Saturday, April 2, 2011

Health - Doctors Inc.: More Physicians Say No to Endless Workdays

Health - Doctors Inc.: More Physicians Say No to Endless Workdays

Doctors Inc.: More Physicians Say No to Endless Workdays

Posted: 02 Apr 2011 05:48 AM PDT

HONESDALE, Pa. — Even as a girl, Dr. Kate Dewar seemed destined to inherit the small-town medical practice of her grandfather and father. At 4, she could explain how to insert a pulmonary catheter. At 12, she could suture a gash. And when she entered medical school, she and her father talked eagerly about practicing together.

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Articles in this series are examining recent shifts in medical care.

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Nicole Bengiveno/The New York Times

Dr. Kate Dewar in the emergency room at Lehigh Valley Hospital in Allentown, Pa. Work in the E.R. varies, but the hours are fixed.

But when she finishes residency this summer, Dr. Dewar, 31, will not be going home. Instead, she will take a job as a salaried emergency room doctor at a hospital in Elmira, N.Y., two hours away. An important reason is that she prefers the fast pace and interesting puzzles of emergency medicine, but another reason is that on Feb. 7 she gave birth to twins, and she cannot imagine raising them while working as hard as her father did.

“My father tried really hard to get home, but work always got in the way,” Dr. Dewar said. “Even on Christmas morning, we would have to wait to open our presents until Dad was done rounding at the hospital.”

Dr. Dewar’s change of heart demonstrates the significant changes in American medicine that are transforming the way patients get care.

For decades, medicine has been dominated by fiercely independent doctors who owned their practices, worked night and day, had comfortable incomes and rarely saw their families.

But with two babies, Dr. Dewar wants a life different from her father’s and grandfather’s. So instead of being an entrepreneur, she will become an employee of a large corporation working 36 hours a week — half the hours her father and grandfather worked.

Indeed, emergency room and critical-care doctors work fewer hours than any other specialty, according to a 2008 report from the federal Department of Health and Human Services.

Her decision is part of a sweeping cultural overhaul of medicine’s traditional ethos that along with wrenching changes in its economics is transforming the profession. Like Dr. Dewar, many other young doctors are taking salaried jobs, working fewer hours, often going part time and even choosing specialties based on family reasons. The beepers and cellphones that once leashed doctors to their patients and practices on nights, weekends and holidays are being abandoned. Metaphorically, medicine has gone from being an individual to a team sport.

For doctors, the changes mean more control of their personal lives but less of their professional ones; for patients, care that is less personal but, as studies have shown, more proficient.

Older doctors view these changes with considerable ambivalence, among them Dr. Dewar’s 90-year-old grandfather and 61-year-old father, although both supported Dr. Kate Dewar’s decisions and were thrilled about the birth of her twins.

“My son and I had deeper feelings for our patients than I think Kate will ever have,” Dr. William Dewar II said over lunch at a diner in Honesdale, about 30 miles northeast of Scranton. Munching on a club sandwich, Dr. William Dewar III gestured toward the diner’s owner, who had greeted them deferentially.

“I’ve had three generations of his family under my care,” he said as a waitress brought his usual Diet Coke without being asked. “Kate will never have that.”

In a separate interview, Dr. Kate Dewar said that treating chronic conditions like diabetes and high cholesterol — a huge part of her father’s daily life — was not that interesting. She likened primary care to the movie “Groundhog Day,” in which the same boring problems recur endlessly. Needing constant stimulus — she e-mails while watching TV — she realized she could not practice the medicine of her forebears.

“I like it when people get better, but I’d rather it happen right in front of my eyes and not years later,” she said. “I like to fix stuff and then move on.”

Her attitude is part of a gradual distancing between doctors and patients. Doctors were once revered, but a host of intermediaries — insurers, lawyers, the Internet, growing patient needs and expectations — have intervened, to the point that many patients now see doctors as interchangeable. Younger doctors are deciding that the personal price of being at their patients’ beck and call is too high, while acknowledging that teams of doctors can offer a higher quality of care. So they are embracing corporate, less entrepreneurial and less intimate roles in part for the uninterrupted family time they bring.

Cuts Leave Patients With Medicaid Cards, but No Specialist to See

Posted: 01 Apr 2011 11:40 PM PDT

LAFAYETTE, La. — Eight-year-old Draven Smith was expelled from school last year for disruptive behavior, and he is being expelled again this year. But his mother and his pediatrician cannot find a mental health specialist to treat him because he is on Medicaid, and the program, which provides health coverage for the poor, pays doctors so little that many refuse to take its patients.

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Michael Stravato for The New York Times

Dr. Rachel Chatters, right, with Ana Smith, says she begs specialists to see Medicaid patients.

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Michael Stravato for The New York Times

Ms. Smith said she has tried for more than a year to find a psychiatrist to treat her son Draven, 8, who is on Medicaid.

The problem is common here and across the country, especially as states, scrambling to balance their budgets, look for cuts in Medicaid, which is one of their biggest expenditures. And it presents the Obama administration with a major challenge, since the new federal health care law relies heavily on Medicaid to cover many people who now lack health insurance.

“Having a Medicaid card in no way assures access to care,” said Dr. James B. Aiken, an emergency physician in New Orleans.

Nicole R. Dardeau, 46, a nurse in Opelousas, La., in the heart of Cajun country, can attest to that. She said she could not work because of unbearable pain in her right arm. Doctors have found three herniated discs in her neck and recommended surgery, but cannot find a surgeon to take her as a Medicaid patient.

From her pocketbook, she pulls an insurance card issued by the Louisiana Department of Health and Hospitals.

“My Medicaid card is useless for me right now,” Ms. Dardeau said over lunch. “It’s a useless piece of plastic. I can’t find an orthopedic surgeon or a pain management doctor who will accept Medicaid.”

Medicaid, which is paid for jointly by the federal and state governments, is the subject of an intense debate in Washington over how to make it more efficient as Congress addresses the budget deficit and the growing federal debt.

But for now the administration is counting on Medicaid to play a vital role in expanding access to care under the law President Obama signed last year. The program is already a major presence here, paying for 70 percent of births in Louisiana. State health officials estimate that the Medicaid program will grow by more than 40 percent as a result of the federal health law, with the addition of 467,000 new recipients to 1.1 million now on the rolls.

“How can an already overtaxed Medicaid system handle such a huge influx of people?” asked Dr. Michael A. Felton, a family doctor in Church Point, La., near Lafayette.

It is a question being asked in many states. With the expansion of Medicaid to cover nearly all people under 65 with incomes up to 133 percent of the official poverty level (up to $29,330 a year for a family of four), Medicaid will soon be the nation’s largest insurer. It accounts for almost half of the increase in coverage expected under Mr. Obama’s health law, but has received less attention than other parts of the law regulating private insurance.

The Congressional Budget Office predicts that average monthly Medicaid enrollment, now 56 million, will rise to 71 million by 2016, with another five million people added to the rolls in the five years after that.

Like many states, Louisiana has been struggling with a fiscal crisis. To hold down costs, it has cut Medicaid payments to doctors, dentists, hospitals and other health care providers several times in the last two years. Many providers report that the cuts, taken together, total 15 percent to 20 percent.

Louisiana officials said the cuts were necessary for two reasons: to avoid a budget deficit in the Medicaid program and to comply with a state law that limits Medicaid spending to amounts appropriated by the State Legislature.

For patients like Draven Smith, whose mother said his behavior problems stemmed from attention-deficit hyperactivity disorder, the result is lack of access to doctors, especially specialists. For Draven’s pediatrician, Dr. Rachel Z. Chatters in Lake Charles, La., caring for poor children is a mission. About 80 percent of her patients are on Medicaid. It is, she said, frustrating to beg and plead with other doctors to see Medicaid recipients.

“I devote one afternoon a week, every Wednesday afternoon, to trying to find specialists for my patients — a pulmonologist for children with chronic persistent asthma, a neurologist for children with seizures or developmental delays, a psychiatrist for children with serious mental health problems, a hematologist for patients with sickle cell disease,” Dr. Chatters said.

Draven’s mother, Ana M. Smith, said: “I have tried for more than a year to find a child psychiatrist or psychologist to get Draven evaluated, but the mental health professionals in this area have told me they absolutely do not take Medicaid. If Draven could get the help he needs, I believe it would be unbelievably beneficial to him.”

Some uninsured people will surely receive better care when they gain Medicaid coverage, doctors say. The new health law calls for a temporary two-year increase in Medicaid payments for some primary care services, but this does not affect specialists.

With the expansion of Medicaid in 2014, Louisiana officials expect to enroll three groups: 260,000 newly eligible parents and childless adults, 20,000 parents now eligible but not enrolled and 187,000 adults and children who drop private coverage and sign up for Medicaid.

Bruce D. Greenstein, secretary of the Louisiana Department of Health and Hospitals, said, “We have a hard time finding specialists for Medicaid enrollees.”

Mr. Greenstein said the state expected to improve care and save money by enrolling most Medicaid recipients in managed care, an approach adopted by many states in recent years. In return for fixed monthly fees paid by the state, private health plans would coordinate the care of Medicaid patients, using networks of providers.

In passing the new health law, Congress wanted to make sure current Medicaid recipients would not lose coverage. Under the law, states generally cannot roll back Medicaid eligibility, but they can cut Medicaid in other ways — by reducing provider payment rates or by eliminating optional benefits.

About 20 states cut Medicaid payment rates for doctors last year, according to a survey by the Kaiser Family Foundation. At least 16 governors have proposed rate reductions this year for health care providers.

Gov. John Kitzhaber of Oregon, a Democrat, proposed cutting Medicaid payment rates for doctors, dentists, hospitals and nursing homes by 19 percent. Christine Miles, a spokeswoman for Mr. Kitzhaber, said his priority was to preserve eligibility.

In Illinois, Gov. Pat Quinn, a Democrat, has proposed reducing Medicaid reimbursement rates by 6 percent for hospitals and nursing homes.

Gov. Brian Sandoval of Nevada, a Republican, has proposed cutting Medicaid rates by 5 percent for hospitals, 15 percent for nonprimary care doctors and 25 percent for dentists.

In South Dakota, Gov. Dennis Daugaard, a Republican, just signed a budget bill cutting Medicaid rates for doctors, dentists, hospitals and nursing homes — even primary care physicians and pediatricians.

States have broad discretion in setting Medicaid payment rates. Federal law sets standards, but they are rather vague. Rates are supposed to be “consistent with efficiency, economy and quality of care,” and sufficient to ensure that services are available to Medicaid recipients at least to the same extent as to the general population in the area.

In a few states, Medicaid recipients and providers have blocked cuts or secured higher reimbursement through litigation. But in many states, the promise of equal access remains unfulfilled.

Dr. Kim A. Hardey, an obstetrician-gynecologist in Lafayette, said he received about $1,000 from the Louisiana Medicaid program for providing prenatal care and delivery for a full-term pregnancy, compared with $2,400 from private insurance.

With the expansion of Medicaid eligibility, he said, more of his patients will be on Medicaid, and fewer will have private insurance, which helps offset the financial losses doctors sustain on their Medicaid business.

Already, Dr. Hardey said, many of his patients have jobs with private insurance but switch to Medicaid when they become pregnant, avoiding premiums, deductibles and co-payments.

Vital Signs: Disparities: Illness More Prevalent Among Older Gay Adults

Posted: 01 Apr 2011 10:08 PM PDT

Older lesbian, gay and bisexual adults in California are more likely to suffer from chronic physical and mental health problems than their heterosexual counterparts, a new analysis has found. They also are less likely to have live-in partners or adult children who can help care for them.

