Wednesday, May 25, 2011

Health - When Doctors Are Called to the Rescue in Midflight

Health - When Doctors Are Called to the Rescue in Midflight

When Doctors Are Called to the Rescue in Midflight

Posted: 24 May 2011 12:00 AM PDT

Dr. Matthew Rhoa is still haunted by one of his lowest moments as a physician. Several years ago, on the first leg of an international flight, he was just settling in for a nap when a flight attendant came on the public address system to ask, “Is there a doctor on the plane?”

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Leif Parsons

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Dr. Rhoa, who lives in San Francisco, didn’t push his call button. “As a gynecologist, I always waited for another doctor,” he said. “There’s never a need for a Pap smear at 30,000 feet.”

He fell asleep, only to be awakened an hour later by a second call for medical help. This time he answered, and at the back of the plane he found two anxious parents with their 18-month-old toddler, who had a cast on her broken leg and was crying inconsolably.

The girl’s toes were blue. Limbs can often swell in flight, and it was clear that the cast was much too tight. Dr. Rhoa slit the cast and pried it open. The girl stopped crying at once.

“I have been riddled by guilt to this day,” said Dr. Rhoa, who now promptly answers every call for medical help on a plane. “I never want that feeling again of a kid suffering like that when I could have done something sooner.”

Since the earliest days of commercial aviation, airlines have coped with medical emergencies in flight by calling on physicians who happen to be passengers. And as more people travel by air, the number of emergencies has risen accordingly.

“Passenger health is becoming more and more of an issue, because of increased life expectancy and more people flying with pre-existing conditions,” said Dr. Paulo Alves, a vice president at MedAire, a company that provides crew members with medical advice from physicians on the ground.

MedAire, which advises more than 60 airlines around the world, managed about 19,000 in-flight medical cases for commercial airlines in 2010. Although few were life-threatening, 442 were serious enough to require diverting the plane — and 94 people died onboard.

The numbers reflect a fraction of the actual number of in-flight emergencies. The Federal Aviation Administration does not track in-flight medical episodes, and airlines are not required to report them.

Airborne calls for medical assistance pose a singular challenge for physicians, who find themselves suddenly caring for a stranger whose history they don’t know, often with a problem well outside their specialty, in a setting with limited equipment but no shortage of onlookers scrutinizing their every move.

And they do this for no compensation. (The fact that Good Samaritan laws generally protect them from lawsuits is a small saving grace.)

So it is little wonder that many physicians hesitate before responding to an emergency call.

Three years ago, Dr. Peter Freed, a psychiatrist in Manhattan, answered a call for a physician during a cross-country flight. A passenger had just had a seizure. Dr. Freed told the flight attendant he had not practiced general medicine since his residency. Still, he was the only doctor to respond, and the flustered crew member told him she was grateful for any help at all.

The passenger, a woman in her 30s traveling from Europe, told Dr. Freed she had a longstanding seizure disorder. He had her take her medication and remained with her, hoping she would be fine for the rest of the flight. But after another 20 minutes, she developed the uncontrollable shaking of a grand mal seizure and fell unconscious.

He asked to speak to a neurologist on the ground, and within minutes the pilot was able to get one on the radio. But as Dr. Freed recalled, he was barred from the cockpit for security reasons and could not speak directly with the specialist.

“I talked to the flight attendant, who talked to the captain in the cockpit, who talked to the doctor,” he said.

Next came the question that many physicians who answer in-flight emergency calls face: Should the plane be diverted to a nearby airport? Ultimately, the decision rests with the pilot, but the pilot looks to the medical expert for guidance. And it is a decision that other passengers await most anxiously.

After calculating that it would take as long to divert the plane as to reach their destination, Dr. Freed decided against it.

Well: On Your Marks, Get Set, Measure Heart Health

Posted: 23 May 2011 02:34 PM PDT

Mind: How a Telescopic Lens Muddles Psychiatric Insights

Posted: 23 May 2011 10:10 PM PDT

No sooner had Dominique Strauss-Kahn been arrested on sexual assault charges in New York than a parade of psychiatrists stepped forward to offer their expert opinion in the news media.

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This cover story in 1964 set a legal precedent that helped change medical rules for psychiatrists for good.

Mr. Strauss-Kahn, who subsequently resigned as chief of the International Monetary Fund, will experience “a terrible grief because he is in prison,” said one. Another offered that he would have “terrible mourning” for “the loss of social status, image and glory.”

Of course, it’s only natural for the media to seek comment from experts. But as a psychiatrist, I cringe at statements like these, for they cross an ethical line that goes back to a presidential campaign nearly half a century ago.

Just before the 1964 election, a muckraking magazine called Fact decided to survey members of the American Psychiatric Association for their professional assessment of Senator Barry Goldwater of Arizona, the Republican nominee against President Lyndon B. Johnson.

Ralph Ginzburg, the magazine’s notoriously provocative publisher, had heavily advertised the issue in advance, saying it would call Mr. Goldwater’s character into question.

A.P.A. members were asked whether they thought Mr. Goldwater was fit to be president and what their psychiatric impressions of him were. It was not American psychiatry’s finest hour.

The survey, highly unscientific even by the standards of the time, was sent to 12,356 psychiatrists, of whom 2,417 responded. The results were published as a special issue: “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.”

The psychiatrists’ assessment was brutal. Half of the respondents judged Mr. Goldwater psychologically unfit to be president. They used terms like “megalomaniac,” “paranoid” and “grossly psychotic,” and some even offered specific diagnoses, including schizophrenia and narcissistic personality disorder.

Only 27 percent of the respondents said Mr. Goldwater was mentally fit, and 23 percent said they didn’t know enough about him to make a judgment.

There were several attempts at a psychodynamic formulation of Mr. Goldwater’s character. One unsigned comment called the candidate “inwardly a frightened person who sees himself as weak and threatened by strong virile power around him,” and added that “his call for aggressiveness and the need for individual strength and prerogatives is an attempt to defend himself against and to deny his feelings of weakness.”

Say what you will about their motivation, these doctors had given very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.

The remarks were immediately condemned by both the American Medical Association and the A.P.A., and Mr. Goldwater brought a $2 million libel suit against Fact and Mr. Ginzburg. The Supreme Court awarded the senator $1 in compensatory damages and $75,000 in punitive damages — and, more important, set a legal precedent that helped change medical ethics for good.

In 1973, the A.P.A. defined a set of requirements for communicating with the media — the Goldwater rule — stating that psychiatrists can comment on mental health issues in general, but that it is explicitly unethical for them to offer a professional opinion about an individual without directly examining that person and getting his or her permission to comment.

So it would be fine for a psychiatrist to say that someone who experiences hallucinations and delusions appears psychotic, but to offer a diagnosis of schizophrenia would cross the line.

The distinction between general description and diagnosis may seem like splitting hairs. But for two reasons, the Goldwater rule is just as important today as it ever was.

First, it is intellectually dishonest for a mental health professional — or any physician — to give a diagnosis without examining the patient. A professional opinion is supposed to reflect a thorough and rigorous evaluation of a patient and all relevant clinical data obtained under the protection of strict confidentiality. Anything short of that misleads the public about what constitutes accepted medical practice and invites distrust of the profession as a whole.

Second — and especially timely as we enter another presidential campaign — the Goldwater rule prevents the misuse of medical authority as a political weapon to denigrate an opponent.

Of course, there are exceptions to all rules. Patient confidentiality is not absolute, for example: If a patient of mine told me he was thinking of killing someone, I would have an ethical and legal duty to violate confidentiality and warn both the person at risk and the police.

And one could reasonably argue that an exception should be made for psychiatric profiles of foreign political leaders, which United States intelligence services (and those of other countries) have been doing at least since World War II. An evaluation of Col. Muammar el-Qaddafi of Libya, for example, might well be in the national interest because it could help guide how we deal with this difficult figure.

Colonel Qaddafi’s ruthlessness, near-delusional grandiosity and love of absolute power all suggest a severe personality disorder called malignant narcissism. Because people with the disorder have a defect in moral conscience, they lack empathy, so there is no room to appeal to them on human terms. Instead, they are more likely to respond to the right mix of flattery, power and a credible threat of force.

Whether the foregoing diagnosis is correct or useful, I have no idea, but it is ethically defensible.

Despite what some of us might believe, though, none of our celebrities or politicians is likely to rise to the level of a national threat that justifies violation of the Goldwater rule.

It’s not sexy and probably won’t make headlines, but experts should just stick to the facts and educate the public, and leave the pleasure of diagnostic speculation to the amateurs.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

Patient Voices: The Youngest Casualties of Cancer

Posted: 23 May 2011 10:20 PM PDT

For all the advances that have been made against childhood cancer, it remains the leading cause of disease-related death among children younger than 15, with 1,500 fatalities a year. And while the five-year survival rate has improved in recent decades — to 80 percent, up from less than half 40 years ago — the number of cases is rising, too; it now stands at 10,000, up from 8,000 in 1975.

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Patient Voices: Childhood Cancer
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David Ahntholz for The New York Times

Max Mikulak

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Michael Stravato for The New York Times

Jaiden Ramirez

More than half of childhood cancers are caused by leukemia or tumors of the central nervous system. They are generally treated the same way as adult cancers, with chemotherapy, radiation and surgery. But other issues in childhood cancer are quite different from those faced by adults.

How do parents temper their emotions, remain clearheaded and determine the best course of treatment? Will the treatment have long-term side effects, and should that matter? How does a child maintain youth and enthusiasm in the face of terrifying and debilitating illness?

Beyond the consequences of the disease itself, cancer can leave deep emotional scars on its patients and their families. It is not easy to explain cancer to a young child, let alone begin a conversation about the possibility of death.

And if a child doesn’t survive, how does a family move on?

On nytimes.com, six people speak from a variety of perspectives about the impact of childhood cancer on their lives. Here are three.

 

John Carey, Colorado Springs

Now 16, he learned he had Hodgkin’s lymphoma at age 13, and has been in remission for a few months.

I’m glad I got cancer, because it completely changed my outlook on life. I think of things completely differently, and I value life so much more.

The worst part of cancer is probably not being a normal kid and just being in a hospital while all your friends are at school. People don’t really like going to school, but when you’re in the hospital getting chemotherapy or in the doctor’s office or just sitting at home being really, really sick, it’s just not fun.

My cancer is doing pretty well. I haven’t relapsed yet, and we’re so happy for that. I’ve been feeling pretty good and just working my way to a more normal life.

Max Mikulak, San Diego

Melissa Mikulak’s son died from a neuroblastoma  on Aug. 31, 2008, at age 7.

Max was told he had “no evidence of disease” when he was 4. We went home and we were ready to plow ahead. We had a great year off. And then he relapsed.

The Monday before he passed away, he was looking great. We were making pancakes for dinner. We thought we had three months left. We thought, “O.K., we’re going to have a great time,” and two days later we learned the cancer had spread into his liver.

It’s been two and a half years since he died, and we’ll always be a family of five. He’ll always be with us.

Never lose hope. Something’s going to happen where someone finds a cure for cancer. Or maybe a cure is not going to be found, but the 18 months that you have with your child could be the best 18 months ever.

Jaiden Ramirez, Houston

Toshia Ramirez’s son Jaiden, 7, has diffuse pontine glioma, an inoperable cancer surrounding his brainstem.

We spend a lot of time on our knees, praying and asking God to let Jaiden be one of the miracles.

Jaiden knows that whatever is in his head is making him sick. He knows that it makes him dizzy, makes him sick to his stomach.

I told Jaiden that there was a possibility that God would take him home with him. So he cried. He said he didn’t want to go live with God; he wanted to stay here with Mommy and Daddy.

And I cried, and I told him, “You know, I want you to stay here too, but ultimately God has the say-so, so we have to abide with his wishes.” We haven’t talked about it again. If he brings it up we talk, and if he doesn’t then we don’t.

Strong Sales of Organic Foods Attract Investors

Posted: 24 May 2011 02:12 AM PDT

PARIS — Even during a period of rising food prices and economic uncertainty, Damien Bignon, a poultry farmer in the Paris region, cannot meet the demand from local markets and stores for his organic eggs.

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Cecilia Garroni-Parisi for The International Herald Tribune

Mr. Bignon's wife, Marie-Helene, cleaning a chicken coop.

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Cecilia Garroni-Parisi for The International Herald Tribune

At the Ferme des Beurreries near Feucherolles, west of the capital, Mr. Bignon employs five people overseeing 3,000 chickens on 432 acres. He also produces organic cereals for his own feed and other clients and wheat to sell to a neighboring mill.

Mr. Bignon thinks he could comfortably expand to 12,000, matching the number of chickens on the farm in 1990 before its conversion to organic operations. But he is determined to manage carefully any growth to maintain quality, keep customers satisfied and not crowd out other local farmers. He charges 2 euros ($2.82) for a half dozen eggs — about twice the cost of factory-farmed eggs at a French supermarket.

“The issue for us is retaining that success without falling into the traps of industrialized agriculture,” he said. “There’s risks in organic becoming a mass market.”

