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Sign-Ups Surge in New York State’s Health Exchange

Written By Unknown on Selasa, 31 Desember 2013 | 13.57

The burst of interest in New York continued even after the deadline, with enrollments rising to 241,522 as of Monday, officials said.

Of those enrollments, 175,146 are in private commercial insurance plans, and 66,376 are in Medicaid, the government insurance program for the poor, which has spurred enrollment by raising its income limit.

Enrollment in the exchanges remains open through March 31. According to federal rules, individuals who apply by the 15th of the month will have insurance coverage on the first day of the following month, but the original Dec. 15 deadline for Jan. 1 coverage was extended because of early troubles on the website of the federal health exchange.

About 75 percent of those enrolling in individual plans on the New York exchange qualify for a subsidy to reduce the cost of coverage.

New York has surpassed the goal set by the federal government of 102,500 sign-ups by Dec. 31.

The federal goal for the March 31 enrollment deadline is 218,000 sign-ups for private insurance, as set forward in a September memo from the Centers for Medicaid and Medicare.

The state set a goal of 1.1 million enrollments by the end of 2016, and said it is on track to meet that goal.

Nationally, enrollment is running behind the 3.3 million for December and 7 million for March targeted in the September memo. After struggling with technical glitches, the federal exchange enrolled more than 975,000 people in private insurance in December alone, bringing the total to 1.1 million since it opened on Oct. 1, federal officials said on Monday.

In Connecticut, 34,295 people had enrolled in private plans through the state's health insurance exchange, Access Health CT, as of Dec. 23, state officials said.

The exchange had enrolled about 1,000 more people than the goal set for the state through March, becoming the first state, officials said, to exceed the goals set out in the September memo.


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The Week: Unsettling News on Knee Surgery, and a Striking Neanderthal Gene

"Houston, you've got yourself a new pump module," Col. Michael S. Hopkins said last Tuesday after some maintenance on the International Space Station. Repairs to the cooling system were needed after a valve malfunctioned, forcing astronauts to dim the lights and curtail operations. "It's like Christmas morning, opening up a little present here," the astronaut Richard A. Mastracchio said.

Developments

Orthopedics

Doubts About a Knee Operation

Arthroscopic knee surgery is no more effective than fake operations for people with a certain kind of injury, according to an unusual study from Finland. People with a torn meniscus (the crescent-shaped cartilage that helps cushion and stabilize knees) were split into groups: One was given surgery, the other only anesthesia and incisions. A year later, most patients in each group said they felt better and would have the procedure again.

The study does not imply the surgery never helps, the authors said, but adds to a body of research that suggests it should be aimed at a narrower subset of patients.

Genetics

An Ancient Link for Diabetes

Researchers have identified gene mutations that may explain why Latinos are almost twice as likely to develop Type 2 diabetes as Caucasians and African-Americans. And in a twist, the quirk can be traced to Neanderthals.

While trying to explain the high rate of Type 2 diabetes among Latinos, an international team of scientists happened on an ancient gene, most likely involved in fat metabolism. Having mutations in that gene raises a person's risk by about 20 percent; having two copies, one from each parent, raises it by 40 percent.

"As far as I know, this is the first time a version of a gene from Neanderthal has been connected to a modern-day disease," David Altshuler, a geneticist at Harvard and an author of the study, told NPR.

Energy

A Plant Fuels Energy Hopes

A company in San Diego says it has cultivated hybrid strains of a plant that could produce enough biofuel to compete with energy sources like petroleum. The plant, jatropha, whose seeds produce a high-quality oil that can be refined into low-carbon fuel, was once dismissed because it produced too few seeds. But thanks to advances in molecular genetics and DNA sequencing, the start-up SGB domesticated the plant in a few years, rather than decades.

The company is also working to identify traits that make certain strains of the plant resistant to heat or cold. If such traits could be identified in cash crops like corn and soybeans, the knowledge could be valuable as climate change accelerates.

Psychology

For Anxiety, Don't Keep Calm

Feeling nervous? Don't bother calming down. You're better off getting excited, according to a new study from Harvard Business School.

Participants in several anxiety-inducing experiments consistently performed better when prompted to get excited rather than to relax, the study found. For example, people told to say "I am excited" before delivering a public speech gave longer, more competent presentations and appeared more relaxed than speakers told to say "I am calm." The shift from anxiety to excitement may be eased by the fact that both are highly aroused states, suggested the author of the study, published in The Journal of Experimental Psychology: General.

Coming Up

Technology

Dry Cleaning Challenge

Can you build a washing machine that uses no liquid, creates no wrinkles and doesn't damage clothes? To win $20,000 from the "open innovation" firm InnoCentive, you don't have to.

The company, which builds inventions from crowdsourced ideas, is seeking proposals for better clothes-washing techniques — no working prototype needed — for its Future Clothes Washing Technology challenge. The deadline is Jan. 11, but be warned: The winner must surrender intellectual property rights. So maybe give them your second-best idea.


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Social Media as a Megaphone to Pressure the Food Industry

Brendan Bannon for The New York Times

Renee Shutters with her son Trenton. She omitted all foods containing petroleum-based dyes from her son's diet a few years ago.

Renee Shutters has long worried that food dyes — used in candy like blue M&M's — were hurting her son, Trenton.

Brendan Bannon for The New York Times

Trenton Shutters eating candy that has none of the artificial dyes that make him ill.

She testified before the Food and Drug Administration, but nothing happened. It wasn't until she went online, using a petition with the help of the Center for Science in the Public Interest, that her pleas to remove artificial dyes from food seemed to be heard.

Mars, the candy's maker, is now hinting that it may soon replace at least one of the dyes with an alternative derived from seaweed.

"I've really thought about calling them," Ms. Shutters said about Mars. "I'm not trying to be this horrible person. What I'm really thinking is that this is an opportunity for their company to lead what would be an awesome publicity coup by taking these dyes out of their products."

While the F.D.A. continues to allow certain dyes to be used in foods, deeming them safe, parents and advocacy groups have been using websites and social media as powerful megaphones to force titans of the food industry to reconsider the ingredients in their foods and the labeling and processing of their products. In several instances in the last year or so, major food companies and fast-food chains have shifted to coloring derived from spices or other plant-based sources, or changed or omitted certain labels from packaging.