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The research brief was based on data from the California Health Interview Survey, the nation’s largest state health survey, gathered in 2003, 2005 and 2007 by the Center for Health Policy Research at the University of California, Los Angeles.

Older gay and bisexual men — ages 50 to 70 — reported higher rates of high blood pressure, diabetes and physical disability than similar heterosexual men, according to the researchers. Older gay and bisexual men also were 45 percent more likely to report symptoms of psychological distress and 50 percent more likely to rate their health as fair or poor. In addition, one in five gay men in California was living with H.I.V. infection, the researchers found.

Yet half of California’s older gay and bisexual men lived alone, compared with 13.4 percent of older heterosexual men.

Older lesbian and bisexual women experienced similar rates of diabetes and hypertension compared with straight women of their age, but reported significantly more physical disabilities and psychological distress and were 26 percent more likely to say their health was fair or poor.

More than one in four older lesbian and bisexual women said they lived alone, compared with only one in five heterosexual women.

Steven P. Wallace, associate director of the U.C.L.A. Center for Health Policy Research and lead author of the brief, said it was important to raise awareness of these disparities in the gay and lesbian community and among the organizations that provide services for seniors.

“The gay culture tends to be youth-driven, and the aging community network doesn’t usually think about gay and lesbian elders,” he said.

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Calorie-Counting Rule to Leave Out Movie Theaters

Posted: 01 Apr 2011 09:53 PM PDT

Movie theaters don’t hesitate to wag a stern finger at their patrons: Shhh! Turn off your cellphone. Don’t talk during the movie.

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A Starbucks counter in New York displays calorie information for muffins. New legislation would require every large restaurant chain in the country to provide caloric data on menus.

But don’t ask them to tell you how many calories are in that jumbo tub of popcorn.

The federal government on Friday released proposed rules requiring chain restaurants and other businesses that serve food to post calorie counts on menus and menu boards. But after objections from theater chains, the rules give a pass to those box-office snacks — even though a large popcorn and soda can contain as many calories as a typical person needs in a day.

The new disclosure rules also exempt alcoholic beverages served in restaurants, including beer, wine and high-calorie mixed drinks like margaritas and daiquiris.

The Food and Drug Administration said it would accept consumer and industry feedback on the rules before finishing them, hopefully by the end of this year. They are expected to go into effect some time next year, said Michael R. Taylor, deputy commissioner for foods at the F.D.A.

“This is a really important and positive step in providing consumers information that they can use to choose healthy diets and fight obesity,” Mr. Taylor said.

The health care overhaul law passed last year included a provision that required chain restaurants and similar establishments that served food at 20 or more locations to display calorie counts for menu items.

The proposed new rules, which would spell out how the law would be applied, would take the place of a grab bag of menu-labeling laws that already exist around the country, including in New York City and California. The restaurant industry supported a federal labeling rule so that it would not have to comply with a range of different regulations.

A preliminary F.D.A. document on the rules released last summer would have included movie theaters.

But Mr. Taylor said officials decided to write the rules so that they would apply only to establishments whose primary purpose was to sell food or where at least half the floor space was dedicated to food sales.

“The thinking has absolutely evolved based on comments we’ve gotten from a number of quarters,” Mr. Taylor said. “This is a different drawing of the circle of what is covered by this law.”

Under the change, the law also would not apply to bowling alleys, carnivals, airplanes and other establishments where the primary purpose was not the sale of food.

But it would cover convenience stores and supermarkets that offer ready-to-eat items like hot dogs, deli sandwiches or rotisserie chicken, as long as they were part of a chain of sufficient size. In such establishments and in restaurants, each item on a salad bar would have to be labeled to show how many calories were in a serving.

Mr. Taylor said the rules would not cover alcohol sold in restaurants because the F.D.A. did not have jurisdiction to regulate alcohol.

In a separate proceeding, the Alcohol and Tobacco Tax and Trade Bureau is considering whether to require nutritional information on the labels of alcoholic beverages.

Margo G. Wootan, director of nutrition policy of the Center for Science in the Public Interest, said leaving out movie theaters from the new rules was a mistake.

“It doesn’t matter whether you happen to be watching a movie while you’re eating,” Ms. Wootan said. “Those calories still count.”

The center, an advocacy group, has issued reports showing that at some theaters, a large tub of popcorn with butter topping can contain nearly 1,500 calories. A large soda can contain 500 calories. Federal dietary guidelines say that the average person needs about 2,000 calories a day. However, Ms. Wootan said that over all, calorie labeling on menus would help people make healthier choices when they go out to eat, and she was pleased to see that the F.D.A. was moving relatively quickly to put the rules in place.

The F.D.A. also issued proposed rules for calorie labeling on vending machines, which was also required by the health care law. Under the rules, vending machine operators with 20 or more machines would have to post the calorie content of items they sell.

The National Association of Theater Owners, a trade group, had called for movie theaters to be exempt from the menu labeling law. On its Web site, the group said that movies were “escapist entertainment” and that moviegoers did not go there with the intent of eating a meal. A representative of the group could not be reached on Friday.

The federal rules would take the place of local or state laws for chain restaurants and other establishments covered by the federal regulations. But local governments would be free to create laws for establishments that were left outside the federal rules. New York City’s labeling law already requires movie theater chains to post calorie information. It also requires calorie labeling for alcoholic beverages listed on menus at restaurant chains.

Patient Money: What to Do When You Can’t Read the Fine Print

Posted: 01 Apr 2011 10:34 PM PDT

EVERYTHING seems to stiffen up as people age, and our eyes are no exception. As the years go by, the lens of the eye becomes harder and less elastic. The result is a gradual worsening of the ability to focus on objects up close, called presbyopia.

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Michael Houghton for The New York Times

Freda Dallas’s optometrist suggested multifocal contact lenses to correct her presbyopia.

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There’s no escaping it. Diet and exercise, the baby boomers’ weapons of choice for warding off age-related health problems, have no effect. Presbyopia generally starts in the mid-40s, when people begin to notice that they have difficulty punching out a number on their mobile phone or reading a book. Over the next 20 years or so, the eyes continue to lose their ability to zoom in on things; by about age 65, it’s often impossible.

“It’s like having a camera with no multifocal option,” said Dr. Rachel J. Bishop, chief of the consult services section of the National Eye Institute.

About four years ago, Freda Dallas noticed that she was having trouble reading and helping her son with his homework. Ms. Dallas, 51, works as a vision therapist with children to correct crossed eyes and other problems at the Ohio State University College of Optometry in Columbus, Ohio.

She knew right away what her problem was. “I was in denial,” she said.

Until then, Ms. Dallas generally wore regular contact lenses to correct her severe myopia, or nearsightedness. She knew that she did not want to switch to glasses with bifocal lenses. Once, during a Jazzercise class, her glasses had flown off and she could not find them without her classmates’ help. She needed an option that would stay put.

Her optometrist suggested multifocal contact lenses, which correct for both distance and near vision problems. Ms. Dallas tried them, and loved them. They’re more expensive than regular contacts or bifocal glasses because she has to replace them every two weeks at an out-of-pocket cost of about $200 annually, including cleaning solution. (Her vision insurance covers another $250 of the cost.)

But it’s worth it. “They’re really comfortable, and I’m sold on them,” she said.

Like many people, when Ms. Dallas first noticed she was having trouble reading she tried to compensate by shining a brighter light on the page. Others try holding reading material at arm’s length. But at some point, even the longest-armed person can no longer read the fine print on a menu.

That’s when it is time to find some help. Both optometrists and ophthalmologists can perform eye exams and prescribe eyeglasses and contact lenses. Ophthalmologists are medical doctors who can also perform eye surgery, like Lasik, to correct refractive errors.

Here’s some advice on what to ask them about, and how to pay for it.

A VISION PLAN Many employers offer or provide vision insurance for their employees, but it can also be purchased as a stand-alone product. At Vision Service Plan, a large vision insurer, individual coverage costs between $149 and $181 annually, depending on the state, said Gary Brooks, V.S.P.’s president for vision care.

A typical plan covers a comprehensive annual eye exam and provides a certain amount, often a few hundred dollars, toward the purchase of contact lenses or glasses. Like health insurance, prices may be cheaper if members use a practitioner in the insurer’s network.

For many types of corrective lenses, however, vision insurance coverage is inadequate, experts agree. The biggest advantage may be that the coverage encourages baby boomers to get annual eye exams, which can catch vision problems at an early stage.

Glaucoma, for example, damages the optic nerve and is the leading cause of irreversible blindness, yet half of people with glaucoma don’t know it, said Dr. J. Alberto Martinez, an ophthalmologist in private practice in Bethesda, Md.

GLASSES The easiest and cheapest solution for presbyopia is to go to your local drug or discount store and buy a pair of $10 reading glasses. For those whose only vision problem is presbyopia, cheap reading glasses may do the trick.

But for many patients, one-size-fits-all reading glasses cause eye fatigue, said Dr. Martinez. If that is the case, prescription glasses or contacts may be best.

The least expensive prescription option is bifocal or trifocal glasses with a visible line separating the top portion of the lens, which corrects for distance if necessary, from the bottom portion, which corrects for presbyopia. On trifocals, there is a middle section that corrects for intermediate distances. These lenses can be bought for under $200; frames are priced separately and can run from under $100 to more than $1,000 for those by high-end designers.

Progressive eyeglass lenses — in which the lens power gradually increases from the top of the lens to the bottom — eliminate the unsightly focal lines and avoid the image jump that can occur with traditional lenses. The downside is that progressive lenses often are significantly more expensive than bifocals or trifocals, sometimes $400 or more, and can cause visual distortions that some people have difficulty adjusting to.

CONTACT LENSES Bifocal and multifocal contact lenses have two or more prescriptions in the same lens, similar to eyeglasses. They come in a range of hard and soft materials with various disposable options.

In the past, some doctors told patients with presbyopia that they were not good candidates for multifocal lenses. Although fitting presbyopic patients with multifocal contacts is more complicated than fitting people without it, it’s a good option for many, said Kathryn Richdale, a senior research associate also at the Ohio State College of Optometry. “The lenses have come a long way in the past few years,” she said.

Expect to pay a fitting fee of up to $200, and up to $500 a year for lenses.

Some patients do well with a different therapeutic approach called monovision. Rather than correcting both eyes for both distance and near vision problems, monovision corrects one eye for distance vision and one eye for near vision. “Your brain learns to ignore the image that’s not in focus,” said Dr. James Salz, a clinical professor of ophthalmology at the University of Southern California.

This can be accomplished with contact lenses or through Lasik surgery, which reshapes the cornea. If someone is considering an irreversible process like Lasik, however, it’s important to test monovision first with contact lenses, say experts. And insurance generally does not cover Lasik surgery, which typically costs up to $2,500 per eye.

Research shows that about 70 percent of patients tolerate monovision, said Barry Weissman, a professor of ophthalmology at the University of California, Los Angeles. As people age and their presbyopia worsens, however, the growing difference between the two corrections often causes discomfort, he added.

LENS REPLACEMENT As the eye ages, the lens may develop cataracts, or cloudiness. Eye surgeons correct the problem by replacing the lens. Now some of these intraocular lenses can also correct for presbyopia.

But be warned: health insurance will generally cover cataract surgery, but if you opt for one of the new lenses that correct presbyopia rather the standard single-focus lens, you’ll have to pay the difference — up to $2,500 an eye.

Some ophthalmologists are now replacing people’s healthy lenses with presbyopia-correcting lenses. Because it is not medically necessary, insurance won’t cover the $3,000 to $7,000 cost per eye.

