letter) Posted: 07 Mar 2011 08:30 PM PST To the Editor: Re “18 Stethoscopes, 1 Heart Murmur and Many Missed Connections” (Cases, March 1): Madeline Drexler’s experience serving as a patient with a heart murmur for a Harvard Medical School class on physical examination illustrates why medical school admissions committees need to place greater emphasis on evaluating applicants’ personal qualities and characteristics when deciding whom to accept. Some medical schools are indeed trying to look beyond applicants’ grades and exam scores. However, many medical schools still consider academic success as the most important factor. Until medical school admissions committees make a united effort to look beyond the numbers, we will still have many future physicians who treat patients like anatomical models and lack the compassion, empathy and communication skills that are essential to good medical practice. Jessica Freedman New York The writer is president, MedEdits Medical Admissions. 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: Anesthesia’s Mysteries (2 Letters) Posted: 07 Mar 2011 08:30 PM PST To the Editor: RSS Feed Get Science News From The New York Times » Re “A Conversation With Emery N. Brown,” (March 1): While I agree wholeheartedly with Dr. Brown that we anesthesiologists do ourselves and our patients a disservice by saying we are “putting you to sleep,” I have to point out the battle is steeply uphill. I have on several occasions used with my more scientifically aware patients the exact wording he suggests — “it’s a drug-induced coma” — and the responses have always bordered on fear, sometimes with expressions suggesting they’d like another doctor. Interestingly, I seem to find better reception with school-age children. Studies have shown they have quite rational fears that (a) they will wake up during the operation (after all, it’s only sleep) or (b) they’ll never wake up if they’re given something that strong. They nod and once in a while look relieved when I explain it’s a special kind of medicine — almost like magic. Hopefully Dr. Brown et alia can flesh out the details our sleight of hand, but, as patients also don’t like hearing, we don’t really know how consciousness works — so unconsciousness is hardly clearer. David Farris, M.D. Portland, Ore. ♦ To the Editor: I had my first corrective surgery due to “infantile paralysis” in 1949. The bill from the anesthesiologist was $400. My mother was horrified, but my father calmed her when he said, “It was probably $50 for the procedure, but I gladly pay the other $350 because he knew how to wake her up.” Ina Pinkney Chicago 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. This posting includes an audio/video/photo media file: Download Now

Letters: Don’t Eat That! (1 Letter) Posted: 07 Mar 2011 08:30 PM PST RSS Feed Get Science News From The New York Times » To the Editor: Re “The 5-Second Rule” (Q&A, March 1): I must strongly disagree with all of that American cleanliness. I am in the best of health at 85. I grew up in Egypt, which is full of awful diseases that they haven’t even heard of here. All of the European immigrants carefully washed or boiled everything before eating it. None ever even touched the Nile water. They all had constant stomach problems, which killed some of them. I, on the other hand, ate everything, even from the dirty floors of the Cairo streets. I swam in the Nile and even drank from it. I was never sick and continued to purposely eat anything anywhere that I dropped on the floor. I was thereby inoculated against all of the common and uncommon diseases that strike all of my friends. I never get a flu shot and have never caught it. My numerous doctors all warn me that I can expect to live to be 100. Frank Nissel Ambler, Pa. This posting includes an audio/video/photo media file: Download Now