Matthew Egol, a partner at Booz & Company, the consulting firm, said that while food companies had benefited from social media to gain rapid insight into trends, data on what products to introduce and which words to use in marketing, they also had been the target of complaints that sometimes become magnified in an online environment.

Mr. Egol said companies were approaching the negative feedback they get with new tools that help them assess the risks posed by consumer criticism. "Instead of relying on a P.R. firm, you have analytical tools to quantify how big an issue it is and how rapidly it's spreading and how influential the people hollering are," he said. "Then you can make a decision about how to respond. It happens much more quickly."

From Cargill's decision to label packages of its ground beef that contain "pink slime," or what the industry prefers to call finely textured meat, to PepsiCo's decision to replace brominated vegetable oil in Gatorade with a natural additive at the behest of a teenager, corporations are increasingly capitulating to consumer demands.

Companies are reluctant to admit a direct connection between the crusades of consumers like Ms. Shutters or Vani Hari, a blogger known as the Food Babe, and their decisions to tweak products, but the link seems clear. More than 140,000 people have signed Ms. Shutters's petition on petroleum-based food dyes, and dozens have commented on Ms. Hari's posts about some of the ingredients in items on Chick-fil-A's menu.

"We've always tried to be a customer-focused organization," said David B. Farmer, vice president for product strategy and development at Chick-fil-A. "What has clearly changed is some of the channels of communications, which wasn't a factor in the past like it is today. We've had to adapt to that."

Two years ago, Ms. Hari marveled in a blog post about the nearly 100 ingredients in a Chick-fil-A chicken sandwich and took issue with some of them, like MSG, artificial colors and TBHQ, or tertiary butylhydroquinone, which is used as a preservative in many foods.

"TBHQ is a derivative of butane," she said in a telephone interview. "The F.D.A. says TBHQ cannot exceed 0.02 percent of fats and oils in a product, but consumers who are eating a sandwich that has it plus French fries and other things that also have it in a single meal may be getting more than that." She followed that post with another, offering a recipe her readers could use to make a chicken sandwich that is a pretty fair imitation of Chick-fil-A's — but with only 13 ingredients, none of them artificial.

Chick-fil-A eventually responded, inviting Ms. Hari in October 2012 to spend a day at its headquarters in Atlanta, where she discussed her concern about some ingredients as well as larger issues like the use of chicken from animals whose feed contains antibiotics and the potential for labeling products that have genetically engineered components.


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Second Official to Leave After Health Site Trouble

WASHINGTON — The No. 2 official at the Centers for Medicare and Medicaid Services, who supervised the troubled rollout of President Obama's health care law, is retiring, administration officials said Monday.

The official, Michelle Snyder, is the agency's chief operating officer. She is the second administration official to depart since problems at the website, HealthCare.gov, frustrated millions of people trying to buy insurance and caused political embarrassment to President Obama.

Ms. Snyder is in charge of the Medicare agency's day-to-day activities and the allocation of resources, including budget and personnel. Technology experts who built the website for the federal insurance exchange reported to her, and she has been actively involved in the effort to fix the site's problems.

Ms. Snyder's departure follows that of the agency's chief information officer, Tony Trenkle, who stepped down in November to take a job in the private sector.

A former agency official who had predicted Ms. Snyder's departure said Monday: "She had to go. She was responsible for the implementation of Obamacare. She controlled all the resources to get it done. She was in charge of information technology. She controlled personnel and budget."

Asked about Ms. Snyder's plans, an agency official said Monday: "It's her personal decision to retire now."

Ms. Snyder could not be reached for comment.

The move comes after a series of congressional oversight hearings at which Republicans and Democrats sought to determine who should be held accountable for the health law's disastrous rollout. At one such hearing on Oct. 30, Kathleen Sebelius, the secretary of health and human services, was asked who was responsible for developing the federal website, and she named Ms. Snyder. But Ms. Sebelius quickly added: "Michelle Snyder is not responsible for those debacles. Hold me accountable for the debacle. I'm responsible."

Ms. Snyder's official biography states that she was responsible for setting up "new programs and activities required by the Affordable Care Act."

In an email to agency employees, Marilyn B. Tavenner, the administrator of the Medicare agency, said Ms. Snyder was retiring this week "after 41 years of outstanding public service," but made no mention of her role overseeing the development of the federal insurance exchange.

"While we celebrate her distinguished career, we are also sadly saying farewell to a good friend and a key member of the agency's leadership team," Ms. Tavenner wrote. "Michelle's intelligence, experience and formidable work ethic have been indispensable to me and to many of you during her tenure."

Ms. Tavenner said that Ms. Snyder was prepared to step down at the end of 2012, but stayed on the job "at my request to help me with the challenges facing C.M.S. in 2013."

The agency, which runs Medicare and Medicaid in addition to carrying out major provisions of the Affordable Care Act, provides health insurance to more than 100 million people and spends more than $800 billion a year, which is substantially more than the Defense Department budget.

Agency officials said that Ms. Snyder's deputy, Tim Love, would fill her position on an acting basis.

Many of the initial problems with the federal insurance exchange have been fixed, but their effects linger as the agency and insurers try to correct enrollment records.

In late September, Ms. Snyder signed an internal memo acknowledging that security controls for the website had not been fully tested and recommending a plan to reduce the risks.

Representative Darrell Issa, a Republican of California and chairman of the House Committee on Oversight and Government Reform, said: "Documents and interviews indicate Michelle Snyder's involvement in bypassing the recommendation of C.M.S.'s top security expert, who recommended delaying the launch of HealthCare.gov."

However, Patti Unruh, a spokeswoman for the Medicare agency, said: "There have been no successful security attacks on HealthCare.gov, and no person or group has maliciously accessed personally identifiable information."

Ms. Snyder became the first chief financial officer of the agency in the late 1990s. In August, she signed a document approving a contract worth up to $11.6 million for "urgently needed financial management services" at the new insurance exchanges. The document said the government did not have time to allow competitive bidding because it had just discovered that it needed more financial expertise.


