Saturday, June 11, 2011

Health - Government Says 2 Common Materials Pose Risk of Cancer

Health - Government Says 2 Common Materials Pose Risk of Cancer

Government Says 2 Common Materials Pose Risk of Cancer

Posted: 10 Jun 2011 10:20 PM PDT

WASHINGTON — The government issued warnings on Friday about two materials used daily by millions of Americans, saying that one causes cancer and the other might.

Government scientists listed formaldehyde as a carcinogen, and said it is found in worrisome quantities in plywood, particle board, mortuaries and hair salons. They also said that styrene, which is used in boats, bathtubs and in disposable foam plastic cups and plates, may cause cancer but is generally found in such low levels in consumer products that risks are low.

Frequent and intense exposures in manufacturing plants are far more worrisome than the intermittent contact that most consumers have, but government scientists said that consumers should still avoid contact with formaldehyde and styrene along with six other chemicals that were added Friday to the government’s official Report on Carcinogens. Its release was delayed for years because of intense lobbying from the chemical industry, which disputed its findings.

John Bucher, associate director of the National Toxicology Program, which produced the report, said evidence of formaldehyde’s carcinogenicity was far stronger than for styrene and that consumers were more likely to be exposed to potentially dangerous quantities of formaldehyde.

The federal Occupational Safety and Health Administration warned in April that a hair-care product, Brazilian Blowout Acai Professional Smoothing Solution, contained unacceptable levels of formaldehyde, and salon workers have reported headaches, nosebleeds, burning eyes, vomiting and asthma attacks after using the product and other hair-straighteners.

Studies of workers like embalmers exposed to high levels of formaldehyde have found increased incidences of myeloid leukemia and rare cancers of the nasal passages and upper mouth.

Dr. Otis Brawley, chief medical officer at the American Cancer Society, said that formaldehyde is both worrisome and inescapable. “It’s the smell in new houses, and it’s in cosmetics like nail polish,” he said. “All a reasonable person can do is manage their exposure and decrease it to as little as possible. It’s everywhere.”

Consumers can reduce their exposure to formaldehyde by avoiding pressed-wood products or buying only those that are labeled as U.L.E.F. (ultra-low-emitting formaldehyde), N.A.F. (no added formaldehyde) or C.A.R.B. (California Air Resources Board) Phase 1 or Phase 2 compliant.

Styrene is mostly a concern for workers who build boats, car parts, bathtubs and shower stalls. Studies of workers exposed to high levels of styrene have found increased risks of leukemia and lymphoma and genetic damage to white blood cells. There is also some evidence that styrene increases the risks of cancer of the pancreas and esophagus among styrene workers, the report found. Consumers can be exposed to styrene from the fumes of building materials, photocopiers and tobacco smoke.

As for styrene’s presence in plastic utensils and other consumer products, Dr. Brawley likened the risk from such products to that of coffee and cellphones — uncertain and slight.

An industry spokesman said the action will hurt small businesses.

“It will unfairly scare workers, plant neighbors and could have a chilling effect on the development of new products,” said Tom Dobbins of the American Composites Manufacturers Association. “And our companies are primarily small businesses, and this could hurt jobs and local economies.”

Cal Dooley, president and chief executive of the American Chemistry Council, a trade association that represents companies that make and use polystyrene and formaldehyde, rejected the report’s conclusions. “We are extremely concerned that politics may have hijacked the scientific process,” he said.

Some in the industry have promised to continue fighting the report, and will appeal elements of its findings. But some manufacturers already have begun using alternatives to formaldehyde in their products.

This is the 12th cancer list released by the toxicology program at the National Institutes of Health, and each has been controversial. In 2000, controversy erupted over the ninth report’s listing of secondhand smoke and tanning beds. The 11th report’s listing in 2005 of naphthalene, which is used in mothballs, caused similar concern.

That this latest report would warn about formaldehyde and styrene has been suspected by industry since shortly after the release of the previous report, and industry groups have fought the process behind its release ever since. As a result, the government added numerous public comment periods to the process, and even after it was written, officials at the Department of Health and Human Services delayed the report’s release for months to cope with industry complaints.

“Industry held this report up for four years,” said Jennifer Sass, a senior scientist at the Natural Resources Defense Council. “They have tried to create the impression that there was real scientific uncertainty here, but there’s not.”

The report also lists aristolochic acids, found in plants and sometimes used in herbal medicines, as a known carcinogen and added to the list of probable carcinogens other substances like captafol (a fungicide no longer sold in the United States), finely spun glass wool fibers (used in insulation), cobalt-tungsten carbide (used in manufacturing), riddelliine (plants eaten by cattle, horses and sheep) and ortho-nitrotoluene (used in dyes).

Aristolochic acids are sometimes used in herbal medicines to treat conditions like arthritis and gout. In 2001, the Food and Drug Administration warned against the use of products containing aristolochic acids after seeing an increase in kidney disease among users. Products using the chemical are Rheumixx and BioSlim Doctor’s Natural Weight Loss System Slim Tone Formula.

Glass wool fibers are finely spun fibers of glass that form a mass resembling wool. They are commonly used for insulation or filtration, and people can be exposed to them when they install or remove insulation during home improvement projects. Animal studies have shown that glass wool fibers cause lung tumors, but there is little evidence from human studies of a risk.

Rare Infection Strikes Victims of a Tornado in Missouri

Posted: 10 Jun 2011 10:48 PM PDT

Several people who were injured when a tornado devastated Joplin, Mo., last month have become sickened by an uncommon, deadly fungal infection and at least three have died, although public health officials said Friday that a link between the infection and the deaths was not certain.

Also on Friday, the death toll from the tornado was raised to 151.

Eight tornado victims have fallen ill from the mysterious infection, and each had “multiple injuries and secondary wound infections,” said Jacqueline Lapine, a spokeswoman for the Missouri Department of Health and Senior Services. Citing confidentiality rules, officials declined to discuss the treatment or condition of the patients.

The fungus that causes the infection, which is believed to be mucormycosis, is most commonly found in soil and wood, according to the Centers for Disease Control and Prevention, which is studying samples from the eight Joplin patients. “It is a very aggressive and severe infection,” said Dr. Benjamin Park, chief of the epidemiology team in the C.D.C.’s Mycotic Diseases Branch. “It is also very rare.”

Mucormycosis enters the body either via a puncture wound or when a victim breathes in its mold spores, officials said. Those who have weakened immune systems have a mortality rate as high as 90 percent. Other people at risk include those with diabetes or cancer and burn victims.

On Friday, the Jasper County coroner’s office said that 151 people died in the May 22 tornado. It is revising the toll as additional death reports come in from hospitals where tornado victims had been taken.

That figure includes the three dead victims who appear to have had the fungal infection — though the cause of those deaths has not yet been established because they had other injuries as well, said Rob Chappel, the Jasper County coroner.

Even before the updated death toll was released Friday, the tornado was the deadliest in the United States since modern record-keeping began. As many as one-third of the town’s buildings were damaged, including the city’s main hospital, St. John’s Regional Medical Center. St. John’s, which lay in the path of the tornado, was evacuated.

Health officials said they were not aware of any other cases of mucormycosis arising from the series of tornadoes that struck the Midwest and the South this spring, killing hundreds of people and injuring thousands.

“Although this is a naturally occurring infection, to have a cluster which potentially involves this many people is highly unusual,” Dr. Park said.

Health officials said even busy hospitals around the country might see no more than a case or two of mucormycosis each year. They have asked that tornado victims from Joplin who have wounds that have failed to heal properly see a doctor immediately. It cannot be spread from person to person.

Mucormycosis and similar fungal infections that enter the skin through puncture wounds can usually be prevented once a wound is disinfected in a hospital, health officials said. But during a natural disaster, when there is confusion and a shortage of medical personnel and supplies, wounds are sometimes treated inadequately. In Joplin, staff members from St. John’s treated some of the thousands injured at makeshift clinics.

Mucormycosis, which can have an incubation period of two weeks or more, must be treated with intravenous antibiotics and in some cases the removal of the affected tissue.

The Poster Plant of Health Food Can Pack Disease Risks

Posted: 10 Jun 2011 09:15 PM PDT

Sprouts are a fixture of salad bars and the epitome of health food to many people. But the reality can be very different.

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Stew Milne for The New York Times

Bean sprouts grow in a tube at Jonathan Sprouts in Rochester, Mass.

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Stew Milne for The New York Times

Bob Sanderson of Jonathan Sprouts says fresh food is the most nutritious, but can be prone to problems because it is not sterile.

As a horrified Europe learned over the past month, sprouts are a high-risk food for carrying harmful bacteria like salmonella or the toxic forms of E. coli, according to public health experts.