Sales of organic foods appear robust across Europe and the United States despite weak economic conditions and rising inflation. The strong sales are attracting more interest and activity from investors, who see potential in mergers through economies of scale, especially in Europe’s more fragmented market.

In December, Compagnie Biodiversité, the French owner of Léa Nature, which supplies organic food, health products, textiles and cosmetics through large retail channels, announced its purchase of a large stake in Ekibio, another French player. That alliance makes it France’s second-biggest organic food specialist, behind Distriborg, which is owned by the Dutch group Royal Wessanen.

Wessanen, which has been divesting assets in North America, is trying to expand in Europe, analysts say.

In Britain, Abel & Cole, which operates a home delivery service for organic products and has been owned by a private equity firm since 2007, is seen by analysts as an acquisition target, perhaps for a supermarket chain.

And Hain Celestial, based in Melville, N.Y., which makes organic food, drinks and personal care products, this year bought Danival, a French organic producer, as well as GG UniqueFiber, a Norwegian natural foods company. The investor Carl C. Icahn has been building a stake in Hain.

Many farmers and analysts expect the sector to remain strong in coming years, helped by increased public awareness of environmental and potential health benefits, better organization and production techniques, new demand from emerging markets and those periodic public scares attending events like the recent nuclear plant radiation leaks in Japan.

Another theory is that, as with the luxury industry, the core consumers, typically with high disposable incomes, are less affected by hard times.

“Over all, it’s very surprising how stable the organic markets have been even in this critical economic situation,” said Urs Niggli, director of FiBL, an independent nonprofit research institute focusing on organic agriculture in Switzerland. He predicted sales would accelerate in coming years, assuming economic growth picked up.

Organic Monitor, a market research firm and consultancy based in London, estimates that the global market for organic food and drink products in 2009 was $55 billion, 5 percent more than in 2008 and more than double the level in 2000. Significantly, the financial crisis and recession slowed the rate of growth in some countries, while the trend continued.

In the United States, sales of organic food reached $26.7 billion last year, according to the Organic Trade Association. That was a 7.7 percent increase from 2009, which itself was 5.1 percent higher than 2008. The United States has now overtaken Europe to become the largest market.

European sales grew 3.9 percent in 2009 after double-digit growth in previous years, according to Organic Monitor. In France, a late starter, and in Sweden and Belgium, sales in 2009 expanded more than 15 percent, according to FiBL. British sales contracted in the face of weaker consumer spending and fewer product lines at large stores, while the German market, Europe’s largest, was stable after a period of strong increases.

Logically, the amount of land set aside for organic farming is also increasing. According to FiBL, land for organic use rose to 1.94 percent of all agricultural land in Europe in 2009, from 1.74 percent in 2008 and 1.25 percent in 2003.

According to the Agriculture Department, certified American organic farmland grew 127 percent from 2002 to 2007 and then by 12 percent from 2007 to 2009.

While both Europe and the United States have helped organic farmers, the methods and motivations have been different.

Europeans nurtured the sector because of perceived environmental and social benefits, while the United States supported standards, certification, research and education, treating the sector “primarily as an expanding market opportunity,” according to paper written several years ago by Carolyn Dimitri and Lydia Oberholtzer, experts at the Agriculture Department.

In Europe, subsidies for organic farming are drawn from European Union funds and disbursed to farmers by national governments, as well as in less direct ways, like marketing and procurement programs.

Organic farms receive on average higher subsidies in absolute terms and per hectare (almost 2.5 acres) than conventional farms, according to the Europe’s Farm Accountancy Data Network. In Western Europe generally, the subsidy amounted to 438 euros ($614) a hectare against 355 euros in 2007.

Yet Christian Eichert, managing director in the German state of Baden-Württemberg for Bioland, that country’s largest organic farmers’ association, said Europe lacked a coherent policy toward the sector. Some countries like Spain and Italy focus on exports, while German support is state-driven and often hostage to local political changes, he said.

Recently, there have been some signs that austerity pressures across Europe are eating into state support.

The French government announced at the start of this year that it was halving a tax break for small farmers converting land to organic production. In Germany last year, the state of Schleswig-Holstein sought to remove organic subsidies but backed down after public pressure.

There is a “general uncertainty” surrounding future support, Mr. Eichert said. And forthcoming changes to the Europe’s Common Agricultural Policy after 2013 have led farmers to expect more cuts.

2 Studies in Conflict on Growth of Bone

Posted: 23 May 2011 10:10 PM PDT

Three years ago, researchers at Columbia came to an astonishing conclusion. The amount of bone people make — and their risk of osteoporosis — seems to depend on levels of serotonin, a chemical known mainly for its effects on the brain.

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The more serotonin, the study found, the weaker the bones. Though the work was done in mice, other researchers have found that in people, those with the lowest bone density tend to have the highest levels of serotonin in their blood.

But now a group of researchers, from Harvard, several other universities and a biotech company, is calling those findings into question.

And while both groups say there may be technical reasons for the conflict in their data, the discordant conclusions raise questions about who is correct and whether any of the results will lead to a way to build bone or treat osteoporosis.

The disagreements were cast in stark relief this week as the two groups of researchers published what are, in effect, dueling papers on serotonin and bone loss. The Columbia group reported in The Journal of Bone and Mineral Research that osteoporosis could be prevented in mice with a drug that blocks production of gut serotonin; the Harvard group said in a paper in Nature Medicine that gut serotonin appeared to have no effect on bone.

Researchers watching from the outside admit that they are perplexed.

“Both labs are credible,” said Dr. Sundeep Khosla, an osteoporosis researcher and professor at the Mayo Clinic. “And both are convincing papers in their own right.

“But it makes you wonder,” he added. “If modest differences in models have such a huge impact, what’s the biological interpretation?”

The original work, led by Dr. Gerard Karsenty, chairman of the department of genetics and development at Columbia, was inspired by studies of humans with an inherited condition that led to bones so weak they could not walk. The disease turned out to be caused by a mutation that inactivated a gene, LRP5 .

So Dr. Karsenty and his colleagues made mice with the LRP5 mutation. The mice, they discovered, were making four to five times the normal amount of serotonin in their guts, and this was preventing their bones from growing.

Dr. Karsenty says he is confident his group’s discovery is correct.

But Dr. Matthew Warman, a professor of genetics and orthopedic surgery at Harvard Medical School, is not so sure. His group tried, but failed, to find that LRP5 has an effect on blood serotonin levels in mice or that those levels have a strong effect on bone.

When his group made mice with overactive LRP5 genes, the mice did make too much bone, but this had no effect on their serotonin levels. And when his group studied mice with inactivated LRP5 genes, the mice had weak bones but no increase in production of gut serotonin.

Dr. Warman and his colleagues also conducted a reverse experiment, producing mice that made very little serotonin in their intestines. They saw very little effect on the animals’ bones.

One member of the research team, David Powell, is a researcher at Lexicon, a company with a drug that blocks serotonin. He said in an e-mail: “Our compound could be a blockbuster osteoporosis therapy for Lexicon if Karsenty is correct. The fact that we cannot duplicate his work is a disappointment to us.”

But the two teams used somewhat different methods to modify the genes they were studying, and different ways of measuring serotonin levels and bone density in mice. Could that be the explanation for their disagreements? Or might mice just be a poor model in this situation, too sensitive to minor changes in experimental design?

“Personally, I think the serotonin connection is incorrect,” Dr. Warman said. “However, it is perhaps most accurate to state that my lab and several other laboratories have been unable to independently verify the serotonin hypothesis.”

Dr. Karsenty said he was puzzled by the other group’s failure to verify his discovery.

“It is strange, I agree,” he said.

But if he is correct, he added, the proof will be using his discovery to develop a drug that builds bone. That, he said, “will determine the validity of one’s claim.”

Global Update: AIDS: A Price Break for Antiretroviral Drugs in 70 of the World’s Poorest Countries

Posted: 24 May 2011 11:07 AM PDT

In a development that could improve AIDS treatment worldwide, modern antiretroviral drugs will be sold at lower prices in 70 of the world’s poorest countries.

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  • Health Guide: AIDS

The most important price breaks, announced last week, were for first-line treatments containing the drugs tenofovir and efavirenz, and second-line regimens containing atazanavir and ritonavir.

Cocktails of AIDS drugs that once sold for $12,000 or more per year in rich nations are now available in poor ones for less than $200. Still, many patients in poor countries get drugs like AZT and nevirapine, which were developed decades ago and can have harsh side effects.

Combinations containing tenofovir, introduced 10 years ago, are now recommended by the World Health Organization because they have fewer side effects and the AIDS virus is less likely to develop resistance to them. The price of one such combination has dropped to $159 from $400 in three years.

The lower prices, offered by eight Indian pharmaceutical companies, were negotiated by the Clinton Health Access Initiative, part of the former president’s foundation. The price-negotiation work is supported by British foreign aid and the Bill and Melinda Gates Foundation.

The money to guarantee the initial payments on behalf of poor countries — crucial to getting the Indian suppliers to expand factories to make these drugs — will come from Unitaid, an independent agency founded at the United Nations that collects several taxes, including one on European airline tickets, to finance global health programs.

Vital Signs: Childbirth: Home Births Are Uncommon but on the Rise

Posted: 24 May 2011 11:10 AM PDT

The number of home births nationwide rose 20 percent from 2004 through 2008, a new study shows.

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Even with the increase, there were just 28,357 home births in 2008, less than 1 percent of the 4.2 million births in the United States that year. Still, the increase reversed a downward trend in such births since 1990.

The turnabout was driven by an increase of 28 percent in home births among non-Hispanic white women, for whom one in 100 births occurred at home in 2008. That rate was three to six times higher than for any other race or ethnic group.

Home births declined slightly among non-Hispanic black women, to 0.28 percent in 2008 from 0.30 percent in 2004, while home births for Hispanic and American Indian women were unchanged, at 0.20 percent and 0.38 percent, respectively. Home births among Asian and Pacific Island women increased slightly, to 0.27 percent from 0.24 percent of all births.

A vast majority of home births were planned, the researchers also found.

Other research has suggested many women choose home birth because of concern about high rates of Caesarean sections and other interventions at hospitals, said the new study’s lead author, Marian F. MacDorman, a statistician with the National Center for Health Statistics. “The two trends are not unrelated,” Dr. MacDorman said.

The report was published online this month in the journal Birth: Issues in Perinatal Care.

Vital Signs: Prevention: Coffee Lowers Risk of Prostate Cancer, Harvard Study Says

Posted: 24 May 2011 12:10 AM PDT

If that’s java in your cup, drink up. A new study says that men who are heavy coffee drinkers are at lower risk for prostate cancer.

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As part of the Health Professionals Follow-Up Study, Harvard scientists followed 47,911 men who periodically described their coffee intake. The researchers found that those who consumed six or more cups a day were almost 20 percent less likely to develop prostate cancer over two decades than those who drank none.

More important, the heavy coffee drinkers were 60 percent less likely than the nondrinkers to develop a lethal form of the disease. Even men who drank just one to three cups of coffee benefited: They were nearly 30 percent less likely to develop lethal prostate cancer, the study said. It did not matter whether the coffee was caffeinated or decaffeinated.

The study, published online on May 17 in The Journal of the National Cancer Institute, is one of the first to link coffee consumption to a lower risk of prostate cancer. Coffee is a major dietary source of antioxidants, and other studies have suggested that drinking it is associated with health benefits including a lower risk of Type 2 diabetes.

“We’re not yet telling men to drink more coffee,” said the lead author, Kathryn M. Wilson, “but there’s mounting evidence that if they do, they don’t have to worry about it.”

Vital Signs: Risks: Allergic to Peanuts, Even in Transfused Blood

Posted: 24 May 2011 11:13 AM PDT

Doctors in the Netherlands said that a 6-year-old boy with an allergy to peanuts went into anaphylactic shock after receiving a blood transfusion from donors who had been snacking on them.

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The episode, described in a letter published on Wednesday in The New England Journal of Medicine, occurred last year as the boy was being treated for leukemia. While receiving a transfusion of blood platelets, he broke out in a rash, his blood pressure dropped and he had difficulty breathing.

He recovered after treatment, but doctors were mystified by his reaction. The boy’s mother then recalled that he had had a similar experience at the age of 1 after eating peanuts, and she said he had not eaten them since.

Blood tests revealed that the child had indeed developed an allergic reaction to peanuts during the transfusion. Three of five donors whose platelets were used recalled that they had eaten peanuts the evening before donating blood.

In their letter, the doctors at Radboud University Nijmegen Medical Center in Nijmegen, the Netherlands, hypothesized that “consumption of peanuts by the donors before blood donation provided the trigger for this patient’s transfusion reaction.”

“It is possible that allergens transferred in blood products to other patients have led to reactions that have gone unexplained and unreported,” they added.

Second Drug Wins Approval For Treatment of Hepatitis C

Posted: 24 May 2011 11:15 AM PDT

Vertex Pharmaceuticals won regulatory approval on Monday for a new hepatitis C drug, setting off a marketing battle with Merck over new drugs that are expected to improve the cure rate of the disease and shorten the duration of treatment.

