| Walter Reed Hospital Holds Closing Ceremony Posted: 27 Jul 2011 10:40 PM PDT WASHINGTON — History has marched through the halls of Walter Reed Army Medical Center, where presidents, princes, kings and generals mingled in their hospital gowns. Walter Reed Army Medical Center An occupational therapist worked with a patient at Walter Reed Army Medical Center in 1959. Luis Alvarez/Associated Press Army personnel took part in a flag-casing ceremony at Walter Reed Army Medical Center on Wednesday. Luis Alvarez/Associated Press Army Secretary John M. McHugh spoke Wednesday at a ceremony that included a flag casing and the Golden Knights parachute team. Walter Reed Army Medical Center, via Associated Press Walter Reed Army Medical Center, named for Maj. Walter Reed, above, will shut its doors next month. Lyndon B. Johnson visited an ill, pajama-clad Richard M. Nixon during the 1960 campaign. President Harry S. Truman went to his first church service here after taking office. President Dwight D. Eisenhower signed the bill that established the Interstate highway system in 1956, while a patient here, according to John Pierce, a retired Army colonel and an expert on the history of the hospital. Eisenhower later spent the last 11 months of his life in the presidential suite, as his health declined, his wife, Mamie, living in a small room nearby. So Walter Reed’s closing — scheduled for the end of August when the keys to its stately brick buildings will be given to the State Department and the District of Columbia — drew an emotional response from many gathered Wednesday to commemorate the occasion. Flags were folded and put away. Songs were sung. A sword was handed down, to symbolize the transition. “These doors may close, the address may change, but the name, the legacy and, most important, the work and healing will endure,” said John M. McHugh, secretary of the Army, in a speech at the ceremony. It was the end of an era for Walter Reed Army Medical Center, the principal hospital for soldiers wounded in Iraq and Afghanistan, which next month will be moved to the National Naval Medical Center in Bethesda, Md., and to a new facility in Fort Belvoir, Va. The hospital’s patients will be moved in ambulances one by one, and outpatients, currently about 430, many of whom live in housing in the Walter Reed complex, will be moved in cars and moving vans over two weekends in August. Maj. Gen. Carla G. Hawley-Bowland, commander of the Army’s Northern Regional Medical Command, to which Walter Reed belongs, said the move was intended to reduce the number of facilities — three in the Washington area, including Walter Reed — in order to better fit the military’s needs. Treatment has improved significantly in the past two decades and today requires less inpatient care, and more outpatient capacity, something the new medical centers will have, the general said. The center’s reputation took a hit in 2007, when The Washington Post published a series of articles exposing poor living conditions and excessive bureaucracy for soldiers at the hospital. In response, officials established a unit designed to assist troops in every stage of the recovery process. Its medical care is among the best in the country, particularly in the area of prosthesis, which have improved significantly since the Persian Gulf war in 1991. General Hawley-Bowland said soldiers now had prosthetic arms that allow them to do push-ups and hold rifles, innovations that did not exist for patients in the past. Joao Silva, a photographer for The New York Times who was wounded in a mine blast in Afghanistan last fall and has been treated in the facility, is now walking briskly on his prosthetic legs. He photographed the event for the newspaper. Charles Dasey, a spokesman for the hospital, said the number of inpatients, currently about 150, will decline to about 50 by the time of the move. New patients, who arrived on a regular schedule Tuesday night, will begin to be diverted directly to Bethesda in early August, he said. The ceremony, which concluded with parachutists swooping down on the hospital lawn with colored smoke trailing behind them, was a chance for everyone to come together before the move began, General Hawley-Bowland said. “This brings closure,” she said. “It’s a celebration of what Walter Reed has meant.” Gen. John J. Pershing and Gen. Douglas MacArthur died here. In 1960, Nixon, haggard and thin with an infected knee, left the hospital against his doctors’ advice to take part in the first televised presidential debate, according to Mr. Pierce. It grew from 80 beds to more than 2,500 during World War I. It now has a capacity of about 250, and serves approximately 150,000 soldiers, their family members and military retirees. The refurbished Bethesda facility, to be renamed the Walter Reed National Military Medical Center, will have a 340-bed capacity, Mr. Dasey said, and will be run by all branches of the military, not just the Army. Patients with the most serious injuries will be taken there. The new Fort Belvoir hospital will have 120 beds. Together, their capacity is enough to cover the current number of patients, Mr. Dasey said. Any surge in need will be handled, in part, by retirees being treated in civilian hospitals. “This place carries a lot of memories,” General Hawley-Bowland said. She added, “My folks will take Walter Reed’s legacy along with them.” |
| Cost of Treating Veterans Will Rise Long Past Wars Posted: 28 Jul 2011 03:20 AM PDT WASHINGTON — Though the withdrawal of American military forces from Iraq and Afghanistan will save the nation billions of dollars a year, another cost of war is projected to continue rising for decades to come: caring for the veterans. Philip Scott Andrews/The New York Times Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America By one measure, the cost of health care and disability compensation for veterans from those conflicts and all previous American wars ranks among the largest for the federal government — less than the military, Social Security and health care programs including Medicare, but nearly the same as paying interest on the national debt, the Treasury Department says. Ending the current wars will not lower those veterans costs; indeed, they will rise ever more steeply for decades to come as the population of veterans from Iraq and Afghanistan expands, ages and becomes more infirm. To date, more than 2.2 million troops have served in those wars. Studies show that the peak years for government health care and disability compensation costs for veterans from past wars came 30 to 40 years after those wars ended. For Vietnam, that peak has not been reached. In Washington, the partisan stalemate over cutting federal spending is now raising alarms among veterans groups and some lawmakers that the seemingly inexorable costs of veterans benefits will spur a backlash against those programs. Though there is currently strong bipartisan support for veterans programs, some budget proposals, including from Senator Tom Coburn, Republican of Oklahoma, and Representative Michele Bachmann, Republican of Minnesota, have called for trimming benefits for veterans and military retirees. “Those proposals have been batted back so far,” said David Autry of the Disabled American Veterans. “But we’ve got more vigorous budget hawks today. If they are willing to bring the nation to the brink of insolvency, who knows what else they might do?” Even if cuts to veterans programs do not occur, the current mood of budgetary constraint seems likely to force the Department of Veterans Affairs to make do without the large spending increases it has received from Congress in the recent past. That means efforts by veterans groups to expand existing health care programs, provide additional benefits to Vietnam veterans or institute new research into things like traumatic brain injury or hearing loss will face difficult uphill battles, lawmakers and veterans advocates say. “No one is thinking about the lifetime costs this country is responsible for,” said Senator Patty Murray, a Washington Democrat who is chairwoman of the Senate Veterans’ Affairs Committee. “I’m really worried.” In a hearing before the panel on Wednesday, Heidi Golding, an analyst with the Congressional Budget Office, testified that the annual cost of caring for veterans from the Iraq and Afghanistan wars would nearly triple or more in the next decade, rising to $5.5 billion to $8.4 billion in 2020, from $1.9 billion in 2010. In that hearing, Paul Rieckhoff, executive director of Iraq and Afghanistan Veterans of America, also raised concerns that veterans’ disability checks might not be paid if Congress fails to raise the debt limit next week. With an annual budget of more than $125 billion, the Department of Veterans Affairs runs a nationwide health care system that cares for more than eight million people who have left military service, of which about 700,000 are from the current wars. The agency also administers disability compensation for millions of veterans wounded in service. Estimating the long-term costs of those programs is a complex, contentious art, and no one inside the government does it beyond 10 years. But independent and government experts agree that for a variety of reasons the costs are just about certain to continue rising, even though large numbers of World War II and Korean War veterans are dying. The reasons have much to do with improvements in battlefield medicine and equipment. More troops today are surviving injuries — 90 percent, up from 86 percent in Vietnam, according to the Congressional Budget Office. But that also means that more troops are coming home with complex and severe wounds. Moreover, nearly one in five service members returning from deployment are thought to have symptoms of post-traumatic stress or major depression, according to a study by the RAND Corporation. A similar number are thought to have sustained traumatic brain injury. Though not all seek help, a significant percentage are expected to receive care from the veterans system, in part because of efforts to reduce the stigma of mental health problems in the military. Further adding to strains on the department, more young veterans have been seeking care from the system than had been anticipated, possibly because they do not have private health insurance. Outreach efforts by the veterans department and veterans groups may have also increased enrollment, experts say. Linda Bilmes, a Harvard academic who has done extensive research on the impact of the wars, said all those factors together suggested that “the actual cost over 30, 40 or 50 years will be even higher than we projected.” “And with life expectancy getting longer,” she said, “the cost will probably peak later than in past wars.” Ms. Bilmes, a senior lecturer in public finance at the Kennedy School of Government, has estimated that the total cost of health care and disability compensation to veterans of the current wars will be nearly $1 trillion over the next 40 years. Some academics and government officials say her projections are too high. But there is broad agreement on her larger point, that the costs will keep going up for decades to come. “Because we have saved more peoples’ lives,” said Gordon Adams, a senior budget official in the Clinton administration, “we’re going to be paying that bill for some time to come.” Mr. Adams, a professor of international relations at American University, said he considered it highly unlikely that Congress would ever cut veterans benefits. But Ms. Bilmes disagrees. “I think when times are tough, there are no sacred cows,” she said. “There was a time when it would be unthinkable that we would be talking about cutting pensions for teachers, firemen and policemen. Yet all over the country that’s what we’re looking at today.” |
| Recipes for Health: Sweet and Sour Eggplant, Tomatoes and Chickpeas Posted: 29 Jul 2011 12:10 AM PDT This Lebanese dish is all about summer. Pomegranate molasses makes it both sweet and sour; you can find it in Middle Eastern markets. Serve the dish as a starter, a side or a main dish with grains. Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. 1 large eggplant (1 1/4 to 1 1/2 pounds), halved lengthwise then cut in 1/2-inch slices Salt to taste 3 to 4 tablespoons extra virgin olive oil, as needed 2 large garlic cloves, minced 1 1/2 pounds tomatoes, grated or peeled, seeded and chopped 1 teaspoon sugar Freshly ground pepper 2 tablespoons pomegranate molasses 1 can chickpeas, drained and rinsed 2 to 3 tablespoons chopped flat-leaf parsley, or a combination of mint and parsley 1. Preheat the oven to 450 degrees. Line a baking sheet with foil, and oil it with olive oil. Lay the eggplant slices on top. Salt lightly and brush with olive oil. Place in the oven for 40 minutes until the eggplant is lightly browned and soft to the touch (the surface will be dry). Remove from the heat, and fold over the foil to make a packet around the eggplant slices. Allow them to soften and steam inside the foil for 15 minutes while you proceed with Step 2. 2. Heat 2 tablespoons of the olive oil over medium heat in a large, heavy lidded casserole or skillet. Add the garlic. Cook just until fragrant, about 30 seconds. Stir in the tomatoes, salt to taste, sugar and pepper. Bring to a simmer, and simmer uncovered over medium heat for 10 to 15 minutes, stirring often, until the tomatoes have cooked down and smell very fragrant. 3. Add the eggplant, molasses and chickpeas. Cover and simmer for another 20 to 30 minutes, stirring from time to time. The mixture should be thick and the eggplant should be very tender, melting into the mixture. Taste and adjust seasoning. Sprinkle on the parsley and/or mint, and serve. Alternately, allow to cool and serve warm or at room temperature. Yield: Serves four to six. Advance preparation: This dish keeps for three or four days in the refrigerator and tastes even better the day after you make it. Reheat gently in a skillet, or serve at room temperature. Nutritional information per serving (four servings): 272 calories; 1 gram saturated fat; 2 grams polyunsaturated fat; 8 grams monounsaturated fat; 0 milligrams cholesterol; 37 grams carbohydrates; 10 grams dietary fiber; 273 milligrams sodium (does not include salt to taste); 8 grams protein Nutritional information per serving (six servings): 181 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligrams cholesterol; 25 grams carbohydrates; 7 grams dietary fiber; 182 milligrams sodium (does not include salt to taste); 5 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health." |