And some doctors are wary of the practice. “To correct just for presbyopia, I myself wouldn’t do that,” said Dr. Bishop. “I don’t believe the risks are outweighed by the benefits.”

When Ailments Pile Up, Asking Patients to Rethink Free Dialysis

Posted: 01 Apr 2011 09:44 AM PDT

Of all the terrible chronic diseases, only one —end-stage kidney disease — gets special treatment by the federal government. A law passed by Congress 39 years ago provides nearly free care to almost all patients whose kidneys have failed, regardless of their age or ability to pay.

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Noah Berger for The New York Times

Dr. Manjula Kurella Tamura, at a clinic in Palo Alto, Calif., said “dialysis at the end of life is a different sort of treatment.”

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But the law has had unintended consequences, kidney experts say. It was meant to keep young and middle-aged people alive and productive. Instead, many of the patients who take advantage of the law are old and have other medical problems, often suffering through dialysis as a replacement for their failed kidneys but not living long because the other chronic diseases kill them.

Kidney specialists are pushing doctors to be more forthright with elderly people who have other serious medical conditions, to tell the patients that even though they are entitled to dialysis, they may want to decline such treatment and enter a hospice instead. In the end, it is always the patient’s choice.

One idea, promoted by leading specialists, is to change the way doctors refer to the decision to forgo dialysis. Instead of saying that a patient is withdrawing from dialysis or agreeing not to start it, these specialists say the patient has chosen “medical management without dialysis.”

“That is the preferred term,” said Nancy Armistead, executive director of the Mid-Atlantic Renal Coalition, a Medicare contractor that collects data and patient grievances.

The phrase, she says, “acknowledges that death is imminent,” but it also sends an important message: “We are not just sending people home to die. We are offering palliative care.”

A committee of the Renal Physicians Association recently formulated guidelines to use in deciding when dialysis is appropriate. It provides questions that doctors should ask themselves before suggesting the treatment. One is the “surprise” question: Would I be surprised if this patient is dead within a year?

But, said the committee’s chairman, Dr. Alvin H. Moss, a nephrologist and ethicist at West Virginia University, the task ahead is like turning around an ocean liner.

“Clearly, when the program was initiated in the 1970s, the hope and expectation was that this program would return otherwise healthy people back into society so they could work and be productive,” said Dr. Manjula Kurella Tamura, a kidney specialist at Stanford. But, she added, “dialysis at the end of life is a different sort of treatment.”

Dialysis is difficult, especially for the old and sick. Most of the nation’s 400,000 dialysis patients spend several hours, three days a week, hooked up to a machine, and additional time traveling back and forth to the clinic.

They have to restrict salt and fluids, and the procedure is so exhausting that some patients rest for the remainder of the day. Although dialysis may alleviate symptoms like fluid accumulation in the legs or lungs, it can lead to dizziness, weakness, leg cramps, nausea and other problems. Complications like bloodstream infections or clogged blood vessels where the dialysis needles are placed are common, often requiring surgery or hospital stays. Ultimately, about one patient in five is unwilling to go on with it.

Yet it can be hard to say no.

An 84-year-old man being treated at a clinic in Elkins, W.Va., run by West Virginia University has been counseled against dialysis. He has high blood pressure and severe congestive heart failure, a condition as lethal as terminal cancer. His heart problems make it hard for him to breathe, and he is often in the hospital. In a telephone interview, the man said he saw friends suffer on dialysis and always thought he would refuse it. But he is getting ready to start anyway. The man, whose name is being withheld to protect his privacy, says he changed his mind after he “sat and thought about how good life is.”

“What choice do you really have?” he asked.

When Congress established the entitlement to pay for kidney patients in October 1972, dialysis and transplants were new procedures that were not covered by health insurance. There were horrifying stories — rich people got dialysis and lived while poor people died. In Seattle, a committee meted out dialysis by voting on who could get it. A man who was supporting a family, for example, took precedence over a single woman.

It also was expected at that time that fewer than 40 patients per million would need dialysis, and that most of those patients would be healthy — except for their failed kidneys — and under age 54.

Now more than 400 people per million start dialysis each year. More than a third of the patients are 65 or older, and they account for about 42 percent of the costs. People over 75 make up the fastest-growing group of dialysis patients. And most elderly dialysis patients have other serious diseases like diabetes, heart failure, stroke and even advanced dementia. One-third of them have four or more chronic conditions.

The federal program, said Dr. Peter S. Aronson, a professor of nephrology at Yale University’s School of Medicine “is so emblematic of good intentions misapplied.”

“The question,” Dr. Aronson said, “is how to dial it back.”

Recent studies have found that dialysis does not prolong life for many elderly people with other serious chronic illnesses. One study found that the procedure’s main effect is to increase the chances that such patients will die in the hospital rather than at home.

Meanwhile, costs are soaring — end-stage kidney disease will cost the nation an estimated $40 billion to $50 billion this year. And doctors are recommending dialysis sooner, even though recent studies have found that an early start confers no additional benefit.

Even so, Ms. Armistead said, when patents are ready to choose “medical management,” family members often struggle with the decision.

It also can be difficult to make some patients understand the gravity of their disease or their choices, said Barbara Weaner, a nurse practitioner at West Virginia University who works with dialysis patients.

“We live in a country where there is a lot of choice, where people tend to be afraid of dying and where palliative treatment is not always recognized as a good alternative,” Ms. Weaner said.

Her patients at the Elkins clinic illustrate her point. Those who are old and very sick often have a choice — they can have “medical management” without dialysis or they can have dialysis, which might fail to improve their lives. But for many, the first choice is not acceptable.

One patient, a 78-year-old woman whose name is being withheld, was not a good candidate for dialysis, her doctors said. She has complications from diabetes, high blood pressure, a heart valve problem and severe coronary artery disease. Her medical problems were so grave that dialysis was likely to lead to a series of medical interventions — hospital stays, drugs and doctor visits — but would not necessarily prolong her life. And her doctors told her that.

But she insisted on dialysis, saying, “Some life is better than no life.” In the seven months she has been on dialysis, she has been hospitalized four times, including twice for heart surgery.

“I go to dialysis because I want to live,” she said in a telephone interview. “I want dialysis.”

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Despite Assurances on Milk, Radiation Fear Lingers

Posted: 01 Apr 2011 06:48 AM PDT

SAN FRANCISCO — By scientific standards, the radiation found over the last week in batches of milk on the West Coast was minuscule and, moreover, not dangerous to humans.

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The dairy aisle at Bryan's Grocery in San Francisco. “There is a big trust issue with this,” one California shopper said.

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But the mere mention of any contamination in that most motherly of beverages still stirred concern in people like Marilyn Margulius, an interior designer from Berkeley, Calif., who called her daughter on Thursday and told her not to let her 10-year-old son drink milk.

“There is a big trust issue with this,” said Ms. Margulius, 71, who was shopping at a Whole Foods Market in Berkeley.

“The health department does not want people to panic. Milk is probably O.K., but who the heck knows?”

There have been repeated public assurances this week — officials said an adult would need to drink thousands of liters of the milk containing radiation at the levels found so far before it would be remotely dangerous. Officials also tried to tamp down anxiety from dairy farmers concerned about bad press.

“I’ve had members call to ask whether we’ve seen the media, and media calling to ask how this is impacting our members,” said Michael Marsh, the chief executive of Western United Dairymen, the milk industry’s West Coast trade association. Mr. Marsh said he had repeated the assurances given by officials, but he also understood the fears in the supermarket’s refrigerated aisle.

“Consumers, doubtless, when they hear about something like this, the cautionary principle kicks in,” he said. “Even if you’d have to drink an oil tanker of this.”

Dr. Elizabeth N. Pearce, an associate professor of medicine at the Boston University School of Medicine and an expert on the thyroid, where radioactive iodine is often absorbed, said there was no health risk, even for small children, from milk on American shelves.

Still, she said, “If people feel safer not drinking it, there are no long-term health effects from abstaining for two weeks, either.”

The alarm was sounded on Wednesday, when federal officials announced that tests had detected a trace amount of iodine 131 — a radioactive byproduct released by leaks at the Fukushima Daiichi nuclear plant in Japan — in a sample taken on March 25 in Spokane, Wash. The level of radiation was tiny and would have to be more than 5,000 times higher to reach the “intervention level” set by federal officials.

Jason Kelly, a spokesman for the Washington State Department of Agriculture, said the positive sample came from a gallon of pasteurized whole milk produced at the Darigold plant in Spokane, which processes milk from a number of farms in Washington and Idaho.

Jim H. Klein, a spokesman for Darigold, said milk from the Spokane plant was distributed in the Northwest, but said there was no reason for concern.

Some people even saw a potential silver lining in their bottom line. Mike Vieira, owner of a small dairy west of Spokane that produces about 250 gallons of milk a day, said the scare might be good for his business because customers know where his milk comes from, as opposed to milk from larger dairies that is pooled at a processing plant.

“We’ve had regular customers come to the farm buying milk,” he said. “And they’re buying six or eight gallons.”

The California health department also confirmed Wednesday that it had detected a tiny amount of radioactive iodine in a sample collected Monday from a dairy in San Luis Obispo County on the state’s Central Coast.

Milk in San Luis Obispo is regularly tested because the Diablo Canyon nuclear power plant is on the county’s southern coast. Officials said that monitoring — done weekly since the crisis began — was accountable for finding the contamination.

Dr. Penny Borenstein, the county’s public health officer, said that the tests would continue and that dairy products would continue to be safe. “The situation in Japan continues to evolve, but we are still 6,000 miles away.”

Jesse McKinley reported from San Francisco, and William Neuman from New York. Isolde Raftery contributed reporting from Eugene, Ore., and Malia Wollan from Berkeley, Calif.

Recipes for Health: Stir-Fried Swiss Chard and Red Peppers

Posted: 01 Apr 2011 12:20 AM PDT

This is particularly beautiful if you can find rainbow chard, those multicolored bunches with red, white and yellow stems. Slice the chard crosswise in thin strips. If the pieces are too thick, they’ll be tough.

Recipes for Health

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

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1 tablespoon soy sauce (low-sodium if desired)

1 tablespoon Shao Hsing rice wine or dry sherry

2 teaspoons dark Asian sesame oil

1/4 to 1/2 teaspoon salt (to taste)

1/4 teaspoon ground pepper, preferably white pepper

1/4 teaspoon sugar

1 tablespoon peanut oil or canola oil

1 tablespoon minced garlic

1 tablespoon minced ginger

1 pound Swiss chard, preferably rainbow chard, stems trimmed, washed in two changes of water and cut crosswise in 1/2-inch strips

1 medium red bell pepper, cut in 1/4-by-2-inch julienne (1 cup julienne)

1/4 cup thinly sliced scallions or minced red onion

1/4 cup coarsely chopped cilantro (optional)

Cooked quinoa, brown or red rice, or rice noodles for serving

1. In a small bowl or measuring cup, combine the soy sauce, rice wine or sherry, and the sesame oil. Combine the salt, pepper and sugar in another small bowl. Have all the ingredients within arm’s length of your pan.

2. Heat a 14-inch flat-bottomed wok or 12-inch steel skillet over high heat until a drop of water evaporates within a second or two in the pan. Swirl in the oil by adding it to the sides of the pan and tilting it back and forth. Add the garlic and ginger, and stir-fry for no more than 10 seconds. Add the chard, and stir-fry for two minutes, until the leaves wilt. Add the red pepper and spring onion or red onion. Turn the heat to high, and stir-fry for one minute, or until the pepper begins to soften. Add the salt, pepper and sugar. Toss together, and add the soy sauce mixture. Stir-fry for two to three minutes until the chard leaves are tender and the stems and red peppers are crisp-tender. Stir in the cilantro, and serve over cooked quinoa, rice or rice noodles.