Incivek, as the drug will be called, is expected to be the first big product for Vertex, and the first it will sell on its own. It is expected to allow the company to finally become profitable after 22 years in business and an expenditure of $4 billion.

Merck’s drug, Victrelis, was approved by the Food and Drug Administration on May 13.

The drugs “represent a new direction in the treatment of hepatitis C and a significant improvement over the current standard of care,” Dr. Margaret A. Hamburg, the commissioner of the F.D.A., said in a conference call on Monday.

Both products borrow from the strategy used by H.I.V. drugs of inhibiting the action of a viral enzyme — in this case, the hepatitis C protease enzyme.

In a clinical trial, 79 percent of people treated with Incivek combined with the existing treatment achieved what is effectively considered a cure, compared with 46 percent for those getting the existing drugs alone.

About half the patients treated with Incivek were able to finish treatment in 24 weeks instead of the usual 48 weeks. That is considered important because treatment, which involves the existing drugs alpha interferon and ribavirin, is arduous. Side effects can include flulike symptoms, anemia and depression.

Incivek has its own side effects, particularly a severe rash. It can also worsen anemia and cause nausea, fatigue and hemorrhoids.

Most analysts expect Vertex’s drug to reach annual sales of $2 billion within three years and to outsell Merck’s drug because it appears to be somewhat more effective in clinical trials, though the two drugs were never compared head to head. Also, the treatment using Vertex’s drug is less complex and requires six pills a day, half as many as required for Merck’s drug.

Vertex set the wholesale price of Incivek, also known as telaprevir, at $49,200 for the entire course of treatment. Merck’s Victrelis, also known as boceprevir, costs $26,400 to $48,400 depending on the duration of treatment. Both drugs would be used in addition to the standard therapy, which costs about $15,000 to $30,000 depending on duration.

Vertex executives defended the price, saying that cures can prevent the problems that can be caused by hepatitis C, like liver cirrhosis, liver cancer and the need for a liver transplant.

“Cure is rare in medicine and that makes the economics very compelling,” said Joshua Boger, who founded Vertex. He stepped down as chief executive two years ago, but is still a director.

The new drugs could appeal to some people who were not cured by the existing treatments and might want to try again. One of those is Michael Desroches, 44, of Methuen, Mass., who said he already had cirrhosis. “It’s not going to get any better by itself, obviously,” he said.

Dr. Boger, who had been a chemist at Merck, started Vertex in 1989 with the aim of revolutionizing drug discovery. But it has been a costly and slow revolution and Vertex now finds itself competing with Dr. Boger’s former company. Vertex did develop two H.I.V. drugs that were sold by GlaxoSmithKline, and it has a couple of promising drugs for cystic fibrosis in development.

Vertex, based in Cambridge, Mass., started on the hepatitis C project in 1993, a few years after the virus was first identified. In 1996, it published the three-dimensional structure of the virus’s protease enzyme. Then it set about finding a chemical that could block the enzyme’s activity.

With the prospects for curing hepatitis C increased, efforts might shift to identifying more of the 3.2 million Americans said to be infected with hepatitis C.

Health authorities say most of those infected, primarily baby boomers who might have been infected decades ago by injecting drugs, or through sex or blood transfusions, do not know it. That is because it can take decades for liver problems to show up, and many times they never do.

Vertex is expected to start a public awareness campaign, with New York City being an initial focus. The company commissioned a study that made the case for screening all people 40 to 64 years old, not just those deemed to have risk factors.

Recipes for Health: Quinoa and Beet Pilaf

Posted: 24 May 2011 12:13 PM PDT

Use regular pearl white quinoa for this beautiful pink pilaf, which uses both roasted beets and their greens.

Recipes for Health

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

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1 bunch of beets (3 large, 4 medium or 5 small), roasted

3/4 to 1 pound beet greens (the greens from 1 generous bunch)

Salt to taste

1 to 2 tablespoons extra virgin olive oil (to taste)

2 garlic cloves, minced

2 teaspoons caraway seeds, lightly crushed

3 cups cooked regular quinoa

2 ounces goat cheese, crumbled or diced (1/2 cup)

1. Scrub and roast the beets. Once they are cooled, remove the skins and cut into 1/4-inch dice. Set aside.

2. Blanch the greens in a large pot of generously salted water or steam them above an inch of boiling water until wilted, one to two minutes. Refresh with cold water, squeeze dry and chop.

3. Heat the olive oil over medium heat in a large, heavy skillet. Add the garlic. Cook, stirring, until fragrant, 30 seconds to a minute. Add the caraway, beet greens, and salt and pepper to taste. Stir over medium heat for 30 seconds to a minute until the greens are nicely infused with the garlic and oil. Add the beets and quinoa. Toss together until the ingredients are well combined and the quinoa is heated through and colored with beet juice. Taste and adjust salt and pepper. Transfer to a wide serving bowl or platter, and sprinkle the goat cheese over the top. Serve hot.

Yield: Serves four to six.

Advance preparation: All of the major ingredients — the roasted beets, blanched greens and cooked quinoa — will keep for four days in the refrigerator.

Nutritional information per serving (four servings): 310 calories; 4 grams saturated fat; 2 grams polyunsaturated fat; 4 grams monounsaturated fat; 15 milligrams cholesterol; 40 grams carbohydrates; 9 grams dietary fiber; 308 milligrams sodium (does not include salt to taste); 14 grams protein

Nutritional information per serving (six servings): 207 calories; 3 grams saturated fat; 1 gram polyunsaturated fat; 3 grams monounsaturated fat; 10 milligrams cholesterol; 27 grams carbohydrates; 6 grams dietary fiber; 205 milligrams sodium (does not include salt to taste); 9 grams protein

Variation: Quinoa and Beet Loaf

Reduce the amount of quinoa to 2 cups. Make the pilaf as directed, then fold in two beaten eggs along with the goat cheese. Place in an oiled 1 1/2-quart pâté tureen or small bread pan. Bake uncovered for 35 to 40 minutes at 375 degrees until set. Allow to cool before slicing and serving.

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

Need Therapy? A Good Man Is Hard to Find

Posted: 23 May 2011 08:08 AM PDT

Between unresolved family conflicts, relationship struggles and his mixed-race identity, James Puckett had enough on his mind in college that he sought professional help. But after bouncing from one therapist to another, he still felt stuck.

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Stuart Hill

At the American Counseling Association's annual conference in March, women predominated, as they do in the profession.

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“They were all female, and they did give me some comfort,” said Mr. Puckett, 30, who works for a domestic-abuse program in Wisconsin. “But I was getting the same rhetoric about changing my behavior without any challenge to see the bigger picture of what was behind these very male coping reactions, like putting your hand through a wall.”

He decided to seek out a male therapist instead, and found that there were few of them. “I’m just glad I ended up with the person I did,” said Mr. Puckett, who is no longer in therapy, “because for me it made all the difference.”

Researchers began tracking the “feminization” of mental health care more than a generation ago, when women started to outnumber men in fields like psychology and counseling. Today the takeover is almost complete.

Men earn only one in five of all master’s degrees awarded in psychology, down from half in the 1970s. They account for less than 10 percent of social workers under the age of 34, according to a recent survey. And their numbers have dwindled among professional counselors — to 10 percent of the American Counseling Association’s membership today from 30 percent in 1982 — and appear to be declining among marriage and family therapists.

Some college psychology programs cannot even attract male applicants, much less students. And at many therapists’ conferences, attendees with salt-and-pepper beards wander the hallways as lonely as peaceniks at a gun fair.

The result, many therapists argue, is that the profession is at risk of losing its appeal for a large group of sufferers — most of them men — who would like to receive therapy but prefer to start with a male therapist.

“There’s a way in which a guy grows up that he knows some things that women don’t know, and vice versa,” said David Moultrup, a psychotherapist in Belmont, Mass. “But that male viewpoint has been so devalued in the course of empowering little girls for the past 40 or 50 years that it is now all but lost in talk therapy. Society needs to have the choice, and the choice is being taken away.”

The reasons for the shift are economic as well as cultural, most people in these professions agree. Managed care took a bite out of therapists’ incomes in the 1990s. Psychiatry, the most male-dominated corner of therapy, increasingly turned to drug treatments. And as women entered the work force in greater numbers, they proved to be more drawn to the talking cure than men — in giving the treatment as well as in receiving it.

“Usually women get blamed when a profession loses status, but in this case the trend started first, and men just evacuated,” said Dorothy Cantor, a former president of American Psychological Association who conducted a landmark study of gender and psychology in 1995. “Women moved up into the field and took their place.”

The impact of this gender switch on the value of therapy is negligible, studies suggest. A good therapist is a good therapist, male or female, and a mediocre one is a mediocre one. Shared experience may even be an impediment, in some cases: therapists often caution students against assuming that they have special insight into person’s problems just because they have something in common.

Still, perception is all important when it comes to seeking help for the very first time. In a recent study among 266 college men, Ronald F. Levant, a psychologist at the University of Akron, found that a man’s willingness to seek therapy was directly related to how strongly he agreed with traditionally male assumptions, like “I can usually handle whatever comes my way.” Such a man on the fence about seeking treatment could be discouraged by the prospect of talking to a woman.

U.S. Objects to New Law on Clinics in Indiana

Posted: 22 May 2011 11:30 PM PDT

WASHINGTON — The Obama administration is raising serious objections to a new Indiana law that cuts off state and federal money for Planned Parenthood clinics providing health care to low-income women on Medicaid.

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The objections set the stage for a clash between the White House and Gov. Mitch Daniels, a Republican, over an issue that ignites passions in both parties.

The changes in Indiana are subject to federal review and approval, and administration officials have made it clear they will not approve the changes in the form adopted by the state.

Federal officials have 90 days to act but may feel pressure to act sooner because Indiana is already enforcing its law, which took effect on May 10, and because legislators in other states are working on similar measures.

If a state Medicaid program is not in compliance with federal law and regulations, federal officials can take corrective action, including “the total or partial withholding” of federal Medicaid money. The mere threat of such a penalty is often enough to get states to comply. Actually imposing the penalty would, in many cases, hurt the very people whom Medicaid is intended to help.

Administration officials said the Indiana law imposed impermissible restrictions on the freedom of Medicaid recipients to choose health care providers.

Indiana is one of at least a half-dozen states that have taken aim at Planned Parenthood because it performs abortions, about one-fourth of those performed in the United States.

Planned Parenthood of Indiana said it provided services last year to 85,000 patients, including 9,300 on Medicaid. Most received contraceptives. In its annual report, Planned Parenthood of Indiana said it also performed 5,580 abortions, 21,150 pregnancy tests, 26,500 Pap tests for cervical cancer and 33,000 tests for sexually transmitted diseases.

Asked for comment on the Indiana law, the federal Centers for Medicare and Medicaid Services provided this statement, cleared by the White House: “Federal law prohibits federal Medicaid dollars from being spent on abortion services. Medicaid does not allow states to stop beneficiaries from getting care they need — like cancer screenings and preventive care — because their provider offers certain other services. We are reviewing this particular situation and situations in other states.”

Medicaid is financed jointly by the federal government and the states, which must comply with federal law as a condition of getting federal money.

Planned Parenthood of Indiana and two of its patients have filed suit in Federal District Court in Indianapolis, challenging the new restrictions as “a blatant violation of the ‘freedom of choice’ provision” of federal law. The federal government is not a party in the case, but the administration’s statement sends a signal to the court, which will hold a hearing in two weeks on whether to block the state law.

States can obtain federal permission to waive certain requirements of the federal Medicaid law. But the federal law says that “no waiver” may restrict the choice of Medicaid beneficiaries in receiving family planning services.

When Indiana legislators were considering the abortion bill last month, state Medicaid officials alerted them to possible legal problems. A “fiscal impact statement” on the bill, prepared by the nonpartisan staff of the legislature, said that “restricting freedom of choice with respect to providers of family planning services is prohibited” by federal law.

Mr. Daniels, the popular governor who said on Sunday that he would not seek the Republican Party’s nomination for president in 2012, once suggested a truce on social issues, saying the nation ought to concentrate on its fiscal problems. But he supported the Indiana law, passed with majorities of more than two to one in both houses of the legislature.

Mr. Daniels said the state law ensured that tax dollars would not subsidize providers of abortion. “Nonabortion services, whether family planning or basic women’s health, will remain readily available” from entities other than Planned Parenthood, Mr. Daniels said.

For years, federal law has barred the use of Medicaid money to pay for abortion except in certain cases of rape or incest or danger to the life of a pregnant woman.

The Indiana law goes much further. It prohibits state agencies from entering contracts with or making grants to “any entity that performs abortions or maintains or operates a facility where abortions are performed.” It also terminates existing state contracts with such entities. The law does not apply to hospitals.

Sara Rosenbaum, a professor of health law and policy at George Washington University, said that under the federal Medicaid law, “states have a lot of latitude to decide who is a qualified provider.” But she added: “There are limits to that latitude. The Indiana restriction seems to have no bearing on the ability of Planned Parenthood to perform family planning and other services for which it has been contracting with the state.”