| Sept. 11 Revealed Psychology’s Limits, Review Finds Posted: 29 Jul 2011 12:03 AM PDT The mental fallout from the Sept. 11 attacks has taught psychologists far more about their field’s limitations than about their potential to shape and predict behavior, a wide-ranging review has found. The report, a collection of articles due to be published next month in a special issue of the journal American Psychologist, relates a succession of humbling missteps after the attacks. Experts greatly overestimated the number of people in New York who would suffer lasting emotional distress. Therapists rushed in to soothe victims using methods that later proved to be harmful to some. And they fell to arguing over whether watching an event on television could produce the same kind of traumatic reaction as actually being there. These and other stumbles have changed the way mental health workers respond to traumatic events, said Roxane Cohen Silver, a psychologist at the University of California, Irvine, who oversaw the special issue along with editors at the journal. “You have to understand,” she said, “that before 9/11 we didn’t have any good way to estimate the response to something like this other than — well, estimates” based on earthquakes and other trauma. Chaos reigned in the New York area after the twin towers fell, both on the streets and in the minds of many mental health professionals who felt compelled to help but were unsure how. Therapists by the dozens volunteered their services, eager to relieve the suffering of anyone who looked stricken. Freudian analysts installed themselves at fire stations, unbidden and unpaid, to help devastated firefighters. Employee assistance programs offered free therapy, warning of the consequences of letting people grieve on their own. Some given treatment undoubtedly benefited, researchers say, but others became annoyed or more upset. At least one commentator referred to therapists’ response as “trauma tourism.” “We did a case study in New York and couldn’t really tell if people had been helped by the providers — but the providers felt great about it,” said Patricia Watson, a co-author of one of the articles and associate director of the terrorism and disaster programs at the National Center for Child Traumatic Stress. “It makes sense; we know that altruism makes people feel better.” But researchers later discovered that the standard approach at the time, in which the therapist urges a distressed person to talk through the experience and emotions, backfires for many people. They plunge even deeper into anxiety and depression when forced to relive the mayhem. Crisis response teams now take a much less intense approach called psychological first aid, teaching basic coping skills and having victims recount experiences only if it seems helpful. One of the biggest lessons of Sept. 11, said Richard McNally, a psychologist at Harvard who did not contribute to the new report, was that it “brought attention to the limitations of this debriefing.” Another, he said, was that it drove home the fact that people are far more resilient than experts thought. No one disputes that thousands of Americans who lost loved ones or fled from the collapsing skyscrapers are still living with deep emotional wounds. Yet estimates after the attack projected epidemic levels of post-traumatic stress, afflicting perhaps 100,000 people, or 35 percent of those exposed to the attack in one way or another. Later studies found rates closer to 10 percent for first responders, and lower for other New Yorkers. (The prevalence in children was slightly higher.) “Some of us were making this case about resilience well before 9/11, but what the attack did was bring a lot more attention to it,” said George A. Bonanno, a psychology professor at Columbia. It also stirred a debate that may soon change the definition of post-traumatic stress. In the breathless weeks and months after the attack, experts and news articles warned that people who had no direct connection to the tragedy would also develop diagnosable symptoms merely from seeing the images on a television screen. Dr. Silver, who was among the first to question overestimates of trauma, has found evidence for such effects in her own studies. “The distress spilled over the outside communities, mostly to people who saw the images and had pre-existing psychological problems,” she said. “The numbers are low, but I think the data is convincing.” Dr. McNally, among others, disagrees. “The notion that TV caused P.T.S.D. seems absurd,” he said in an e-mail. The editors of the Diagnostic and Statistical Manual, the so-called encyclopedia of mental disorders compiled by the American Psychiatric Association, are debating whether to change the criteria for post-traumatic stress to exclude such at-a-distance cases. The new report reviewed hundreds of other types of 9/11 studies, political and social. Americans on average became more prejudiced toward Arabs after the attack, as well as more likely to contribute to charities and more supportive of aggressive government action against suspected terrorists. But these and other findings were not new; studies after previous attacks in other countries found similar things. For all their fury and devastation, the attacks gave rise to no new theories of behavior, no new therapies. Instead, some authors said, the chief effect on the social sciences was to caution against applying theories so readily to real life. Another author in the new collection, Philip E. Tetlock, a psychologist at the Wharton School at the University of Pennsylvania, notes that intelligence agencies employ scientists to try to predict the behavior of foreign leaders and terrorists — and that their track record has been mixed. “The closer scientists come to applying their favorite abstractions to real-world problems,” the article concludes, “the harder it becomes to keep track of the inevitably numerous variables and to resist premature closure on desired conclusions.” |
| Drug App Comes Free, Ads Included Posted: 29 Jul 2011 12:05 PM PDT Epocrates has won over nearly half of the nation’s doctors for its free smartphone apps that lets them look up information on drug dosing, interactions and insurance coverage while seeing a patient. Laura Pedrick for The New York Times Rose Crane, chief executive of Epocrates, said the company’s drug descriptions were unbiased and opened “a trusted channel†for drug makers to communicate with physicians through doctor alerts. A "DocAlert" on migraine pain from Epocrates, a free smartphone app for doctors, quickly turns to promoting a pill made by the pharmaceutical company that sponsored the alert. But like so much else on the Web, “free” comes with a price: doctors must wade through marketing messages on Epocrates that try to sway their choices of which drugs to prescribe. The apps can select messages based on each doctor’s search and prescription histories, and the company has ambitious plans for expanded smartphone offerings. One possibility is a virtual sales rep that would help drug makers get their wares in front of physicians who decline to see human sales representatives. The marketing messages are difficult to ignore. For example, a psychiatrist in Massachusetts who recently opened Epocrates (pronounced ee-POC-ra-teez) on his iPhone said that before he could look up any drugs, he had to click past “DocAlert” messages on hypertension, bipolar disorder and migraines. Two of the three showed they had been paid for by pharmaceutical companies promoting their products. “Some doctors will not have time for that nonsense,” said the psychiatrist, Dr. Daniel J. Carlat, who also writes a blog and newsletter on medical issues. Of course, any casual user of the Web is bombarded with ads derived from their browsing history. However, the marketing through Epocrates is more insidious, according to Dr. Adriane Fugh-Berman, an associate professor of medicine at Georgetown University and founder of PharmedOut, a nonprofit group critical of drug companies’ marketing practices. “With targeted ads in Google, you may buy something that’s an unwise purchase,” she said. “But when a physician is influenced in Epocrates, it’s the patient who’s bearing the financial and health risk.” Dr. Fugh-Berman and other critics of drug marketing say the apps promote more expensive and sometimes less effective drugs. The companies say they are helping doctors find the best medicines. Dr. Rachel E. Sherman, associate director of medical policy at the Food and Drug Administration, said the agency was trying to get a handle on all the emerging electronic channels of communication used by drug makers.“It’s a mess,” she said. Epocrates is betting that the 320,000 physicians who use its apps, much like those who use Google and other advertising-supported data services, will tolerate some marketing to get the information they want at no charge. Epocrates is also used by a million nurses, pharmacists and medical students. One in five doctors will not see drug sales representatives at work, according to the market research firm SK&A, and Epocrates says that getting a smartphone sales pitch in front of doctors just as they are writing prescriptions is immensely valuable to pharmaceutical companies. Epocrates says drug makers get $3 in increased sales from every dollar spent on DocAlerts. The claim comes from comparing prescription records of doctors who see DocAlerts with those who do not, company officials said. But they declined to share the research, saying it was paid for by drug companies and was confidential. Pfizer, the world’s largest drug maker, has certainly found the marketing channel to be an effective way to reach doctors. “The beauty of the work we do with Epocrates is that we literally put ourselves in the palm of their hand,” said Dr. Freda Lewis Hall, chief medical officer at Pfizer. Epocrates says drug makers can present alerts to doctors based on specific drugs or classes of drugs they have looked up and by specialty, geography and insurance plan. The company will also send alerts to “customer target lists” — specific physicians, like those identified by pharmaceutical manufacturers as being the most frequent prescribers. Epocrates acknowledges the challenges of balancing the needs of its two groups of customers: medical professionals and drug companies. “The credibility of our brand is dependent in large part on the medical community’s continued perception of us as independent from our health care industry clients, particularly pharmaceutical companies,” the company said in a securities filing this year. Pharmaceutical companies provide at least 70 percent of Epocrates’s revenue, which totaled $104 million last year and is projected to be $125 million this year, according to analysts at William Blair & Company, the investment house that helped underwrite the company’s initial public offering in February. (Shares sold for $16 then and closed at $16.50 on Thursday.) “Our first commitment is the value to the physician,” Rosemary A. Crane, president and chief executive of Epocrates, said in an interview. Ms. Crane said the company’s drug descriptions were unbiased and opened “a trusted channel” for drug makers to communicate with physicians through doctor alerts, which are downloaded each time the doctor updates the frequently changing drug information on the app. Ms. Crane said that having alerts based on tracking what doctors look up made the alerts more relevant to the physicians receiving the messages. But such data tracking is opposed by some doctors and lawmakers. The Supreme Court last month overturned a Vermont law that would have restricted IMS Health, an industry data firm, from providing to drug marketers the prescription histories of individual physicians. |
| Study of Medical Device Rules Is Attacked, Unseen Posted: 27 Jul 2011 11:00 PM PDT Allies of the medical device industry are waging an extraordinary campaign in Washington to discredit a coming report by one of the country’s pre-eminent scientific groups that examines possible new regulations on the industry. Joshua Borough for The New York Times A metal-on-metal artificial hip that was removed from a patient after problems appeared. The scientific group, the Institute of Medicine, is scheduled to release a report on Friday that could propose a tougher approval process for a wide range of devices like hip implants, hospital pumps and external heart defibrillators. The report, commissioned by the Food and Drug Administration, comes after several well-publicized recalls in recent years of devices that have failed in thousands of patients, causing numerous injuries. But a business group and others have taken the highly unusual step of making a pre-emptive strike, arguing that the report is biased. That attack began even before the study panel finished its review, and has intensified in recent weeks. Device producers have also released a series of their own reports that say more regulation would slow innovation, harm patients and cost jobs. An official of a group that represents surgeons who implant hips and other artificial joints has also voiced support for a recent filing by a pro-business organization that challenged the scientific report’s credibility and argued that the F.D.A. was statutorily required to ignore it. Christine Stencel, a spokeswoman for the Institute of Medicine, which is part of the National Academy of Sciences, said the group was unaware of a previous instance in which one of its reports, sight unseen, was the target of a similar effort to invalidate it. Dr. Sheldon Greenfield of the University of California, Irvine, who has served on several Institute of Medicine panels, said he was surprised by the campaign’s intensity. “It is pretty audacious,” he said. The challenge to the panel has been led by Ralph F. Hall, a professor of law at the University of Minnesota and a device industry lawyer, who said the criticism was not an attempt to front-run the report’s conclusions but rather to air legitimate concerns about how the review had been conducted. “I could have waited until the report came out,” Mr. Hall said in an interview. “That seems intellectually less than satisfactory with me.” Medical experts said the institute’s study, regardless of how it falls, was likely to have a significant impact on patient safety, device effectiveness and the speed at which new products reached the market. With millions of dollars of product sales at stake, the experts said, it is not surprising that the device industry and others would want to avert what they see as potentially restrictive new rules. Still, the lobbying has taken on a tone akin to Washington infighting over an issue like bank regulation, rather than patient health, they said. “We are trying to get to good policies, and the spin game doesn’t help us,” said Dr. Harlan M. Krumholz, a professor of medicine at Yale who has served on a different Institute of Medicine panel. The Institute of Medicine is a widely respected organization that assembles experts to study a range of health-related issues, often at the request of government agencies. In 2009, the F.D.A. contracted with the group to review the adequacy of one of the two regulatory pathways though which it approves medical devices, a process known as 510K. Some devices, like implanted heart defibrillators, undergo clinical trials in patients before they can be sold. But most medical devices, including implanted hips, go through the 510K route. Under that pathway, a producer need show only that a new product is “substantially equivalent” to one already sold to gain approval. For example, so-called metal-on-metal artificial hips, which are currently the subject of scrutiny and lawsuits, appeared to work well when tested only on mechanical simulators but then failed disastrously when implanted in patients. The 12-member review panel assembled by the Institute of Medicine included physicians, academics and two lawyers who had worked for device makers on regulatory issues. Another lawyer on the panel, Brian Wolfman, who once worked for Public Citizen, a consumer advocacy group, has come under particular attack by business-affiliated groups. Mr. Wolfman and several other panel members declined to be interviewed for this article or did not respond to telephone calls or e-mails. |