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Roughed Up by an Orca? There’s a Code for That

Written By Unknown on Senin, 30 Desember 2013 | 13.57

Bill Starling for The New York Times

"If you don't code properly, you don't get paid," said Dr. W. Jeff Terry, a urologist in Mobile, Ala.

Know someone who drowned from jumping off burning water skis? Well, there's a new medical billing code for that.

Been injured in a spacecraft? There's a new code for that, too.

Roughed up by an Orca whale? It's on the list.

Next fall, a transformation is coming to the arcane world of medical billing. Overnight, virtually the entire health care system — Medicare, Medicaid, private insurers, hospitals, doctors and various middlemen — will switch to a new set of computerized codes used for determining what ailments patients have and how much they and their insurers should pay for a specific treatment.

The changes are unrelated to the Obama administration's new health care law. But given the lurching start of the federal health insurance website, HealthCare.gov, some doctors and health care information technology specialists fear major disruptions to health care delivery if the new coding system — also heavily computer-reliant — isn't put in place properly.

They are pushing for a delay of the scheduled start date of Oct. 1 — or at least more testing beforehand. "If you don't code properly, you don't get paid," said Dr. W. Jeff Terry, a urologist in Mobile, Ala., who is one of those who thinks staffs and computer systems, particularly in small medical practices, will not be ready in time. "It's going to put a lot of doctors out of business."

The new set of codes, known as I.C.D.-10, allows for much greater detail than the existing code, I.C.D.-9, in describing illnesses, injuries and treatment procedures. That could allow for improved tracking of public health threats and trends, and better analysis of the effectiveness of various treatments.

Officials at the Centers for Medicare and Medicaid Services declined to be interviewed about the new codes. But a spokeswoman said that the agency was "committed to implementing I.C.D.-10 on Oct. 1, 2014, and that will not change."

In a letter in November, Kathleen Sebelius, the secretary of health and human services, told Senator Jeff Sessions, Republican of Alabama, that the Medicare and Medicaid officials were working diligently to help doctors get ready. "I.C.D.-10 is foundational for building a modernized health care system that will facilitate broader access to high quality care," she wrote.

Still, the troubles with HealthCare.gov have given new ammunition to those urging a go-slow approach on I.C.D.-10 and have made it harder for the government to stand behind assurances that the transition will go smoothly.

"Failure to appropriately test I.C.D.-10 could result in operational problems similar to what the Department experienced with the rollout of HealthCare.gov," the Medical Group Management Association, which represents the business managers of medical practices, said in a letter this month to Ms. Sebelius.

The Medicare and Medicaid office now appears to be open to greater testing of the system. Also this month, the Obama administration relaxed some deadlines for parts of the health care law, and some deadlines under a separate law for enacting electronic medical records.

"I think that people at C.M.S. understand the stakes with respect to I.C.D.-10 in a heightened way as a result of HealthCare.gov," said Linda E. Fishman, senior vice president for policy at the American Hospital Association.

Dr. John D. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston, said the need to prepare for I.C.D.-10 and the Affordable Care Act and to achieve so-called meaningful use of electronic health records all at once could overwhelm computer staffs throughout the health care industry.

"It's just this collective sum of activities that exceeds the capacity of the system to absorb it simultaneously," he said.

He said his hospital was spending $5 million this year on I.C.D.-10, $7 million for the Affordable Care Act, $2 million on meaningful use, and $3 million to comply with a federal health care privacy law. "Basically, I'm not doing anything but federal regulatory mandates," he said.

I.C.D.-10 has already been postponed by a year. It was originally scheduled to go into effect this past Oct. 1, which would have coincided with the rollout of the insurance website.


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A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs

Ramin Rahimian for The New York Times

Stephen Hinshaw, a University of California, Berkeley, researcher in an influential 1990s study, said skills training should be a priority in A.D.H.D. cases.

Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both?

The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies' campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills.

But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments.

The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews. Less emphasis was placed on improving children's longer-term academic and social skills, which behavioral therapy addresses by teaching children, parents and teachers to create less distracting and more organized learning environments.

Recent papers have also cast doubt on whether medication's benefits last as long as those from therapy.

"There was lost opportunity to give kids the advantage of both and develop more resources in schools to support the child — that value was dismissed," said Dr. Gene Arnold, a child psychiatrist and professor at Ohio State University and one of the principal researchers on the study, known as the Multimodal Treatment Study of Children With A.D.H.D.

Another co-author, Dr. Lily Hechtman of McGill University in Montreal, added: "I hope it didn't do irreparable damage. The people who pay the price in the end is the kids. That's the biggest tragedy in all of this."

A.D.H.D. narrowly trails asthma as the most frequent long-term medical diagnosis in children. More than 1 in 7 children in the United States receive a diagnosis of the disorder by the time they turn 18, according to the Centers for Disease Control and Prevention. At least 70 percent of those are prescribed stimulant medication like Adderall or Concerta because, despite potential side effects like insomnia and appetite suppression, it can quickly mollify symptoms and can cost an insured family less than $200 a year.

Comprehensive behavioral (also called psychosocial) therapy is used far less often to treat children with the disorder largely because it is more time-consuming and expensive. Cost-conscious schools have few aides to help teachers assist the expanding population of children with the diagnosis, which in some communities reaches 20 percent of students. Many insurance plans inadequately cover private or group therapy for families, which can cost $1,000 a year or more.

"Medication helps a person be receptive to learning new skills and behaviors," said Ruth Hughes, a psychologist and the chief executive of the advocacy group Children and Adults With Attention-Deficit/Hyperactivity Disorder. "But those skills and behaviors don't magically appear. They have to be taught."

Accepting no support from the pharmaceutical industry — "to keep it clean," Dr. Arnold said — the National Institute of Mental Health gathered more than a dozen top experts on A.D.H.D. in the mid-1990s to try to identify the best approach. Over 14 months, almost 600 children with the disorder ages 7 to 9 across the United States and Canada received one of four treatments: medication alone, behavioral therapy alone, the combination, or nothing beyond whatever treatments they were already receiving.

