Health - Internet Use Affects Memory, Study Finds

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• Internet Use Affects Memory, Study Finds
• Food Makers Push Back on Ads for Children
• Genetic Code of E. Coli Is Hijacked by Biologists
• Well: When Hospital Overcrowding Becomes Personal
• Two Studies Show Pills Can Prevent H.I.V. Infection
• Judge Blocks City’s Crisis Pregnancy Center Law
• In Effort to Cut U.S. Deficit, New York Teaching Hospitals May Lose Aid
• Agreement on Debt Talks: Health Groups Dislike Proposals
• Drive to Stem Shingles Meets Few Expectations
• Obama Administration Rolls Out Standards for Health Insurance Marketplaces
• Pills Morph as Patients Try to Cope
• Recipes for Health: Morning Oatmeal With Cherries and Pistachios
• Well: When Fatty Feasts Are Driven by Automatic Pilot
• 18 and Under: Guarding Privacy May Not Always Protect Patients
• Analysis: A Player Defined by Greatness and Illness
• New Study Implicates Environmental Factors in Autism
• Well: Summer Cherry Season, Short and Sweet
• Well: Gym Class: Ballet Workout
• Well: Think Like a Doctor: The Gardener's Illness Solved
• Well: Small Health Woes Increase Dementia Risk
• Well: Think Like a Doctor: The Gardener’s Illness
• Personal Health: Water Holds Pleasures, and Menaces That Lurk
• Well: The Claim: A Tennis Ball to Cut Snoring
• The New Old Age: White Flight From the Nursing Home
• The New Old Age: Two Words to Live By
• The New Old Age: The Fight Against Shingles Falters
• Doctors Inc.: New for Aspiring Doctors, the People Skills Test
• As Same-Sex Marriage Becomes Legal, Some Choices May Be Lost
• First Study of Its Kind Shows Benefits of Providing Medical Insurance to Poor
• Obama Summons G.O.P. and Democratic Leaders for Deficit Reduction Talks
• Vital Signs: Nostrums: Cutting Salt Has Little Effect on Heart Risk
• Vital Signs: Risks: Perhaps July’s Reputation Is Justified
• Vital Signs: Childbirth: Wait to Restart the Pill, C.D.C. Says
• How Bright Promise in Cancer Testing Fell Apart
• Recipes for Health: Cherry Cobbler With Almond-Buttermilk Topping
• Recipes for Health: Cold Cherry Soup
• Recipes for Health: Cherry Almond Smoothie
• Recipes for Health: A Short Season for Cherries

Internet Use Affects Memory, Study Finds Posted: 14 Jul 2011 08:20 PM PDT The widespread use of search engines and online databases has affected the way people remember information, researchers are reporting. The scientists, led by  Betsy Sparrow, an assistant professor of psychology at Columbia, wondered whether  people were more likely to remember information that could be easily retrieved from a computer, just as students are more likely to recall facts they believe will be on a test. Dr. Sparrow and her collaborators, Daniel M. Wegner of Harvard and Jenny Liu of the University of Wisconsin, Madison, staged four different memory experiments. In one, participants typed 40 bits of trivia — for example, “an ostrich’s eye is bigger than its brain” — into a computer. Half of the subjects believed the information would be saved in the computer; the other half believed the items they typed would be erased. The subjects were significantly more likely to remember information if they thought they would not be able to find it later. “Participants did not make the effort to remember when they thought they could later look up the trivia statement they had read,” the authors write. A second experiment was aimed at determining whether computer accessibility affects precisely what we remember. “If asked the question whether there are any countries with only one color in their flag, for example,” the researchers wrote, “do we think about flags — or immediately think to go online to find out?” In this case, participants were asked to remember both the trivia statement itself and which of five computer folders it was saved in. The researchers were surprised to find that people seemed better able to recall the folder. “That kind of blew my mind,” Dr. Sparrow said in an interview. The experiment explores an aspect of what is known as transactive memory — the notion that we rely on our family, friends and co-workers as well as reference material to store information for us. “I love watching baseball,” Dr. Sparrow said. “But I know my husband knows baseball facts, so when I want to know something I ask him, and I don’t bother to remember it.” The Internet’s effects on memory are still largely unexplored, Dr. Sparrow said, adding that her experiments had led her to conclude that the Internet has become our primary external storage system. “Human memory,” she said, “is adapting to new communications technology.”

Food Makers Push Back on Ads for Children Posted: 14 Jul 2011 09:23 PM PDT Are Goldfish crackers junk food? Enlarge This Image Tony Cenicola/The New York Times Goldfish crackers are a point of contention between regulators and the food industry as they address issues of nutrition and marketing. Enlarge This Image Jin Lee/Bloomberg News Jon Leibowitz, chairman of the Federal Trade Commission, said the food industry's advertising initiative was a "significant advance." Under proposed new nutritional guidelines, the federal government says yes, and it does not want food like the crackers advertised to children because they contain too much saturated fat and salt and are made from white flour. But food makers say the fish-shaped treats, made by Campbell Soup’s Pepperidge Farm division, belong on a list of healthful foods that are fine to market to children. The seeming tempest in a fishbowl is typical of a growing tug of war as government and public health advocates tighten pressure on the food industry to fight childhood obesity by making and marketing healthier products. In the latest example, a group of food manufacturers and restaurant chains announced Thursday that they would revise a set of voluntary standards for cereals, snacks and other foods that they market to children so as to reduce sugars, fats and other ingredients that are unhealthful in large amounts. But the new guidelines are modest and would not require food makers to change much — two-thirds of the products the companies now advertise already meet them. And the levels fall far short of nutritional standards proposed by regulators. Another industry initiative, announced a day earlier, is aimed at improving the number of healthful offerings on children’s menus at restaurants. Again, the plan set such easy targets that virtually all cooperating restaurant chains were already meeting the standard. Children’s health advocates say the industry’s moves are meant to head off government action. “They’re willing to move, but not very far,” said Margo Wootan, director of nutrition policy for the Center for Science in the Public Interest, an advocacy group. “This is a typical industry tactic of a pre-emptive move. Rather than have government come up with the standards for food marketing, they want to develop them themselves.” But the industry actions drew at least qualified praise from regulators, who said they were encouraged that companies were willing to take steps in the right direction. “The industry’s uniform standards are a significant advance and exactly the type of initiative the commission had in mind when we started pushing for self-regulation more than five years ago,” Jon Leibowitz, chairman of the Federal Trade Commission, said in a statement about the advertising initiative. The marketing standards announced on Thursday are part of an industry program called the Children’s Food and Beverage Advertising Initiative, which has participants like Campbell, Burger King, McDonald’s, Kraft Foods, PepsiCo and Kellogg. “We tried to find a way that pushed the envelope, that made the standards stricter while also finding something that was realistic,” said Elaine D. Kolish, director of the industry initiative, which is operated by the Council of Better Business Bureaus. The new standards are set to go into effect in January 2014, giving companies time to reformulate products to meet the criteria. The standards would apply equally to all companies that participate. That would be an improvement over the current initiative, which was often criticized because it allowed each company to create its own nutritional standards for deciding which foods were healthful enough to advertise to children. Sugary cereals like Kellogg’s Apple Jacks made the cut, as did salty foods like ConAgra’s Chef Boyardee canned pastas. In response to such inconsistencies, Congress asked the Federal Trade Commission to coordinate with several other agencies to recommend an objective set of criteria that could be held up as a voluntary standard for industry. A preliminary version of the commission’s proposal was released in April, and it was more strict than the industry initiative. The commission proposed a single standard for all companies to follow, with rigid limits on less healthful ingredients and requirements that food advertised to children be heavy on nutritious ingredients like fresh fruit, whole grains and low-fat dairy products. The agency did not name specific products but said that a large percentage of the foods now advertised to children would not qualify under the F.T.C. proposal. Thursday was the final day for the industry and the public to submit comments on the federal proposal. The commission said that it would consider the comments while preparing a final version of its recommendations that it expected to submit to Congress by the end of the year. Regulators say they hope that industry embraces the guidelines voluntarily and there are no plans to make them enforceable through legislation or formal regulation. Under the restaurant menu initiative announced Wednesday, participating chains agreed to include at least one children’s meal that had no more than 600 calories and met other nutritional requirements. Health advocates said the move would have little effect because other unhealthful offerings would remain on the menu. The food industry characterized both initiatives as significant progress. When announcing the advertising initiative on Thursday, Ms. Kolish said that a third of the foods now advertised to children by the participating companies would not meet the new guidelines. She declined to give examples because she said she did not want to make any of the products look bad. It appeared that many products would need to be tweaked just slightly to get in under the new bar. For example, the new industry standard for sugar in cereal would drop to 10 grams per serving, from 12 grams under the old standard. The proposed government standard would be 8 grams per serving. Many cereals contain 10 to 12 grams of sugar. And the Goldfish crackers would not have to change at all. Juli Mandel Sloves, a spokeswoman for Campbell, said the company had already improved its Goldfish recipe over the years to make the product healthier. She said it took steps like eliminating trans fats, reducing the salt content in some versions, eliminating artificial colorings and introducing a whole-wheat version (although most are still made with white flour). “We are looking at marketing products that are wholesome and that we know can meet the criteria that have been established” by the industry marketing initiative, Ms. Sloves said. But she said it did not make sense to go so far in reformulating a product that children would not eat it. “If people don’t enjoy their food, they don’t eat it and they make other choices,” she said.

Genetic Code of E. Coli Is Hijacked by Biologists Posted: 14 Jul 2011 09:30 PM PDT Synthetic biology, the quest to hijack living systems and convert them to human-directed goals, is on the march. Last year biologists synthesized the entire genome of a small bacterium and showed how it could successfully infect a second bacterium. Now, in what may be a more significant advance, biologists have shown they can radically change a genome, not just copy it. A team led by Farren J. Isaacs and George M. Church of the Harvard Medical School has devised a method for making hundreds of changes in a genome simultaneously. This massively parallel intervention, as the changes are known, is one of the advances that would be needed in another project Dr. Church and others have contemplated, that of recreating the mammoth by starting with an elephant’s genome and changing it at the 400,000 sites at which elephant DNA differs from that of the mammoth. In the present instance, Dr. Isaacs and Dr. Church have been working not with a mammoth but with the standard laboratory bacterium known as E. coli. To prove they can seize control of the microbe’s genetic code and reprogram it, they have focused on one of the code’s 64 elements, known as the amber stop codon. In Thursday’s issue of the journal Science, they report that they will soon be able to delete the amber stop codon from all 314 sites where it occurs in the E. coli genome, without harm to the organism. The codon can then be reinserted, but with a new function, like introducing a novel chemical unit into the bacterium’s proteins. Genetic engineers have become adept at changing one gene in a genome, but it is quite another thing to alter a genome at 314 sites simultaneously. “This is the first instance that a genome has been altered at such a large scale,” said James J. Collins, a synthetic biologist at Boston University. Along with the synthesis of a bacterial genome last year by J. Craig Venter, the advance takes synthetic biology from the gene to the genome level. “It is a major technical breakthrough which has great promise for scientific breakthroughs to follow,” said Dr. Gerald J. Joyce, a biologist who studies the origin of life at the Scripps Research Institute in San Diego. “This is really macho molecular biotechnology.” By taking control of the amber stop codon, Dr. Isaacs and Dr. Church have opened a door into the bacterium’s genetic programming. They could now make the bacterium incorporate a novel kind of amino acid unit into its proteins, although they have not yet done so, to Dr. Joyce’s disappointment. “They could have taken their amber codon and put in something blinky there,” he said, like a dye that would have made the bacterium fluoresce. The two leading laboratories that have taken synthetic biology to the genome level are those of Dr. Venter and Dr. Church, but their approaches are very different. Dr. Venter’s company, Synthetic Genomics, spent $500,000 to make a synthetic copy of the genome of a bacterium that infects goats. Dr. Church has focused on changing an existing genome — that of the well-studied E. coli bacterium — thus avoiding the high cost of sequencing. Dr. Church said his approach was modular, so it could be tested at each stage, whereas Dr. Venter’s whole genome was nearly brought down by a single mutation. In contrast to Dr. Venter’s method, “our genome engineering technologies treat the chromosome as an editable and evolvable template,” Dr. Church says in his Science article. Dr. Venter was not available for an interview, but his office issued a statement in which he said his goal — to design cells from scratch — could be attained only by whole-genome synthesis. He called Dr. Church’s approach, without excessive praise, “a positive addition to the field.” Dr. Joyce of the Scripps Research Institute summed it up this way: “Craig builds the house from scratch, and George is more the remodeler, but they are both interesting houses to live in.” The goal of synthetic biology is to take control of nature’s manufacturing system and divert it to other ends. Dr. Church’s method, which has been seven years in development, focuses on the genetic code that is common to all living things. The four different bases of DNA can be combined to make 64 three-letter words, or codons, the units in which the cell translates its genetic information into protein products. What Dr. Church has done is to grab one of these codons for his own use by forcing the bacterium to stop using it. In future experiments he can assign this codon to other uses. Most of the codons in the genetic code are used to designate one or another of the 20 standard amino acids that make up proteins. But three of the units are punctuation marks, all signaling to the cell to stop adding to a growing chain of amino acids. The chain is then released and folds up into a protein. The E. coli bacterium uses all three stop codons, which are known as amber, ocher and umber (the first is named for Harris Bernstein, a former graduate student at the California Institute of Technology whose surname means amber in German). Dr. Church’s team converted all 314 amber stop codons in the E. coli genome to the ocher variety by changing all instances of T-A-G, in the four-letter alphabet of DNA units, to T-A-A. The ocher stop codon works just as well as amber and, after one final step — yet to be completed — the team will have an E. coli bacterium that is not dependent on amber. They will then delete the gene whose protein recognizes the amber codon and forces a break in the protein chain. That will allow them to reinsert amber codons and, with a method devised by Peter G. Schultz of the Scripps Research Institute, reassign them to incorporate a novel amino acid into the bacterium’s proteins. Charles R. Cantor, chief scientific officer of Sequenom, a genetic analysis and diagnostics company in San Diego, said the new method was “wonderful because it would allow expansion of the genetic code to a 21st amino acid genomewide.” Other codons are available to be hijacked by Dr. Church’s method, and the bacterium in principle could be forced to operate an entire chemistry that was orthogonal to its own, as synthetic biologists say, meaning it had no interaction with the microbe’s natural chemistry.

