F.D.A. Approves Eliquis From Bristol and Pfizer

The Food and Drug Administration on Friday approved Eliquis, an anticlotting drug that has been highly anticipated by cardiologists and is expected to be a blockbuster for Bristol-Myers Squibb, which will make the drug, and Pfizer, which will help market it.

The agency approved Eliquis for reducing the risk of stroke and dangerous blood clots in people with atrial fibrillation, a common heart arrhythmia that afflicts millions of people in the United States.

The drug, also known as apixaban, is the third anticlotting medicine to be approved in recent years and the companies are expected to aggressively compete to pitch their products as a replacement for warfarin, an older treatment that requires more careful monitoring. Warfarin is also known by the brand name Coumadin.

"The marketing games will now begin," said Dr. Sanjay Kaul, a cardiologist at the Cedars-Sinai Medical Center in Los Angeles, who was not involved in the development of any of the drugs.

He said that cardiologists would now have to sort out the differences among Eliquis and its competitors already on the market: Pradaxa, sold by Boehringer Ingelheim, and Xarelto, sold by Johnson & Johnson and Bayer.

While some experts have argued that Eliquis offers the best balance between the drug's benefits and risks, Dr. Kaul said since there have been no clinical trials comparing the three new drugs, "it is impossible to adjudicate which of these new agents is the preferred one."

Bristol-Myers and Pfizer issued a brief statement Friday saying they were pleased with the approval. In a news release in November announcing the drug's approval in Europe, Bristol-Myers noted that Eliquis was the only drug in the group that has shown an advantage over warfarin in reducing the risk of stroke and dangerous blood clots, major bleeding and death.

The agency also warned that patients with prosthetic heart valves should not take Eliquis, nor should patients with atrial fibrillation that is caused by a heart valve problem.

Despite the promise of Eliquis and the other new drugs, some cautioned against prescribing them too enthusiastically.

Dr. Garret FitzGerald, a cardiologist and chairman of pharmacology at the University of Pennsylvania, said the trial results for Eliquis were impressive. But he added in an e-mail on Friday: "What matters to a patient is the individual effect in them."

He noted that patients taking Eliquis also suffered major bleeding episodes and said all drugs that prevent clotting carried a risk of bleeding. "Thus the F.D.A.'s warning to be on the lookout for bleeding seems just as appropriate as approval of Eliquis," he said.

Dr. Kaul says he tends to wait to prescribe new drugs until he learns more from the experience of colleagues, and Eliquis will be no exception. "I'm going to sit back by the sidelines and see how it pans out," he said, adding that he had begun to prescribe Pradaxa and Xarelto to patients.

Eliquis's entry into the United States market has been eagerly anticipated by Bristol-Myers and Pfizer after a succession of delays this year. Bristol-Myers, in particular, has been struggling since its best-selling blood-thinner drug, Plavix, lost its patent protection in May. Sales of Plavix, which Bristol-Myers sells in partnership with Sanofi, fell 96 percent in the third quarter of this year after cheaper generic alternatives flooded the market and the company has struggled to replace the lost sales.

Eliquis is "very important for Bristol because it's one of the legs of their investment case, that they can leapfrog over the Plavix expiration," said Les Funtleyder, the fund manager of Poliwogg, a private equity and hedge fund. He said he expected Eliquis to eventually earn more than $1 billion for its sellers.

In such a crowded field of competitors, Mr. Funtleyder said, consumers and doctors should brace themselves for a marketing onslaught. "I wonder if we'll see our first Eliquis commercial before the new year," he said.

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Well: Food Myths

Let's start the new year on scientifically sound footing by addressing some nutritional falsehoods that circulate widely in cyberspace, locker rooms, supermarkets and health food stores. As a result, millions of people are squandering hard-earned dollars on questionable, even hazardous foods and supplements.

For starters, when did "chemical" become a dirty word? That's a question raised by one of Canada's brightest scientific minds: Joe Schwarcz, director of the Office for Science and Society at McGill University in Montreal. Dr. Schwarcz, who has received high honors from Canadian and American scientific societies, is the author of several best-selling books that attempt to set the record straight on a host of issues that commonly concern health-conscious people.

I've read two of his books, "Science, Sense and Nonsense" (published in 2009) and "The Right Chemistry" (2012), and recently attended a symposium on the science of food that Dr. Schwarcz organized at McGill.

What follows are tips from his books and the symposium that can help you make wiser choices about what does, and does not, pass your lips in 2013.

CURED MEATS Many health-conscious people avoid cured meats like hot dogs and bacon because the nitrites with which they are preserved can react with naturally occurring amines to form nitrosamines. Nitrosamines have produced mutations in cells cultured in the laboratory and cancer in animals treated with very high doses.

As an alternative, sandwich lovers often buy organic versions of processed meats or products without added nitrites. Without preservatives, these foods may not be protected from bacterial contamination. And despite their labels, they may contain nitrites. According to Dr. Schwarcz, organic processed meats labeled "uncured" may be preserved with highly concentrated, nitrate-rich celery juice treated with a bacterial culture that produces nitrites.

If you're really concerned about your health, you'd be wise to steer clear of processed meats — organic, nitrite-free or otherwise. High saturated fat and salt content place them low on the nutritional totem pole.

MEAT GLUE Never heard of it? You may have eaten it, especially if you dine out often. At WD-50 in New York, the chef, Wylie Dufresne, makes his famous shrimp noodles with the enzyme transglutaminase, a k a meat glue. It binds protein molecules, gluing together small pieces of fish, meat or poultry.

The Japanese use meat glue to create artificial crab meat from pollock. Others use it to combine lamb and scallops, or to make sausages that hold together without casings.

Sound frightening? It shouldn't. The enzyme is classified by the Food and Drug Administration as "generally recognized as safe," and there is no reason to think otherwise. Our bodies produce it to help blood clot, Dr. Schwarcz points out. When consumed, it breaks down like any protein into its component amino acids in our digestive tracts.

There is, however, one possible indirect hazard: If glued-together animal protein is not thoroughly cooked, dangerous bacteria that originally contaminated the meat could remain viable within the fused product.

TRANS FATS The removal of heart-damaging trans fats from processed foods is a much-ballyhooed boon to health. But "not all trans fats are fiends," Dr. Schwarcz notes. Certain ones can legally, and healthfully, be added to dairy products, meal-replacement bars, soy milk and fruit juice.

The word "trans" refers to the arrangement of hydrogen and carbon atoms in a fatty acid. The trans formation linked to heart disease is formed when vegetable oils are hardened to prolong shelf life in a manufacturing process called hydrogenation. Natural trans fats, like those in meat and dairy products, take a slightly different form, resulting in an entirely different effect on health.

The most widely consumed "good" trans fat is conjugated linoleic acid, which research has shown can help weight-conscious people lose fat and gain muscle. Various studies have suggested that C.L.A., now widely sold as a supplement, also can enhance immune function and reduce atherosclerosis, high blood pressure and inflammation.

ORGANIC OR NOT? Wherever I shop for food these days, I find an ever-widening array of food products labeled "organic" and "natural." But are consumers getting the health benefits they pay a premium for?

Until the 20th century, Dr. Schwarcz wrote, all farming was "organic," with manure and compost used as fertilizer and "natural" compounds of arsenic, mercury and lead used as pesticides.

Might manure used today on organic farms contain disease-causing micro-organisms? Might organic produce unprotected by insecticides harbor cancer-causing molds? It's a possibility, Dr. Schwarcz said. But consumers aren't looking beyond the organic sales pitch.

Also questionable is whether organic foods, which are certainly kinder to the environment, are more nutritious. Though some may contain slightly higher levels of essential micronutrients, like vitamin C, the difference between them and conventionally grown crops may depend more on where they are produced than how.

A further concern: Organic producers disavow genetic modification, which can be used to improve a crop's nutritional content, enhance resistance to pests and diminish its need for water. A genetically modified tomato developed at the University of Exeter, for example, contains nearly 80 times the antioxidants of conventional tomatoes. Healthier, yes — but it can't be called organic.

FARMED SALMON Most of the salmon consumed nowadays is farmed. Even if we all could afford the wild variety, there's simply not enough of it to satisfy the current demand for this heart-healthy fish.

There may be legitimate concerns about possible pollutants in farmed salmon, but one concern that is a nonissue involves that "salmon" color, produced by adding astaxanthin to fish feed. This commercially made pigment is an antioxidant found naturally in algae, and it is carried up the food chain to give wild salmon its color, too.

NUTS Growing up, I was often warned to avoid nuts because they're "fattening." Now I know better. Although about three-fourths of the calories in peanuts, for example, come from fat, people who regularly eat nuts and nut butters in normal amounts weigh less, on average, than nut avoiders.

The fat in nuts is unsaturated and heart-healthy. Nuts are also good sources of protein, antioxidants, vitamins, minerals and fiber, and can help keep between-meal hunger at bay. The same is true of avocados — just don't go overboard.

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Chinese Firm Is Cleared to Buy American DNA Sequencing Company

Ramin Rahimian for The New York Times

DNA sequencing machines at Complete Genomics in California. The firm dismissed concerns about its acquisition.