The study's primary paper, published in 1999, concluded that medication "was superior to behavioral treatment" by a considerable margin — the first time a major independent study had reached that conclusion. Combining the two, it said, "did not yield significantly greater benefits than medication" alone for symptoms of the disorder.

In what became a simple horse race, medication was ushered into the winner's circle.

"Behavioral therapy alone is not as effective as drugs," ABC's "World News Now" reported. One medical publication said, "Psychosocial interventions of no benefit even when used with medication."

Looking back, some study researchers say several factors in the study's design and presentation to the public disguised the performance of psychosocial therapy, which has allowed many doctors, drug companies and schools to discourage its use.


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The Cancer Divide: India’s Efforts to Aid Poor Worry Drug Makers

NEW DELHI — Alka Kudesia needs an expensive drug to treat her breast cancer, but refuses to tell her children for fear they will take out loans to buy the medicine and spend the rest of their lives in debt.

"We're barely able to afford the treatment I'm already getting," Ms. Kudesia, 48, said with quiet defiance. "My kids are just starting out in life. There is no way I'm going to be a burden to them."

The drug, Herceptin, is one of the most effective treatments for an aggressive form of breast cancer. But in India, at a cost of at least $18,000 for one course of treatment, only a small fraction of the women who need it get it.

The Indian government last year threatened to allow production of less costly, generic versions of Herceptin. Its maker, Roche Holdings of Switzerland, initially resisted, but surrendered its patent rights this year in large measure because it concluded that it would lose a legal contest in Indian courts.

The skirmishing over Herceptin and other cancer medicines is part of a new and critical phase in a struggle to make drugs affordable to the world's poorest people, one that began in earnest more than a decade ago when advocates campaigned successfully to make AIDS medicines accessible to millions of Africans.

"Cancer is the next H.I.V./AIDS issue, and the fight has only begun," said Shamnad Basheer, a professor of law at West Bengal National University of Juridical Sciences in Kolkata.

American trade officials have voiced concerns about India's treatment of drug patents, including its reasons for sometimes overriding them. President Obama discussed the issue this year with Prime Minister Manmohan Singh of India in the Oval Office, administration officials said.

Executives in the international pharmaceutical industry, increasingly dependent on drug sales in emerging markets like India, China and Brazil, contend that India's efforts to cancel patents threaten the global system for discovering cures while doing little to resolve the health challenges most patients here face.

"We are open to discussing what the best way is to bring innovative medicines to patients," said Daniel Grotzky, a spokesman for Roche, which has a large portfolio of cancer medicines. "But a society that wants to develop new medicines and technology must reward innovation through a solid protection of intellectual property."

Some health experts say investing in earlier diagnosis of breast cancer and improved testing, surgery and access to radiation therapy is more important than access to expensive drugs. "Chemotherapy is not the major issue for cancer control in India," said Dr. Richard Sullivan, a professor of cancer policy and global health at King's Health Partners' Integrated Cancer Center in London.

But health advocates say similar arguments were made by the United States government and the pharmaceutical industry as they sought to protect patents on AIDS medicines through much of the 1990s, a stance that former President Bill Clinton has since said he regrets. It would be unfair to delay improving access to cancer drugs until India's broken system for cancer care was fixed, they say. They note that more than twice as many people in India die of cancer than of AIDS.

As the world has made progress against malnutrition and infectious diseases, more people are living into old age and dying of chronic illnesses like heart disease and cancer, which now cause two-thirds of deaths globally. In 2012, there were 14.1 million new cancer cases across the world and 8.2 million cancer deaths, according to the World Health Organization. And the number of breast cancer cases is growing. About 6.3 million women were living with the disease last year.

The rise in the cancer caseload is already a heavy burden on India's hobbled health system. Indian women, while less likely to get breast cancer than those in the United States, are far more likely to die of it. Breast cancer is diagnosed in about 115,000 women here every year, and in 2008 some 54,000 died from it, according to the World Health Organization.

At intersections in New Delhi, women carrying doctors' notes beg for money for their prescribed treatments. India has just 27 dedicated public cancer centers for 1.2 billion people. The government has promised to add an additional 50 in the coming years, but medical experts say even that will be grossly inadequate.

India, which is one of the world's leading producers of generic pharmaceuticals, has long viewed patent rights on medicines skeptically. It has already ruled invalid patents protecting exclusive sales of Novartis's Gleevec, Pfizer's Sutent and Roche's Tarceva, all cancer medicines. In a landmark decision last year, the government agreed that the patent protecting Bayer's Nexavar, also a cancer drug, was valid but overrode it anyway because a generic company promised to lower the price from $4,500 to about $140 per month of treatment.


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Well: With A-Fib Rhythms, Higher Odds of Stroke

When a lean, healthy, physically active person has a stroke, seemingly out of the blue, the cause may well be a heart rhythm abnormality called atrial fibrillation.

Such was the fate of Pamela Bolen of Brooklyn, then 67, who said she collapsed last year at home. Luckily, her husband, Jack, heard her fall, called an ambulance, and within minutes she was at New York Methodist Hospital. There she was given the drug tissue plasminogen activator, or tPA, to dissolve the clot that was blocking circulation in her brain. The treatment spared her lasting disability.

"I had high blood pressure which was completely controlled with medication, but I didn't know I had atrial fibrillation until I had a stroke," Ms. Bolen said in an interview. The condition slows blood flow from the heart and was the likely cause of the clot that resulted in her stroke.

About three million Americans have atrial fibrillation, characterized by multiple irregular electrical signals that cause the heart's upper chambers, the atria, to contract rapidly, without their usual coordination. This sends an erratic signal to the ventricles, the lower chambers that supply blood to the lungs and rest of the body. People with the disorder face a much higher risk of stroke, and most require treatment to prevent this potentially crippling and sometimes fatal consequence.

"As many as one in five or six strokes is due to atrial fibrillation, and in a lot of these people the rhythm disorder was undetected before the stroke," said Dr. Christian T. Ruff, cardiologist at Brigham and Women's Hospital in Boston, who studies new treatments for the disorder.

People with symptomatic A-fib, as it is commonly called, may experience periodic palpitations (a sense that the heart is pounding or fluttering), chest discomfort, shortness of breath, unusual fatigue or dizziness.