This year, at least two American growers have recalled sprouts contaminated with salmonella, and outbreaks of illness from tainted sprouts have occurred so often in the United States that health investigators have a special name for them: sproutbreaks.

Many sprout growers try to kill pathogens by soaking their seeds before germination in a concentrated chlorine solution, similar to but much stronger than the disinfectant used in swimming pools. While the Food and Drug Administration recommends a sanitizing step like the chlorine treatment, it does not require it and some growers skip it or use less stringent methods.

German authorities said on Friday that they had conclusively identified sprouts as the cause of the E. coli infections that have swept Europe since early May, killing at least 31 people and sickening about 3,000, including more than 700 with a severe kidney complications.

Epidemiologists in the United States said they were perplexed that it took German authorities so long to identify the culprit.

“I’m just staggered,” said William E. Keene, a senior epidemiologist of the Oregon Public Health Division. “This is basic outbreak investigation 101. This is on the high end of suspect vehicles. You always rule out raw milk, you always rule out ground beef, you always rule out sprouts. It just happens in the beginning steps.”

After a series of outbreaks of sprout-related illnesses in this country and abroad in the 1990s, the F.D.A. began encouraging sprout growers, known as sprouters, to take steps to sanitize their seeds and test their products for pathogens before sale.

The agency also warned the public that uncooked sprouts were a risky food, saying that children, the elderly, pregnant women and those with weak immune systems should not eat raw sprouts. The bacteria that can contaminate sprouts can be destroyed by cooking.

The F.D.A. says there have been at least 30 outbreaks of disease associated with sprouts in this country since 1996. The Center for Science in the Public Interest, an advocacy group that tracks food safety, said that its review of government data revealed 45 sprout-related outbreaks since 1990, including 2,500 illnesses. The group said that it was aware of one death, in a salmonella outbreak in 2003.

One of the most severe E. coli outbreaks ever recorded, in Japan in 1996, was associated with radish sprouts. About 10,000 people, many of them children, fell ill.

Bob Sanderson, president of Jonathan Sprouts in Massachusetts and the head of the International Sprout Growers Association, said that it would be wrong to draw conclusions about the safety of American sprouts based on the German outbreak, since growers there may use different methods than their counterparts here. “Fresh food is the most nutritious food and inherently prone to these problems,” Mr. Sanderson said of sprouts and other vegetables. “That’s what makes it fresh. It’s not sterile.”

Mr. Sanderson’s company recalled alfalfa and some mixed sprouts in April after routine federal testing found salmonella in them. Mr. Sanderson said that no illnesses had been associated with his products. After the recall, he said, he improved his testing methods.

Some sprout growers complain that the strong chlorine mixture recommended by the F.D.A. to sanitize seed can be dangerous for workers to handle.

Mr. Sanderson said that he used a lower concentration of chlorine for that reason, but he feels that the tests his company conducts on sprouts as they are growing are sufficient to catch any problems.

Sidney Chang, the owner of Chang Farm, another Massachusetts sprouter, recalled some of his sprouts two years ago after tests found listeria, another dangerous bacteria. Since then, he has built a new, more modern facility and now sanitizes his sprouts with a hot-water process. He also uses a less concentrated chlorine wash.

Experts say they believe sprout seeds can become contaminated in the fields where they are grown. Bacteria can hide inside damaged seeds, where sanitizing steps may not always be able to reach them.

Michelle Smith, an F.D.A. senior policy analyst, said that a single bacterium surviving in a kilogram of seed can be enough to contaminate a batch of sprouts because the way they are grown allows bacteria to spread.

Dr. Smith said that the F.D.A. expected to include new rules for sprouts as it wrote regulations as part of a major food safety law that went into effect this year.

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Germany Says Bean Sprouts Likely E.Coli Source

Posted: 10 Jun 2011 10:15 PM PDT

BERLIN — After days of confusion, German authorities said on Friday that they had concluded that contaminated sprouts from an organic farm in the country’s north were the most likely cause of one of the world’s worst outbreaks of E. coli.

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Investigators on Monday examined a farm in Bienenbüttel, Germany, that is believed to be the source of contaminated sprouts.

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Officials acknowledged, however, that laboratory tests to confirm the findings had produced only negative results and that questions remained about how the sprouts had been contaminated in the first place.

To reach their conclusion, health officials said they relied on an epidemiological study of the pattern of infection among patients, tracking the outbreak along the food chain, from hospital beds to restaurants and back to the farm, southeast of Hamburg, at Bienenbüttel.

Hours after the announcement in Berlin, officials in a different region, North Rhine-Westphalia, said they had, for the first time, identified the pathogens thought to be causing the outbreak in an open package of bean sprouts from the same farm.

Johannes Remmel, the state consumer protection minister, said the discovery — in a garbage can at the home of two infected patients in Cologne — meant that it was “becoming increasingly more likely that bean sprouts” from the farm had caused the outbreak. Federal officials cautioned that the findings still needed to be confirmed.

Friday’s announcement seemed intended to assure Germans that foods suspected earlier of containing toxins — cucumbers, tomatoes and lettuce — were safe to eat. But many shopkeepers remained angry over the handling of the crisis.

“The whole thing is a big scandal,” said Riza Cetinkaya, 24, who works in her father’s grocery store in the Charlottenburg district of Berlin, where, she said, sales had dropped about 70 percent.

“People were very unsettled. Every day something different was announced,” Ms. Cetinkaya said. “Now I hear on the radio that it was the sprouts. But people were even buying less fruit. That is simply insane.”

The outbreak has claimed at least 30 lives in Germany, unsettled the nation and thrown European agriculture into disarray. Although the authorities have made “decisive progress,” the outbreak “is not yet over,” said Reinhard Burger, the president of the Robert Koch Institute, the country’s disease control agency, because new cases will still be reported.

At a news conference in Berlin, Dr. Burger said the institute’s scientists did not yet know how pathogens came in contact with the sprouts or whether some of the contaminated produce was still in circulation.

As the outbreak spread, German authorities blamed cucumbers, tomatoes or lettuce imported from Spain and urged people, particularly in northern Germany, which seems to be the epicenter of the outbreak, to avoid the products.

On Friday, German health officials declared cucumbers, tomatoes and lettuce to be safe, but said consumers should still avoid the consumption of raw sprouts, a popular addition to salads and ready-made sandwiches.

“It is possible that the source of the infection has now been exhausted, that is to say, that the food has either been eaten or thrown away,” Dr. Burger said.

By studying the pattern of the infection as it spread, he said, “it was possible to narrow down epidemiologically the highly probable cause of the outbreak of the illness to the consumption of sprouts.”

“It was the sprouts,” Dr. Burger said.

He said investigators had examined 112 people, 19 of whom had been infected with E. coli during a group visit to a single restaurant, and had examined recipes for the food they had eaten, spoken to the chefs and even examined photographs they had taken of one another with their choices of food on the table.

The aim was “to discover exactly how each meal was prepared, which ingredients went into it,” Dr. Burger said. Customers who ate sprouts were found to be almost nine times as likely to be infected as other diners. It was this trail that led health inspectors to the organic farm where the sprouts originated.

On Friday, state authorities in Lower Saxony said they had sealed off the farm and ordered its operators to suspend sales of any other products. The state agriculture minister, Gert Lindemann, said the owners of the farm had agreed on Sunday to stop selling produce after the farm came under suspicion.

The German authorities say the outbreak has been particularly virulent because it has led to a potentially lethal complication, known as hemolytic uremic syndrome, or H.U.S., which causes kidney failure and neurological damage.

In a separate statement on its Web site on Friday, the Robert Koch Institute said the number of new cases of E. coli being reported was “clearly lower.” The death toll in Germany stood at 30, including 21 people who had died of the H.U.S. complication. Over all, 2,988 people have been infected, and 759 of them have been stricken with H.U.S.

In addition to the 30 deaths in Germany, one was reported in Sweden.

The outbreak spread alarm across Europe, with Spanish farmers demanding compensation after demand for their crops plummeted, and farmers in Germany and other European countries said demand for cucumbers, lettuce and tomatoes had slumped so much that they were forced to dump tons of unsold produce.

In response to the spread of E. coli, Russia banned all imports of vegetables from Europe, causing an outcry among European farmers that one of its biggest markets had been closed down.

Russia promised on Friday to lift its ban once the European Union provided documented proof of the safety of its produce, according to news reports from Nizhny Novgorod on the Volga River, where President Dmitri A. Medvedev met with European Union leaders.

“We are ready to resume the shipments under guarantees of the European Union authorities,” The Associated Press quoted Mr. Medvedev as saying at a news conference. It was not clear what kind of guarantees would satisfy the Russian authorities.

Victor Homola and Stefan Pauly contributed reporting.