| Practical Traveler: Planning a Vac(cin)ation Posted: 27 Jul 2011 12:05 PM PDT GETTING vaccinated may be the last thing on your mind when heading off on vacation, but it’s important — whether you are traveling to an exotic destination or not. Case in point: the Centers for Disease Control and Prevention issued a health advisory last month pointing out that the United States is currently experiencing the highest number of measles cases since 1996, many of which were acquired overseas. As of June 17, 156 confirmed cases of measles had been reported to the center this year; 136 of them involved unvaccinated Americans who had recently traveled abroad, unvaccinated visitors to the United States and people who didn’t travel but may have caught the disease from those who did. The advisory, which encourages travelers planning trips abroad to make sure they have had the M.M.R. (measles, mumps and rubella) vaccine before they leave, illustrates that it isn’t just far-flung places that are a source of concern — outbreaks are occurring in places like France, Britain, Spain and Switzerland. “Those of us who run travel clinics are very used to seeing people going to developing countries or tropical countries” getting the relevant shots, said Dr. David O. Freedman, a board member at the International Society of Travel Medicine and a professor of medicine and epidemiology at the University of Alabama at Birmingham. “But nobody thinks about it when they go to Europe.” The thinking is similar, he said, for other popular destinations, including Mexico and parts of Central America. “There’s not a perception that you need to go and get a bunch of shots if you’re going to Cancún,” Dr. Freedman said. But in fact, he added, you should consider being vaccinated for certain food- and water-borne diseases like hepatitis A — one of the most common vaccine-preventable infections acquired during travel — which is prevalent in Mexico and other destinations in Latin America. In 2007, international travel was the most frequently identified risk factor for hepatitis A among United States cases for which exposure information was collected, according to the Centers for Disease Control and Prevention. As in previous years, most of those travel-related cases (85 percent) were associated with travel to Mexico, Central America or South America. Though many people recover from hepatitis A within a few weeks, in some cases the symptoms — fatigue, nausea, diarrhea and jaundice — can last two months or longer. As a general rule, travelers should be up to date on routine immunizations “no matter where they are going and what they are doing,” said Dr. Phyllis Kozarsky, a travel health consultant at the C.D.C. and a professor of medicine at Emory University in Atlanta. In addition to the M.M.R., these vaccinations include a tetanus booster every 10 years and the influenza vaccine during flu season each year. As for measles, the highly contagious disease has always been a risk for travelers in the developing world, experts say. But the increase in cases in the United States and large outbreaks occurring in Europe are recent issues, stemming in part from fears of parents who refuse to vaccinate their children because they believe immunizations cause illnesses, particularly autism, even though multiple studies have found no reputable evidence to support such a claim. Although most Americans have been vaccinated for measles or are immune because they’ve had the disease, public health officials are concerned about those who have not been immunized, including babies and those born after 1957 (the cut-off year for people likely to be immune since the disease was endemic then), but before 1970, when vaccination became routine. Before any international travel, infants 6 months through 11 months of age should have at least one dose of measles vaccine, according to the Centers for Disease Control and Prevention. Children 12 months or older should have two doses separated by at least 28 days — whether traveling or not. And adults should review their vaccination records to ensure they’re up to date. The Web site cdc.gov offers a “Q&A” page about measles that includes more guidance on how to know if you need a vaccine. You can also look up recommended vaccinations and information about disease prevention by destination on the agency’s Web site. But be sure to consult a travel medicine expert, ideally four to six weeks before your trip, for a complete risk assessment. The International Society of Travel Medicine offers a searchable directory of its members at istm.org. “A backpacker going to the Thailand-Cambodian border visiting a refugee camp versus a C.E.O. of an international company staying at a deluxe hotel in Bangkok versus someone going on a honeymoon to the beaches are all very different, and very different risks,” said Dr. Kozarsky of the C.D.C. A good doctor who specializes in travel medicine will go through your entire itinerary carefully, and consider everything from the regions you will be visiting (urban versus rural), your travel style (backpacking versus luxury hotel) and the time of year (which can influence exposure to mosquitoes, which spread malaria and dengue) to determine if the recommended vaccines or prevention measures are really necessary for your vacation. Malaria and Japanese encephalitis are among the diseases listed under the C.D.C.’s travel health page for China, for example. But travelers visiting only major cities, like Beijing or Shanghai, don’t need to carry malaria pills or get a shot for Japanese encephalitis (a mosquito-borne disease endemic to rural areas in China). Travel medicine experts can also be helpful in determining whether you need a yellow fever vaccine, which is required under international health regulations for travel to certain countries, including parts of sub-Saharan Africa and tropical South America, and must be administered at certified yellow fever vaccination centers, which can be found on the agency’s Web site. Many countries require an “international certificate of vaccination or prophylaxis” signed by a medical provider for the yellow fever vaccine from travelers coming from an infected area. For example, Indian health regulations may ask for evidence of vaccination against yellow fever if you are arriving from sub-Saharan Africa or other yellow fever areas. If you do not have such proof, you could be subject to immediate deportation or a six-day detention in a yellow fever quarantine center, according to the State Department’s India information sheet. If you travel through any part of sub-Saharan Africa, even for one day, you are advised to carry proof of yellow fever immunization. To be sure, travel vaccines aren’t cheap. And for the most part, insurance won’t cover them. The Travel Clinic of New York City, for example, charges $130 for a yellow fever shot and $90 for hepatitis A, according to its Web site, travelclinicnyc.com. That’s in addition to an $80 consultation fee. But as long as you aren’t paying for unnecessary immunizations, the shots are worth it. Bottom line, said Dr. Freedman of the International Society of Travel Medicine, “Vaccines are your insurance policy.” |
| McDonald’s Trims Its Happy Meal Posted: 26 Jul 2011 10:17 PM PDT Bowing to pressure from health advocates and parents, McDonald’s is putting the Happy Meal on a diet. David Paul Morris/Getty Images A Happy Meal in San Francisco, which banned the inclusion of toys in children's meals unless nutritional requirements were met. The company announced Tuesday that it would more than halve the amount of French fries and add fruit to its popular children’s meal in an effort to reduce the overall calorie count by 20 percent. But McDonald’s appeasement only went so far. A toy will still come with each Happy Meal despite criticism that the trinkets, often with tie-ins to movies like “Toy Story,” foster a powerful connection between children and the often calorie-laden meals. While Happy Meals account for less than 10 percent of all McDonald’s sales, the signature box and its contents — first introduced in 1979 — have become a favorite target in recent years. Lawmakers and consumers have rallied around breaking that childhood link between toys and fast food, with the efforts increasing as Michelle Obama and national public health officials point to the estimated 17 percent rate of obesity among the nation’s youths. San Francisco, for example, has banned the inclusion of toys in children’s meals unless certain nutritional requirements are met. A New York City councilman is proposing a similar law. Other restaurant chains have gone further than McDonald’s in acceding to calls for improving the fare on children’s menus and eliminating marketing appeals. In June, Jack in the Box announced the end of toys in its children’s meals, and this month, Burger King, IHOP and more than a dozen other restaurant chains backed an effort led by the National Restaurant Association to serve and promote healthier options for youngsters. “McDonald’s is not giving the whole loaf, but it is giving a half or two thirds of a loaf,” said Michael F. Jacobson, executive director of the Center for Science in the Public Interest, which is representing a woman in California who is suing McDonald’s for including toys in its Happy Meals. “This is an important step in the right direction.” McDonald’s made it clear that it was changing the composition of Happy Meals in response to parental and consumer pressure. It also pledged to reduce the sodium content in all of its foods by 15 percent, with the exceptions of soda and desserts. It set a deadline of 2015 for limiting salt, and said it would spend the rest of this decade cutting back on sugars, saturated fats and calories and making adjustments to portion sizes. The new Happy Meals will be introduced in September and rolled out across the company’s 14,000 restaurants by April 2012. They will all include apple slices, but in a smaller amount of three to five slices than the current eight to 10 offered as an alternative. (The Apple Dippers also will be renamed after the company phases out the caramel dipping sauce, according to Tuesday’s announcement.) “It’s a trade-off between everybody getting a small portion and 10 percent of kids getting a larger portion, which is better than nothing and maybe will accustom kids to eating fresh fruits and vegetables when they go out to eat,” Mr. Jacobson said. Parents will have the option of requesting more fruit or, possibly at a later date, vegetables instead of fries. McDonald’s will also offer a fat-free chocolate milk option, along with the option of low-fat milk or the traditional soda. The price is not expected to change. Today’s Happy Meal with chicken nuggets has 520 calories and 26 grams of fat, and the reconstituted version, with 1 percent milk, will total 410 calories and 19 grams of fat, according to the company. The company said it had experimented with eliminating French fries altogether from the boxes, but that generated a lot of customer complaints. Danya Proud, a spokeswoman for the company, said that McDonald’s tests also found that parents wanted soda among the drinks available, too. “That’s what we’ve really felt all along, that ultimately, it’s a parent decision to make about their child’s well-being,” she said. McDonald’s has long offered parents the option of asking for fruit rather than fries, although a study by Yale University’s Rudd Center for Food Policy and Obesity found that only 11 percent took advantage of that option. While some critics of fast-food and public health officials praised the moves (Mrs. Obama called them “positive steps”), others complained that McDonald’s did not go far enough. Marion Nestle, a professor of nutrition at New York University and an outspoken critic of the food industry, called the changes a “sham,” in part because McDonald’s is not doing more to limit soda with the Happy Meal. “They’re going to get huge publicity for this — an ounce less of French fries,” Dr. Nestle said. “I’m not impressed.” In fact, when apples are added to the Happy Meal with a soda, the amount of sugar in the new package increases. As part of an effort to provide better access to nutritional information about its foods, the company has developed its first mobile application for the public. McDonald’s executives also plan to tour the country to hear directly from consumers about their concerns. “We are doing what we can,” Ms. Proud said. “We have to evolve with the times, and the times require us and our customers are asking us to offer more options.” Ms. Proud said that even with the changes, the Happy Meal would not meet San Francisco’s requirements, which demand both a fruit and vegetable serving, among other things, before a company can include a toy with a child’s meal. Public health experts expect the company to mount a legal challenge to that ordinance before it goes into effect in December, but Ms. Proud said McDonald’s was still evaluating its options. William Neuman contributed reporting. This posting includes an audio/video/photo media file: Download Now |
| That’s Not Trash, That’s Dinner Posted: 27 Jul 2011 08:15 AM PDT LAST week in Chelsea, Mich., as people wilted and vegetables flourished in the intense heat, Anne Elder ran through some of her favorite summer ingredients: pearly garlic “rounds” that flower at the top of the plant in hot weather, the spreading leaves of the broccoli plant, yellow dandelion flowers that she dips whole into batter and deep fries. “When kids visit the farm, we give them cornstalks to chew,” she said. Like sugar cane, the stalks contain sweet juice. For Ms. Elder, who runs the Community Farm of Ann Arbor, the edible vegetable begins with the sprouts and does not end until the leaves, vines, tubers, shoots and seeds have given their all. If home cooks reconsidered what should go into the pot, and what into the trash, what would they find? What new flavors might emerge, what old techniques? Pre-industrial cooks, for whom thrift was a necessity as well as a virtue, once knew many ways to put the entire garden to work. Fried green tomatoes and pickled watermelon rind are examples of dishes that preserved a bumper crop before rot set in. “Some people these days are so unfamiliar with vegetables in their natural state, they don’t even know that a broccoli stalk is just as edible as the florets,” said Julia Wylie, an organic farmer in Watsonville, Calif. The produce she grows at Mariquita Farm is served at Bay Area restaurants like Delfina, Zuni Cafe and Chez Panisse. At some large farms, she said, only the florets are processed for freezing or food service; the stems are shredded into the chokingly dry “broccoli slaw” sold in sealed bags at the supermarket. (A much better way to treat broccoli stalks: cut off and discard the tough outer peel, shave what remains into ribbons with a vegetable peeler, scatter with lemon zest and shards of Parmigiano-Reggiano cheese: all the pleasure of raw artichoke salad with half the work.) Mariquita Farm also runs a flourishing Community Supported Agriculture (C.S.A.) program and sells at farmers’ markets, where, Ms. Wylie said, she has become expert at holding shoppers’ hands when it comes to stem-to-root cooking. She reminds them that even the thick ribs of chard, beets and other greens soften with braising (most kale stems, though, are too fibrous to eat). She encourages them to cook the leaves that sprout from the tops of radishes (they have a delicious bitterness) and offers a traditional French method of baking fish at high heat on a bed of fennel stalks. Among her favorite neglected greens are the big, sweet leaves that grow around heads of cauliflower — leaves that supermarket shoppers never see and recipes never call for. She cuts them across the ribs, then sautés them with minced onion. “It’s like a silky version of a cabbage leaf, with a hint