Well: When Hospital Overcrowding Becomes Personal Posted: 14 Jul 2011 02:26 PM PDT

Two Studies Show Pills Can Prevent H.I.V. Infection Posted: 14 Jul 2011 11:40 PM PDT Two new studies released on Wednesday add to the growing body of evidence that taking a daily pill containing one or two AIDS drugs can keep an uninfected person from catching the fatal human immunodeficiency virus. Enlarge This Image Paul Sakuma/Associated Press Gilead Sciences' Truvada cut the odds of becoming infected. Related Health Guide: AIDS The studies were the first to show protection in heterosexuals; the only earlier one with similarly encouraging results involved gay men. As it becomes ever clearer that modern antiretroviral drugs can not only treat the disease but prevent it, pressure is likely to increase on donors to find more money to supply them in places like Africa and on pharmaceutical manufacturers to either sell them cheaply or release their patents to companies that can. “This is an extremely exciting day for H.I.V. prevention,” said Dr. Kevin Fenton, director of AIDS prevention at the Centers for Disease Control and Prevention in Atlanta. “It’s clear we’re not going to find a magic pill that prevents it, but this is adding more to the tool kit.” Until a few years ago, condoms and abstinence were alone in that tool kit. Recent studies have added circumcision, vaginal microbicides, a daily pill for the uninfected (known as pre-exposure prophylaxis, or PrEP) and early treatment for the infected (known as “treatment as prevention”). One study released Wednesday, known as Partners PrEP and conducted in Kenya and Uganda by researchers from the University of Washington, showed that participants who took a daily Truvada pill — a mix of tenofovir and emtricitabine — had a 73 percent lower chance of getting infected. The study was done in 4,758 “discordant couples,” those in which one partner was infected and the other was not. Partners who took a Viread pill — which contains only tenofovir — had a 62 percent lower chance. The second study, called TDF2 and done in Botswana by the C.D.C., found that those taking Truvada had a 63 percent lower chance of infection. The subjects were 1,200 sexually active young adults. The studies were due to be released at an AIDS conference in Rome next week. But the University of Washington study was stopped early because it was so clear that the pills were working that it would be unethical to continue distributing placebos. The C.D.C. decided to release its results simultaneously. These studies follow a breakthrough pre-exposure prophylaxis study, known as iPrEx, that was based in San Francisco and conducted among gay men in six countries, with the results published in November. In it, men who took Truvada daily were 44 percent less likely to become infected. But those whose blood samples showed they took it faithfully had 90 percent protection. Then in April, the field had an unexpected setback, when FEM PrEP, a study in African women, was stopped early because it was not working. Researchers questioned whether many women either did not take their pills or gave them to their infected boyfriends or husbands. Blood samples are the best way to tell whether study participants actually take their pills. Blood samples were drawn in both that study and the two new studies, but because all three stopped early, the samples have not been analyzed. Two similar studies are in the works — another among heterosexuals in Africa and one among drug users in Thailand. “We don’t anticipate needing more,” said Dr. Jonathan Mermin, a C.D.C. specialist in AIDS prevention. The new studies may lead some heterosexual Americans to ask their doctors for Truvada. Although it will take several months to write new C.D.C. guidelines, Dr. Mermin said, doctors could use the guidelines written for gay patients after the San Francisco study, with the proviso that Truvada has not been tested in pregnant women. This posting includes an audio/video/photo media file: Download Now

Judge Blocks City’s Crisis Pregnancy Center Law Posted: 14 Jul 2011 01:11 PM PDT Scolding city officials for supporting a law he called “offensive to free speech principles,” a federal judge on Wednesday temporarily barred New York City from enforcing a new law that would require crisis pregnancy centers to disclose more information about their services. The law, which had the strong backing of Christine C. Quinn, the City Council speaker, and Mayor Michael R. Bloomberg, was scheduled to go into effect on Thursday. It would have required such centers to detail whether they provided abortions or emergency contraception, and whether they had a licensed medical provider on-site. The City Council had enacted the law in March, framing it as a matter of consumer protection and truth in advertising, not long after Naral Pro-Choice New York released a report saying it had found crisis pregnancy centers using deceptive tactics and false claims to dissuade women from having abortions. But opponents of the law argued that it violated free speech rights and was motivated chiefly by politics. And in an often tart 22-page ruling, Judge William H. Pauley III essentially sided with the opponents, writing that the city’s definition of commercial speech was too broad. As a result, he concluded, because the new law “relates to the provision of emergency contraception and abortion — among the most controversial issues in our public discourse — the risk of discriminatory enforcement is high.” City officials are expected to appeal the decision. But opponents, citing a similar law that was struck down in Baltimore recently, applauded the judge’s decision and expressed confidence that the law would never be carried out. “We think this is a resounding defeat of the Gestapo-like tactics of Christine Quinn and Mayor Bloomberg,” said Chris Slattery, founder of Expectant Mother Care/EMC FrontLine Pregnancy Centers, a plaintiff that operates about a dozen centers in the city. “This is one of the most important First Amendment decisions in American history, and will very strongly boost pro-life free speech initiatives and protect pregnancy centers not only here in New York, but across America.” Judge Pauley did not mince words, either, with the law’s opponents. He wrote that “the prevention of deception related to reproductive health care is of paramount importance” and that unlicensed ultrasound technicians “operating in pseudo-medical settings can spawn significant harms to pregnant, at-risk women who believe they are receiving care.” So the plaintiffs’ claims that such deception simply did not exist “feigns ignorance of the obvious,” he wrote. To address those concerns, Judge Pauley took the unusual tack of making a few policy suggestions. One was that the city convey its message through a public service advertising campaign; another was that the city impose requirements, or lobby the State Legislature, to require licensing for ultrasound technicians. He noted that two states, New Mexico and Oregon, required ultrasounds to be performed by a licensed professional. But in a statement, Ms. Quinn dismissed the judge’s suggestions, saying they were “completely unworkable and would create even more legal problems.” She added, “In issuing this injunction, the court has failed to protect pregnant women in an extremely vulnerable time in their lives.” In an interview on Wednesday, Councilwoman Jessica S. Lappin, the law’s chief sponsor, expressed disappointment, but vowed to press ahead. “The judge got it wrong,” she said. “This is an important measure to protect women from dangerous and deceptive practices, and we’re not going to give up. We’re going to keep fighting.” This posting includes an audio/video/photo media file: Download Now

In Effort to Cut U.S. Deficit, New York Teaching Hospitals May Lose Aid Posted: 12 Jul 2011 10:10 PM PDT New York State’s prestigious teaching hospitals could lose more than $1 billion a year as part of plans under negotiation in Washington to reduce the federal deficit that the hospitals say will lead to drastic service reductions. Enlarge This Image Michael Kamber for The New York Times Among the other residents at the hospital are, from left, Dr. Teresa Martorella, Dr. Arunjot Singh and Dr. Netta Schneller. Montefiore could lose much of the Medicare subsidy it gets for training doctors. The cuts would reduce the Medicare subsidy for training doctors and for providing intensive medical services like trauma centers and burn units and sophisticated equipment that the teaching hospitals offer. The plan would apply to teaching hospitals nationwide but would have its most profound impact in cities like New York and Boston, where medical schools and their affiliated hospitals have a significant presence. Dating to the 1960s, the subsidy has helped make New York State the world capital of medical education, training about 16,000 doctors a year, or 14.5 percent of the nation’s total, more than any other state. The benefits have been criticized for years by both conservatives and liberals who see them as a sweetheart deal for teaching hospitals in a few states. But now, with the pressure on the federal budget, they are being seriously considered in talks among the Obama administration and leaders of both parties in Congress. The fate of the proposal, part of negotiations on raising the nation’s debt ceiling, is still unclear. A smaller package of cuts is also being considered. Critics of the Medicare payment say it has become a hidden subsidy for hospitals’ operating costs. But the administrators of New York’s teaching hospitals say they operate on very thin margins because they serve large proportions of patients who are receiving government insurance for the poor and the elderly, and because they provide some of the most sophisticated — and expensive — medical treatment in the country. Either way, the hospitals have come to depend on the money. Three New York hospitals — Montefiore Medical Center in the Bronx and Mount Sinai Medical Center and NewYork-Presbyterian Hospital in Manhattan — would be the hardest hit in the nation, followed by U.P.M.C.-Presbyterian in Pittsburgh, the Hospital of the University of Pennsylvania in Philadelphia and Massachusetts General Hospital. “The impact would be devastating to a place like Montefiore and to the borough of the Bronx and the City of New York,” Dr. Steven M. Safyer, president and chief executive of the medical center, said Monday. “It would be incomprehensible what it would lead to. We’re the main employer in the Bronx, with 18,000 employees. It would lead to loss of jobs, curtailing the pipeline of the doctors of tomorrow, exacerbating the health needs of this very challenged community, the Bronx.” Though the final numbers may well change, under the worst-case situation New York hospitals estimate they would lose $1.25 billion, or 57 percent, of the $2.19 billion a year they currently receive in Medicare subsides for medical education, according to the Greater New York Hospital Association, a powerful lobbying group. It expects the cut would begin in 2015. Nationwide, hospitals would lose $5.8 billion of their current $10.9 billion in payments, or 53 percent, according to the group. A more modest deficit-reduction package now being discussed, however, would cut only $1.4 billion nationwide over 10 years. If the larger proposal is passed, Montefiore will lose $100 million a year in revenue, or $1 billion over 10 years. The hospital trains 1,200 residents at any one time, turning out 350 to 400 doctors a year, Dr. Safyer said. A vast majority of its patients — 80 percent — are on either Medicare, the government insurance for the elderly, or Medicaid, the program for the poor. A nonprofit institution, Montefiore has a budget of about $3 billion. Because of the hospital’s high percentage of poor and elderly patients, its revenue exceeds expenses by only one percentage point, and that money is invested back into the hospital, Dr. Safyer said. The New York hospitals and hospital union leaders have historically had great success in staving off cuts in Albany and Washington, and are planning a trip to Washington on Wednesday to lobby the state’s Congressional delegation, said Kenneth E. Raske, president of the hospital association. The association is also planning a one-day print advertising campaign. The advertisements accuse Democrats of being “about to kill health reform” and challenge Republicans to keep their promise to protect Medicare. Representative Carolyn B. Maloney, a Democrat whose district includes parts of Manhattan and Queens, said in a statement on Monday that cutting money for medical education would be a mistake. Ten teaching hospitals on the East Side of Manhattan rely on the subsidy and “train doctors who will, once trained, provide care for Americans across the country,” Ms. Maloney said. A White House spokesman, Nicholas Papas, said of the proposal, “We haven’t been commenting on the details of the negotiations.” Federal financial support for medical education began with the G.I. Bill of Rights after World War II, and became part of Medicare after it was established in 1965, according to a study in the Journal of General Internal Medicine. It has survived, with modifications, many attempts to curtail it over the years. 1 2 Next Page » Jo Craven McGinty contributed reporting.

