Health - Personal Best: When Running Up Mileage, 10 Percent Isn’t the Cap

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• Personal Best: When Running Up Mileage, 10 Percent Isn’t the Cap
• Treatment May Help Ease Effect of Cancer
• Cases: Stereotyping Patients, and Their Ailments
• Global Update: Asia’s Heavy Use of Asbestos Is Expected to Cause Rise in Deaths in Coming Decades
• Vital Signs: Perceptions: Cancer Drugs Get on a Faster Track in U.S.
• Recipes for Health: Asparagus With an Italian Twist
• Ban on Hearing Aids Is Forcing Out Veteran New York City Police Officers
• Debate Swirls Around Research Showing Lung Problems for Returned Troops
• Chemical Suicides, Popular in Japan, Are Increasing in the U.S.
• Economic View: Seriously, Some Consensus About Health Care
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• The Boss: Seeking Cures, Then and Now
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• Business Briefing | HEALTH: F.D.A. Panel Endorses an Eye Treatment
• A Schizophrenic, a Slain Worker, Troubling Questions
• Memory Implant Gives Rats Sharper Recollection
• Aspen Journal: Meatless Mondays Catch On, Even With Carnivores
• Well: Warning on Risks of Portable Pools
• Well: Summing Up a Father's First Year
• Well: A Dual Portrait of American Fatherhood
• Well: Making Fava Beans a Favorite
• Well: A Report Card for Doctors
• Ann Patchett’s Amazon Wonder Drug Novel
• The Pseudoscience of Hysteria
• The New Old Age: A Missed Opportunity to Recruit Specialists in Elder Care
• The New Old Age: Ask an Elder Law Attorney: Late-Life Marriage Issues
• F.D.A. Confronts Challenge of Monitoring Imports
• Children on Medicaid Shown to Wait Longer for Care
• In Tiny Worm, Unlocking Secrets of the Brain
• Recipes for Health: Asparagus With Anchovies and Capers
• Recipes for Health: Mediterranean Artichoke and Fresh Fava Stew

Personal Best: When Running Up Mileage, 10 Percent Isn’t the Cap Posted: 20 Jun 2011 11:16 AM PDT My friend Martin Strauss of Ann Arbor, Mich., was running 60 miles a week when he suffered a stress fracture that put him on crutches for three months. Now that he’s better, he wants to play it safe to avoid another injury. But what’s the best way to do that? How quickly can he ramp up the miles? Related More Personal Best Columns Martin decided to follow the 10 percent rule, one of the most widely known in running. It does not specify a starting distance but says you should increase your mileage no more than 10 percent a week. The idea is that this is a safe way to increase your distance without risking injury. (Within limits, of course; if you started at 30 minutes a day and kept increasing 10 percent a week, after 41 weeks you’d be running 24 hours a day.) Martin’s first run was on March 15. He ran half a mile, on a treadmill. Over the next five weeks, he increased his distance to ten miles a week, then began using the ten percent rule. Last week he ran 22 miles, including a long run of 10 miles. He calculates that it will take him a total of 18 weeks from when he started his program to get back to running 60 miles a week. I, like most runners, have heard of the rule and, like most, tried it once. But, like many, I did not stay with it. Another friend, Rafael Escandon of Philadelphia, tried it years ago when he was training for his first marathon. It was the slowest marathon he ever ran, slower even than one when he tore his calf muscle at mile 17 and somehow forced himself to finish the race, limping for the last 9 miles. Cliff Rosen, a distance runner in Maine, said he tried it once but “it didn’t seem to work.” That made me wonder, Where did this rule come from? Carl Foster, director of the Human Performance Laboratory at the University of Wisconsin in La Crosse, said its origin “is lost in history,” and added, “Whether it is right is undocumented.” It might be more correct to say “almost undocumented.” There is at least one large and rigorous study of the 10 percent rule, the sort of study that is a rarity in exercise science. Conducted by Dr. Ida Buist, Dr. Steef W. Bredeweg, Dr. Ron L. Diercks and their colleagues at the University of Groningen in the Netherlands, it’s one of a continuing series of studies on how to prevent running injuries. The injury problem is huge, said Dr. Diercks, head of the sports medicine program at the university — as many as 40 percent of runners are injured, usually to their feet, ankles, knees or legs. At his university’s running clinics, 30 to 40 percent of beginning runners gave up because of injuries. Although there are many training programs for beginning runners, none are based on good scientific evidence, Dr. Diercks said. He and his colleagues decided to conduct such a study. They investigated the 10 percent rule because it is so popular and seemed to make sense with its gradual increase in effort. The study involved 532 novice runners whose average age was 40 and who wanted to train for a four-mile race held every year in the small town of Groningen. Half the participants were assigned to a training program that increased their running time by 10 percent a week over 11 weeks, ending at 90 minutes a week. The others had an eight-week program that ended at 95 minutes a week. Everyone warmed up before each run by walking for five minutes. And everyone ran just three days a week. And the results? The two groups had the same injury rate — about 1 in 5 runners. Maybe, the investigators thought, they might prevent injuries with a conditioning program before the training started. So they did another clinical trial, randomly assigning one group of novice runners to a four-week program of walking, hopping and jumping rope before starting the running program. The others started right in with running. The conditioning program had no effect. Once again, about 1 in 5 runners in both groups wound up with injuries. The researchers are at a loss. Most people who take up running, Dr. Diercks says, think it will be easy — all they need is a pair of shoes. But in fact, running is a difficult sport, and most people quit before it becomes fun, often because they are injured. Experienced runners know how to adjust and return to the sport. Novices usually do not, he says. Now the Groningen group wants to do a large and rigorous study of barefoot running, comparing it to running with shoes — another study that has never been done. For now, though, the lesson is that running lore often is just that. And the 10 percent rule is a case in point. “Nobody found out if it works or what is the basis of it,” Dr. Diercks said. And that is the way it often goes in exercise science. People “hear something, they read something,” he said, “and then it’s like a religion.” This is the first of three summer columns on exercise lore.

Treatment May Help Ease Effect of Cancer Posted: 20 Jun 2011 11:03 AM PDT Top plastic surgeons from around the country met in Manhattan last month to observe an experimental surgery that may cure lymphedema, a serious complication of breast cancer treatment. Related Health Guide: Breast Cancer As some surgeons crowded into an operating room at New York Eye and Ear Infirmary and others watched a live video broadcast, Dr. Corinne Becker, the French doctor who pioneered the procedure, harvested lymph nodes from a patient’s groin to transplant to her underarm, where nodes had been removed earlier during cancer treatment. “Voila!” she exclaimed, motioning to her colleagues as she rubbed a small piece of tissue between thumb and fingertips to check for the presence of the small, pearl-shaped lymph nodes. “Look what is here — a wonderful node.” She warned that extracting too much tissue could injure the patient, even causing lymphedema in another limb. Using the French word for ‘greedy,’ she said, “It’s better not to be ‘gourmand’ — aggressive.” This innovative procedure, called an autologous vascularized lymph node transfer, is used to treat lymphedema, a common side effect of breast cancer treatment. Removal of the lymph nodes under the arm closest to the affected breast is believed to stem the spread of cancer, although new research suggests it can be avoided in many cases. But the loss of lymph nodes often leads to chronic swelling and soreness in the arm. In the new experimental surgery, the missing lymph nodes are replaced with a handful of healthy nodes transplanted from elsewhere in the patient. If all goes according to plan, the lymph nodes make themselves at home in their new location and connect with lymph vessels and start doing their job, filtering waste and draining fluid that has accumulated in the arm. But the operation is controversial and not without risk, and though it is reported to have cured some patients and improved the condition in many others, it is seldom performed in the United States. Even proponents say it should be reserved for patients who don’t respond to conventional treatment. The first randomized clinical trial of its effectiveness is just getting underway, led by Dr. Constance Chen, a New York City plastic surgeon who specializes in muscle-sparing reconstructive breast surgery that uses the patient’s own tissue. Even in the absence of good data, however, demand for the procedure is bound to grow. More than 2 million women in the United States have been treated for breast cancer, and some studies suggest lymphedema develops within five years in up to 40 percent of women who have undergone breast cancer surgery. While the condition can be managed with constant care and physical therapy, it often severely restricts activity and is generally considered incurable. In the absence of better data about the benefits of lymph node transfer, however, insurers may balk at covering the procedure, which involves expensive, complex microvascular surgery to connect tiny blood vessels. “From just a plumbing standpoint, it makes sense — someone took out the lymph nodes, you put them back in,” said Dr. Babak Mehrara, a reconstructive plastic surgeon at Memorial Sloan-Kettering Hospital in Manhattan. “The problem is that some of the science doesn’t support it. It probably works for some people and doesn’t for others.” Prior to transferring nodes to their new location, Dr. Becker aggressively clears away dense scar tissue under the arm that may be “clogging up” the lymphatic channels and preventing fluid circulation. That is one of the riskiest aspects of the surgery, because nerves and blood vessels leading to the arm could be affected. “We worry that if a person already has a compromised lymphatic surgery, you can go in there and do further damage. We always say the less surgery the better,” said Saskia Thiadens, executive director of the National Lymphedema Network. But, she added, “Obviously we’re eager to see what the outcomes are.” Dr. Chen, who co-organized the symposium hosting Dr. Becker with Dr. Joshua L. Levine, director of breast reconstructive services at New York Eye and Ear Infirmary, agrees that more scientific evidence is needed. But she is optimistic the surgery will benefit patients and says the toll lymphedema takes has not been fully appreciated by the medical community. “Treatment for lymphedema generally doesn’t end,” Dr. Chen said. “Women will say managing their lymphedema is worse than coping with breast cancer — now they have to deal with an every day affliction that affects their day to day lives.” She is launching the first double-blinded randomized clinical trial of lymph node transfer, a multicenter study that will enroll 88 patients with lymphedema in one arm. Half will be randomly assigned to lymph node transfer, while the others will undergo a dummy surgical procedure. The patients will be followed for two years after the operation to see if their quality of life improves. “There are naysayers with every single surgical innovation that comes along,” Dr. Chen said. Dr. Becker claims to have had enormous success, but while she has operated prolifically in Europe and other parts of the world on patients with cancer as well as those with congenital lymphedema, she has published only sporadically. In a 2006 paper in Annals of Surgery, she reported that 90 percent of patients improved after surgery and almost half were cured, but the sample included only 24 women and there was no control group. One of the patients operated on by Dr. Becker and Dr. Chen during the daylong symposium, Jennifer Miller, 40, a portfolio manager at an investment firm in Manhattan, said she has already felt a dramatic improvement. “I used to have this pain that was like my whole arm had a headache, and that’s gone,” Ms. Miller said. Ten days after surgery the swelling in her right arm was reduced by half, compared with measurements taken 10 days prior to the operation, and she has been able to bare her arm, which she used to keep covered in a compression treatment sleeve most of the day. Though her right arm is still swollen and larger than her left, she said, “It already feels more manageable, and I’m still recovering from surgery. Even if this is all the improvement I get, I’m happy.” But whether the change is a true effect of the transfer or a placebo effect of undergoing treatment is not known. Doctors say it is unlikely the transplanted nodes are already functioning, and it’s possible some other aspect of the surgery is having a beneficial effect, Dr. Chen suggested.