of cauliflower,” she said. At this time of year, cooks around the country haul home full bags from the farmers’ market or a weekly box from a local farm but also wonder how to make the most of their produce. Eating more vegetables, being spontaneous in the kitchen and celebrating the season are the aspirations that lead people to join C.S.A.’s. But many find that they don’t know what do to with boxloads of melon, tomatoes, onions and leafy greens, not to mention their stalks, tops, peels and stems. “I joined a C.S.A. because I wanted to be frugal and I thought it would force me to be creative in the kitchen,” said Megan Smith, a learning specialist in Brooklyn. “But it generated a huge amount of work and all this debris.” Much of what is tossed out is edible, but not everyone greets the opportunity to recycle food scraps as an exciting food adventure. “When you mention using them for stock, that’s when people start to roll their eyes,” said Ronna Welsh, a cooking teacher in Park Slope, Brooklyn, who chronicles her adventures with chard stems and watermelon rinds on her Web site Purple Kale Kitchenworks, in a column called “Otherwise, Trash.” Her students are the kind of home cooks who make the extra effort to go the farmers’ market and support local agriculture, she said, but whose schedules and lack of skills cause them to feel stressed by a refrigerator full of raw ingredients. Ms. Welsh likes to generate recipes for trimmings, she said, because using up everything satisfies some of the same urges that fuel the desire to be a better cook. “When you spend $40 at the Greenmarket, the pressure starts right there,” she said. “You feel more invested in the carrots you buy from the farmer than the ones you buy at Key Food. You feel sentimental about them, you have more respect for them.” Ann Arbor, with its thriving farms, gardens and greenmarkets — including a new one this summer that is held in the evening so that working people can shop — is a fertile source of stem-to-root ideas. “People know that nasturtium flowers are edible, but the leaves are also great salads and the seed pods, if you pickle them, make a wonderful substitute for capers,” said Kevin Sharp, an outreach manager at the People’s Food Co-op there, one of the oldest in the country. He substitutes the palm-size leaves from stalks of brussels sprouts in recipes that call for collard greens, cooks the leaves and shoots of sweet potatoes and battles a bumper crop of asparagus by making a sweet relish from the woody ends. Lindsay-Jean Hard, who works at a new farm-to-table Web network called Real Time Farms, said that she chops the leaves atop celery stalks to make a pungent, fluffy celery salt. Last year, hundreds of homeowners around Ann Arbor joined a local 350 Gardens Challenge, a global climate-change initiative that includes “visible food production” (like a garden in an urban front yard) as one of its engines for sustainable food. |
| Scant Evidence to Link 9/11 to Cancer, U.S. Report Says Posted: 26 Jul 2011 09:50 PM PDT There is not enough evidence yet to say whether the dust and smoke cloud produced by the terrorist attack on the World Trade Center caused cancer, federal officials concluded in a report released on Tuesday. The finding, based on an initial review required by a new federal law, disappointed rescue and recovery workers and people who lived near the World Trade Center who have cancer diagnoses that they attribute to the attack. It means that they do not qualify for federal benefits to treat or compensate them for their cancer, at least until further study. Scientists say that cancer takes 5 to 20 years to develop, so if there was a very strong effect from toxic substances released by the collapse of the twin towers, it might be expected to manifest itself by now, nearly 10 years after the attack. But the report, released by Dr. John Howard, the director of the National Institute for Occupational Safety and Health, said that there was very little evidence to go on, as there have only been 18 published research studies on the attack that even mentioned cancer, and only five of those were peer-reviewed. The results of the peer-reviewed studies were mixed. Even if it appeared that the events of 9/11 caused cancer in certain people, it would be hard to prove because cancer is widespread in the general population. In the United States, the probability that a person will develop cancer over a lifetime is one in two for men and one in three for women, the report said. “Drawing causal inferences about exposures resulting from the Sept. 11, 2001, terrorist attacks and the observation of cancer cases in responders and survivors is especially challenging since cancer is not a rare disease,” the report said. The report was required by the James Zadroga 9/11 Health and Compensation Act, which took effect on Jan. 2; it provides $4.3 billion over the next five years to monitor, treat and compensate people who were exposed to the fumes and dust. The act provides treatment and compensation for a specific list of illnesses, mainly asthma and other respiratory diseases. As part of a political compromise needed to pass the bill, cancer was not included. A provision of the law, however, specified that the administrator of the National Institute for Occupational Safety and Health would periodically review the evidence to determine whether cancer, which could be one of the most expensive illnesses to treat and compensate for, should be added to the list. Three New York representatives — Carolyn B. Maloney and Jerrold Nadler, both Democrats, and Peter T. King, a Republican — said in a statement that they were confident future studies would support a link between cancer and 9/11. They noted that the act provided money for research, and said, “Thankfully, we know that today’s announcement is not the last word.” Dr. Howard said that a second review of the cancer evidence would be conducted in early to mid-2012. Robert Vecchione, a New York City police detective who retired in 2005, a year after he learned he had Hodgkin’s lymphoma, said it did not seem fair that rescue and recovery workers who had broken legs or asthma were compensated for their injuries while those with cancer were not. People who responded to the terrorist attack, he said, did so out of a sense of duty and should be considered injured in the line of duty if they became ill. “We all went wholeheartedly,” Mr. Vecchione said. “As far as the cancers are concerned, if that gets out — we’ll cover you for asthma, we’ll cover you for a broken leg, but if you get really ill you won’t get covered — guys are going to look at you, they’re going to take off their uniforms and they’re going to walk away.” Mr. Vecchione, 49, expects to receive money from a legal settlement between 9/11 responders and the city, but said he thought everyone who was sick should be compensated equally. He was sent to ground zero when the attack occurred and later that day transferred to Downtown Brooklyn. He then did 12-hour shifts, two or three times a month, for 10 months sifting for evidence and human remains at the Fresh Kills Landfill on Staten Island, where debris from the World Trade Center was taken. He said that he believed he had been exposed to toxic substances at the landfill, and that his doctor, who treated other police officers, had told him he had seen several similar cancers in first responders. Some doctors treating people exposed to the dust and smoke believe that cancer is a likely consequence. Dr. Philip J. Landrigan, head of a 9/11 treatment, monitoring and research program at Mount Sinai Medical Center, said Tuesday that the possibility of cancer in the responders increases as time goes by. Mount Sinai, he said, is tracking the rates of 60 different cancers, and will be feeding that information to the federal government. Dr. Landrigan said his researchers were looking especially hard at multiple myeloma, because they had already found eight cases — an unusually high number — in responders younger than 45. Usually, he said, myeloma is found in people who are older. People at the World Trade Center on 9/11 were exposed to a large number of substances, Dr. Landrigan said, “and each different exposure has its own signature cancers, so there are a wide range of possibilities here.” |
| National Briefing | WASHINGTON: Bill to Ban Stimulant Drug Advances in Senate Posted: 28 Jul 2011 10:00 PM PDT A bill that would ban the new stimulant drug known as bath salts passed the Senate Judiciary Committee unanimously Thursday. The bill, which was sponsored by Senator Charles E. Schumer, Democrat of New York, would make mephedrone and methylenedioxypyrovalerone illegal to possess or sell. Both would be added to the list of controlled Schedule I substances. Bath salts are typically sold online or in convenience stores or head shops, and doctors report seeing agitated, violent behavior in some users. At least 29 states have banned bath salts, which are sold under names including Ivory Wave and Vanilla Sky and are typically injected, smoked or snorted. The bill will go to the Senate floor. |
| National Briefing | SOUTH: North Carolina: 24-Hour Waiting Period for Abortions Posted: 28 Jul 2011 10:00 PM PDT Women seeking abortions in North Carolina will be required to wait 24 hours and receive state-mandated counseling before a procedure. The Republican-led Legislature completed its override Thursday of a measure vetoed by Gov. Bev Perdue, a Democrat. The House agreed to the override earlier this week. Half of all states require counseling and a waiting period before an abortion. |
| News Analysis: Grasping for Any Way to Prevent Alzheimer’s Posted: 25 Jul 2011 09:20 PM PDT Is there a way to prevent Alzheimer’s disease? Last week, a study presented at the Alzheimer’s Association International Conference in Paris suggested there might be, something that would give hope to millions who worry that one day they may be struggling with dementia. Share your thoughts on this column at the Well blog. Go to Well » The new study, by researchers at the University of California, San Francisco, estimated how many Alzheimer’s cases might be attributable to certain behaviors or conditions: physical inactivity, smoking, depression, low education, hypertension, obesity and diabetes. The authors used a mathematical model to surmise that these behaviors and conditions, all of which can be modified, are responsible for about half of the roughly 5.3 million Alzheimer’s cases in the United States and 34 million cases worldwide. And they calculated that if people addressed these risks — by exercising, quitting smoking, increasing their education or losing weight, for example — a significant number of Alzheimer’s cases could be prevented. Reducing the prevalence of these risk factors by 10 percent, the researchers estimated, could prevent 1.1 million cases worldwide; reducing these risk factors by 25 percent could prevent more than three million cases. The operative word was “could.” As the researchers pointed out, there is not yet scientific proof that any of these risk factors in fact cause Alzheimer’s. Only if they are shown to do so could the new analysis be considered a practical recipe for preventing the disease. “These things are not definitive,” said one author, Dr. Kristine Yaffe, a professor of psychiatry, neurology and epidemiology. “We’re assuming that these are sort of causally related to the risk of dementia and Alzheimer’s, but unless you have a great trial, you just don’t know.” But while experts may have understood that distinction, not everyone else did. Some headlines made things sound more certain: “7 Things You Can Do to Fight Alzheimer’s” or “7 Steps to Prevent Alzheimer’s.” In an editorial accompanying the study, both published in the journal Lancet Neurology, Dr. Laura Fratiglioni, director of the Aging Research Center at the Karolinska Institute in Sweden, suggested that the report was valuable, but said that the estimates “could be regarded as only theoretical” until more rigorous research is done. “We have been able to identify some possible preventive factors,” Dr. Fratiglioni said, “but we do not have the final answer because we do not have the experimental studies.” Indeed, research on prevention of Alzheimer’s is in its infancy. It has only been since the 1980s that dementia has not been considered a symptom of normal aging. And studies on preventing Alzheimer’s can be complicated and costly, especially the randomized controlled trials that provide the strongest evidence. Such trials have to follow people for years, and isolating individual risk factors — separating obesity from hypertension, diabetes, nutrition and physical inactivity, for instance — is challenging. Last year, a National Institutes of Health panel of experts with no vested interest in Alzheimer’s research concluded that “no evidence of even moderate scientific quality exists to support the association of any modifiable factor (such as nutritional supplements, herbal preparations, dietary factors, prescription or nonprescription drugs, social or economic factors, medical conditions, toxins or environmental exposures) with reduced risk of Alzheimer’s disease.” Most research, the panel found, involved observational studies, showing that people who did or did not get Alzheimer’s had certain characteristics beforehand, but not whether the characteristics were causal. The panel found the strongest evidence for only one conclusion: that the herb gingko biloba does not prevent Alzheimer’s. There was moderate evidence that neither vitamin E nor drugs called cholinesterase inhibitors, used to treat dementia symptoms, decrease risk of Alzheimer’s. And there was moderate evidence that the gene ApoE4 significantly increases Alzheimer’s risk, as does menopause therapy with estrogens and progestins. Evidence for or against any other causal factor was poor, often because studies were small, used vague or changing definitions, or did not rigorously monitor what subjects were doing. “We debated for hours and hours and hours how to write the report, because certainly we didn’t want it to be the carrier of bad news,” said Dr. Martha Daviglus, the panel’s chairwoman and a preventive medicine expert at Northwestern University. But “we wanted the public to realize that at this point nothing that people can sell to them is proven to work.” Many members of the Alzheimer’s community were stung, considering the panel’s conclusions a “glass half empty,” said William Thies, the Alzheimer’s Association’s chief medical and scientific officer. “We would agree that we haven’t proven any of these risk factors, but there’s data that are pretty good for some of them. And in a world where we have lots of Alzheimer’s disease and no definitive medical intervention, prevention strategies that are based on lifestyle changes are certainly attractive.” Dr. Yaffe and her colleague Deborah Barnes excluded risk factors like nutrition or brain exercise because they believed research was not solid enough. They used a more elastic threshold to evaluate research than the N.I.H. panel because, Dr. Yaffe said, the panel “didn’t quite do the field justice.” Their model weighed the strength of existing research and how widespread the risk factors were. In the United States, they estimated that 1.1 million Alzheimer’s cases, or 21 percent, may be linked to physical inactivity. Fifteen percent may owe to depression, 11 percent to smoking, 8 percent to midlife hypertension, 7 percent to obesity, 7 percent to low education and 3 percent to diabetes. Their estimates for the risk factors worldwide differed because some behaviors and conditions are more common than in the United States. So low education accounted for 19 percent, or 6.5 million cases, worldwide, while physical inactivity accounted for 13 percent and obesity 2 percent. Dr. John W. Williams Jr., a professor of medicine at Duke University who led an analysis of Alzheimer’s prevention research for the N.I.H. panel, said studies like Dr. Yaffe’s can be informative “when we don’t have other evidence” and can help shapers of public policy “make decisions about where to invest to reduce risk.” But he said: “What should individuals do with it? Probably not much.” Among the limitations, he said, was that some risk factors, like physical inactivity and obesity, “are darn hard to change.” And does a risk factor like depression cause Alzheimer’s — or is it the other way around? Still, everyone agrees these risks merit attention for other reasons: preventing cancer or heart disease, improving overall health. “It’s good if you can do it, but not in the name of Alzheimer’s,” Dr. Daviglus said. “But maybe we will find out that by doing this for other diseases, we are also doing it for Alzheimer’s.” |