Agreement on Debt Talks: Health Groups Dislike Proposals Posted: 13 Jul 2011 09:51 PM PDT WASHINGTON — Budget negotiators have not found a way to avert a government default on federal debt obligations, but with their ideas to cut Medicare and Medicaid they have managed to provoke opposition from almost every major group that represents beneficiaries and health care providers. Stephen Crowley/The New York Times Kathleen Sebelius, the secretary of health and human services, at a House hearing Tuesday. Related Tensions Escalate as Stakes Grow in Fiscal Clash (July 14, 2011) Related in Opinion Op-Ed Contributor: The Republican Case for Compromise (July 14, 2011) Nicholas D. Kristof: The Opposing Party (July 14, 2011) Blogs The Caucus The latest on President Obama, the new Congress and other news from Washington and around the nation. Join the discussion. FiveThirtyEight: Nate Silver's Political Calculus More Politics News Enlarge This Image Jim Lo Scalzo/European Pressphoto Agency Representative Eric Cantor, Republican of Virgina, preparing to discuss the budget negotiations. The latest provocation was a list of proposed savings presented at the White House this week by the House majority leader, Representative Eric Cantor, Republican of Virginia. Mr. Cantor said Tuesday that the ideas had all been seriously discussed, with varying levels of Democratic support, in seven weeks of negotiations led by Vice President Joseph R. Biden Jr. But with House Republicans adamantly opposed to new taxes, Democrats said they would not accept cuts in Medicare that reduced benefits. Mr. Cantor’s list included 27 proposals that he said would save up to $353 billion over 10 years, in the context of a budget deal that could save anywhere from $2 trillion to $4 trillion over the same period. Items on the list touched off howls of protest from lobbyists and Democratic lawmakers who saw details for the first time on Tuesday. Some of the proposals would hit Medicare patients in the pocketbook, charging co-payments for home health care and clinical laboratory services like blood tests. One proposal would increase premiums and co-payments for beneficiaries with relatively high incomes. Another would require millions of recipients to pay more of the costs now covered by private insurance policies that supplement Medicare. The Congressional Budget Office says the proposal could save Medicare up to $53 billion over 10 years, mainly by curbing the use of health care by people with supplemental coverage known as Medigap policies. Studies show that such policyholders use about 25 percent more services than Medicare patients who have no supplemental coverage, the budget office said. But Medigap policies are popular with older Americans, who like the financial security they get from the extra insurance. “The Medigap proposal would shift costs onto Medicare beneficiaries,” said Howard J. Bedlin, vice president of the National Council on Aging, a service and advocacy group. “Our fear is that many would go without the care they need and end up in a hospital emergency room, which costs Medicare more than proper treatment would have cost.” Likewise, Mr. Bedlin said, the proposed co-payments for home health care would “significantly increase out-of-pocket costs for many low-income widows with multiple chronic conditions.” When such co-payments were seriously considered in the past, Democrats wheeled some of the widows into the Capitol to denounce the idea. Mr. Cantor’s list includes $100 billion in savings from Medicaid over 10 years — the same amount sought in a White House proposal that has caused consternation among some officials at the Department of Health and Human Services. Laboratories were surprised to learn Tuesday of the proposal to start charging Medicare beneficiaries a $1 co-payment for each lab test. Lab tests and home health visits are now exempt from such cost-sharing. Alan B. Mertz, president of the American Clinical Laboratory Association, a trade group, said that collecting the co-payments from beneficiaries would be “a huge administrative hassle.” The average lab test costs $12 or $13, Mr. Mertz said, and labs typically “do not have a face-to-face relationship with patients.” In many cases, he said, “we will not be able to collect the money, or the cost of collecting it will be more than the amount of the co-payment.” Representative Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee, said the din of criticism was disappointing. “These are not big Medicare savers,” Mr. Ryan said in an interview. “They do not save a lot of money in the whole scheme of things. If we come to a political paralysis over a few hundred billion dollars, the credit markets will really start turning on us.” The Obama administration said Tuesday that instead of cutting benefits or increasing co-payments, Congress should increase the power of an independent agency, created by the new health care law, to make sweeping cuts in the growth of Medicare spending. At a hearing of the House Budget Committee, Kathleen Sebelius, the secretary of health and human services, said the new agency, the Independent Payment Advisory Board, would be a backstop to ensure a sharp reduction in the growth of Medicare spending per beneficiary. Mr. Ryan said the 15-member board was “just a mechanism to take power out of the hands of politicians so they can absolve themselves of responsibility for the inevitable price controlling and rationing that is to come in Medicare.” Such rationing, he said, “is not necessary if you do fundamental Medicare reform.”

Drive to Stem Shingles Meets Few Expectations Posted: 13 Jul 2011 12:00 AM PDT Five years have passed since the Food and Drug Administration approved a vaccine against shingles. By now, experts had expected a substantial proportion of people older than 60, the most vulnerable population, to be protected from outbreaks of this nasty viral disease and the persistent, debilitating pain it can leave behind. The New Old Age Share your thoughts on this column at The New Old Age blog. Join the discussion » Related Health Guide: Shingles Indeed, the vaccine, called Zostavax, could so sharply reduce the number of adults who suffer from shingles — currently more than one million a year — that in March, the Food and Drug Administration approved its use by those ages 50 and older. But even with this weapon at the ready, the campaign against shingles has bogged down. Some experts say it never really got under way. A combination of factors has dissuaded many physicians’ offices and clinics from carrying Zostavax. And its manufacturer, Merck, has been unable to produce sufficient quantities to meet even modest demand. Intermittent shortages that last months have kept the company from consistently marketing the vaccine and have forestalled public health campaigns that could have built awareness of the need for it. “It really, really has been frustrating,” said Dr. Rafael Harpaz, an epidemiologist at the federal Centers for Disease Control and Prevention. “There hasn’t been a single year since the vaccine was licensed in 2006 that there’s been no problem with supply.” As a result of these obstacles, just 10 percent of adults 60 and older were vaccinated against shingles in 2009, the most recent federal survey reports — far fewer than scientists and public health officials originally had hoped. (By comparison, two-thirds of those 65 and older got a flu shot that year.) And with Zostavax again in short supply, a C.D.C. advisory committee in June declined to vote on whether to recommend the vaccine for people in their 50s, even though the F.D.A. had already approved it for that group. “Maybe it’s not appropriate to expand a vaccine when it’s not available to the people who can most benefit from it,” Dr. Harpaz said. “How much more disease might you cause by diverting vaccine to a younger group at lower risk?” This stalemate was not what researchers had in mind when they began gearing up to test the vaccine in 1992. If ever there was an opportunity to advance public health, they knew, this was surely it. Virtually the entire adult population harbors the virus that causes shingles, called varicella zoster, and each one faces a one-in-three chance of developing shingles at some point. The virus causes childhood chickenpox, then goes dormant for decades. When reactivated in later adulthood — how that happens is not well understood, though the risk rises with age — the virus causes a hallmark rash. The lesions typically last 7 to 10 days and heal in two to four weeks, but the scarring and pigment changes can be permanent. About half of shingles victims describe the pain as “horrible” or “excruciating,” the C.D.C. has reported. In 10 percent to 25 percent of cases, the virus attacks an eye and can permanently impair vision. The severity of symptoms increases with age: 18 percent of all patients experience postherpetic neuralgia, nerve pain which can linger for months or even years after the rash clears, according to one decade-long Minnesota study. Among patients over age 79, the incidence of postherpetic neuralgia climbs to 33 percent. Prompt treatment with antiviral drugs can reduce the severity of the outbreaks but hasn’t been shown to prevent the neuralgia, which can disrupt sleep and work and, if it continues, lead to depression and social isolation. “You can have your life ruined,” said Dr. Michael Oxman, an infectious disease researcher who led the first large clinical trial demonstrating the vaccine’s effectiveness. Researchers and federal regulators long ago agreed, therefore, that their priority is to protect older adults. In 2005, to much fanfare, Dr. Oxman and his colleagues at 22 research sites reported that the vaccine produced a 51 percent reduction in outbreaks of shingles and a 67 percent reduction in postherpetic neuralgia in patients age 60 and older. The researchers also found that the vaccine was less likely to prevent disease in those over age 80. Yet a subsequent community study of more than 300,000 adults age 60 and older at Kaiser Permanente health centers in California — more closely reflecting real-world conditions — found that the vaccine reduced shingles by 55 percent across all age groups. “The burden of the disease is so great that reducing it by half is a real public health benefit,” said Dr. Harpaz of the C.D.C. The vaccine also lowered the rate of ophthalmic cases and of hospitalizations, indicating that even when it doesn’t prevent shingles, “the vaccine can alleviate symptoms,” said Hung-fu Tseng, a research scientist at Kaiser Permanente and lead author of the study. But although Merck managed to ship two million doses in the first half of this year, more than in any previous full year, Zostavax is once more in scant supply. The vaccine is made with a live attenuated virus that has proved difficult to grow in bulk, and also is needed to make the childhood chickenpox vaccine, said Dr. Eddy Bresnitz, global medical affairs director of Merck Vaccines. The company is spending $1 billion to increase production and has built a new manufacturing plant in Durham, N.C. But it won’t be fully licensed and operational until 2013, Dr. Bresnitz said. Even when it’s available, Zostavax is the most expensive adult vaccine, selling for about $160 a dose, not counting the cost of an office visit and injection. Few insurers will currently cover the cost for patients under age 60. Because the vaccine must be stored frozen and few doctors’ offices are equipped with freezers, many patients must turn to pharmacies for the shot. Fortunately, pharmacies can bill Medicare directly, under Part D, whereas physicians are reimbursed under Part B and therefore may require patients to pay for the vaccine themselves, then file for reimbursement. That outlay alone discourages many older adults from getting vaccinated, research has shown. Patients in their 50s also must shoulder the cost, since many insurers are reluctant to cover vaccinations the C.D.C. hasn’t officially recommended. Every year, shingles strikes 200,000 adults ages 50 to 59. “If someone 52 came to me worried about shingles, I’d vaccinate him,” Dr. Oxman said. “The only toxicity I’m aware of is to the wallet.” Patients may also require an eventual booster, since it is not yet clear how long the vaccine remains effective. But that’s a less urgent matter than getting people at risk vaccinated in the first place. Directly or indirectly, “the public foots the bill for all this research,” Dr. Oxman added. “So I’m disappointed that a much higher proportion of those who would benefit from the vaccine haven’t gotten it. We ought to be able to do a lot better than this.”

Obama Administration Rolls Out Standards for Health Insurance Marketplaces Posted: 12 Jul 2011 08:32 AM PDT WASHINGTON — In a big step to carry out the new health care law, the Obama administration unveiled standards on Monday for insurance marketplaces that will allow individuals, families and small businesses in every state to shop for insurance, compare prices and benefits and buy coverage. Blogs The Caucus The latest on President Obama, the new Congress and other news from Washington and around the nation. Join the discussion. FiveThirtyEight: Nate Silver's Political Calculus More Politics News Kathleen Sebelius, the secretary of health and human services, said the insurance exchanges, the centerpiece of the new law, “will offer Americans competition, choice and clout.” In theory, the exchanges will pool insurance risks and premiums so that individuals and small businesses will have “the same purchasing power as big businesses,” Ms. Sebelius said. Issuance of the proposed rules shows how President Obama is moving inexorably to carry out his health care overhaul, despite attacks on the new law in Congress and the courts, where more than two dozen states are challenging the constitutionality of a requirement for most Americans to carry insurance. In principle, liberals and conservatives support the exchanges, which they see as a way to increase the purchasing power of individuals and small businesses, but they disagree on how the exchanges should be configured. The regulations issued Monday, which provide a fair amount of latitude to states, were welcomed by consumer groups, patient advocates and some business lobbyists.      But they may not satisfy liberals who argue that the exchanges should tightly regulate insurance and contract with selected health plans that offer the best deals. And they may not satisfy conservatives who want the exchanges to be wide open to any insurers that want to participate and meet minimum federal standards. Every state will have an exchange by Jan. 1, 2014. Federal officials will assess states’ “operational readiness” as of Jan. 1, 2013, and will run the exchange in any state that is unable or unwilling to do so. Many states have been pondering how to proceed, and the regulations will provide guidance. The National Conference of State Legislatures says 12 states have enacted laws to establish exchanges. Bills failed in nine states and are pending in 11 others, the organization said. The Congressional Budget Office predicts that by 2019, about 24 million people will have insurance through exchanges, with four-fifths of them getting federal subsidies that average $6,400 a year per person. People with incomes up to four times the poverty level (about $89,000 a year for a family of four) will be eligible for subsidies to make insurance more affordable. Each state exchange will certify “qualified health plans,” provide the public with “standardized comparative information” on costs and benefits, and rate each plan based on the quality and price of care. In addition, the exchange will help people determine if they are eligible for Medicaid or the Children’s Health Insurance Program, or for federal tax credits to subsidize the purchase of private insurance. Federal officials said they would issue a separate rule later this year specifying the “essential health benefits” that must be offered by all health plans. Trumpeting the advent of the exchanges, the administration said Monday that they would “give Americans the same insurance choices as members of Congress.” However, in response to questions after a news conference on Monday, health officials acknowledged that this claim was not necessarily correct. A small employer will be able to pick “a level of coverage” for its employees. A higher level will pay more of the consumer’s medical costs. Under the law, members of Congress must generally get their coverage through an exchange. But a small business could legally choose a level of coverage lower than those offered to federal employees, including members of Congress. Under the rules, an employer may allow employees to choose any health plan at a given level of coverage. But an exchange may also allow an employer to limit its workers to one or two health plans — far fewer than the number available to members of Congress and other federal workers. With some states like Florida balking at the new law, federal officials went out of their way Monday to strike a conciliatory note, promising to be flexible. If a state is not ready by January 2013, Ms. Sebelius said, it still might qualify for “conditional approval” if it was on track to operate an exchange by January 2014. In addition, federal officials said, a state could set up and operate its own exchange in 2015 or later years if it is not ready in 2104.