The federal government has given national security clearance to the controversial purchase of an American DNA sequencing company by a Chinese firm.

The Chinese firm, BGI-Shenzhen, said in a statement this weekend that its acquisition of Complete Genomics, based in Mountain View, Calif., had been cleared by the federal Committee on Foreign Investment in the United States, which reviews the national security implications of foreign takeovers of American companies. The deal still requires antitrust clearance by the Federal Trade Commission.

Some scientists, politicians and industry executives had said the takeover represented a threat to American competitiveness in DNA sequencing, a technology that is becoming crucial for the development of drugs, diagnostics and improved crops.

The fact that the $117.6 million deal was controversial at all reflects a change in the genomics community.

A decade ago, the Human Genome Project, in which scientists from many nations helped unravel the genetic blueprint of mankind, was celebrated for its spirit of international cooperation. One of the participants in the project was BGI, which was then known as the Beijing Genomics Institute.

But with DNA sequencing now becoming a big business and linchpin of the biotechnology industry, international rivalries and nationalism are starting to move front and center in any acquisition.

Much of the alarm about the deal has been raised by Illumina, a San Diego company that is the market leader in sequencing machines. It has potentially the most to lose from the deal because BGI might buy fewer Illumina products and even become a competitor. Weeks after the BGI deal was announced, Illumina made its own belated bid for Complete Genomics, offering 15 cents a share more than BGI's bid of $3.15. But Complete Genomics rebuffed Illumina, saying such a merger would never clear antitrust review.

Illumina also hired a Washington lobbyist, the Glover Park Group, to stir up opposition to the deal in Congress. Representative Frank R. Wolf, Republican of Virginia, was the only member of Congress known to have publicly expressed concern.

BGI and Complete Genomics point out that Illumina has long sold its sequencing machines — including a record-setting order of 128 high-end machines — to BGI without raising any security concerns. Sequencing machines have not been subject to export controls like aerospace equipment, lasers, sensors and other gear that can have clear military uses.

"Illumina has never previously considered its business with BGI as 'sensitive' in the least," Ye Yin, the chief operating officer of BGI, said in a November letter to Complete Genomics that was made public in a regulatory filing. In the letter, Illumina was accused of "obvious hypocrisy."

BGI and Complete said that Illumina was trying to derail the agreement and acquire Complete Genomics itself in order to "eliminate its closest competitor, Complete."

BGI is already one of the most prolific DNA sequencers in the world, but it buys the sequencing machines it uses from others, mainly Illumina.

Illumina, joined by some American scientists, said it worried that if BGI gained access to Complete's sequencing technology, the Chinese company might use low prices to undercut the American sequencing companies that now dominate the industry.

Some also said that with Complete Genomics providing an American base, BGI would have access to more DNA samples from Americans, helping it compile a huge database of genetic information that could be used to develop drugs and diagnostic tests. Some also worried about protection of the privacy of genetic information.

"What's to stop them from mining genomic data of American samples to some unknown nefarious end?" Elaine R. Mardis, co-director of the genome sequencing center at Washington University in St. Louis, said in an e-mail.

Dr. Mardis could not specify what kind of nefarious end she imagined. But opponents of the deal cited a November article in The Atlantic saying that in the future, pathogens could be genetically engineered to attack particular individuals, including the president, based on their DNA sequences.

BGI and Complete Genomics dismissed such concerns as preposterous.

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Dr. Rita Levi-Montalcini, a Revolutionary in the Study of the Brain, Dies at 103

Fabio Campana/European Pressphoto Agency

Dr. Rita Levi-Montalcini in 2007. She discovered chemical tools the body uses to direct cell growth and build nerve networks.

Dr. Rita Levi-Montalcini, a Nobel Prize-winning neurologist who discovered critical chemical tools that the body uses to direct cell growth and build nerve networks, opening the way for the study of how those processes can go wrong in diseases like dementia and cancer, died on Sunday at her home in Rome. She was 103.

Her death was announced by Mayor Gianni Alemanno of Rome.

"I don't use these words easily, but her work revolutionized the study of neural development, from how we think about it to how we intervene," said Dr. Gerald D. Fishbach, a neuroscientist and professor emeritus at Columbia.

Scientists had virtually no idea how embryo cells built a latticework of intricate connections to other cells when Dr. Levi-Montalcini began studying chicken embryos in the bedroom of her house in Turin, Italy, during World War II. After years of obsessive study, much of it at Washington University in St. Louis with Dr. Viktor Hamburger, she found a protein that, when released by cells, attracted nerve growth from nearby developing cells.

In the early 1950s, she and Dr. Stanley Cohen, a biochemist also at Washington University, isolated and described the chemical, known as nerve growth factor — and in the process altered the study of cell growth and development. Scientists soon realized that the protein gave them a new way to study and understand disorders of neural growth, like cancer, or of degeneration, like Alzheimer's disease, and to potentially develop therapies.

In the years after the discovery, Dr. Levi-Montalcini, Dr. Cohen and others described a large family of such growth-promoting agents, each of which worked to regulate the growth of specific cells. One, called epidermal growth factor and discovered by Dr. Cohen, plays a central role in breast cancer; in part by studying its behavior, scientists developed drugs to combat the abnormal growth.

In 1986, Dr. Levi-Montalcini and Dr. Cohen shared the Nobel Prize in Physiology or Medicine for their work.

Dr. Cohen, now an emeritus professor at Vanderbilt University, said Dr. Levi-Montalcini possessed a rare combination of intuition and passion, as well as biological knowledge. "She had this feeling for what was happening biologically," he said. "She was an intuitive observer, and she saw that something was making these nerve connections grow and was determined to find out what it was."

One of four children, Rita Levi-Montalcini was born in Turin on April 22, 1909, to Adamo Levi, an engineer, and Adele Montalcini, a painter, both Italian Jews who traced their roots to the Roman Empire. In keeping with the Victorian customs of the time, Mr. Levi discouraged his three daughters from entering college, fearing that it would interfere with their lives as wives and mothers.

It was not a future that Rita wanted. She had decided to become a doctor and told her father so. "He listened, looking at me with that serious and penetrating gaze of his that caused me such trepidation," she wrote in her autobiography, "In Praise of Imperfection" (1988). He also agreed to support her.

She graduated summa cum laude from the University of Turin medical school in 1936. Two years later, Mussolini issued a manifesto barring non-Aryan Italians from having professional careers. She began her research anyway, setting up a small laboratory in her home to study chick embryos, inspired by the work of Dr. Hamburger, a prominent researcher in St. Louis who also worked with the embryos.

During World War II, the family fled Turin for the countryside, and in 1943 the invasion by Germany forced them to Florence. The family returned at the close of the war, in 1945, and Dr. Hamburger soon invited Dr. Levi-Montalcini to work for a year in his lab at Washington University.

She stayed on, becoming an associate professor in 1956 and a full professor in 1958. In 1962, she helped establish the Institute of Cell Biology in Rome and became its first director. She retired from Washington University in 1977, becoming a guest professor and splitting her time between Rome and St. Louis.

Italy honored her in 2001 by making her a senator for life.

An elegant presence, confident and passionate, she was a sought-after speaker until late in life. "At 100, I have a mind that is superior — thanks to experience — than when I was 20," she said in 2009.

She never married and had no children. In addition to her autobiography, she was the author or co-author of dozens of research studies and received numerous professional awards, including the National Medal of Science.

"It is imperfection — not perfection — that is the end result of the program written into that formidably complex engine that is the human brain," Dr. Levi-Montalcini wrote in her autobiography, "and of the influences exerted upon us by the environment and whoever takes care of us during the long years of our physical, psychological and intellectual development."

This article has been revised to reflect the following correction:

Correction: December 30, 2012

An earlier version of this obituary misstated the year Mussolini issued a manifesto barring non-Aryan Italians from having professional careers. It was 1938, not 1936.

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The Boss: For Kathryn Giusti, Two Wars Against Multiple Myeloma

MY identical twin sister, Karen, and I have two older brothers. We were raised in Blue Bell, Pa., where my father was a family physician and my mother was a nurse. We spent summers on Long Beach Island, N.J., where both of us were waitresses at a busy seafood restaurant.

Kathryn E. Giusti is the C.E.O. and co-founder of the Multiple Myeloma Research Founda- tion in Norwalk, Conn.

AGE 54

LOVES TO Watch her son, who plays baseball, and her daughter, a cheerleader, at their events.

My sister and I have always been best friends. We even went to the same college, the University of Vermont. I was scientifically inclined and majored in biology. We graduated in 1980, and my sister later became a lawyer.

I was accepted to medical school, but my father was opposed to that. He thought I was too impatient to cope with medicine's bureaucracy. Instead, I took a job in sales at Merck, the drug maker.

To my chagrin, the company sent me to its site in West Point, Pa., very close to home. After two years, I moved over to work in the company's marketing and communications area, but I began to realize that I needed some formal business education.