| Books: Their Zeal Changed Lives, if Not the System Posted: 25 Jul 2011 09:30 PM PDT “Man down in the men’s washroom!” This cry is not part of the usual hospital soundtrack, but when Dr. David A. Ansell heard it as he sped down a corridor in the old Cook County Hospital in Chicago, he barely broke stride. He veered into the men’s room, tried the locked door of the stall where a crumpled body lay, hoisted himself up over the fetid contents of the adjacent toilet, balanced on the metal divider and prepared to descend and administer CPR. That was when the disheveled corpse on the floor roared to life, a lighted cigarette dangling from one hand, and requested with vigorous profanity that Dr. Ansell remove himself from the premises. Dr. Ansell did just that. “Call security,” he muttered to the few onlookers paying any attention to the drama, and continued on his way. This anecdote may help explain why some people who take jobs in large urban public hospitals escape as soon as possible, while others stay on forever, bound to these deeply flawed, impossibly colorful institutions with a devotion as passionate, as long-lasting and as illogical as the kind generally directed at flawed and colorful human beings. Superlatives flood these hospitals: They have the poorest and sickest patients; the longest-suffering, most inefficient and occasionally most corrupt administrations; the most disengaged nurses in the world, and the most dedicated; the cruelest and kindest doctors. These players stage a hundred Dickensian morality plays an hour, for a panorama that calls out to would-be writers and would-be reformers alike. Dr. Ansell is both, which makes his account of almost two decades at Cook County more than the usual collection of medical war stories. He arrived at the hospital as an intern in the late 1970s, a low point for the hospital and medical residency training in general. The hospital, built in 1914, was bursting at the seams, a filthy, unventilated, mismanaged horror. Today’s methodical protocols for educating young doctors had yet to evolve: The newbies were pretty much left to train one another back then, inmates running the asylum. As it turned out, the residents at Cook County were an unusually energetic group, schooled in the activism of the late ’60s, deeply committed to a liberal agenda and prepared to go mano a mano with Chicago’s entrenched political machine. And so, to the hospital’s history of medical firsts, which include America’s first blood bank and first trauma unit, Dr. Ansell and his peers added a few of their own. They were the among the first in the country to expose the all-too-common practice of “dumping,” in which uninsured patients who turned up at a private hospital were cheerfully bundled into an ambulance and sent to a public facility, no matter how sick they were. In a large review published in The New England Journal of Medicine, the Cook County group outlined the unnecessary deaths that resulted. Dr. Ansell subsequently testified before a Congressional committee on the subject, and a 1986 law made the practice illegal without substantial safeguards. Those were the days when an uninsured Chicago woman who found a lump in her breast had only one alternative: a trip to the Cook County emergency room, where, after waiting for hours, she would be referred to the hospital’s breast clinic, with an appointment generally some three months off. “Take it or leave it,” clerks told their largely African-American clientele. Dr. Ansell and his colleagues grappled with administrators to loosen a hogtied budget and open one of the first breast cancer screening programs in the country, with suitably prompt appointments and follow-up. Did their accomplishment change Chicago’s giant racial gap in breast cancer mortality? Not one whit. Fairy tales seldom come true in places like Cook County, where Dr. Ansell (who left the hospital in 1995) found on a visit back that despite a major reorganization and the opening of a brand-new facility, the “crammed, tense” waiting rooms of 2006 looked just like the ones of 1978. “If anything, things had gotten worse.” Three decades’ worth of herculean efforts to reorganize health care delivery in Chicago, he concludes, simply applied a few dingy Band-Aids to our fundamentally flawed national system. Indeed, as an advocate of a single-payer national health insurance, he sees the health care overhaul of 2010 as just another, larger Band-Aid. Public hospitals seem to bring out the writer in many of their young doctors, with fairly uniform results. In “The Making of a Surgeon” (1970), Dr. William A. Nolen told stories like Dr. Ansell’s about Bellevue Hospital in New York in the 1950s, while Dr. Fitzhugh Mullan waged a political struggle much like Dr. Ansell’s at Lincoln Hospital in the Bronx, then told his story in “White Coat, Clenched Fist” (1976). Dr. Ansell is not as proficient a writer as either of these two; his chapters move at a herky-jerky pace, full of redundancies and loose ends. But when it comes to the stories of his patients, many of whom he cared for over decades, from clinic to hospital to funeral, Dr. Ansell soars. These sketches are, to be sure, the standard-issue material of a good doctor trying to do right by a set of immensely beleaguered fellow citizens. But unlike fairy tales, we cannot have too many of these stories in circulation, to bear witness, to inform and to inspire. |
| Men in Grief Seek Others Who Mourn as They Do Posted: 26 Jul 2011 12:42 AM PDT In 1990, Sam and Gretchen Feldman cashed out on their share of a national chain of men’s apparel stores and retired to Martha’s Vineyard, Mass. There, they devoted their time to volunteer work and an active social calendar. The following years were golden ones for the Feldmans, but in 2007 Mrs. Feldman learned she had cancer. She died a year later. Alex di Suvero for The New York Times From top, Bolivar Valentine, Tony Loreto and Rob Kearney have taken part in a bereavement group at Calvary Hospital in the Bronx. Share your thoughts on this column at the Well blog. Go to Well » Alex di Suvero for The New York Times The Feldmans had been married 53 years, and Mr. Feldman’s grief was palpable to friends who knew him as a buoyant, resilient personality. “There was a huge hole in my life that no amount of activity could replace,” said Mr. Feldman, now 82. “And except for my two daughters, there was no one I could turn to for solace.” There was a local bereavement group for spouses, but Mr. Feldman opted out when he learned it consisted only of women. “I just didn’t think women would relate to my pain,” he said. “And, frankly, I come from a generation that feels uncomfortable exposing our sadness and vulnerability to the opposite sex.” The loss of a loved one is a profoundly heartbreaking experience, but it is not the same for everyone. Research increasingly suggests that men and women experience grief in different ways, and the realization has bolstered a nascent movement of bereavement groups geared to men throughout the country. Many of them are affiliated with hospitals and hospice centers. Concern about reaching men in grief has gained new urgency with shifting demographics. The number of men age 65 and older increased by 21 percent from 2000 to 2010, nearly double the 11.2 percent growth rate for women in that age group, according to census figures. As the gender gap in life span narrows, experts suggest that more men will be facing the loss of loved ones, particularly spouses. Many will be not be prepared for the experience. The loss of a spouse often is crushing for men physically as well as psychologically. In a 2001 paper published in The Review of General Psychology, psychologists at the University of Utrecht in the Netherlands confirmed earlier data showing widowers have a higher incidence of mental and physical illness, disabilities, death and suicide than widows do. While women who lose their husbands often speak of feeling abandoned or deserted, widowers tend to experience the loss “as one of dismemberment, as if they had lost something that kept them organized and whole,” Michael Caserta, chairman of the Center for Healthy Aging at the University of Utah, said by e-mail. The Harvard Bereavement Study, a landmark late 1960s investigation of spousal loss, found that widowers experienced the death of a wife as a multifaceted tragedy, a loss of protection, support and comfort that left many at sea. The men in the study relied heavily on their wives to manage their domestic lives, from household chores to raising their children, the researchers noted. The grief of men is compounded, Dr. Caserta added, by the fact that so many have been reluctant to directly address real feelings of deep sadness; until recently, men were expected to be emotionally controlled and inexpressive. Simply persuading grief-stricken men to attend a bereavement group is still no small challenge. “While there’s strong indication that grief therapy helps men, historically men generally don’t join groups,” Phyllis Silverman, a grief researcher and an author of “Widower: When Men Are Left Alone,” said in a telephone interview. There are also differences in the length of time men grieve, compared with women, and how long it takes to move on. An old axiom that “women mourn, men replace” turns out to be untrue. “It used to be thought that men grieve acutely and heal more quickly, and that women grieve chronically over a longer time period,” said George A. Bonanno, a clinical psychology professor at Columbia University in New York. But now, Dr. Bonanno said, many researchers believe that grief follows a more complex pattern in both men and women. “No matter what sex, we oscillate between positive and negative emotions, between waves of sadness about the loss and hope for the future,” he said in a telephone interview. “This can be frustrating for men, who often seek the ‘quick-fix’ approach.” Sherry Schachter, director of bereavement services at Calvary Hospital in the Bronx and a grief specialist for 25 years, said in a telephone interview: “While women grieve intuitively, open to expressing their feelings, men are ‘instrumental’ grievers. They’re not comfortable with talking about their feelings, and they prefer to do things to cope.” In a men’s group she has run for the last few years, she said, “I never ask, ‘How do you feel?’ Rather, I ask, ‘What did you do?’ ” In some cases, what men are doing is taking grief counseling into their own hands. Mr. Feldman started a biweekly bereavement group for widowers on Martha’s Vineyard, and two years ago spearheaded the Men’s Bereavement Network, a nonprofit organization seeking to establish and support grief groups for men nationwide. The network is helping to establish bereavement groups for men in places as diverse as DePere, Wis.; Clearwater, Fla.; and Danvers, Mass. At a recent peer-led gathering of the Martha’s Vineyard group begun by Mr. Feldman, eight men in their late 40s to late 80s sat around the dining room table at the home of the session leader, Foster Greene. Dr. George Cohn, a local psychiatrist, sat alongside, for the most part a silent observer. A retired fisherman, at 85 one of the older members of the group, spoke in a low voice, looking mostly into his coffee cup. His wife of 54 years died in 2010. “I don’t know about you guys,” he said, quickly glancing around the table of men, “but for me it gets harder, not easier.” The other men nodded. Later Dr. Cohn said, “Sometimes that’s all a man wants or needs — a sympathetic ear.” |
| Well: Cooking With Summer Tomatoes Posted: 29 Jul 2011 10:00 AM PDT |
| Well: Breast-Feeding Doll Is Coming to U.S. Posted: 29 Jul 2011 08:46 AM PDT |
| Well: Designing a Better Food Label Posted: 28 Jul 2011 09:16 AM PDT |
| Well: The Hidden Costs of Medical Student Debt Posted: 27 Jul 2011 09:01 PM PDT |
| Well: Some Nose-Job Patients May Have Mental Illness Posted: 27 Jul 2011 08:58 AM PDT |
| Fixes: Treating the Cause, Not the Illness Posted: 28 Jul 2011 06:40 PM PDT |
| Op-Ed Contributor: Useless Studies, Real Harm Posted: 29 Jul 2011 08:45 AM PDT Minneapolis LAST month, the Archives of Internal Medicine published a scathing reassessment of a 12-year-old research study of Neurontin, a seizure drug made by Pfizer. The study, which had included more than 2,700 subjects and was carried out by Parke-Davis (now part of Pfizer), was notable for how poorly it was conducted. The investigators were inexperienced and untrained, and the design of the study was so flawed it generated few if any useful conclusions. Even more alarming, 11 patients in the study died and 73 more experienced “serious adverse events.” Yet there have been few headlines, no demands for sanctions or apologies, no national bioethics commissions pledging to investigate. Why not? One reason is that the study was not quite what it seemed. It looked like a clinical trial, but as litigation documents have shown, it was actually a marketing device known as a “seeding trial.” The purpose of seeding trials is not to advance research but to make doctors familiar with a new drug. In a typical seeding trial, a pharmaceutical company will identify several hundred doctors and invite them to take part in a research study. Often the doctors are paid for each subject they recruit. As the trial proceeds, the doctors gradually get to know the drug, making them more likely to prescribe it later. In an age of for-profit clinical research, this is the new face of scandal. Pharmaceutical companies promote their drugs with pseudo-studies that have little if any scientific merit, and patients naïvely sign up, unaware of the ways in which they are being used. Nobody really knows how often companies conduct such trials, but they appear with alarming regularity in pharmaceutical marketing documents. In the marketing plan for the antidepressant Lexapro for the 2004 fiscal year, Forest Laboratories described 102 Phase IV trials — the classification under which seeding trials fall — in a section labeled “Marketing Tactics.” Oversight bodies like the Food and Drug Administration generally don’t view seeding trials as research scandals: seeding trials are not illegal, and the drugs in question have already received F.D.A. approval. But even after particularly egregious seeding trials have been exposed, the F.D.A. has not issued sanctions. Take the notorious Advantage study, a seeding trial of the pain reliever Vioxx conducted by