A-fib can show up during an electrocardiogram, or EKG, but because the abnormal rhythm may not occur all the time, people suspected of having the condition usually must wear a Holter monitor for days or weeks to obtain a certain diagnosis. This small portable device, connected to electrodes on the chest, continuously records the heart's rhythm and sends the data to a doctor or company for evaluation.

A-fib is more common in men, tall people and the elderly. As the population ages, the incidence is rising; more than 460,000 new cases are diagnosed annually, a number expected to double in the next 25 years. The condition is also becoming more prevalent at any age, experts say, because of a rise in three leading risk factors — high blood pressure, diabetes and obesity.

These conditions can damage the heart's electrical system, Dr. Ruff wrote last year in the journal Circulation. Other risk factors include a prior heart attack, overactive thyroid, sleep apnea, excessive alcohol consumption, abnormal heart valves, lung disease and congenital heart defects.

Researchers at the University of California, San Francisco, reported this month in Annals of Internal Medicine that people with a high rate of premature atrial contractions, which can be detected by a Holter monitor worn for 24 hours, face a significantly increased risk of developing A-fib. Dr. Gregory M. Marcus, the senior author and director of clinical research at U.C.S.F.'s cardiology division, theorized that eradicating these premature contractions with drugs or a procedure that destroys the malfunctioning area of the heart may reduce the risk of the rhythm disorder.

Step 1 in treating A-fib is to identify and correct reversible risk factors. Step 2 — and most important, according to Dr. Ruff — is to prevent blood clots from forming by treating patients with anticoagulants.

The most commonly prescribed and least costly treatment is warfarin, also known by the brand name Coumadin, in use for more than half a century. But while highly effective at reducing the risk of stroke, warfarin is a very tricky drug. It interacts with a number of foods, especially those like spinach and kale that are rich in vitamin K, and other drugs that a patient may have to take.

People metabolize warfarin at different rates, making it necessary to repeatedly check a patient's clotting ability to reduce the risk of excessive bleeding while maintaining an effective anticoagulant level.

Dr. Ruff said that more than half of A-fib patients were either not on an anticoagulant or on an ineffective dose. Fearful of a hemorrhage in the brain, or uncontrolled bleeding in an accident or emergency surgery, doctors may prescribe an amount of warfarin insufficient to prevent a stroke, he said.

This concern has spurred the development of several other anticoagulants that are considerably safer and easier to take, but also far more expensive than the generic warfarin. The Food and Drug Administration has already approved three such medications — apixaban (Eliquis), dabigatran etexilate mesylate (Pradaxa) and rivaroxaban (Xarelto) — and others are being studied.

Patients with A-fib are also often prescribed drugs to normalize the rate and rhythm of the heart's contractions. Ed Goldman, 73, of Manhattan, who was found to have A-fib 17 years ago, takes amiodarone hydrochloride (Cordarone) and verapamil (Calan and other brand names), and said in an interview that he rarely experienced a slight increase in his heart rate.

Sometimes an electrical shock to the heart, called cardioversion, is used to restore a normal rhythm.

For some patients, however, neither medication nor cardioversion is able to maintain normal heart rhythm. An invasive procedure called ablation is needed to knock out the area or areas of the heart sending out errant signals. A catheter is inserted into a vein, usually through a small cut in the groin, and snaked up to the heart. Small electrodes placed in the heart identify malfunctioning areas, which are then destroyed.

Last year, Dr. Sanjiv Narayan, an electrophysiologist at the University of California, San Diego, and co-authors described a way to more accurately identify the electrical "hot spots" in the heart responsible for an abnormal rhythm. Ablating those regions was nearly twice as effective as the standard approach to eliminating atrial fibrillation with ablation, the team reported in The Journal of the American College of Cardiology.

But even when all traces of A-fib are eliminated, Dr. Ruff said, continued treatment with an anticoagulant is needed to guard against stroke. "Once a person has had A-fib, there is an increased risk of stroke even if their heart is in normal rhythm," he said.


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The New Old Age Blog: Medicare to Cover More Mental Health Costs

Written By Unknown on Minggu, 29 Desember 2013 | 13.57

For decades, older adults with depression, anxiety and other psychological conditions have received unequal treatment under Medicare. The program paid a smaller share of the bill for therapy from psychiatrists, psychologists or clinical social workers than it did for medical services. And Medicare imposed strict lifetime limits on stays in psychiatric hospitals, although no such limits applied to medical care received in inpatient facilities.

There was never a good rationale for this disparity, and in 2008 Congress passed the Medicare Improvements for Patients and Providers Act. The law required Medicare to begin covering a larger share of the cost of outpatient mental health services in 2010 and to phase in additional increases over time.

On Jan. 1, that process will be complete, and for the first time since Medicare's creation seniors who seek psychological therapy will be responsible for 20 percent of the bill while Medicare will pay 80 percent, the same percentage it covers for most medical services. (Payment kicks in once someone exhausts an annual deductible — $147 next year.)

In 2008, Medicare covered 50 percent of the cost of psychological treatment. Last year, it covered 65 percent.

The Medicare change follows new regulations issued last month by the administration for the Mental Health Parity and Addiction Equity Act, which expanded the principle of equal treatment for psychological illnesses to all forms health insurance. But that law does not apply to Medicare.

"Hopefully, older adults who previously were unable to afford to see a therapist will now be more likely to do so," said Andrea Callow, a policy lawyer with the Center for Medicare Advocacy.

But parity under Medicare remains incomplete, and hurdles still stand in the way of older adults receiving services. A 190-day lifetime limit on inpatient services at psychiatric hospitals is the most notable example. There is no similar cap on any other inpatient medical services provided through Medicare.

"It's just an arbitrary cap that targets people with serious mental illnesses who need care," Ms. Callow said.

Are mental health services covered under Medicare otherwise on equal footing with medical and surgical services? And do Medicare Advantage plans — private, managed-care-style arrangements that serve more than 14 million elderly people — apply the same sort of controls to mental health that they do to medical and surgical services?

Sadly, no one knows. "There are no analyses of this issue that I'm aware of," said Ron Manderscheid, a leading expert on mental health care and the executive director of the National Association of County Behavioral Health and Developmental Disability Directors.