In 1983, I entered Harvard Business School, specializing in marketing. I met my husband, Paul Giusti, there. After we earned our M.B.A.'s in 1985, he started a real estate development business in the Midwest, and I joined Gillette in Boston in its personal care division.

We married in 1990 and moved to Chicago, and I worked briefly at Brach's, the candy manufacturer, in Oakbrook Terrace, Ill. I then joined G. D. Searle in Skokie, helping to develop new products like Ambien. Later, I was promoted to manage the company's worldwide arthritis drugs division.

In late 1995, I was feeling tired and went in for a physical. Blood tests found that I had multiple myeloma, an incurable blood cancer. I was shocked because I was only 37. My grandfather had had the disease, but I wasn't in the usual demographic or age group. The scariest part was that there were no drugs in the pipeline to combat the cancer.

Our first child, Nicole, was about 2 when I received the diagnosis. I was determined that I was going to have another child, which I did. Our son, David, was born in 1997.

At that point, I did not expect to live beyond a few years, so we moved to New Canaan, Conn., to be closer to our families. Paul sold his company, but the new owners who were based in McLean, Va., asked him to remain as chief operating officer, which he did, working from a New Canaan office.

After our move, my sister and I organized a fund-raiser, garnering $400,000. We used that to start the Multiple Myeloma Research Foundation, which initially made grants to speed development of cancer-fighting drugs. (Later, it also worked with academic and clinical centers and pharmaceutical companies on initiatives like a tissue bank.) Six years later, in 2004, I started the Multiple Myeloma Research Consortium to foster collaboration among cancer centers, to start a patient tissue bank for research and to encourage broader participation in clinical trials.

I was working full time and raising my family, but in 2005 my health began to deteriorate. In early 2006, I received a stem cell transplant. Karen donated the cells, and the operation was done at the Dana-Farber Cancer Institute in Boston. When I came home, I weighed 90 pounds and was bald and fragile.

It took several months to recover, but I returned to work later that year and kept building our network of 16 clinics and hospitals that participate in the clinical trials, tissue bank and genome research. We've raised $200 million since the foundation opened and are now focused on helping patients use individualized medicine to fight cancer.

I still get a huge knot in my stomach every two months, when I check in at Dana-Farber for my test results. But I believe we have made some real progress because I continue to work impatiently to cure this disease and other cancers as well.

As told to Elizabeth Olson.

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Cough Syrup Suspected to Have Killed 33 in Pakistan

LAHORE, Pakistan (AP) — The Pakistani authorities are investigating claims that cough syrup has killed 33 people over the past three days, a government official said Saturday, the second time in recent months that medicine is suspected of causing multiple deaths.

The deaths occurred in the eastern city of Gujranwala and in nearby villages, said a local official, Abdul Jabbar Shaheen. City hospitals were also treating 54 others thought to have consumed the syrup. Officials say they believe that the victims drank the syrup to get high, Mr. Shaheen added.

Tests show the victims' stomachs contained dextromethorphan, a synthetic morphine derivative used in cough syrup that can have mind-altering effects if consumed in large quantities, Mr. Shaheen said. Investigators are trying to determine whether the victims drank too much syrup, or whether there was a problem with the medicine itself, he said.

Twenty-three people died in the nearby city of Lahore in November after drinking bad cough syrup sold under the brand name Tyno. At the time, they were also described as people who had consumed the syrup to get high.

Mr. Shaheen said the cough syrup involved in the episodes in and around Gujranwala was not sold under a single brand. He said that some people in the city made cough syrup to sell specifically to drug addicts, and that officials were trying to arrest them.

Officials temporarily closed one pharmaceutical company based in Lahore whose cough syrup was found in the possession of some affected in Gujranwala. They are investigating whether it caused any of the deaths, Mr. Shaheen said.

Also Saturday, an explosion ripped through a passenger bus while it was at a terminal in the southern city of Karachi, killing six people and wounding 52 others, the police and hospital officials said. It was unclear whether the blast was caused by a bomb or a gas canister. Many buses in Pakistan run on natural gas.

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Questcor Finds Profit for Acthar Drug, at $28,000 a Vial

Kevin Moloney for The New York Times

Christina Culver with her son Tyler, 6, at home in Colorado Springs this month. In 2007, Tyler was hospitalized when the price of Acthar soared.

THE doctor was dumbfounded: a drug that used to cost $50 was now selling for $28,000 for a 5-milliliter vial.

The physician, Dr. Ladislas Lazaro IV, remembered occasionally prescribing this anti-inflammatory, named H.P. Acthar Gel, for gout back in the early 1990s. Then the drug seemed to fade from view. Dr. Lazaro had all but forgotten about it, until a sales representative from a company called Questcor Pharmaceuticals appeared at his office and suggested that he try it for various rheumatologic conditions.

"I've never seen anything like this," Dr. Lazaro, a rheumatologist in Lafayette, La., says of the price increase.

How the price of this drug rose so far, so fast is a story for these troubled times in American health care — a tale of aggressive marketing, questionable medicine and, not least, out-of-control costs. At the center of it is Questcor, which turned the once-obscure Acthar into a hugely profitable wonder drug and itself into one of Wall Street's highest fliers.

At least until recently, that is. Now some doctors, insurance companies and investors are beginning to have doubts about whether the drug is really any better than much cheaper alternatives. Short-sellers have written scathing criticisms of the company, questioning its marketing tactics and predicting that its shareholders are highly vulnerable.

 That Acthar is even a potential blockbuster is a remarkable turn of events, considering that the drug was developed in the 1950s by a division of Armour & Company, the meatpacking company that once ruled the Union Stock Yards of Chicago. As in the 1950s, Acthar is still extracted from the pituitary glands of slaughtered pigs — essentially a byproduct of the meatpacking industry.

The most important use of Acthar has been to treat infantile spasms, also known as West syndrome, a rare, sometimes fatal epileptic disorder that generally strikes before the age of 1.

For several years, Questcor, which is based in Anaheim, lost money on Acthar because the drug's market was so small. In 2007, it raised the price overnight, to more than $23,000 a vial, from $1,650, bringing the cost of a typical course of treatment for infantile spasms to above $100,000. It said it needed the high price to keep the drug on the market.

"We have this drug at a very high price right now because, really, our principal market is infantile spasms," Don M. Bailey, Questcor's chief executive, told analysts in 2009. "And we only have about 800 patients a year. It's a very, very small — tiny — market."

Companies often charge stratospheric prices for drugs for rare diseases — known as orphan drugs — and Acthar's price is not as high as some. Society generally tolerates those costs to encourage drug companies to develop crucial, possibly lifesaving drugs for these often neglected diseases.

But Questcor did almost no research or development to bring Acthar to market, merely buying the rights to the drug from its previous owner for $100,000 in 2001. And while the manufacturing of Acthar is complex, it accounts for only about 1 cent of every dollar that Questcor charges for the drug.

Moreover, the tiny "orphan" market soon became much bigger. Before long, Questcor began marketing the drug for multiple sclerosis, nephrotic syndrome and rheumatologic conditions, even though there is little evidence that Acthar is more effective for those other conditions than alternatives that are far cheaper. And the company did so without being required to prove that the drug actually works. That is because Acthar was approved for use in 1952, before the Food and Drug Administration required clinical trials to show a drug is effective for a particular disease. Acthar is essentially grandfathered in.

Today, only about 10 percent of the drug's sales are for infantile spasms. The new uses, Mr. Bailey has told analysts, represent multibillion-dollar opportunities for Acthar and Questcor, its sole maker.

The results have been beyond even the company's wildest dreams. Sales of Acthar, which accounts for essentially all of Questcor's sales, totaled nearly $350 million in the first nine months this year, up 145 percent from the period a year earlier. In the same period, Questcor's earnings per share nearly tripled, to $2.12. In the five years after the big Acthar price increase in August 2007, Questcor shares rose from around 60 cents to about $50, in one of the best performances of any stock in any industry.

But in September, the shares plummeted after Aetna, the big insurer, said it would no longer pay for Acthar, except to treat infantile spasms, because of lack of evidence the drug worked for other diseases. The stock now trades at $26.93.

Peter Wickersham, senior vice president for cost of care at Prime Therapeutics, a pharmacy benefits manager that has found the drug is possibly being overused, says the huge increase in Acthar's price for patients "just invites the type of scrutiny that it's received."

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Well: Spinach Recipes for Health

Spinach goes well with all kinds of foods. It's also a green that is easy to find year-round. As Martha Rose Shulman writes in this week's Recipes for Health:

Spinach has remained a part of my holiday ritual. I love the convenience of bagged spinach, but I prefer the richness of the lush bunches I get at the farmers' market. I don't mind stemming and washing it, but if you are pressed for time the bagged spinach is a godsend, especially if you live in a cold climate and don't have access to farmers' market spinach in December.

Below are five new ways to add spinach to your meal. And for more spinach recipes, see "Making Spinach the Star of the Meal."

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Spinach and Millet Timbale With Tomato Sauce
A timbale is a molded custard, somewhat similar to a quiche without a crust.