Without waiting for a decision from the federal government, Indiana has moved ahead.

“The state law is in effect right now,” said Marcus J. Barlow, a spokesman for the Indiana Family and Social Services Administration. “Medicaid clients who went to Planned Parenthood will have to go to someone else. This is not a change in services. It’s a change in providers.”

Most of the money at stake is federal. The federal government pays about 66 percent of the cost of most services covered by Medicaid in Indiana, but for family planning the federal share is 90 percent — an indication of the importance historically attached to such services by Congress.

The United States House of Representatives voted 241 to 185 on April 14 to cut off federal money for the Planned Parenthood Federation of America and its affiliates. The Senate killed the proposal, 58 to 42.

“It’s morally wrong to take the taxpayer dollars of millions of pro-life Americans and use them to subsidize the largest abortion provider in America,” said Representative Mike Pence, Republican of Indiana.

Other states that have considered legislation to restrict payments to Planned Parenthood, under various programs, include Kansas, North Carolina, Oklahoma, Texas and Wisconsin.

Both houses of the Kansas Legislature have approved a 2012 budget bill that would redirect about $300,000 in federal family planning money from Planned Parenthood to state and local clinics. Gov. Sam Brownback, a Republican, is expected to sign it.

A Doctor’s Push for Single-Payer Health Care for All Finds Traction in Vermont

Posted: 21 May 2011 11:20 PM PDT

MONTPELIER, Vt. — Many people move to Vermont in search of a slower pace; Dr. Deb Richter came in 1999 to work obsessively toward a far-fetched goal.

She wanted Vermont to become the first state to adopt a single-payer health care system, run and paid for by the government, with every resident eligible for a uniform benefit package. So Dr. Richter, a buoyant primary care doctor from Buffalo who had given up on New York’s embracing such a system, started lining up speaking engagements and meeting with lawmakers, whom she found more accessible than their New York counterparts.

“I wrote a letter to the editor, and the speaker of the House called me up to talk about it,” Dr. Richter, 56, recalled recently. “It was astounding. In New York, I couldn’t even get an appointment with my legislator.”

Twelve years later, Dr. Richter will watch Gov. Peter Shumlin, a Democrat, sign a bill on Thursday that sets Vermont on a path toward a single-payer system — the nation’s first such experiment — thanks in no small part to her persistence. Though scores of people pushed for the bill, she was the most actively involved doctor — “the backbone,” Mr. Shumlin has said, of a grass-roots effort that helped sway the Democratic Legislature to pass it this spring even as other states were suing to block the less ambitious federal health care law.

“We wouldn’t be where we are without Deb,” Mr. Shumlin said in an interview. “She’s made this her passion. And like anyone that’s making significant social change, she has qualities of persuasiveness and leadership and good judgment that are hard to find.”

As in all states, the cost of health care has increased sharply in Vermont in recent years. It has doubled here over the last decade to roughly $5 billion a year, taking a particular toll on small businesses and the middle class. All 620,000 of the state’s residents would be eligible for coverage under the new system, which proponents say would be cheaper over all than the current patchwork of insurers. A five-member board appointed by the governor is to determine payment rates for doctors, what benefits to cover and other details.

But much remains to be worked out — so much that even under the most optimistic projections the plan might not take effect until 2017. Most significantly, Mr. Shumlin still has to figure out how much it will cost and how to pay for it, possibly through a new payroll tax. Whether he will still be in charge by 2017 is among the complicating factors.

“If we had the exact same Legislature and the same governor we could get it done,” Dr. Richter said. “It’s a big if, because the opposition has a ton more money to convince people that the governor is evil and this is socialized medicine and all kinds of other scary stuff.”

The opposition will probably include insurance companies, drug makers and some employers who say there are too many unknowns. Many doctors, too, are wary of the change and what it might mean for their income. Dr. Richter said she believed a “slim majority” of the state’s 1,700 licensed physicians were supportive.

“One of the bigger worries I have is we’ve had all this hoopla and nothing’s going to happen,” she said at a coffee shop here recently on a rare quiet afternoon. “But it might also be helpful to us, because it’s going to be hard for any opposition to be steadily pushing for seven years.”

The federal health care law has complicated Vermont’s plans, requiring the state to first create a health insurance exchange to help residents shop for coverage by 2014. The state would then need a federal waiver to trade its exchange for a government-run system.

Dr. Richter said she embraced the idea of a single-payer system as a young doctor in Buffalo, where many of her patients put off crucial treatments because they were uninsured. As a medical student, she saw a patient with a life-threatening heart infection caused by an infected tooth that had gone untreated because he lacked dental insurance.

“He was in the hospital for six weeks, and I was like, ‘This makes no sense,’ ” she said.

AIDS Funds Frozen for China in Grant Dispute

Posted: 20 May 2011 09:50 PM PDT

BEIJING — The Global Fund to Fight AIDS, Tuberculosis and Malaria has frozen payments on hundreds of millions of dollars worth of disease-fighting grants to China, one of the charity’s biggest recipients, in a dispute over China’s management of the grants and its hostility toward involving grass-roots organizations in public health issues.

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The dispute may add to a growing debate among global health experts whether China, which spent an estimated $46 billion staging the 2008 Olympic games and last year’s Shanghai Expo and financed a $586 billion economic stimulus package, should be a recipient of such aid at all.

The fund, which has expanded to 150 countries since it was founded in 2002 as a pool for public and private donations to fight the world’s worst diseases, quietly decided to hold back payments from a major AIDS grant to China in November. It froze payments from other grants to China several weeks ago because of fresh concerns over lack of monitoring of funds.

Its decisions appear rooted in a collision between the fund’s conviction that grass-roots organizations must be intrinsically involved in the fight to control diseases like AIDS, and the Chinese government’s growing suspicion of any civil-society groups that are not directly under its control. They follow complaints by some AIDS activists that Chinese officials have sought to suppress their public-health activities, have shunted grant money to groups under government control and have failed to account for how some funds were spent.

At stake are hundreds of millions of dollars for programs to reduce the incidence of tuberculosis, prevent and treat H.I.V. infections and wipe out malaria. China has received $539 million from the Global Fund since 2003, according to the fund’s Web site. An additional $295 million is in the pipeline, making China the fund’s fourth largest recipient behind Ethiopia, India and Tanzania, one global health expert said.

A decision by the Global Fund to pull out of China would be hugely embarrassing for the Chinese government because it would suggest that China was unable to meet the standards of an international organization that dispersed funds to far less sophisticated governments. The fund can terminate grants that have been mismanaged or short of that,  formally suspend them. Suspension is a harsher step than halting payments and sets up a series of major obstacles to the release of additional funds.

Those more punitive measures seemed to have been averted Friday after two days of tense meetings between officials from the fund and the government. Jon Liden , a spokesman for the Global Fund, said China agreed Friday to a number of stipulations on how money would be used and monitored. “We came to a point where we needed to make clear signals to China,” he said. “We seem to share an understanding of the way forward.” This week, sources familiar with the negotiations said China pledged to the Global Fund that it would repay any funds that were misspent. But some fear that the inclusion of civil society groups in the health effort may still be an issue.

The meetings took place against the backdrop of growing questions over whether China should be allowed to benefit from the fund’s largesse. As a middle-income country, China qualifies for grants, as do Thailand, India, the Philippines and a number of Latin American countries. Unlike poorer countries, those nations are expected to contribute a certain percentage of the cost of the programs financed.

But China’s huge success in winning awards — coupled with growing evidence of the government’s deep pockets — has inspired fiery criticism, including from Jack Chow, a former first assistant director general of the World Health Organization who helped create the Global Fund. Dr. Chow, now a professor at Carnegie Mellon University, has argued that China’s Health Ministry seeks aid only because the Chinese government chooses instead to lavish funds on “hard power” agencies or to invest it in other sectors.

“China’s persistent appetite threatens to undermine the entire premise behind the Global Fund,” he wrote in the July issue of Foreign Policy. At a time when the fund is struggling for contributions, he wrote, “Donors will grow even more reluctant if they realize that substantial funds are being awarded to a country that can more than pay for its own health programs.”

China’s contributions to the fund amount to a mere $16 million, compared with $5.5 billion from the United States, the leading donor, he wrote. Fund officials have been reviewing the question of eligibility criteria, and lower-than-expected donations are now forcing them to be more selective about recipients.

Jonathan Ansfield contributed reporting, and Li Bibo contributed research.

Cases: Arc of Life and Love, Unbent by Treatment

Posted: 17 May 2011 08:02 AM PDT

Gavin Snow’s skin cancer was discovered routinely enough: a mole on his back seemed suspicious to a dermatologist, who removed it for biopsy. The diagnosis was less typical. In 2006, Mr. Snow had Stage 3 melanoma, a disease usually found in people three decades older.

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ENDURANCE Gavin Snow was fitted with a halo before his third gamma knife procedure on Jan. 13 at New York University Medical Center. The no-knife surgery blasts its target with hundreds of high-intensity radiation beams in a session. He has undergone countless treatments and drug trials.

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COMFORTING Haley Tanner was surrounded by her family in a hospital room on Feb. 17, the day Gavin suffered a brain hemorrhage, caused by bleeding tumors.

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Raymond McCrea Jones/The New York Times

On. Feb. 20, friends and family gathered at Ms. Tanner's home in Mt. Kisco, N.Y. to sit shiva and share photographs.

Treatment began, and two months later Mr. Snow, of Nashville, met the love of his life, Haley Tanner, a fellow counselor at a summer camp for American teenagers abroad in Cambridge, England. “The things she talked about and the way she talked about them was so interesting to me and so fascinating,” he said in an interview. “I was just so overcome by her.”

For the next few months, the couple divided their time between Tennessee and New York City, where Ms. Tanner lived. Then one weekend, Mr. Snow canceled his return flight and moved in with Ms. Tanner.

They spent the next two years going to medical appointments together. For two years every scan was clear. Mr. Snow was “N.E.D.” — no evidence of disease.

Until December 2008, when a routine PET scan found lesions in his right lung, meaning that the melanoma had spread and was now Stage 4 — usually a terminal diagnosis. In January 2011 his oncologist told the couple that they had exhausted all options.

Ms. Tanner was devastated. But for Mr. Snow, there was an unexpected feeling of elation. “Now, after five years of being tied to exam rooms and surgeries, I was free,” he said. “I’m a free man now.”

The rest is a story of love that includes wedding plans, drug trials, budding careers, unexpected tragedy and hope in the face of insurmountable odds.

Well: Gym Class: Samurai Sword Fighting

Posted: 24 May 2011 09:14 AM PDT

Well: Is There a Doctor on the Plane?

Posted: 24 May 2011 11:59 AM PDT

Well: Having Baby at Home: Share Your Story

Posted: 23 May 2011 11:29 AM PDT

Well: How Much Do Your Children Sleep?

Posted: 23 May 2011 10:45 AM PDT

Well: Hold the Onions and Cook With Leeks

Posted: 20 May 2011 08:22 AM PDT

Personal Health: Zombie Prevention: Your Child’s Sleep

Posted: 23 May 2011 10:30 PM PDT

I have an important question — actually, several related questions — for all parents of school-age children: Do you know how much your children sleep? Do you know how much sleep they really need?

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And do you know what their biological clocks are telling them about when to go to sleep and when to wake up?

Although young children are likely to arouse their groggy parents every morning, with no respect for weekends, after puberty the tables turn. Often I hear a familiar lament from parents of adolescents: Every day it’s a struggle to get the kids up and out to school on time.

Many youngsters and most teenagers do not get enough sleep, and this can result in serious consequences, impairing school performance and even raising the risk of depression and other mood disorders.

To help you and your children better appreciate their sleep needs, I’d like to suggest a little test. For a week or two before school ends and again during summer vacation, keep a three-column sleep diary for your children. Or, if they are able and willing, ask them to do it themselves.

In one column, record lights-out time during the school week and on weekends or vacation days. In a second column, record sleep latency — that is, how long it takes them to fall asleep. And in the third column, record wake-up time, noting whether arousal occurs naturally or with an alarm (or dousing with cold water!).

While it’s true that sleep needs vary from one person to another, there are some very reasonable, science-based guidelines to help you determine whether children are getting the sleep they need to function at their best in school and at play and to get along well with friends and relations.

And if you are a parent of teenagers, you may come to a much better understanding of why they have so much trouble getting up on school mornings in time to wash, dress, eat breakfast and get to the bus or their first class on time.

In years past, TV got all the blame for curtailing the sleep of the younger set. Now, the modern devices that were meant to enhance communication and save us so much time have created nearly endless days. There is no longer a “sacred” hour beyond which a child cannot contact someone, search for information or shop online. And for far too many youngsters, sleep takes a back burner to staying in touch, whether by cellphone, e-mail, instant or text messages or Skype.

By the Numbers

According to the National Sleep Foundation, newborns should sleep 12 to 18 hours out of every 24 (every new parent hopes), with a gradual reduction to 12 to 14 hours for toddlers ages 1 to 3; 11 to 13 hours for preschoolers 3 to 5; and (yes!) 10 to 11 hours for schoolchildren ages 5 to 10.