Recipes for Health: Fava Bean Stew With Bulgur Posted: 07 Mar 2011 03:00 PM PST I usually go through the tedious process of shelling and skinning fava beans to make this robust stew. But if fava beans aren’t available in local markets, use frozen skinned favas instead. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Vegan Recipes for Lent (March 7, 2011) Recipes for Health: Carrots and Lentils in Olive Oil (March 8, 2011) Recipes for Health: Cabbage With Tomatoes, Bulgur and Chickpeas (March 9, 2011) Recipes for Health: Wheat Berries With Winter Squash and Chickpeas (March 11, 2011) 3 tablespoons extra virgin olive oil, plus additional for drizzling 2 medium onions, chopped 6 garlic cloves, minced 1/4 cup chopped fresh parsley 1/4 cup chopped cilantro Salt 1 (14-ounce) can chopped tomatoes, with liquid 1 pound frozen shelled and skinned fava beans, or 2 pounds fresh favas, shelled and skinned 2 tablespoons tomato paste 3/4 teaspoon cinnamon 1 tablespoon paprika 1/4 to 1/2 teaspoon cayenne (to taste) Freshly ground pepper 1 cup coarse bulgur 1. In a large, lidded skillet or Dutch oven, heat the olive oil over medium heat. Add the onions. Cook, stirring, until tender, about five minutes. Add the garlic, half the parsley, half the cilantro and salt to taste. Continue to cook for another minute or two, stirring. Add the tomatoes, and cook, stirring often, for 10 to 15 minutes until the tomatoes have cooked down and smell fragrant. 2. Add the fava beans, tomato paste, cinnamon, paprika, cayenne and 2 cups water, or enough to just cover the vegetables, and bring to a simmer. Simmer 30 minutes or until the favas are tender and the stew very fragrant. Stir in the remaining parsley and cilantro, grind in some pepper and taste and adjust salt. 3. While the stew is simmering, reconstitute the bulgur. Bring 2 cups water to a boil in a medium saucepan. Add the bulgur and salt to taste, reduce the heat, cover and simmer 20 minutes or until the water is absorbed. Remove from the heat and uncover. Place a clean dish towel over the pan, then replace the lid. Allow to sit undisturbed for 10 minutes. Alternatively, place the bulgur in a medium bowl with salt to taste, and cover with 2 cups hot or boiling water. Allow to sit for 20 to 25 minutes until most of the water is absorbed. Drain through a strainer, and squeeze out the water. 4. Spoon bulgur into wide soup bowls, and top with the fava bean stew. Drizzle on some olive oil, and serve. Yield: Serves four. Advance preparation: This can be made up to a day ahead and reheated. Wait until you reheat before adding the remaining parsley and cilantro. Leftovers will taste great for about five days. Nutritional information per serving: 342 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligrams cholesterol; 58 grams carbohydrates; 17 grams dietary fiber; 259 milligrams sodium (does not include salt to taste); 14 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Carrots and Lentils in Olive Oil Posted: 08 Mar 2011 12:10 AM PST This is an adaptation of a Turkish recipe, a sweet and savory combination of lentils, onions and carrots that can be served hot or at room temperature, as a main dish or a side. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Vegan Recipes for Lent (March 7, 2011) Recipes for Health: Cabbage With Tomatoes, Bulgur and Chickpeas (March 9, 2011) Recipes for Health: Fava Bean Stew With Bulgur (March 10, 2011) Recipes for Health: Wheat Berries With Winter Squash and Chickpeas (March 11, 2011) 1 cup brown, green or black lentils, rinsed 3 cups water 1/4 cup extra virgin olive oil 1 onion, halved lengthwise, then sliced thin across the grain 1 teaspoon coriander seeds 4 garlic cloves, minced 1 1/2 pounds carrots, peeled and sliced thin (about 4 cups sliced) 1 tablespoon tomato paste dissolved in 1 cup water 1 teaspoon sugar Salt to taste 1/2 cup chopped fresh mint 1. Combine the lentils with 3 cups water in a saucepan, and bring to a boil. Reduce the heat, cover and simmer for 15 minutes. Set a strainer over a bowl, and drain. 2. Heat the oil over medium heat in a heavy casserole or skillet. Add the onion and coriander seeds. Cook, stirring, until the onion is tender, about five minutes. Add the garlic and carrots and salt to taste. Cook, stirring, for two to three minutes until the carrots begin to soften. Stir in the dissolved tomato paste, sugar and lentils. Add 1 to 1 1/2 cups of the cooking water from the lentils (enough to cover the lentils), salt to taste and half the mint. Bring to a simmer, and simmer uncovered for 15 to 20 minutes until the lentils are tender and much of the liquid has evaporated. Taste and adjust salt. Remove from the heat, sprinkle on the remaining