Yield: Serves three to four.

Advance preparation: Like all stir-fries, this is last-minute. But you can have everything prepped and ready to go hours ahead of time.

Nutritional information per serving (three servings; grains or noodles not included): 128 calories; 1 gram saturated fat; 3 grams polyunsaturated fat; 3 grams monounsaturated fat; 0 milligrams cholesterol; 11 grams carbohydrates; 4 grams dietary fiber; 652 milligrams sodium (does not include salt to taste); 4 grams protein

Nutritional information per serving (four servings; grains or noodles not included): 96 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 3 grams monounsaturated fat; 0 milligrams cholesterol; 8 grams carbohydrates; 3 grams dietary fiber; 489 milligrams sodium (does not include salt to taste); 3 grams protein

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

After Japan Crisis, New Urgency for Radiation Drugs

Posted: 31 Mar 2011 10:20 PM PDT

A flash of blue light signaled the end for Hisashi Ouchi and Masato Shinohara. It meant that a nuclear chain reaction had started unexpectedly, bathing the two men in lethal doses of radiation. After they ran out of the room, Mr. Ouchi, who received the higher dose, briefly lost consciousness, then began vomiting.

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JCO, via Associated Press

Some workers in a nuclear accident in 1999 at a uranium processing plant in Japan died of radiation-related problems.

But the two men — who were injured in a nuclear fuel accident in Japan in 1999, not during the current crisis — did not die right away. Drugs and procedures unavailable when the atomic age began kept Mr. Ouchi alive for 82 days, and Mr. Shinohara for about seven months.

As radiation spreads in Japan from crippled nuclear reactors, with workers at the Fukushima Daiichi nuclear plant potentially exposed to extremely hazardous levels, experts say that progress has been made in developing treatments for radiation poisoning. But there is still much work to do.

The crisis has put a spotlight on some small biotechnology companies developing drugs to treat people exposed to radiation. Some say they are accelerating their efforts in light of the problems in Japan.

Most of the companies are working under contracts from the United States government, aimed at treating people after a military or terrorist attack involving a nuclear or radioactive weapon. Such drugs would also be of use in a nuclear power plant accident, particularly for the nuclear plant workers, who might be exposed to the highest doses.

“There would definitely be a zone around ground zero where you could save a lot of people with these drugs,” said Mark H. Whitnall, program advisor for radiation countermeasures at the Armed Forces Radiobiology Research Institute in Bethesda, Md.

He said the drugs under development would allow people to survive doses 20 to 40 percent higher than what is now considered lethal. “We’d like to do a lot better,” he said.

The Japanese crisis has caused upticks in the shares of some of the companies focusing on this research, like Cleveland Biolabs. Some 5.6 million shares of Aeolus Pharmaceuticals changed hands on a single day after the crisis began, over 1,000 times the usual trading volume.

“It was crazy, just crazy,” said John McManus, chief executive of the company, based in Mission Viejo, Calif. In February, it received a federal contract worth up to $118 million to help it develop a drug to protect the lungs from radiation damage.

Several of the companies say they want to make their drugs available for use in Japan, but the government there has not ordered any. The drugs in question have not been approved by the Food and Drug Administration, and it is unclear whether anyone in Japan, even workers at the Fukushima plant, have been exposed to enough radiation to warrant such treatments.

Most of the drugs in development are two to five years away from possible regulatory approval, federal officials say, and even once approved there would still be some slight uncertainty about how well they would work in people. Because it would be unethical to expose people to high levels of radiation in a clinical trial, the F.D.A. allows approval of this type of drug if it proves effective in two species of animals and is shown to be safe in people at doses corresponding to those used in the animals.

Getting federal support for the research is one thing. It might be harder to get the government to buy large quantities to be stockpiled for use in an emergency.

Hollis-Eden Pharmaceuticals provides a cautionary tale. It was developing a steroidlike compound that was championed by Defense Department scientists, but in 2007, after the company spent $85 million on development, the Department of Health and Human Services decided not to buy the drug, saying it did not meet technical requirements.

Hollis-Eden’s stock price collapsed and has never recovered. The company dropped the drug and changed its name to Harbor BioSciences.

Some federal officials and experts say that Health and Human Services decided it needed drugs that could be effective even if given 24 hours after exposure, reasoning that after a terrorist attack it would be hard to get the drug to people immediately. The Hollis-Eden drug did not meet that requirement.

The department plans a big purchase, but not of an experimental drug developed by a tiny company. Rather, it is looking to buy hundreds of millions of dollars worth of Amgen’s Neupogen or a similar drug, including generic versions of Neupogen that have been approved in Europe, according to Robin Robinson, director of the department’s Biomedical Advanced Research and Development Authority.

Neupogen helps the body build infection-fighting white blood cells, which can be depleted by radiation. The drug is approved to help prevent infections in cancer patients undergoing chemotherapy, but the F.D.A. has issued an “emergency use authorization” that would allow the drug to be used to treat radiation exposure.

Biodefense work has largely fallen to small biotechnology companies because they need the money, especially at a time when investors are averse to risk. Federal grants can help defray the costs of developing a drug for commercial uses. In the case of radiation treatments, the commercial use would mainly be to protect cancer patients from the side effects of radiation therapy.

“It’s significant funding for a biotech company like ours,” said Ram Mandalam, chief executive of Cellerant Therapeutics, a private company that won a federal contract worth up to $153 million over five years to develop a drug using stem cells to help bolster the immune system after radiation exposure.

Radiation can have various health effects, depending on the dose and form. For nuclear power plant accidents, the major exposure for the public would come from radioactive isotopes, and there already are some approved drugs for these that are in the federal stockpile.

Potassium iodide can help prevent thyroid cancer that can be caused by iodine-131, which has been detected in some milk, produce and tap water in Japan. Elevated levels of radioactive iodine have also been detected in milk in Washington State and California but the levels are still far too low to pose a health threat, the Environmental Protection Agency said on Wednesday. It has stepped up monitoring of radiation levels.

Exposure to cesium-137 can be treated with Prussian blue, a pharmaceutical version of an industrial dye, while plutonium exposure can be treated with DTPA. Both drugs bind to the isotopes and help the body to excrete them.

The drugs being developed by the biotech companies would probably not reduce the long-term risk of cancer after radiation exposure. They are aimed more at treating what is called acute radiation syndrome.

Death from this is often caused by bone marrow failure, which depletes the body of white blood cells and platelets, which control excess bleeding. The gastrointestinal tract and other organs can also be heavily damaged.

Progress has been fastest in reconstituting the immune system, using Neupogen, bone marrow transplants or other treatments. The two workers in Japan overcame bone marrow failure, only to die later from failure of several other organs.

But bone marrow transplants cannot be done on a mass scale, and even Neupogen is not ideal if there are thousands of people exposed after an attack because it requires refrigeration and medical care. So the government is searching for alternatives.

Cleveland Biolabs, which despite its name is based in Buffalo, is developing a drug derived from a bacterial protein. It fools the body into believing there has been a “massive salmonella infection,” said Andrei Gudkov, chief scientist. The body’s response is to produce substances, including the protein in Neupogen, that help restore the immune system and gastrointestinal tract.

Dr. Gudkov said the drug was at least a year away from approval.

Onconova Therapeutics, a private company in Newtown, Pa., has a drug called Ex-Rad that facilitates repair of DNA damaged by radiation and helps prevent cell death.

Osiris Therapeutics has a $224 million contract from the Defense Department to develop a therapy using stem cells to help repair gastrointestinal injuries. Of that, $200 million would be possible purchases of the drug, if it is approved by the F.D.A.

Safety is an obstacle, especially if a drug is to be given to healthy people in advance of possible exposure. Side effects could also slow down rescue or cleanup workers entering a contaminated area.

“You do not want to vomit in a hazmat suit,” said John E. Moulder, a professor of radiation oncology at the Medical College of Wisconsin. “You don’t really want to have diarrhea. You want to get in there, get the job done and get out.”

Assessing overall progress, he said, “I think we have moved to show that a radiological counterterrorism program is medically possible.” But he added: “Are we ready to go if it’s a large number of people? No.”

Artificial Dye Safe to Eat, Panel Says

Posted: 02 Apr 2011 11:18 AM PDT

WASHINGTON — There is no proof that foods with artificial colorings cause hyperactivity in most children and there is no need for these foods to carry special warning labels, a government advisory panel voted Thursday.

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The Food and Drug Administration convened the expert panel after agency scientists for the first time decided that while typical children may be unaffected by the dyes, those with behavior problems may see their symptoms worsen by eating food with synthetic color additives.

The debate over artificial dyes began in the 1970s when Dr. Benjamin Feingold, a pediatric allergist from California, had success treating the symptoms of hyperactivity in some children by prescribing a diet that, among other things, eliminated foods with artificial coloring.

But once the agency conceded that some children might be negatively affected by the foods, it had to decide what to do. The Center for Science in the Public Interest, an advocacy group, petitioned the agency to ban the dyes or, at the very least, mandate warnings that foods containing the dyes cause hyperactivity in children. Major food manufacturers staunchly defended the safety of artificial dyes and said no bans or warnings were needed.

Artificial coloring is present in popular products like Froot Loops cereal, Jell-O, Life Savers candy and Hostess Twinkies.

The F.D.A. did not ask the committee about a ban, and the committee voted 8 to 6 that even a warning was not needed.

The Grocery Manufacturers Association hailed the votes. “We agree with today’s F.D.A.’s advisory committee finding which determined that there is insufficient evidence of a causal link between artificial colors and hyperactivity in children,” it said.

Dr. Michael Jacobson, executive director of the advocacy group, said he was disappointed but pleased that the debate about the safety of artificial colorings had been renewed. “At least the F.D.A. is now acknowledging that dyes affect some children,” he said. “That’s a big change.”

Standards Set for Joint Ventures to Improve Health Care

Posted: 31 Mar 2011 08:10 PM PDT

WASHINGTON — The Obama administration proposed long-awaited regulations on Thursday encouraging doctors and hospitals to band together, coordinate care and cut costs.

In return, the government offered financial rewards to health care providers that slow spending growth and meet detailed federal standards for the quality of their services.

The proposed rules explain how doctors, hospitals, nursing homes and home health agencies can qualify for federal bonus payments by forming joint ventures known as accountable care organizations.

Proponents — Democrats and some Republicans — see these entities as a potential boon to patients, a way to transform a health care system that is notoriously fragmented.

Federal officials predicted that 1.5 million to 4 million of the 47 million Medicare beneficiaries would be involved in the program, with the creation of 75 to 150 accountable care organizations.

“These organizations will increase coordination among doctors and hospitals, improve the quality of care and help lower costs,” said Kathleen Sebelius, the secretary of health and human services. Better care can cost less, she asserted, because diagnostic tests are not duplicated and fewer patients are readmitted to hospitals.

Until now, accountable care organizations were like unicorns, creatures that flourished in the imagination but proved persistently elusive in the natural world. The rules define the new entity as a team of doctors, hospitals and other providers that “work together to manage and coordinate care” for people in the traditional fee-for-service Medicare program.

The new entities are specifically authorized for Medicare patients under the health overhaul that President Obama signed in March last year. However, federal officials and health care executives said the standards would also guide similar efforts in the private sector, for people with commercial insurance.