I suspect, though, that relatively few fourth and fifth graders get 10 hours of shut-eye a night. My grandsons, at 10, were lucky to sleep eight or nine hours, even on weekends. Researchers at Stanford University have reported that 9- and 10-year-olds need only about eight hours a night.

But things get really challenging at puberty and throughout adolescence. Not only do teenagers need more sleep than adults — eight and a half to nine and a quarter hours a night, according to the sleep foundation — but the times at which they get sleepy and are able to awaken naturally and feel rested shift in a way that does not mesh with the start times at most schools.

The typical teenager, sleep studies have shown repeatedly, does not fall asleep readily before 11 p.m. or later. Yet many have to get up by 6 a.m. or earlier to get to school for a class that starts at 7:30 or 8 a.m. More than a few doze off during that class, and often the next one as well. Even if awake, they’re in no condition to learn much of anything.

In one study, more than 90 percent of teenagers reported sleeping less than nine hours a night, and 10 percent said they slept less than six hours. As James B. Maas, a Cornell University psychologist and leading sleep researcher, has observed, most teenagers are “walking zombies” because they get far too little sleep.

Even in 1998, before smartphones and iPads could be blamed for teenagers’ sleep deprivation, a study of more than 3,000 adolescents by two sleep specialists, Amy R. Wolfson of the College of the Holy Cross and Mary A. Carskadon of Brown University, found that high school students who got poor grades slept an average of 25 minutes less and went to bed 40 minutes later than those who got A’s and B’s.

In a laboratory study of 40 high school students, Dr. Carskadon and colleagues found that nearly half the students who began school at 7:20 a.m. were “pathologically sleepy” at 8:30 a.m. Calling such early start times “abusive,” she said, “These kids may be up and at school at 8:30, but I’m convinced their brains are back on the pillow at home.”

This is the first of two columns on sleep needs.

Really?: The Claim: Playing a Wind Instrument Causes Respiratory Infection

Posted: 24 May 2011 11:22 AM PDT

THE FACTS

Christoph Niemann

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For years, scientists have noticed that people who play wind instruments seem to be at greater risk of chronic sore throats and airway inflammation. Some research suggested that saliva and microorganisms might build up in the mouthpieces, then get blown deeper into the instruments.

But until recently, scientists did not know whether the germs could breed and survive long enough to sicken someone playing the instrument a day or two later.

In a study published this month in The International Journal of Environmental Health Research, Tufts University scientists tested 20 instruments — flutes, clarinets, trumpets and saxophones. All were found to harbor living bacteria, mold and yeast, some of which survived for several days when cultured. Wooden reeds and mouthpieces had the most contamination.

While researchers have not looked specifically at infection rates in musicians, there have been numerous case reports of lung problems linked to instruments. One published in the journal Chest last year described a 35-year-old trombone player who had suffered a bad cough for 15 years; it went away after he started disinfecting the instrument with rubbing alcohol. In another, also published in Chest, a 67-year-old saxophonist with shortness of breath saw the problem disappear after he made a habit of washing his mouthpiece.

Experts say that in addition to regularly cleaning mouthpieces, musicians should routinely disassemble and clean wind instruments with soap and water or alcohol wipes, especially if it’s shared.

THE BOTTOM LINE

Certain instruments can raise the risk of infections if not routinely cleaned.

ANAHAD O’CONNOR

scitimes@nytimes.com

Drugs Stop AIDS. Take Your Medicine.

Posted: 22 May 2011 09:05 PM PDT

THERE is now, for the first time, hard clinical evidence of an effect that AIDS doctors have suspected for years: If you are H.I.V.-positive, being on antiretroviral drugs will probably save not only your life, but also the lives of your sexual partners.

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This month, a randomized clinical trial — the gold standard in medical research — showed that the drugs lowered the chances of infecting a partner by 96 percent.

This is good news for the infected and their lovers. But it is a moral dilemma for doctors whose infected patients do not want to start taking drugs immediately, usually because they do not yet feel sick and have heard exaggerated rumors about side effects.

What does a responsible doctor do with a patient who is sexually active and teeming with a fatal and incurable virus? Advise him to use condoms and trust him to act decently? Beg?

Behind each doctor — whose primary duty is to one patient — there is a government public health bureaucracy, whose duty is to protect the whole country. The epidemic has been killing Americans for 30 years now.

Whose rights should be paramount? Those of the patient? Or those of his healthy spouse — or boyfriend, or date, or hookup, or client, or rape victim, or incest target?

This debate has been going on since AIDS began, and has always been inextricably mixed with the circumstances of its birth: it was a sexually transmitted disease that emerged among gay men in the middle of the sexual revolution and the new gay rights movement. AIDS still carries a huge stigma and provokes hatred wildly out of proportion with the fact that it is simply a new virus. (Neither SARS nor H1N1 were called “God’s wrath.”)

But the fact that there is a new form of prophylaxis reopens old questions.

Several AIDS clinicians interviewed for this article said the idea of forcing treatment onto a patient was repulsive to them.

“It was unthinkable when we had this debate in the early 1980s, and it’s unthinkable in 2011,” said Dr. Myron S. Cohen of the University of North Carolina, who led the study that found the 96 percent protection rate. During a long discussion, he called the idea “medieval” and “a violation of civil rights.”

Recalcitrant patients “ultimately do come around,” argued Dr. Wafaa El-Sadr, who has treated AIDS patients in Harlem and Africa for decades. “You talk to them, you talk to them, you talk to them. Forcing them would make them run away.”

Ronald Bayer, who teaches ethics at Columbia University’s Mailman School of Public Health, agreed, even as he reflected that he is “rarely in the position where I’m the one urging restraint — they used to call me ‘Dr. Coercion’ because I’m often on the side of public health trumping individual rights.”

Hypothetically, he said, if there were a single pill that could render a patient noninfectious for a year, forced treatment might be imaginable.

But there is not, and the practical barriers to forcing someone onto daily pills for life are enormous. Dr. Bayer compared it to Jeremy Bentham’s notion of a Panopticon — a late 18th century jail where every prisoner knows he can be watched at all times.

Furthermore, several doctors said, it would be unethical to expend effort on forcing a tiny minority of selfish and self-destructive patients into treatment when so many others lack it, when 8,000 Americans are on waiting lists for the drugs, and millions of others, mostly in Africa, have little hope of getting them.

And yet in many legal circumstances, people can be forced into treatment to protect others. In New York’s outbreak of drug-resistant tuberculosis in the 1990s, uncooperative patients were locked into Bellevue Hospital. Mental patients can be involuntarily medicated if a judge or medical panel rules them dangerous; “Kendra’s Law” permitting just that in New York State was named for a young woman killed by one.

Women with hepatitis B can be forced to immunize their babies within 12 hours of birth. Children must have shots before they enter school not just for their own sake but also to protect their classmates who are allergic to vaccines or have compromised immune systems.

And most of the quarantine laws written a century ago, when cholera, typhus and plague were around, are still on the books. “Typhoid Mary” was not imprisoned for 25 years for treatment. She was never sick, didn’t believe in germs although she carried them, and attacked a public health official with a fork when he demanded a stool sample. She was imprisoned because she kept taking jobs as a cook, sometimes under false names, infecting 51 people.

Dr. Thomas R. Frieden has been on both sides of the dilemma. As head of the Centers for Disease Control and Prevention, he is a leader in the national response to AIDS. As health commissioner of New York City during the tuberculosis outbreak, he had to imprison some patients.

“I see a bright line between tuberculosis, which can be passed standing next to someone in an elevator, and H.I.V., which usually requires consensual sexual activity,” he said in an interview.

But, it was argued to him, even consensual sex isn’t truly consensual when someone is lied to, or drunk, or in a dozen other situations that would negate the ideal of “informed consent” if, say, a contract were being signed.

“I know,” he said, describing interviews he had done with infected men early in the epidemic. “The stories were heartbreaking — young men, moving to New York to finally come out as gay, and they’d say, ‘I know who did it. I just can’t believe they’d have lied to me about something like this.’ ”

Nonetheless, he said, he still would never force a patient into treatment.

“It’s a small subset of people who pass on the virus by lying,” he said, “and people have a right to refuse treatment.”

Dr. Howard Markel, a medical historian at the University of Michigan, said that, even after 30 years, there is still a sense of what he called “AIDS exceptionalism” — the belief that this illness is like no other, despite historical precedents. (The obvious one is syphilis, which until antibiotics became widespread in the 1940s was the exemplar of a slow-progressing fatal disease. To stop it, mandatory testing was adopted; many states would not issue a marriage license without a negative result. AIDS tests are not only not mandatory, but also it is often legally difficult to add them to routine blood work.)

“Is it time for AIDS exceptionalism to become a historical relic?” Dr. Markel asked. “That’s an interesting question. It may be time for it to just blend in with the others. But that might not happen until some other attention-getting disease comes along.”

The New Old Age: When to Treat Prostate Cancer?

Posted: 24 May 2011 11:11 AM PDT

The New Old Age: Moving My Father

Posted: 20 May 2011 05:00 AM PDT

The New Old Age: Another Month, Another Home

Posted: 19 May 2011 01:10 PM PDT

Letters: Many Reasons to Run (2 Letters)

Posted: 24 May 2011 12:00 AM PDT

To the Editor:

Re “One Runner’s Suffering Is Another’s Inspiration” (Personal Best, May 17): The question posted at the beginning of the article, “Do we run because we like the pain?” implies that pain is a universal, necessary experience for runners. It isn’t.

I’ve been running (though not at the front of any pack) for about 20 years, and the only pain I’ve suffered has been from the occasional blister and a collision with a dog that left me with a minor shoulder injury.

So let’s not discourage even the slow and klutzy from trying an exercise that is inexpensive, easy to start and self-paced.

Lisa J. Bernt

Belmont, Mass.

♦

To the Editor:

I read with interest Gina Kolata’s column, hoping to find an answer as to why I ran six miles in Philadelphia’s 10-mile Broad Street Run despite intense pain that resulted in a stress fracture and no running for at least six weeks.

I had wanted to prove that I could do it again, and also I thought that if I pushed on I would be rewarded with just a touch of the euphoria that Ms. Kolata writes about.

Part of me is proud of my accomplishment, but as I sit here in an air cast, I also feel kind of stupid. At least, it is good to see that I am not the only one.

Ronni Gordon

South Hadley, Mass.

Science Times welcomes letters from readers. Those submitted for publication must include the writer’s name, address and telephone number. E-mail should be sent to scitimes@nytimes.com. Send letters to Science Editor, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018.

Letters: Give to Receive (1 Letter)

Posted: 24 May 2011 12:00 AM PDT

To the Editor:

Re “One Death Provides New Life for Many” (May 17): If more people were as generous as Julio Garcia, over 50 percent of Americans who are waiting for organ transplants would not die each year. Most of these deaths are needless. Americans bury or cremate 20,000 transplantable organs every year. There are now more than 110,000 people on the national transplant waiting list.

There is a simple way to put a big dent in the organ shortage: Give donated organs first to people who have agreed to donate their own organs when they die. Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren’t willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

David J. Undis

Nashville

The writer is director of LifeSharers, a nonprofit group.

Science Times welcomes letters from readers. Those submitted for publication must include the writer’s name, address and telephone number. E-mail should be sent to scitimes@nytimes.com. Send letters to Science Editor, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018.

Letters: Happy and You Know It (1 Letter)

Posted: 24 May 2011 12:00 AM PDT

To the Editor:

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Re “A New Gauge to See What’s Beyond Happiness” (Findings, May 17): Martin Seligman, the father of positive psychology, now thinks that happiness is overrated and that we should be studying something called “flourishing” rather than “life satisfaction.” But in practice people’s answers to a survey asking them about this type of happiness were largely determined by how they felt at the moment, not how they judged their lives overall.

The remedy is not to stop researching life satisfactions, but to craft questions that distinguish this concept from what psychologists refer to as affect or mood.

I sometimes ask my patients in counseling to imagine being at the end of their lives, looking back not only on what happened but how they responded.

If they can say they are satisfied with themselves as human beings and can reflect on their experiences with equanimity, they will — no matter how cheerful or sad they were along the way — be expressing life satisfaction.

Richard Trachtman

New York

Science Times welcomes letters from readers. Those submitted for publication must include the writer’s name, address and telephone number. E-mail should be sent to scitimes@nytimes.com. Send letters to Science Editor, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018.

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National Briefing | WEST: California: Judge Blocks Cap-and-Trade Plan

Posted: 20 May 2011 10:48 PM PDT

A California judge ruled on Friday that state air regulators must stop carrying out a cap-and-trade plan until they examine alternatives to emissions trading to meet the state’s aggressive greenhouse gas-reduction targets. The judge, Ernest Goldsmith of the Superior Court of California in San Francisco, said that the California Air Resources Board should “take no action” to put its cap-and-trade plans into effect until it completes the analysis of the alternatives. Last month, Judge Goldsmith said the A.R.B., the agency devising the state’s cap-and-trade plan, had failed to adequately study alternatives to creating a carbon market. The regulatory agency had been sued by an environmental justice group called the Association for Irritated Residents, who said that the future greenhouse gas market could cut air quality in some parts of the state while benefiting others. “This includes any further rule-making and implementation of cap and trade,” the judge wrote in his decision.