Cases: Stereotyping Patients, and Their Ailments Posted: 20 Jun 2011 01:13 PM PDT When Mr. S. was doing time at Rikers Island in the early 1990s, he was given a standard battery of tests for the medical ailments that run rampant behind bars — AIDS, hepatitis, tuberculosis. He received the unwelcome news that he was H.I.V. positive, though his T-cell count was still in the normal range. Enlarge This Image David Pohl Related More Cases Columns After his release from prison, he made his way to our hospital’s H.I.V. clinic. He took his medications and showed up for his appointments, but he almost never got lab tests, since decades of drug use had obliterated his veins. Despite the other medical assaults on his body — diabetes, hypertension, hepatitis C, stubborn leg ulcers — his immune system remained intact. About once a year, he’d allow his methadone doctor to draw blood from a ragged vein in his neck — practically the last vein to his name. His T-cell count stayed high enough to protect him from opportunistic infections. He seemed to be one of the rare, lucky “nonprogressors.” But after several years of consistently robust T-cell counts, one of the nurse practitioners had a hunch. She asked the methadone doctor not just for a T-cell count but also for a new H.I.V. test. Lo and behold, it came back negative. The diagnosis had been wrong all along; the H.I.V. test at Rikers had been a false positive. He was promptly discharged from the H.I.V. clinic and sent to the general medical clinic, where I became his doctor. Mr. S. has the craggy, almost grandfatherly look of someone who has retired from the drug-addled 1980s. His skin is corrugated from years of injecting. His tattoos have faded to a murky bluish gray. His voice is raspy but steady. I wondered how the misdiagnosis could have persisted for so long — why we chose to explain his vigorous T-cells by classifying him as a nonprogressor, rather than considering that his initial H.I.V. test might have been incorrect. Was it that we put too much faith in the test’s “objectivity”? Or was it simply that Mr. S. fit the H.I.V. picture too well — Rikers prisoner, drug user, hepatitis C, tattoos — that we never imagined he could be negative? When we first met, his calves were filleted open from knee to ankle with ulcers in various states of disrepair. He handed me a pagelong list of supplies he needed for the ulcers — saline bottles, gauze wraps, surgical tape, iodine, Silvadene cream, latex gloves, occlusive dressings — and I admit I was a little taken aback. I’d never seen a “druggie” — even an ex-druggie — so organized. He didn’t fit the picture. Amazingly, over the years, thanks to his assiduous care, the ulcers gradually healed until there were only thin snaking scars on his calves to mark their sites. He didn’t fit the picture. One day, after two decades of taking methadone at an impressively high dose, he abruptly tapered himself off. “I’ve had enough,” he told me bluntly. He didn’t fit the picture. When I asked him how he felt about the misdiagnosis of H.I.V., he simply shrugged: “It is what it is.” Perhaps, given all the other things he’d suffered in his life, eight years of carrying a false diagnosis wasn’t the worst thing. But it made me think about the assumptions that medical professionals — and society in general — make about those who seem to fit a certain picture. Over the years, Mr. S. shattered myth after myth. But in reality, he didn’t do anything; he simply was who he was. It was society that had to shatter its myths: If we’d observed the conflicting data more carefully in the beginning, if we’d examined our own biases before being so positive in our judgment, he would have been spared this brush with H.I.V. — the stigma, the costly and unnecessary medical care, the drugs and their side effects. Ultimately, he bequeathed me this lesson about my profession’s penchant for stereotypes and snap judgments. I just wish he hadn’t had to suffer all those years to convey it. Dr. Danielle Ofri is an internist in New York City. Her newest book is “Medicine in Translation: Journeys With My Patients.”

Global Update: Asia’s Heavy Use of Asbestos Is Expected to Cause Rise in Deaths in Coming Decades Posted: 20 Jun 2011 12:31 PM PDT Deaths from asbestos-related diseases will surge in Asia over the next 20 years, a recent study has warned. Asia now accounts for 64 percent of the world’s asbestos use, according to the study in Respirology, the journal of the Asian Pacific Society of Respirology, but for only about 13 percent of the asbestos-related deaths in World Health Organization mortality data. It takes 30 to 50 years after exposure to develop asbestosis, mesothelioma or a related lung cancer. Asbestos is a mineral used as fireproofing in construction, and sometimes in cars and ships. In the United States and Europe, most uses have been banned, and workers must wear respirators to keep from inhaling fibers 1,000 times finer than a human hair. In Asia, asbestos has many uses, from roofing to cement to power plants. Companies in India that make cheap roofing sheets like those pictured above employ 100,000 people, many in badly ventilated factories, according to a recent article in the Indian business press. They import asbestos from Russia and Canada. India, China and some other large Asian countries do not record asbestos data, so their official death counts are probably artificially low, the study said. Several countries, including Japan and South Korea, banned the mineral after they saw deaths climb. Dr. Ken Takahashi, the lead author and director of a W.H.O. occupational health group, warned that Asian governments must brace themselves for an “asbestos tsunami.”

Vital Signs: Perceptions: Cancer Drugs Get on a Faster Track in U.S. Posted: 20 Jun 2011 12:28 PM PDT New cancer drugs are approved in just six months on average in the United States, half the time it takes for the same drugs to be approved in Europe, a new report finds. Related Health Guide: Cancer More Vital Signs Columns The analysis, published online this month by the journal Health Affairs, appears to refute critics who have charged the Food and Drug Administration is less efficient than the European Medicines Agency and has been slower to approve new cancer drugs. The study’s authors compiled a list of 35 new cancer drugs approved by either of the agencies between 2003 and 2010. They found that the F.D.A. had approved 32 of the products in an average of 182 days from the time that the first applications were filed. Only three products took more than a year to receive approval. By contrast, the European Medicines Agency approved only 26 of the drugs, taking just under a year on average. Nine drugs were not approved. All of the drugs that were approved by both agencies were available to patients in the United States first. The results surprised the study’s authors. “When we realized we were correct, we thought, ‘No one is going to believe us because this goes against urban legend,’ ” said Ellen V. Sigal, chair and founder of Friends of Cancer Research.

Recipes for Health: Asparagus With an Italian Twist Posted: 20 Jun 2011 12:45 PM PDT Some weeks all I want to cook is Italian food, and so it was this week as I availed myself of the last of the season’s asparagus. Italians have a way with this vegetable, both the pencil-thin stalks that grow wild in the countryside and the thicker cultivated varieties. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Asparagus With Anchovies and Capers (June 21, 2011) Recipes for Health: Lasagna With Asparagus and Chives (June 22, 2011) Recipes for Health: Asparagus Rolled in Herb Crêpes (June 23, 2011) Recipes for Health: Asparagus With Gremolata, Lemon and Olive Oil (June 24, 2011) Simply steamed or boiled, asparagus can be served with a range of condiments and sauces, from Parmesan and butter to anchovies and capers to gremolata -- a mixture of finely chopped parsley, garlic and lemon zest. Italian cooks also use asparagus in risottos and toss it with pastas; they scramble the thin variety with eggs and use it to fill frittatas. One of my favorite Italian dishes is a crêpe filled with cooked asparagus spears and a little cheese, then baked until bubbly. Asparagus is an excellent, low-calorie source of vitamin K, folate, vitamin C, vitamin A and such nutrients as tryptophan, manganese and fiber. Asparagus and Mushroom Salad I’ve eaten antipasti like this all over Italy. Sometimes celery is substituted for asparagus, but there’s no need at this time of year. Both thick and thin stems will work. 1 pound asparagus 1/2 pound mushrooms, thinly sliced 1/4 cup chopped fresh herbs, such as parsley, tarragon and chives 1 cup baby arugula 2 to 3 tablespoons fresh lemon juice (to taste) Salt and freshly ground pepper to taste 1 small garlic clove, minced or pureed 5 tablespoons extra virgin olive oil 1 ounce slivered Parmesan 1. Steam the asparagus for three to five minutes, depending on how thick the stalks are. It should be tender but still have some bite. Rinse with cold water, and drain for a minute on a kitchen towel. Cut into 1-inch lengths. Place in a salad bowl, and toss with the mushrooms, herbs and arugula. 2. Whisk together the lemon juice, salt and pepper, garlic and olive oil. Toss with the asparagus mixture and the slivered Parmesan, and serve. Yield: Serves four to six. Advance preparation: You can assemble this several hours ahead through Step 1 and refrigerate. Toss with the dressing shortly before serving. Nutritional information per serving (four servings): 222 calories; 4 grams saturated fat; 2 grams polyunsaturated fat; 13 grams monounsaturated fat; 6 milligrams cholesterol; 8 grams carbohydrates; 3 grams dietary fiber; 115 milligrams sodium (does not include salt to taste); 7 grams protein Nutritional information per serving (six servings): 148 calories; 2 grams saturated fat; 1 grams polyunsaturated fat; 9 grams monounsaturated fat; 4 milligrams cholesterol; 5 grams carbohydrates; 2 grams dietary fiber; 77 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."

Ban on Hearing Aids Is Forcing Out Veteran New York City Police Officers Posted: 19 Jun 2011 10:50 PM PDT The New York Police Department’s policy regarding a job candidate’s hearing ability is straightforward enough: Applicants who fail a basic hearing test will not be hired as officers. Enlarge This Image Suzanne DeChillo/The New York Times Jim Phillips, 40, was forced to retire as a New York police sergeant after wearing a hearing aid. But for police officers already on the job, the policy is not so clear-cut. After years of informally allowing officers to wear hearing aids, and even paying for some, the department in late 2009 began enforcing a ban on the hearing devices, forcing older officers who had them to retire and instructing younger officers to stop wearing them at work. Two of those forced to retire have filed a complaint with the federal Equal Employment Opportunity Commission, contending that the policy forbidding hearing aids is discriminatory toward those with hearing loss, according to the officers’ lawyer, Colleen M. Meenan. The former officers, Daniel Carione, 44, and Jim Phillips, 40, also contend that the policy serves as a deterrent to officers who otherwise might report their hearing loss. “This just forces the ones with hearing impairments to hide,” said Mr. Carione, a former deputy inspector who received a hearing aid in 2009 that was paid for by the department, only to be forced into retirement two years later. “It sends a message to anyone who is suffering from hearing loss that if you come forward and make that known, we will end your career,” he said. The two men say that because the department does not routinely test officers for hearing, the hearing-aid ban does little to weed out officers with hearing loss. One officer, who normally wears a hearing aid but removes it while on duty, said he believed that his hearing deficiency left him less equipped to adequately serve. “I do everything I can to reduce the odds of getting myself hurt, or someone else hurt,” said the officer, who insisted on anonymity because of his condition. He acknowledged that there were times when he could not properly hear communications on the police radio. “I had to do a warrant check and I couldn’t hear the words,” he said. “I could hear the sound, but I couldn’t hear the words.” Paul J. Browne, the department’s chief spokesman, said it was “not actively looking to see if people have hearing aids.” “But presumably if someone came forward and said, ‘I need a hearing aid,’ and it indicates that your hearing is diminished, then that could lead to a disability retirement,” he added. The department has not publicized its ban on hearing aids for active officers. In three cases, the Police Department has told officers to stop wearing their hearing aids even though it had previously authorized their use, Ms. Meenan said. Mr. Browne said those three cases involved “officers who were under the impression they needed hearing aids, but did not.” Mr. Browne said hearing aids were incompatible with police work because they were vulnerable to “mechanical failure, earwax buildup or any number of things,” and could not completely compensate for hearing deficiencies that might render an officer unable to hear a command properly. In challenging the department’s policy, Mr. Carione and Mr. Phillips also raise questions about the extent of job-related hearing loss among police officers, who hear some of the loudest noises the city has to offer, in higher doses than ordinary citizens experience. Over the years, many police officers who had spent their careers working in the subways complained of hearing loss, said Robert Valentino, a former spokesman for the transit police, which was a separate police force until 1995. “You work in the subway over time, no matter what, you’ll have hearing loss,” said Mr. Valentino, who said his own hearing declined noticeably between 1968 and 1980, the period when he worked underground. “The noise is just incredible.” A study about noise in the city’s mass transit system that was published in The American Journal of Public Health in 2009 found that “exposures of a few hours to as little as 2 minutes a day” to the noise levels on some subway platforms “would be expected to cause hearing loss for some people given chronic exposure.” Mr. Carione’s hearing loss dates to July 4, 1996, he said, when he shot and killed a drunken man who was menacing him with a knife. Another officer fired five shots less than two feet from Mr. Carione’s ear. Mr. Carione pointed out that in 2004, despite his impairment, he could hear well enough to dive off Canarsie Pier while fishing one night and save a drowning autistic man. “I heard enough to hear that splash, didn’t I?” Mr. Carione said in a recent interview. 1 2 Next Page »