The new law has already set off a wave of mergers, joint ventures and alliances in the health care industry, as providers try to position themselves to cash in on the new incentives.

Officials from the Justice Department and the Federal Trade Commission said Thursday that they would relax enforcement of antitrust laws to promote collaboration by doctors and hospitals that could show how consumers would benefit.

In a joint statement on enforcement policy, the two agencies acknowledged that, “under certain conditions, accountable care organizations could reduce competition and harm consumers through higher prices or lower quality of care” — a fear expressed by some consumer advocates as well.

To minimize this risk, the antitrust agencies said they would closely review any proposed accountable care organization that would have more than 50 percent of the local market for any service.

In an interview, Jon Leibowitz, the chairman of the trade commission, said that doctor-hospital collaborations would be subject to “a relaxed form of antitrust scrutiny” if they met Medicare’s standards for clinical cooperation.

Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said her group was disappointed with the joint statement. “The antitrust laws still appear to be a barrier to clinical integration among health care providers who try to coordinate services for patients,” Ms. Hatton said.

Doctors and hospitals would have to inform Medicare beneficiaries if they were going participate in an accountable care organization. And they would have to tell patients that the providers might profit from the arrangement.

Dr. Donald M. Berwick, administrator of the federal Centers for Medicare and Medicaid Services, said the new entities would not restrict the ability of patients to choose their doctors and hospitals.

“Medicare beneficiaries retain all the rights they have to see any Medicare provider they wish,” Dr. Berwick said. “There’s no loss of choice at all.”

Nora Super, a lobbyist for AARP, the organization for older Americans, said it was good that patients would be informed. But she said, “We are concerned that the draft regulation may not provide patients with timely information, leading some to learn about an A.C.O. only after arriving at a doctor’s office.”

Medicare beneficiaries can opt out, but may pay a price. If a beneficiary’s doctor becomes part of an accountable care organization and the patient does not wish to receive care coordinated by the new entity, the beneficiary can go to a different doctor, the rules say.

Medicare will distribute 50 percent to 60 percent of its savings to hospitals and doctors who meet its quality standards and hold costs below benchmarks set by the government.

Federal health officials predicted that the government would pay $800 million in such shared savings to providers in the next three years. Even after these payments, they said, Medicare would save $510 million, and its savings could be as much as $960 million over three years.

Under the proposed rules, each accountable care organization must agree to take responsibility for at least 5,000 Medicare beneficiaries. The government could cancel its contract with any organization that stints on care or tries to save money by avoiding high-risk, high-cost patients.

The Texas Tribune: Child-Only Insurance Vanishes, a Health Act Victim

Posted: 31 Mar 2011 09:30 PM PDT

Only months from their 65th birthdays and the switch from employer-offered health coverage to Medicare, Phillip and Diann Green of Forney realized they had a problem. After retirement, none of the state’s insurance companies will cover their 12-year-old granddaughter, Aria, whom they have raised since her infancy.

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Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

Insurers in Texas and across the nation — protesting a provision of the 2010 federal health care overhaul that prohibits pre-existing condition limitations for children under 19, have simply stopped offering new child-only policies. For children being raised by their grandparents, who are not poor enough to qualify for Medicaid and have no employer-offered insurance or family plans to cover them, there are few options.

No agency keeps track of how many children in Texas are affected by the elimination of child-only plans, but experts suggest it is in the thousands.

“Raising a child — finding her health insurance — it’s certainly not something you expect at our age,” said Mr. Green, who, with his wife, gained custody of Aria when she was 7 months old because her biological parents were ill prepared to raise her. “But everybody has come up with an excuse for not taking her.”

Jared Wolfe, executive director of the Texas Association of Health Plans, said it is not because insurers do not want to cover children. The federal health care overhaul, and in particular the pre-existing condition language, has been interpreted to mean that insurers must write a policy for any child who applies, Mr. Wolfe said. That effectively ensures that only sick children will apply for benefits, he said — an unworkable financial scenario for insurance companies.

“It’s a bad situation,” Mr. Wolfe said. The child-only plans “are a very small percentage of the market, but for those people, it means quite a bit.”

Some states have responded to these insurers with legislation. In Texas, Representative Garnet Coleman, Democrat of Houston, has filed a bill that would require insurers participating in the individual insurance market to accept applications from children under 19 — legislation that he said mirrors measures passed in California, Kentucky, New Hampshire and Washington.

“We have to correct the market to make sure children don’t go without coverage,” Mr. Coleman said. But with an overwhelming Republican majority in the State Legislature that both cannot stand the federal health care overhaul and believes that the child-only insurance market should work itself out, such a bill appears unlikely to pass.

“Time will tell whether there really is a problem or not,” said Representative John Zerwas, an anesthesiologist and Republican of Simonton. “If there’s a viable market for it, I would like for it to sustain itself.”

Mr. and Mrs. Green never thought that being retired and having health insurance for their granddaughter were mutually exclusive. As they approached 65, and the threshold for getting on Medicare, the federal health care plan for older Americans, they started making all the requisite inquiries to get Aria insured. But in call after call last fall, insurance companies operating in Texas told them they no longer offered new child-only policies — and acknowledged that the Greens had few choices.

The Greens’ income level means Aria, who has no pre-existing conditions, does not qualify for the joint state-federal Children’s Health Insurance Program, or CHIP. Nor can she apply for a high-risk pool, which experts say requires that a child have a pre-existing condition and receive a formal denial from a private insurance company. (When no plans are offered, insurers do not have to issue denials.)

For now, Aria — who is currently insured through Mrs. Green’s employer, Wal-Mart — only has one option, Mr. Green said: a Cobra plan that costs nearly $550 a month and lasts for only a year and a half.

Officials with the Texas Department of Insurance say that they are looking for ways to entice insurers into selling child-only plans.

Some providers say they are searching for a middle ground. Blue Cross Blue Shield of Texas, which stopped offering child-only coverage last fall, said it was seeking approval from the Department of Insurance for a new child-only policy that would have “benefits and rates appropriate to the new market requirements.”

Mr. Green said that when he called federal lawmakers about the matter, they told him it is a state issue; his state representatives told him he should approach the federal government.

“Everyone I talk to about this, their response is, ‘What would you like for us to do about this?’ ” said Mr. Green, who had to take early retirement from his job at the Unisys Corporation at age 50 after having a heart attack at 34 and a quadruple bypass at 42. “I just want them to fix it.”

eramshaw@texastribune.org

U.S. Panel Suggests Research Into Causes and Prevalence of Health Issues Facing Gays

Posted: 31 Mar 2011 07:50 PM PDT

WASHINGTON — The federal government should systematically collect demographic data on gay, lesbian and transgender people and should conduct biomedical research to understand why they are more likely to have certain chronic conditions, the National Academy of Sciences said Thursday.

In a report requested by the National Institutes of Health, the academy proposed an ambitious research agenda to investigate the prevalence and causes of obesity, depression, cancer, heart disease and other conditions among gay people.

Federal officials had asked the academy’s Institute of Medicine to identify gaps in research on the health of gay Americans. Dr. Robert O. Graham, the chairman of the panel that did the study, said that was impossible.

“The available evidence on the health of lesbian, gay, bisexual and transgender people is sparse,” said Dr. Graham, a professor of family medicine at the University of Cincinnati. “Researchers need to do much more than simply filling gaps.”

The panel, appointed by the Institute of Medicine, said the government should finance research to develop standardized measures of sexual orientation and gender identity — “one’s basic sense of being a man, woman or other gender, such as transgender.”

Gay people often face “barriers to equitable health care,” decline to seek care in times of need and receive substandard care when they seek it, the report said.

“Fearing discrimination and prejudice,” it said, “many lesbian, gay, bisexual and transgender people refrain from disclosing their sexual orientation or gender identity to researchers and health care providers.”

In addition, the report said, many doctors lack the necessary training. “Medical schools teach very little about sexuality in general and little or nothing about the unique aspects of lesbian, gay and bisexual health,” it said.

The panel said the National Institutes of Health should strongly encourage researchers to include “sexual and gender minorities” in studies whenever possible, just as they include women, blacks, Asian-Americans and Hispanics.

In its report, which offers a comprehensive survey of information about the health of gay Americans, the panel made these points:

¶“On average, men tend to show greater interest in sex and express a desire to engage in sex more frequently than women. These patterns appear to occur in both heterosexual and homosexual populations.”

¶Gay youths and adults are typically well adjusted and mentally healthy, but some research indicates that they are more likely to be depressed, have suicidal thoughts and attempt suicide.

¶“Lesbians and bisexual women may be at higher risk for breast cancer than heterosexual women.”

¶Some studies suggest that long-term use of hormone therapy by transgender people may increase their risk for cancer, but more research is needed.

In addition, the report said, “Some research suggests that lesbians and bisexual women have a higher risk of obesity than heterosexual females.” Lesbians may also have higher rates of smoking and alcohol consumption than heterosexual women, it said.

Cellphone Radiation May Alter Your Brain. Let’s Talk.

Posted: 31 Mar 2011 02:01 PM PDT

In a culture where people cradle their cellphones next to their heads with the same constancy and affection that toddlers hold their security blankets, it was unsettling last month when a study published in The Journal of the American Medical Association indicated that doing so could alter brain activity.

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From left, the Windows Phone 7, the Apple iPhone and the Motorola Droid.

The report said it was unclear whether the changes in the brain — an increase in glucose metabolism after using the phone for less than an hour — had any negative health or behavioral effects. But it has many people wondering what they can do to protect themselves short of (gasp) using a landline.

“Cellphones are fantastic and have done much to increase productivity,” said Dr. Nora Volkow, the lead investigator of the study and director of the National Institute of Drug Abuse at the National Institutes of Health. “I’d never tell people to stop using them entirely.”

Yet, in light of her findings, she advises users to keep cellphones at a distance by putting them on speaker mode or using a wired headset whenever possible. The next best option is a wireless Bluetooth headset or earpiece, which emit radiation at far lower levels. If a headset isn’t feasible, holding your phone just slightly away from your ear can make a big difference; the intensity of radiation diminishes sharply with distance. “Every millimeter counts,” said Louis Slesin, editor of Microwave News, an online newsletter covering health and safety issues related to exposure to electromagnetic radiation.

So crushing your cellphone into your ear to hear better in a crowded bar is probably a bad idea. Go outside if you have to take or make a call. And you might not want to put your cellphone in your breast or pants pocket either, because that also puts it right up against your body. Carry it in a purse or briefcase or get a nonmetallic belt clip that orients it away from your body.

Some studies have suggested a link between cellphone use and cancer, lower bone density and infertility in men. But other studies show no effect at all. Given the mixed messages and continuing research, Robert Kenny, a Federal Communications Commission spokesman, said in an e-mail, “As always, we will continue to study this issue and coordinate with our federal partners.”

The phone used in Dr. Volkow’s study was a Samsung Knack, model SCH-U310, a flip phone that was in wide use when she began planning her experiments two and half years ago. But today’s ubiquitous smartphones emit even more radiation as they transmit more, and more complex, data.

You can get an idea of the relative amounts of radiation various cellphone models emit by looking at their SAR, or specific absorption rate. This number indicates how much radiation is absorbed by the body when using the handset at maximum power. A cellphone cannot be sold in the United States unless an F.C.C.-approved laboratory says its SAR is below 1.6 watts per kilogram. In Europe, the maximum is 2 watts per kilogram.