mint and serve, or allow to cool and serve at room temperature with cooked whole grains, like bulgur or quinoa. Yield: Serves four to six. Advance preparation: This will keep for three to four days in the refrigerator. The dish is delicious served at room temperature. Nutritional information per serving (four servings): 380 calories; 2 grams saturated fat; 2 grams polyunsaturated fat; 10 grams monounsaturated fat; 0 milligrams cholesterol; 51 grams carbohydrates; 17 grams dietary fiber; 140 milligrams sodium (does not include salt to taste); 15 grams protein Nutritional information per serving (six servings): 253 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 7 grams monounsaturated fat; 0 milligrams cholesterol; 34 grams carbohydrates; 12 grams dietary fiber; 93 milligrams sodium (does not include salt to taste); 10 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Vegan Recipes for Lent Posted: 08 Mar 2011 02:44 PM PST This week marks the beginning of Lent, when many of us choose to abstain from meat or dairy products until Easter. Hearty vegan dishes are perfect for the season. The ones offered here last year were Greek in origin. This year’s Lenten recipes are Mediterranean, too, but with Middle Eastern and North African flavors. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Cabbage With Tomatoes, Bulgur and Chickpeas (March 9, 2011) Recipes for Health: Carrots and Lentils in Olive Oil (March 8, 2011) Recipes for Health: Fava Bean Stew With Bulgur (March 10, 2011) Recipes for Health: Wheat Berries With Winter Squash and Chickpeas (March 11, 2011) All of this week’s vegan recipes can be made ahead of serving, and they’re suitable for the slow-cooker. Some of these dishes are traditionally served at room temperature, though I usually serve them warm. And while they may be appropriate for a time of self-sacrifice, “abstinence” is certainly not the word that comes to mind when they arrive at the table. Baked Beans With Mint, Peppers and Tomatoes I’m becoming hooked on baked beans. The long, slow, gentle cooking called for in this recipe results in a thick, sweet sauce and very soft beans. 1 pound borlotti or pinto beans, rinsed, picked over and soaked, if desired, in 2 quarts water for six hours or overnight 1 dried or fresh hot red chili pepper Salt 2 medium onions, chopped 1/4 cup extra virgin olive oil 3 large garlic cloves, minced or pressed 2 red bell peppers, chopped 2 teaspoons paprika 1 14-ounce can chopped tomatoes with juice 2 tablespoons tomato paste Freshly ground pepper 2 tablespoons chopped fresh mint, plus additional for garnish 1. If you have soaked the beans, drain them over a bowl and use the soaking water for cooking. Combine with enough water to cover by two inches in a large, ovenproof casserole or Dutch oven. Add the dried chili, bring to a boil, reduce the heat and simmer 45 minutes to an hour until the beans are tender but intact. Stir in salt to taste. 2. While the beans are simmering, heat the oven to 300 degrees and prepare the remaining vegetables. Heat the oil over medium heat in a large, heavy frying pan. Add the onions. Stir together, cover and cook, stirring occasionally, for 15 minutes until lightly browned. Stir in the garlic, the red peppers and a pinch of salt, and cook, stirring, for five minutes until the peppers are just tender and the mixture is fragrant. Add the paprika, tomatoes and tomato paste, and cook, stirring often, until the tomatoes have cooked down a little, five to 10 minutes. Remove from the heat, and add this mixture to the beans. Add freshly ground pepper and the mint, and blend the mixture thoroughly. Taste and adjust salt. 3. Place the beans in the oven, and bake, covered, for 1 1/2 hours until very tender and the broth has reduced to a thick sauce. Stir and check from time to time to make sure the beans are covered with liquid. Add hot water if necessary. Garnish with additional mint and serve, or allow to cool and serve warm. Yield: Serves six. Advance preparation: The beans can be prepared through Step 2 up to a day before you bake them. The baked beans will keep for three to five days in the refrigerator. Nutritional information per serving: 384 calories; 2 grams saturated fat; 1 gram polyunsaturated fat; 7 grams monounsaturated