Business Briefing | Legal News: Gilead, Maker of H.I.V. Drugs, Discloses a Subpoena

Posted: 10 Jun 2011 09:42 PM PDT

Gilead Sciences, the world’s largest maker of H.I.V. drugs, said it had received a subpoena for documents related to its manufacturing and quality and distribution practices. News of the subpoena, from the United States attorney’s office for the Northern District of California, sent the drug maker’s shares down 2.4 percent, to $39.25. Gilead said it was cooperating in the civil and criminal investigation.

Russians Adopt U.S. Tactics in Opposing Abortion

Posted: 09 Jun 2011 11:40 PM PDT

MOSCOW — While the United States is often derided as a model of immorality in Russia, its anti-abortion movement has become a model for Russian activists, who have even adopted the English-language term “pro-life” as their own. American-style pickets of abortion clinics are becoming a staple of the movement in Russia.

The campaign is heavily influenced by the Russian Orthodox Church, which is drawing on the tacit support of the first lady, Svetlana Medvedeva, and prominent politicians. The church, increasingly vocal on social issues under Patriarch Kirill I, draws on widespread fears that Russians may become an ethnic minority in their own vast country.

This week, politicians introduced amendments to a draft law in the State Duma that would place some restrictions on abortion. Rallied by dioceses across Russia, demonstrators marked International Children’s Day by distributing leaflets on dangers of abortion and releasing hundreds of balloons over Ulyanovsk, Lenin’s birthplace, to support “Russia without abortions.”

Abortion was common and readily available in the Soviet era, championed by early 20th-century Communists in the name of women’s liberation. After the Soviet Union became the first country to legalize abortion, it was restricted by Stalin in his drive to increase the population. In the post-Stalin era, however, Soviet women sometimes had multiple abortions, either because they had little access to contraception or feared it.

Official statistics say 1.3 million abortions were performed in 2009 in Russia, in a population of just under 143 million and falling. Opponents of abortion and the morning-after pill, which they lump together, say the real number is much higher.

“The number of abortions in our country reaches six to eight million a year,” said Valery Draganov, who proposed more rigid anti-abortion legislation in the Duma last week that was hastily withdrawn, highlighting tension on the issue. “Every minute, two abortions are carried out in Russia. Due to botched abortions, 20 percent of families lose the ability to become parents. One in every five pregnant women who dies, dies as a result of abortion. These are catastrophic statistics.”

Some abortion opponents are more strident. A Moscow priest, the Rev. Dmitri Smirnov, said last year that women who have abortions should be jailed for murder and that women considering abortion should be advised “not to be worse than Himmler and Goebbels, who didn’t kill their own children.” Russian feminists condemned his remarks.

The amendments would institute a mandatory waiting period for abortions of 48 hours to one week, depending on how long the woman had been pregnant. They would also require women to sign a statement that they agreed to abortion after reading of possible negative consequences, including “the onset of infertility.”

Women over six weeks pregnant would be required to see their embryo or fetus on ultrasound, hear its heartbeat and have counseling. Another amendment would restrict sale of the morning-after pill.

Yelena Mizulina, chair of the Duma committee that proposed the amendments, said that Russians support a waiting period before abortions are granted but that for now only 25 percent favor eliminating state financing for early-term abortions. Late last year, at a forum, she was stridently against abortion.

That forum was convened by Sanctity of Motherhood, an organization led by Natalia Yakunina, the wife of Vladimir Yakunin, the powerful chief of Russia’s railroads, who has created several foundations to back the Russian Orthodox Church and to promote patriotism.

Speakers urged Russian women to have at least three children. The high birth rate among Muslims in Russia was spoken of with some awe, both as a threat and as something to emulate. A Russian Orthodox priest who has 18 children was showered with praise.

Mrs. Medvedeva, whose Foundation for Social and Cultural Initiatives promotes family values, spoke of Russia’s religious pluralism. But she also talked about the “rights of a child to life” and about “socioeconomic indicators” and general lack of support that she said usually drove women to “artificial termination of pregnancy,” carefully sidestepping the word abortion or saying outright that she opposes it.

“The state must help women keep their babies,” she said.

At a roundtable session, the vice president of Mrs. Medvedeva’s foundation, Tatyana Shumova, said: “Due to the nature of our foundation and the president of our foundation, we can’t say we’re against abortion, because we would immediately be accused of curtailing democracy and violating human rights, and everyone is free to choose.

“But we say ‘Give Me Life,”’ she said, referring to a foundation program to promote family values.

Days later, in his state of the federation address, President Dmitri A. Medvedev focused on Russia’s demographic crisis and proposed measures to lift the birth rate.

At the conference, Mrs. Yakunina said Sanctity of Motherhood was conducting a pilot program in Krasnoyarsk, an industrial city in Siberia, working with doctors and journalists to shift public opinion and women’s choice away from abortion. The abortion rate in Krasnoyarsk among women who had gone through the program dropped by 16 percent, she said, which if applied to Russia as a whole would mean 200,000 more babies a year, based on the official figure of 1.3 million annual abortions.

The Health Consumer: Some Heart Disease Screens May Be Unnecessary

Posted: 10 Jun 2011 10:20 PM PDT

HEART disease remains the No. 1 cause of death in the United States, killing more than 800,000 people each year, and accounting for one in three of all deaths. It is no wonder, then, that screening for heart disease is a routine part of just about every physical exam given in this country.

Fred R. Conrad/The New York Times

Dr. John Santa, of Consumer Reports Health, says some cardiac screening is unwarranted and costly.

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Fred R. Conrad/The New York Times

Monitoring blood pressure is both useful and inexpensive.

The number of these tests has increased significantly over the last 20 to 30 years, and these days screening may involve any of a dozen procedures — some as simple as taking a patient’s blood pressure, some as complicated as CT angiography, an expensive, controversial test that may carry health risks.

But as important as screening is, excessive and inappropriate testing can lead to “a cascade of unnecessary, costly and in some cases risky follow-up tests and treatment,” said Dr. John Santa, director of the health ratings center at Consumer Reports Health. “Many people who are screened will show signs of heart disease but will never actually suffer from the disease or a heart attack.”

When do you need to be screened for heart disease? What tests are worth having? Here is some advice from experts.

Step 1: In the absence of risk factors, rely on basic, not high-tech, screening tests.

Cost: Insurance should cover the cost as part of your annual physical. There may be some additional lab fees for blood work.

Patients without obvious symptoms of heart disease routinely receive blood pressure and cholesterol tests. Experts say both are relatively simple, inexpensive and worth your time.

High blood pressure, or hypertension, is commonly associated with heart disease and can cause stroke, heart failure and heart attack. Fortunately, the so-called silent killer is readily detectable. A doctor or nurse puts the cuff around your arm and inflates it until blood flow is cut off. As the cuff deflates, the doctor records the points at which blood can be heard to begin flowing again (the systolic pressure) and as it fully resumes (the diastolic pressure).

A normal reading for a healthy person is below 140/90 millimeters of mercury. Any abnormal reading should be confirmed at least three times, as single readings can be misleading. Some patients experience an increase in pressure simply because they’re in the doctor’s office — “white coat hypertension,” it’s called.

A cholesterol screening, also called a fasting lipoprotein profile, helps doctors find coronary artery disease, the most common type of heart disease, and other artery diseases. C.A.D. occurs when fatty deposits, or plaque, choke off the flow of blood in arteries supplying the heart, weakening the muscle and often causing chest pain.

A simple test tells doctors your blood levels of total cholesterol, LDL (or “bad” cholesterol), HDL (“good” cholesterol) and fats called triglycerides. The test indicates a possible risk for heart disease if:

¶ Total cholesterol is above 200 milligrams per deciliter.

¶ HDL is below 40 milligrams per deciliter in men, or 50 milligrams per deciliter in women.

¶ LDL is above 130 milligrams per deciliter.

¶ Triglycerides are above 150 milligrams per deciliter.

The American Heart Association recommends that adults over age 20 receive a blood pressure screening at every doctor’s visit or at least once every two years. Cholesterol screenings should be given once every five years to men under age 45 and women under age 50 who have no other risks for heart disease.

Avoid: Several studies have suggested that expensive tests for biomarkers that are sometimes indicative of heart disease — such as C-reactive protein, a sign of systemic inflammation — are not cost-effective in generally healthy patients. More sophisticated testing should be done only in patients with known heart risks.

Step 2: If you are overweight or obese, get an annual fasting blood sugar test.

Cost: The test usually is included in an annual physical, although you may pay a small fee for lab work. Free diabetes screening often is available at health fairs and community centers.

People with Type 2 diabetes are far more likely than those without to develop heart disease — indeed, it is what kills most adults with diabetes. Up to a third of heart attack patients have diabetes, and 25 percent of heart attack patients have high blood sugar levels.

The test measures levels of blood sugar, or glucose, which is the body’s fuel. A reading of 126 milligrams per deciliter or higher signals a problem. Again, you should undergo the test more than once to get an accurate reading.