Debate Swirls Around Research Showing Lung Problems for Returned Troops Posted: 19 Jun 2011 10:55 PM PDT As a teenager in northern New York, Gary Durham ran cross-country and hiked the Adirondack’s high peaks. In Army basic training, he did two-mile runs in under 13 minutes. But after a yearlong deployment to Iraq with the 101st Airborne Division in 2003, he says he started gasping for air while just mowing the lawn. An emerging body of research indicates that Mr. Durham is one of a significant number of American service members who are reporting respiratory problems like coughing, wheezing or chest pains that started during deployment and continued after they returned home. In 2009, a major survey of military personnel, the Millennium Cohort Study, found that 14 percent of troops who had deployed reported new breathing problems, compared with 10 percent among those who had not deployed. Though the percentage difference seems small, when extrapolated for the two million troops who have deployed since 2001, the survey suggested that at least 80,000 additional service members had developed post-deployment breathing problems. But now, a fierce debate is under way over just how long-lasting and severe those problems really are. On one side are scientists, many working for the government, who say that a large number of returning troops have serious and potentially lifelong ailments. They point to an array of respiratory hazards in Iraq and Afghanistan — including powerful dust storms, fine dust laced with toxins and “burn pits” used to incinerate garbage at military bases — as potential culprits. Those scientists also question whether the government has acted swiftly enough to study the effects of prolonged exposure to dust, allergens and pollution in Iraq and Afghanistan, and whether it is properly compensating those who may have service-connected lung injuries or diseases. “I’m concerned that this exposure is not getting the serious review it needs,” said Capt. Mark Lyles, the chairman of medical sciences and biotechnology at the Center for Naval Warfare Studies in Newport, R.I., who has studied dust from Iraq and Afghanistan. On the other side of the debate are officials with the Pentagon and the Department of Veterans Affairs who assert that current research remains inconclusive. They acknowledge that some troops are returning with respiratory symptoms but say those problems vary widely depending on genetic background or location of deployment and are usually temporary. “I think we are going to find that there is some increase in respiratory symptoms, and maybe even respiratory diagnoses,” said Col. Lisa Zacher, a doctor who is the pulmonary consultant to the Army’s surgeon general. “But I think we’ll find the majority who deploy do not have long-term chronic pulmonary diseases related to deployment.” Mr. Durham’s breathing struggles have proved to be long-term. When he returned to Fort Campbell, Ky., in 2004, Mr. Durham was coughing up phlegm daily. Running became impossible. Yet a battery of lung tests showed nothing wrong. Before he was medically discharged as a sergeant in 2005, an Army doctor suggested that his problem might be psychological, records show. Then last year, Mr. Durham read about a specialist at Vanderbilt University Medical Center who had treated Iraq veterans for breathing problems. The doctor did a lung biopsy on Mr. Durham and concluded that he had a debilitating and largely untreatable injury known as constrictive bronchiolitis. Though the diagnosis might have seemed devastating, Mr. Durham felt vindicated. “I had been told there was nothing wrong with me by so many doctors,” he said. “I just wanted to know what was wrong with me.” Dr. Robert F. Miller, who treated Mr. Durham, has conducted similar biopsies on 56 previously deployed veterans, many from Fort Campbell. He found that 40 of them had constrictive bronchiolitis, an irreversible scarring of the small airways that can make breathing during moderate exercise feel like “sucking air through a straw,” Dr. Miller said. Fifteen other biopsies led to diagnoses of other lung ailments. Almost all of his patients had been through standard lung function tests like CT scans and spirometry that found nothing wrong. Constrictive bronchiolitis is typically found in people with lung transplants or rheumatoid arthritis, or who work with industrial chemicals, but is rare in the general population. “My concern is that these guys come back from war, can’t do a two-mile run and then are dismissed from the Army,” Dr. Miller said. “They are told: ‘Maybe you’re out of condition.’ ” 1 2 Next Page »

Chemical Suicides, Popular in Japan, Are Increasing in the U.S. Posted: 20 Jun 2011 08:26 AM PDT In Japan it is known as detergent suicide, a near-instant death achieved by mixing common household chemicals into a poisonous cloud of gas. Enlarge This Image Michael Kamber for The New York Times Janet Kelly's 24-year-old son, John, killed himself with a mix of chemicals inside a Jeep in Irvington, N.Y. Enlarge This Image Michael Kamber for The New York Times Photos of John Kelly. A sign on the window of the car he killed himself in warned against breaking the glass and urged rescuers to call a hazardous materials team. By some counts, more than 2,000 people there have taken their own lives, inhaling the gas — in most cases hydrogen sulfide — in cars, closets or other enclosed spaces. The police now say they are seeing an increasing number of similar suicides in the United States, inspired by Web sites that carry recipes for the chemical mix as well as detailed instructions on how to use it. And as in Japan, where the suicides have caused whole neighborhoods to be evacuated and sent dozens of people to the hospital, the desperate and despondent are not the only victims. Of 72 chemical suicides experts have documented in the United States since 2008, at least 80 percent have resulted in injuries to police officers, firefighters, emergency workers or civilians exposed to the gas, despite the efforts of suicide victims to protect others by putting warning signs on car windows or closet doors, said Deputy Chief Jacob Oreshan of the New York State Office of Fire Prevention and Control, who has been tracking the cases. Last year there were 36 chemical suicides in the United States. Since Jan. 1, there have been at least 27, indicating that the incidence is rising, Chief Oreshan said. Those numbers, however, still represent a tiny fraction of the 34,000 or so suicides reported each year. The injuries to first responders have so far been minor. But in some cases where police officers have opened car doors or broken car windows without protective equipment, the gas “is knocking them right to the ground,” Chief Oreshan said. To avoid exposure, rescuers cannot reach the victim until the hazard is cleared, a process that can take hours. And that, said Michael Cerone, the police chief in Irvington, N.Y., is “heart wrenching.” “You want to help,” he said. “You want to get in there.” On March 28, Chief Cerone went to investigate a report of a person slumped inside a Jeep Liberty parked on a deserted dirt road. A sign on the window warned against breaking the glass and urged rescuers to call a hazardous materials team, he said. The bomb squad was summoned, and a robot was sent to breach the car’s rear window. Houses in the neighborhood were evacuated. At that moment, a few miles away, Dr. Stephen Kelly, a family practice physician, was at the police station in Irvington waiting to file a missing person report on his 24-year-old son, John. As he stood there, a dispatcher on the police radio described the car and the body found inside and Dr. Kelly knew immediately what had happened. He and his wife, Janet, a nurse, had spent hours that afternoon in an increasingly frantic search for their son, who had suffered since childhood from a severe form of obsessive-compulsive disorder and depression and had been hospitalized in December after a suicide attempt. Dr. Kelly had quit his practice to stay home and try to help John overcome his depression. Despite John’s illness, he had graduated from college with a degree in psychology and was working at a nearby psychiatric hospital. “He didn’t let people know,” his mother said. “He was always counseling others.” Other suicides have followed a similar pattern. On May 23, a 23-year-old woman died in her car in the Hollywood Hills neighborhood of Los Angeles, after mixing up the recipe and placing signs on the window saying “Danger! Chemicals Inside! Call 911.” She had made a suicide pact with a man who changed his mind at the last minute and left the car, the police said. In a suicide in Baldwin, Mich., on Jan. 8, emergency workers were taken to the hospital after a firefighter moved a canister in the car of a suicide victim, causing the gas to be re-released. And in Massachusetts, an elderly woman was sickened when the toxic fumes leaked through her ceiling from an upstairs apartment. “Suicide is generally intended for one victim,” said Richard Perrin, under sheriff of the Lake County Sheriff’s Department, who was at the scene of the suicide in Michigan. “Whereas this form of suicide has the potential to affect many, whether it be intended or unintended, and that’s what makes it so dangerous.” Under Sheriff Perrin is one of about 50 police and fire officials who are part of a nationwide working group organized by Chief Oreshan to educate first responders about the suicides. 1 2 Next Page »

Economic View: Seriously, Some Consensus About Health Care Posted: 18 Jun 2011 09:56 PM PDT WE are entering the season of polarization. With various Republicans vying to replace Barack Obama, the president eager to keep his job, and both the House and the Senate up for grabs, candidates from both sides of the aisle will spend the next year and a half stressing their differences. Enlarge This Image Carl Wiens Podcast But beneath this veneer of partisanship lie a few fundamental agreements. Consider health care, which will be at the center of the political debate. Here are four aspects of the issue in which Republicans and Democrats have stumbled into consensus. THE VALUE OF COMPETITION Representative Paul D. Ryan, Republican of Wisconsin, has attracted much attention with his plan to reform Medicare. He proposes replacing the current fee-for-service program, in which the government picks up the bill for medical expenses, with a “premium-support” system in which seniors use federal dollars to choose among competing private insurance plans. Democratic critics of the plan suggest that enacting it would be akin to pushing Grandma over a cliff. But they rarely point out that the premium-support model is in some ways similar to the system set up under President Obama’s health care law. If choosing among competing private plans on a government-regulated exchange is a good idea for someone at age 50, why is it so horrific for someone who is 70? Republicans, meanwhile, are eager to repeal Obamacare and so are also reluctant to point out its parallels with Ryancare. We can take heart, however, in the kernel of agreement about the value of private competition. THE INSURANCE MANDATE Perhaps the most controversial piece of the Obama plan is the mandate for individuals to have health insurance. But think for a moment about what this really means. No one has proposed putting the uninsured in jail. Instead, those without insurance will be fined. A mandate is just a financial incentive to have insurance. What is the Republican alternative for having more people insured? It is unclear what the Republicans would do if they ever succeeded in repealing the health care reform law. However, their last presidential nominee — Senator John McCain — proposed a tax credit for buying health insurance. That may seem more palatable than a mandate, because it uses a carrot rather than a stick. But consider who would pay for that tax credit. The answer is all taxpayers. This tax burden would be particularly hard on the uninsured, who would face higher taxes without enjoying the credit’s benefit. In other words, giving a tax credit to those who buy insurance is a back-door way to impose fines on those who don’t. TAXING THE RICH Democrats want to increase taxes on the rich to fund the looming fiscal gap, which is driven largely by soaring health costs. Republicans object, saying higher taxes create economic distortions, discourage work and impede growth. Last month, John A. Boehner, the House speaker, said that we should instead consider means-testing Medicare. But what does that mean? Here is how means-testing might work. We could start by choosing some income threshold — say, $250,000 — and then require people over 65 with higher annual income to pay more in Medicare premiums than they do now. For example, for every $1,000 of income beyond the threshold, they might have to pay an extra $10 in annual premiums. Sounds good, right? But notice that the economic effects of means-testing are much the same as a tax increase. This particular plan is like increasing the income tax rate by one percentage point for high-income seniors. It is only semantics as to whether the $10 is called a “tax” or a “premium.” Indeed, means-testing could create more economic distortions than would broad-based tax increases. Seniors have more flexibility in how much they work than do typical Americans. In particular, for many people, the timing of retirement is discretionary. The higher marginal tax rates implicit in means-testing will induce people to leave the labor force earlier than they otherwise would. This would deprive the economy of some of its most experienced and productive workers. BLINKERED OPTIMISM Democrats and Republicans generally have different approaches to controlling the growth of health care spending. Democrats often favor a top-down approach: a panel of experts set up by the recent health care law will decide which medical procedures are cost-effective and which are wasteful. Republicans tend to prefer a bottom-up approach: empower consumers to make their own choices, they say, and the power of competition among private providers will keep costs down. One thing that the two parties share, however, is the belief that controlling health care costs is possible. Yet many economists believe that the rise in health spending is largely the result of medical advances, which prolong and enhance life at a high cost. Perhaps health spending will inevitably, and even should, keep rising as a share of national income. This possibility raises a question: If health care becomes an increasing share of the economy, how will we allocate it, and how will we pay for it? That is, if controlling the cost of health care fails, what is Plan B? That is a question that candidates from both political parties agree on as well: they all seem determined to avoid it. N. Gregory Mankiw is a professor of economics at Harvard. He is advising Mitt Romney, the former governor of Massachusetts, in the campaign for the Republican presidential nomination.