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Garlic Soup With Spinach
A quick and easy soup that is a great way to use any leftover turkey stock from Thanksgiving.

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Penne With Mushroom Ragout and Spinach
This is a delicious meal no matter what variety of mushrooms you have on hand.

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Spinach Gnocchi
A considerably lighter version of the classic gnocchi made with spinach and ricotta.

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Spinach, Sardine and Rice Gratin
This classic Provençal gratin is a good way to work fish that is high in omega-3s into your diet.

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Surgery Returns to NYU Langone Medical Center

Chang W. Lee/The New York Times

Senator Charles E. Schumer spoke at a news conference Thursday about the reopening of NYU Langone Medical Center.

NYU Langone Medical Center opened its doors to surgical patients on Thursday, almost two months after Hurricane Sandy overflowed the banks of the East River and forced the evacuation of hundreds of patients.

While the medical center had been treating many outpatients, it had farmed out surgery to other hospitals, which created scheduling problems that forced many patients to have their operations on nights and weekends, when staffing is traditionally low. Some patients and doctors had to postpone not just elective but also necessary operations for lack of space at other hospitals.

The medical center's Tisch Hospital, its major hospital for inpatient services, between 30th and 34th Streets on First Avenue, had been closed since the hurricane knocked out power and forced the evacuation of more than 300 patients, some on sleds brought down darkened flights of stairs.

"I think it's a little bit of a miracle on 34th Street that this happened so quickly," Senator Charles E. Schumer of New York said Thursday.

Mr. Schumer credited the medical center's leadership and esprit de corps, and also a tour of the damaged hospital on Nov. 9 by the administrator of the Federal Emergency Management Agency, W. Craig Fugate, whom he and others escorted through watery basement hallways.

"Every time I talk to Fugate there are a lot of questions, but one is, 'How are you doing at NYU?' " the senator said.

The reopening of Tisch to surgery patients and associated services, like intensive care, some types of radiology and recovery room anesthesia, was part of a phased restoration that will continue. Besides providing an essential service, surgery is among the more lucrative of hospital services.

The hospital's emergency department is expected to delay its reopening for about 11 months, in part to accommodate an expansion in capacity to 65,000 patient visits a year, from 43,000, said Dr. Andrew W. Brotman, its senior vice president and vice dean for clinical affairs and strategy.

In the meantime, NYU Langone is setting up an urgent care center with 31 bays and an observation unit, which will be able to treat some emergency patients. It will initially not accept ambulances, but might be able to later, Dr. Brotman said. Nearby Bellevue Hospital Center, which was also evacuated, opened its emergency department to noncritical injuries on Monday.

Labor and delivery, the cancer floor, epilepsy treatment and pediatrics and neurology beyond surgery are expected to open in mid-January, Langone officials said. While some radiology equipment, which was in the basement, has been restored, other equipment — including a Gamma Knife, a device using radiation to treat brain tumors — is not back.

The flooded basement is still being worked on, and electrical gear has temporarily been moved upstairs. Mr. Schumer, a Democrat, said that a $60 billion bill to pay for hurricane losses and recovery in New York and New Jersey was nearing a vote, and that he was optimistic it would pass in the Senate with bipartisan support. But the measure's fate in the Republican-controlled House is far less certain.

The bill includes $1.2 billion for damage and lost revenue at NYU Langone, including some money from the National Institutes of Health to restore research projects. It would also cover Long Beach Medical Center in Nassau County, Bellevue, Coney Island Hospital and the Veterans Affairs hospital in Manhattan.

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F.D.A. Approves Eliquis From Bristol and Pfizer

The Food and Drug Administration on Friday approved Eliquis, an anticlotting drug that has been highly anticipated by cardiologists and is expected to be a blockbuster for Bristol-Myers Squibb, which will make the drug, and Pfizer, which will help market it.

The agency approved Eliquis for reducing the risk of stroke and dangerous blood clots in people with atrial fibrillation, a common heart arrhythmia that afflicts millions of people in the United States.

The drug, also known as apixaban, is the third anticlotting medicine to be approved in recent years and the companies are expected to aggressively compete to pitch their products as a replacement for warfarin, an older treatment that requires more careful monitoring. Warfarin is also known by the brand name Coumadin.

"The marketing games will now begin," said Dr. Sanjay Kaul, a cardiologist at the Cedars-Sinai Medical Center in Los Angeles, who was not involved in the development of any of the drugs.

He said that cardiologists would now have to sort out the differences among Eliquis and its competitors already on the market: Pradaxa, sold by Boehringer Ingelheim, and Xarelto, sold by Johnson & Johnson and Bayer.

While some experts have argued that Eliquis offers the best balance between the drug's benefits and risks, Dr. Kaul said since there have been no clinical trials comparing the three new drugs, "it is impossible to adjudicate which of these new agents is the preferred one."

Bristol-Myers and Pfizer issued a brief statement Friday saying they were pleased with the approval. In a news release in November announcing the drug's approval in Europe, Bristol-Myers noted that Eliquis was the only drug in the group that has shown an advantage over warfarin in reducing the risk of stroke and dangerous blood clots, major bleeding and death.

The agency also warned that patients with prosthetic heart valves should not take Eliquis, nor should patients with atrial fibrillation that is caused by a heart valve problem.

Despite the promise of Eliquis and the other new drugs, some cautioned against prescribing them too enthusiastically.

Dr. Garret FitzGerald, a cardiologist and chairman of pharmacology at the University of Pennsylvania, said the trial results for Eliquis were impressive. But he added in an e-mail on Friday: "What matters to a patient is the individual effect in them."

He noted that patients taking Eliquis also suffered major bleeding episodes and said all drugs that prevent clotting carried a risk of bleeding. "Thus the F.D.A.'s warning to be on the lookout for bleeding seems just as appropriate as approval of Eliquis," he said.

Dr. Kaul says he tends to wait to prescribe new drugs until he learns more from the experience of colleagues, and Eliquis will be no exception. "I'm going to sit back by the sidelines and see how it pans out," he said, adding that he had begun to prescribe Pradaxa and Xarelto to patients.

Eliquis's entry into the United States market has been eagerly anticipated by Bristol-Myers and Pfizer after a succession of delays this year. Bristol-Myers, in particular, has been struggling since its best-selling blood-thinner drug, Plavix, lost its patent protection in May. Sales of Plavix, which Bristol-Myers sells in partnership with Sanofi, fell 96 percent in the third quarter of this year after cheaper generic alternatives flooded the market and the company has struggled to replace the lost sales.

Eliquis is "very important for Bristol because it's one of the legs of their investment case, that they can leapfrog over the Plavix expiration," said Les Funtleyder, the fund manager of Poliwogg, a private equity and hedge fund. He said he expected Eliquis to eventually earn more than $1 billion for its sellers.

In such a crowded field of competitors, Mr. Funtleyder said, consumers and doctors should brace themselves for a marketing onslaught. "I wonder if we'll see our first Eliquis commercial before the new year," he said.

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Memphis Aims to Be a Friendlier Place for Cyclists

Lance Murphey for The New York Times

The Shelby Farms Greenline, which replaced a Memphis rail line.

MEMPHIS — John Jordan, a 64-year-old condo appraiser here, has been pedaling his cruiser bicycle around town nearly every day, tooling about at lunchtime or zipping to downtown appointments.

"It's my cholesterol-lowering device," said Mr. Jordan, clad in a leather vest and wearing a bright white beard. "The problem is, the city needs to educate motorists to not run over" the bicyclists.

Bike-friendly behavior has never come naturally to Memphis, which has long been among the country's most perilous places for cyclists. In recent years, though, riders have taken to the streets like never before, spurred by a mayor who has worked to change the way residents think about commuting.

Mayor A. C. Wharton Jr., elected in 2009, assumed office a year after Bicycling magazine named Memphis one of the worst cities in America for cyclists, not the first time the city had received such a biking dishonor. But Mr. Wharton spied an opportunity.

In 2008, Memphis had a mile and a half of bike lanes. There are now about 50 miles of dedicated lanes, and about 160 miles when trails and shared roads are included. The bulk of the nearly $1 million investment came from stimulus money and other federal sources, and Shelby County, which includes Memphis, was recently awarded an additional $4.7 million for bike projects.

In June, federal officials awarded Memphis $15 million to turn part of the steel truss Harahan Bridge, which spans the Mississippi River, into a bike and pedestrian crossing. Scheduled to open in about two years, the $30 million project will link downtown Memphis with West Memphis, Ark.

"We need to make biking part of our DNA," Mr. Wharton said. "I'm trying to build a city for the people who will be running it 5, 10, 15 years from now. And in a region known to some for rigid thinking, the receptivity has been remarkable."

City planners are using bike lanes as an economic development tool, setting the stage for new stores and enhanced urban vibrancy, said Kyle Wagenschutz, the city's bike-pedestrian coordinator, a position the mayor created.

"The cycling advocates have been vocal the past 10 years, but nothing ever happened," Mr. Wagenschutz said. "It took a change of political will to catalyze the movement."