Insurers Told to Justify Rate Increases Over 10 Percent

Posted: 20 May 2011 02:40 PM PDT

WASHINGTON — Alarmed at soaring premiums and profits in the health insurance industry, the Obama administration demanded on Thursday that insurers justify proposed rate increases of more than 10 percent, starting in September.

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Kathleen Sebelius, the secretary of health and human services, issued a rule Thursday on procedures for reviews of premiums.

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Kathleen Sebelius, the secretary of health and human services, issued a final rule establishing procedures for federal and state insurance experts to scrutinize premiums. Insurers, she said, will have to justify rate increases in an environment in which they are doing well financially, with profits exceeding the expectations of many Wall Street analysts.

“Health insurance companies have recently reported some of their highest profits in years and are holding record reserves,” Ms. Sebelius said. “Insurers are seeing lower medical costs as people put off care and treatment in a recovering economy, but many insurance companies continue to raise their rates. Often, these increases come without any explanation or justification.”

Federal health officials proposed the 10 percent threshold in December. The insurance industry criticized it as an arbitrary test that could brand a majority of rate increases as presumptively unreasonable. But the administration rejected the criticism and insisted on the 10 percent standard in the final rule, issued Thursday.

Starting in September 2012, the federal government will set a separate threshold for each state, reflecting trends in insurance and health care costs.

In some states like New Hampshire, groups of more than 20 workers have experienced premium increases of around 20 percent this year, while smaller groups have seen increases of 40 percent or more. At the same time, insurance agents say, coverage is shrinking as deductibles have increased and insurers limit the choice of hospitals.

To ensure that “consumers get value for their dollars,” the new health care law required annual reviews of “unreasonable increases in premiums.”

Under the new rule, federal and state officials will review rates in the individual and small-group insurance markets. In effect, the administration said, large employers can take care of themselves, as they are more sophisticated purchasers and have more leverage in negotiating with insurers.

Federal officials acknowledged that they did not have the authority to block rates that were found to be unjustified. But they said many states had such authority, and the federal government is providing $250 million to states to strengthen their capacity. A small number of states, opposed to the federal health care law, have turned down the money.

The new rule says a rate increase is unreasonable if it is excessive, unjustified or “unfairly discriminatory.” An increase is deemed excessive if it is “unreasonably high in relation to the benefits provided.”

Consumer advocates generally welcomed the rule. “The days of insurance companies running roughshod over consumers and jacking up rates whenever they want are over,” said Ethan S. Rome, executive director of Health Care for America Now, a coalition that includes labor unions and civil rights groups.

Insurers said the rule did nothing to address the underlying costs of health care, which they described as the main factor driving up premiums.

“If we believe health care costs are crushing the economy, we ought to have a debate about how to bring costs under control,” said Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group. “Focusing on premiums diverts attention from that debate.”

In many cases, Ms. Ignagni said, rate increases of more than 10 percent may be justified by rising health costs and the tendency of younger, healthier people to drop coverage, forcing up costs for other policyholders.

States will have the primary responsibility for reviewing rate increases. “But if a state does not have the authority or the resources to conduct a review, our department will step in,” said Ms. Sebelius, a former state insurance commissioner in Kansas.

Under the rule, as part of an effective rate review program, states must have “a mechanism for receiving public comments” on proposed rate increases.

Elizabeth P. Sammis, the acting insurance commissioner in Maryland, said this would be a big change. In many cases, she said, consumers learn of premium increases when they receive notices in the mail, and then they call the commissioner’s office to ask, “Why are rates going up?”

China Reports AIDS Mortality Is Cut by Two-Thirds

Posted: 24 May 2011 09:05 AM PDT

China has slashed AIDS mortality by nearly two-thirds since it began distributing free antiretroviral drugs in 2002, Chinese government scientists are reporting.

About 63 percent of all those needing AIDS drugs are getting them, up from virtually zero in 2002.  That has caused a 64 percent drop in mortality in “person-years,” as China measures it, an estimate of how long someone would have lived without the disease.

AIDS mortality dropped to 14.2 per 100 person-years in 2009, from 39.3 in 2002.

The study, led by China’s national center for control and prevention of AIDS and other sexually transmitted diseases, was published online on Wednesday by Lancet Infectious Diseases.

China’s success in such a short time “is a testimony to the young midlevel scientists who convinced the leadership that this was the right thing to do,” said Dr. Myron Cohen, an AIDS specialist from the University of North Carolina who has lived in China and helped it battle the epidemic.

A different report, released Wednesday by the International Labor Organization of the United Nations, criticized China’s health-care system, saying that people infected with H.I.V., the virus that causes AIDS, were frequently turned away by hospitals.

The report, based on interviews with patients, health care workers and hospital managers, says patients are sent by general hospitals to infectious-disease hospitals. But they often refuse to perform surgery, for example, for fear that paying patients will avoid the hospital if word spreads that it operates on AIDS patients. China’s national center for AIDS control, a co-author of the report, agreed that hospital discrimination was a problem.

The number of infected people in China — 740,000, according to estimates by the government and U.N.AIDS — is large by comparison with most countries, but small in a population of 1.3 billion. Of those, 323,252 have been tested and 82,540 are being treated.

If the total caseload estimate is correct, China has tested nearly half its infected people. By comparison, the United States estimates that 80 percent of its 1.1 million infected people have been tested.

China now begins treating when a patient’s CD4 cell count, a measure of immune system strength, drops below 350 per cubic millimeter.

It is now debating whether to start treatment as soon as a patient tests positive for H.I.V., Dr. Cohen said. A study released last week showed that this strategy, known as “treatment as prevention,” could reduce the risk of new infections by 96 percent by protecting an infected person’s sexual partners.

China’s biggest treatment success was among former plasma sellers.   In the 1990s, tens of thousands of poor farmers sold plasma to commercial “bloodhead” operations. Their blood was mixed, the plasma skimmed off, and the mixed red cells were reinfused back into the sellers.

Reinfusion is routine in plasma donation, but the process allowed H.I.V. to spread rapidly among donors. Soon, in some rural villages, 50 percent of adults were infected.

Many of the early victims died before 2002, but among the survivors, according to the study, 80 percent are now getting antiretroviral drugs. By contrast, the figure for those infected through sex is about 60 percent; for those infected by injecting drugs, it is about 40 percent.

Drug injection is most common in the southern and western regions bordering Myanmar and Afghanistan, both of which grow opium. China now offers free needles and methadone to addicts, which draws many in to be tested for AIDS.

Infection through sex is most common among gay men and customers of prostitutes. Many gay people still keep their sexual orientation hidden. Also, visiting prostitutes is common among migrant laborers living illegally in crowded city apartments.

In 2010, China estimated that 85 percent of female prostitutes used condoms. Other studies suggest that fewer than 1 percent are infected, but high-risk sex is common enough to let infections continue.

The Lancet report says the health care system still fails homosexuals, drug users, prostitutes and ethnic minorities because of lingering prejudices against them and against AIDS in general. And it is not reaching many elderly patients and migrants.

Still, China is no longer in deep denial about its epidemic, as it was until a decade ago.

 In 1990, the education ministry said sexual morality and self-discipline would keep AIDS out. Imports of blood products were banned and foreigners were required to take blood tests. The police barred foreigners from dance halls and took other steps to prevent sex with outsiders. In 1999, China’s first condom ad was banned as offensive two days after it was released. 

In 2001, there was an official change of heart. The government publicly admitted that 500,000 to one million people were infected and asked for outside help. Condoms were reclassified as “safety devices.” At the same time, China said that if Western companies did not lower their prices, it would make antiretroviral drugs itself.

In 2002, China applied for $90 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria to begin its free drugs program. In return, it was forced to free an AIDS activist who had been imprisoned after posting details of unsanitary sales of blood in Henan Province. AIDS activists are still sometimes detained.

Chemical Suspected in Cancer Is in Baby Products

Posted: 18 May 2011 03:43 PM PDT

More than 30 years after chemical flame retardants were removed from children’s pajamas because they were suspected of being carcinogens, new research into flame retardants shows that one of the chemicals is prevalent in baby’s products made with polyurethane foam, including nursing pillows, car seats and highchairs.

The research does not determine if children absorbed the chemical, chlorinated Tris, from the products. But in an article to be published Wednesday in the journal Environmental Science & Technology, the researchers suggest that infants who use the products have higher exposure to the chemical than the government recommends.

Earlier research by one of the article’s authors, Arlene Blum, a biophysical chemist, contributed to the elimination of Tris flame retardants, including chlorinated Tris, in children’s pajamas in the 1970s. Although the chemical was not banned at that time, the Consumer Product Safety Commission now says that it “may pose a significant health risk to consumers.”

The new research found that foam samples from more than a third of the 101 baby products that were tested contained chlorinated Tris. Over all, 80 of the products contained chemical flame retardants of some kind, some of which are considered toxic, though legal to use. In one instance, flame retardants represented 12 percent of the weight of the foam in a changing pad; most products were closer to 3 to 5 percent.

Among the products examined were changing table pads, sleep positioners, portable mattresses, baby carriers, rocking chairs and highchairs.

Fourteen of the products contained the flame retardant TCEP, which the State of California describes as a cancer-causing agent. Four of them contained Penta-BDE, a flame retardant that builds up in human tissue and that manufacturers voluntarily phased out in 2004; it is banned in many countries, but not the United States, and in some states, including New York.

“Why do you need fire retardant in a nursing pillow?” said Dr. Blum, who is the executive director of the Green Science Policy Institute, a nonprofit organization that brings scientific data about toxic chemicals to policy makers.

“The whole issue is, they are toxic chemicals that are in our homes at high levels; and right now, people don’t know much about it,” she said.

Asked about the new research, the Juvenile Products Manufacturers Association, an industry trade group, said all nursery products sold in the United States conform to “tough federal safety standards.”

“Not only do these safety standards contain flammability requirements, they also restrict the use of substances that are harmful or toxic and to which children might be exposed,” the association said in a statement.

The association also noted that chlorinated Tris was not banned by the government, but rather a related compound, brominated Tris, also found in the pajamas decades ago. “This study does not support allegations that the banned retardant Tris is in use,” the association said.

Gordon L. Nelson, a chemistry professor at Florida Institute of Technology, said the new research was interesting but hardly proof that the flame retardants were doing harm. He noted that some children’s products that use foams have plastic covers around them, which would prevent flame retardants from leaching out.

“The question is, in actual use, does the flame retardant come out?” Dr. Nelson said. He says he has done research on fire safety for decades and occasionally accepts research money or consulting fees from the industry.

In addition, Dr. Nelson maintained that fire retardants have vastly reduced the number of fire deaths caused by upholstered furniture, a point that critics of the chemicals dispute.

The new research is being released amid a broader, and often bitter, debate about flame retardants and a California flammability rule that has become the de facto national standard.

The California standard, passed in 1975, requires that polyurethane foam in upholstered furniture be able to withstand an open flame for 12 seconds without catching fire. Because there is no other state or federal standard, many manufacturers comply with the California rule, usually by adding flame retardants with the foam, Dr. Blum said.

Report Finds Data Lacking on Exposure to Defoliant

Posted: 20 May 2011 10:40 PM PDT

An independent panel of experts has concluded that there is not enough data available to determine whether sailors who served on deep-water ships during the Vietnam War were exposed to Agent Orange, the defoliant that has been linked to cancer and other serious diseases.

That conclusion, part of a 112-page report released Friday by the Institute of Medicine, makes it highly unlikely that the Department of Veterans Affairs will establish rules that would make it easier for so-called blue-water sailors to receive benefits for diseases linked to Agent Orange.

A spokesman for Eric K. Shinseki, the secretary of veterans affairs, who requested the study, said the department was still reviewing the report and had no comment on Friday.

But advocates for expanding benefits for Navy veterans said they would continue pushing for legislation that would make it as easy for deep-water sailors to receive health care and disability payments for Agent Orange exposure as it is for infantrymen.

Senator Kirsten Gillibrand, a Democrat from New York who has sponsored legislation for the blue-water veterans, said the new report did not disprove the possibility that deep-sea sailors were sickened by Agent Orange during Vietnam. She said that as many as 800,000 service members might have been exposed to Agent Orange, even though they did not set foot in Vietnam.

“This report does not invalidate the claims of thousands of blue-water Navy veterans who are still suffering from the same illnesses as those who served ashore in Vietnam,” the senator said in a statement.

Under a law passed in 1991, the government presumed that Vietnam veterans with certain diseases had been exposed to Agent Orange, and were therefore eligible for disability compensation and health care benefits. But in 2002, the Department of Veterans Affairs said that it would apply that law only to veterans who actually been to Vietnam.

That decision, which was upheld by a federal court, effectively excluded sailors who served on large ships, like aircraft carriers, that operated farther from the Vietnam coast. However, sailors on small boats that operated inland, known as brown-water sailors, were still eligible for those benefits.