Pills Morph as Patients Try to Cope Posted: 11 Jul 2011 09:30 PM PDT Later this year, when the popular statin Lipitor becomes available as a generic drug, many who have taken it faithfully will get a surprise. No longer will their cholesterol-lowering pills be oblong and white. If they choose a generic alternative, their pills will be anything but that color and shape, and their appearance may change from refill to refill as pharmacists switch among generic competitors. The result may well be confusion among patients, who often take multiple drugs and have trouble keeping track of them if their shapes and colors change all the time, two researchers at Harvard University say. With generics accounting for 70 percent of all drugs on the market, the seldom-discussed issue of their ever-changing appearances affects almost anyone who fills a prescription. “If a patient is on five medications, which is not that unusual, there are over 3,000 possible combinations of pills to navigate,” said Dr. Jeremy A. Greene, a physician and historian of science at Harvard Medical School, referring to the number of ways of combining five pills of different shapes or colors. When patients get confused, many stop taking their drugs. “Everyone has seen a patient who has gone off of a medication because it changed color,” Dr. Greene said. “It can lead to disastrous outcomes.” In an article in the current issue of The New England Journal of Medicine, Dr. Greene and Dr. Aaron S. Kesselheim, a physician and lawyer at Harvard Medical School, ask why generic pills look different from their brand-name equivalents and from competitors that the Food and drug Administration certifies as being bioequivalent — having the same effect on the body. The question seems to have caught many drug makers off guard. Kate Connors, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, a trade group that represents makers of brand-name drugs, said, “We have never seen this come up as an issue.” Bob Lee, a trademark lawyer for Eli Lilly, said patients should know when they are taking something other than a brand-name drug, and a different shape or color communicates this point. Different appearances also help prevent counterfeiters from flooding the market with look-alikes, he said. By suggesting that generics should look the same as the brand-name drug, Mr. Lee said, the Harvard researchers are advocating a solution that will not help patients. “What they are really arguing for is a deception,” Mr. Lee said. The shape and color of a particular pill has become a valuable part of its marketing, so much so that generic drug manufacturers sometimes will license the right to make an “authorized” generic — pills that look exactly like the brand-name drugs they are competing with. Prasco, a maker of authorized generics in Ohio, buys drugs from brand-name manufacturers and puts them in its own bottles. They are identical to the drugs patients are used to, said a company spokeswoman, Kimberly Carroll. “Wouldn’t you like a generic option that provides the identical experience as the brand?” the company asks doctors on its Web site. A drug’s appearance, said Dr. Greene, “has become one more thing that can be sold on the market.” The purpose of an authorized generic, he said, is to tell consumers, “Yes, it’s a generic, but you can trust it.” He and Dr. Kesselheim report that the idea that generics should look different from the brand-name drugs they replace emerged in the 1960s and 1970s. Some pharmacists began covertly substituting generic pills that looked just like brand-name drugs but were not as effective. Courts agreed that companies had a right to protect the appearance of their drugs. But in the 1970s and 1980s, the Food and Drug Administration began regulating generic drugs and requiring that they be bioequivalent to their brand-name products they replaced. As a result, said Dr. Greene, “the problem of poor quality generics became less of a public health concern.” But once in control of the appearance of their brand-name drugs, manufacturers began using a pill’s shape and color as a marketing tool. For example, Pfizer featured its distinctive pill for erectile dysfunction, Viagra, in its advertisements, making sure patients knew it was blue and diamond-shaped. AstraZeneca advertised the gastric acid blocker Prilosec as “the purple pill.” When it went off patent in 1989, the company began marketing its replacement, Nexium, as “the new purple pill.” Prilosec, on the other hand, was colored pink after it became available as an over-the-counter drug. Generic drug makers who license an “authorized” generic can start selling their drug as soon as the brand-name drug’s patent expires. Not so for most generic drug makers. They compete to get their documentation to the F.D.A. when a drug is going off patent, said David Belian, a spokesman for the Generic Pharmaceuticals Association, an industry group. The first company to get the Food and Drug Administration’s approval to sell its generic drug receives, in return, a period of six months when its drug is the only generic on the market, unless an authorized generic also has been licensed. If so, that six-month period can be a significant advantage for the authorized generic. In the six months after the antidepressant Paxil went off patent, there were two generics on the market. One was authorized and looked just like Paxil. It ended up with two-thirds of the market. The Generic Pharmaceuticals Association opposes letting authorized generics on the market immediately, during the time when the first ordinary generic is supposed to have the market to itself. “Exclusivity should be just that,” Mr. Belian said. But Prasco says that authorized generics bring prices down by increasing competition in that six-month period. And look-alike generics make life easier for patients, Ms. Carroll said. Dr. Greene, however, wonders whether an endlessly multiplying array of drug shapes and colors really makes sense for consumers. “The current situation reflects an approach to public health law that made sense a half-century ago, but is no longer in sync with how people manage disease with generic drugs today,” he said.

Recipes for Health: Morning Oatmeal With Cherries and Pistachios Posted: 15 Jul 2011 12:00 AM PDT You can now find steel-cut oats that cook quickly. If you steep them the night before in boiling water (pit the cherries then, too), this breakfast is a quick one to put together. 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: A Short Season for Cherries (July 11, 2011) Recipes for Health: Cherry Almond Smoothie (July 12, 2011) Recipes for Health: Cold Cherry Soup (July 13, 2011) Recipes for Health: Cherry Cobbler With Almond-Buttermilk Topping (July 14, 2011) 1/2 cup steel-cut oatmeal, preferably the quick-cooking variety Salt to taste 1 1/2 cups water 1 to 2 teaspoons honey, brown sugar or agave nectar 1 to 2 tablespoons pistachios, lightly toasted 3 ounces cherries (12 to 14, depending on the size), pitted and halved Milk or almond beverage as desired 1. The night before you plan to make this dish, place the oatmeal in a large microwave-safe bowl or in a saucepan with the salt. Bring the water to a boil, and pour over the oatmeal. Cover tightly and leave overnight. 2. In the morning, stir in the honey, pistachios and cherries. Cover and microwave three to five minutes, or simmer for 10 minutes or so until the oatmeal has absorbed the liquid remaining in the bowl. Stir in milk or almond beverage as desired. Yield: Two servings. Advance preparation: I like to have this oatmeal cooked and ready in the refrigerator to reheat before I leave in the morning. It will keep there for three days. Nutritional information per serving: 217 calories; 0 grams saturated fat; 2 grams polyunsaturated fat; 2 grams monounsaturated fat; 0 milligrams cholesterol; 37 grams carbohydrates; 9 grams dietary fiber; 6 milligrams sodium; 7 grams protein Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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18 and Under: Guarding Privacy May Not Always Protect Patients Posted: 11 Jul 2011 09:22 PM PDT Many years ago, I helped persuade a teenage patient to tell her parents that she was sexually active. She had been hospitalized with a sexually transmitted infection, and it seemed clear that they must be suspicious. They were concerned, too, and they didn’t seem crazy. Enlarge This Image Alex Nabaum Well Share your thoughts on this column at the Well blog. Go to Well » Related More 18 and Under Columns So against her better judgment, she told her parents her diagnosis. Her father’s reaction was to inform her that once she got out of the hospital, she was no longer welcome to return home. Juggling parental concern with an adolescent patient’s legal and ethical right to privacy opens up some tricky questions. The law varies state by state, but many, including New York, allow minors to consent by themselves to medical care involving such sensitive needs as contraception, pregnancy, sexually transmitted diseases and mental health. Clinics for adolescents are keenly conscious that the promise of confidential care is essential to gain and hold their young patients’ trust. But in those same clinics, doctors often try to convince teenagers to bring parents into the conversation. We warn our patients that confidentiality will be broken if there is an imminent risk of serious harm or death. But it’s not always that clear-cut. What to do with the adolescent who tells you something worrisome but not clearly over the line? Who is not crying out for help and support, but admits to sampling amphetamines, say, or sees regular cocaine use as nothing unusual? A 15-year-old girl came to see a colleague of mine for a routine checkup. She turned out to be pregnant. When the doctor asked about her sexual activity, the girl flatly denied any at all. And no, she didn’t want the doctor to speak to her mother. When promising confidentiality to an adolescent patient, a physician must set certain limits: “If I hear something that makes me worry that you might not be safe, I will have to tell someone and make sure you get help.” That’s the loophole the doctor will invoke if a young patient is suicidal, for example, or manifests an out-of-control eating disorder. But in a case like this, nothing was clear. Was the girl in denial — or in danger? Maybe she was being abused. Maybe she was scared to say how she got pregnant. Sometimes as a physician, you decide that whatever you’ve heard is just too scary. You tell the young patient why, and you break confidentiality. My colleague ended up calling child protection services and eventually contacting the child’s mother. More often, the doctor is called upon to carry out a more subtle strategy. Sometimes you say, “I won’t tell your parents any details, but I am going to tell them that I’m concerned about you and that they need to talk to you about what’s going on in your life.” Sometimes you cut a deal: “I won’t tell your parents, but you have to talk to a therapist.” And sometimes you do what internists do — counsel, warn, advise — and then watch the patient leave the room and wonder what will happen next. College students over age 18 are generally entitled to full adult confidentiality, but that doesn’t always make it simpler for their doctors. When something goes wrong, their parents often are still the safety net and support. “In the vast majority of cases when we’re working with a student who has some sort of medical or mental health news, they want their parents involved and we are able to communicate freely,” said Dr. Sarah Van Orman, executive director of University Health Services at the University of Wisconsin, Madison, and vice president of the board of directors of the American College Health Association. But the more problematic cases arise when mental health issues are involved, especially eating disorders. With drug and alcohol use, colleges have worried that the specter of parental notification can be so terrifying that college students won’t call for help if they think it may lead to parents finding out about the circumstances. Some campuses have instituted “medical amnesty” or “good Samaritan” policies; If one student seeks help for another because of concerns about alcohol toxicity, there will be no consequences for either for violating campus rules. Parents sometimes worry about confidentiality, about whether important family secrets are being revealed in the pediatrician’s office. Doctors, in our turn, are troubled about the conversations that are not happening between parents and children: the questions that go unasked, the behaviors that go unremarked, the subjects that go undiscussed. Dr. Van Orman pointed out that as part of sending children off to college, parents should discuss the issues that might come up and make it clear that they want to stay involved. “We need to say to families, talk to their students,” she said. In my first or second year teaching undergraduates, a student e-mailed me to say her life was falling apart. In class that day, I tried to figure out a response. My mind kept running over medical assessment questions that, as her teacher, I had no right to ask. After class, I told her that I was worried about her. The academic stress seemed to be getting to her, I said. She nodded and agreed to visit the campus health clinic. I walked her over. But as she went in, I realized that no one would ever call me and report back. Someone else would ask all the questions I had been contemplating: family, friends, love life, living situation. Her medical and psychiatric history. I would never know the answers, and why should I? I was her professor, and like her parents, I was now on the other side of the wall. This posting includes an audio/video/photo media file: Download Now