Ambition + Desire = Trouble Posted: 20 Jun 2011 06:36 AM PDT “I DON’T know what I was thinking.” Multimedia Interactive Feature Milestones: Anthony D. Weiner Related Times Topic: Anthony Weiner Enlarge This Image Jin Lee/Bloomberg News Anthony D. Weiner. So said Anthony D. Weiner in a news conference moments after finally admitting that he had sent naughty photos of himself to women he had met on the Internet. The married former congressman, who resigned on Thursday, 10 days after that confessional press conference, might not know what he had been thinking — but scientists have an idea or two. Scholars studied brain architecture and chemistry long before Mr. Weiner pinged photos of his unmentionables into cyberspace. And their research — some of it subject to dispute — suggests that physiology played a role in Mr. Weiner’s digital dalliances. “Most people who get as far as he’s gotten are high-testosterone people,” said Helen Fisher, the biological anthropologist and a member of the Center for Human Evolutionary Studies in the anthropology department at Rutgers. “Along with that ambition comes a high sex drive. Testosterone’s linked with both of them.” According to some, seeking prominence is part of an inborn survival strategy. “Men, particularly successful men, have an evolutionary history of polygamy,” said David C. Geary, curators’ professor in the department of psychological sciences at the University of Missouri at Columbia. Men who pursue politics are also pursuing power, Dr. Geary said, and “from an evolutionary perspective the whole goal of men striving for power is to increase their access to sexual opportunities.” But in an era of easily followed digital footprints, the chances of catting around and being caught are greater than ever. So why cheat and tweet? One possible answer: there’s a correlation between testosterone and risk-taking. “If you asked one of these guys ‘What are the chances of you getting caught?’ you would see an underestimation of the risks,” Dr. Geary said. “And the severity of the consequences is underestimated.” Women, on the other hand, said Dr. Geary, “tend to focus on the potential harm of the consequences.” (Studies about subjects other than sex — like money — have also reported a link between testosterone and overconfidence.) According to Dr. Fisher, women have on average more long-range neural connections than most men. As a result, she said, men tend to narrowly focus on the here and now instead of potential long-term consequences. A convenient excuse for philandering? “I’m not going to excuse this guy or any of them,” Dr. Fisher said, referring to Mr. Weiner, “but when he says ‘I don’t know what I was thinking,’ he probably literally was not seeing or evaluating or weighing properly all of the outcomes for this. He was focused on the short term.” Gender generalizations are a dangerous area. Men and women are more alike than different, and their neurological differences have historically been used to justify sexism. Among the most notable: women were once considered less intelligent than men when studies showed their brains weren’t as big. Critics also contend that many neurological gender studies have too-small subject groups, or other design flaws. And it’s not always clear how or whether neurological differences translate into specific behavior. Our actions are shaped by other factors as well, like personal experiences, culture and genetics. Bianca Acevedo, a National Science Foundation postdoctoral researcher fellow in the department of psychological and brain sciences at the University of California, Santa Barbara, explained in an e-mail: “For example, individuals that need to exert much control in their daily lives (such as powerful politicians) may have less cognitive resources to regulate their behavior in other life domains.” That said, studies that have nothing to do with gender differences still underscore just how powerless someone — male or female — can feel in the grip of sexual desire. Brain areas involving desire are activated in the blink of an eye — less than 200 milliseconds, according to research by Stephanie Ortigue, an assistant professor at the psychology department at Syracuse University and at the University of Geneva in Switzerland, and Francesco Bianchi-Demicheli, also of the University of Geneva. Even before you realize that some detail about a person has caught your eye, be it in an online photograph or while passing on a sidewalk, your unconscious brain knows that person will activate your reward system, and your brain begins to anticipate the reward. 1 2 Next Page »

Studied: With Botox, Looking Good and Feeling Less Posted: 20 Jun 2011 10:00 AM PDT THE GIST Using Botox decreases a person’s ability to empathize with others. Related Times Topic: Botox (Drug) THE SOURCE “Embodied Emotion Perception: Amplifying and Dampening Facial Feedback Modulates Emotional Perception Accuracy” by David T. Neal and Tanya L. Chartrand, published in “Social Psychological and Personality Science.” It’s no shock that we can’t tell what the Botoxed are feeling. But it turns out that people with frozen faces have little idea what we’re feeling, either. No, Botox injections don’t zap brain cells. (At least not so far as we know.) According to a new study by David T. Neal, an assistant professor of psychology at the University of Southern California, and Tanya L. Chartrand, a professor of marketing and psychology at the Duke University Fuqua School of Business, people who have had Botox injections are physically unable to mimic emotions of others. This failure to mirror the faces of those they are watching or talking to robs them of the ability to understand what people are feeling, the study says. The idea for the paper stemmed from a study conducted in the 1980s, which found that long-married men and women began to resemble each other over time, especially if they were happily wed. “So we thought, what’s going to happen now that there’s Botox?” Dr. Neal said. The toxin might interfere with “embodied cognition,” the way in which facial feedback helps people perceive emotion. According to the theory in the study, a listener unconsciously imitates another person’s expression. This mimicry then generates a signal from the person’s face to his or her brain. Finally, the signal enables the listener to understand the other person’s meaning or intention. While the first two steps of this process had been established by research, it was unclear whether facial feedback helped people make better judgments about other peoples’ emotions. Enter the Botoxed person, a useful new laboratory specimen. And, as a control, the user of Restylane, a skin filler that does not alter muscle function. In one experiment, women who had been injected with Botox within the last two weeks were offered $200 to look at a set of photographs of human eyes and match them with human emotions. Restylane users performed the same tasks, which were in both cases conducted via computer. Women with Botox were significantly less accurate at decoding both positive and negative facial expressions than those who had used Restylane, whose abilities closely approximated those of plain old wrinkled adults. On average, the Botox group guessed 2 more out of 36 facial expressions wrong. A second experiment found that people with amplified expressions do a better job deciphering emotions. Participants who had a gel on their faces that effectively made their muscles work harder to convey emotions could more accurately identify emotions in others. The gel was similar to an over-the-counter facial mask. Ah, the trials of beauty! While Botox doesn’t go to the brain (the poison doesn’t cross the blood-brain barrier), it does seem to affect its users ability to think. Such findings might perturb those who have dipped into the Clostridium botulinum. Not that we can tell.

The Boss: Seeking Cures, Then and Now Posted: 18 Jun 2011 10:00 PM PDT MY mother gave my sister, Suzy, and me our first lessons in stewardship. On Saturday afternoons, she would drive us to volunteer somewhere. We might go to a homeless shelter, or to the Red Cross or to an ill neighbor’s house to do laundry. One day we complained and she pulled off onto the side of the road and gave us her stewardship talk. She told us that it was up to us to fix what was wrong in this country. Susan G. Komen for the Cure Nancy Brinker,  C.E.O. of Susan G. Komen for the Cure, a foundation based in Dallas. HOMETOWN Peoria, Ill. COLLECTS Hungarian art HISTORICAL FIGURE SHE MOST ADMIRES Marie Curie My sister was 8 and I was 5. We decided to give a show in our backyard to benefit polio research. Suzy told me that I had to sing and dance and that she’d sell tickets. I sang the only songs I knew — Rosemary Clooney tunes. I thought I was wonderful, but when I was done, Suzy said that the next time she’d sing and that I could sell the tickets. We raised $64. I attended the University of Illinois at Urbana-Champaign. I didn’t learn well in a classroom, probably because of an undiagnosed learning disability. I asked a lot of questions and learned experientially — and I was president of my sorority and active in several clubs. After graduating from college in 1968, I entered the executive training program at Neiman Marcus in Dallas. I loved the psychology of marketing. I was also an adviser for Bozell & Jacobs, a public relations company in Dallas. My sister died of breast cancer in 1980. Two years later, I founded the precursor of our current foundation and served as a volunteer. In the late 1970s, when my sister’s cancer was diagnosed, breast cancer wasn’t discussed freely in the media. There were no “800” numbers for information, or breast cancer Web sites or patient advocacy groups the way there are today. In 2001, President George W. Bush appointed me as ambassador to Hungary. I knew the Bush family because I lived in Texas and also through my breast cancer work. In 2002, to raise awareness of the disease, I walked across the Szechenyi Bridge in Budapest with the Hungarian minister of health and several hundred breast cancer survivors. In 2003, I refocused fully again on the foundation’s activities, and in 2007 was appointed White House chief of protocol. My father was sick and I wanted to care for him, but he told me that there would never be a perfect time to serve and that he wanted me to do it. As chief of protocol, I was first to greet Pope Benedict XVI when he visited the United States in 2008. I also visited a Pepfar (President’s Emergency Plan for AIDS Relief) clinic in Tanzania that year with President Bush. In 2009, I was appointed goodwill ambassador for cancer control for the United Nations World Health Organization. Tobacco use is growing in other countries and cancer rates are rising. Awareness campaigns make a difference. I called for a regional meeting in Egypt with health ministers to increase awareness of the harmful effects of tobacco. I also became C.E.O. of Susan G. Komen for the Cure, named for my sister, that year. Our group has benefited from the knowledge I’ve gained in every position I’ve held. Seeing how other countries deal with health care was especially enlightening. We began in Dallas and now have offices there and in Washington, with affiliates in 120 American communities and in 50 countries. When I started this group, I hoped it would take 10 years to find a cure. We’re not there yet. But we’ve made great incremental gains in understanding biology and increasing awareness. The survivor rate has increased immensely. I’m a breast cancer survivor myself. We’ve invested more than $1.9 billion in breast cancer research and programs. We’ve given voice to survivors — our pink ribbon is a symbol worldwide. It was my sister’s favorite color. As told to Patricia R. Olsen.

Medicare Claims Show Overuse for CT Scanning Posted: 18 Jun 2011 12:29 PM PDT Long after questions were first raised about the overuse of powerful CT scans, hundreds of hospitals across the country needlessly exposed patients to radiation by scanning their chests twice on the same day, according to federal records and interviews with researchers. Multimedia Interactive Map Scanning Twice Related More Articles in This Series Enlarge This Image Christopher Capozziello for The New York Times Richard Miller during a CT scan in Waterford, Conn. Performing two scans in succession is rarely necessary, radiologists say, yet some hospitals were doing that more than 80 percent of the time for their Medicare chest patients, according to Medicare outpatient claims from 2008, the most recent year available. The rate is typically less than 1 percent, or in some cases zero, at major university teaching hospitals. Next month, the Center for Medicare and Medicaid Services is expected to release figures for 2009, but according to people who have seen the numbers, the practice of double scanning chest patients has continued. “When I saw the 2009 numbers, they were the same essentially, and I was disquieted by that,” said Dr. Michael J. Pentecost, a radiologist and Medicare consultant who also reviews claims for commercial clients. The overuse of scans has been the subject of growing concern in recent years, but a review of the federal data, focusing on a common procedure performed millions of times a year, offers a rare and detailed snapshot of the problem state by state, hospital by hospital. In 2008, about 75,000 patients received double scans, one using iodine contrast to check blood flow, and one that did not. “If you do both, you bill for both,” Dr. Pentecost said. Radiologists say one scan or the other is needed depending on the patient’s condition, but rarely both. Double scanning is also common among privately insured patients who tend to be younger. Double scans expose patients to extra radiation while heaping millions of dollars in extra costs on an already overburdened Medicare program. A single CT scan of the chest is equal to about 350 standard chest X-rays, so two scans are twice that amount. “The primary concern relates to radiation exposure,” said Dr. James A. Brink, chief of diagnostic radiology at Yale-New Haven Hospital, where double scans accounted for only a fraction of 1 percent of cases. He added: “It is incumbent upon all of us to limit it to the amount needed to make a diagnosis.” Officials at hospitals with high scan rates said radiologists ordered the extra chest scan figuring that more information is better. In rare instances, the two scans might help a doctor distinguish between tangled blood vessels and a tumor, Dr. Pentecost said. The Medicare agency distributed the data to hospitals last year to show how they performed relative to each other and to encourage more efficient, safer practices. The review of that data found more than 200 hospitals that administered double scans on more than 30 percent of their Medicare outpatients — a percentage that the federal agency and radiology experts considers far too high. The national average is 5.4 percent. The figures show wide variation among states as well, from 1 percent in Massachusetts to 13 percent in Oklahoma. Overall, Medicare paid hospitals roughly $25 million for double scans in 2008. Double scanning is more likely to occur at smaller, community hospitals such as Memorial Medical Center of West Michigan in Ludington. It gave two scans to 89 percent of its Medicare chest patients.. “We aren’t radiologists, but as we understand the practice, it was strictly a matter of physicians, independent practitioners who were doing their best to get to the bottom of what was ailing their patients,” said Bill Kerans, a spokesman for that hospital. Since 2008, Memorial Medical Center lowered its rate to 42.4 percent in 2010 and to 3 percent in the first part of 2011. “We have made some dramatic changes in protocols and practices,” Mr. Kerans said. A few large hospitals have had problems as well. St. John Health System in Tulsa double-scanned 80 percent — or 800 of its Medicare outpatients in 2008. “We recognized in late 2008 and early 2009 those numbers were higher than we needed to be,” said Charles Anderson, the hospital’s president and chief executive. By changing protocols, the percentage of double scans is now “hovering around 5 percent,” Mr. Anderson said. “What that means for us is when a physician orders a scan from a radiology department, the radiologist begins to engage in a conversation with those physicians, talking about what might be a more reasonable and acceptable approach.” 1 2 Next Page »