Agent Orange, the most common herbicide used in Vietnam to clear jungle canopy and destroy crops, contained one of the most toxic forms of dioxin, which has since been linked to some cancers.

Electrode Experiment Shows Promise as a Paralyzed Man Stands

Posted: 19 May 2011 10:48 PM PDT

A young man paralyzed by an injury to his spinal cord has regained the ability to stand for short periods, take steps with help and move his legs and feet at will, with the help of an electrical stimulator implanted in his lower back.

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Rob Summers, 25, paralyzed for five years, regained some ability to stand after surgeons implanted electrodes in the lower part of his back to stimulate his spinal cord.

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The device is experimental and not available to other patients, and because it has been studied in only one person it is not known whether it would work as well in other people with different types of spinal injury.

But the researchers say that scientifically the work is an important advance, because it shows that a bit of electrical stimulation can unlock the ability of the spinal cord to control movement — even if its signals from the brain have been cut off by injury. Similar findings had been made in animals.

“It’s been thought that the brain controls all our movement,” said Susan Harkema, research director at the Kentucky Spinal Cord Injury Research Center in Louisville and the lead author of an article about the research being published online on Thursday in the journal Lancet. “But the spinal cord is the primary controller.”

Another author, V. Reggie Edgerton, a leading expert at the University of California, Los Angeles, on animal research on paralysis, said: “People think everything below the injury dies and is nonfunctional. But in fact in most injuries, the damage is just to a few segments, and the neurons below it remain intact.

“These neurons are very smart. They know what to do. They play a major role in your normal movement.”

A researcher not involved in the study, Dr. W. Zev Rymer, vice president of research at the Rehabilitation Institute of Chicago, said: “From a scientific and research standpoint, it’s outstanding. Will it make a difference in the lives of many people with spinal cord injury? I don’t know yet.”

Animal studies had suggested that signals from the brain were not needed to control the details of movement, but just to activate the spinal cord.

The man in the study was Rob Summers, now 25, who has been paralyzed since he was hit by a car when he was 20. He lost all motor control in his legs, but retained some feeling, and could use his hands and arms. He had been an athlete — a baseball player for Oregon State University — and was determined to walk and even play ball again.

At the center in Louisville, he underwent 170 sessions over 26 months in which he was placed in a harness and therapists worked to helped him stand and make stepping motions on a treadmill. He made almost no progress.

Then, in December 2009, surgeons implanted electrodes in the lower part of his back to stimulate his spinal cord. The electrodes are attached to a pulse generator, similar to a pacemaker, which is also fully implanted and controlled by a remote device outside the body. The device was switched on for about two hours a day, for therapy sessions.

On his third day of electrical stimulation, Mr. Summers managed to stand on his own. He did not rise from a sitting position, but managed to support his own weight briefly when the harness that had been holding him was gradually released.

“It was unbelievable,” he said in a telephone interview. “There was so much going through my head at that point; I was amazed, was in shock.”

Dr. Harkema was surprised, too. “It certainly fits with the theory we were testing, but we didn’t expect it to happen this early,” she said. Mr. Summers went through hundreds more therapy sessions and began to gain strength and muscle mass, and his overall health improved. He still hopes to walk someday.

Dr. Harkema said that four more patients would receive electrode implants, but that the research had a long way to go.

The study was paid for by the National Institutes of Health and the Christopher and Dana Reeve Foundation.

A Blood Test Offers Clues to Longevity

Posted: 18 May 2011 10:43 PM PDT

Want to know how long you will live?

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University of Texas

Telomeres are structures on the tips of chromosomes that shorten as people age.

Toni Albir/EFE, Via European Pressphoto Agency

Elizabeth H. Blackburn shared a Nobel Prize in 2009 for discoveries related to telomeres.

Blood tests that seek to tell people their biological age — possibly offering a clue to their longevity or how healthy they will remain — are now going on sale.

But contrary to various recent media reports, the tests cannot specify how many months or years someone can expect to live. Some experts say the tests will not provide any useful information.

The tests measure telomeres, which are structures on the tips of chromosomes that shorten as people age. Various studies have shown that people with shorter telomeres in their white blood cells are more likely to develop illnesses like cancer, heart disease and Alzheimer’s disease, or even to die earlier. Studies in mice have suggested that extending telomeres lengthens lives.

Seizing on that, laboratories are beginning to offer tests of telomere length, setting off a new debate over what genetic tests should be offered to the public and what would be the ethical implications if the results were used by employers or others.

Some of the laboratories offering the tests emphasize that the results are merely intended to raise a warning flag.

“We see it as a kind of wake-up call for the patient and the clinician to say, ‘You know, you’re on a rapidly aging path,’ ” said Otto Schaefer, vice president for sales and marketing at SpectraCell Laboratories in Houston, which offers a test for $290.

A company in Spain, provocatively named Life Length, has begun selling a test for 500 euros ($712), that says that it can tell people their biological age, which may not correspond to their chronologic age.

Another company, Telome Health of Menlo Park, Calif., plans to begin offering a test later this year for about $200. It was co-founded by Elizabeth H. Blackburn of the University of California, San Francisco, who shared a Nobel Prize in 2009 for discoveries related to telomeres.

Calvin B. Harley, the chief scientific officer at Telome Health, said the test would be akin to a car’s dashboard signal, a “check engine light.” He compared it with a cholesterol test, but more versatile since it can predict a risk of various illnesses, not just heart attacks.

But among the critics of such tests is Carol Greider, a molecular biologist at Johns Hopkins University, who was a co-winner of the Nobel Prize with Dr. Blackburn.

Dr. Greider acknowledged that solid evidence showed that the 1 percent of people with the shortest telomeres were at an increased risk of certain diseases, particularly bone marrow failure and pulmonary fibrosis, a fatal scarring of the lungs. But outside of that 1 percent, she said, “The science really isn’t there to tell us what the consequences are of your telomere length.”

Dr. Greider said that there was great variability in telomere length. “A given telomere length can be from a 20-year-old or a 70-year-old,” she said. “You could send me a DNA sample and I couldn’t tell you how old that person is.”

Dr. Peter Lansdorp, a telomere expert at the British Columbia Cancer Agency, also had doubts. “If telomeres are short for you or me, what does it mean?” he said. Dr. Lansdorp started a company, Repeat Diagnostics, which conducts telomere testing for medical researchers only.

Recent media reports speculated on the tests and their possible implications, including ethical problems.

“You could imagine insurance companies wanting this knowledge to set rates or deny coverage,” said Jerry W. Shay, a professor of cell biology at the University of Texas Southwestern Medical Center in Dallas, who is an adviser to Life Length.

Test vendors say the speculation is running wild.

“It doesn’t mean we will tell anyone how long they will live,” said María Blasco, a co-founder of Life Length and a molecular biologist at the Spanish National Cancer Research Center in Madrid. Even if a 50-year-old has the telomere length more typical of a 70-year-old, she said, “This doesn’t mean your whole body is like a 70-year-old person’s body.”

Still, she said, “We think it can be helpful to people who are especially keen on knowing how healthy they are.”

Generally tests offered by a single laboratory do not have to be approved by the Food and Drug Administration. But the F.D.A. has been cracking down recently on some tests offered to the public, saying they may need approval. The FDA said in a statement Wednesday that it was aware of the tests, and had not come to any conclusions.

Executives at both Telome Health and Life Length say they will require a doctor to be involved in ordering the test, though SpectraCell said it allowed individuals to order the test.

Drug Study a Setback for Abbott

Posted: 17 May 2011 10:00 PM PDT

A study has suggested that an anticholesterol drug, TriLipix, does not protect against heart attacks or strokes better than a generic medicine, according to a report released on Tuesday. As a result, uses of the drug, made by Abbott Laboratories, may be limited in the United States or be subject to more testing.

The Food and Drug Administration is also considering whether to add data from the clinical trial to TriLipix’s prescribing information, the report said. Outside advisers to the agency will consider the proposed options at a meeting on Thursday in Silver Spring, Md.

The review focuses on a study released in March 2010 comparing Abbott’s TriCor, an older version of TriLipix also known as fenofibrate, to the generic cholesterol pill simvastatin. New restrictions may jeopardize sales of TriLipix, which together with TriCor generated $1.58 billion last year, or 4.5 percent of Abbott’s revenue.

“Since complete data were not available, it is difficult to definitively assess the safety profile of fenofibrate plus simvastatin versus simvastatin plus placebo,” the F.D.A. said in its staff report.

The trial, named Accord, followed about 5,500 patients with Type 2 diabetes who were at high risk of developing heart disease, for an average of almost five years. Study results showed no significant reduction in the number of heart attacks, strokes and cardiac deaths in people taking TriCor along with simvastatin, compared with those taking simvastatin alone.

The F.D.A. is asking its advisory panel to weigh several options: whether TriLipix should be withdrawn for use with a statin; continue to be used with a statin with data from the study added to the prescribing information; tested in a new study; or face no changes.

TriLipix is the focus of the F.D.A.’s review because TriCor is not approved for use in combination with a statin treatment.

About two-thirds of the study participants did not have high triglycerides and low levels of good cholesterol, two criteria for use in the drugs’ prescribing information, Jim Stolzenbach, head of cardiovascular development for Abbott, said in a telephone interview. Patients who met those criteria benefited from TriCor, he said. The trial was financed by the National Institutes of Health.

The risk to Abbott will be minimized because TriCor is already expected to lose revenue when cheaper copies enter the market beginning in mid-2012, according to Larry Biegelsen, an analyst at Wells Fargo in New York. He estimates that sales will fall to $990 million next year because of generic competition.

Abbott said in October that about 30 percent of patients had switched from TriCor to TriLipix, a delayed-release version that was approved in 2008.

Last year, Abbott abandoned efforts to win approval for Certriad, an experimental heart pill that combined TriLipix with Crestor, from AstraZeneca.

Recipes for Health: Quinoa and Chard Cakes

Posted: 24 May 2011 12:15 PM PDT

I’d been thinking about making a sort of “burger” with quinoa and vegetables when I saw a recipe for chard cakes in the Dining section of The Times. I combined the two ideas and came up with these quinoa and chard cakes, which you can serve as a main dish or a side. A few days later, I made the same recipe but used spinach, which is lower in sodium, instead of chard (see variation below). Top these cakes with yogurt spiked with puréed garlic.

Recipes for Health

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

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1 1/2 pounds Swiss chard, washed and stemmed (do not discard the stems)

2 tablespoons extra virgin olive oil

2 plump garlic cloves, minced, or 2 teaspoons minced green garlic

2 teaspoons cumin seeds, lightly toasted and ground

Salt and freshly ground pepper

1 cup cooked quinoa

1/3 cup freshly grated Parmesan (1 1/2 ounces)

1 egg, beaten

1 tablespoon canola oil

For serving:

1/2 cup plain yogurt

1 garlic clove, puréed with a generous pinch of salt

1. Fill a bowl with ice water. Bring a large pot of water to a boil, salt generously and add the chard leaves. Blanch for two to three minutes until tender, then transfer to the ice water. Drain, squeeze out excess water and chop medium-fine. Add the chard stems to the water, and cook four to five minutes until tender. Transfer to the ice water, then drain and cut in 1/4-inch dice. Measure out 3/4 cup of the stems, and reserve the rest for another purpose.

Alternatively, steam the chard leaves, then the stems, above an inch of boiling water until tender. The leaves will take three to four minutes, the stems five minutes.

2. Heat 1 tablespoon of the olive oil over medium heat in a medium or large skillet. Add the garlic. When it is fragrant, in 30 seconds to a minute, stir in the chard leaves and stems and the cumin. Stir together for about a minute, and season to taste with salt and pepper. Transfer to a large bowl, and add the quinoa, Parmesan and egg. Stir together.

3. Heat the remaining tablespoon of olive oil and the canola oil together over medium-high heat in a large, heavy skillet. Moisten your hands, and shape the quinoa and chard mixture into four hamburger-size patties (or make smaller, fritter-ish patties). Carefully place the patties in the hot oil, taking care not to crowd them in the pan. Press down on the tops of the patties with the bottom of your spatula to prevent them from falling apart; if they are thick enough, they should stay together. Cook for four to five minutes on each side until nicely browned. Remove from the heat and serve.

Variation: Substitute 2 pounds bunch spinach for the chard. Stem and wash the leaves (discard the stems) and wilt, in batches, in a large frying pan in the water left on their leaves after washing. Proceed as instructed.

Yield: Serves four.

Advance preparation: The cooked chard and cooked quinoa will keep for four days in the refrigerator. The mixture will keep for a day.

Nutritional information per serving: 242 calories; 2 grams saturated fat; 3 grams polyunsaturated fat; 9 grams monounsaturated fat; 53 milligrams cholesterol; 18 grams carbohydrates; 3 grams dietary fiber; 485 milligrams sodium (does not include salt to taste); 11 grams protein

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

Recipes for Health: Proper Uses for Quinoa

Posted: 24 May 2011 12:37 PM PDT

I’ve been thinking a lot lately about how best to use quinoa, in part because of some misguided dishes I’ve recently had in restaurants.