Merck. According to a 2008 report in the Annals of Internal Medicine, litigation documents show that the Advantage study was conceived and managed by Merck’s marketing department. Three subjects died in the Advantage trial; five more subjects experienced heart attacks. Oversight bodies should treat the Advantage study as a violation of research ethics. How can studies that endanger human subjects attract so little scrutiny? Forty years ago, when most clinical research took place in academic settings, the main dangers to research subjects came in service to genuine scientific aims. A large regulatory apparatus was developed to protect human subjects from the ambitions of overweening academic researchers. In the early 1990s, however, pharmaceutical companies realized that it was faster and less expensive to conduct trials in the private sector, where the driving force is not knowledge, but profit. And the regulatory apparatus designed for the old era has proved woefully inadequate for the new one. The main source of protection for research subjects is a patchwork system of ethics committees known as institutional review boards, or I.R.B.’s. These are small, federally empowered bodies that review research proposals before they are carried out, to ensure that the studies are ethically sound. But they don’t typically pass judgment on whether a study is being carried out merely to market a drug. Nor do most I.R.B.’s have the requisite expertise to do so. Even worse, many I.R.B.’s are now themselves for-profit businesses, paid directly by the sponsors of the studies they evaluate. If one I.R.B. gets a reputation for being too strict, a pharmaceutical company can simply go elsewhere for its review. Last week, the federal government announced that it was overhauling its rules governing the protection of human subjects. But the new rules would not stop seeding trials. It is time to admit that I.R.B.’s are simply incapable of overseeing a global, multibillion-dollar corporate enterprise. They should be replaced with an oversight system that is financially and administratively independent of the research it oversees. The system must have the power to impose sanctions, and its responsibilities must extend to fraud, bribery and corruption. Many patients volunteer for research in the hope that the knowledge generated will benefit others. When a company deceives them into volunteering for a useless study, it cynically exploits their good will, undermining the cause of legitimate research everywhere. Carl Elliott teaches bioethics at the University of Minnesota and is the author of “White Coat, Black Hat: Adventures on the Dark Side of Medicine.†|
| Personal Health: Sun’s Rays May Leave Mysterious Marks Posted: 25 Jul 2011 11:48 PM PDT For adults and children alike, summer is the season to take in the mystery of the outdoors, its unexpected pleasures and hidden thrills. But summer has its share of unpleasant discoveries, too — as dermatologists know all too well. For this is also the season of the mystery rash. “This time of year, a lot of people come in with rashes and have no idea what happened,” said Dr. Deborah S. Sarnoff, a dermatologist in New York. In truth, many of these rashes are not at all mysterious. Very often, Dr. Sarnoff and other dermatologists find, they result from a photosensitivity reaction, a combination of the sun’s UVA radiation and exposure to a drug, perfume or another substance. Many commonly used drugs can cause such a reaction, including antibiotics like the tetracyclines (doxycycline is one), ciprofloxacin and the sulfa drugs (Bactrim, for example); the diuretic hydrochlorothiazide; and over-the-counter anti-inflammatory drugs, like ibuprofen and naproxen. People with the photosensitive reactions “may have been on the drug for a long time, so they don’t put two and two together,” said Dr. Sarnoff, who is senior vice president of the Skin Cancer Foundation. The full list of substances that can touch off a photosensitive reaction is very long and includes, ironically, sunscreens that contain benzophenones, the retinoids used to treat acne and sun-induced wrinkles, and fragrances like musk and coumarins. The guilty substances change with the times, as compounds go in and out of fashion. But the problem never vanishes. New irritants frequently appear, keeping dermatologists on their toes and consumers mystified. Most photosensitivity reactions result from exposure to UVA radiation, the so-called tanning rays that have been linked to premature aging of the skin and to melanoma, the most deadly form of skin cancer. UVA radiation can pass through glass, so a reaction can occur after a car ride or sitting indoors near a window, further mystifying affected individuals. And though the sun is the most common source of UVA radiation, it is not the only source. This type of UV radiation is found in tanning booths and, in small amounts, is emitted by fluorescent bulbs. Some people also react to the wavelengths that make up visible light. Two Kinds of Photosensitivity Photosensitivity — “a broad umbrella,” Dr. Sarnoff said — refers to two types of reactions. One, the kind that can happen to anyone, is called phototoxic, the effects of which resemble a very bad sunburn. It can occur the first time a person is exposed to a trigger. The culprit, like many of the substances mentioned above, may be ingested or applied topically. It gets into the skin, where it is activated by UVA rays. Within a day, the sun-exposed skin turns very red. While in theory anyone exposed to sufficient amounts of a phototoxic drug should react to UVA exposure, one’s susceptibility can be influenced by such factors as the amount of drug present in the skin, the color and thickness of the skin, and environmental conditions like humidity, temperature and wind. Some phototoxic reactions depend on oxygen, and taking antioxidants like vitamin C and vitamin E orally may be protective, Dr. Sarnoff said. The second type, called photoallergic dermatitis, is much less common, affecting 1 to 2 percent of the population. It is what doctors call a delayed hypersensitivity reaction, more often resulting from application of topical substances, like perfumes, that can induce allergic reactions. In past years, the sunscreen ingredient PABA caused photoallergic reactions in many people, and its use was discontinued. In one 20-year study of 69 people with documented photoallergic dermatitis, doctors at New York University found that antibiotics and ingredients in sunscreens each caused 23 percent of the reactions, other medications 20 percent, fragrances 13 percent and substances from plants 11 percent. As with poison ivy, for a photoallergy to develop a person must have exposure to the substance that resulted in no visible reaction, but alerted the immune system to recognize future exposures as something foreign. Unlike phototoxic reactions, which require a rather strong exposure to the offending substance, a photoallergic response can result from relatively small amounts of the allergen. A photoallergic reaction doesn’t show up until two or three days later, so sufferers may not link it to sun exposure. The irritation can spread to areas that were not exposed to the sun. The rash may be itchy at first, then, like poison ivy, turn into watery blisters. Some people with chronic illnesses are highly susceptible to photosensitivity reactions and must always protect themselves from UVA exposure. The conditions include lupus, pellagra and porphyria. People with a rare inherited disorder called xeroderma pigmentosum have extreme sensitivity to the sun and must avoid exposure at all times. There is also a chronic form of sun sensitivity, most often seen in elderly men, that shows up as itchy red, inflamed bumps and scaly patches on sun-exposed skin, Dr. Sarnoff and co-authors wrote in The Skin Cancer Foundation Journal in 2008. Testing and Treatment Determining the cause of a photosensitivity reaction is likely to start with an inventory of the substances you are exposed to that are common culprits. Were you on an antibiotic, or do you take a thiazide diuretic or a nonsteroidal anti-inflammatory drug? Have you recently begun using a new scent or sunscreen? Might you have been working with a particular plant or a pesticide? To confirm sensitivity, you will have to undergo a photopatch test, similar to that used by allergists to test for allergic sensitivities. Several suspect substances are tested at once on the patient’s back, with two sites for each substance. One site is exposed to UVA, and its matching site is not. Then, some hours later, the doctor checks for a reaction. “If there is a reaction at the UVA-exposed site but not at the protected one, there’s a high probability there will be a photosensitivity reaction in real life,” Dr. Sarnoff said. The best way to deal with a photosensitivity reaction is to sidestep it. If at all possible, avoid exposure to the substance that caused it. If a medication was responsible, ask your doctor if you can switch to an alternative. If it resulted from a drug that you must take, you will have to avoid UVA exposure. Dr. Sarnoff warned that sunscreens with high S.P.F. ratings that lack good UVA blockers are especially hazardous, because they allow you to stay in the sun without burning for far too long. Several sunscreen ingredients are good UVA blockers. The best are micronized inorganic substances, titanium dioxide and zinc oxide, found in a number of products (check the labels). Avobenzone (Parsol 1789), Mexoryl and Helioplex (in Neutrogena products) are good UVA blockers, as well. Specially designed sun-blocking garments are effective though expensive. The alternative is a regular garment made of tightly woven fabric, hardly an ideal solution on a hot summer day. Keep in mind that when an ordinary garment gets wet, it loses most of its ability to block sunlight. |
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| Letters: The Value of Vaccines (2 Letters) Posted: 25 Jul 2011 09:40 PM PDT To the Editor: Re “A Vaccine May Shield Boys Too” (The Consumer, July 19): It is true that use of the Gardisil vaccine in men may provide more of a public health benefit (preventing cervical cancer in women) than an individual benefit (preventing anal and penile cancer in the male vaccine recipient). However, that is the case with other vaccines that children routinely. For instance, measles is rare in the United States, and while an unvaccinated child personally might avoid measles, there is a public benefit from the “herd immunity” obtained from universal childhood vaccination. The author implies that many girls don’t complete the vaccination series because of concerns regarding vaccine safety. It is likely that gaps in insurance coverage, poor self-care skills and missed appointments are the cause of incomplete vaccination. Catherine Diamond, M.D. Orange, Calif. ♦ To the Editor: The yearly rate (2 cases per 1,000 people) for genital warts cited in your article comes from insurance claims, which seriously undercount sexually transmitted infections. A better estimate, from the National Health and Nutrition Examination Survey, is that 4 percent of men and 7 percent of women ages 18 to 59 reported having had genital warts, higher in some population groups. Even these figures probably are underestimates, as they are derived from self-report. Genital warts usually are not serious, but they are an unpleasant inconvenience and often distressing, and they cost millions of dollars in health care annually. H. Hunter Handsfield, M.D. Seattle Disclosure: The writer is a paid consultant to Merck, as a member of the company’s Gardasil Male Population Advisory Board. No Merck personnel participated in writing this letter. 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: Mixed Messages on Pain (1 Letter) Posted: 25 Jul 2011 09:40 PM PDT To the Editor: Re “Giving Chronic Pain a Medical Platform of Its Own” (Well, July 19): The recently published Institute of Medicine report “Relieving Pain in America” asserts that 116 million American adults are “affected” by pain and that treatment is inadequate. Yet at the same time, the Centers for Disease Control and Prevention has chronicled a dramatic rise in prescription opioid use and in drug-induced deaths. In 1997, total opiate sales in the United States were 96 milligrams per person, rising to 698 milligrams per person in 2007, a 627 percent increase — enough for every American to take 5 milligrams of Vicodin every four hours for three weeks. In the same period, the CDC report noted a 296 percent increase in overdose deaths. As a physician I feel frustrated and whipsawed by these contrasting messages. While the I.O.M. report sensibly calls for better research, care and education, I cannot help but feel it also exaggerates the scope of the problem and adds fuel to the nationwide demand for more prescription pain medications. John Zurlo, M.D. Hershey, Pa. 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. |
| Correction Posted: 25 Jul 2011 09:40 PM PDT A letter on July 19 about obstacles to getting the shingles vaccine included incorrect advice, given to the writer by a lab technician, to avoid being around small children and to restrict travel after the injection. Neither precaution is necessary, according to the Centers for Disease Control and Prevention. More information can be found at cdc.gov/vaccines. |