fat; 0 milligrams cholesterol; 58 grams carbohydrates; 19 grams dietary fiber; 125 milligrams sodium (does not include salt to taste); 18 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Urban Athlete: Happy to Bend Over Backward Posted: 03 Mar 2011 09:50 PM PST IT might seem strange that when Adam Woolley turned 26 in November, a group of his colleagues sang “Happy Birthday” as they, and he, were doing handstands. Handstands, though, are not so difficult for this crowd: they’re all students in a contortion class taught by Jonathan Nosan, and for most of them basic acrobatic moves are child’s play. The class, which Mr. Nosan has been teaching weekly since last fall at the Sankalpah Yoga Studio in Manhattan, tends to draw people who, as one student put it, use their bodies to make a living. Mr. Woolley is a professional hand balancer, and aerialists, a fitness pole dancer and ballet and modern dancers are among the other regulars. Even Isaac Peña, who founded the studio (with Jude English) and teaches yoga, takes Mr. Nosan’s class. At first blush, it resembles some yoga classes, minus music, chanting or incense, but it transforms. “Yoga is more of an all-around wellness sort of thing, where it’s all about balance,” Mr. Peña said after a recent class. “Contortion is more extreme.” Students spend a good part of the 75 minutes bent over backward. And they’re not just poised in a backbend, but doing exercises like “the waterfall,” which requires them to lean back, touch the floor, return to a standing position and then repeat the motion several times — a reverse toe touch, more or less. “This one is a real sternum cracker,” Mr. Nosan said during one class as he coached his charges (and made an observer cringe). The atmosphere in what Mr. Nosan calls his “contorture chamber” is light. The instructor giggles, and students joke and congratulate one another after difficult maneuvers. The camaraderie is palpable, partly because, outside of class, some of these folks move in the same circles. “The circus world is minuscule,” said Rachel Salzman, an aerialist and hand balancer who has done yoga with Mr. Peña and performed with other students in the class. “We all kind of know each other somehow.” But the airy atmosphere belies students’ intensity, and Mr. Nosan can be exacting. At a recent class he took time to work with Mr. Peña on the placement of one toe. “Are you feeling something?,” he polled the students while they were doing hanging back bends (long leans backward, but your hands are not touching the floor). “I would hate to have you in this position and not feeling anything.” Once he even advised a student to “relax the forehead.” That actually counts as job advice for this crowd. “I’ve been doing yoga for a long time, but you don’t train like this in a yoga class,” said Marlo Fisken, a teacher and performer who won the American Pole Fitness Championships last fall, but still finds contortion class challenging. “I come here to work on my weaknesses,” she said. Clearly this class is not for everyone, but it may not be as much of a stretch as it sounds to those among us who huff and puff when bending over to tie our shoelaces. Mr. Nosan himself couldn’t even touch his toes 20 years ago. A former academic devoted to Asian studies at the University of California, Berkeley, and a Fulbright scholar, Mr. Nosan is today, at 42, a full-time contortionist who has performed in theater and circus events and has been a stunt double in films and commercials. He can touch his toes now, even bending over backward.

National Briefing | Washington: U.S. Appeals Florida Health Care Ruling Posted: 08 Mar 2011 11:40 PM PST The Justice Department filed notice on Tuesday that it was appealing a decision by a federal judge in Florida who struck down the new health care law, saying it was unconstitutional for the federal government to require Americans to obtain health insurance. The judge, Roger Vinson of Federal District Court in Pensacola, voided the entire law after finding that the insurance requirement was “inextricably bound” to other provisions of the statute. The Justice Department said it was asking the United States Court of Appeals for the 11th Circuit, in Atlanta, to provide an “expedited review” of the decision.