The SAR number is not displayed when you compare cellphones at your local wireless store, and trying to find it in the fine print of your user manual is an exercise in frustration. The F.C.C. maintains that SAR values “do not provide sufficient information” to reliably compare cellphone radiation emissions because certain phones might rarely operate at maximum power. Still, the Environmental Working Group, a nonprofit organization, has a comprehensive list of the SAR values for most cellphones available from major carriers on its Web site. (For instance, the Apple iPhone 4 is listed at 1.17 watts per kilogram, the Motorola Droid at 1.5 and the LG Quantum at 0.35.)

But more important than looking for a low-SAR phone is how you use it. Many cellphones emit the most radiation when they initially establish contact with the cell tower, making their “digital handshake.” To reduce exposure it’s best to wait until after your call has been connected to put your cellphone next to your ear.

During the ensuing conversation, it’s advisable to tilt the phone away from your ear when you are talking and only bring it in close to your ear when you are listening. That bit of teeter-totter works because the emission of radiation is “significantly less when a cellphone is receiving signals than when it is transmitting,” said Lin Zhong, assistant professor of electrical and computer engineering at Rice University in Houston.

Moreover, your cellphone emits less when you are stationary because when you are moving rapidly — say, in a car or train — it must repeatedly issue little bursts of radiation to make digital handshakes with different towers as it moves in and out of range. (More cause to hang up when you buckle up.)

Want another reason to complain about your carrier’s poor coverage? Any situation where your cellphone has a weak signal indicates it has to work harder and thus will emit more radiation. “Fewer bars means more radiation,” said Om Gandhi, professor of electrical engineering at the University of Utah in Salt Lake City. Inside buildings and elevators, in rural areas, the Grand Canyon — these are not good places to make a call if you’re trying to reduce your exposure to radiation.

Of course, parents using their iPhones to pacify cranky kids might want to reconsider rattles. Children’s developing brains and tissues are thought to be most vulnerable to cellphone radiation. Health authorities in Britain, France, Germany and Russia have all issued warnings against allowing small children to use cellphones for extended periods, if at all.

There are cellphone attachments that purport to shield users from radiation, and most are “hoaxes,” said Mr. Gandhi. Beware of pendants that sellers claim snatch radiation from the air. Pong Research offers a cellphone case for iPhones and BlackBerrys that it says has been shown by an F.C.C.-approved testing lab to redirect radiation from the phone’s antenna away from the head.

While the manufacturer says it reduces radiation more than 60 percent, some electrical engineering experts question whether the case may have the opposite effect at orientations where your head is in the way of the cell tower because your phone may have to increase its transmission strength somewhat to compensate for the redirected signal. The company disputes this. Nevertheless, the net effect of using the device throughout the course of the day may be a reduction in total exposure.

Texting, instead of talking, might be safer. “The whole trend toward texting instead of talking on cellphones is probably a good thing,” said Mr. Slesin at Microwave News.

That is, if you don’t rest your cellphone against your body while typing out your message.

Low Levels of Radiation Found in American Milk

Posted: 30 Mar 2011 10:30 PM PDT

Tests of milk samples taken last week in Spokane, Wash., indicate the presence of radioactive iodine from the troubled Fukushima Daiichi nuclear plant in Japan, but at levels far below those at which action would have to be taken, the Environmental Protection Agency said on Wednesday.

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Radioactive materials in liquids are measured in pico-curies per liter, and the sample, taken March 25, showed a reading of 0.8 pico-curies, the agency said. Those numbers, it said, would have to be 5,000 times higher to reach the “intervention level” set by the Food and Drug Administration.

“These types of findings are to be expected in the coming days and are far below levels of public health concern, including for infants and children,” the environmental agency said.

Levels of iodine 131 entering the air can be very diluted, but if the iodine is deposited on grass eaten by cows, the cows will reconcentrate it in their milk by a factor of 1,000. This is mainly a concern with fresh milk, not for dairy products that are stored before consumption.

Iodine 131 has a half-life of eight days, meaning that every eight days it loses half its strength. Since production of iodine 131 stopped when the Fukushima reactors shut down on March 11, it has already been through two half-lives and could easily be halved once or twice more again before the milk is consumed as cheese or yogurt.

Iodine 131 emits beta particles, which resemble electrons. They are not considered a major hazard outside the human body, although in large doses, they can damage the cornea of the eye.

The problem arises when materials that emit beta particles are ingested or inhaled. Iodine 131 is chemically identical to normal, nonradioactive iodine and thus is absorbed into the body just as normal iodine is, mainly in the thyroid gland, where it delivers a concentrated dose to that small organ and can cause cancer.

In the Chernobyl nuclear accident of 1986, the biggest health effect was cases of thyroid cancer, especially in children living near the nuclear plant in Ukraine.

Deaths of 9 Alabama Patients Tied to Intravenous Supplement

Posted: 31 Mar 2011 07:10 AM PDT

BIRMINGHAM, Ala. — State and federal health officials are investigating the deaths of nine patients at Alabama hospitals who were all given an intravenous nutritional supplement that investigators have found was contaminated by bacteria.

Ten other patients who received the supplement also were sickened by the bacteria, called Serratia marcescens, which is most commonly found in water, including some tap water, and sometimes in bathrooms. It can be introduced into the bloodstream via contaminated fluid administered through a catheter.

Dr. Alexander J. Kallen, a medical officer with the Centers for Disease Control and Prevention, said the investigation into the outbreak at six Alabama hospitals would not conclude for at least a week. But he said similar investigations in the past typically determined that contamination occurred during the mixing of intravenous supplements.

“Historically, what we’ve seen is a breakdown in the manufacturing process,” Dr. Kallen said.

Dr. Donald E. Williamson, Alabama’s state health officer, emphasized that it remained unclear whether the deaths were due to the bacteria or to underlying serious illnesses.

“I cannot ascribe those nine deaths to the Serratia marcescens,” Dr. Williamson said Tuesday. “These were patients who were getting treatment, so they were by definition ill.”

State officials have identified the source of the supplement, which is known as Total Parenteral Nutrition, or T.P.N., as the Meds IV Pharmacy in Birmingham, a compounding pharmacy that makes medications that do not come premixed.

On Wednesday, the pharmacy’s unmarked office in a business park was dark, with a “closed” sign hanging on the door. Workers in neighboring offices said they had seen the firm’s principal arrive that morning, but he did not respond to repeated calls or knocks.

According to incorporation papers listed with the Alabama secretary of state, the company formed last April and its registered agent is Edward Cingoranelli of Alabaster, Ala.

Alisha Miskelley, a supervisor for a contact lens distributor located across the parking lot from Meds IV, said men wearing suits had been in and out of the pharmacy’s office last week. “There was a lot of commotion,” she said.

State officials said the pharmacy has stopped distributing the supplement and was no longer open. Dr. Kallen said it was unlikely the company would reopen, adding that it had made the decision to close on its own.

Dr. Mary G. McIntyre of the state health department said that about 35 percent of the patients who received T.P.N. from Meds IV in March sustained infections. The first two occurrences were in January and February, she said. The affected patients ranged in age from 38 to 94. Eleven were women and eight were men.

Dr. Williamson said there was little chance that other patients would become infected, although he said officials were making sure the supplement had been entirely removed from all Alabama health facilities.

“Right now it looks like we have a contained and closed problem,” he said.

The supplement is typically administered to patients whose gastrointestinal systems are not working properly, including those undergoing chemotherapy or recovering from major surgery. The mix is delivered to hospitals in containers presumed to be sterile and has a limited shelf life.

Dr. Williamson said the state health department had been notified about Serratia marcescens infections on March 16 by two Birmingham-area hospitals, Princeton Baptist Medical Center and Shelby Baptist Medical Center. The state then sought assistance from the Centers for Disease Control, which was able to track the outbreak to Meds IV. Soon after, the pharmacy notified customers about the contamination, and last Thursday it voluntarily recalled the product.

In addition to the Baptist hospitals, the supplement was delivered to three other hospitals in the Birmingham area and one in Prattville, health officials said.

A statement issued by Baptist Health System, which operates Princeton Baptist and Shelby Baptist, said six of the nine deaths had occurred at those medical centers. A total of seven patients were infected at Princeton Baptist, four of whom died, and five were sickened at Shelby Baptist, two of whom died.

“Because quality patient care is our top priority, this event is deeply disturbing to all of us,” Dr. Elizabeth D. Ennis, the group’s chief medical officer, said in the statement. She added, “We don’t know, and may never know, if the Serratia marcescens bloodstream infection played a role in the deaths of these patients.”

The health system also said it had ended its relationship with the pharmacy, and noted that “as a precaution, we have removed all other products from the supplier.”

Melody Kitchen, a spokeswoman for the parent company of Prattville Baptist Hospital, which had one infection-associated death, said in a statement that Meds IV was “universally believed and considered to be a reputable and trustworthy entity.”

Haley T. Montgomery, a spokeswoman for Medical West hospital in Bessemer, said the hospital discovered that three patients had been infected with the bacteria, and treated them with antibiotics. One of those patients died. “I can say it was a critically ill patient,” Ms. Montgomery said.

Kevin Sack reported from Birmingham, Ala., and Timothy Williams from New York.

Well: Fat Stigma Is Fast Spreading Around the Globe

Posted: 31 Mar 2011 10:11 AM PDT

Well: An Older Generation Falls Prey to Eating Disorders

Posted: 29 Mar 2011 03:58 PM PDT

Cuomo to Tighten Requirements for Workers in Homes for Disabled

Posted: 29 Mar 2011 10:40 PM PDT

ALBANY — Gov. Andrew M. Cuomo’s administration is planning to announce initial steps aimed at addressing problems of abuse in homes for the developmentally disabled that are overseen by the state.

The moves, however, are unlikely to mollify advocates and aggrieved parents, long frustrated by widespread problems of abuse and mismanagement within the thousands of homes.

Under the changes, which are scheduled to be formally announced on Wednesday, new direct-care workers employed by the state will be required to have high school diplomas and undergo psychological and drug testing, according to a copy of a press release outlining the changes that was obtained by The New York Times. The administration is not changing existing policies that do not automatically disqualify all convicted felons.

The agency overseeing the homes, the Office for People with Developmental Disabilities, also plans to create a central unit to follow up and analyze all reports of abuse and neglect, in both homes operated by the state and homes operated by nonprofit service providers. A review panel will seek to ensure that discipline is administered consistently when employees are punished.

New training will be provided to direct-care workers and clinicians employed by the state, as well as supervisors, and state officials will also send out a memorandum to nonprofit groups to urge them to take similar steps.

Courtney Burke, the acting commissioner of the agency, called the moves “critical first steps.”

“We must thoroughly examine and reform the system to fulfill our duty and privilege to serve and protect the vulnerable individuals in our system from abuse and neglect,” Ms. Burke said in a statement.

This month, an article in The Times detailed widespread problems in state-run homes after a yearlong investigation. In hundreds of cases reviewed by The Times, employees who sexually abused, beat or taunted residents were rarely fired, even after repeated offenses, and in many cases were simply transferred to other group homes run by the state. Residents in the homes have conditions like Down syndrome, autism and cerebral palsy.

Michael Carey, a prominent Albany advocate for the developmentally disabled, said of the Cuomo administration’s new measures: “It’s not remotely enough.”

“There’s a lot more that needs to be done swiftly — a lot more than they’re saying needs to be done,” he said. Mr. Carey’s 13-year-old son, Jonathan, died in state care in 2007, in a death that was ruled a homicide at the hands of a state worker.

Mr. Carey expressed concern that internal committees within the troubled agency were being set up to review problems when a far broader overhaul of the agency’s management was still needed. He also said steps needed to be taken to ensure that cases of abuse were investigated outside of the agency.