Memphis, with a population of 650,000, is often cited among the unhealthiest, most crime-ridden and most auto-centric cities in the country. Investments in bicycling are being viewed here as a way to promote healthy habits, community bonds and greater environmental stewardship.

But as city leaders struggle with a sprawling landscape — Memphis covers about the same amount of land as Dallas, yet has half the population — their persistence has run up against another bedeviling factor: merchants and others who are disgruntled about the lanes.

A clash between merchants and bike advocates flared last year after the mayor announced new bike lanes on Madison Avenue, a commercial artery, that would remove two traffic lanes. Many merchants, like Eric Vernon, who runs the Bar-B-Q Shop, feared that removing car lanes would hurt businesses and cause parking confusion. Mr. Vernon said that sales had not fallen significantly since the bike lanes were installed, but that he thought merchants were left out of the process.

On McLean Boulevard, a narrow residential strip where roadside parking was replaced by bike paths, homeowners cried foul. The city reached a compromise with residents in which parking was outlawed during the day but permitted at night, when fewer cyclists were out. Mr. Wagenschutz called the nocturnal arrangement a "Cinderella lane."

Some residents, however, were not mollified. "I'm not against bike lanes, but we're isolated because there's no place to park," said Carey Potter, 53, a longtime resident who started a petition to reinstate full-time parking.

The changes have been panned by some members of the City Council. Councilman Jim Strickland went as far as to say that the bike signs that dot the streets add "to the blight of our city."

Tensions aside, the mayor's office says that the potential economic ripple effect of bike lanes is proof that they are a sound investment.

A study in 2011 by the University of Massachusetts found that building bike lanes created more jobs — about 11 per $1 million spent — than any other type of road project. Several bike shops here have expanded to accommodate new cyclists, including Midtown Bike Company, which recently moved to a location three times the size of its former one. "The new lanes have been great for business," said the manager, Daniel Duckworth.

Wanda Rushing, a professor at the University of Memphis and an expert on urban change in the South, said bike improvements were of a piece with a development model sweeping the region: bolstering transportation infrastructure and population density in the inner city.

"Memphis is not alone in acknowledging that sprawl is not sustainable," Dr. Rushing said. "Economic necessity is a pretty good melding substance."

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Home Tech: Devices to Monitor Physical Activity and Food Intake

STEP LIVELY Fitbit One pedometer clips onto your belt or pocket to record activity.

WHEN I received the results of a routine cholesterol test this summer, I was certain there had been some kind of mistake. I'm young, unstressed and healthy, or so I imagined. I work out, too, and most impartial observers — and some partial ones — would describe me as lean. Plus, I eat a nutritious diet, I swear. So why did my LDL levels surpass my I.Q. — or, for that matter, Einstein's?

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TOTAL RECALL Lose It! is one of several calorie-tracking apps the writer tested.

The facts were stark: My genes predisposed me to metabolic syndrome, my doctor told me. Like my forebears, I was on a fast path to heart disease and diabetes. My doctor ordered me to reduce my carbs and come up with a more stringent exercise plan. I've rarely monitored what I eat and how much exercise I get. I had no idea how to go about the logistics of it. How would I count my carbs? How would I track my fitness routine?

Of course, there are apps for that. I set out to scour the market for devices and programs to help me and any family member who wished to join me in my low-carb adventure improve our health. I found two kinds of technologies: fitness trackers to monitor physical activity, and P.C. and smartphone apps to track diet. I spent weeks testing several of them. And while I found a few to be quite helpful, they were all just short of fantastic.

I tried four high-end fitness gadgets: Nike's FuelBand ($149), the Fitbit One ($99.95), Jawbone's Up ($129.99) and the BodyMedia FIT wireless armband ($149). I also threw in a plain-Jane pedometer, the Omron HJ-720ITC, which I found for $31 at many stores online.

All of these devices work in a similar way. You attach them to your person (the FuelBand and Up fit around your wrist, the FIT goes around your upper arm, and the Fitbit and Omron pedometer can be placed in a pocket or clipped to your belt). Then, as you move, the devices measure your activity.

Unfortunately each device had major drawbacks. Even though I had gotten the proper size, I found that the Up and the FuelBand did not fit well around my wrist. They tapped against my desk while I typed, and they slid about uncomfortably when I washed the dishes. (They are both water-resistant.) BodyMedia's FIT, meanwhile, is about the size of a man's large wristwatch. Positioned directly against the skin around the upper arm, it is ungainly — I found it distracting when I was in a short-sleeve workout shirt, and strange-looking under a nice button-down shirt.

The pedometer and the Fitbit were easier to handle; I hardly noticed them crammed with my keys and phone in my pocket. On the other hand, because they are not wearable, I often forgot them on my bedside table, where they did no good.

Still, among these vast offerings, I found the Fitbit and the cheap Omron to be best. The Fitbit is an unobtrusive slab of plastic about the size of a U.S.B. thumb drive. Its software — which is available for Macs and Windows P.C.'s, as well as iOS and Android devices — is simple to learn and offers plenty of graphs and stats to track your progress. The most useful is a graph of your activity over the course of the day: you can see how many calories you burned while at work and alter your behavior accordingly. Maybe go for a brief walk after lunch?

(I was a big fan of Jawbone's Up software, too, but I ultimately found it too limited: It works only on Apple's iOS devices; the company has not yet made versions for P.C.'s or Android devices.)

The best thing about the Fitbit is its wireless syncing capability. It comes with a tiny receiver that plugs into your computer's U.S.B. port; whenever your Fitbit is near your machine, it sends its data over the air, no physical docking required. It also syncs directly to your phone over Bluetooth. (You do have to plug your Fitbit in to charge it, but only rarely — you can go more than a week between charges.)

The Omron, by comparison, does not do wireless syncing, and its optional P.C. software is pretty basic. But paucity is its beauty. No setup is required. Just turn it on and leave it in your pocket. At the end of the day, peek at its screen — in large, readable type, it shows a single stat: how many steps you have walked that day. The Omron does not promise the world, but it delivers enough information to keep you healthy.

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Well: Too Young to Have a Heart Attack

The foreshadowing escaped me: The night before we left for our summer vacation in Michigan, I accidentally stepped on my Kindle — which, like my heart, I cannot live without — and broke it. Reduced to reading novels on my iPhone, I made the best of it several days later, sitting in a sunroom overlooking Eight Point Lake, where my family gathers each year with friends.

The day before, proving to my teenage sons that 48 isn't too old for fun, I had hung on for dear life as I zoomed behind a speedboat on a ski tube. The next day, I was enjoying a few moments of solitude in those blissful minutes before the sun goes down, finger-swiping to turn the page of my novel on my phone's tiny screen, when my left arm started hurting.

You know that childhood feeling when your mother is mad at you, grabs your arm and squeezes it as she drags you away from whatever grief you've been causing? It felt like that, times 10, from shoulder to wrist. My chest got slightly uncomfortable, and I started sweating profusely. For the next four or five minutes, I kept to myself. I was incredibly antsy — up, down, sitting, standing, leaning, lying; my arm and I simply couldn't get comfortable.

I instinctively knew what was happening but wasn't ready to say it out loud, trying to reassure myself. There was no elephant on my chest; I'm too young – no one in my family has had heart trouble before age 55; I'm 50 pounds overweight but carry it well. Nevertheless, I motioned my husband up from the dock and, cradling my arm, told him something was really wrong.

He rushed to get some baby aspirin he'd seen earlier in the bathroom, which I chewed. I noticed him quietly doing a Google search for "heart attack symptoms" on his phone as family and friends gathered around us, but I was otherwise inside my head, no longer able to focus on what anyone else was doing or saying.

Our friend drove us to the E.R., where my EKG looked normal and the first nitroglycerin pill had no effect. But 10 minutes later, about the time the second and third nitro pill were making the pain dissipate, the doctor showed up with the result of my cardiac enzyme blood test. It's supposed to be 0, but mine was much higher. And, he said, that weird somersault feeling I was having right at that moment at the base of my throat was actually tachycardia, a rapid heart rate. Before he was even done talking, an ambulance crew was waiting to take me to a bigger hospital 30 minutes away for a cardiac catheterization.

A little balloon angioplasty through the groin? I could deal with that, and maybe I could convince them to let me go back to the cottage in time for dessert. Instead, I woke up the next day, struggling to breathe, wrists strapped to the rails of a hospital bed, hearing the word "surgery." I was extremely agitated, confused and unable to ask questions because of the breathing tube running down my throat.

This was not the summer vacation I had planned.

It turned out my "tortuous" left anterior descending artery was 95 percent clogged, and the angioplasty effort tore the inner artery wall, making a stent impossible and creating an even more critical situation. While I was still anesthetized, a surgical team was rounded up at 3 a.m. for an emergency heart bypass. In the span of a couple of hours, I went from expecting a teeny balloon in my artery and a little puncture in my groin to having open heart surgery and an eight-inch scar bisecting my chest.

Did I ever expect this? Not really. I'd read enough to know that heart disease is the No. 1 killer of women, that our heart attack symptoms often are radically different from men's (just ask Rosie O'Donnell, whose heart attack symptoms the same week as mine seemed more like the flu), and that a third of cardiovascular-disease deaths happen to people younger than 65. But this stuff doesn't happen to us, right?