Drug Firms Face Billions in Losses in ’11 as Patents End Posted: 08 Mar 2011 12:00 AM PST At the end of November, Pfizer stands to lose a $10-billion-a-year revenue stream when the patent on its blockbuster cholesterol drug Lipitor expires and cheaper generics begin to cut into the company’s huge sales. Multimedia Graphic Fewer New Drugs Gain Approval Add to Portfolio Novartis AG Pfizer Inc Eli Lilly and Company GlaxoSmithKline PLC Sanofi-Aventis S.A Genzyme Corp Merck & Company Inc Morgan Stanley Go to your Portfolio » Enlarge This Image J.B. Reed/Bloomberg News Pfizer could lose $10 billion in annual revenue when the patent on Lipitor, the cholesterol-cutting drug, expires in November. The loss poses a daunting challenge for Pfizer, one shared by nearly every major pharmaceutical company. This year alone, because of patent expirations, the drug industry will lose control over more than 10 megamedicines whose combined annual sales have neared $50 billion. This is a sobering reversal for an industry that just a few years ago was the world’s most profitable business sector but is now under pressure to reinvent itself and shed its dependence on blockbuster drugs. And it casts a spotlight on the problems drug companies now face: a drought of big drug breakthroughs and research discoveries; pressure from insurers and the government to hold down prices; regulatory vigilance and government investigations; and thousands of layoffs in research and development. Morgan Stanley recently downgraded the entire group of multinational pharmaceutical companies based in Europe — AstraZeneca, Bayer, GlaxoSmithKline, Novartis, Novo Nordisk and Roche — in a report titled “An Avalanche of Risk? Downgrading to Cautious.” The analysts wrote, “The operating environment for pharma is worsening rapidly.” The same concerns apply to drug giants in the United States. They are all struggling with research failures as they scramble to replace their cash cows, like Pfizer’s multimillion-dollar gamble on a replacement for the cholesterol-lowering drug Lipitor, which failed miserably in clinical trials. Drug companies cut 53,000 jobs last year and 61,000 in 2009, far more than most other sectors, according to the outplacement company Challenger, Gray & Christmas. “This is panic time, this is truly panic time for the industry,” said Kenneth I. Kaitin, director of the Center for the Study of Drug Development at Tufts University in Medford, Mass. “I don’t think there’s a company out there that doesn’t realize they don’t have enough products in the pipeline or the portfolio, don’t have enough revenue to sustain their research and development.” While industrywide research and development spending has nearly doubled to $45 billion a year over the last decade, the Food and Drug Administration has approved fewer and fewer new drugs. Pfizer and Eli Lilly had major setbacks last year in once-promising Alzheimer’s drug experiments. Merck discontinued one of two major clinical trials testing its top acquisition from its merger with Schering Plough, a blood thinner that caused dangerous amounts of bleeding in some patients. Drug company executives have begun addressing the calls for reinvention. “We have to fix our innovative core,” Pfizer’s new president, Ian C. Read, said in an interview recently. To do that, the company is refocusing on smaller niches in cancer, inflammation, neuroscience and branded generics — and slashing as much as 30 percent of its own research and development spending in the next two years as its scientists work on only the most potentially profitable prospects. Consumers should see a financial benefit as lower-cost generics replace the expensive elite drugs, but may suffer in the long term if companies reduce research and do not produce new drugs that meet the public’s needs. “You don’t lay off R&D if it’s just a cycle,” says Erik Gordon, a clinical assistant professor at the University of Michigan business school who follows the pharmaceutical industry. “That kills progress.” The federal government is also concerned about the slowing pace of new drugs coming from the industry. Francis S. Collins, director of the National Institutes of Health, recently proposed a billion-dollar drug development center at the agency. “We seem to have a systemic problem here,” Dr. Collins said, adding that government research efforts were intended to feed the private sector, not compete with it. Mr. Read of Pfizer says new products can replace some but not all of the patent losses. “The hurricane is making landfall,” said Jeremy Batstone-Carr, an analyst at Charles Stanley Securities, but he added that Pfizer is among several drug companies giving solace to shareholders by returning money through stock buybacks and dividends. Pfizer’s best asset, he said, is its $20 billion stockpile of cash. Yet since 2000, Pfizer’s and Merck’s share prices dropped about 60 