| Study Faults Approval Process for Medical Devices Posted: 29 Jul 2011 10:40 AM PDT The government’s system for regulating many medical devices like artificial hips should be abandoned and replaced because it fails to examine their safety and effectiveness before sale, according to one of the nation’s top scientific groups. In a report, released Friday, a panel of the Institute of Medicine found that the existing rules were never intended to provide safeguards for screening out dangerous or ineffective products. The panel urged the Food and Drug Administration to devise a new regulatory system for the so-called moderate risk devices — a category that now includes artificial hips, external heart defibrillators and hospital pumps — because the current system was not fixable. “If you want to make sure that a product is safe and effective, you have to start by asking the question whether it is safe and effective,” said William Vodra, a member of the 12-person panel assembled by Institute of Medicine and a lawyer who has worked closely with device producers. The report, which was commissioned by the F.D.A., follows a number of recalls of medical devices, like one involving so-called metal-on-metal artificial hips that have failed in thousands of patients, crippling some of them. Those implants received little, if any, testing in patients prior to being implanted in tens of thousands of people. It is not immediately clear what impact, if any, the new report will have. But it is likely to set off a high-powered lobbying battle in coming months over the possible future shape of F.D.A. rules. Even before the report’s release, allies of the industry had waged an aggressive campaign to discredit it, and had taken legal steps intended to bar the F.D.A. from adopting its recommendations. On Friday, a trade group, the Advanced Medical Technology Association, which represents device industry giants like Medtronic, Boston Scientific and Johnson & Johnson, unequivocally rejected the report, saying it did not deserve “serious consideration” from Congress or the Obama administration. Patient advocacy groups, however, seized on the study as an affirmation that current rules allow dangerous or ineffective devices onto the market with scant review. For their part, F.D.A. officials, who had anticipated recommendations on how to improve the existing system, appeared taken back by the panel’s finding that it was unfixable. Dr. Jeffrey E. Shuren, the director of the F.D.A.’s Center for Devices and Radiological Health, said in a statement that he did not believe the existing regulatory system should be scrapped, adding that any significant changes would have to be approved by Congress. Dr. David R. Challoner, who served as the panel’s chairman, said that members of the group were stunned when they realized that the current system could not be salvaged. “We surprised ourselves,” Dr. Challoner said. The Institute of Medicine review covered the approval system for a wide range of moderate-risk products, known as the 510(k) clearance process. It did not examine devices that carry the highest risk to patients if they fail, like implanted heart defibrillators. Those products go through a separate regulatory pathway that requires extensive testing before sale. The big problem, the study found, is that the Congressional law that created the 510(k) pathway, the Medical Device Amendments of 1976, required producers of such products only to show that they were “substantially equivalent,” or similar, to one already on the market. The committee’s report emphasized that its members believed most medical devices in use were safe and beneficial. But the panel concluded that existing rules had created a daisy-chain system of regulation, in which new devices simply piggy-back on earlier ones, without any examination of their safety or their value to patients. “The committee concludes that the 510(k) process lacks the legal basis to be a reliable premarket screen of the safety and effectiveness” of moderate-risk devices, the report concluded, adding, “Furthermore, that it cannot be transformed into one.” The panel also concluded that the F.D.A. should act quickly to determine whether artificial joints, such as hips, which are currently approved through the 510(k) process, should have to undergo the type of rigorous scrutiny that high-risk devices now go through prior to sale. Another industry trade group, the Medical Device Manufacturers Association, said Friday that it was “concerned about efforts to overhaul a regulatory pathway that would create additional uncertainties and slow patient access to medical therapies.” Among other recommendations, the report also urged the F.D.A. to quickly tighten the way it tracked the performance of devices once they are on the market, and said the agency needed to move more quickly to stop the sales of harmful ones. It also said that the agency should better monitor software used in diagnostic tools because of the growing use of such technology.In many ways, the report is a rebuke to the medical device industry and its allies, who have been waging a campaign over the last year to dispute the need for any new regulations. Last month, the Washington Legal Foundation, a pro-business group, filed a petition with the F.D.A. arguing that the agency was statutorily barred from adopting any of the report’s recommendations because of what it claimed was the panel’s bias. The legal foundation argued that the Institute of Medicine, which is part of the National Academy of Sciences, had failed to balance the panel by including officials from the device industry, the investment community or patients who had benefited from devices. An F.D.A. official said the agency was happy with the panel’s composition, which included doctors, academics and three lawyers, included two who worked closely with the industry. The report on Friday addressed several other complaints by the industry on possible new regulation, including the claim that toughened rules would slow the introduction of innovative products that could benefit patients. The panel said there was no way of assessing, based on a review of available evidence, whether current regulations were having either a positive or a negative effect on innovation. The group, however, recommended that the F.D.A. assemble a group to review the issue. This posting includes an audio/video/photo media file: Download Now |
| Gene Patent in Cancer Test Upheld by Appeals Panel Posted: 29 Jul 2011 12:43 PM PDT A federal appeals court ruled on Friday that genes can be patented, overturning a lower court decision that had shocked the biotechnology industry. The Court of Appeals for the Federal Circuit, which specializes in patent cases, said that Myriad Genetics was entitled to patents on two human genes used to predict if women have an increased risk of getting breast and ovarian cancer. The court ruled that DNA isolated from the body was eligible for patents because it was “markedly different” in its chemical structure from DNA that exists in the body. As a result, the isolated DNA is not simply a product of nature, which would not be eligible for a patent. The 2-to-1 decision on the gene patenting issue was also a rejection of arguments made by the Obama administration, which had filed a friend of the court brief arguing that isolated DNA should not be patented. That brief went against the long-standing policy of the United States Patent and Trademark Office to grant such patents. The appeals court ruled against Myriad in another part of the case, however. The court said that Myriad’s patent claims on the process of analyzing whether a patient’s genes had mutations that raised the risk of cancer was not patentable because it involved only “patent-ineligible abstract mental steps.” The case may come before the Supreme Court, which has already agreed to hear another case related to the patentability of diagnostics based on chemical changes in the human body. The decision on the patentability of genes and DNA cheered much, though not all, of the biotechnology industry. Thousands of human genes have been patented, and biotechnology executives say such patents are essential for encouraging innovation, particularly development of diagnostic tests. Critics have said it is unethical to patent something that is part of the human body or the natural world. Some critics have also said that the patents can impede patient care. Myriad’s full test for breast cancer risk costs more than $3,000 since the gene patents give the company a monopoly on such testing. A lawsuit challenging the patents on the breast cancer risk genes was filed by the American Civil Liberties Union and the Public Patent Foundation, acting as the lawyers for various cancer patients, medical researchers and medical societies. In an opinion issued in March 2010, United States District Judge Robert W. Sweet in Manhattan ruled the patents were invalid. The importance of DNA, he said, was the information content it carried in terms of how proteins should be made. In that aspect, he said, the isolated DNA was not really different from the DNA in the body. The claim that isolating the DNA made it different, he said, was just “a lawyer’s trick.” But the appellate decision rejected that argument, saying that since DNA is a chemical, the chemical structure is what matters and that “informational content is irrelevant to that fact.” “We conclude that the challenged claims are drawn to patentable subject matter because the claims cover molecules that are markedly different — have a distinctive chemical identity and nature — from molecules that exist in nature,” Judge Alan D. Lourie wrote for the court. He said that isolating DNA was not simply a matter of purifying it, like extracting a mineral from the earth. Judge Kimberly A. Moore wrote a separate opinion, agreeing that the breast cancer risk genes were patentable but citing somewhat different reasoning, including that only Congress should change Patent Office policy to grant such patents. “Judicial restraint is particularly important here because an entire industry developed in the decades since the Patent Office first granted patents to isolated DNA,” Judge Moore wrote. “Disturbing the biotechnology industry’s expectation now risks impeding, not promoting, innovation.” But the third judge on the panel, William C. Bryson, dissented, saying that the genes should not be patented just because they were isolated from the body. In some respects, he wrote, “extracting a gene is akin to snapping a leaf from a tree.” Judge Bryson argued that upholding the patents could impede the movement in diagnostics toward whole-genome sequencing. In a few years, experts say, it should be possible for a person to have his or her entire DNA sequenced for less than Myriad charges for just two genes. But separate patents held on many individual genes could make that cumbersome. This posting includes an audio/video/photo media file: Download Now |
| Judge May Strike Circumcision Ban Posted: 27 Jul 2011 10:48 PM PDT SAN FRANCISCO (AP) — A judge said Wednesday that she intended to strike a ban on circumcision of male children from the city’s November ballot. Judge Loretta M. Giorgi of Superior Court said in a tentative ruling on a challenge brought by the city attorney’s office and Jewish groups that the ban violated a California law that makes regulating medical procedures a function of the state, not cities. “It serves no legitimate purpose to allow a measure whose invalidity can be determined as a matter of law to remain on the ballot,” she wrote in ordering the city’s elections director to remove the measure from the ballot. The city would have been the first in the nation to hold a public vote on whether to outlaw the circumcision of minors. The citizens’ initiative would have made the practice a misdemeanor punishable by a fine of up to $1,000 or up to one year in jail. |
| Justices Are Asked to Hear Challenge to Health Care Law Posted: 27 Jul 2011 10:48 PM PDT WASHINGTON — The Supreme Court was asked on Wednesday to hear a challenge to the health care overhaul law, raising the possibility that the justices could rule on the matter by next summer, just months before the presidential election. Similar requests are likely to follow, and it is not clear which if any of them the court will agree to hear. The petition submitted Wednesday was an appeal from a divided decision last month by a three-judge panel of the United States Court of Appeals for the Sixth Circuit, in Cincinnati. The decision was the first appeals court ruling on the constitutionality of the law, the Patient Protection and Affordable Care Act. The decision was also notable because Judge Jeffrey S. Sutton, a prominent conservative judge who had served as a law clerk to Justice Antonin Scalia, joined the majority in upholding the law. Additional decisions on the constitutionality of the law are expected soon from other federal appeals courts, including ones in Atlanta and Richmond, Va. The Sixth Circuit case was brought by several individuals and the Thomas More Law Center, which describes itself as a defender of “America’s Christian heritage and moral values.” They argued that a provision of the law, which requires the purchase of insurance in some circumstances, exceeds the powers granted to Congress by the Constitution. The Supreme Court is particularly apt to hear cases on which the lower courts are divided, but there is for now only a single decision from a federal appeals court. It also quite often hears cases in which a federal law has been struck down as unconstitutional, but here the law was upheld. The Supreme Court also occasionally agrees to hear cases that involve, as its rules put it, “an important question of federal law that has not been, but should be, settled by this court.” That may be enough here, though the justices may also wait to see what the other appeals courts do. Most petitions seeking Supreme Court review are largely devoted to trying to persuade the justices that the case warrants their attention. The brief filed Wednesday was instead devoted in large part to arguments about why the lower court was wrong. The petition urged the justices to hear the case to decide whether there is “a meaningful limitation on Congressional power under the Commerce Clause” of the Constitution. It said the leading Supreme Court decisions in the area have a “vexation quotient” prompted by “the incongruity and inconsistency of the court’s own jurisprudence.” This posting includes an audio/video/photo media file: Download Now |
| Vital Signs: Regimens: Downside for a Urinary Infection Remedy Posted: 25 Jul 2011 10:15 PM PDT Women with recurrent urinary tract infections sometimes must take low-dose antibiotics for months to control the problem. Many prefer to try something less onerous, like cranberry extract or juice, which several studies have suggested can prevent these infections. But a new study finds that a commonly used antibiotic works much better than cranberry, with one significant drawback: It encourages the development of resistant strains of bacteria. Dutch researchers randomly assigned 221 women with a history of infections to two groups. The first took a daily dose of 480 milligrams of Bactrim, an antibiotic, and the second took 1,000 milligrams of cranberry extract. The study, published Monday in The Archives of Internal Medicine, found that by any of three measures — the number of symptomatic infections, the proportion of patients with at least one infection or the average time to the first infection after starting the regimens — antibiotics controlled the infections more effectively in the study participants. But when the researchers tested the subjects’ urine and feces, they found a large increase in the presence of antibiotic-resistant strains of E. coli, the most common cause of the infections, in those who used the antibiotic. Dr. Suzanne E. Geerlings, the senior author and an infectious disease specialist at the Academic Medical Center of the University of Amsterdam, said the findings did not rule out using cranberry and noted that antibiotics have risks. “Antibiotics work better,” she said, “but when you get an infection resistant to antibiotics, you have a bigger problem.” |
| Vital Signs: Patterns: How Milk Is Expressed Affects Nursing Posted: 25 Jul 2011 09:30 PM PDT When a newborn fails to latch onto the breast or suck successfully, mothers can express their breast milk by hand or by using an electric pump. A new study suggests that those who express by hand are more likely to still be nursing two months later. Researchers at the University of California, San Francisco, studied 68 mothers of infants 12 to 36 hours old who had difficulty breast-feeding, randomly assigning the women to either 15 minutes of electric pumping or 15 minutes of hand expression. There were no differences in the amount of milk expressed, but two months later 97.1 percent of mothers who had expressed by hand were still breast-feeding, compared with 72.7 percent of those who used the machines. The reasons are unclear, but feeling embarrassed could discourage breast-feeding, and mothers in the hand-expression group reported greater comfort in expressing milk when others were present, the researchers reported. Milk volumes were very small in both groups — about 1 milliliter — which may have seemed normal to the hand expressers but inadequate to those using the machine’s large collecting cup. “Either machine or hand expression would be appropriate,” said the lead author, Dr. Valerie J. Flaherman, an assistant professor at U.C.S.F. “But hand expression would be preferred.” The study was published online July 11 in Archives of Disease in Childhood, Fetal and Neonatal Edition. |