Not only did it happen to me; it happened to me twice. I was lucky enough to arrange a flight home on a small plane — larger planes have pressure issues, and the doctors wouldn't let us drive — but 30 minutes into the flight, my left arm started hurting and I started sweating, not to mention crying at the thought of going through this all over again.

We made an emergency landing. Later, after five hours of tests and discussion, a doctor told me it was stress-induced angina: the symptoms of a heart attack without the life-threatening blockage. He wanted me to stay overnight for observation, but finally agreed to let me continue my trip home.

I'd been relatively pain-free in the hospital, but once I was home, the agony of my titanium-twist-tied sternum was startling. I've had to take everything — shifting positions, showering, even breathing — slowly. I'm more aware of my heartbeat, which can be a little freaky. And while I won't be running marathons any time soon, it's heartening to hear from friends that I look "terrific," nothing like a person who had a heart attack five months ago.

I've learned many things throughout all of this. Among them, that doctors now try to use a mammary artery, from the chest, for the bypass instead of grafting one from the leg because the mammary bypasses tend to last longer. And it's likely that a lot of my previous complaints over the past few years — extreme fatigue, lack of endurance, poor circulation, jaw pain (not T.M.J., after all), and so many other vague symptoms — were due to this growing accumulation of plaque in my artery, not perimenopause. Even though I'm far from healed yet, I feel amazingly more alert and less muddled than I did before the surgery, and many of those other symptoms suddenly disappeared.

I also quickly learned I have more friends than I realized, as people brought dinners and well wishes for weeks on end (not to mention commiseration about trying to read a book on an iPhone, a heart-attack-inducing event if ever there was one). However, I'm still coming to terms with the idea of a heart-healthy diet here in Wisconsin, the land of aged and artisan cheeses.

Perhaps most important, I've learned to relinquish some control. Even if your doctor says you don't need help walking up the stairs, let your husband or children escort you anyway. When you've been this close to death, the recovery is as much theirs as yours.

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7-Eleven Stores Focus on Healthier Food Options

The chain that is home of the Slurpee, Big Gulp and self-serve nachos with chili and cheese is betting that consumers will stop in for yogurt parfaits, crudité and lean turkey on whole wheat bread.

7-Eleven, the convenience store chain, is restocking its shelves with an eye toward health. Over the last year, the retailer has introduced a line of fresh foods for the calorie conscious and trimmed down its more indulgent fare by creating portion-size items.

The change is as much about consumers' expanding waistlines as the company's bottom line. By 2015, the retailer aims to have 20 percent of sales come from fresh foods in its American and Canadian stores, up from about 10 percent currently, according to a company spokesman.

"We're aspiring to be more of a food and beverage company, and that aligns with what the consumer now wants, which is more tasty, healthy, fresh food choices," said Joseph M. DePinto, the chief executive of 7-Eleven, a subsidiary of the Japanese company, Seven & i Holdings.

Convenience stores have typically been among the most nimble of retailers. In the 1980s, they added Pac-Man arcade games as a way to keep customers in stores longer and to buy more merchandise. They installed A.T.M.'s a decade later, taking a slice of the transaction fees. More recently, they built refrigerated dairy cases, with milk, eggs, cheese and other staples.

But just as they have taken business from traditional supermarkets, convenience stores have faced increased competition from the likes of Dunkin' Donuts and Starbucks, which offer a basic menu of fresh foods for consumers on the go.

At the same time, a major profit driver for convenience stores — cigarettes — has been in steady decline over the last decade as the rate of smoking has dropped in the United States.

Fresh foods can help offset some of those losses. The markup on such merchandise can be significant, bolstering a store's overall profits. It's also a fast-growing category.

"If you can figure out how to deliver consistent quality and the products consumers want, fresh food is attractive because margins are higher, and it addresses some of the competitive issues you're facing," said Richard Meyer, a longtime consultant for the convenience store industry. "But it's not easy to do."

7-Eleven has been selling fresh food since the late 1990s. But much of its innovation has been limited to the variety of hot dogs spinning on the roller grill or the breakfast sandwiches languishing beneath a heating lamp.

As 7-Eleven refocuses its lineup, the retail chain has assembled a team of culinary and food science experts to study industry trends and develop new products. Such groups have been around for a while at fast-food restaurants like McDonald's and packaged-goods manufacturers like Kraft. But it's a relatively new concept for players like 7-Eleven, which have typically relied on their suppliers to provide product innovation.

"We're working to create a portfolio of fresh foods," said Anne Readhimer, senior director of fresh food innovation, who joined the company in May from Yum Brands, where she had worked on the KFC and Pizza Hut brands. "Some will be for snacking, some for a quick meal, but we hope everything we offer our guests is convenient and tasty."

One new menu item just hitting stores is a Bistro Snack Protein Pack, which includes mini pita rounds, cheddar cheese cubes, grapes, celery, baby carrots and hummus. The meal in a box, similar to one carried by Starbucks, is part of a broader menu with healthier items under 400 calories.

The company is also taking existing products and retooling them for single portions. For example, customers can now buy jelly doughnuts and tacos, in mini sizes.

"There are definitely customers who want healthy options, but there are also lots of customers who are excited about the new sandwich options that aren't low calorie — and minidoughnuts are doing very well," said Lori Primavera, senior manager of fresh food innovation at 7-Eleven, who previously worked for Food and Drink Resources, a consulting firm for restaurant companies.

Norman Jemal, a franchisee, said sales of the new products are growing steadily in the three 7-Eleven stores that he owns in Manhattan. "At first, people are surprised when they come in here and see a bag of carrots and celery," Mr. Jemal said. "They say, 'I came in here for a bag of chips — I can't believe you have fruit cups or yogurt cups.' "

He said the Yoplait Parfait, a cup of vanilla yogurt topped with fresh strawberries or blueberries and granola, is his best-selling fresh food item, while the 7 Smart turkey sandwich is his top sandwich.

The fresh food in Mr. Jemal's stores and other locations around the country are supplied from a system of 29 commissaries and bakeries that fulfill orders from 7-Eleven. They tailor menu items for specific markets. In the Miami area, they produce a hot Cuban sandwich with ham, cheese, pickles and mustard. The Turkey Gobbler with turkey, stuffing and cranberry sauce sells in Northeastern stores around the holidays.

Each store has a data system that allows it to see exactly what is selling, which helps manage waste. Stores can track consumers' purchase habits over a month, and adjust their orders based on those behaviors.

"In this 28-day cycle, I know I sold 3,563 bananas to customers in this store," said Todd Ferguson, who owns five 7-Eleven locations in Las Vegas.

Mr. Ferguson has owned 7-Eleven franchises since 1986, and he said the variety of fresh food options in the stores is far better than before. The category already accounts for 20 percent of his sales, and his goal is to reach a quarter of sales volume.

"We used to be a place for people to buy beer, wine, cigarettes, candy and chips, and people would occasionally ask where they could go to get something to eat," Mr. Ferguson said. "We're no longer getting that question because now you can get something to eat right here."

This article has been revised to reflect the following correction:

Correction: December 27, 2012

An earlier version of this article incorrectly identified a 7-Eleven franchisee in Las Vegas. He is Todd Ferguson, not Tom Ferguson.

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Surgery Returns to NYU Langone Medical Center

Chang W. Lee/The New York Times

Senator Charles E. Schumer spoke at a news conference Thursday about the reopening of NYU Langone Medical Center.

NYU Langone Medical Center opened its doors to surgical patients on Thursday, almost two months after Hurricane Sandy overflowed the banks of the East River and forced the evacuation of hundreds of patients.

While the medical center had been treating many outpatients, it had farmed out surgery to other hospitals, which created scheduling problems that forced many patients to have their operations on nights and weekends, when staffing is traditionally low. Some patients and doctors had to postpone not just elective but also necessary operations for lack of space at other hospitals.

The medical center's Tisch Hospital, its major hospital for inpatient services, between 30th and 34th Streets on First Avenue, had been closed since the hurricane knocked out power and forced the evacuation of more than 300 patients, some on sleds brought down darkened flights of stairs.

"I think it's a little bit of a miracle on 34th Street that this happened so quickly," Senator Charles E. Schumer of New York said Thursday.

Mr. Schumer credited the medical center's leadership and esprit de corps, and also a tour of the damaged hospital on Nov. 9 by the administrator of the Federal Emergency Management Agency, W. Craig Fugate, whom he and others escorted through watery basement hallways.

"Every time I talk to Fugate there are a lot of questions, but one is, 'How are you doing at NYU?' " the senator said.

The reopening of Tisch to surgery patients and associated services, like intensive care, some types of radiology and recovery room anesthesia, was part of a phased restoration that will continue. Besides providing an essential service, surgery is among the more lucrative of hospital services.

The hospital's emergency department is expected to delay its reopening for about 11 months, in part to accommodate an expansion in capacity to 65,000 patient visits a year, from 43,000, said Dr. Andrew W. Brotman, its senior vice president and vice dean for clinical affairs and strategy.