Analysis: A Player Defined by Greatness and Illness Posted: 09 Jul 2011 11:09 PM PDT As John Mackey described the biggest game he won, he merely demonstrated all he had lost. Multimedia Suffering From Dementia Suffering From Dementia Close Video See More Videos » Related John Mackey Dies at 69; Helped Revolutionize N.F.L. (July 8, 2011) The Fifth Down: Remembering John Mackey (July 8, 2011) Health Guide: Dementia The latest news, notes and analysis of the N.F.L. playoffs. Go to The Fifth Down Blog N.F.L. Live Scoreboard Standings Stats | Injuries Giants Schedule/Results Stats | Roster Depth Chart Jets Schedule/Results Stats | Roster Depth Chart Enlarge This Image Eddie Hausner/The New York Times Mackey was a leader in N.F.L. players' fight for free agency. Enlarge This Image Brendan Smialowski for The New York Times Once Mackey became sick, his wife, Sylvia, fought for increased aid for families of retired players with dementia. In March 2007, in his Hall of Fame golf shirt and trademark black cowboy hat, Mackey proudly recounted how in Super Bowl V, he caught a 75-yard touchdown pass that fueled his Baltimore Colts’ 16-13 victory over Dallas. The problem was, the question was only, “Where do you live, John?” When asked about that 75-yard catch, he answered with clipped non sequiturs like, “They put me in the Hall of Fame” and “I want a cookie.” He used a spoon to drink his coffee, thinking it was soup. The legacy of Mackey, who died Wednesday at age 69, will derive less from how his muscles revolutionized the tight end position from 1963 to 1972, or how his heart fought for players’ free-agency rights, but from how his brain atrophied before football’s eyes. No player so vividly advertised the growing problem of early-onset dementia among veterans of his era, or so unknowingly spurred the N.F.L. to recognize it. Mackey was first found to have frontal temporal dementia in 2000, the same year that the owner of the Cowboys, Jerry Jones, told ESPN he would push his oft-concussed quarterback Troy Aikman into crucial games because “there is no evidence of any long-term, lasting impact” from head trauma in the N.F.L. A few years later, a committee of doctors appointed by the league published several papers making the same claim, to the howls of more independent experts. As this unfolded, Mackey deteriorated to the point that he needed continual in-home care. He could no longer fly after becoming so enraged at an airport security checkpoint — agents asked him to remove his Super Bowl V and Hall of Fame rings — that he burst toward the gate and had to be wrestled to the ground, screaming, by armed officials. He kept mumbling, “I got in the end zone.” While the N.F.L. minted videos featuring the hallowed Colts of Unitas and Moore and Mackey, Sylvia Mackey, John’s 60-year-old wife, became a United Airlines flight attendant to pay mounting medical bills. She grew so distraught that she wrote a three-page letter to Paul Tagliabue, the departing N.F.L. commissioner, to alert him to what was happening to one of the game’s legends. Sylvia Mackey’s haunting description of dementia — “a slow, deteriorating, ugly, caregiver-killing, degenerative, brain-destroying tragic horror,” she called it — almost brought Tagliabue to tears. He and the players union swiftly created a fund that would pay up to $88,000 in medical expenses to the families of retired players with dementia. Why $88,000? John Mackey wore No. 88. It continues today simply as the 88 Plan, forever identified with Sylvia as much as John. The move was not entirely magnanimous. The N.F.L. — and, curiously, the players union of which Mackey was once president — continued to claim that football and dementia were not related, that the 88 Plan was merely an effort to help players in need. (Dementia, a league spokesman explained, was a condition “that affects many elderly people.”) But the fuse was lighted, and an explosion loomed. Dozens of applications poured in, demonstrating the wide population of N.F.L. veterans with cognitive decline. Sylvia Mackey became the nexus of a growing support network of N.F.L. wives whose husbands were mentally vanishing in middle age. She offered them expertise and empathy, often during layovers in Denver or elsewhere. She signed off e-mails as Mrs. #88. A total of 166 players have benefited from the 88 Plan over four years, receiving almost $13 million and counting. Their age distribution also helped confirm that N.F.L. players were, indeed, receiving diagnoses of dementia or other memory-related diseases earlier and more often than other American men, prompting Congressional hearings and safety-related reform from the professionals to the pee-wees. Whether John Mackey’s condition actually resulted from football will probably remain a mystery. Sylvia Mackey pledged last year to donate his brain to researchers at Boston University to see if he had chronic traumatic encephalopathy, the collision-induced disease that compromises cognitive function and has been discovered in almost two dozen retired N.F.L. players. But even a positive diagnosis cannot definitively confirm her suspicions of football’s role. “I can’t say I do know for certain,” Mackey said. “In an exhibition game in Hershey, Pa., he ran into the goal post headfirst. Well, he has frontal temporal dementia, but how can I prove it? I can’t even find a record of that. I just remember the incident because I was there.” In his mid-60s, Mackey’s downturn became more poignant. He petulantly refused to brush his teeth or shower until Sylvia printed out a fake N.F.L. directive — she signed Paul Tagliabue’s name at the bottom — and taped it to his bathroom door. (He immediately followed orders.) He would forget which mailbox was his until being reminded it was Johnny Unitas’s uniform number, 19. Linked to football or not, Mackey’s dementia became the most resonant among scores of more anonymous cases dotted across the United States. It was the elephant in reunion rooms, with some players changing the subject if the name came up. In some ways John Mackey became the Lou Gehrig of football, a legend defined by his demise. In the end, mercifully, the only football insider who did not know John Mackey’s fate — and lasting impact — was No. 88 himself. “John doesn’t know what’s happening to him,” Sylvia Mackey said in March 2007, sitting beside her husband as he swallowed a dozen Oreos. “John is happy, everything is fine, he is above ground, he is having a good time, he is enjoying life, and he played football.”

New Study Implicates Environmental Factors in Autism Posted: 07 Jul 2011 12:14 PM PDT A new study of twins suggests that environmental factors, including conditions in the womb, may be at least as important as genes in causing autism. Related Health Guide: Autism The researchers did not say which environmental influences might be at work. But other experts said the new study, released online on Monday, marked an important shift in thinking about the causes of autism, which is now thought to affect at least 1 percent of the population in the developed world. “This is a very significant study because it confirms that genetic factors are involved in the cause of the disorder,” said Dr. Peter Szatmari, a leading autism researcher who is the head of child psychiatry and behavioral neuroscience at McMaster University in Ontario. “But it shifts the focus to the possibility that environmental factors could also be really important.” As recently as a few decades ago, psychiatrists thought autism was caused by a lack of maternal warmth. And while that notion has been discarded in favor of genetic explanations, there has been growing acceptance that genes do not tell the whole story, in part because autism rates appear to have increased far faster than our genes can evolve. “I think we now understand that both genetic and environmental factors have to be taken seriously,” said Dr. Joachim Hallmayer, an associate professor of psychiatry and behavioral sciences at Stanford and the lead author of the new study, which is to be published in the November issue of Archives of General Psychiatry. Other experts have cited factors like parental age, multiple pregnancies, low birth weight and exposure to medications or maternal infection during pregnancy. In the new study, the largest of its kind among twins, researchers looked at 192 pairs of identical and fraternal twins whose cases were drawn from California databases. At least one twin in each pair had the classic form of autism, which is marked by extreme social withdrawal, communication problems and repetitive behaviors. In many cases, the other twin also had classic autism or a milder “autism spectrum” disorder like Asperger’s syndrome. Identical twins share 100 percent of their genes; fraternal twins share 50 percent of their genes. So comparing autism rates in both types of twins can enable researchers to measure the importance of genes versus shared environment. The study found that autism or autism spectrum disorders occurred in both children in 77 percent of the male identical twins and in 50 percent of the female identical twins. As expected, the rates among fraternal twins were lower: 31 percent of males and 36 percent of females. But surprisingly, mathematical modeling suggested that only 38 percent of the cases could be attributed to genetic factors, compared with the 90 percent suggested by previous studies. And more surprising still, shared environmental factors appeared to be at work in 58 percent of the cases. “We, like everyone else, were very surprised because we didn’t expect it to be that high,” said a senior author of the study, Neil Risch, a geneticist and epidemiologist at the University of California, San Francisco. The rate of autism occurring in two siblings who are not twins is much lower, suggesting that the conditions the twins shared in the womb, rather than what they were exposed to after birth, contributed to the development of autism. A second article, also released early on the journal’s Web site, found an elevated risk of autism in children whose mothers took a popular type of antidepressant during the year before delivery. But the authors reassured women taking these drugs — so-called S.S.R.I.’s like Prozac, Zoloft, Celexa and Lexapro — that the risk was still quite low: 2.1 percent in children whose mothers used them in the year before delivery, and 2.3 percent in the first trimester of pregnancy. Dr. Joseph Coyle, the editor in chief of the psychiatry journal, called the two studies “game changers.” Clara Lajonchere, an author of the twin study and vice president of clinical programs for the research and advocacy organization Autism Speaks, said that “much more emphasis is going to be put on looking at prenatal and perinatal factors with respect to autism susceptibility.” She added, “We need to not just study the environmental factors, but the relation between the genes and the environment.” “For pregnant women or those thinking about having a family,” she said, “prenatal care is critical, and if a pregnant woman is taking any kinds of medication, she should work closely with a physician.”

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Personal Health: Water Holds Pleasures, and Menaces That Lurk Posted: 12 Jul 2011 09:57 AM PDT I learned to swim at age 3 at Brighton Beach, where each morning, June to October, my father swam freestyle back and forth between the rock jetties. Summering near water was a family essential as I was growing up, a pleasure I carried into adulthood. For more than 30 summers, I swam daily from Minnesota to Wisconsin and back against the current of the scenic St. Croix River. In my 40s, I joined the local YMCA so I could swim year-round. Enlarge This Image Yvetta Fedorova Related Simple Ways to Prevent Injuries and Drownings (July 12, 2011) Swimming is the second most popular sports activity in this country (after walking), replete with health benefits. Swimmers have about half the risk of death of inactive people. Swimming can improve both mental and physical well-being, and it is ideal for people with chronic ailments like arthritis, fibromyalgia, anxiety disorders and physical disabilities — not to mention the temporary relief from gravity it can bring to pregnant women. For me, swimming is also a meditation exercise; with nothing but the water to distract me, I get some of my best ideas while swimming laps. Dr. Oliver Sacks, the neurologist and best-selling author, wrote in an autobiographical essay called “Water Babies” that the mind-altering properties of swimming can inspire as nothing else can. But whether you swim in a river, lake, ocean or pool, the last thing you want afterward is what the Centers for Disease Control and Prevention calls a “recreational water illness,” an infection or irritation caused by germs or chemicals contaminating the water. These unseen pollutants can cause ailments of the ears, eyes, skin, nervous system, gastrointestinal and respiratory tracts, and any cut or scratch you may have. Five years ago, the centers examined 78 waterborne disease outbreaks in 31 states associated with recreational sports, a “substantial increase” in the number of reports from previous years. The outbreaks involved 4,412 cases of illness, 116 hospitalizations and five deaths. And while you might expect otherwise, fully 94 percent of the cases resulted from swimming in treated water — pools and the like that were supposed to be sanitized. The usual culprit was a bacterium called Cryptosporidium, which is resistant to chlorine. Fortunately, there are measures every swimmer can take to keep water play safe. The most common problem is diarrhea from swallowing water contaminated with germ-laden feces. Should one swimmer have diarrhea, the millions of germs in that person’s stool “can easily contaminate the water in a large pool or water park,” the C.D.C. reports. Natural waters can become contaminated with fecal and other germs by sewage overflow, storm water runoff, boating wastes and septic systems that malfunction. It is a myth that seawater quickly kills pathogens; coastal waters in particular are rich in nutrients that enable bacteria to survive despite the salt. Viruses can be even more of a problem, because they live longer than bacteria in saltwater. In one study of beaches in Texas, intestinal viruses were found in more than 40 percent of waters listed as safe for recreational swimming based on bacterial standards. Protection starts by following usual health department rules to shower before entering a pool — not just a superficial rinse but a full-body soak with special attention to germ-laden body parts. Respect fellow swimmers by staying out of the water if you have a diarrheal illness. Keep ill babies away, too — swim diapers are no guarantee that they won’t sicken others. Be sure pool water is tested regularly for proper chemical balance: twice a day in public facilities and two or more times a week in private ones. Concerned swimmers can invest in chlorine test strips (available at pool supply and home improvement stores) to check the level of disinfectant. Inflatable and hard plastic kiddie pools are often breeding grounds for infectious organisms. Most are filled with tap water without added disinfectants. The C.D.C. recommends that children be given “a cleansing soap shower or bath” before they use a kiddie pool, which should be emptied and scrubbed clean after each use. Finally, stay out of water that has been closed by pool or health officials, whose job it is to make sure that water is safe for swimming. But even a well-maintained swim site can result in inflammation of the ears and eyes. So-called swimmer’s ear (acute otitis externa) results in pain, tenderness, redness and swelling of the external ear canal, usually caused by a bacterial infection in the outer ear canal. Residual moisture is the primary culprit, and the best preventive is to keep the ear canals dry with earplugs or a tight-fitting cap. After swimming, tilt your ear first to one side then the other and shake out any water that got in. Then dry your ears thoroughly with a towel (or hair dryer set on low) and alcohol-based ear drops. Eyes are even easier to protect. I use goggles wherever I swim, both to protect my eyes and help me see. Wear goggles that fit snugly and are your own. Borrowed goggles could be contaminated with germs that cause conjunctivitis (better known as pinkeye). Without goggles, the chemicals used to disinfect pools can irritate your eyes, especially when combined with human urea or sunlight. If your eyes are immersed in pool water, one competitive swimmer suggests neutralizing the chlorine with a few drops of milk. The salt in ocean water can also be irritating. In addition to polluting microbes, ocean waters sometimes have free-swimming organisms that cause swimmer’s itch, as well as the stinging cells of jellyfish. Swimmer’s itch, or cercarial dermatitis, is a rash caused by an allergic reaction to microscopic parasites of birds and mammals that are released into both fresh water and saltwater by snails, their intermediate hosts. Avoid swimming in areas where snails are common or where signs have been posted warning of this problem or the presence of jellyfish. To counter the effects of swimmer’s itch, use a corticosteroid or anti-itch cream, and bathe in Epsom salts or baking soda. If stung by jellyfish, try dabbing the skin with vinegar to neutralize the toxin and relieve the pain. People with a bee sting allergy should be especially careful to stay out of waters containing jellyfish. If you are allergic to one, you may well be allergic to the other.