percent, while the Dow rose 19 percent. Several of the drug titans have bought competitors with newer products to fill their own sales gaps, essentially paying cash for future revenue as their own research was flagging. In the last two years, Pfizer paid $68 billion for Wyeth, Merck paid $41 billion for Schering-Plough, Roche paid $46 billion for Genentech, and Sanofi-Aventis paid $20 billion for Genzyme. Henry G. Grabowski, a professor of economics and director of the Duke University program in pharmaceutical health economics, likened the recent pharmaceutical megamergers to those that occurred in the banking and telecommunications industries when they were hit by financial shocks in the 1990s. But he warned that this wave would not guarantee significant research developments in the long term. “It’s never been shown that these big horizontal mergers are good for R&D productivity,” Dr. Grabowski said. “I’m in a show-me mode that they get you any real advances other than some short-term cost efficiencies that wear out.” 1 2 Next Page »

In Montana, an Economic Boon Faces Repeal Effort Posted: 05 Mar 2011 10:40 PM PST BOZEMAN, Mont. — With his electrician’s tool belt and company logo cap, Rick Schmidt looks every bit the small-business owner he in fact is. That he often reeks of marijuana these days ... well, it is just part of the job, he said. Enlarge This Image Mike Albans for The New York Times The six-year-old medical marijuana industry is thriving in the state, but lawmakers are considering a measure that would shut it down. “I went on a service call the other day — walked in and a guy said to me, ‘What have you been smoking?’ ” said Mr. Schmidt, 39. For Gallatin Electric, a six-employee company founded by Mr. Schmidt’s father, Richard, as for other businesses in this corner of south-central Montana, medical marijuana has been central to surviving hard times as the construction industry and the second-home market collapsed. Not the smoking of it, the growing of it or even the selling of it, but the fully legal, taxable revenues being collected from the industry’s new, emerging class of entrepreneurs. Three of the four electricians on staff at Gallatin, Mr. Schmidt said, are there only because of the work building indoor marijuana factories. Questions about who really benefits from medical marijuana are now gripping Montana. In the Legislature, a resurgent Republican majority elected last fall is leading a drive to repeal the six-year-old voter-approved statute permitting the use of marijuana for medical purposes, which opponents argue is promoting recreational use and crime. If repeal forces succeed — the House last month voted strongly for repeal, and the Senate is now considering it — Montana would be the first to recant among the 15 states and the District of Columbia that have such laws. In Bozeman, a college and tourism town north of Yellowstone National Park, construction jobs and tax collections dried up just as the marijuana business was blossoming; residents and politicians here say the interconnection of economics and legal drugs would be much more complicated to undo. Economic ripples or entanglements extend in every direction, business people like the Schmidts say — gardening supply companies where marijuana growers are buying equipment, mainstream bakeries that are contracting for pot-laced pastries, and even the state’s biggest utility, NorthWestern Energy, which is seeing a surge in electricity use by the new factories. Medical marijuana, measured by numbers of patients, has roughly quadrupled in Montana in the last year. “It’s new territory we’re treading in here,” said Brad Van Wert, a sales associate at Independent Power Systems, a Bozeman company that completed its first solar installation last month — a six-kilowatt rooftop solar array, costing about $40,000 — for a medical marijuana provider called Sensible Alternatives. Mr. Van Wert said that his company was assertively going after this new market, and that marijuana entrepreneurs, facing big tax bills, were responding to the appeal of a 30 percent tax credit offered by the state for expansion of renewable energy. The Bozeman City Council passed regulations last year sharply restricting the numbers of storefront suppliers downtown. But growers and providers say that even though the regulations restricted their numbers, they also created a climate of legitimacy that has made other businesses more comfortable in dealing with them for equipment and supplies. And unlike the situation in sunny California or Colorado, where medical marijuana has similarly surged, growing marijuana indoors is all but mandatory here, a fact that has compounded the capital expenditures for start-ups and spread the economic benefits around further still. An industry group formed by marijuana growers estimates that they spend $12 million annually around the state, and that 