In the meantime, NYU Langone is setting up an urgent care center with 31 bays and an observation unit, which will be able to treat some emergency patients. It will initially not accept ambulances, but might be able to later, Dr. Brotman said. Nearby Bellevue Hospital Center, which was also evacuated, opened its emergency department to noncritical injuries on Monday.

Labor and delivery, the cancer floor, epilepsy treatment and pediatrics and neurology beyond surgery are expected to open in mid-January, Langone officials said. While some radiology equipment, which was in the basement, has been restored, other equipment — including a Gamma Knife, a device using radiation to treat brain tumors — is not back.

The flooded basement is still being worked on, and electrical gear has temporarily been moved upstairs. Mr. Schumer, a Democrat, said that a $60 billion bill to pay for hurricane losses and recovery in New York and New Jersey was nearing a vote, and that he was optimistic it would pass in the Senate with bipartisan support. But the measure's fate in the Republican-controlled House is far less certain.

The bill includes $1.2 billion for damage and lost revenue at NYU Langone, including some money from the National Institutes of Health to restore research projects. It would also cover Long Beach Medical Center in Nassau County, Bellevue, Coney Island Hospital and the Veterans Affairs hospital in Manhattan.

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New York’s Mental Health System Thrashed by Services Lost to Storm

Marcus Yam for The New York Times

Dr. Richard Rosenthal, physician in chief of behavioral services for Continuum hospitals, at St. Luke's-Roosevelt Hospital Center.

When a young woman in the grip of paranoid delusions threatened a neighbor with a meat cleaver one Saturday last month, the police took her by ambulance to the nearest psychiatric emergency room. Or rather, they took her to Beth Israel Medical Center, the only comprehensive psychiatric E.R. functioning in Lower Manhattan since Hurricane Sandy shrank and strained New York's mental health resources.

The case was one of 9,548 "emotionally disturbed person" calls that the Police Department answered in November, and one of the 2,848 that resulted in transportation to a hospital, a small increase over a year earlier.

But the woman was discharged within hours, to the shock of the mental health professionals who had called the police. It took four more days, and strong protests from her psychiatrist and caseworkers, to get her admitted for two weeks of inpatient treatment, said Tony Lee, who works for Community Access, a nonprofit agency that provides supportive housing to people with mental illness, managing the Lower East Side apartment building where she lives.

Psychiatric hospital admission is always a judgment call. But in the city, according to hospital records and interviews with psychiatrists and veteran advocates of community care, the odds of securing mental health treatment in a crisis have worsened significantly since the hurricane. The storm's surge knocked out several of the city's largest psychiatric hospitals, disrupted outpatient services and flooded scores of coastal nursing homes and "adult homes" where many mentally ill people had found housing of last resort.

One of the most affected hospitals, Beth Israel, recorded a 69 percent spike in psychiatric emergency room cases last month, with its inpatient slots overflowing. Instead of admitting more than one out of three such cases, as it did in November 2011, it admitted only one out of four of the 691 emergency arrivals this November, records show. Capacity was so overtaxed that ambulances had to be diverted to other hospitals 15 times in the month, almost double the rate last year, in periods typically lasting for eight hours, officials said.

Dr. Richard Rosenthal, physician in chief of behavioral services for Continuum Health Partners, Beth Israel's parent organization, said he was proud of how much Continuum's hospitals had done to handle psychiatric overflow since storm damage shuttered Bellevue Hospital Center, the city's flagship public hospital; NYU Langone Medical Center; and the Veterans Affairs Hospital. But these days, he said, as he walks on Amsterdam Avenue between Continuum's Roosevelt hospital on West 59th Street and its St. Luke's hospital on West 114th Street, he notices more mentally ill people in the streets than he has seen in years.

"When you have the most vulnerable folks, all you need is one chink in the system and you lose them," Dr. Rosenthal said. "Whether they lost their housing, or the outpatient services they usually go to were closed and they were lost to follow-up, they have become disconnected, with predictable results."

Similar patterns are playing out in Brooklyn, where Maimonides Medical Center has been overwhelmed with mental health emergencies from the Coney Island vicinity since Coney Island Hospital, one of the city's largest acute care psychiatric hospitals, suspended operations, hospital officials said.

"Triage has reached a different level: You have to get sicker to get in," said Dr. Andrew Kolodny, the chairman of psychiatry at Maimonides, citing a 56 percent increase in psychiatric emergency room visits there from Oct. 26 to Dec. 7, compared with the same period last year, and a 24 percent rise in admissions. The increase in admissions was possible only with emergency permission from the state to exceed licensed limits.

"Not only is there decreased capacity, because Bellevue and Coney Island are off line," Dr. Kolodny added, "but there's increased demand because the storm or the loss of their residence has been a stressor for mental illness."

The storm battered a mental health system that still relies heavily on private nursing homes and substandard adult homes to house people with mental illness. Such institutions have a sordid history of neglect and exploitation, and the courts have repeatedly found that their overuse by the state isolated thousands of people in violation of the Americans With Disabilities Act.

Plans are under way to increase supportive housing — dwellings where mentally ill people can live relatively independently, with support services. But even before Hurricane Sandy, the expansion fell far short of demand.

The storm underscored the fragility of the system. Many disabled evacuees who were sent first to makeshift school shelters lost access to the psychiatric medications that kept their symptoms at bay, Dr. Kolodny said. Even those lucky enough to have the drugs they need are at greater risk of relapse as they experience crowded living conditions. "If they're now sleeping in a gym with 100 people, that can tip them over the edge and start making them really paranoid," he said.

On Staten Island, where the chief of psychiatry at Richmond University Medical Center says psychiatric resources have been stretched to the limit, clergy members report that mentally ill people transferred to a large adult home in New Brighton from one that was washed away in Far Rockaway, Queens, are now showing up at church rectories, begging for socks and underwear.

"It's heartbreaking, because they just found us by chance," said Margaret Moschetto, a missionary at the Church of Assumption-St. Paul in New Brighton. "They were just walking around the neighborhood. They really didn't know where they were."

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Creating the Ultimate Housework Workout

Robert Wright for The New York Times

Chris Ely, an English butler, and Carol Johnson, a fitness instructor at Crunch NYC, perfecting a houseworkout.

CAN housework help you live longer? A New York Times blog post by Gretchen Reynolds last month cited research linking vigorous activity, including housework, and longevity. The study, which tracked the death rates of British civil servants, was the latest in a flurry of scientific reports crediting domestic chores with health benefits like a lowered risk for breast and colon cancers. In one piquant study published in 2009, researchers found that couples who spent more hours on housework had sex more frequently (with each other) though presumably not while vacuuming. (The report did not specify.)

Intrigued by science that merged the efforts of a Martha with the results of an Arnold (a buffer buffer?), this reporter challenged a household expert and a fitness authority to create the ultimate housework workout — a houseworkout — in her East Village apartment. Perhaps she could add a few years to her own life while learning some fancy new moves for her Swiffer. Christopher Ely, once a footman at Buckingham Palace, and Brooke Astor's longtime butler, was appointed cleaner-in-chief. Mr. Ely is a man who approaches what the professionals call household management with the range and depth of an Oxford don. Although he is working on his memoirs (he described his book as a room-by-room primer with anecdotes from his years in service), he was happy enough to put his writing aside for an afternoon. His collaborator was Carol Johnson, a dancer and fitness instructor who develops classes at Crunch NYC, including those based on Broadway musicals like "Legally Blonde" and "Rock of Ages."

Mr. Ely arrived first, beautifully dressed in dark gray wool pants, a black suit coat and a crisp white shirt with silver cuff links. He cleans house in a white shirt? "I know how to clean it," he countered, meaning the shirt. When Ms. Johnson appeared (in black spandex and a ruffly white chiffon blouse, which she switched out for a Crunch T-shirt), theory, method and materials were discussed.

"If you're dreading the laundry," Ms. Johnson said, "why not create a space where it's actually fun to do by putting on some music?" If fitness is defined by cardio health, she added, it will be a challenge to create housework that leaves you slightly out of breath. "I'm thinking interval training," she said. As it happens, one trend in exercise has been workouts that are inspired by real-world chores, or what Rob Morea, a high-end Manhattan trainer, described the other day as "mimicking hard labor activities." In his NoHo studio, Mr. Morea has clients simulate the actions of construction workers hefting cement bags over their shoulders (Mr. Morea uses sand bags) or pushing a wheelbarrow or chopping wood.

Mr. Ely averred that service — extreme housekeeping — is physically demanding, with sore feet and bad knees the least of its debilitating byproducts. Mr. Ely still suffers from an injury he incurred while carrying a poodle to its mistress over icy front steps in Washington When the inevitable occurred, and Mr. Ely wiped out, he threw the dog to his employer before falling hard on his backside. And the right equipment matters: After two weeks' employ in an Upper East Side penthouse, he was handed a pair of Reeboks by his new boss, the better to withstand the apartment's wall-to-wall granite floors. (For cleaning, Mr. Ely wears slippers, deck shoes or socks.)