While a blood sugar test may provide helpful information, there is controversy over the effectiveness of intensive measures to control heart risks in diabetic patients. Only statins, a type of prescription drug, have been shown consistently to be effective.

Step 3: If preliminary testing turns up signs of heart disease, or if you are experiencing symptoms or are at risk for other reasons, more sophisticated screening tests may be in order.

Cost: An electrocardiogram costs around $50 and a stress test costs about $200. Insurance often covers at least part of the fee.

If your doctor determines you are at risk of heart disease or you have a family history of heart disease, you may need to consider an electrocardiogram, or E.K.G., or an exercise stress test.

In an E.K.G., electrodes are attached to your chest, limbs and abdomen to ascertain your heart rate and its pattern, as well as the size and thickness of the heart walls. The electrodes can detect electrical signals of the heart through the skin, which are transcribed onto a graph. You can get results immediately.

A stress test measures the heart’s ability to function while exercising, usually while walking on a treadmill. Some signs of heart disease aren’t visible when your heart is at rest. During exercise you need more blood and oxygen; if your arteries are narrowed, it will be evident during the test.

Step 4: If evidence of heart disease is present, consider coronary angiography.

Cost: Just under $5,000, depending on where you live and your health care provider. At least part of the cost should be covered by insurance.

If the results of an E.K.G. or stress test are worrisome, or if you are having symptoms of heart disease, doctors may prescribe coronary angiography. In some cases, it may be warranted without a stress test first if the patient has a condition that could make the stress test too risky.

During the test, a flexible tube is threaded from the groin into the coronary arteries. A dye is also injected into the bloodstream, so that any blockages in the arteries can be detected on an X-ray. Physicians look for blood vessels that are 50 percent or more blocked.

Avoid: Some sophisticated, expensive heart disease screening tests may pose risks to the patient and may not be effective. For example, patients who receive CT angiography — in which multiple CT scans are used to produce a three-dimensional image of the heart — are exposed to amounts of radiation.

According to a study published last month in The Archives of Internal Medicine, patients at low risk of heart disease who got this test were more likely to be treated aggressively with invasive and potentially risky procedures, but in the end were not less likely to have a heart attack or other coronary problem. For more information on screening tools, visit Consumer Reports Health (consumerreportshealth.org) or the American Heart Association (heart.org).

Recipes for Health: Whole-Wheat and Walnut Breadsticks

Posted: 10 Jun 2011 11:07 AM PDT

I used walnut oil instead of olive oil in these nutty breadsticks. Chop the walnuts finely so that they don’t tear the dough when you shape the breadsticks.

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 teaspoons active dry yeast

1 1/2 cup lukewarm water

1 teaspoon honey, agave nectar, malt extract or rice syrup

1/4 cup walnut oil

2 cups whole-wheat flour

About 1 1/3 cups unbleached all-purpose flour

1/2 cup finely chopped walnuts

1 1/2 teaspoons salt

1. Dissolve the yeast in the water in a large bowl or in the bowl of a stand mixer. Stir in the honey, agave nectar, malt extract or rice syrup. Let stand for five minutes. Stir in the walnut oil.

2. Combine the whole-wheat flour, 1 cup of the unbleached all-purpose flour, the walnuts and the salt. Add to the liquid mixture. If kneading by hand, stir until you can turn the dough out onto a lightly floured surface; knead for 10 minutes, adding flour as necessary to keep the dough from sticking to your hands and worktop.

If using an electric mixer, mix at medium speed for 8 to 10 minutes. Add flour as necessary so that the dough comes away from the sides of the bowl. The dough should be elastic and just slightly sticky.

3. Lightly flour your work surface or brush with walnut oil. Using your hands or a rolling pin, roll the dough into a 14-by-4-inch rectangle. Make sure there is enough flour or oil underneath the dough so that it doesn’t stick to the work surface. Brush the top with oil. Cover with plastic wrap, then with a damp kitchen towel. Allow to rise for 1 to 1 1/2 hours until nearly doubled. (If you need the workspace, lightly oil the underside of a sheet pan and place the dough on top.)

4. Preheat the oven to 400 degrees with the racks positioned in the middle and upper thirds of the interior space. Brush sheet pans with olive oil or walnut oil. Cut the dough crosswise into four equal pieces. Cut each piece crosswise into six equal pieces. Roll each between the board and your hands as if you were making a rope until it is as long as the baking sheet. For a tighter strip, twist the strands from one end to the other. Place 1 inch apart on the baking sheets until you’ve filled two baking sheets. Continue to shape the remaining breadsticks while the first batch is baking.

5. Place in the oven, and bake 15 minutes. Switch the pans top to bottom and front to back, and bake another 10 minutes until the breadsticks are nicely browned. (They will be darker on the bottom; you can flip them over halfway through for more even baking.) Remove from the heat, and cool on a rack. Shape and bake any remaining dough as instructed.

Yield: Two dozen breadsticks.

Advance preparation: The breadsticks will keep for several days in an airtight container or wrapped in foil. They can be frozen and recrisped in a medium oven for 10 minutes.

Nutritional information per breadstick: 97 calories; 0 grams saturated fat; 3 grams polyunsaturated fat; 1 gram monounsaturated fat; 0 grams cholesterol; 13 grams carbohydrates; 2 grams dietary fiber; 146 milligrams sodium; 3 grams protein

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

The Long Hard Ride of Damian Lopez Alfonso

Posted: 11 Jun 2011 08:20 AM PDT

WITH only the tips of his elbows touching his bicycle’s upturned handlebars, Damian Lopez Alfonso pedaled along the Hudson River bike path on a cool March day. His balancing act elicited stares from disbelieving pedestrians and curious double-takes from fellow cyclists.

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Damian's Ride
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Because not only does Mr. Alfonso ride his bike without forearms, lost in a devastating childhood accident, but he also rides it very, very fast.

Tracy Lea first witnessed his unorthodox cycling method during a race outside Havana nearly eight years ago.

Ms. Lea, a former elite racer from Maryland, found herself in a ragtag pack of riders on a highway pocked with “car eating” potholes outside the Cuban capital. “I’m worried about these guys in tight, fast conditions,” she remembered thinking, “and all of a sudden, I’m racing next to a guy with no arms!”

She watched as he powered through the course, lifting his body to shift gears with the nubs of his elbows or press down on the brakes. “Then I realized he had more control than most of the people in the race,” she said.

Despite his disadvantages, Mr. Alfonso, 34, has won local competitions at home in Cuba and he races nearly every weekend against able-bodied cyclists in informal events. But the alterations to his bike that allow him to do so — turning the handlebars nearly 180 degrees upward, so the brakes and gear shifters face him — have also kept him out of officially sanctioned international competitions, which have strict equipment rules.

But not for much longer.

In July, Mr. Alfonso is scheduled to race in Canada, the first event on his road to qualifying for the 2012 Paralympic Games in London. If all goes well, it will be the culmination of a nearly decade-long journey for Mr. Alfonso, a story of sudden tragedy, grim determination and a little help from a lot of perfect strangers in a bicycling community thousands of miles away.

Since Ms. Lea and others began spreading word about the Cuban cyclist with no arms and disfiguring injuries to his face — also from the childhood accident — riders from as far away as California and Germany have sent money, and companies including Fuji, Shimano and a prosthetics maker, Hanger, have provided state-of-the-art products that will help him ride in the standard position so he can compete at an elite level.

But Mr. Alfonso’s strongest supporters are in and around New York, following his progress on Facebook or the widely read local racing blog NYVelocity, and donating their time, money and spare bedrooms to help him in the city, where he came for medical tests and has spent nearly four months undergoing a series of painful reconstructive operations and being fitted for prosthetic arms.

The operations alone would normally have cost hundreds of thousands of dollars but are being done free.

One rider provided the use of a car service to get Mr. Alfonso around town; another lent him an old iPhone; several have acted as translators on doctor visits; still others have made small cash donations totaling $8,000 to support him during his stay.

And a few have gone even further. Ace McDade, a former New York racer who lives in Ridgewood, N.J., opened his home after seeing a Facebook post early this year.

First it was for just a few days in March, before the operations.

Then there were 10 days between operations, and now Mr. Alfonso will probably stay with Mr. McDade, his wife and three daughters — ages 12, 9 and 7 — until he returns to Cuba late this month.

“It was an easy thing to offer; we have so much to give and he’s in such a tough spot,” Mr. McDade, 48, said. “He and my daughter Mei” — the 7-year-old — “have this wonderful relationship where he calls her crazy and she turns around says, ‘No, you’re crazy, Damian, Soy es loco.’ ”

Perhaps it is his surprising self-confidence that draws people in, leading them to help a stranger from Cuba who never asked for any help.