Program Offering Waivers for Health Law Is Ending Posted: 17 Jun 2011 10:30 PM PDT WASHINGTON — The Obama administration said Friday that it was shutting down a program that had provided exemptions from the new health care law for many employers and labor unions offering bare-bones insurance coverage to workers. Related Judges Weigh Limits of Health Law’s Powers (June 9, 2011) No more applications will be accepted after Sept. 22, federal health officials said. Steven B. Larsen, director of the federal Center for Consumer Information and Insurance Oversight, said employers and labor unions had until that date to seek exemptions or request the extension of waivers already granted. The new health care law generally requires employers to provide at least $750,000 in coverage to each person in their health insurance plans this year. Many restaurants, retailers and small businesses do not meet the standard. Some provide “mini-med” coverage with annual limits that may be as low as $10,000. “Mini-med plans do not provide comprehensive health coverage, but unfortunately they are the only insurance options some consumers have today,” Mr. Larsen said. The minimum amount of coverage will increase. Federal rules require health plans to provide at least $1.25 million in coverage next year and $2 million in 2013. In 2014, annual limits for new health plans will be banned. In that year, individuals and small businesses will be able to buy comprehensive coverage through state-supervised insurance exchanges. Waivers granted or renewed in the next three months will run through 2013. To date, the administration has granted waivers to 1,433 health plans covering 3.2 million people. On Friday, the administration disclosed that it had denied 100 applications and then approved nearly one-third of them after reconsidering the evidence. To obtain waivers, employers and health plans must show that compliance with the federal requirements would cause a significant increase in premiums or a significant decrease in access to benefits. Without waivers, some employers said, they would have increased premiums or dropped coverage this year because they could not afford to provide higher health benefits. Republicans have seized on the waivers as evidence that the law is fundamentally flawed. “If the law is so good, why are more and more employers begging for a waiver to get relief from its burdensome mandates?” asked Senator John Barrasso, Republican of Wyoming. “Americans need waivers from the president’s law because it causes health premiums to go up.” The policy announced Friday may eliminate the waivers as an issue in the 2012 election year. Under the policy, the administration said, employers and insurers with annual coverage limits below $2 million will have “a reasonable opportunity” to apply for waivers in the next three months. Republicans have repeatedly asserted that the administration was giving preferential treatment to its political allies by granting waivers to health plans sponsored by labor unions that had supported the legislation. But in a study this week, the Government Accountability Office, an investigative arm of Congress, said health officials had used objective criteria in deciding whether to grant waivers. E. Neil Trautwein, a vice president of the National Retail Federation, a trade group, said that ending the waivers was “a wise, appropriate step for the administration to take.” “This step will avoid unnecessary politics and furor over the waivers,” Mr. Trautwein said.

Business Briefing | HEALTH: F.D.A. Panel Endorses an Eye Treatment Posted: 17 Jun 2011 09:50 PM PDT Add to Portfolio Bayer AG Regeneron Pharmaceuticals Inc Go to your Portfolio » A new eye medicine from Regeneron Pharmaceuticals and Bayer A.G. is safe and effective for treating a common cause of vision loss, a federal advisory panel said on Friday. The panel, which makes recommendations to the Food and Drug Administration, voted unanimously to recommend the treatment, Eylea, for a form of macular degeneration that affects at least 1.5 million Americans. The advisers also said the drug, which is given by injection, could be given once every two months, giving it an edge over the typical monthly dosing of its chief competitor, Lucentis, from Roche Holding. The F.D.A. usually follows the advice of its advisory panels and is expected to rule on Eylea by Aug. 20.

A Schizophrenic, a Slain Worker, Troubling Questions Posted: 17 Jun 2011 02:54 PM PDT BOSTON — Last November, Yvette Chappell found herself increasingly anxious that her 27-year-old son, Deshawn James Chappell, was spiraling downward into deep psychosis. He was exhibiting intense paranoia and calling late at night to complain about deafening voices in his head. Multimedia Slide Show A Schizophrenic, a Slain Worker, Troubling Questions Enlarge This Image Ryan Papazian THE VICTIM    Stephanie Moulton was killed at a group home in January. More Photos » For over a year, Mr. Chappell, a schizophrenic with a violent criminal record, had seemed relatively stable in a state-financed group home in Charlestown. But after a fight with another resident, Mr. Chappell was shuttled from home to home, and his mother believed that he had fallen off his medication along the way. Ms. Chappell said she had tried to communicate this concern to his caretakers, but it was not until mid-January that she found somebody who listened. The woman introduced herself as Stephanie and said she would be Mr. Chappell’s counselor at his new group home in Revere. She confirmed that Mr. Chappell had stopped getting his antipsychotic injections but made his mother a promise: “She said: ‘Don’t worry. I’m going to get Deshawn back on track.’ “I thought everything was going to be O.K. because he had somebody who cared,” Ms. Chappell said, her voice breaking. Two days after that conversation, Stephanie Moulton, a petite, street-smart 25-year-old, was dead, and Mr. Chappell was accused of murdering her. They had been alone at the Revere home, where, her family said, Ms. Moulton generally worked a solo shift. Mr. Chappell beat her, stabbed her repeatedly and then dumped her partially nude body in a church parking lot, prosecutors said. The killing on Jan. 20 stunned the mental health care community in Massachusetts. The “shattering event,” as one former state mental health official called it, occurred days before Gov. Deval Patrick, a Democrat, released his proposed budget, which would slash mental health spending for the third year in a row. And it raised the timely but uncomfortable question of whether such continuous belt-tightening had played a role in Ms. Moulton’s death. Many people wondered aloud whether the system had failed both the suspect and the victim. How had Ms. Moulton ended up alone in a home with a psychotic man who had a history of violence and was off his medication? How had Mr. Chappell been allowed to deteriorate without setting off alarms? Should he have still been living in a group home, or did he need the tighter supervision of a hospital? “People are reeling right now,” Dr. Kenneth Duckworth, a former medical director for the State Department of Mental Health, said after the killing. “Will this case be the canary in the coal mine? Will it signal that we’ve gone too far in reducing client-staff ratios, in closing hospitals, in pushing independence for people who may still be too sick?” Massachusetts, which compared with other states faces a relatively modest budget shortfall of $1.5 billion, is hardly alone in cutting money for mental health care. State mental health departments, serving vulnerable populations with little political clout, almost always get disproportionately squeezed during tough times. During the current fiscal crisis, many states have sharply reduced both inpatient and community-based mental health care. Yet Massachusetts has been in the mental health vanguard since it opened the country’s first large public asylum in the early 19th century. It handled deinstitutionalization better than most states, forging a comparatively robust community system — group homes, outpatient clinics, day treatment centers — to replace shuttered hospitals. And it has a Democratic-led legislature, historically progressive on social welfare policy, as well as a governor who has acknowledged his own wife’s battle with crippling depression. The state mental health commissioner, Barbara A. Leadholm, said she believed her department was providing high-quality care despite the budget cuts it was obliged to accommodate. “We have to be responsive to what the administration and the legislature feel they can financially afford,” she said, adding that a “major recontracting initiative” had transformed the system positively while cuts were being made. 1 2 3 4 5 6 7 8 Next Page »

Memory Implant Gives Rats Sharper Recollection Posted: 19 Jun 2011 12:30 AM PDT Scientists have designed a brain implant that restored lost memory function and strengthened recall of new information in laboratory rats — a crucial first step in the development of so-called neuroprosthetic devices to repair deficits from dementia, stroke and other brain injuries in humans. RSS Feed Get Science News From The New York Times » Though still a long way from being tested in humans, the implant demonstrates for the first time that a cognitive function can be improved with a device that mimics the firing patterns of neurons. In recent years neuroscientists have developed implants that allow paralyzed people to move prosthetic limbs or a computer cursor, using their thoughts to activate the machines. In the new work, being published Friday, researchers at Wake Forest University and the University of Southern California used some of the same techniques to read neural activity. But they translated those signals internally, to improve brain function rather than to activate outside appendages. “It’s technically very impressive to pull something like this off, given our current level of technology,” said Daryl Kipke, a professor of bioengineering at the University of Michigan who was not involved in the experiment. “We are just scratching the surface when it comes to interacting with the brain, but this experiment shows what’s possible and the great potential of interacting with the brain in this way.” In a series of experiments, scientists at Wake Forest led by Sam A. Deadwyler trained rats to remember which of two identical levers to press to receive water; the animals first saw one of the two levers appear and then (after being distracted) had to remember to press the other lever to be rewarded. Repeated training on this task teaches rats the general rule, but in each trial the animal has to remember which lever appeared first, to inform the later choice. The rats were implanted with a tiny array of electrodes, which threaded from the top of the head down into two neighboring pieces of the hippocampus, a structure that is crucial for forming these new memories, in rats as in humans. The two slivers of tissue, called CA1 and CA3, communicate with each other as the brain learns and stores new information. The device transmits these exchanges to a computer. To test the effect of the implant, the researchers used a drug to shut down the activity of CA1. Without CA1 online, the rats could not remember which lever to push to get water. They remembered the rule — push the opposite lever of the one that first appeared — but not which they had seen first. The researchers, having recorded the appropriate signal from CA1, simply replayed it, like a melody on a player piano — and the animals remembered. The implant acted as if it were CA1, at least for this one task. “Turn the switch on, the animal has the memory; turn it off and they don’t: that’s exactly how it worked,” said Theodore W. Berger, a professor of engineering at U.S.C. and the lead author of the study, being published in The Journal of Neural Engineering. His co-authors were Robert E. Hampson and Anushka Goonawardena, along with Dr. Deadwyler, of Wake Forest, and Dong Song and Vasilis Z. Marmarelis of U.S.C. In rats that did not receive the drug, new memories faded by about 40 percent after a long distraction period. But if the researchers amplified the corresponding CA1 signals using the implant, the memories eroded only about 10 percent in that time. The authors said that with wireless technology and computer chips, the system could be easily fitted for human use. But there are a number of technical and theoretical obstacles. For one, the implant must first record a memory trace before playing it back or amplifying it; in patients with significant memory problems, those signals may be too weak. In addition, human memory is a rich, diverse neural process that involves many other brain areas, not just CA3 and CA1; implants in this area will be limited. Still, some restored memories — Where is the bathroom? Where are the pots and pans stored? — could make a big difference in the lives of someone with dementia. “If you’re caring for someone in the house, for example,” Dr. Berger said, “it might be enough to keep the person out of the nursing home.” This posting includes an audio/video/photo media file: Download Now