| Vital Signs: Childbirth: A Drug Shortens Labor but Does Little Else Posted: 25 Jul 2011 09:30 PM PDT The drug Pitocin is a safe and effective way to speed childbirth, a new review of studies has found, but it does not reduce the number of Caesarean sections or forceps deliveries. Slow progress in labor is associated with fetal and maternal morbidity, and failure to progress is one common reason for a Caesarean section. Pitocin, a synthetic version of the pituitary hormone oxytocin, is given to increase uterine contractions and reduce the need for assisted deliveries. But an analysis published online July 6 in The Cochrane Library suggests that the drug may not be accomplishing its purpose. Researchers at Nottingham University Hospitals in England pooled data from eight randomized studies involving 1,338 low-risk women in the first stage of labor. Compared with no treatment, the use of Pitocin shortened labor by about two hours, but it did not reduce the number of Caesarean sections or increase the number of unassisted deliveries. Giving Pitocin early or late in labor made no difference. It appeared to cause no harm to babies or mothers, but the sample was too small know if it has any effect on the death rates of newborns. “We need better ways of managing slow progress in labor,” said Dr. George J. Bugg, the lead author and an obstetrician at Nottingham University Hospitals. “It’s a real problem, and the method we’ve relied on for so many years doesn’t actually work.” |
| Rule Changes Proposed for Research on Humans Posted: 24 Jul 2011 09:50 PM PDT The government is proposing sweeping changes in the rules covering research involving human subjects, an effort officials say would strengthen protections while reducing red tape that can impede studies. The officials said the changes were needed to deal with a vastly altered research climate, whose new features include genomics studies using patients’ DNA samples, the use of the Internet and a growing reliance on studies that take place at many sites at once. “These are the first substantial changes that have been made to the rules governing human subjects in decades, so this is really quite a historic moment,” Kathy Hudson, a deputy director of the National Institutes of Health, said in a telephone news conference on Friday. The changes would be in the rules that cover topics like the informed consent that research participants must provide and the institutional review boards that oversee research at universities and hospitals. Initially drawn up by the Department of Health and Human Services in the 1970s and ’80s, the system was adopted by 14 other federal agencies and departments in 1991 and became known as the Common Rule. But some experts said it had become too cumbersome. “It’s a terrible drag on getting good research done,” said Dr. Robert J. Levine, a professor of medicine and a bioethicist at Yale who headed the university’s institutional review board for 31 years. He said Sunday that while he had not thoroughly reviewed the government’s lengthy proposal, he was encouraged by what he had seen. The process is still at an early stage. The government has described possible changes and asked for public comment over the next 60 days; after that, specific rules will be formulated and again sent out for comment. The government said its proposal was consistent with President Obama’s executive order in January calling on agencies to weed out unnecessary regulations. But some of the proposed changes would add regulation. One change would expand the rules’ coverage to all studies conducted at institutions that receive money from any of the 15 federal agencies that have adopted the Common Rule. For example, if a university gets financing from the National Institutes of Health, then even a study at that university paid for by a drug company would be covered by the rules. While that would encompass more medical research, it was not clear whether trials financed by drug companies and conducted at individual physicians’ offices would be covered. Another proposed change would allow a single institutional review board to oversee studies that take place at multiple sites. Right now, the institutional review board at each location generally must endorse a trial, which can lead to long delays. Federal officials said that besides eliminating redundancy and delays, having a single reviewer that is truly accountable for its decisions might actually strengthen oversight. Other proposed changes would be aimed at making it less cumbersome to do surveys or other social science research in which the risks to participants are usually less than for medical studies. Carl Wieman, associate director for science at the White House Office of Science and Technology Policy, said it was now difficult to observe teachers and students in classrooms to help determine what makes a good teacher, given all the consent required. “You’re not doing anything here except watching people,” he said. Another possible change would be that donors of blood, DNA or tissue samples would be asked to give consent before those samples could be used in subsequent research. Now, if the identity of the donor cannot be determined, samples can often be used for further research without permission. But Dr. Hudson, of the health institutes, said that with modern DNA sequencing, biological specimens are “inherently identifiable.” So the proposal would make consent required. |
| Recipes for Health: Sicilian Stuffed Tomatoes Posted: 28 Jul 2011 12:30 AM PDT This is an easy stuffed tomato recipe, based on one in Carlo Middione’s book "The Food of Southern Italy." If salt isn’t an issue for you and you want an even more robust flavor, use more anchovies. Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. 6 medium-size firm tomatoes (about 2 pounds) 2 tablespoons extra virgin olive oil 1 large onion, peeled and finely chopped 2 garlic cloves, minced 4 anchovy fillets in oil, finely chopped 3 tablespoons finely chopped parsley 2 tablespoons capers, coarsely chopped 2 ounces imported black olives, pitted and coarsely chopped (about 1/3 cup) 1/2 cup bread crumbs, preferably whole-wheat Salt and freshly ground pepper 1. Preheat the oven to 350 degrees. Oil a baking dish large enough to accommodate all of the tomatoes. Cut off the top fourth of the tomatoes, and reserve the tops. Place a strainer over a bowl, and gently scoop or squeeze out the seeds without breaking the tomatoes. Rub the seed pockets against the strainer to extract juice. Discard the seeds. Using a grapefruit spoon, scoop out as much of the tomato pulp from inside the skins as you can, but don’t break the skins. Chop the pulp, and set aside. 2. Heat 1 tablespoon of the olive oil over medium heat in a medium skillet. Add the onion. Cook five to eight minutes, stirring often, until tender and beginning to color. Add the garlic. Stir until fragrant, about 30 seconds. Add the anchovies, parsley, capers, olives, bread crumbs and tomato pulp. Season to taste with salt and pepper, and stir for about two minutes until fragrant and well amalgamated. Moisten as desired with the strained juice. Fill the tomatoes with this mixture and place them in the baking dish. Return the tops. Brush with the remaining olive oil. 3. Place in the oven, and bake 20 to 25 minutes, until the skins begin to wrinkle. The tomatoes should be soft but not mushy. Serve hot, warm or at room temperature. Yield: Serves six. Advance preparation: You can make these tomatoes a day ahead if serving cold. Nutritional information per serving: 151 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 2 milligrams cholesterol; 17 grams carbohydrates; 3 grams dietary fiber; 413 milligrams sodium (does not include salt to taste); 4 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health." |
| Recipes for Health: Tomato Stracciatella Posted: 27 Jul 2011 01:20 PM PDT Stracciatella is like an Italian egg drop soup. This particular version is adapted from one of my favorite cookbooks, "Cooking From an Italian Garden," by Jon Cohen and Paola Scaravelli. I’d never seen a stracciatella with tomatoes until I came across this recipe. Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. 1 tablespoon extra virgin olive oil 3 to 4 plump garlic cloves, minced 1 14-ounce can chopped tomatoes, or 1 1/2 cups grated tomatoes Salt to taste 1 basil sprig 2 quarts vegetable broth or chicken stock 4 eggs 1/4 cup bread crumbs or semolina 6 tablespoons freshly grated Parmesan 2 tablespoons finely chopped parsley 2 tablespoons finely chopped basil or chives Freshly ground pepper Optional: Cooked soup pasta for serving 1. Heat the olive oil over medium heat in a large, heavy soup pot or Dutch oven. Add the garlic. Stir until fragrant, about 30 seconds. Add the tomatoes and basil sprig. Cook, stirring, until the tomatoes have cooked down slightly and smell fragrant, about 10 minutes. Season to taste, and add the vegetable or chicken stock. Bring to a simmer, cover and simmer 20 minutes. Season to taste with salt and pepper. 2. In a large mixing bowl, beat together the eggs, bread crumbs or semolina, Parmesan, parsley and basil or chives. Beat until frothy. 3. Bring the soup to a boil, and slowly drizzle in a thin stream of the egg mixture, stirring constantly. After the mixture has been added, reduce the heat and simmer five minutes. Taste and adjust seasonings. Add a spoonful of cooked soup pasta to the bowl if desired. Yield: Serves six. Advance preparation: You can make this through Step 1 up to a day ahead of serving and refrigerate it. Bring it back to a simmer, and proceed with Step 2. Nutritional information per serving: 125 calories; 2 grams saturated fat; 1 gram polyunsaturated fat; 3 grams monounsaturated fat; 128 milligrams cholesterol; 7 grams carbohydrates; 1 gram dietary fiber; 173 milligrams sodium (does not include salt to taste); 8 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health." |
| Recipes for Health: Slow-Roasted Cherry Tomatoes With Basil Oil Posted: 27 Jul 2011 01:11 PM PDT When you roast cherry tomatoes, they caramelize and become even sweeter. This dish was inspired by a huge pile of roasted red and yellow cherry tomatoes that a friend served at a dinner party recently; they were drizzled with diluted pesto and placed alongside a luxurious mound of burrata. Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. You can serve these as an appetizer (have napkins close by) or side dish, or tossed with pasta. You can easily multiply this recipe, but you won’t have to use much more olive oil to coat the tomatoes. 2 baskets sweet cherry tomatoes (can use a mixture of colors) Salt to taste A couple of pinches of sugar 3 tablespoons extra virgin olive oil About 1 tablespoon basil olive oil (see below) 1. Preheat the oven to 300 degrees. Place the tomatoes in a baking dish large enough to fit them in a single layer. Add the salt and sugar, and toss together. Add the regular olive oil, and toss again. Place in the oven for 45 minutes until the skins have shriveled and just split; the tomatoes should still be still intact. Remove from the heat, and allow to cool. 2. Arrange the tomatoes on a platter. Drizzle the bright green basil oil decoratively around and over them, and pour on any juices from the pan. Serve warm or at room temperature. Yield: Serves 8 to 10 as an hors d’oeuvre, about 6 as a side dish or sauce. Advance preparation: You can make these tomatoes several hours ahead of serving. They will keep overnight in the refrigerator. Basil Oil This gorgeous emerald-colored oil is a condiment that you can keep in your refrigerator for up to a week. Keep it in a squeeze bottle, and drizzle it over tomatoes, fish, chicken or other vegetables. It looks beautiful on a white plate, and a little goes a long way. Salt to taste 2 cups basil 1/2 cup extra virgin olive oil 1. Bring a pot of water to a boil, and salt generously. Fill a medium bowl with ice water. Place the basil in the boiling water, and blanch for 15 seconds. Remove with a skimmer, and transfer to the ice water. Drain and squeeze out excess water, then place on a clean dish towel and again squeeze out as much water as you can. Place in a blender with the olive oil. Blend one to two minutes until the olive oil is green and tinged with flecks of basil. Transfer to a squeeze bottle, and refrigerate. Nutritional information per serving (six servings): 107 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 6 grams monounsaturated fat; 0 milligrams cholesterol; 7 grams carbohydrates; 2 grams dietary fiber; 14 milligrams sodium (does not include salt to taste); 1 gram protein Nutritional information per serving (eight servings): 80 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligrams cholesterol; 5 grams carbohydrates; 1 gram dietary fiber; 10 milligrams sodium (does not include salt to taste); 1 gram protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health." |
| Recipes for Health: Summer’s Treasure: Tomatoes Posted: 27 Jul 2011 01:11 PM PDT Elizabeth Eckholt, a chef in Northern California who specializes in “healing” foods, believes that greens, cucumbers, celery and seaweeds help maintain health by preventing the body from becoming overly acidic. This notion gives me pause, and for one big reason: I love tomatoes, and they are notoriously acidic. Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. But Ms. Eckholt recently told me that tomatoes are welcome among the healing-foods folks, too, because they are quickly digested, limiting their impact on the body’s Ph balance. And whether you subscribe to the healing foods philosophy or not, it’s well known that tomatoes are very rich source of vitamin A and vitamin C, not to mention lycopenes, phytonutrients that some scientists believe may have antioxidant properties. Relieved, I am heading out to my garden to reap this summer’s bounty. Tomato, Spelt and Herb Salad This is a light summer chopped salad with chewy and crunchy textures. Give it time to marinate for the best flavor. 1 cup cooked spelt, farro or wheat berries 1 pound tomatoes, diced 1 cup diced cucumber 1/2 cup diced celery 1 cup finely chopped fresh herbs, like a mixture of parsley, dill, mint and basil 1/2 cup crumbled feta 2 tablespoons fresh lemon juice 1 teaspoon balsamic vinegar 1 small garlic clove, minced or puréed (optional) Salt and freshly ground pepper 1/4 cup extra virgin olive oil 1. Combine the spelt, tomatoes, cucumber, celery, herbs and feta in a salad bowl. Season to taste with salt and pepper. 2. Mix together the lemon juice, balsamic vinegar, optional garlic, salt, pepper and olive oil. Toss with the salad. Place in the refrigerator, and marinate for one hour or longer before serving. Yield: Serves four to six. Advance preparation: The salad will keep for a couple of days in the refrigerator. The tomatoes and cucumbers will make it a bit juicy. Toss it all together and serve it with bread to soak up the excess. Nutritional information per serving (four servings): 351 calories; 5 grams saturated fat; 2 grams polyunsaturated fat; 11 grams monounsaturated fat; 17 milligrams cholesterol; 39 grams carbohydrates; 7 grams dietary fiber; 238 milligrams sodium (does not include salt to taste); 11 grams protein Nutritional information per serving (six servings): 234 calories; 3 grams saturated fat; 1 gram polyunsaturated fat; 7 grams monounsaturated fat; 11 milligrams cholesterol; 26 grams carbohydrates; 5 grams dietary fiber; 159 milligrams sodium (does not include salt to taste); 7 grams protein Martha Rose Shulman is the author of “The Very Best of Recipes for Health.” |
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