Whatever the reason, the cyclists who have rallied around Mr. Lopez took their common interest and used it to turn the big city into a small town, a place where bonds form by chance and compelling need is met with overwhelming generosity.

Mr. Alfonso, who had never visited New York before arriving in December for a series of medical tests, now calls it “the best city in the world.” And here, as in his native Havana, everyone simply calls him Damian.

BUT last month, between rounds of facial operations at NYU Langone Medical Center, Mr. Alfonso was depressed.

Behind the Scenes, Plans for Insurance Exchange

Posted: 09 Jun 2011 09:00 PM PDT

Gov. Rick Perry has made no secret of his disdain for federal health reform or for one of its key tenets, a Travelocity-like state insurance marketplace in which consumers could choose from public and private health plans.

The Texas Tribune

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The threat of Mr. Perry’s veto pen even derailed legislation by one of his fellow Republican “anti-Obamacare” colleagues, who fears that if state lawmakers do not implement a health insurance exchange of their own, the federal government will do it for them — in his view, an even worse fate.

But among Mr. Perry’s gubernatorial peers, his stance on the health insurance exchange appears to be losing popularity: Politico reported last week that the Republican governors Haley Barbour of Mississippi, Mitch Daniels of Indiana and Scott Walker of Wisconsin are taking steps to comply with that piece of the law — even as they continue to oppose the federal health care program over all.

Meanwhile, despite Mr. Perry’s stated opposition to a federally-mandated health insurance exchange and the state’s participation in lawsuits aimed at overturning federal health reform, officials at the Texas Department of Insurance acknowledge that since last fall, with the help of a $1 million grant from the United States Department of Health and Human Services, they have been working quietly to plan for a health insurance exchange.

“We’ve been going full speed ahead on implementation, doing the due diligence so that we can be on time with what the law says,” said John Greeley, a spokesman for the agency.

Lucy Nashed, a spokeswoman for Mr. Perry, said the governor is aware of the grant, which she said is exploratory and does not require Texas to set up an exchange. While Mr. Perry prefers local solutions to Texas’ health care problems, Ms. Nashed said the governor remains hopeful the courts will overturn the federal health law. “The governor’s firm belief that Texans should be in charge of our health care programs is unchanged,” she said.

If the courts uphold the health reform plan, states have until 2014 to implement an insurance exchange before the federal government steps in. State Representative John M. Zerwas, Republican of Simonton, who filed the Texas health exchange bill that failed in the session that just ended, said that if the federal government threatened to install a one-size-fits-all program in Texas, “we could, in fact, pull something off in really short order.”

Still, he said, given the antipathy between some Texas officials and the Obama administration, he worries about delays in setting up an exchange.

“I would have some concerns that they would say, ‘You all didn’t bother to make significant efforts with the lead time you had,’ ” Dr. Zerwas said. “I wouldn’t put it past them not to certify what we came up with in a last-minute effort.”

In the end, it may not be so last-minute. The state’s insurance department is using the $1 million federal grant to hire a consultant to consider options for both a state-run and a federally run health insurance exchange.

Mr. Greeley said department officials had initially believed a change in state law would be required to establish a health insurance exchange. Now, he said, “the indication we’re getting is this could happen without it.”

Insurance groups, however, question whether state agencies can do anything constructive without full support from state leadership. Jared Wolfe, executive director of the Texas Association of Health Plans, said Texas’ insurance market is too complex for a blanket federal exchange. “We knew anything related to federal reform was going to be controversial,” he said, “but we’d much prefer to see the state run it.”

eramshaw@texastribune.org

Sex Assaults Underreported, Inquiry Into V.A. Concludes

Posted: 08 Jun 2011 11:00 PM PDT

WASHINGTON — Veterans Affairs facilities that provide mental health treatment failed to properly report many sexual assaults from 2007 to 2010, according to an investigation by the Government Accountability Office.

The G.A.O.’s report, delivered this week to the House Veterans Affairs Committee, found that sexual assaults were underreported and, when they were reported, that officials often did not follow up through designated channels.

For instance, V.A. policy requires that accusations of rape be reported to the department’s Office of the Inspector General. Yet the report, based on a three-year investigation at five facilities, found that nearly two-thirds of the 67 rape accusations never made it to the office.

In most of the nearly 300 total cases investigated by the G.A.O., the assaults were committed by other patients or unknown suspects and not V.A. employees. The report defined sexual assault as “any type of sexual contact or attempted sexual contact that occurs without the explicit consent of the recipient.”

The report noted that the department had made a point of making mental health treatment accessible to several specific groups — including women, young veterans from the military operations in Iraq and Afghanistan and veterans facing legal issues. Serving these groups presents “unique challenges for V.A. both in providing and maintaining accessible care and keeping veterans and staff safe in V.A. medical facilities,” the report said.

The report recommended establishing clearer definitions on what constitutes sexual assault and what to do if an assault is reported. It also said the department needed to increase oversight for these processes.

The department did not immediately respond to a phone call Wednesday seeking comment. But the report included a letter from the department’s chief of staff, John Gingrich, with an annotated version of the G.A.O.’s recommendations to the report, detailing how the department will move forward.

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Pfizer Suspends Sales of Chicken Drug With Arsenic

Posted: 08 Jun 2011 10:20 PM PDT

WASHINGTON — Farmers have for decades fed chickens an arsenic-containing drug that promotes growth, but after a government study found trace amounts of this poisonous carcinogen in chickens, its maker will suspend its sales.

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A.J. Mast for The New York Times

For decades, farmers have fed chickens a drug that contains arsenic to promote their growth.

Officials at the Food and Drug Administration said the amounts found were so low that chickens treated with the drug, called 3-Nitro, do not pose a serious health risk and will continue to be sold. Perdue and organic chicken producers do not use the drug.

“The presence of that carcinogenic residue obviously raises concerns, and it’s completely avoidable,” said Michael R. Taylor, F.D.A.’s deputy commissioner for foods. “It needed to be acted on.”

Pfizer, which makes 3-Nitro, also known as roxarsone, will suspend the drug’s sales in 30 days, giving producers time to find alternatives. The drug, first approved in 1944, kills intestinal parasites, promotes growth and makes meat look pinker. And since 3-Nitro contains organic arsenic, which is far less toxic than its inorganic counterpart, producers assumed that it would have no effect on people who ate the animals.

But there has been growing evidence that organic arsenic can change into its more toxic cousin. So F.D.A. researchers developed a way to measure inorganic arsenic in meat. They got 100 chickens, fed roxarsone to about half of them and measured levels of inorganic arsenic in their livers. Chickens fed roxarsone had consistently higher levels of inorganic arsenic, a known carcinogen.

Scott Brown, a veterinarian at Pfizer Animal Health, said that Pfizer’s own studies of 3-Nitro had all found it safe, but that the F.D.A.’s trial led the company to suspend sales of the drug while Pfizer did a “full scientific assessment” of the drug. That assessment will also include another smaller-selling arsenic-based feed medicine called Histostat, or nitarsone, that was not studied by the F.D.A. and whose sales have not been suspended.

Consumer advocates cheered the move.

“Inorganic arsenic is cancer-causing, and action on this drug is long overdue,” said Dr. Michael K. Hansen, a senior scientist with Consumers Union.

Each year, the United States produces $45 billion worth of broiler chickens, the kind used for meat — about 37 billion pounds in 2010, according to the Agriculture Department. That equals about 80 pounds a year for each American, according to the National Chicken Council, which represents major companies like Perdue and Tyson. Georgia, Arkansas and Alabama are the biggest producers.

Richard Lobb, a spokesman for the chicken council, said 3-Nitro was used widely “but certainly not universally” by the industry. Mr. Lobb said that questions about roxarsone’s safety had been raised in the past but “we’ve always been able to show that there’s really no reason to be concerned about human health.”

Environmentalists have long been concerned that the waste from chickens treated with roxarsone, when used as fertilizer on crops, causes arsenic to leach into water supplies and estuaries. Even cattle are exposed, since chicken litter is sometimes included in feed.

About 90 percent of roxarsone’s use is in chickens, although the product is also used to a more limited extent in turkeys and swine, said Dr. William Flynn of the F.D.A.’s Center for Veterinary Medicine.

The F.D.A. once routinely conducted its own studies of animal and human drugs, but limited budgets led the agency to eliminate much of its scientific and laboratory capacity over the years. The roxarsone study is a triumph for agency scientists but one unlikely to be repeated very often. The agency asked for $183 million in additional funds for food safety efforts next year, but House Republicans have instead proposed cutting $87 million.

“This is exactly the kind of thing we try to direct research efforts towards,” Dr. Flynn said.