By far the largest group of Medicare beneficiaries needing mental care have psychological conditions such as minor depression that, while painful, can be treated successfully and are not permanently disabling. But the move toward parity may not help many of them, because the law does little to remedy a lack of access to appropriately trained professionals.

"There are a lot of mental health providers out there, but very few have training to work with older adults," said Dr. Gary Kennedy, director of the division of geriatric psychiatry at Montefiore Medical Center in New York City. And there is little incentive for that to change, because Medicare reimbursement rates are relatively low, given the amount of time providers spend with patients.

A study published this month in JAMA Psychiatry reported an alarming trend: a nearly 20 percent decline in the number of psychiatrists willing to accept new patients covered by Medicare between 2005 and 2010. Just over half of psychiatrists (54.8 percent) reported being willing to take payments from Medicare in 2010, potentially compromising care for the elderly.

What is needed to bring adequate mental health care to more older adults? Kimberly Williams, director of the Geriatric Mental Health Alliance in New York City, suggests that Medicare should pay more to providers who care for psychologically troubled homebound seniors. A wider range of therapists with varying levels of training should be approved to deliver services, she said.

And Medicare should pay for much-needed coordination between primary care doctors and psychiatrists, psychologists or social workers – something that rarely happens at present.

What problems have you observed with Medicare's coverage of mental health? And what kinds of changes do you think are necessary?


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Vaccine Aide Gunned Down in Pakistan

a Majeed/Agence France-Presse — Getty Images

Pakistani rescuers transported a health worker who was injured while on duty for an anti-polio vaccination campaign at a hospital in Peshawar on Saturday.

ISLAMABAD, Pakistan — A health worker supervising a polio vaccination campaign was fatally shot and two others were wounded on Saturday when gunmen opened fire at a hospital in northwestern Pakistan, officials said.

No one immediately took responsibility for the killing, but the Taliban, which accuses the United States of using a drive to eradicate polio in the country as a cover for spying, has threatened the lives of health workers who immunize children.

Pakistani officials said two gunmen riding a motorbike had opened fire at a government hospital in Matni, a suburb of Peshawar, the provincial capital of the restive Khyber-Pakhtunkhwa Province. Zahid Gul, who was overseeing the vaccination campaign, was killed and another man and a woman were wounded in the attack. The gunmen fled.

Saturday's episode was a particular setback to the former cricket star and current opposition leader Imran Khan, whose political party controls Khyber-Pakhtunkhwa.

Mr. Khan this month condemned the attacks on health workers taking part in vaccination efforts. He said that he would personally lead the anti-polio drive and warned that the country risked being quarantined internationally if the attacks continued. Pakistan is one of only a few countries where the polio virus is still rampant.

Mr. Khan has supported peace talks with Taliban militants and opposes the Pakistani military's operations against them in the semiautonomous tribal regions adjoining Khyber-Pakhtunkhwa Province. He also vehemently opposes drone strikes by the United States Central Intelligence Agency and says civilian casualties from the missile strikes fuel more militancy, instead of curbing it. 

The Taliban's resistance to polio vaccination hardened after the raid in May 2011 on Osama bin Laden's compound in northern Pakistan, as revelations surfaced that the C.I.A. had used a Pakistani doctor, Shakil Afridi, to run a vaccination campaign that aided efforts to locate Bin Laden. 

Since then, the Taliban has repeatedly targeted the vaccination campaign.


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Datapoints: Placing Odds on Your Health (and Its Cost)

What is the chance that you will rack up big health care bills in 2014?

For the typical American adult under 65 who does not have health insurance, the total of all health care bills would be $2,700. That's according to calculations by Milliman, an actuarial firm.

The obvious problem is that you can't know in advance if your costs for the year will be typical. If you are unfortunate enough to have a costly medical problem, you could end up with far higher bills. Milliman calculated that 5 percent of the population will incur bills, absent insurance, exceeding $47,300.

Milliman estimated what patients will be billed without insurance, not what is paid to providers. According to Milliman, uninsured patients, who don't have the benefit of insurance negotiators, are billed about 30 percent more than insured patients. The Affordable Care Act requires individuals to purchase insurance, but at what coverage level? If half of Americans without insurance will be billed less than $2,700, as Milliman projects, a healthy person, might do better under a plan with lower premiums but with high deductibles. (They can generally run as high as $5,000 for an individual and $10,000 for a couple.)

Of course, Milliman doesn't know whether you are likely to become sick and to be among the top 5 percent or even the top 20 percent (who are billed more than $13,300). When choosing insurance, consumers need to consider their personal situations — and their stomach for risk.


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Prototype: A Second Wind From an Injured Knee

When Kim Gustafson moved to Vail Valley in Colorado more than a decade ago, he was 54 and had recently retired as an executive in the office-equipment business. But he wasn't ready to stop working. "I'm not the type of person who wanted to play checkers," he says.

Mr. Gustafson is one of a growing number of baby boomers starting businesses later in life — though that was not his original plan. Initially, he worked as a ski instructor. But he found that degenerative arthritis and the wear-and-tear of his rigorous skiing schedule were exacerbating an injury he had sustained several years earlier after falling from a ladder.

Mr. Gustafson sought treatment at the Steadman Clinic, an orthopedic surgery center based in Vail, eventually undergoing five knee surgeries. To continue to teach skiing, he was told, he would need to wear a hard, cumbersome knee brace every time he hit the slopes.

As he grew accustomed to the brace, he began to wonder whether people with less vulnerable joints than his might benefit from a more pliable and comfortable form of knee support — perhaps a pair of tights. To explore this possibility, he turned to a group of biomechanical experts at the Steadman Philippon Research Institute, a branch of the Steadman Clinic.

Coincidentally, the researchers had been contemplating something similar, and they began drawing sketches of nylon and spandex tights embedded with bands of rigid fabric to protect the knees by restoring them to their natural alignment.

Mr. Gustafson and scientists from the institute struck up an unusual agreement: They would develop the tights together, and if the product reached the marketplace, the institute would receive royalties to be applied to future research projects or the hiring of scientists. Within two years, Mr. Gustafson started a company he eventually called Opedix and began selling the biomechanically engineered tights online.