“If anybody is involved in an apparent crime, it needs to be reported to law enforcement,” he said, contrasting that need with the policy of having the agency investigating itself or turning to “another state agency that’s going to sweep it under the rug.”

A vast majority of the roughly 13,000 allegations of abuse that come in annually are handled internally, despite a state law requiring that incidents in which a crime may have been committed be reported to law enforcement. Records turned over by the state show that fewer than 5 percent of allegations of abuse were referred to law enforcement, though the Cuomo administration is currently reviewing the agency’s recordkeeping practices under previous administrations.

The administration is also setting up an e-mail address for the public to submit suggestions or complaints: people.first@opwdd.ny.gov.

Well: Doctors Who Want a Life

Posted: 02 Apr 2011 10:45 AM PDT

Well: Going Green for Spring With Chard

Posted: 01 Apr 2011 09:52 AM PDT

Well: When Aging Eyes Can't Read the Fine Print

Posted: 01 Apr 2011 02:26 PM PDT

Well: Making the Hospital Into a Home

Posted: 01 Apr 2011 06:34 AM PDT

Well: Toddler Twins — Secret Language or Babble?

Posted: 31 Mar 2011 11:44 AM PDT

You Are Here: Does the Mediterranean Diet Even Exist?

Posted: 01 Apr 2011 07:50 PM PDT

Every Saturday, a fleet of cars and trucks pulls into a windswept parking lot just off the Mediterranean. Under flapping white awnings, women slit open eggplants the size of a large man’s thumb and stuff them with a mix of chopped garlic, red peppers and walnuts. This is Souk el Tayeb, the farmers’ market that has helped make Beirut a hot destination for globe-trotting foodies. But if you want to see how the new generation of Lebanese really wants to eat, you have to go somewhere else. You have to go to Roadster Diner.

Roadster is a chain of 1950s-Americana restaurants. Its original motto, “There goes my heart,” evokes both Elvis and his artery-clogging diet. The Roadster in my Beirut neighborhood had a life-size statue of a grinning black man with huge white teeth singing into a microphone. Unlike the strenuously authentic Lebanese restaurants beloved by tourists and visiting food writers, Roadster’s nine retail franchises across Lebanon are always packed with locals.

In Europe and the United States, the so-called Mediterranean diet — rich in olive oil, whole grains, fish, fruits and vegetables and wine — is a multibillion-dollar global brand, encompassing everything from hummus to package trips to Italy, where “enogastronomic tourism” rakes in as much as five billion euros a year. Studies at Harvard and elsewhere correlate the Mediterranean diet with lower rates of heart disease, diabetes and depression. In America, health gurus like Mehmet Oz exhort followers to “eat like a Greek.” But according to data from the United Nations Food and Agriculture Organization, Mediterranean people have some of the worst diets in Europe, and the Greeks are the fattest: about 75 percent of the Greek population is overweight. So if the Mediterranean diet is not what people in the Mediterranean eat, then what is it?

Before there was a Mediterranean diet, there was WWII and the food shortages that went along with it. When the fighting was over, Haqvin Mamrol, a researcher in Sweden, showed that mortality from coronary disease declined in Northern European countries during the war. This was, he believed, the result of wartime restrictions on milk, butter, eggs and meat. At about the same time, a Minnesota scientist named Ancel Keys, who had been studying the effects of starvation on a group of volunteer subjects, moved on to study the diets of Midwestern businessmen. He found that these well-fed Americans were more prone to heart disease than were men in war-deprived Northern Europe. Keys postulated that saturated fats led to high levels of cholesterol and from there to cardiovascular disease. To prove it, he initiated a long-term study in seven countries, including Italy and Greece. He concluded that we should cut down drastically on saturated fat and turn to vegetable oils instead. Keys and his wife wrote two best sellers that changed the way Americans ate.

The Mediterranean diet was always a composite. Spaniards love pork; Egyptians, as a rule, do not. In some regions, people made pesto with lard, not olive oil. “There is no such thing called the Mediterranean diet; there are Mediterranean diets,” says Rami Zurayk, an agriculture professor at the American University in Beirut. “They share some commonalities — there is a lot of fruits and vegetables, there is a lot of fresh produce in them, they are eaten in small dishes, there is less meat in them. These are common characteristics, but there are many different Mediterranean diets.”

The healthy versions of these diets do have one other thing in common: they are what the Italians called “cucina povera,” the “food of the poor.” In Ancel Keys’s day, Mediterraneans ate lentils instead of meat because they had no choice. “A lot of it is to do with poverty, not geography,” says Sami Zubaida, a leading scholar on food and culture.

Diet is mostly about desire. The diet that Keys and his colleagues invented bore little resemblance to what Mediterraneans actually wanted to eat. “I’m not sure whether the prestige of such a diet would be high enough for many of the people in the Mediterranean to follow it,” says Josef Schmidhuber, a senior economist at the United Nations Food and Agriculture Organization. “Because they aspire to a Western diet, which they conflate with prestige and wealth.”

Last year, Unesco added the Mediterranean diet to its list of the world’s great intangible cultural treasures in need of safeguarding. Today, more than half the populations of Italy, Portugal and Spain are overweight. In Eastern Mediterranean countries like Lebanon, obesity is growing — especially among the young, an increasing number of whom are happy to trade their eggplants for French fries and milkshakes at Roadster.

Annia Ciezadlo is the author of Day of Honey: A Memoir of Food, Love, and War.

The New Old Age: Dialysis in Elderly Patients

Posted: 01 Apr 2011 02:28 PM PDT

The New Old Age: After Dementia, Counting

Posted: 31 Mar 2011 08:13 AM PDT

The New Old Age: Caregiver’s Bookshelf

Posted: 30 Mar 2011 05:00 AM PDT

Prescriptions: New Regulations Proposed for Accountable Care Organizations

Posted: 31 Mar 2011 01:39 PM PDT

Prescriptions: Medicare Will Pay for Prostate Drug

Posted: 30 Mar 2011 05:13 PM PDT

Prescriptions: Another Tylenol Recall

Posted: 29 Mar 2011 02:45 PM PDT

Recipes for Health: Swiss Chard and Chickpea Minestrone

Posted: 31 Mar 2011 12:10 AM PDT

This simple minestrone, packed with Swiss chard, does not require a lot of time on the stove.

Recipes for Health

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

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2 tablespoons olive oil

1 medium onion, chopped

2 medium carrots, cut in small dice

1 celery stalk, cut in small dice

1 leek, white and light green parts only, halved lengthwise, cleaned thoroughly and sliced thin

Salt

4 large garlic cloves, minced

7 cups water

2 tablespoons tomato paste

A bouquet garni consisting of 1 Parmesan rind, 1 bay leaf, 3 sprigs parsley and 3 sprigs thyme, tied together with kitchen string or tied into a piece of cheesecloth

1 (15-ounce) can chickpeas, drained and rinsed

1/2 pound Swiss chard, stemmed, leaves washed and cut crosswise in thin strips (chiffonade) (4 cups, tightly packed, chiffonade)

1/2 cup soup pasta, like elbow macaroni or broken spaghetti

Freshly ground pepper to taste

Freshly grated Parmesan

1. Heat the olive oil over medium-low heat in a large, heavy soup pot or Dutch oven. Add the onion, carrots and celery. Cook, stirring, until beginning to soften, about three minutes. Add 1/2 teaspoon salt and the leek. Continue to cook, stirring often, until tender, about three minutes. Add the garlic, stir for about a minute, and then stir in the water, tomato paste and the bouquet garni. Bring to a simmer. Add salt to taste, reduce the heat to low, cover and simmer 30 minutes. Stir in the chickpeas. Taste and adjust salt. Remove the bouquet garni.

2. Add the Swiss chard and the pasta to the soup, bring back to a simmer, and simmer another 10 minutes or until the pasta is cooked al dente. Grind in some pepper, taste and adjust seasonings. It should be savory and rich-tasting. Serve in wide soup bowls, with a sprinkling of Parmesan over the top.

Yield: Serves six to eight.

Advance preparation: You can make this through Step 1 several days ahead and keep in the refrigerator or freeze. The closer to serving time you add the chard, the brighter it will be.

Nutritional information per serving (six servings): 169 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 4 grams monounsaturated fat; 0 milligrams cholesterol; 25 grams carbohydrates; 5 grams dietary fiber; 314 milligrams sodium (does not include salt to taste); 6 grams protein

Nutritional information per serving (eight servings): 126 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 3 grams monounsaturated fat; 0 milligrams cholesterol; 19 grams carbohydrates; 4 grams dietary fiber; 236 milligrams sodium (does not include salt to taste); 5 grams protein

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

Recipes for Health: Bruschetta With Swiss Chard and Smoked Trout

Posted: 30 Mar 2011 12:50 AM PDT

You can serve these bruschetta for lunch or dinner, or cut them into smaller pieces and serve them as appetizers. I use drained, canned smoked trout packed in oil (although it doesn’t have to be packed in oil). Don’t forget to squeeze on a little lemon juice when you serve these; it’s a perfect touch. The trout is an excellent source of omega-3 fats.

Recipes for Health

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

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1/2 pound Swiss chard

2 tablespoons extra virgin olive oil

2 garlic cloves, 1 minced, 1 cut in half

Salt and freshly ground pepper

2 thick slices whole-grain country bread (about 2 ounces each)

4 ounces smoked trout

Lemon wedges for serving

1. Stem the chard, and wash the leaves and stems in two rinses of water. Cut the stems in small dice. Blanch the chard leaves in salted boiling water (or steam them) for one to two minutes until tender. Transfer to a bowl of ice water, then drain and squeeze out excess water. Chop medium-fine.

2. Heat the olive oil over medium heat in a medium skillet. Add the chard stalks. Cook, stirring often, until tender, five to eight minutes. Stir in the minced garlic, and cook, stirring, just until fragrant, about 30 seconds. Add the chopped chard leaves, and toss together for about a minute. Remove from the heat. Season to taste with salt and pepper.

3. Lightly toast the bread, and rub with the cut garlic. Brush with the remaining olive oil. Top with the chard, and press down with the back of a spoon. Use a fork to flake the trout, and place on top. Squeeze on a few drops of lemon juice, and serve.

Yield: Two servings.

Advance preparation: You can prepare the chard through Step 2 and keep in the refrigerator for two to three days.

Nutritional information per serving: 310 calories; 3 grams saturated fat; 4 grams polyunsaturated fat; 13 grams monounsaturated fat; 25 milligrams cholesterol; 18 grams carbohydrates; 4 grams dietary fiber; 749 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."

Recipes for Health: Onion Pizza With Ricotta and Chard

Posted: 29 Mar 2011 12:30 AM PDT

This luxurious pizza is topped with tender caramelized onions spread over a creamy mixture of ricotta, Parmesan cheese and chopped Swiss chard.

Recipes for Health

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

Related

2 tablespoons extra virgin olive oil

1 1/4 pounds onions, sliced

1 teaspoon chopped fresh thyme leaves

2 garlic cloves, minced

Salt and freshly ground pepper

1/2 pound chard, stemmed, leaves washed

1 14-inch pizza crust (1/2 batch pizza dough)

3/4 cup ricotta (6 ounces)

2 ounces Parmesan, grated (1/2 cup, tightly packed)

1 egg yolk

1. Thirty minutes before baking the pizza, preheat the oven to 500 degrees. Heat the olive oil over medium heat in a large, heavy skillet. Add the onions. Cook, stirring often, until tender and just beginning to color, about 10 minutes. Add the thyme, garlic and a generous pinch of salt. Turn the heat to low, cover and cook another 10 to 20 minutes, stirring often, until the onions are golden brown and very sweet and soft. Remove from the heat.