Roxarsone is still approved for use in chickens and swine in Canada, Mexico, Malaysia, Indonesia, the Philippines and Vietnam and in poultry only in Chile, Argentina, Peru, Venezuela, Brazil, Australia, Pakistan and Jordan.

Representative Steve Israel, Democrat of New York, proposed legislation in 2009 banning roxarsone. “I’m relieved the decision was made to make our poultry safer and healthier and hope the F.D.A. will take the final step and ban roxarsone altogether,” Mr. Israel said.

Pfizer has promised not to resume sales of the drug until it has resolved F.D.A. concerns about it.

William Neuman contributed reporting.

Judges Weigh Limits of Health Law’s Powers

Posted: 10 Jun 2011 02:19 PM PDT

ATLANTA — In perhaps the weightiest of the dozens of challenges to the Obama health care law, a panel of appellate judges grappled Wednesday with the essential quandary of the case: if the federal government can require Americans to buy medical insurance, what constitutional limit would prevent it from mandating all manner of purchases and activities?

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Crystal Johnson, right, argued Wednesday with a protester outside the court in Atlanta where judges weighed the health care law.

The three judges, selected at random from among 10 members of the United States Court of Appeals for the 11th Circuit, sprayed lawyers Gatling-gun style with questions about where a limiting principle might be drawn, as it must if the sweeping law is to pass judicial review. After a nearly three-hour hearing, Chief Judge Joel F. Dubina called the litigation “a very difficult case,” but provided no clues as to when or how the court might rule.

In the past five weeks, the health care litigation has taken on the feel of a traveling road show in wingtips, with similar hearings in appellate courts in Cincinnati, Richmond, Va., and now Atlanta. At each stop, the august courtrooms have been populated with many of the same lawyers and observers, and the same advocacy groups and commentators have held dueling news conferences outside each courthouse.

Lawyers involved in the cases have trouble forecasting which might ultimately be accepted for review by the Supreme Court.

But the 11th Circuit case, because of the political heft of the plaintiffs and the intellectual firepower of the lawyers, has garnered the most attention. Spectators and reporters began lining up before 6 a.m. for the 9:30 a.m. hearing, and some had to be seated in an overflow courtroom.

The plaintiffs include Republican governors and attorneys general from 26 states, and five of the attorneys general attended Wednesday. The hearing featured a clash of titans among three experienced litigators who claim 73 Supreme Court appearances among them: Acting Solicitor General Neal K. Katyal for the Obama administration; former Solicitor General Paul D. Clement for the states; and Michael A. Carvin for the National Federation of Independent Business, another plaintiff.

One of the Supreme Court cases that Mr. Clement won as solicitor general was Gonzales v. Raich in 2005, when the court held that Congress’s authority over commerce was so broad that it could regulate even an individual’s home cultivation of medical marijuana. That precedent is now central to the government’s defense of the health care law that Mr. Clement is challenging.

The law, the Affordable Care Act, enacted in March 2010, aims to insure 32 million Americans by mandating that most people obtain health insurance, subsidizing policies for the poor and requiring that insurers accept even those with pre-existing health problems. Supporters of those provisions, which take effect in 2014, argue that insurers will be able to cover the sick only if healthier consumers are forced to pay into the insurance pool.

Among 31 separate legal challenges to the law, five cases have yielded decisions on the merits from lower-level district court judges. Three judges appointed by Democratic presidents upheld the law, while two Republican appointees rejected all or part of it.

The 11th Circuit panel includes Judge Frank M. Hull, who was named by President Bill Clinton; Judge Stanley Marcus, a Clinton appointee who had previously been placed on the District Court by Ronald Reagan; and Chief Judge Dubina, who was appointed by the first President Bush.

Judge Dubina’s daughter, Representative Martha Roby, is a newly elected Republican from Alabama who voted with the majority in January to repeal the health care law. That measure failed in the Democrat-controlled Senate, leaving the law’s future in the lap of the courts, at least until the 2012 election.

The decision at issue on Wednesday was handed down on Jan. 31 by Judge Roger Vinson of Federal District Court in Pensacola, Fla. Judge Vinson invalidated the insurance requirement, and then ruled that the mandate was so essential to the architecture of the law that the entire act must fall. He later stayed his ruling so the law would remain in effect pending appeals.

Judge Vinson wrote that while the Commerce Clause of the Constitution gave the government broad authority to regulate interstate commerce, it did not allow Congress to penalize people for the “inactivity” of declining to buy a commercial product. The health law imposes an income tax penalty on those who do not have coverage.

Mr. Clement, who was retained by the states for a fee of $250,000, argued that by requiring Americans to buy insurance, the act unconstitutionally conscripted citizens into the stream of commerce. He stressed that the insurance mandate constituted an unprecedented assertion of federal power that could leave virtually every human act — and passive choice — subject to Congress’s whim.

It would be permissible, Mr. Clement acknowledged under questioning, for Congress to require insurance or other payment by those who are being treated in an emergency room, because they would already be in the stream of commerce. But he said it was a different matter to require them to pay prospectively for future care.

“It boils down to the question of whether the federal government can compel people into commerce to better regulate the individual,” Mr. Clement said.

The judges repeatedly posed formulations of that question to Mr. Katyal. “If they could compel this, what purchase could they not compel?” Judge Marcus asked.

But Mr. Katyal urged the judges to see the law not as a mandate to buy an insurance policy, but as a regulation of the means of payment for care that individuals would inevitably consume. Americans would not be conscripted into the market, Mr. Katyal suggested, because the uniquely unpredictable demand for health care would have already placed them there.

“It’s all about financing,” Mr. Katyal asserted. “It’s about regulating whether people are paying cash or credit.”

Mr. Katyal said that the insurance mandate clearly had an economic rationale because governments, hospitals and the privately insured end up shouldering costs for uninsured patients who cannot pay. That rationale, he said, satisfies the test set by the Supreme Court in a string of prior decisions: that the Commerce Clause permits Congress to regulate activities that have a substantial effect on interstate commerce.

What the Supreme Court has never considered is whether a choice to not buy a product can be considered an “activity” that can be regulated, as the government asserts.

Last week, the Court of Appeals for the Sixth Circuit in Cincinnati considered a Michigan ruling that upheld the health law. Three weeks before that, the Fourth Circuit in Richmond heard arguments in two cases from different courts that yielded contradictory outcomes. Another hearing is scheduled for September in the District of Columbia.

California Insurer Says It Will Cap Earnings

Posted: 09 Jun 2011 11:24 AM PDT

Blue Shield of California, a large nonprofit health insurer that has come under sharp criticism in recent months for its double-digit rate increases, said on Tuesday that it planned to cap its earning and refund the bulk of any excess income to its policyholders.

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Peter DaSilva for The New York Times

Bruce Bodaken, chief executive of Blue Shield of California, which plans to limit its profit to 2 percent of its revenue.

The insurer said it would limit its profit to no more than 2 percent of its revenue and said it already planned to return $180 million, the profit the company says it made above its 2010 target.

“With our 2 percent pledge, we hope to make coverage a bit more affordable for our members,” Bruce Bodaken, Blue Shield’s chairman and chief executive, said in a speech at the Commonwealth Club in San Francisco. “But more important, we want to demonstrate that health care affordability, which is the key to universal coverage, is Blue Shield’s top priority.”

In a telephone interview, Mr. Bodaken said: “It’s one further step in a long series of steps in which we believe that we and others all need to step up and reduce the cost of health care.”

While it is unclear whether other insurers will make similar pledges, the federal health care law is aimed at making sure insurers are not able to set their premiums too much above their costs. Some experts expect other insurers to take similar actions as the law goes into effect.

“This would be the logical next step,” said Timothy S. Jost, a law professor at Washington and Lee University, who said some insurers have already started considering similar refunds. Last September, for example, Blue Cross and Blue Shield of North Carolina said it planned to refund $156 million to policyholders.

Blue Shield of California said it would refund $167 million to policyholders, typically giving them a 30 percent credit toward one month’s premiums. A family of four, for example, may receive $250 toward the cost of a policy. Hospitals and doctors that participate in programs aimed at better coordinating care for patients will receive $10 million, and the insurer’s foundation will receive $3 million.

As a nonprofit, the insurer does not generate returns for investors but uses any money it earns to further its mission.

An early proponent of many of the changes in the federal health care law, Blue Shield has been the target of public outcry. Like many nonprofit insurers, Blue Shield has been criticized for seeking large premium increases and for maintaining overly generous reserves. Federal and state regulators are increasingly scrutinizing the rate requests of all insurers because of the federal health care law, and medical costs have been lower than many companies had anticipated, leading to substantial profits.

Mr. Bodaken said the decision to limit profits was made well before state insurance regulators raised concerns about its rate increases. Earlier this year, Blue Shield bowed to pressure from regulators and consumer groups and dropped a request for higher rates. “It really has nothing to do with our rate increases,” he said.