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Doctors Inc.: New for Aspiring Doctors, the People Skills Test Posted: 11 Jul 2011 12:58 PM PDT ROANOKE, Va. — Doctors save lives, but they can sometimes be insufferable know-it-alls who bully nurses and do not listen to patients. Medical schools have traditionally done little to screen out such flawed applicants or to train them to behave better, but that is changing. Enlarge This Image Jeremy M. Lange for The New York Times Applicants prepared for the first phase of the “multiple mini interview” at Virginia Tech Carilion. Teamwork Wanted Articles in this series are examining recent shifts in medical care. Previous Article in the Series » Are You a Doctor? Share your insights on the changing medical profession with The New York Times and the Public Insight Network from American Public Media. Tell us your story. Well Share your thoughts on this column at the Well blog. Go to Well » Enlarge This Image Jeremy M. Lange for The New York Times Allison Brown digested a description of an ethical conundrum that served as the subject of a short interview during the admissions process at the Virginia Tech Carilion School of Medicine. At Virginia Tech Carilion, the nation’s newest medical school, administrators decided against relying solely on grades, test scores and hourlong interviews to determine who got in. Instead, the school invited candidates to the admissions equivalent of speed-dating: nine brief interviews that forced candidates to show they had the social skills to navigate a health care system in which good communication has become critical. The new process has enormous consequences not only for the lives of the applicants but, its backers hope, also for the entire health care system. It is called the multiple mini interview, or M.M.I., and its use is spreading. At least eight medical schools in the United States — including those at Stanford, the University of California, Los Angeles, and the University of Cincinnati — and 13 in Canada are using it. At Virginia Tech Carilion, 26 candidates showed up on a Saturday in March and stood with their backs to the doors of 26 small rooms. When a bell sounded, the applicants spun around and read a sheet of paper taped to the door that described an ethical conundrum. Two minutes later, the bell sounded again and the applicants charged into the small rooms and found an interviewer waiting. A chorus of cheerful greetings rang out, and the doors shut. The candidates had eight minutes to discuss that room’s situation. Then they moved to the next room, the next surprise conundrum and the next interviewer, who scored each applicant with a number and sometimes a brief note. The school asked that the actual questions be kept secret, but some sample questions include whether giving patients unproven alternative remedies is ethical, whether pediatricians should support parents who want to circumcise their baby boys and whether insurance co-pays for medical visits are appropriate. Virginia Tech Carilion administrators said they created questions that assessed how well candidates think on their feet and how willing they are to work in teams. The most important part of the interviews are often not candidates’ initial responses — there are no right or wrong answers — but how well they respond when someone disagrees with them, something that happens when working in teams. Candidates who jump to improper conclusions, fail to listen or are overly opinionated fare poorly because such behavior undermines teams. Those who respond appropriately to the emotional tenor of the interviewer or ask for more information do well in the new admissions process because such tendencies are helpful not only with colleagues but also with patients. “We are trying to weed out the students who look great on paper but haven’t developed the people or communication skills we think are important,” said Dr. Stephen Workman, associate dean for admissions and administration at Virginia Tech Carilion. Dr. Charles Prober, senior associate dean at the Stanford University School of Medicine, said Stanford always valued social skills in students — particularly the ability to work collaboratively with colleagues and establish trust with patients — but did not have a reliable way of ferreting these skills out until adopting mini interviews. The system grew out of research that found that interviewers rarely change their scores after the first five minutes, that using multiple interviewers removes random bias and that situational interviews rather than personal ones are more likely to reveal character flaws, said Dr. Harold Reiter, a professor at McMaster University in Hamilton, Ontario, who developed the system. In fact, candidate scores on multiple mini interviews have proved highly predictive of scores on medical licensing exams three to five years later that test doctors’ decision-making, patient interactions and cultural competency, Dr. Reiter said. A pleasant bedside manner and an attentive ear have always been desirable traits in doctors, of course, but two trends have led school administrators to make the hunt for these qualities a priority. The first is a growing catalog of studies that pin the blame for an appalling share of preventable deaths on poor communication among doctors, patients and nurses that often results because some doctors, while technically competent, are socially inept. 1 2 Next Page »

As Same-Sex Marriage Becomes Legal, Some Choices May Be Lost Posted: 11 Jul 2011 02:43 PM PDT Now that same-sex marriage has been legalized in New York, at least a few large companies are requiring their employees to tie the knot if they want their partners to qualify for health insurance. Enlarge This Image Michael Falco for The New York Times Ross Levi of Empire State Pride Agenda said some companies were making changes too quickly. Bucks Companies That Make Gay Couples Marry to Get Benefits Should companies require gay employees to marry if they want health coverage for their same-sex partners? Post a Comment Add to Portfolio Raytheon Co International Business Machines Corporation Eastman Kodak Co Corning Inc Go to your Portfolio » Corning, I.B.M. and Raytheon all provide domestic partner benefits to employees with same-sex partners in states where they cannot marry. But now that they can legally wed in New York, five other states and the District of Columbia, they will be required to do so if they want their partner to be covered for a routine checkup or a root canal. On the surface, this appears to put the couples on an even footing with heterosexual married couples. After all, this is precisely what they have been fighting for: being treated as a spouse. But some gay and lesbian advocates are arguing that the change may have come too soon: some couples may face complications, since their unions are not recognized by the federal government. “Even with the complications, many people will want to get married for the reasons people want to get married,” said Ross D. Levi, executive director of the Empire State Pride Agenda. “But from our perspective, to hinge something as important as insurance for your family to what is still a complicated legal matter for same-sex couples doesn’t seem to be a fair thing to do.” He said that there were a variety of reasons — legal, financial and personal — that companies should keep the domestic partnership option at least until gay marriage was recognized at the federal level. Legally speaking, getting married could create immigration issues or it could potentially muddy the process of adopting a child. In some instances, he added, an employee may work in a gay marriage state but live in a neighboring state that does not recognize the marriage. The couple may want to wait to marry until they can be legally wed in their home state. “There are certainly reasons why a couple may not wish to marry,” added Camilla Taylor, marriage project director at Lambda Legal. “People with certain immigration statuses might want to think very carefully before getting married. There are some types of visas that are meant to be temporary, and if you get married to someone who is a citizen, it could flag your renewal application and reflect your more permanent decision to stay.” When it comes to adopting a child, couples may run into trouble if they are trying to adopt from a place that restricts same-sex married couples from adopting. Having one parent adopt while still single may be easier. “If you want to be able to answer honestly in paperwork, multiple interviews and background checks, then you won’t want to get married,” Ms. Taylor said, adding that many foreign countries ban adoptions to same-sex couples. Marrying could also have serious implications for couples who relocate to a nonmarriage state, and ultimately decide to split up. Getting a divorce can be complicated, since one member of a couple may have to return to the gay marriage state and live there before their split can be completed. The employers making the changes said they spoke regularly with their gay and lesbian employee groups and planned to phase in the requirement. Corning, based in Corning, N.Y., said it would offer a reasonable grace period, though it had not completed the details. “After waiting so much time for that right, we want them to have the opportunity to enjoy that,” said Christy Pambianchi, a senior vice president for human resources at Corning, which put the policy into effect in New Hampshire and Massachusetts when gay marriage became legal there. She said employees did not raise concerns about the requirement. “They are delighted,” she said. Raytheon, based in Waltham, Mass. — another state where gay marriage is legal — said it would give employees several months to comply with its marriage requirement. Like Corning and I.B.M., the company said domestic partner benefits would remain in states where couples cannot marry (Raytheon also has an exemption for active members of the military, so they are covered for benefits without having to marry. Getting married violates the “don’t ask, don’t tell” policy, which is being phased out). I.B.M., based in Armonk, N.Y., said its workers would have up to a year to get married to maintain their current benefits. At least for now, these companies seem to be in the minority, though it is unclear whether more employers will follow their lead. Eastman Kodak, based in Rochester, said it would continue to offer domestic partner coverage to both same-sex and opposite-sex partners. “My impression is that there has been lots of discussion about dropping domestic partner coverage when marriage is first opened up to same-sex couples, but very few employers actually end up taking this step,” said Jennifer C. Pizer, legal director at the Williams Institute, which studies sexual orientation law and policy issues. “Some employers initially believe that it is fairer of them to impose the same marriage requirements on all employees, regardless of sexual orientation. But then employees and others explain that employees with a same-sex life partner remain in difficult circumstances due to the continuing federal discrimination.” Whether same-sex couples marry, they will still be responsible for paying federal income taxes on the value of their partner or spouse’s benefits since they are not recognized by the federal government as an economic unit, unless the person covered is considered a dependent. Couples will not owe those taxes at the state level in places like New York that recognize gay marriage. But it should become easier for gay employees who marry and live in New York to obtain insurance for their spouses. (There are an estimated 42,000 same-sex couples in New York, according to the Williams Institute.) Not only are the same-sex spouses of state workers eligible for spousal coverage, but the same goes for many people who work for private employers. There could be some exceptions, however. Employers who do not contract with an insurance company but instead pay for health benefits out of their own assets — so-called self-insured plans — are not subject to the state’s insurance laws but are governed by federal law. Most large employers have self-insured plans, said Helen Darling, president of the National Business Group on Health, a membership organization that focuses on health policies for large employers. That means they can choose to cover same-sex employees, but they do not have to. While virtually all large company plans cover legal spouses, she added, some companies offer domestic partner benefits only to gay employees who do not have the option to marry. (Some companies also extend the benefits to heterosexual unmarried couples.) “I am getting a lot of questions about what other employers are doing,” Ms. Darling said. “I see a movement coming where marriage will be a factor where marriage is possible.”

First Study of Its Kind Shows Benefits of Providing Medical Insurance to Poor Posted: 06 Jul 2011 11:10 PM PDT When poor people are given medical insurance, they not only find regular doctors and see doctors more often but they also feel better, are less depressed and are better able to maintain financial stability, according to a new, large-scale study that provides the first rigorously controlled assessment of the impact of Medicaid. Related Administration Offers Health Care Cuts as Part of Budget Negotiations (July 5, 2011) Times Topic: Medicaid While the findings may seem obvious, health economists and policy makers have long questioned whether it would make any difference to provide health insurance to poor people. It has become part of the debate on Medicaid, at a time when states are cutting back on this insurance program for the poor. In fact, the only reason the study could be done was that Oregon was running out of money and had to choose some people to get insurance and exclude others, providing groups for comparison. Some said that of course it would help to insure the uninsured. Others said maybe not. There was already a safety net: emergency rooms, charity care, free clinics and the option to go to a doctor and simply not pay the bill. And in any case, the argument goes, if Medicaid coverage is expanded, people will still have trouble seeing a doctor because so few accept that insurance. Until now, the arguments were pretty much irresolvable. Researchers compared people who happened to have insurance with those who did not have it. But those who do not have insurance tend to be different in many ways from people who have it. They tend to be less educated and to have worse health habits and lower incomes, said Dr. Alan M. Garber, an internist and health economist at Stanford. No matter how carefully researchers try to correct for the differences “they cannot be completely successful,” Dr. Garber said. “There is always some doubt.” The new study, published Thursday by the National Bureau of Economic Research, avoided that problem. Its design is like that used to test new drugs. People were randomly selected to have Medicaid or not, and researchers then asked if the insurance made any difference. Health economists and other researchers said the study was historic and would be cited for years to come, shaping health care debates. “It’s obviously a really important paper,” said James Smith, an economist at the RAND Corporation. “It is going to be a classic.” Richard M. Suzman, director of the behavioral and social research program at the National Institute on Aging, a major source of financing for the research, said it was “one of the most important studies that our division has funded since I’ve been at the N.I.A.,” a period of more than a quarter-century. In its first year of data collection, the study found a long list of differences between the insured and uninsured, adding up to an extra 25 percent in medical expenditures for the insured. Those with Medicaid were 35 percent more likely to go to a clinic or see a doctor, 15 percent more likely to use prescription drugs and 30 percent more likely to be admitted to a hospital. Researchers were unable to detect a change in emergency room use. Women with insurance were 60 percent more likely to have mammograms, and those with insurance were 20 percent more likely to have their cholesterol checked. They were 70 percent more likely to have a particular clinic or office for medical care and 55 percent more likely to have a doctor whom they usually saw. The insured also felt better: the likelihood that they said their health was good or excellent increased by 25 percent, and they were 40 percent less likely to say that their health had worsened in the past year than those without insurance. The study is now in its next phase, an assessment of the health effects of having insurance. The researchers interviewed 12,000 people — 6,000 who received Medicaid and 6,000 who did not — and measured things like blood pressure, cholesterol and weight. The study became possible because of an unusual situation in Oregon. In 2008, the state wanted to expand its Medicaid program to include more uninsured people but could afford to add only 10,000 to its rolls. Yet nearly 90,000 applied. Oregon decided to select the 10,000 by lottery. Economists were electrified. Here was their chance to compare those who got insurance with those who were randomly assigned to go without it. No one had ever done anything like that before, in part because it would be considered unethical to devise a study that would explicitly deny some people coverage while giving it to others. But this situation was perfect for assessing the impact of Medicaid, said Katherine Baicker, professor of health economics at the Harvard School of Public Health. Dr. Baicker and Amy Finkelstein, professor of economics at M.I.T., are the principal investigators for the study. “Amy and I stumbled across the lottery in Oregon and thought, ‘This is an unbelievable opportunity to actually find out once and for all what expanding public health insurance does,’ ” Dr. Baicker said. They had just a short window of time. Within two years, Oregon found the money to offer Medicaid to the nearly 80,000 who had been turned down in the lottery. As an economist, Dr. Finkelstein was interested, among other things, in whether Medicaid did what all insurance — homeowner’s, auto, health — is supposed to do: shield people from financial catastrophe. Almost no one had even tried to investigate that question, she said. “It is shocking that it is not even in the discourse,” Dr. Finkelstein said. The study found that those with insurance were 25 percent less likely to have an unpaid bill sent to a collection agency and were 40 percent less likely to borrow money or fail to pay other bills because they had to pay medical bills. Dr. Finkelstein said she had thought that the people were so poor to begin with that they just did not spend very much out of pocket on medical care when they did not have insurance. “Yet look at the results,” she said. Dr. Baicker interviewed people for Part 2 of the study and was impressed by what she heard. “Being uninsured is incredibly stressful from a financial perspective, a psychological perspective, a physical perspective,” she said. “It is a huge relief to people not to have to worry about it day in and day out.”