Recipes for Health

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

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Note to chefs: Quinoa doesn’t work as a risotto. It doesn’t have enough starch for the broth, which is what makes a good risotto creamy. Quinoa also has a grassy flavor and a texture that ranges from fluffy — too fluffy for risotto — to granular.

Quinoa is perfect, however, for a salad. It can be the main ingredient, or it can play alongside lettuces and other greens. Quinoa works very well as a pilaf, but think about adding vegetables that will complement its grassy flavor. I often add cooked quinoa to baked goods like muffins and breads, and this week I added it to my son’s habitual whole-wheat buttermilk pancakes.

Many of you may have been disturbed by the news that quinoa’s popularity abroad is making it unaffordable in Bolivia, where it has long been a staple. The good news is that several companies are committed to paying farmers fair market value for their produce. Look for brands displaying the Fair Trade Certified label.

Rainbow Quinoa Tabbouleh

Quinoa lends itself to lemony salads, and the rainbow mix is particularly nice because each type of quinoa has a slightly different texture. The pearl white grains are the fluffiest, the red and black more compact.

1 cup rainbow quinoa (a mixture of equal parts white, red and black quinoa)

3 cups water

Salt to taste

1/2 cup fresh lemon juice

1/2 teaspoon ground cumin

1/4 cup extra virgin olive oil

1 cup finely chopped flat-leaf parsley

1/4 cup finely chopped fresh mint

1 bunch scallions, white part and green, finely chopped

1 red bell pepper, chopped

1 cup finely diced cucumber

Small leaves romaine lettuce, for garnish

In summer: 1 pound ripe tomatoes, cut in small dice

1. Rinse the quinoa thoroughly, and combine with the water and salt to taste in a large saucepan. Bring to a boil, cover and reduce the heat to low. Simmer 15 to 20 minutes until the quinoa displays a little white spiral. Drain through a strainer, tap to remove excess water, then return the quinoa to the pot. Place a dish towel over the top of the pot, and return the lid. Let sit for 15 minutes. The quinoa should now be fluffy.

2. Transfer the quinoa to a large bowl. Mix together the lemon juice, salt to taste and cumin, and toss half of it with the quinoa. Allow the quinoa to cool. Combine the remaining lemon juice and olive oil, and toss with the cooled quinoa. Add the remaining ingredients, except the lettuce leaves, and toss together. Taste and adjust seasoning. Serve on a large platter or in a wide salad bowl, garnished with the lettuce leaves.

Yield: Serves four to six.

Advance preparation: The cooked quinoa will keep for four days in the refrigerator. You can make the salad several hours ahead and refrigerate.

Nutritional information per serving (analysis includes fresh tomatoes; four servings): 343 calories; 2 grams saturated fat; 3 grams polyunsaturated fat; 11 grams monounsaturated fat; 0 milligrams cholesterol; 42 grams carbohydrates; 8 grams dietary fiber; 36 milligrams sodium (does not include salt to taste); 8 grams protein

Nutritional information per serving (six servings): 228 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 7 grams monounsaturated fat; 0 milligrams cholesterol; 28 grams carbohydrates; 5 grams dietary fiber; 24 milligrams sodium (does not include salt to taste); 6 grams protein

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

Recipes for Health: Leeks in White Wine

Posted: 19 May 2011 11:30 PM PDT

When you cook leeks in wine, they develop great depth of flavor. This is my favorite way to prepare leeks on their own.

Recipes for Health

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

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6 medium leeks, about 2 1/2 pounds, white and light green parts only

Salt

2 tablespoons extra-virgin olive oil

1 cup dry white wine, like pinot grigio or sauvignon blanc

Freshly ground pepper to taste

4 large garlic cloves, minced

2 tablespoons chopped flat-leaf parsley, mint or dill (or a combination)

1. Cut the ends and the dark green leaves off the leeks, and then cut them in half lengthwise. Place in a bowl of cold water for 10 minutes, then run them under the faucet to remove any sand that may be lingering in between the layers. Cut into 2-inch pieces.

2. Bring a large pot of water to a boil, salt generously and add the leeks. Parboil for two minutes and drain.

3. Spoon the olive oil into a wide, lidded skillet, and place the leeks in the skillet in an even layer. Pour in the wine, and add salt and freshly ground pepper to taste, and the garlic. Bring to a boil, cover and reduce the heat to low. Simmer for 30 to 45 minutes, until the leeks are very tender but still intact and most of the liquid has evaporated.

4. Remove from the heat, and allow the leeks to cool in the juices left in the pan. Transfer to a serving dish. Taste and adjust seasonings. Sprinkle on the fresh herbs and serve.

Yield: Serves four to six.

Advance preparation: The leeks will keep for a day or two in the refrigerator. Reheat or bring to room temperature before serving.

Nutritional information per serving (four servings): 278 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligrams cholesterol; 42 grams carbohydrates; 5 grams dietary fiber; 61 milligrams sodium (does not include salt to taste); 5 grams protein

Nutritional information per serving (six servings): 185 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 3 grams monounsaturated fat; 0 milligrams cholesterol; 28 grams carbohydrates; 3 grams dietary fiber; 41 milligrams sodium (does not include salt to taste); 3 grams protein

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

Recipes for Health: Roasted Leeks and Potatoes Vinaigrette

Posted: 18 May 2011 11:40 PM PDT

I prefer using tiny whole potatoes for this elegant potato and leek salad if I can find them. Firm red potatoes or fingerlings are good alternatives.

Recipes for Health

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

Related

1 1/4 to 1 1/2 pounds (2 large) leeks, white and light green part only, cut in half lengthwise, cleaned and cut in 1 1/2-inch lengths

1 pound red potatoes or fingerlings, washed and cut in 1-inch dice, or very small potatoes left whole

1/2 cup dry white wine

Salt and freshly ground pepper to taste

1/4 cup extra virgin olive oil

1 tablespoon Champagne vinegar or sherry vinegar (more to taste)

1 tablespoon lemon juice (more to taste)

1 to 2 hard-boiled eggs (to taste)

1 tablespoon chopped flat-leaf parsley

1. Preheat the oven to 400 degrees. Combine the leeks and potatoes in a baking dish large enough for them to fit in a single layer. Toss with the white wine, salt, pepper and 2 tablespoons of the olive oil. Cover the baking dish tightly, and place in the oven. Roast for 30 minutes. Uncover, raise the heat to 450 degrees, and return to the oven for another 10 to 15 minutes until the leeks and potatoes are tender but not mushy and just beginning to color. Remove from the heat, and add the remaining olive oil, vinegar, lemon juice and additional salt and pepper if desired. Toss together and allow to cool.

2. Put the hard-boiled eggs through a sieve, and season with salt and pepper. Arrange over the leeks and potatoes (I like to arrange the sieved egg in a wide stripe down the middle), sprinkle with parsley and serve.

Yield: Serves four.

Advance preparation: You can make this several hours ahead of mealtime and serve at room temperature.

Nutritional information per serving: 332 calories; 2 grams saturated fat; 2 grams polyunsaturated fat; 10 grams monounsaturated fat; 47 milligrams cholesterol; 41 grams carbohydrates; 5 grams dietary fiber; 55 milligrams sodium (does not include salt to taste); 6 grams protein

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

Reporter's File: When Sinus Problems Won’t Go Away

Posted: 12 May 2011 09:56 AM PDT

The humble sinuses, those hollow cavities hidden in the bones around the nose, usually draw little appreciation. But nothing makes one yearn for clear sinuses like sinusitis, a condition that can make the head feel as if it were filled with cement and can render every breath a struggle.

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By the Numbers

For millions of people, sinusitis can drag on for months or years, unresolved by medical interventions. The focus used to be on antibiotic treatments to purge infections that most experts believed were causing chronic sinusitis. Yet many patients relapsed, leading researchers and clinicians to question their assumptions.

In the last decade, a new insight has emerged. “People have taken a step back and looked at chronic sinusitis as being probably more of an inflammatory disease process,” more like asthma, said Dr. Bradley Marple, an otolaryngologist at the University of Texas Southwestern Medical Center in Dallas. “We may not be dealing with an infectious disease all the time,” he said, in which case antibiotics may not help much.

Clinicians have refocused treatment on attacking the underlying inflammation of chronic sinusitis, using anti-inflammatory measures like steroid drugs. And scientists are seeking to uncover what causes the inflammation in the first place.

Each year, millions of adults complain of sinusitis. Normally, the sinuses produce mucus and drain it through small openings into the nasal passages. But in rhinosinusitis, as the disorder is technically known, swelling in both the nose and sinuses blocks that drainage.

The result is a stuffed-up nose and an endless outpouring of green or yellow mucus. Pain or pressure builds up around the eyes or in the face, sometimes accompanied by headaches and toothaches.

For Cindy Martinez, a 43-year-old teacher in Santa Cruz, Calif., the pressure became so bad, “I just wanted to crack open my sinuses to get the stuff out, because it was pushing so hard on my face.” She battled repeated sinusitis attacks for six years.

Short-term episodes of sinusitis that last up to four weeks are caused by infections and, if bacteria are involved, can be remedied with antibiotics and steroids. But the story isn’t so simple with the stubborn symptoms of chronic sinusitis, which may afflict as many as 14 percent of Americans, according to self-reported data, though some experts say these numbers are inflated.

Until recently, scientists and doctors couldn’t even agree on what, exactly, chronic sinusitis is. It wasn’t until 2003 that several medical societies redefined the condition not as a single disease but as a group of disorders marked by sinus and nasal inflammation lasting at least 12 weeks. And the problem can arise from multiple causes.

Predisposing factors for persistent sinus trouble are numerous, ranging from a deviated septum and bad allergies to immunodeficiency. But the underlying disease process has long been an enigma. Over the years, experts bounced from one popular theory to another that promised to explain why sinuses become chronically sick.

Sinusitis is a bit of a “fad-based specialty,” Dr. James N. Palmer, director of rhinology at the University of Pennsylvania, said with a chuckle. “The fad at one point was, ‘It’s all bacterial infection.’ Then a fad was, ‘All you had to do is open up the sinuses’ ” — with surgery — “and everything would drain out.” Another hot theory blamed an allergic reaction to fungi for a majority of chronic sinusitis cases.

None of those ideas proved to be the answer. A fungal allergy can be a culprit — but only in some cases. And while sinus surgery can bring significant relief by clearing out inflamed tissue and nasal polyps, which are a common source of sinus blockages, the polyps often grow back.

Different research groups are now pursuing other explanations for the abnormally heightened inflammatory response that occurs in chronic sinusitis. Some are exploring weaknesses in the innate immune defenses of the sinuses and nose. Others are teasing apart the role of bacteria, which can stimulate inflammation by their presence without necessarily causing infections.

Dr. Palmer and his colleagues are exploring the role of communities of bacteria called biofilms in the sinuses of chronic sinusitis patients. The investigators speculate that in some individuals, biofilms — particularly those containing the bacteria Pseudomonas aeruginosa or Staphylococcus aureus — can spur the immune system to mount an overexuberant inflammatory response that leads to sinusitis symptoms. Because the biofilm structure makes it hard for antibiotics to kill the bacteria, surgery to remove inflamed sinus tissue may ultimately be the best way to deal with the problem, Dr. Palmer said.

Dr. Palmer estimates that biofilms play a role in 25 to 30 percent of chronic sinusitis cases. But the theory remains unproved, and it is possible that biofilms are just innocent bystanders. Many patients with the ailment test negative for biofilms — and some healthy people test positive.

A different hypothesis, proposed by Dr. Claus Bachert, an ear, nose and throat doctor at University Hospital Ghent in Belgium, is that Staph aureus bacteria release a toxin or “superantigen” in chronic sinusitis sufferers with nasal polyps, unleashing a storm of inflammation. Such patients “really suffer much more than others,” he said. They often have recurring polyps and get severe asthma, perhaps through the same inflammatory process.

In unpublished trials, his team tested experimental inflammation-fighting drugs that target the immune proteins IgE or interleukin-5 in polyp patients, with encouraging results, Dr. Bachert said. In other research, he found that doxycycline, an antibiotic that also suppresses inflammation, provided longer-lasting benefits in shrinking nasal polyps than an oral steroid did.

Regardless of what may be causing chronic sinusitis, the treatment goal is controlling inflammation and helping the sinuses to drain.

The most effective first-line intervention, said Dr. Palmer, is nasal irrigation using a neti pot or saline irrigation bottle, which helps flush out mucus and any inflammatory bacteria or allergens in it. “If you took all the people who say they have chronic sinusitis in the world, and you put them all on nasal saline irrigations, a big proportion would not have any symptoms anymore,” he said.

Medicines for quelling inflammation include steroids, Dr. Marple said, and sinus surgery can sometimes be useful for removing obstructions to mucus clearance. Still, for many people, chronic sinusitis is “a disease that you’re not going to cure,” he said. The most you can hope for is “to manage it.”

Publish date: 5/12/2011
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