California lawmakers are considering legislation that would give state regulators the authority to approve insurers’ rate requests before they go into effect. Federal and state officials emphasized that Blue Shield’s actions did not diminish the need for strong regulatory oversight.

Kathleen Sebelius, the secretary of health and human services, said in a statement: “While such voluntary efforts are great for Blue Shield’s policyholders in California, today’s announcement also reinforces the importance of the Affordable Care Act and rigorous state review of insurance rates.”

California’s state insurance commissioner, Dave Jones, who has pushed for state legislation that would allow him to block excessive rate increases, said Blue Shield’s action demonstrated the need for the law. “The announcement is an admission by an insurer, in this case a nonprofit insurer, that they are making excessive profits,” he said.

The insurer’s profits about doubled from 2009 to 2010 and he said its $3.5 billion in reserves were higher than regulations require.

Consumer advocates also emphasized that Blue Shield’s pledge did not change the need for regulators to make sure insurers were not charging people too much. “Certainly, there are some consumers who will be getting rebates who will welcome the news,” said Anthony Wright, executive director of Health Access California, a state advocacy group. Still, he said, “consumers should not be overcharged on the front end.”

Given the recent outcry over its high rate requests and the generous pay package of its chief executive, which amounted to $4.6 million last year, Blue Shield may be trying to improve its image, Mr. Wright said.

To address the high cost of health care, Mr. Bodaken said that insurers like Blue Shield must work with hospitals, doctors and patients to address some of the underlying cost pressures. But he said the insurer’s goal was to demonstrate that it was not seeking higher profits when it asked for higher rates.

“It makes it very clear that we are not about profits,” he said. “We are about getting people health care they need and deserve.”

In Santa Monica, Circumcision Opponent Abandons Efforts

Posted: 07 Jun 2011 10:30 PM PDT

LOS ANGELES — The primary backer of an effort to get a ban on circumcision on the ballot in Santa Monica is abandoning her push, saying the proposed legislation had been misrepresented as an effort to impinge on religious freedom. A similar measure in San Francisco is scheduled for a fall vote.

Monica Almeida/The New York Times

Jena Troutman said her plan had been misrepresented.

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The woman, Jena Troutman, a mother of two boys who began the process of trying to get a ban on the Santa Monica municipal ballot in 2012, said the news media had distorted the effort.

“The religious opposition really rose up, and I never intended it to be about that at all,” Ms. Troutman said. “Ninety-five percent of babies who are circumcised have nothing to do with religion — that’s what I was focused on. Once I discovered this bill was not going to open up the conversation but was closing it down, I wanted no part of it.”

Ms. Troutman said she wanted to focus on educating parents through the Web site she runs, wholebabyrevolution.com.

In recent days, criticism of the two measures had focused on their author, Matthew Hess, who lives in San Diego and created an online comic called “Foreskin Man,” which features characters like “Monster Mohel.” Several organizations, including the Anti-Defamation League, said the comic relied on anti-Semitic imagery.

Mr. Hess defended the comic, saying it was intended to be from a baby’s point of view. “It was designed to really evoke a response that talking about studies and statistics never does,” Mr. Hess said. “What would that baby be thinking other than ‘That man coming at me with a knife is a monster’?”

Mr. Hess said Tuesday that he was optimistic about the prospect of the ban passing in San Francisco.

Catherine Schneider, senior vice president of community engagement at the Jewish Federation of Greater Los Angeles, which had begun efforts to fight the plan, said she was relieved that the issue had been dropped in Santa Monica. But, she said, many leaders expect that similar efforts will crop up in other cities.

“It’s scary to think that we would have had to launch a political campaign to maintain status quo,” she said. “To fight one of these campaigns, you need to raise around $500,000, and in this economy we can all think of better ways to spend that money.”

Well: Blaming Sprouts Again

Posted: 11 Jun 2011 11:34 AM PDT

Well: Baking a Better Breadstick

Posted: 10 Jun 2011 09:57 AM PDT

Well: Lives Cut Short by Depression

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Well: Readers Ask: Give a Dog a Bone?

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Well: When the Therapist Yawns

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The New Old Age: Drawbacks to Assisted Living

Posted: 10 Jun 2011 08:51 AM PDT

The New Old Age: New Recruits for Team Dad

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The New Old Age: Escape From the Hospital Bed

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A Memoir of Self-Destruction and Therapy

Posted: 10 Jun 2011 10:54 AM PDT

Emma Forrest’s memoir, “Your Voice in My Head,” is part of a literary tradition that began long before Susanna Kaysen’s girlhood was interrupted or Elizabeth Wurtzel got her first Prozac prescription. Indeed, on her book’s first page Forrest invokes the patron saint of mentally ill beauties with bad taste in men, as she describes how, at 13, she began making regular pilgrimages after school to the Tate in London, to visit Millais’s portrait of the drowned Ophelia. “I believe that she infected me,” she writes. “I was afraid . . . that I saw in her my own destiny.”

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Seamus McGarvey

Emma Forrest

YOUR VOICE IN MY HEAD

A Memoir

By Emma Forrest

215 pp. Other Press. $22.95.

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A decade ago, when she was in her 20s, Forrest (now a screenwriter in Los Angeles) moved to Manhattan. Although she had the support of her parents — whom she portrays as not merely functional but downright adorable — as well as a precocious career in journalism and a first ­novel, “Namedropper,” already on the way, she became a bulimic and an obsessive cutter, and soon began walking “hand in hand with the thought of suicide.” She also had a knack for acquiring terrible boyfriends whose bad behavior inspired her to hurt herself more, and who sometimes aided and abetted the abuse. “I couldn’t work fast enough to harm myself, so the boyfriend was helping out,” she writes of a sexual injury that landed her in the emergency room. Soon after this event, she met the therapist who ultimately changed her life, a man she refers to as Dr. R.

Forrest’s description of her descent into madness is initially as dizzying as the mania she recounts experiencing between her bouts of despair. The book takes antic jumps ahead in time: one moment we’re meeting Forrest’s salty grandmother; next we’re on Avenue B in Manhattan, witnessing a little boy shouting a colorful come-on at girls twice his age; and in between we get a litany of the places on Forrest’s body where she began slicing herself with razors. We learn that Dr. R. has died before we know anything about his effect on Forrest’s life. We also meet a man she calls G. H., or Gypsy Husband, who is introduced in such a way that readers begin to suspect that we might be headed toward the worst kind of treacly happy ending, in which a lunatic girl is redeemed by the love of a good man: “Do you mind me writing in my book that you’re ‘The One?’ I ask G. H., typing on the porch as he makes salmon for dinner. ‘I’d love that,’ he answers, ‘because it means we’re ‘The Two.’ ” Fortunately for us, and probably also for Forrest, that’s not quite how things work out.

Forrest’s spare, dialogue-heavy accounts of her sessions with Dr. R. give the book a much-needed dose of sustained narrative focus. She renders Dr. R.’s gentle elicitations with affecting subtlety; at one point, as her story of a near-rape intertwines with her story of a session, we understand both Dr. R.’s compassion and the tenderness and trust that characterized Forrest’s relationship with him.

This bond is broken by Dr. R.’s unexpected death, which occurs just as Forrest is falling, hard, for G. H., a major movie star (anyone with access to the Internet can figure out which one) who seems to have more than matched Forrest’s flair for drama. He writes her poetry, takes her on exotic vacations, sends her text messages constantly while on set, and FedExes her a dirty T-shirt that he’s covered in a verse invitation to meet him in New York. He buys their imaginary future child a fluffy pink coat as they stroll through a picturesque Portuguese fishing village. He says things like “I would rather die than not knock you up.” And then, as quickly as he arrived in Forrest’s life, he leaves it — “I think I need space,” he tells her — threatening to undo years of Forrest’s and Dr. R.’s hard work.

It’s a testament to Forrest’s skill that we don’t see this breakup coming. Her descriptions of the affair are untainted by premonitions of doom, and even in describing its end she resists the temptation to portray herself as wronged or G. H. as outrageously callous. She does show herself flailing — considering suicide again, texting G. H. pathetic missives to which he responds (if he responds) with robotic detachment — but she doesn’t wallow or condemn him. G. H. appears to be an irresistible sociopath, the kind of man lots of women will date eventually, though with the irresistible and sociopathic aspects dialed up a few notches because of his fame.

Forrest comes off as a talented, intense woman who knows she’s lucky to have had some high-caliber help in her struggle to make sense of it all. She acknowledges that she is privileged to be able to mine her suffering for material. Writing about an abortion, she admits, “I have the luxury to find inspiration in the pain because I am a middle-class girl with a tight-knit family.”