Aspen Journal: Meatless Mondays Catch On, Even With Carnivores Posted: 16 Jun 2011 11:48 PM PDT ASPEN, Colo. — Friction between the health-and-eco-minded hippies who came here for a Rocky Mountain High in the 1970s and the super-wealthy second-homers who followed from the intersection of Hollywood and Hedge Fund is an old story here at 8,000 feet. Enlarge This Image Matthew Staver for The New York Times Prepping vegetables at Syzygy, where meatless dishes vie with elk and bison on Mondays. But now there is a new potential skirmish line: Meatless Mondays. For whatever reason, chefs and restaurateurs say, the big outside money that fuels economic life here, often flying in by private jet from places like Malibu or the Main Line, tilts heavily toward the carnivorous. “It’s very interesting, but for some reason when people come to Aspen, they want to eat meat,” said Mimi Lenk, a vegetarian for more than a decade and the manager of Syzygy, a downtown restaurant where elk, bison and lamb are the big sellers. A new nationwide pro-veggie effort, however — aimed at persuading people to go meatless at least one day a week — has been embraced here more than in any other city in America. At least 20 institutions and restaurants, including Syzygy, are offering vegetarian choices on Mondays under a plan announced this month. “Nobody is saying, ‘go become a vegetarian,’ ” said Martin Oswald, a restaurateur who led the effort in signing up Meatless Monday participants among his food-industry friends. Mr. Oswald said he thought the dynamic that made Aspen such a prime place to expand Meatless Monday was not philosophy or health, but rather the cutthroat economics of the restaurant business — keeping up with the Joneses for fear of being left out. “The key was to get enough restaurants involved, then I could say: ‘Well, that guy does it and that guy over there and this guy does it over here. Do you want to do it, too?’ ” he said, sitting across the table at one of his restaurants, Pyramid Bistro. That approach, with its hard-to-say-no overtones, worked well. “So far, nobody has actually refused,” he said. In food, as in so many other things, Aspen was already nowhere near average. In a state with the lowest obesity rate in the nation, an alpine outdoor menu — biking, rafting, hiking, rock-climbing and, of course, skiing — make it a fitness capital. And local institutions already led the charge in healthier eating. Aspen Valley Hospital began boosting vegetarian choices several years ago in its food services. This month, the cardiac rehabilitation unit, where 20 percent to 30 percent of the patients are second-homers, began urging patients to patronize Meatless Monday restaurants in town. In the public school system, which embraced Meatless Monday two years ago, whole grain pancakes, dubbed “breakfast for lunch,” are a popular Monday rotation in the elementary and middle schools. And even during the rest of the week, school lunches, down to and including the ketchup, are made from scratch, overseen by a chef hired away from a downtown restaurant. “We roast our own beets,” said Tenille Folk, the director of food services for the Aspen School District’s middle and elementary schools. The ambition and scale of the wider restaurant effort for Meatless Monday, which started on June 6, has made Aspen “the nation’s first true Meatless Monday community,” said the Meatless Monday campaign, a national effort in association with the Johns Hopkins University School of Public Health. It can be a delicate process, and many chefs here stress that they are not trying to convert anyone. The customer is always right, they say, whatever he or she wants to eat. Indeed, many say that in the tougher economic times of the past few years, meat consumption has probably gone up, perhaps as comfort food. A strictly vegetarian restaurant in Aspen closed a few years ago. But that environment of competition and cost-control also created an opening, boosters of Meatless Monday say. Vegetables, in addition to having less impact on the planet than meat in energy and water usage, are much cheaper as an ingredient. And some local restaurateurs participating in Meatless Monday also said they had noticed an increasingly prominent gender gap, too, in recent years — with women tending more toward the vegetable side of the menu — which they can now overtly exploit on Mondays. “It’s all about getting somebody in the door,” said Tico Starr, the chef at Rustique Bistro. Still, some restaurants remain skittish. “It’s something you need to study,” said Alex Harvier, the manager at Cache Cache, a French restaurant where entrees on recent Monday night included osso buco and calf’s liver, with prices ranging from $30 to $58. He said the integrity of the menu and the dining experience had to be considered in adding any new dishes. “You can’t just tack something on,” he said. The local government has also taken a cautious approach. Meatless Monday backers, in approaching the City Council for a public resolution of support — similar to ones passed in San Francisco and Washington, among other cities — got nowhere. Some residents said the Council’s reluctance was rooted in the old Aspen — rowdy and antiauthoritarian, as epitomized by the gonzo author Hunter S. Thompson, who came to the area in the 1970s and died in 2005. Others said it was the newer Aspen at work — a fear of alienating second-homers by acting in a way that might come off as superior or elitist. “It’s not government’s role, or municipal government’s role, to be talking about personal choice,” said Torre, a City Council member, who uses only one name. Torre, a tennis instructor when not on city business, said he and one other person on the five-member Council already practice one-day-a-week vegetarianism. “But is it appropriate to pass a resolution on behalf of Aspen?” he said. “That’s a lengthier conversation.”

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Ann Patchett’s Amazon Wonder Drug Novel Posted: 18 Jun 2011 09:20 PM PDT Ann Patchett’s most characteristic subject is the hell turned unlikely paradise, a kind of reverse “Lord of the Flies” in which a group of strangers, shipwrecked into a disaster beyond their imagining, manage nonetheless to create a peaceable habitat where love and decency prevail. Patchett’s best-­selling 2001 novel, “Bel Canto,” opened with a botched terrorist operation in a South American country, after which an American opera diva, a Japanese industrialist, a French ambassador, various Russian businessmen and their Marxist-Leninist guerrilla captors turned their long captivity into a peculiar sort of idyll. “State of Wonder,” Patchett’s eighth book and sixth novel, is no less multinational in its cast of characters, or high-stakes in its plot. Enlarge This Image Melissa Ann Pinney Ann Patchett STATE OF WONDER By Ann Patchett 353 pp. Harper/HarperCollins Publishers. $26.99 Related Excerpt: ‘State of Wonder’ (June 2, 2011) Books of The Times: ‘State of Wonder’ by Ann Patchett (June 2, 2011) Marina Singh, a medical researcher at a pharmaceutical company in Minnesota, is sent deep into the Amazon basin to investigate the circumstances surrounding the death of Anders Eckman, her lab partner. Anders had originally been dispatched to Brazil to bring back news of Dr. Annick Swenson, a charismatic but despotic professor who, on the company’s bankroll, was developing a miracle fertility drug. Distressingly, Dr. Swenson had become uncommunicative about both the progress of her study and her whereabouts. “She found a village of people in the Amazon, a tribe,” Anders had told Marina, “where the women go on bearing children until the end of their lives. . . . Their eggs aren’t aging, do you get that? The rest of the body goes along its path to destruction while the reproductive system stays daisy fresh. This is the end of I.V.F. No more expense, no more shots that don’t end up working, no more donor eggs and surrogates. This is ovum in perpetuity, menstruation everlasting. . . . Pretend for a moment that you are a clinical pharmacologist working for a major drug development firm. Imagine someone offering you the equivalent of ‘Lost Horizon’ for American ovaries.” As the novel opens, a curt letter has arrived from Dr. Swenson, announcing that Anders has died of a sudden fever at her secret research station. He was buried on the spot; his few possessions are being kept for his widow, Karen. The pharmaceutical company’s position is unequivocal: Dr. Swenson must be tracked down immediately, her drug rushed into development and prepared for submission to the F.D.A. Karen’s position is equally unequivocal: she does not believe her husband is dead. Only Marina, it is decided, can perform the mission impossible — come home with evidence that will satisfy both parties. It’s a task straight out of classical mythology: bring back the head of the Gorgon, the Golden Fleece, or, in Marina’s case, the potion conferring everlasting fertility and the dead husband’s watch. As in the myths, she must be ready to outwit tyrants, behead monsters, charm cannibal tribes. Although doggedly dutiful, Marina is by various counts the last person who should be sent into this Heart of Darkness. A die-hard homebody, she is rooted to her native patch of Minnesota, a suburb of Minneapolis called Eden Prairie. Added to this Midwesterner’s almost genetic antipathy to the jungle are the psychological side effects of the antimalarial medicine she must take, which throw her back into the same harrowing nightmares that haunted her youth. (Successful dream sequences, it must be said, are even rarer in novels than good sex scenes; it is one of Patchett’s more unusual achievements that Marina’s nightmares are made to constitute a hypnotic, complex and weirdly funny counterpoint to the novel’s waking life.) Most disabling of all, however, is that Marina is a former student of Dr. Swenson’s. Indeed, unbeknownst to anyone else, Dr. Swenson played a significant role in a terrible accident that, 12 years earlier, compelled Marina to abandon her career in obstetrics and retreat to the safer shores of pharmacological research. “State of Wonder” is an engaging, consummately told tale. Patchett’s deadpan narrative style showcases a dry humor that enables her to wed, with fine effect, the world of “Avatar” or the “Odyssey” with that of corporate board meetings, R&D reports and peer review. This unlikely marriage of the magical and the prosaic, of poison-tipped arrows and Fourth of July barbecues, informs every line of her prose. She refers to the “mid­morning shift” of insects and describes how the Lakashi Indians — who when first encountered by Marina in the jungle are ululating, flame-brandishing bacchantes — appear in the morning as “a working-­class tribe, a sober group of people who went about the business of their day without fanfare or flame.” And if she succeeds in domesticating the exotic, Patchett’s even greater gift is in defamiliarizing the homey, giving suburban housewives and Minnesota flatlands the aching beauty and primal force of elements found in a creation myth. Although “State of Wonder” tackles the larger Hippocratic quandary posed by scientific exploration — how does one extract whatever raw materials one has come for without destroying the habitat and the indigenous people who harbor them? — Patchett’s interests are actually more private. At the book’s true heart is the confrontation between Marina and her former teacher, one in which mild-mannered decency must win out over brute will masquerading as scientific imperative. In the end, Marina, whose imagination has “been systematically chipped apart by years of studying inorganic chemistry and charting lipids,” who has “put her faith in data,” will have to navigate through a realm where reason is of no use to her and enter “a circle of hell” that requires “an entirely different set of skills that she did not possess.” Paradoxically, she will get what she wants only through an act of betrayal, by leaving behind what she loves most. “State of Wonder” is an immensely touching novel, although as with much of Patchett’s work, its emotional impact is somewhat muted by her indefatigable niceness. Her corporate executives are invariably meek as lambs. Even the unscrupulous Dr. Swenson, Patchett’s great shot at a megavillainess, turns out to be a woman blinded by love. In “Truth & Beauty,” her 2004 memoir of her friendship with Lucy Grealy, a writer disfigured by childhood cancer who died of a heroin overdose, Patchett describes her own feeling that “the world was a blister of grief with only the thinnest layer of tightly stretched skin holding everything in place.” Someday, perhaps, she will let that blister pop and unloose the rage and terror implicit in her stories. It isn’t a writer’s job to hold everything in place. Fernanda Eberstadt’s most recent novel, “Rat,” is now out in paperback.