Obama Summons G.O.P. and Democratic Leaders for Deficit Reduction Talks Posted: 05 Jul 2011 10:48 PM PDT WASHINGTON — President Obama stepped up pressure on Congressional Republicans on Tuesday to agree to a broad deficit-cutting deal, pledging to put popular entitlement programs like Medicare on the table in return for Republican acquiescence to some higher taxes. Post a Comment Related The Caucus: Reid Shifts Senate Attention From Libya to Debt Limit Times Topic: Federal Debt Limit (Debt Ceiling) Blogs The Caucus The latest on President Obama, the new Congress and other news from Washington and around the nation. Join the discussion. FiveThirtyEight: Nate Silver's Political Calculus More Politics News Enlarge This Image Stephen Crowley/The New York Times In the Senate, Jeff Sessions, Republican of Alabama, spoke to other members of the Senate Budget Committee. Mr. Obama, who met secretly with Speaker John A. Boehner at the White House on Sunday to try to advance the talks, called House and Senate leaders from both parties to the White House for further negotiations on Thursday. And he rejected talk of an interim deal that would get the government past a looming deadline on raising the federal debt limit without settling some of the longer-term issues contributing to the government’s fiscal imbalances. “We’ve got a unique opportunity to do something big, to tackle our deficit in a way that forces our government to live within its means,” he said in an appearance in the White House briefing room, casting himself as much an honest broker as a partisan participant in the talks. “This will require both parties to get out of our comfort zones, and both parties to agree on real compromise.” Mr. Obama’s previously undisclosed Sunday meeting with Mr. Boehner suggests that the talks are entering a critical phase. There were also intense staff-level negotiations between the White House and Congress over the details of a multi-trillion-dollar package of spending cuts that could clear the way for a vote to raise the debt ceiling, constrain the growth of government and radically reshape the role of government in American society. The two sides remain in a deadlock over the president’s insistence that the package contain tax increases as well as spending cuts. While Mr. Obama did not retreat from that demand Tuesday, he coupled it with a pledge to take on spending in “entitlement programs,” a promise likely to unsettle many Democrats. While a broad-based agreement may appeal to the White House, neither Senate Republicans nor Democrats may be as eager to embrace one. Democrats worry that a deal that cuts Medicare could rob them of what they see as their political advantage on the issue; Republicans trying to win the majority next year might not like an agreement that is seen as giving Democrats credibility on reducing the deficit. But Mr. Boehner, while again saying that higher taxes were a nonstarter, expressed pleasure at Mr. Obama’s willingness to single out entitlements. “I’m pleased the president stated today that we need to address the big, long-term challenges facing our country,” he said in a statement. The speaker’s session with Mr. Obama was their first face-to-face encounter since the talks presided over by Vice President Joseph R. Biden Jr. collapsed last month, officials with knowledge of the meeting said, though the speaker and the president also met privately just before those discussions broke up. The substance of their talks was not disclosed. But Mr. Boehner’s meeting was evidently made known to other House and Senate Republican leaders. Mr. Obama said the two sides needed to reach a deal within two weeks to pass legislation before Aug. 2, when the Treasury Department says the government risks defaulting on its debt. And he restated that Congress should not procrastinate and let negotiations “come down to the last second.” Senate Republicans have suggested in recent days that a “mini-deal” be struck, which would allow the government to get past the Aug. 2 deadline but leave the larger fiscal choices to be thrashed out in the 2012 election. The president rejected that, saying: “I don’t think the American people sent us here to avoid tough problems. That’s, in fact, what drives them nuts about Washington, when both parties simply take the path of least resistance.” Still, Mr. Obama eased his tone noticeably from his feisty news conference last week, in which he compared the work habits of lawmakers unfavorably with those of his daughters, Malia and Sasha. “It’s my hope that everybody’s going to leave their ultimatums at the door, that we’ll all leave our political rhetoric at the door,” he said. Mr. Obama also eschewed a populist tone, making no reference to “millionaires and billionaires” or owners of corporate jets, even as he spoke of the necessity of eliminating tax breaks and loopholes. The budget impasse is dominating the White House and Congress. With Republicans protesting that the Senate should be concentrating on fiscal issues this week, Senator Harry Reid, the Nevada Democrat and majority leader, conceded the point on Tuesday and abruptly called off a planned debate on Libya. After complaints by Republicans that their Fourth of July break had been canceled to deal with the debt-limit fight and not Libya, Mr. Reid essentially threw in the towel and said the Senate would instead take nonbinding votes later this week on how to address the debt-limit dispute. “Notwithstanding the broad support for the Libya resolution, the most important thing to focus on this week is the budget,” Mr. Reid said. Senator Mitch McConnell of Kentucky, the Republican leader, restated his opposition to any budget deal containing new taxes. He accused Democrats of a “cheap attempt” at making Republicans look bad by saying that Republicans refused to consider ending a tax break for corporate jets. Senate Democratic leaders last week called off their planned Fourth of July break due to the Aug. 2 deadline. But the budget talks are occurring mainly off the floor in leadership offices and at the White House so Mr. Reid scheduled the bipartisan Libya resolution for floor debate.

Vital Signs: Nostrums: Cutting Salt Has Little Effect on Heart Risk Posted: 13 Jul 2011 12:40 AM PDT Cutting down on salt may lower blood pressure, but there is no evidence that it leads to fewer deaths or reduces the risk of heart attack or stroke in the long run, according to a new report. Related Health Guide: High Blood Pressure The meta-analysis, by The Cochrane Review, included six randomized clinical trials. It found that people who cut their dietary salt intake in half were able to modestly lower their blood pressure. Medication, however, was more effective than dietary change. But even when the trials were examined collectively, they still were too small to provide proof of significant differences in heart events and deaths, possibly because people have a hard time sticking to a low-salt diet over time, the authors said. Much of the earlier evidence that suggested greater benefits from low-sodium diets was drawn from observational studies comparing different population groups, rather than randomized trials, which are considered the gold standard in medicine, said the review’s lead author, Rod S. Taylor, professor of health services research at Peninsula Medical School at University of Exeter in England. Dr. Taylor said that people should still try to limit salt in food but that additional steps, like warning labels about salt content in processed foods, are needed. “The results do not mean that asking people to reduce salt intake is not a good thing,” he said.

Vital Signs: Risks: Perhaps July’s Reputation Is Justified Posted: 11 Jul 2011 11:40 PM PDT Until recently there was little proof that medical errors spike in the summer when new medical trainees start working at teaching hospitals — a phenomenon known as the “July effect.” But a new review has found evidence that death rates do increase in July, and that many patients stay in the hospital longer than in other months. Related More Vital Signs Columns The paper, published Tuesday in Annals of Internal Medicine, is believed to be the first systematic review of the data from previous studies. While the analysis found inconsistencies among nearly 40 studies examined, the data produced by the largest and best-designed ones indicated that patient death rates in teaching hospitals increase by 8 percent in July. Those studies also reported longer hospital stays, more drawn-out procedures and higher hospital charges in July, when 20 to 30 percent of the more experienced doctors-in-training leave and a class of newly minted doctors starts working at teaching hospitals, said Dr. John Q. Young, the paper’s lead author, who is associate program director for the residency training program in psychiatry at the University of California, San Francisco. “This changeover is dramatic, and it affects everything,” Dr. Young said. “It’s like a football team in a high-stakes game, and in the middle of that final drive you bring out four or five players who never played in the pros before and don’t know the playbook, and the players that remained get changed to positions they never played before, and they never practiced together. That’s what happens in July.”

Vital Signs: Childbirth: Wait to Restart the Pill, C.D.C. Says Posted: 11 Jul 2011 11:40 PM PDT Women who have just given birth should wait at least three weeks before they start using birth control pills because of the risk of serious, potentially fatal blood clots, public health officials announced last week. Women who deliver by Caesarean section or have other risk factors for blood clots — like obesity or a history of previous blood clots — should wait at least six weeks before using these medications, they said. Related Health Guide: Birth Control More Vital Signs Columns The new recommendations, by the Centers for Disease Control and Prevention, are more restrictive than guidelines issued last year and are similar to recommendations made in 2010 by the World Health Organization. Women are far more likely to develop a blood clot in the weeks after delivery than nonpregnant women of reproductive age who have not just had a baby, several studies have shown. The risk declines rapidly after 21 days but does not return to normal until 42 days after delivery. Birth control pills that include both estrogen and progestin also increase the risk of blood clots in the deep veins (venous thromboembolism). Women who are breast-feeding may want to avoid hormonal contraceptives because they can interfere with lactation, the C.D.C. said. The guidelines were published in the C.D.C.’s Morbidity and Mortality Weekly Report on Friday.