2. While the onions are cooking, stem and wash the chard leaves, and bring a medium pot of water to a boil. Fill a medium bowl with ice water. When the water comes to a boil, salt generously and add the chard. Blanch for one to two minutes, just until the leaves are tender, and transfer to the ice water. Drain and squeeze out excess water. Alternatively, steam the chard for two to three minutes until wilted, and rinse with cold water. Chop the chard medium-fine.

3. Roll out the dough, oil a 14-inch pizza pan and dust with cornmeal or semolina. Place the dough on the pan.

4. In a medium bowl, combine the ricotta, egg yolk, Parmesan and chard. Spread over the pizza dough in an even layer, leaving a 1-inch border around the rim. Spread the onions over the ricotta mixture.

5. Place in the hot oven, and bake 10 to 15 minutes until the crust and bits of the onion are nicely browned. Remove from the heat, and serve hot or warm.

Yield: One 14-inch pizza (eight slices).

Advance preparation: The cooked onions and the blanched or steamed chard will keep for three or four days in the refrigerator.

Nutritional information per slice: 227 calories; 4 grams saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 41 milligrams cholesterol; 25 grams carbohydrates; 3 grams dietary fiber; 375 grams sodium (does not include salt to taste); 10 grams protein

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

Officer’s Death Shows Struggle to Define Link Between 9/11 Dust and Disease

Posted: 30 Mar 2011 09:32 PM PDT

When George Wong, a retired police officer, died last week after a battle with gastric cancer, his family assumed, as Mr. Wong had, that the cause of his disease was the many hours he had put in directing traffic around ground zero in 2001.

And when a doctor wrote on Mr. Wong’s death certificate that toxic 9/11 particles had contributed to his death, the family believed that was the end of the matter.

But they were stunned at the phone call they received during his wake: it was the New York City medical examiner’s office, saying it needed his body, right away. The office wanted to look into the assertion that Mr. Wong, 48, had died from exposures to toxic substances around ground zero.

After the family and some police officers protested, the medical examiner agreed to wait until after the wake, and pick up the body at 10:15 p.m. Monday and return it the next morning.

“To treat a hero like this, who died at the call of duty?” a family acquaintance who was at the wake, Wellington Chen, said on Wednesday.

The city’s reaction, as awkward as it seemed, raised the question that continues to bedevil doctors, researchers, police officers and firefighters: what qualifies as a death resulting from the terrorist attacks on the World Trade Center on Sept. 11, 2001?

Because the family declined to have an autopsy on Mr. Wong’s body, the medical examiner’s office performed only an external examination before releasing Mr. Wong’s body back to the funeral home on Tuesday. The results of that examination are pending.

But the city’s official position has been that cancer has not yet been proved to be linked to the toxic dust and debris that rose from the collapsing towers.

That position is also echoed in federal legislation: the James Zadroga 9/11 Health and Compensation Act, which is meant to treat those injured and made ill by the attacks. The law, which was passed at the end of last year, does require that scientific and medical evidence be periodically reviewed to determine whether any cancer should be added to the list of health conditions related to 9/11.

The city’s Health Department, where death certificates are filed, had flagged Mr. Wong’s case because researchers “are actively studying” the relationship between cancer and the disaster, said Susan Craig, a department spokeswoman. “Anytime there is something that says World Trade Center on a death certificate, we make sure that we do an examination of the health record or an autopsy,” she said.

Lyla Correoso, the doctor who filled out the death certificate, did not return a call for comment on Wednesday.

Ellen Borakove, a spokeswoman for the medical examiner, said the office had contacted the family to tell them that “it might be in their best interest if we performed an autopsy.” And Mayor Michael R. Bloomberg defended the medical examiner’s request, which was reported by The New York Post on Wednesday.

“When there is a death that the death certificate says is not of natural causes,” the mayor said, “the medical examiner is required by law to go and to perform whatever they think is appropriate."

Ms. Borakove said 12 families had asked the medical examiner to review cases to determine whether they belonged on the list of Sept. 11 deaths. So far only one name from that group has been added: Felicia Dunn-Jones, 42, a civil rights lawyer who was engulfed by the toxic cloud on Sept. 11 as she ran from her office one block away. She died of sarcoidosis, an inflammatory disease, and was added to the list in 2007.

The medical examiner declined to add Detective Zadroga, who had taken part in rescue efforts, concluding that his death was related to injecting prescription drugs, not inhaling ground zero dust.

Separately, the medical examiner has added two others: Leon Heyward, 45, who helped evacuate people from a nearby city office where he worked, and who died of “lymphoma complicating sarcoidosis”; and Sneha Anne Philip, a doctor who lived near ground zero and disappeared on Sept. 11, and who was added by court order in 2008.

Ms. Borakove said the office had encouraged families to ask for review if they believed deaths were related to Sept. 11, and was preserving the records, so that “if something were to come to light years down the road,” new determinations could be made.

At Mr. Wong’s funeral in Chinatown on Wednesday, attended by bagpipers and police officers, Frank Cosom, a former partner on the force, said that when Mr. Wong had begun to feel ill, eating less and looking more frail, he “thought he may be getting sick from 9/11; he was a healthy guy.”

Mr. Wong retired in 2006 on a regular pension, and in 2010 was awarded a disability pension related to the World Trade Center attacks, Paul J. Browne, a spokesman for the Police Department, said. That increased his pension to 75 percent of his final pay, from 50 percent.

The Police Department’s medical board and the police pension fund board decide whether an officer’s death happened in the line of duty, which would increase the benefits paid to his family. A decision has not been made for Mr. Wong. But such decisions are based on a presumption that a sickness was related to the Sept. 11 attacks if the officer dies of certain respiratory illnesses or cancers. The officers would also have to have been assigned to the World Trade Center within 48 hours of the attack, or to ground zero, the morgue or the Fresh Kills landfill, where remains were being sifted, for at least 40 hours, Mr. Browne said.

Thirty-eight deaths of police officers have been determined to be in the line of duty and related to ground zero work, Mr. Browne said, not including the 23 “combat line of duty” deaths of officers killed when the towers fell.

Juliet Linderman contributed reporting.

F.D.A. Panel to Consider Warnings for Artificial Food Colorings

Posted: 02 Apr 2011 11:18 AM PDT

WASHINGTON — After staunchly defending the safety of artificial food colorings, the federal government is for the first time publicly reassessing whether foods like Jell-O, Lucky Charms cereal and Minute Maid Lemonade should carry warnings that the bright artificial colorings in them worsen behavior problems like hyperactivity in some children.

Tony Cenicola/The New York Times

Froot Loops cereal contains artificial dyes.

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Enlarge This Image
Jim Wilson/The New York Times

A 2006 art installation by Liz Hickok in San Francisco featured Jell-O. As a food, Jell-O could be affected by the review.

Enlarge This Image
Tim Boyle/Bloomberg News

Kraft is making some of its macaroni and cheese without dyes.

The Food and Drug Administration concluded long ago that there was no definitive link between the colorings and behavior or health problems, and the agency is unlikely to change its mind any time soon. But on Wednesday and Thursday, the F.D.A. will ask a panel of experts to review the evidence and advise on possible policy changes, which could include warning labels on food.

The hearings signal that the growing list of studies suggesting a link between artificial colorings and behavioral changes in children has at least gotten regulators’ attention — and, for consumer advocates, that in itself is a victory.

In a concluding report, staff scientists from the F.D.A. wrote that while typical children might be unaffected by the dyes, those with behavioral disorders might have their conditions “exacerbated by exposure to a number of substances in food, including, but not limited to, synthetic color additives.”

Renee Shutters, a mother of two from Jamestown, N.Y., said in a telephone interview on Tuesday that two years ago, her son Trenton, then 5, was having serious behavioral problems at school until she eliminated artificial food colorings from his diet. “I know for sure I found the root cause of this one because you can turn it on and off like a switch,” Ms. Shutters said.

But Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif., said evidence that diet plays a significant role in most childhood behavioral disorders was minimal to nonexistent. “These are urban legends that won’t die,” Dr. Diller said.

There is no debate about the safety of natural food colorings, and manufacturers have long defended the safety of artificial ones as well. In a statement, the Grocery Manufacturers Association said, “All of the major safety bodies globally have reviewed the available science and have determined that there is no demonstrable link between artificial food colors and hyperactivity among children.”

In a 2008 petition filed with federal food regulators, the Center for Science in the Public Interest, a consumer advocacy group, argued that some parents of susceptible children do not know that their children are at risk and so “the appropriate public health approach is to remove those dangerous and unnecessary substances from the food supply.”

The federal government has been cracking down on artificial food dyes for more than a century in part because some early ones were not only toxic but were also sometimes used to mask filth or rot. In 1950, many children became ill after eating Halloween candy containing Orange No. 1 dye, and the F.D.A. banned it after more rigorous testing suggested that it was toxic. In 1976, the agency banned Red No. 2 because it was suspected to be carcinogenic. It was then replaced by Red No. 40.

Many of the artificial colorings used today were approved by the F.D.A. in 1931, including Blue No. 1, Yellow No. 5 and Red No. 3. Artificial dyes were developed — just as aspirin was — from coal tar, but are now made from petroleum products.

In the 1970s, Dr. Benjamin Feingold, a pediatric allergist from California, had success treating the symptoms of hyperactivity in some children by prescribing a diet that, among other things, eliminated artificial colorings. And some studies, including one published in The Lancet medical journal in 2007, have found that artificial colorings might lead to behavioral changes even in typical children.

The consumer science group asked the government to ban the dyes, or at least require manufacturers to include prominent warnings that “artificial colorings in this food cause hyperactivity and behavioral problems in some children.”

Citizen petitions are routinely dismissed by the F.D.A. without much comment. Not this time. Still, the agency is not asking the experts to consider a ban during their two-day meeting, and agency scientists in lengthy analyses expressed skepticism about the scientific merits of the Lancet study and others suggesting any definitive link between dyes and behavioral issues. Importantly, the research offers almost no clue about the relative risks of individual dyes, making specific regulatory actions against, say, Green No. 3 or Yellow No. 6 almost impossible.

The F.D.A. scientists suggested that problems associated with artificial coloring might be akin to a peanut allergy, or “a unique intolerance to these substances and not to any inherent neurotoxic properties” of the dyes themselves. As it does for peanuts and other foods that can cause reactions, the F.D.A. already requires manufacturers to disclose on food labels the presence of artificial colorings.

A spokeswoman for General Mills refused to comment. Valerie Moens, a spokeswoman for Kraft Foods Inc., wrote in an e-mail that all of the food colors the company used were approved and clearly labeled, but that the company was expanding its “portfolio to include products without added colors,” like Kool-Aid Invisible, Capri Sun juices and Kraft Macaroni and Cheese Organic White Cheddar.

The panel will almost certainly ask that more research on the subject be conducted, but such calls are routinely ignored. Research on pediatric behaviors can be difficult and expensive to conduct since it often involves regular and subjective assessments of children by parents and teachers who should be kept in the dark about the specifics of the test. And since the patents on the dyes expired long ago, manufacturers have little incentive to finance such research themselves.

Popular foods that have artificial dyes include Cheetos snacks, Froot Loops cereal, Pop-Tarts and Hostess Twinkies, according to an extensive listing in the consumer advocacy group’s petition. Some grocery chains, including Whole Foods Market and Trader Joe’s, refuse to sell foods with artificial coloring.

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