The Pseudoscience of Hysteria Posted: 18 Jun 2011 09:20 PM PDT Readers who can’t identify Jean-Martin Charcot as the name of the French neurologist whose 19th-century experiments with hypnosis influenced Sigmund Freud’s theory of neurosis may yet recognize the work he conducted at the Saltpêtrière Hospital in Paris. Photographs and illustrations of Charcot’s patients, all women suffering hysteria, remain in currency today, 140 years after they were made, if more as curiosities than as clinically valuable documents. Once seen, these images — of, for example, a woman wearing little more than a tangle of bed sheets, her eyes rolled up into her head in either “ecstasy” or “delirium,” or fixed on the invisible object of her “amorous supplication” — are not easily forgotten, let alone dismissed. Poses classified as “passionate attitudes,” they have the disquieting aspect of pornography masquerading as intellectual inquiry. Enlarge This Image From Yale University, Harvey Cushing/John Hay Whitney Medical Library “Pornography masquerading as intellectual inquiry”: a photograph of a patient at Salpêtrière, titled “Onset of an Attack: Cry,” by Paul Regnard (circa 1878). MEDICAL MUSES Hysteria in Nineteenth-Century Paris By Asti Hustvedt Illustrated. 372 pp. W. W. Norton & Company. $26.95. Multimedia In order to view this feature, you must download the latest version of flash player here. Related Excerpt: ‘Medical Muses’ (Google Books) Charcot, as portrayed in Asti Hust­vedt’s consistently enthralling “Medical Muses,” focused intently — myopically, one could argue — on using hypnosis to induce hysteria and make “his hysterics, with their bizarre fits and spasms, into ideal medical specimens.” But the provocative behavior of those “specimens” transformed Saltpêtrière into something closer to a carnival than a teaching hospital. As much showman as physician, Charcot gave weekly two-hour lectures to a packed amphitheater, including demonstrations designed to captivate an audience accustomed to staged séances and exhibitions of mesmerism or telepathy. One of Charcot’s students described the dramatic potential of exhibiting hypnotized women: “We can cut them, prick them and burn them, and they feel nothing.” Plus ça change, Charcot might say, were he to cast his eye, described in Freud’s obituary of his teacher as artistic rather than intellectual, over current illnesses that, like hysteria, exist, Hustvedt says, “on the problematic border between psychosomatic and somatic disorders”: anorexia and bulimia nervosa, self-­mutilation, idiopathic chronic fatigue, dissociative identity disorder. Charcot died in 1893 without having found the brain lesion he believed caused his patients’ confounding symptoms. Two years later Freud declared hysteria to be the result of “repressed memories and ideas,” and in 1925 faulted the neurologist for failing to examine the psychology of what he deemed manifestations of repressed emotion. By 1977, a University of Rochester scientist, George L. Engel, had posited today’s “biopsychosocial” paradigm, a ready example of the gun analogy frequently applied to anorexia nervosa, in which, as is often said, “genes load the gun and environment pulls the trigger.” As Elaine Showalter concluded in “Hystories,” her controversial study of 20th-century manifestations of hysteria, the illness, “relabeled for a new era,” is more contagious than ever, a result of mass and increasingly instant media. But no matter how hysteria might mutate, virus-like, from one age to the next, in the public imagination it remains what Hustvedt says it partly always was: “an illness of being a woman in an era that strictly limited female roles.” So how did the 19th-century hysteric announce her condition? Evidence of primping — “the care that she takes in her toilette; the styling of her hair, the ribbons she likes to adorn herself with” — was enough for Charcot’s disciple, Désiré-­Magloire Bourneville, to predict what diagnostic hair-pulling, pinching and pricking confirmed. The attacks that followed — which might include fainting, contortions, paralysis, vomiting, screaming, hallucinations and seizures — proved the doctors’ findings. “The hysteric always seems to be outside the rule,” Bourneville explained. Often misperceived as willful bids for attention, yesterday’s hysteria and neurasthenia, today’s eating disorders, and whatever problematic behaviors emerge in the future command attention because they defy reduction by medical minds. They resist treatment. Sometimes, in their sufferers’ refusal to be fixed and studied like insects pinned to a board, they inspire sadism. For his part, Charcot, the author notes, “confronted the chaos of the hysterical female body” and discovered “hysterogenic zones” privileging the ovaries and breasts that, when stimulated, either provoked or halted hysterical symptoms. Certainly his “ovary compressor,” a device whose illustration begs for inclusion in a catalog of arcane implements of torture, got his patients’ attention like nothing else could, allowing Saltpêtrière’s doctors to administer what “closely resembled a sexual assault” with clinical detachment, dirtying no one’s hands. If such therapies were not purposefully misogynistic, they were imposed, Hust­vedt shows, by “healthy, educated and bourgeois” male doctors on “diseased, uneducated and lower-class” women who had been committed, often for life, to a warehouse for not only the mad but also the homeless, the pregnant and unwed, and others who refused to abide by the conventions of a stifling society — in other words, the same disenfranchised women who, centuries earlier, might have been tried and executed as witches. The lure of voyeurism made hysterical patients into celebrities, muses for their doctors and for a public that regarded the “condition of being a woman” as “one that can at any moment veer out of control and is therefore in need of medical regulation.” But if Hustvedt’s meticulous analysis of Charcot’s methodology provides evidence of his exploitation of what he called his vast “reservoir of material,” it also demonstrates that patients collaborated in what was an iatrogenic condition, “forged between patient and doctor.” The “career” of Marie Wittmann, known throughout Europe as the “Queen of Hysterics” began inauspiciously. “Remarkable for her spirit of duplicity, lying and simulation” (as all women suffering hysteria were said to be), Wittmann, called Blanche by Charcot, arrived at Saltpêtrière because she had nowhere else to go after a childhood marked by tantrums so violent they prevented her going to school, the predation of an insane father, the early deaths of her mother and five of her eight siblings, and apprenticeship to a lecherous furrier whose advances provoked convulsions and loss of consciousness. Eighteen years old, exhausted by squalor and strife, she entered the hospital where she would spend the rest of her days. Initially too “unpredictable and unruly” to be of clinical value, Wittmann was transferred from the hysterics’ quarters to a cell in the ward for the mad. Allowed to return to Charcot’s care after seven and a half months of what had been intended as a punishment for breaking windows and tearing up linens, she worked to secure her place in her increasingly famous physician’s magnum opus, the ward for hysteria offering freedom and comforts denied inmates of other wards. There, the ubiquity of “photographs, drawings, wax casts, as well as staged re-­enactments” encouraged any enterprising patient to determine and reproduce the ideal hysterical profile. Once she evolved into the “most hypnotizable” (and therefore predictable) of hysterics, she became Charcot’s star performer, her symptoms “molded, altered and tweaked to fit his elaborate nosology.” She even requested the “ovary compressor.” Is it progress to replace antiquity’s notion of the wandering womb with the conceit that there wasn’t any hysteria — any acting out — that couldn’t be effectively treated by striking out at the very organs in which femaleness resides? Though “equating hysterical symptoms with hypnotically induced symptoms” allowed Charcot to lay the groundwork for psychoanalysis, he necessarily failed to cure what “Medical Muses” reveals as women’s defiance of patriarchal strictures. Misogyny and hysteria: another circle, this one vicious, to add to the notorious chicken-and-egg. Kathryn Harrison’s new novel, “Enchantments,” will be published next year.

The New Old Age: A Missed Opportunity to Recruit Specialists in Elder Care Posted: 20 Jun 2011 09:47 AM PDT

The New Old Age: Ask an Elder Law Attorney: Late-Life Marriage Issues Posted: 16 Jun 2011 11:41 AM PDT

F.D.A. Confronts Challenge of Monitoring Imports Posted: 20 Jun 2011 11:11 AM PDT WASHINGTON — The Food and Drug Administration commissioner, Dr. Margaret Hamburg, has repeatedly expressed alarm about the waves of imported food and drugs overwhelming her organization’s ability to monitor them, but through the first two years of her leadership she had not provided a strategy to deal comprehensively with this problem — until now. On Monday, the F.D.A. released a rare special report titled “Pathway to Global Product Safety and Quality” that is likely to win plaudits not so much for the four “building blocks” it outlines for dealing with imports but for the frank way it acknowledges the problem. “This report in large part is meant to frame the issue so that all of our colleagues inside the F.D.A. and external to the F.D.A. really understand how much the world has changed and the necessity of how much we do business in the F.D.A. has to be dramatically transformed,” Dr. Hamburg said in an interview. “This is something that I’ve been stressing as a priority from Day 1.” A decade ago, the F.D.A. was responsible for policing 6 million separate shipments coming through 300 different ports. This year, that number is expected to grow to 24 million shipments, the report noted. Nearly two-thirds of all fruits and vegetables and three-quarters of all seafood consumed in the United States now come from outside the country. The situation with drugs and medical devices is even more alarming. More than 80 percent of the active ingredients for drugs sold in the United States are manufactured abroad — mostly in manufacturing plants in China and India that are rarely inspected by the F.D.A. Half of all medical devices sold in the United States are made abroad. Many kinds of antibiotics, steroids, cancer medicines and even aspirin are no longer produced in the United States, or in many cases anywhere in the Western world. Government investigators estimated in 2008 that the Food and Drug Administration would need 13 years to check every foreign drug manufacturing plant, 27 years to check every foreign medical device plant and 1,900 years to check every foreign food plant at its rate of inspections at the time. And with imports growing faster than the agency’s inspection force, those numbers have only grown. Many popular over-the-counter medicines and vitamins are made almost entirely in Chinese plants that have never been inspected by the F.D.A. Domestic suppliers often boast that they test their imported ingredients rigorously, but such sampling is akin to testing a bucket of soil from a mountain and then declaring the entire mountain free of pollutants. And once these products reach American shores, almost nothing is done. The F.D.A. has a few hundred inspectors — not even enough for every port. The most they know about the vast majority of imports is a brief description on a computer screen. They crack open a tiny fraction of all shipments and send to the agency’s laboratories an even tinier fraction. Less than one pound in a million of imported seafood even gets a visual inspection. Monday’s report acknowledges that “the safety of America’s food and medical products remains under serious threat,” and it lists a few recent and deadly scares: contaminated heparin from China, counterfeit glucose monitoring strips and tainted pet food from China. The F.D.A. won new powers to police foreign foods in legislation signed by President Obama in January, but with those new powers came new responsibilities: The law directed the agency to inspect at least 600 foreign food facilities within the next year and then increase that number every year afterward. But instead of raising the agency’s budget to perform those inspections, House Republicans voted last week to cut it. “While the goal may be attainable in the first year, it would be impossible for F.D.A. to complete 19,200 foreign food inspections in year six without a substantial increase in resources or a complete overhaul in the way it operates,” the report notes. Many in the food industry, angered by contamination scares that have cost hundreds of millions, have volunteered to pay fees directly to the F.D.A. to underwrite more inspections. Consumer groups have cheered this suggestion. But Republicans in the Senate have so far refused to consider such fees, calling them an unacceptable tax. Polls have shown overwhelming and bipartisan support among voters for strengthened federal oversight of the food system. So in the absence of the people and money needed to perform its functions adequately today, Dr. Hamburg has proposed creating integrated “global coalitions of regulators dedicated to building and strengthening the product safety net around the world,” the report states. To support this integrated network, “F.D.A. intends to develop a global data information system” so regulators can talk to each other. The F.D.A. already has some limited cooperation agreements with regulators in Europe and elsewhere, and it has recently stationed employees in China, India and Central America. Closer cooperation between the F.D.A. and European authorities, for instance, could spare manufacturers and governments the expense of repeated inspections of the same plants. And better sharing could allow the findings of an alarming audit by one country to alert others to problems. But Chinese authorities have in some instances refused to cooperate with F.D.A. investigations of counterfeit ingredients, and some other countries have corrupt or largely non-existent regulatory authorities with which to cooperate. Carl R. Nielsen, who retired as the director of the Food and Drug Administration’s import operations in 2005, said the plan sounds reasonable as far as it goes. But before the F.D.A. can consider communicating regularly with Brussels or Beijing, it needs to start talking with its offices in Texas and California, he said. “Until you repair the in-house computer system, how are you going to create an international one?” Mr. Nielsen asked. Indeed, a computerized alert system for imports that was started at the F.D.A. in 2001 is still not complete. But Dr. Hamburg said in the interview that despite possible budget cuts and challenges domestically, the agency has no choice but to become more globally engaged. And just stepping up inspections at the border will not be enough, she said. “It’s all very nice for people to feel that we have one of the safest food supplies in the world,” she said, repeating a phrase House Republicans used to justify cutting the agency’s budget. “But we really need to recognize that our food is increasingly coming from this complex supply chain and coming from parts of the world where there are not as robust standards and practice. And we cannot be complacent.” This posting includes an audio/video/photo media file: Download Now