His decision to start a business in his late 50s is far from unusual. A report this year by the Ewing Marion Kauffman Foundation found that late-in-life entrepreneurs — ages 55 to 64 — now comprise 23 percent of new business owners, up from 14 percent in 1996. And the results of a survey released this month by the Pew Research Center showed that baby boomers were less likely to say that job security was "extremely important" to them compared with two younger groups: millennials and members of Generation X — suggesting an inclination toward entrepreneurship.

The trend is partly rooted in a quest for personal fulfillment, says Stewart Friedman, director of the Work/Life Integration Project at the Wharton School of Business at the University of Pennsylvania. "Among boomers, of which I am one, our whole early life in the '60s and '70s was about self-actualization," Mr. Friedman says, adding that many in his generation are finally now revisiting career aspirations that they abandoned years ago.

Age and experience, however, aren't always considered assets in wider entrepreneurial circles, says Elizabeth Isele, founder of Senior Entrepreneurship Works, which runs entrepreneurship training courses for those over 50. She says that many lenders are skeptical of older people's ability to repay loans and that the biggest challenge for this age group is access to capital.

"Part of that is because people haven't heard of senior entrepreneurship," she says.

So far, Mr. Gustafson has self-funded his venture along with his brother, David, who serves as president. But even for older entrepreneurs investing their own money in start-ups, the financial risks of a new venture can be daunting.

Opedix faces several challenges, including the fact that it is competing in a crowded field. "There's a long history of companies trying to come up with technologies to restore normal function to an injured joint or prevent injury to a joint that's at risk," says Bruce Beynnon, director of research at the department of orthopedics and rehabilitation at the University of Vermont's College of Medicine.

Opedix has struggled to differentiate itself from another type of garment that's popular with runners and looks very similar: compression tights. What sets Opedix tights apart, Mr. Gustafson says, are the bands of stiff fabric that descend down the leg from the hips, wrap around the knees and extend to the ankles.

The added complexity confers a higher price: Opedix tights sell for $225 a pair, usually twice the price of compression tights. But to the uneducated eye, the two tights are virtually indistinguishable, which can confuse shoppers. (Earlier this year, Opedix also began selling shorts designed to restore the pelvis's natural alignment; they cost $165.)

One of Mr. Gustafson's strategies for educating potential customers is to put the tights in the hands of physical therapists, trainers, sports instructors and professional athletes who are likely to understand the banding technology — and, he hopes, to spread the word. 

Mr. Gustafson sees an advantage in making a product geared toward the boomer population. The tights could hold wide appeal for the many members of this generation who have benefited from medical advances and plan to stay active into their 70s and 80s. By 2017, the over-50 set will control 70 percent of the disposable income in the United States and is expected to comprise about half of the population, according to data compiled by Nielsen.

Mr. Gustafson says he believes the experience and skills he cultivated in his earlier career, which included tenures at two start-ups, have been a plus in his work at Opedix. For instance, he knew how laborious it would be to develop and test a new product, and he understood the benefits of working in a field he liked.

"I love the ski business," he says. "It's a whole lot more exciting and interesting than office equipment, I'll tell you."


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Well: For Fitness, Intensity Matters

Written By Unknown on Sabtu, 28 Desember 2013 | 13.57

Phys Ed

Gretchen Reynolds on the science of fitness.

This year, exercise science expanded and fine-tuned our understanding of how physical activity affects our brains, joints, hearts, and even genes, beginning before birth and continuing throughout our lifespans, which can be lengthened, it seems, by exercise, especially if we pick up the pace.

This year's fitness news, as a look back through 2013's Phys Ed columns shows, was variously enlightening, validating (if, like me, you never bothered cooling down after a workout anyway), and practical (D.I.Y. concussion testing, anyone?). It was also occasionally deflating, at least if you hoped that barefoot running invariably would reduce the risk of injury, gentle exercise would quash your appetite, or training for a marathon would automatically exempt you from being a couch potato.

But the lesson that seemed to emerge most persistently from the fitness-related studies published this year was that intensity matters, especially if you wish to complete your workout quickly. The most popular column that I wrote this year, by a wide margin, detailed "The Scientific 7-Minute Workout," a concept that appealed, I have no doubt, because the time commitment was so slight. But the vigor required was considerable; to gain health benefits from those seven minutes, you needed to maintain a thumping heart rate and spray sweat droplets around the room.

Almost halving the time spent exercising was also effective, a later and likewise popular column showed. In that study, out-of-shape volunteers who ran on a treadmill for a mere four minutes three times a week for 10 weeks raised their maximal oxygen uptake, or endurance capacity, by about 10 percent and significantly improved their blood sugar control and blood pressure profiles.

The results undercut a common excuse for skipping workouts. "One of the main reasons people give" for not exercising is that they don't have time, said Arnt Erik Tjonna, a postdoctoral fellow at the Norwegian University of Science and Technology, who led the study.

But they emphasize, too, the potency of hard effort. The volunteers ran at 90 percent of their maximum aerobic capacity for those four minutes, a level that is frankly unpleasant. But, in four minutes, they were done.

There were other hints throughout the year that exerting yourself vigorously may have unique payoffs, compared with less strenuous exercise. In a study that I wrote about a few weeks ago, for instance, people who walked briskly, at a pace of 17 minutes per mile or less, generally lived longer than those men and women who strolled during their walks, at a pace of 20 minutes per mile or slower, although the study was not designed to determine why the intensity of the exercise mattered.

And in September, I wrote about two studies showing that strenuous exercise blunted volunteers' appetites after workouts more effectively than longer sessions of easy exercise did. The studies were small, though, and involved only young-ish, overweight men. Whether the results are applicable to other people, including those of us who are not male, requires additional experiments. I expect to be covering the results in 2014.

Meanwhile, other studies that I wrote about this year emphasize how pervasive the impacts of any amount and type of exercise can be. One of my favorite experiments of 2013 detailed how rodents that ran on wheels for several weeks responded far better to stressful situations than sedentary animals, in large part, it seems, because their brains contained specialized cells that dampened unnecessary anxiety. At a molecular level, the runners' brains were calmer than those of their sedentary lab mates.