1,400 jobs were created mostly in the last year in a state of only 975,000 people. “Twenty-five thousand dollars a month,” one new grower and medical marijuana provider, Rob Dobrowski, said of his outlay for electricity alone, mainly for his light-intensive grow operation that supplies four stores around the state. Mr. Dobrowski was a construction contractor until the recession hit, as were two of his brothers who have joined him in the business. He said he now employs 33 people, from a standing start of zero a year ago. Bozeman’s mayor, Jeff Krauss, a Republican, said he thought there was an element of economic fairness to be considered in the debate about medical marijuana’s future. “I don’t think anybody passed it thinking we were creating an industry,” he said, referring to the 2004 voter referendum. But like it or not, he said, it has become one, and legal investments in the millions of dollars have been made. “Somewhere around 25 people have made anywhere from a $60,000 to a $100,000 bet on this industry,” Mr. Krauss said, referring to the local startups and their capital costs. 1 2 Next Page »

Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy Posted: 07 Mar 2011 11:01 AM PST DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help. Farewell to the Couch Articles in this series will examine recent shifts in medical care. Well Share your thoughts on this column at the Well blog. Go to Well » Are You a Doctor? Share your insights on the changing medical profession with The New York Times and the Public Insight Network from American Public Media. Tell us your story. Enlarge This Image David Ahntholz for The New York Times Dr. Matthew Levin, son of Dr. Donald Levin, is completing training to be a psychiatrist. The elder Dr. Levin said he hoped his son would not feel his ambivalence about their profession. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.” Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved. Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry. Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday. Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional. Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.” Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system. “It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.” With thinning hair, a gray beard and rimless glasses, Dr. Levin looks every bit the psychiatrist pictured for decades in New Yorker cartoons. His office, just above Dog Daze Canine Hair Designs in this suburb of Philadelphia, has matching leather chairs, and African masks and a moose head on the wall. But there is no couch or daybed; Dr. Levin has neither the time nor the space for patients to lie down anymore. On a recent day, a 50-year-old man visited Dr. Levin to get his prescriptions renewed, an encounter that took about 12 minutes. Two years ago, the man developed rheumatoid arthritis and became severely depressed. His family doctor prescribed an antidepressant, to no effect. He went on medical leave from his job at an insurance company, withdrew to his basement and rarely ventured out. “I became like a bear hibernating,” he said. Missing the Intrigue He looked for a psychiatrist who would provide talk therapy, write prescriptions if needed and accept his insurance. He found none. He settled on Dr. Levin, who persuaded him to get talk therapy from a psychologist and spent months adjusting a mix of medications that now includes different antidepressants and an antipsychotic. The man eventually returned to work and now goes out to movies and friends’ houses. The man’s recovery has been gratifying for Dr. Levin, but the brevity of his appointments — like those of all of his patients — leaves him unfulfilled. “I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.” “I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.” The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills. 1 2 3 4 Next Page »

Cancer Research Before Activism, Billionaire Conservative Donor Says Posted: 05 Mar 2011 01:40 AM PST CAMBRIDGE, Mass. — More than a thousand miles from the labor tumult in Wisconsin — where his name shows up on the signs of protesters and a liberal blogger impersonating him got through to the governor on the phone and said “gotta crush that union!” — the real David H. Koch was greeted rather more warmly here Friday when he officially opened a new cancer research institute bearing his name. Enlarge This Image (AP Photo/The Desert Sun, Crystal Chatham) RIVERSIDE PRESS-ENTERPRISE OUT; NO FOREIGN Mr. Koch and his brother Charles, both No. 5 in Forbes’s list of the richest Americans, are targets of liberal activists. Mr. Koch, a billionaire who is perhaps best known for his family’s contributions to conservative causes, got a standing ovation from scientists, Nobel laureates and politicians of various political stripes as he opened the new David H. Koch Institute for