Children on Medicaid Shown to Wait Longer for Care Posted: 16 Jun 2011 08:28 AM PDT Children with Medicaid are far more likely than those with private insurance to be turned away by medical specialists or be made to wait more than a month for an appointment, even for serious medical problems, a new study finds. Well Share your thoughts on this column at the Well blog. Go to Well » Related As Number of Medicaid Patients Goes Up, Their Benefits Are About to Drop (June 16, 2011) Times Topic: Medicaid Lower payments by Medicaid, delays in paying and red tape are largely to blame, researchers say. The study, with findings that match anecdotal reports from other parts of the country, is one of only a few efforts to measure access to health care among people with Medicaid. Nationwide, those patients are caught between states’ threats to cut Medicaid payments and the Obama administration’s plans to use the program to cover more and more people as part of its health care law. “There’s never been a study this comprehensive or this rigorous that actually measured access to specialty care, let alone children’s access,” said Dr. Karin V. Rhodes, an author of the study and director of emergency care policy research in the department of emergency medicine at the University of Pennsylvania. The study used a “secret shopper” technique in which researchers posed as the parent of a sick or injured child and called 273 specialty practices in Cook County, Ill., to schedule appointments. The callers, working from January to May 2010, described problems that were urgent but not emergencies, like diabetes, seizures, uncontrolled asthma, a broken bone or severe depression. If they were asked, they said that primary care doctors or emergency departments had referred them. Sixty-six percent of those who mentioned Medicaid-CHIP (Children’s Health Insurance Program) were denied appointments, compared with 11 percent who said they had private insurance, according to an article being published Thursday in The New England Journal of Medicine. In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was an average of 22 days longer. “It’s very disturbing,” Dr. Rhodes said. “As a mother, if I had a kid who was having seizures or newly diagnosed juvenile diabetes, I would want to get them in right away.” With many states planning cuts in Medicaid, Dr. Rhodes said, public insurance programs were already being strained to the breaking point. “If we keep whittling away at them, it will hurt children and adults alike,” she said. Other doctors said the issue was so pronounced that Dr. Rhodes’s findings were hardly surprising. “This is a nationwide problem,” said Dr. Stephen Stabile, associate chief medical officer of the Ambulatory and Community Health Network at Cook County Health and Hospitals System. Another physician not connected with the study, Dr. Judy Neafsey, medical director of the specialty care center at Stroger Hospital, part of Cook County’s public hospital system, said: “It’s interesting to think you even need a study to prove that. It’s pretty much common knowledge.” Mike Claffey, a spokesman for the Illinois Department of Healthcare and Family Services, said by e-mail that the study “provides data that highlights an issue that has been and continues to be an area of focus for” his agency and Medicaid programs in all states. In Illinois, according to Dr. Rhodes’s article, Medicaid will pay $99.86 for an office visit for a problem of “moderate severity,” compared with $160 from a private insurer. Many doctors said they could not keep their practices going if they accepted too many Medicaid patients. And specialists affiliated with academic medical centers said they were willing to treat Medicaid patients but were under pressure from the medical centers to bring in more money by seeing more people with private insurance, Dr. Rhodes said. This month, Dr. Rhodes and her colleagues had a similar study published in the journal Pediatrics, finding that dentists were far less likely to accept children with public insurance than those with private coverage, even for an urgent problem like a broken front tooth. Another study of hers uncovered patients’ difficulties in obtaining psychiatric care. Dr. Rhodes said she became interested in access to care more than a decade ago, when, as an emergency room doctor, she kept seeing patients who did not belong in the emergency room but could not find treatment anyplace else. Her current study of specialty care grew out of a lawsuit by health advocates against the state of Illinois, Memisovski v. Maram, on behalf of 600,000 children covered by Medicaid. In that case, a judge found in 2004 that children on Medicaid did not have the same access to preventive health care as did those with private insurance. The case led to higher payment rates and other changes in Illinois, and also a requirement that the state pay for a study of low-income children’s access to medical specialists. Dr. Rhodes was asked to conduct the study. “I was very disappointed to find this level of disparities,” she said. The researchers focused on eight specialties: dermatology; otolaryngology (ear, nose and throat); endocrinology (for diabetes); neurology; allergy; pulmonology; psychiatry and orthopedics. “The disparity held across every specialty that was tested,” Dr. Rhodes said. “This is systemic.” Dr. Stabile said that poor people in Chicago could be treated at county hospitals, but that those in the suburbs had a much harder time finding providers who accepted Medicaid. “And that’s where poor people are moving to around Chicago,” Dr. Stabile said, adding that the county system was trying to move more services to the suburbs. Lisa Hannum, who lives in Schaumburg, about 30 miles from Chicago but still in Cook County, has three children who qualify for Medicaid because they were wards of the state before she adopted them. Over the years, she said, she has encountered multiple doctors who would not accept them as patients because they were on Medicaid. At times she just gave up and paid for their treatment herself. Just recently, she said, an urgent-care clinic declined to treat her daughter for a dog bite because the clinic did not accept Medicaid. For her son, an eye clinic did accept Medicaid, but it took nearly five months to provide the new eyeglasses he needed. “People say: ‘Sure, I take insurance. Oh, I don’t take Medicaid,’ ” Ms. Hannum said. “I guess I’m lucky that my kids are almost never sick.”

In Tiny Worm, Unlocking Secrets of the Brain Posted: 20 Jun 2011 12:50 PM PDT In an eighth-floor laboratory overlooking the East River, Cornelia I. Bargmann watches two colleagues manipulate a microscopic roundworm. They have trapped it in a tiny groove on a clear plastic chip, with just its nose sticking into a channel. Pheromones — signaling chemicals produced by other worms — are being pumped through the channel, and the researchers have genetically engineered two neurons in the worm’s head to glow bright green if a neuron responds. Multimedia Graphic Only Connect RSS Feed Get Science News From The New York Times » Enlarge This Image Fred R. Conrad/The New York Times Cornelia I. Bargmann is decoding how the brain of the roundworm functions. These ingenious techniques for exploring a tiny animal’s behavior are the fruit of many years’ work by Dr. Bargmann’s and other labs. Despite the roundworm’s lowliness on the scale of intellectual achievement, the study of its nervous system offers one of the most promising approaches for understanding the human brain, since it uses much the same working parts but is around a million times less complex. Caenorhabditis elegans, as the roundworm is properly known, is a tiny, transparent animal just a millimeter long. In nature, it feeds on the bacteria that thrive in rotting plants and animals. It is a favorite laboratory organism for several reasons, including the comparative simplicity of its brain, which has just 302 neurons and 8,000 synapses, or neuron-to-neuron connections. These connections are pretty much the same from one individual to another, meaning that in all worms the brain is wired up in essentially the same way. Such a system should be considerably easier to understand than the human brain, a structure with close to 100 million neurons, 100,000 miles of biological wiring and 100 trillion synapses. The biologist Sydney Brenner chose the roundworm as an experimental animal in 1974 with this goal in mind. He figured that once someone provided him with the wiring diagram of how 302 neurons were connected, he could then compute the worm’s behavior. The task of reconstructing the worm’s wiring system fell on John G. White, now at the University of Wisconsin. After more than a decade’s labor, which required examining 20,000 electron microscope cross sections of the worm’s anatomy, Dr. White worked out exactly how the 302 neurons were interconnected. But the wiring diagram of even the worm’s brain proved too complex for Dr. Brenner’s computational approach to work. Dr. Bargmann was one of the first biologists to take Dr. White’s wiring diagram and see if it could be understood in other ways. Cori Bargmann grew up in Athens, Ga., a small college town in the Deep South where her father taught statistics at the University of Georgia. Both her parents had been translators and met while Rolf Bargmann was working at the Nuremberg trials. Her mother, Ilse, would read to her in German the works of the Austrian animal behaviorists Konrad Lorenz and Karl von Frisch, planting the seeds of an interest in neuroscience. “I went into science because I loved the labs,” Dr. Bargmann says. She liked the machines and instruments, the fun of building things with one’s own hands, of learning what no one else knew. An outstanding student, she chose for her Ph.D. degree to work in the M.I.T. lab of Robert A. Weinberg, a leading cancer biologist. The first mutated genes capable of causing cancer were being isolated. “It was an incredibly exciting time,” she says. Her task was to clone a rat gene called neu. When mutated, the gene causes a tumor, but one that the rat’s immune system can attack and destroy. Several years later, the human version of neu, called HER-2, was found to be amplified in breast cancer, and its receptor protein product is the target of the artificial antibody known as Herceptin, a leading breast cancer drug. For her postdoctoral work, Dr. Bargmann decided to work on animal behavior. The mouse is a standard organism for such studies, but she did not like hurting furry animals. “In Weinberg’s lab I would start to cry every time I had to do anything with a mouse,” she says. A nonfurry alternative was the fruit fly. She interviewed with a leading laboratory in California, but her husband at the time did not wish to move there. That left the roundworm. There are now several hundred worm labs around the world, of which perhaps 30 or so, like Dr. Bargmann’s, focus on the worm’s nervous system. In 1987, “worms weren’t entirely respectable,” Dr. Bargmann says. But right there at M.I.T., H. Robert Horvitz had established one of the first serious worm labs in the United States. She joined his lab and read everything written on the worm, including all the back copies of the little field’s informal journal, The Worm Breeder’s Gazette. She noticed that a particular behavior of C. elegans had been described but not well explored: it can taste waterborne chemicals and move toward those it finds attractive. Dr. White’s wiring diagram had been published the year before, in 1986. With this in hand, she told Dr. Horvitz she planned to identify which of the worm’s 302 neurons controlled its chemical-tracking behavior. He thought the project was too ambitious, but said she could spend six months on the attempt. Each neuron in the worm’s brain is known, and is assigned a three letter name. Specific neurons can be identified under a microscope and zapped with a laser beam, allowing the neuron’s role to be deduced from whatever function the worm may seem to have lost. Dr. Bargmann slogged her way through the task of killing each neuron one by one. Telling one neuron from another under the microscope is not easy. “It’s like knowing each grape in a bunch is different, but not quite being able to see it,” Dr. Horvitz said. “The first thing she had to do was learn the worm’s neuroanatomy, and she did so in a way only one other person has ever done.” (He was referring to John E. Sulston, who traced the lineage from the egg of all 959 cells in the adult worm’s body). 1 2 3 Next Page » This posting includes an audio/video/photo media file: Download Now

Recipes for Health: Asparagus With Anchovies and Capers Posted: 20 Jun 2011 12:46 PM PDT This is a common springtime dish in Italy and in a neighboring region of Croatia, Istria, where it’s made with wild asparagus that is thinner than a pencil. If you can find thin spears at your farmers’ market, use them. The recipe is inspired by a dish in Carol Field’s "Italy in Small Bites." Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Asparagus With an Italian Twist (June 20, 2011) Recipes for Health: Lasagna With Asparagus and Chives (June 22, 2011) Recipes for Health: Asparagus With Gremolata, Lemon and Olive Oil (June 24, 2011) Recipes for Health: Asparagus Rolled in Herb Crêpes (June 23, 2011) 1 to 2 garlic cloves (to taste), peeled, halved, green shoot removed 3 anchovy fillets, rinsed 2 teaspoons capers, rinsed 2 tablespoons extra virgin olive oil 1/4 cup finely chopped onion 1 to 2 teaspoons fresh lemon juice 1 teaspoon chopped fresh mint Salt and freshly ground pepper 1 pound asparagus, preferably thin stalks, trimmed 1. Place the garlic, anchovy fillets and capers in a mortar and pestle, and mash to a paste. 2. Heat 1 tablespoon of the olive oil over medium heat in a small skillet. Add the onion and a pinch of salt. Cook, stirring often, until tender (do not brown), three to five minutes. Stir in the garlic and anchovy paste, and cook, stirring, for another minute. Remove from the heat, and stir in the lemon juice, mint, salt and pepper. Set aside for 15 to 30 minutes or longer. The flavors will mellow. 3. Steam the asparagus for three to five minutes until just tender. Remove to a platter or a wide bowl, and add the remaining olive oil and the onion mixture. Toss gently and serve. Yield: Serves four. Advance preparation: You can make this through Step 2 several hours before cooking the asparagus. Nutritional information per serving (four servings): 96 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 3 milligrams cholesterol; 6 grams carbohydrates; 3 grams dietary fiber; 150 milligrams sodium (does not include salt to taste); 4 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: Mediterranean Artichoke and Fresh Fava Stew Posted: 17 Jun 2011 12:30 AM PDT Favas, artichokes, spring onions and green garlic are all fleetingly in season at the same time. Here’s a way to use them all together. This dish is based on a Greek olive oil recipe, meaning that the vegetables are traditionally stewed in two or three times as much oil as I use here. I substitute water for some of the oil. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Farm-Fresh Favas (June 13, 2011) Recipes for Health: Fava and Buttermilk Soup (June 14, 2011) Recipes for Health: Spaghetti With Fava Beans, Bread Crumbs and Marjoram (June 15, 2011) Recipes for Health: Fresh Fava Bean and Shrimp Risotto (June 16, 2011) 12 baby artichokes, trimmed 2 lemons 1/4 cup extra virgin olive oil 1 bunch of spring onions, chopped 3 large garlic cloves, minced, or 1 bulb of green garlic, skinned and minced 3 pounds fresh fava beans, shelled and skinned 1/4 cup chopped fresh fennel or dill Salt and freshly ground pepper to taste 1. Trim the artichokes, cut in half and immediately submerge in a bowl of water acidulated with the juice of 1/2 lemon. 2. Heat 2 tablespoons of the oil over medium heat in a large, heavy casserole or Dutch oven. Add the onion, and cook, stirring, until tender, about three minutes. Add the garlic, and cook, stirring, for a minute until fragrant. Drain the artichokes, and add the skinned fava beans, the fennel or dill, and the juice of 1 lemon (3 tablespoons) and the remaining olive oil. Add enough water to just cover everything, and salt to taste. Bring to a simmer. Cover and simmer 20 to 30 minutes until the vegetables are tender and the broth fragrant. 3. Turn the heat to high, and reduce the liquid in the pan by about a third. Stir in a generous amount of freshly ground pepper. Taste and adjust salt. Serve warm. Yield: Serves six. Advance preparation: You can prepare this a day or two ahead of serving, and reheat on top of the stove. Leftovers will be good for four to five days. The color of the favas will fade, but the flavors won’t. Nutritional information per serving: 316 calories; 2 grams saturated fat; 2 grams polyunsaturated fat; 7 grams monounsaturated fats; 0 milligrams cholesterol; 43 grams carbohydrates; 18 grams dietary fiber; 239 grams sodium (does not include salt to taste); 17 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

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