Mr. Ely, whose talents and expertise are wide-ranging (he can stock a wine cellar, do the flowers, set a silver service, iron like a maestro and clean gutters, as he did once or twice at Holly Hill, Mrs. Astor's Westchester estate), is a minimalist when it comes to materials. He favors any simple dish detergent as a multipurpose cleaner, along with a little vinegar, for glass, and not much else. "Dish detergent is designed for cutting grease; there's nothing better," he said. He's anti-ammonia, anti-bleach. He said bleach destroys fabric, particularly anything with elastic in it. "Knickers and bleach are a terrible combination," he said. "I had a boss who thought he had skin cancer. His entire trunk had turned red and itchy." It seems his underpants were being washed in bleach. (Collective wince.) "It's horrible stuff."

As for tools, he likes a cobweb cleaner — this reporter had bought Oxo's extendable duster, which has a fluffy orange cotton duster that snaps onto a sort of wand, but Mr. Ely prefers the kind that looks like a round chimney brush. (If you live in a house, he also suggests leaving the cobwebs by the front and back doors, so the spiders can eat any mosquitoes coming or going.) Choose a mop with microfiber fronds (he suggested the O Cedar brand) because it dries quickly and doesn't smell. And a sturdy vacuum. Also, stacks of microfiber cloths or a terry cloth towel ripped up.

But first, to stretch. Ms. Johnson took hold of this reporter's Bona floor mop (it's like a Swiffer, but with a reusable washcloth) and Mr. Ely followed along with an old-fashioned string mop. Though Mr. Ely has a kind of loose-limbed elegance, he is not exactly limber. He grimaced as he parroted Ms. Johnson, who used her mop as Gene Kelly did his umbrella, stretching her arms overhead, one by one, twisting from side to side, sucking in her stomach, rising up on tip toes. (Mr. Ely said his old poodle-hurling injury was kicking in.) Ms. Johnson adjusted his chin — "You're going to hurt yourself if you keep sticking your neck out," she warned — and Mr. Ely raised a black-socked foot napped with cat hair and chastised this reporter: "Would you look at that?" (The cat had vanished early on, but his "debris," as Mr. Ely put it, was still very much in evidence. The reporter hung her head. Did she know that cat spit is toxic? Mr. Ely wondered.)

"We're warming up the spine," said Ms. Johnson. "Squeeze your abdominals."

Mr. Ely looked worried: "I don't think I have abdominals!"

MR. ELY'S technique is to clean a room from top to bottom. That means he begins with the cobweb cleaner, wafting it along ceiling corners, moldings, soffits and, uh, the top of the fridge (major dust harvest there). His form was pretty, like a serve by Roger Federer, if not exactly aerobic. For Mr. Ely kept stopping to lecture this reporter — on condensation; on the basic principles of heat transfer and why one needs to vacuum the refrigerator coils; on the movement of moist air in a kitchen; on floor care, which involved a long story about a Belgian monastery whose inhabitants never washed the kitchen floor; on how to dust the halogen spot lights (use a cotton cloth, not a microfiber one, and make sure the lights are off, and cool).  "I do rabbit on, don't I?" he said. Ms. Johnson gamely hustled him along, noting that anytime you raise your arms over your head you can raise your heart rate. "What about a balance exercise?" she cajoled, executing a neat series of leg lifts. "That's good for the butler's booty!"

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Home Tech: Devices to Monitor Physical Activity and Food Intake

STEP LIVELY Fitbit One pedometer clips onto your belt or pocket to record activity.

WHEN I received the results of a routine cholesterol test this summer, I was certain there had been some kind of mistake. I'm young, unstressed and healthy, or so I imagined. I work out, too, and most impartial observers — and some partial ones — would describe me as lean. Plus, I eat a nutritious diet, I swear. So why did my LDL levels surpass my I.Q. — or, for that matter, Einstein's?

The facts were stark: My genes predisposed me to metabolic syndrome, my doctor told me. Like my forebears, I was on a fast path to heart disease and diabetes. My doctor ordered me to reduce my carbs and come up with a more stringent exercise plan. I've rarely monitored what I eat and how much exercise I get. I had no idea how to go about the logistics of it. How would I count my carbs? How would I track my fitness routine?

Of course, there are apps for that. I set out to scour the market for devices and programs to help me and any family member who wished to join me in my low-carb adventure improve our health. I found two kinds of technologies: fitness trackers to monitor physical activity, and P.C. and smartphone apps to track diet. I spent weeks testing several of them. And while I found a few to be quite helpful, they were all just short of fantastic.

I tried four high-end fitness gadgets: Nike's FuelBand ($149), the Fitbit One ($99.95), Jawbone's Up ($129.99) and the BodyMedia FIT wireless armband ($149). I also threw in a plain-Jane pedometer, the Omron HJ-720ITC, which I found for $31 at many stores online.

All of these devices work in a similar way. You attach them to your person (the FuelBand and Up fit around your wrist, the FIT goes around your upper arm, and the Fitbit and Omron pedometer can be placed in a pocket or clipped to your belt). Then, as you move, the devices measure your activity.

Unfortunately each device had major drawbacks. Even though I had gotten the proper size, I found that the Up and the FuelBand did not fit well around my wrist. They tapped against my desk while I typed, and they slid about uncomfortably when I washed the dishes. (They are both water-resistant.) BodyMedia's FIT, meanwhile, is about the size of a man's large wristwatch. Positioned directly against the skin around the upper arm, it is ungainly — I found it distracting when I was in a short-sleeve workout shirt, and strange-looking under a nice button-down shirt.

The pedometer and the Fitbit were easier to handle; I hardly noticed them crammed with my keys and phone in my pocket. On the other hand, because they are not wearable, I often forgot them on my bedside table, where they did no good.

Still, among these vast offerings, I found the Fitbit and the cheap Omron to be best. The Fitbit is an unobtrusive slab of plastic about the size of a U.S.B. thumb drive. Its software — which is available for Macs and Windows P.C.'s, as well as iOS and Android devices — is simple to learn and offers plenty of graphs and stats to track your progress. The most useful is a graph of your activity over the course of the day: you can see how many calories you burned while at work and alter your behavior accordingly. Maybe go for a brief walk after lunch?

(I was a big fan of Jawbone's Up software, too, but I ultimately found it too limited: It works only on Apple's iOS devices; the company has not yet made versions for P.C.'s or Android devices.)

The best thing about the Fitbit is its wireless syncing capability. It comes with a tiny receiver that plugs into your computer's U.S.B. port; whenever your Fitbit is near your machine, it sends its data over the air, no physical docking required. It also syncs directly to your phone over Bluetooth. (You do have to plug your Fitbit in to charge it, but only rarely — you can go more than a week between charges.)

The Omron, by comparison, does not do wireless syncing, and its optional P.C. software is pretty basic. But paucity is its beauty. No setup is required. Just turn it on and leave it in your pocket. At the end of the day, peek at its screen — in large, readable type, it shows a single stat: how many steps you have walked that day. The Omron does not promise the world, but it delivers enough information to keep you healthy.

While all of these devices made it easy to track my activity, they were of little help in monitoring my diet. The Up, Fitbit and BodyMedia FIT include food-logging options in their companion software, but I found them all to be a little slow. The problem with tracking food is that you eat a lot of it, so you need something that will make quick work of adding the many items you have consumed throughout the day. Ideally, the software would let you add multiple items with a single action, would remember what you eat repeatedly and would be connected to a vast library of foodstuffs — so that when you told it that you ate, say, a slice of meatloaf from a Cook's Illustrated recipe, it could instantly calculate your plate's nutritional information.

I tried a few programs that promised to be so savvy, including FitDay and Lose It! But there was one that ranked far above the rest: My Fitness Pal, a free calorie-counting app that runs on the Web as well as iOS devices, Androids, the BlackBerry and Windows Phone. My Fitness Pal did exactly what I describe above: It let me add many foods at a time, and remembered my most frequent consumables so that I could add them with a single tap every day. I also loved My Fitness Pal's bar code scanner. Point your smartphone's camera at the U.P.C. symbol of that peanut butter you are slathering on that piece of bread and the app instantly understands what you are eating.

But My Fitness Pal's killer feature is its enormous database. The app claims to have knowledge of more than a million food items, from apple strudel to zucchini walnut bread. In my tests, I found it almost creepily comprehensive. It had caloric info on that Cook's Illustrated meatloaf, as well as a flounder recipe I made from Bon Appétit, and pretty much anything you could ever buy in a grocery and even many restaurants. If it does not have an item, My Fitness Pal allows you to enter your own recipe; for example, you can type in the ingredients of your mom's apple pie, and it will figure out how many inches a slice will add to your waist.

Combine all these features and you get an app that makes dieting less of a drag. With My Fitness Pal, I am able to log an entire day's meals in just a minute or two. I do yearn for the time when some kind of sensor will automatically track my intake. But that day is not imminent. For now, tracking your diet with My Fitness Pal is the next best thing to eating any old thing you want.

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