Integrative Cancer Research at the Massachusetts Institute of Technology, which he gave $100 million to help build. And in a brief, and rare, interview, Mr. Koch, 70, spoke of his hopes for the new center, his prostate cancer and the prank call heard around the world. “It’s a case of identity theft,” Mr. Koch said of the call in which the liberal blogger got through to Gov. Scott Walker of Wisconsin, drew him out about his plans to weaken unions and posted a recording of the call on the Internet, making news and embarrassing the governor. Mr. Koch, whose company, Koch Industries, had given major campaign support to Governor Walker, among other conservative candidates and causes, added, “I didn’t even know his name before this brouhaha erupted.” Mr. Koch joked that the call could cause him problems. “I was thinking to myself, ‘My God, if I called up a senator or a congressman to discuss something with them, and they heard ‘David Koch is on the line,’ they’d immediately say, ‘That’s that fraud again — tell him to get lost!’ ” he said with a laugh Mr. Koch said that only a relatively small portion of his giving goes to politics and public policy — most, he said, goes to cancer research, followed by cultural and educational institutions. But he said that he felt he had been vilified for his support of conservative causes, which have ranged from opposition to the health care bill and pushing for small government and low taxes, to questioning whether climate change is caused by humans. He and his brother Charles are known, on the left, as the billionaires who bankrolled the public policy and citizen action groups that helped cultivate the Tea Party. “I read stuff about me and I say, ‘God, I’m a terrible guy,’ ” he said. “And then I come here and everybody treats me like I’m a wonderful fellow, and I say, ‘Well, maybe I’m not so bad after all.’ ” The new institute here is taking an innovative approach by uniting cancer scientists and engineers under one roof — an approach that the institute’s director, Tyler Jacks, who is also the David H. Koch Professor of Biology, said should yield results. “Engineers are more problem-solvers; cancer scientists tend to be more discoverers,” Dr. Jacks said in an interview. “And the combination is actually extremely powerful.” “So we have engineers who are interested in nanotechnology, for delivering cancer drugs more effectively and more specifically to cancer cells — that’s an engineering problem,” he said. “We have other engineers who are interested in building new devices that can monitor the state of an individual’s health more sensitively and more continuously — imagine implantable sensors that would allow you to know whether your disease is in remission or undergoing relapse. Again, that’s an engineering problem.” In his speech at the opening ceremony, Mr. Koch warned that government spending cuts could impede cancer research. And he urged donors to fill the gap. “The National Institutes of Health, and the National Cancer Institute in particular, are facing serious cutbacks in their funding due to the massive deficits the federal government is incurring,” he said in his speech, in a tent outside the seven-story building. “If the cutbacks happen, it will significantly diminish the level of research that can be carried on at the Koch Institute. I earnestly ask you to do all you can to help maintain the superb research at the Koch Institute at its maximum level.” Mr. Koch is tied with his brother Charles as the fifth wealthiest American in Forbes magazine’s most recent ranking, and came in 45th in the Chronicle of Philanthropy’s list of donors who gave the most in 2010. Stacy Palmer, the editor of the Chronicle, said that Mr. Koch was unusual in the wide range of his philanthropy, which supports cancer research, the arts and the public policy sphere. His roles do not always fit neatly together. His gift here means that one of the biggest donors to the Massachusetts Institute of Technology, home to some of the top climate scientists in the nation, is an owner of a company that Greenpeace called “a kingpin of climate change denial.” Koch Industries — which owns oil refineries, pipelines and consumer brands like Dixie cups and Lycra — responded that “it is Greenpeace that is the denier here — denier of any rational and honest dialogue on the underlying scientific debate regarding climate change.” And while he has become a major financier of cancer research around the country, one of his companies, Georgia-Pacific, which produces formaldehyde, has been trying to convince the government not to list formaldehyde as a human carcinogen. Koch Industries said it would respect and comply with any new governmental regulation. Mr. Koch said that he and his brother had not decided how much money to spend to influence the 2012 elections. 1 2 Next Page »

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