Letters from Dr. R.’s other patients provide some of the most moving passages in the book, even though Forrest’s decision to use them to mark the endings of some otherwise unrelated chapters doesn’t always work. We also spend four pages listening to a sermon by her rabbi, about the story of Jacob, who, after spending a night wrestling with an angel, had his name changed to Israel. This protracted meditation on the blessing of self-­transformation — “You’ve struggled,” the rabbi says, “and now you can change” — is profound. Forrest didn’t write it, but through these words we share her insight: there’s something to be said for occasionally listening to a voice other than your own.

Emily Gould is the author of the essay collection “And the Heart Says Whatever.”

Op-Ed Contributor: Ronald’s Exit Interview

Posted: 10 Jun 2011 08:46 PM PDT

McDonald’s Corp. is standing by its clown. The 48-year-old, red-haired mascot has come under fire from health-care professionals and consumer groups who, in recent days, have asked the fast-food chain to retire Ronald McDonald.

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Chris Kuzma

— The Wall Street Journal, May 20

HUMAN RESOURCES Good morning, and thank you for participating in this fully confidential exit interview. Just to begin, how many years have you been with the company?

RONALD MCDONALD (stares blankly at the wall, not seeming to hear)

H.R. Er ... Mr. McDonald?

RONALD ( singing the Big Mac song softly, like a hymn) ... two all-beef patties ... special sauce, lettuce, cheese ... (Distraught, he retrieves three single-serving packets of ketchup from his jumpsuit and squeezes them directly into his mouth.)

H.R. I realize this must be difficult for you. It’s quite normal for employees in your position to experience a period of grief.

RONALD Forty-eight years ... forty-eight years... (kneading his forehead) How could I have been so stupid! Why didn’t I put away more? Or even a little! I don’t even have a résumé! (suddenly engaged) Hey, maybe there’s something else I could do! Maybe in payroll or Web-development — even something on the political side? I know politicians! I once went on a golf trip with Steny Hoyer. (pulls out cellphone) Hold on, I think he’s still in my contacts —

H.R. Mr. McDonald, once again, I want to stress that this has nothing to do with your performance. Management simply feels that, amid skyrocketing rates of diabetes and childhood obesity, it is no longer appropriate to retain a children’s character within the corporate structure.

RONALD Good point. So maybe we can “age me up” a little bit? Lose the wig, hire a trainer, maybe engineer one of those sham P.R. relationships — how about Ke$ha? And then I could be Rona£d! You know, with a pound sign.

H.R. I don’t know if we want to go there.

RONALD (backtracking) Right, you’re right. Forget it. That’s just the ketchup talking. (introspective sigh) I guess I should have seen this coming. I heard they’re test marketing a Filet-o-Kale. Is that true?

H.R. I wouldn’t —

RONALD Aw, forget it, you wouldn’t give me a straight answer anyway. “Chinese wall,” right? (dark chuckle) You wanna know the hardest part? They’re right. (slaps his knee) They’re totally right! Maybe it didn’t seem so bad in the ’60s, but today? With everything we know about sodium intake and LDL levels? And let’s not even talk about factory farming! Who are we kidding? They’re not “Happy Meals,” they’re “Gateway Meals!” (shaken) I’m a monster.

H.R. You’re not a monster.

RONALD Statistically, I am. H.R. (protective) But how could you have known?

RONALD Oh, don’t be naïve. We all knew! Grimace knew! And he has a brain the size of a pearl onion. To be honest, I’m amazed that guy can even stand up.

H.R. (suddenly indignant) Mr. McDonald, you’re an ambassador of joy and optimism and generosity — everything that makes America great! You’re not just a clown. You’re an icon.

Long, awkward pause.

RONALD O.K. Well, thanks. That’s nice to hear.

Longer, more awkward pause. Suddenly, Ronald’s cellphone rings.

RONALD (He glances at the caller I.D.) Well, will you look at that? If it isn’t my good friend, Steny Hoyer!

H.R. (skeptical) Really?

RONALD (Guilty pause. He lowers his eyes.) No.

Yoni Brenner is a writer for print, film and television.

Editorial: The Fair Rewards of Invention

Posted: 08 Jun 2011 12:41 PM PDT

Before the Bayh-Dole Act was passed in 1980, the billions of federal dollars spent on scientific research rarely benefited the public through commercial applications. Fewer than 5 percent of government patents were licensed to industry. To push patents into practical use, the law set up a scheme for awarding the rights to institutions, like universities, that have incentive to bring inventions to market.

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Since 1980, the Massachusetts Institute of Technology, for example, has been granted control of 3,673 patents. A recent study found that companies started by M.I.T.’s graduates, faculty and staff generate annual world sales of $2 trillion.

In a 7-to-2 decision this week, the Supreme Court undermined the act’s purpose by ruling that it does not automatically give a university title to an invention by a faculty member when the research is federally financed.

The case, Stanford University v. Roche Molecular Systems, involved a Stanford researcher who had transferred his rights to methods for testing AIDS treatments to a private company that was eventually acquired by Roche. Roche commercialized the procedure and incorporated it into H.I.V. test kits. Stanford sued Roche, arguing that the researcher’s assignment of rights was invalid under the Bayh-Dole Act. The court held that even though the researcher may have had an obligation to the university, he had legally assigned his rights to the private firm.

Although the decision is based on a literal reading of a poorly drafted initial agreement between Stanford and the researcher, it is likely to have a broader effect. It could change the culture of research universities by requiring them to be far more vigilant in obtaining ironclad assignments from faculty members and monitoring any contracts between researchers and private companies. Relationships between the university and its faculty are likely to become more legalistic and more mercantile.

By stressing “the general rule that rights in an invention belong to the inventor,” the majority opinion of Chief Justice John Roberts Jr. romanticizes the role of the solo inventor. It fails to acknowledge the Bayh-Dole Act’s importance in fostering collaborative enterprises and its substantial benefit to the American economy.

Recipes for Health: Rye Caraway Breadsticks

Posted: 09 Jun 2011 12:10 AM PDT

Rye and caraway have always been a match made in heaven, but until now I never thought of using them in something other than Jewish rye bread and rye crisps.

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 teaspoons active dry yeast

1 1/2 cup lukewarm water

1 teaspoon honey, agave nectar, malt extract or rice syrup

1/4 cup extra virgin olive oil

1 cup rye flour

1 cup whole-wheat flour

About 1 1/3 cups unbleached all-purpose flour

3 tablespoons caraway seeds

1 1/2 teaspoons salt

1. Dissolve the yeast in the water in a large bowl or in the bowl of a stand mixer. Stir in the honey, agave nectar, malt extract or rice syrup. Let stand for five minutes. Stir in the olive oil.

2. Combine the rye flour, whole-wheat flour, 1 cup of the unbleached all-purpose flour, caraway seeds and the salt. Add to the liquid mixture. If kneading by hand, stir until you can turn the dough out onto a lightly floured surface; knead for 10 minutes, adding flour as necessary to keep the dough from sticking to your hands and worktable.

If using an electric mixer, mix at medium speed for 8 to 10 minutes. Add flour as necessary so that the dough comes away from the sides of the bowl. The dough should be elastic and just slightly sticky.

3. Lightly flour your work surface or brush with olive oil. Using your hands or a rolling pin, roll the dough into a 14-by-4-inch rectangle. Make sure there is enough flour or oil underneath the dough so that it doesn’t stick to the work surface. Brush the top with oil. Cover with plastic wrap, then with a damp kitchen towel. Allow to rise for 1 to 1 1/2 hours until nearly doubled. (If you need the workspace, lightly oil the underside of a sheet pan and place the dough on top.)

4. Preheat the oven to 400 degrees with the racks positioned in the middle and upper thirds of the interior space. Brush sheet pans with olive oil. Cut the dough crosswise into four equal pieces. Cut each piece crosswise into six equal pieces. Roll each between the board and your hands as you were making a rope until it is as long as the baking sheet. For a tighter strip, twist the strands from one end to the other. Place 1 inch apart on the baking sheets until you’ve filled two baking sheets. Continue to shape the remaining breadsticks while the first batch is baking.

5. Place in the oven, and bake 15 minutes. Switch the pans top to bottom and front to back, and bake another 10 minutes until the breadsticks are nicely browned. (They will be darker on the bottom; if you want them more evenly browned, flip the breadsticks over halfway through.) Remove from the heat, and cool on a rack. Shape and bake any remaining dough as instructed.

Yield: Two dozen breadsticks.

Advance preparation: The breadsticks will keep for several days in an airtight container or wrapped in foil. They can be frozen and recrisped in a medium oven for 10 minutes.

Nutritional information per breadstick: 79 calories; 0 grams saturated fat; 0 grams polyunsaturated fat; 2 grams monounsaturated fat; 0 grams cholesterol; 12 grams carbohydrates; 2 grams dietary fiber; 146 milligrams sodium; 2 grams protein

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

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