How Bright Promise in Cancer Testing Fell Apart Posted: 14 Jul 2011 01:30 PM PDT When Juliet Jacobs found out she had lung cancer, she was terrified, but realized that her hope lay in getting the best treatment medicine could offer. So she got a second opinion, then a third. In February of 2010, she ended up at Duke University, where she entered a research study whose promise seemed stunning. Doctors would assess her tumor cells, looking for gene patterns that would determine which drugs would best attack her particular cancer. She would not waste precious time with ineffective drugs or trial-and-error treatment. The Duke program — considered a breakthrough at the time — was the first fruit of the new genomics, a way of letting a cancer cell’s own genes reveal the cancer’s weaknesses. But the research at Duke turned out to be wrong. Its gene-based tests proved worthless, and the research behind them was discredited. Ms. Jacobs died a few months after treatment, and her husband and other patients’ relatives have retained lawyers. The episode is a stark illustration of serious problems in a field in which the medical community has placed great hope: using patterns from large groups of genes or other molecules to improve the detection and treatment of cancer. Companies have been formed and products have been introduced that claim to use genetics in this way, but assertions have turned out to be unfounded. While researchers agree there is great promise in this science, it has yet to yield many reliable methods for diagnosing cancer or identifying the best treatment. Instead, as patients and their doctors try to make critical decisions about serious illnesses, they may be getting worthless information that is based on bad science. The scientific world is concerned enough that two prominent groups, the National Cancer Institute and the Institute of Medicine, have begun examining the Duke case; they hope to find new ways to evaluate claims based on emerging and complex analyses of patterns of genes and other molecules. So far, the Food and Drug Administration “has generally not enforced” its regulation of tests created by individual labs because, until recently, such tests were relatively simple and relied heavily on the expertise of a particular doctor, said Erica Jefferson, a spokeswoman for the agency. But now, with labs offering more complex tests on a large scale, the F.D.A. is taking a new look at enforcement. Dr. Scott Ramsey, director of cancer outcomes research at the Fred Hutchinson Cancer Center in Seattle, says there is already “a mini-gold rush” of companies trying to market tests based on the new techniques, at a time when good science has not caught up with the financial push. “That’s the scariest part of all,” Dr. Ramsey said. Doctors say the heart of the problem is the intricacy of the analyses in this emerging field and the difficulty in finding errors. Even well-respected scientists often “oversee a machine they do not understand and cannot supervise directly” because each segment of the research requires different areas of expertise, said Dr. Lajos Pusztai, a breast cancer researcher at M. D. Anderson Cancer Center at the University of Texas. As a senior scientist, he added, “It’s true for me, too.” The Duke case came right after two other claims that gave medical researchers pause. Like the Duke case, they used complex analyses to detect patterns of genes or cell proteins. But these were tests that were supposed to find ovarian cancer in patients’ blood. One, OvaSure, was developed by a Yale scientist, Dr. Gil G. Mor, licensed by the university and sold to patients before it was found to be useless. The other, OvaCheck, was developed by a company, Correlogic, with contributions from scientists from the National Cancer Institute and the Food and Drug Administration. Major commercial labs licensed it and were about to start using it before two statisticians from M. D. Anderson discovered and publicized its faults. The Duke saga began when a prestigious journal, Nature Medicine, published a paper on Nov. 6, 2006, by Dr. Anil Potti, a cancer researcher at Duke University Medical Center; Joseph R. Nevins, a senior scientist there; and their colleagues. They wrote about genomic tests they developed that looked at the molecular traits of a cancerous tumor and figured out which chemotherapy would work best. Other groups of cancer researchers had been trying to do the same thing. “Our group was despondent to get beaten out,” said Dr. John Minna, a lung cancer researcher at the University of Texas Southwestern Medical Center. But Dr. Minna rallied; at the very least, he thought, he would make use of this incredible discovery to select drugs for lung cancer patients. First, though, he asked two statisticians at M. D. Anderson, Keith Baggerly and Kevin Coombes, to check the work. Several other doctors approached them with the same request. Dr. Baggerly and Dr. Coombes found errors almost immediately. Some seemed careless — moving a row or a column over by one in a giant spreadsheet — while others seemed inexplicable. The Duke team shrugged them off as “clerical errors.” And the Duke researchers continued to publish papers on their genomic signatures in prestigious journals. Meanwhile, they started three trials using the work to decide which drugs to give patients. Dr. Baggerly and Dr. Coombes tried to sound an alarm. They got the attention of the National Cancer Institute, whose own investigators wanted to use the Duke system in a clinical trial but were dissuaded by the criticisms. Finally, they published their analysis in The Annals of Applied Statistics, a journal that medical scientists rarely read. The situation finally grabbed the cancer world’s attention last July, not because of the efforts of Dr. Baggerly and Dr. Coombes, but because a trade publication, The Cancer Letter, reported that the lead researcher, Dr. Potti, had falsified parts of his résumé. He claimed, among other things, that he had been a Rhodes scholar. “It took that to make people sit up and take notice,” said Dr. Steven Goodman, professor of oncology, pediatrics, epidemiology and biostatistics at Johns Hopkins University. In the end, four gene signature papers were retracted. Duke shut down three trials using the results. Dr. Potti resigned from Duke. He declined to be interviewed for this article. His collaborator and mentor, Dr. Nevins, no longer directs one of Duke’s genomics centers. The cancer world is reeling. The Duke researchers had even set up a company — now disbanded — and planned to sell their test to determine cancer treatments. Duke cancer patients and their families, including Mrs. Jacobs’s husband, Walter Jacobs, say they feel angry and betrayed. And medical researchers see the story as a call to action. With such huge data sets and complicated analyses, researchers can no longer trust their hunches that a result does — or does not — make sense. “Our intuition is pretty darn poor,” Dr. Baggerly said.

Recipes for Health: Cherry Cobbler With Almond-Buttermilk Topping Posted: 14 Jul 2011 12:00 AM PDT The topping for this almond-scented cobbler is a buttermilk biscuit batter made with a mixture of flours. Cornmeal contributes texture, and whole-wheat and almond flours add nuttiness. For a gluten-free version, substitute almond meal or rice flour for the whole-wheat flour. 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: A Short Season for Cherries (July 11, 2011) Recipes for Health: Cherry Almond Smoothie (July 12, 2011) Recipes for Health: Cold Cherry Soup (July 13, 2011) Recipes for Health: Morning Oatmeal With Cherries and Pistachios (July 15, 2011) 1 1/2 pounds cherries, stemmed and pitted (about 5 cups) 2 tablespoons sugar 1 tablespoon fresh lemon juice 1 tablespoon sifted all-purpose flour 1/4 teaspoon almond extract For the topping: 1/2 cup whole-wheat pastry flour 1/2 cup almond meal, also called almond flour or almond powder (1 1/2 ounces) 1/2 cup fine cornmeal 2 teaspoons baking powder 1/2 teaspoon baking soda 1/4 cup sugar 1/4 teaspoon salt 5 tablespoons cold unsalted butter, cut into 1/2-inch pieces 2/3 cup buttermilk 1. Preheat the oven to 400 degrees. Butter a 2-quart baking dish. Place the cherries in a large bowl, and add the sugar, lemon juice and all-purpose flour. Carefully mix them together with a rubber spatula or a large spoon until the sugar and flour have dissolved into the liquids. Transfer to the baking dish, making sure to scrape out all of the liquid in the bowl. 2. Sift all of the dry ingredients for the topping. If some of the cornmeal and almond flour remain in the sifter, just dump it into the bowl with the sifted flours. Place in the bowl of a food processor fitted with the steel blade, and pulse a few times. Add the butter, and pulse to cut in the butter until the mixture looks like coarse cornmeal. Turn on the food processor, and pour in the buttermilk with the machine running. As soon as the dough comes together, stop the machine. 3. Spoon the topping over the cherries by the heaped tablespoon. The cherries should be just about covered but may peek out here and there. Place in the oven, and bake 35 to 40 minutes until the top is nicely browned and the cherries are bubbling. Remove from the heat, and allow to cool to warm before serving. Serve warm (heat in a low oven for 15 minutes if necessary before serving). Yield: Serves eight. Advance preparation: You can make this several hours before serving, but reheat and serve warm. Nutritional information per serving: 260 calories; 5 grams saturated fat; 1 gram polyunsaturated fat; 4 grams monounsaturated fat; 20 milligrams cholesterol; 38 grams carbohydrates; 4 grams dietary fiber; 274 milligrams sodium; 5 grams protein Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

Recipes for Health: Cold Cherry Soup Posted: 13 Jul 2011 12:10 AM PDT Many versions of cold cherry soup originated in Hungary and Poland, where cooks would use sour cherries and a lot of sugar. Traditional cherry soups also are made with sour cream and heavy cream, and sometimes they are thickened with flour. I like this lighter version, which is made with drained yogurt instead of cream. 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: A Short Season for Cherries (July 11, 2011) Recipes for Health: Cherry Almond Smoothie (July 12, 2011) Recipes for Health: Cherry Cobbler With Almond-Buttermilk Topping (July 14, 2011) Recipes for Health: Morning Oatmeal With Cherries and Pistachios (July 15, 2011) 5 cups water 1/2 cup sugar 1/2 cup red wine 1/4 teaspoon salt Grated zest of 1/2 lemon 1 1/2 pounds sweet, dark cherries 1 cup drained yogurt 1. Pit the cherries, and place the pitted cherries in a bowl and the pits in a large soup pot. Add the water to the pot, and bring to a boil. Reduce the heat and simmer five minutes. With a skimmer, remove the pits from the water. Add the sugar, red wine, salt and lemon zest, and bring back to a boil over medium-high heat. Boil five minutes, then add the cherries. Bring to a simmer, turn the heat to low, cover and simmer five minutes. Remove from the heat. 2. Place the yogurt in a large bowl and slowly whisk in a cup of the liquid from the soup once it is no longer simmering. Whisk until the mixture is smooth. Slowly add the rest of the soup, and whisk or stir until smooth. Allow to cool, stirring from time to time, then refrigerate until cold. Before serving, you will have to stir or whisk again, as the liquid and yogurt will separate. Still, the soup is easily homogenized. 3. Serve in bowls or in glass tumblers. If you wish, garnish with additional halved, pitted fresh cherries. Yield: Serves six to eight. Advance preparation: The soup will keep for two or three days in the refrigerator. (I found myself snacking on the leftovers -- very refreshing on a hot summer day.) Nutritional information per serving (six servings): 178 calories; 1 gram saturated fat; 0 grams polyunsaturated fat; 0 grams monounsaturated fat; 3 milligrams cholesterol; 37 grams carbohydrates; 2 grams dietary fiber; 116 milligrams sodium; 4 grams protein Nutritional information per serving (eight servings): 134 calories; 0 grams saturated fat; 0 grams polyunsaturated fat; 0 grams monounsaturated fat; 2 milligrams cholesterol; 28 grams carbohydrates; 2 grams dietary fiber; 87 milligrams sodium; 3 grams protein Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

Recipes for Health: Cherry Almond Smoothie Posted: 12 Jul 2011 03:09 PM PDT 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: A Short Season for Cherries (July 11, 2011) Recipes for Health: Cold Cherry Soup (July 13, 2011) Recipes for Health: Cherry Cobbler With Almond-Buttermilk Topping (July 14, 2011) Recipes for Health: Morning Oatmeal With Cherries and Pistachios (July 15, 2011) This dairy-free smoothie serves well at breakfast or as an afternoon snack. 12 cherries, pitted (about 3 ounces) 1/4 cup almond meal, also called almond flour or almond powder (3/4 ounce) 1/4 teaspoon almond extract 1/2 cup almond beverage or milk 1/2 plum or peach 1 teaspoon agave nectar 3 ice cubes 1. Place all of the ingredients in a blender, and blend until smooth. Yield: One serving. Advance preparation: This smoothie is best when freshly made but will keep for a few hours in the refrigerator. Shake well before drinking. Nutritional information per serving: 285 calories; 1 gram saturated fat; 4 grams polyunsaturated fat; 10 grams monounsaturated fat; 0 milligrams cholesterol; 33 grams carbohydrates; 6 grams dietary fiber; 85 milligrams sodium; 8 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Recipes for Health: A Short Season for Cherries Posted: 12 Jul 2011 03:10 PM PDT The season for freshly picked cherries is short, usually no longer than a month. And in most parts of the country, that month is July. 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: Cherry Almond Smoothie (July 12, 2011) Recipes for Health: Cold Cherry Soup (July 13, 2011) Recipes for Health: Cherry Cobbler With Almond-Buttermilk Topping (July 14, 2011) Recipes for Health: Morning Oatmeal With Cherries and Pistachios (July 15, 2011) Like other dark red, blue and purple fruits and vegetables, cherries contain anthocyanins, phytonutrients that some experts believe may help reduce inflammation and may have antioxidant properties. Because cherries are ripe when they’re picked, this is one fruit that will be sweet and juicy whether you buy it at a supermarket or a farmers’ market. I’ve tried a variety of different uses for them this week — including a soup, a smoothie and a cobbler — but a big bowl of cold, unadorned cherries is pretty hard to beat. Cherry Clafouti This classic French dessert looks fancy, but it is a cinch to make. I use yogurt in my clafouti, although it isn’t traditional (the French use cream). And I always enjoy leftovers for breakfast. 1 1/2 pounds (about 5 cups) fresh ripe cherries, stemmed and pitted if desired 2 tablespoons kirsch 6 tablespoons sugar 3 large eggs 1 vanilla bean, scraped Pinch of salt 2/3 cup sifted unbleached all-purpose flour 3/4 cup low-fat yogurt 2 tablespoons milk 2 teaspoons confectioners’ sugar (optional) 1. Toss the cherries with the kirsch and 2 tablespoons of the sugar, and let sit for 30 minutes. Drain over a bowl. 2. Preheat the oven to 375 degrees. Butter a 10- or 10 1/2-inch ceramic tart pan or clafouti dish. Fill the dish with the drained cherries. 3. In a medium bowl, beat the eggs with the remaining sugar and the seeds from the vanilla bean. Add the salt and the liquid from the cherries, and combine well. Slowly beat in the flour, and whisk until smooth. Add the yogurt and milk, and combine well. Pour over the cherries, scraping out all of the batter with a rubber spatula. 4. Bake in the preheated oven for 30 to 40 minutes until the top is browned and the clafouti is firm and puffed. Press gently on the top in the middle to see if it’s firm. If not, return to the oven for five minutes. 5. Remove from the oven and cool on a rack. When the clafouti is warm or cool, sift on the powdered sugar. Serve warm or at room temperature. Yield: Serves eight. Advance preparation: If you’re making this for a dinner, you can make it several hours ahead. The leftovers will keep for about three days in the refrigerator. Nutritional information per serving: 176 calories; 1 gram saturated fat; 0 grams polyunsaturated fat; 1 gram monounsaturated fat; 71 milligrams cholesterol; 33 grams carbohydrates; 2 grams dietary fiber; 45 milligrams sodium; 6 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

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