But perhaps the most remarkable studies of the year examined the effect of exercise on our DNA. In several experiments, which I wrote about in July, scientists found that exercise reshapes genes in human cells, changing how atoms attach to the outside of individual portions of our DNA. As a result, I wrote, the behavior of the gene changes. In one of the studies, researchers found that six months of moderate exercise profoundly remodeled genes related to the risk for diabetes and heart disease. But for those of us too impatient to wait six months, the other study found that a single session of bike riding altered genes in volunteers' muscle cells. The effects showed up whether the pedaling was easy or strenuous, but, in line with so much of this year's exercise science, were more pronounced when cyclists rode vigorously.

Still, for everyone, as one of the scientists told me, the studies are an important and inspirational reminder of "the robust effect exercise can have on the human body, even at the level of our DNA."


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Well: A Nurse Gains Fame in the Days of Polio

In the years after World War II, polls perennially showed that Eleanor Roosevelt was the woman whom Americans admired most in the world. But in a 1951 Gallup poll, that distinction went to an Australian nurse, Elizabeth Kenny, popularly known as Sister Kenny.

Today, she is largely forgotten. But thanks to "Polio Wars: Sister Kenny and the Golden Age of American Medicine," a new biography by Naomi Rogers, a Yale University medical historian, readers can learn why she gained such fame. And while Ms. Kenny's work was mostly in polio, which has nearly been eradicated, her emphasis on the care of individual patients and close bedside observation could not be more relevant in an era dominated by randomized controlled trials.

Ms. Kenny was an unlikely celebrity. Born in Australia in 1880, she became a "bush nurse," serving a largely rural population. It was World War I that opened up her vistas; she worked as a British army nurse on troop ships, reaching the rank of lieutenant and earning the honorific title "Sister" for her service. Contrary to popular belief, Ms. Kenny was not a nun.

In Australia and around the world, the rates of polio were rising in the 1920s and '30s. Although only one in 200 cases damaged nerves in the spinal cord, the viral disease was dreaded. Most of its victims were children and young adults. Those severely affected first developed fever and body aches, which progressed to varying degrees of paralysis in hours to days. The most advanced cases affected the brain stem and respiratory muscles; those patients required iron lungs, an early version of the respirator, to breathe. Five percent to 10 percent of paralyzed polio patients died and as many as half had persistent partial paralysis.

Ms. Kenny had encountered polio patients before the war and made a crucial observation: Heated woolen cloths and muscle exercises seemed to relieve patients' pain and contractures, or muscle shortening, which she thought resulted from muscle spasm in addition to nerve damage. Plus, Ms. Kenny believed that patients needed to play an active role in their recovery, learning the names of affected muscles and how they worked. These interventions flew in the face of traditional polio treatment, which emphasized using splints to immobilize paralyzed limbs. Doctors believed that rest protected the damaged limbs and that persistent contractures could be treated by surgery.

Ms. Kenny's apparent successes led her to travel throughout Australia and England to demonstrate her techniques. But it was in the United States where she achieved her greatest fame and lived out most of her life. Based in Minneapolis, she opened the Elizabeth Kenny Clinic to treat polio patients from across the country. A 1946 Hollywood movie, "Sister Kenny," starred Rosalind Russell.

Ms. Kenny attracted passionate support from patients and families who believed that her ministrations had restored their strength and mobility. In her 1943 autobiography, "And They Shall Walk," Ms. Kenny quoted one of her young patients as saying: "I want them rags that wells my legs." The National Foundation for Infantile Paralysis, later known as the March of Dimes, provided financial support for her efforts.

But Ms. Kenny was criticized as well. Physicians and physical therapists who relied on immobilization believed there was no scientific basis for her therapy. They pointed to other claims made by Ms. Kenny, notably that massaged muscles might send out nerve fibers to help heal more severely damaged muscles, as evidence that she did not understand the physiology of the disease. Those critics called for randomized clinical trials, which were never done, to ascertain whether Ms. Kenny's system had value.

As Dr. Rogers shows, Ms. Kenny irked the American Medical Association and the rest of the medical establishment for reasons beyond her medical theories. First, she was a nurse questioning the authority of physicians. Second, she was a woman — and a very outspoken one fond of dramatic hats and corsages — challenging the overwhelmingly male medical profession. Third, as Dr. Rogers admits, Ms. Kenny was prone to embellish both her own story and those of her patients.

But it was Ms. Kenny's fierce adherence to what she observed at the bedside that holds the most relevance today. She thought that she could see and feel muscles improve as she ministered to her patients. She saw her patients recover at rates that she believed were much higher than those treated conservatively. Who needed clinical trials when the proof was right in front of her? According to Ms. Kenny, Dr. Rogers writes, "the empirical evidence embodied in her patients' recovery proved her therapy worked."

Was Ms. Kenny correct? Yes and no. Her emphasis on early mobilization has come to be a mainstay of not only polio treatment but of physical therapy more broadly. Yet some of her claims about the nature of the disease and how patients recovered proved wrong. The successful development of a polio vaccine in the 1950s made these debates much less pressing.

But perhaps Ms. Kenny's greatest legacy, in an era of evidence-based medicine and reliance on large-scale clinical trials involving thousands of patients, is that keen clinical observation — what the physician and writer Abraham Verghese has termed "bedside medicine"— still has its place. Her opponents, Ms. Kenny once wrote, "have eyes, but they see not."


Barron H. Lerner, a professor of medicine and population health at New York University School of Medicine, is the author of five books, including the forthcoming "The Good Doctor: A Father, A Son and the Evolution of Medical Ethics."


This post has been revised to reflect the following correction:

Correction: December 27, 2013

An earlier version of this post misstated the year Elizabeth Kenny won a Gallup poll and what the poll measured. She won a poll in 1951, not 1952, as the woman Americans admired most, not America's most admired woman.


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Well: Adding Citrus to Salads and Desserts

I always stuff an orange or a tangerine into the toe of my son's Christmas stocking. He is more interested in the chocolate in his stocking and I usually end up eating his orange, but I'll never forego this European tradition that dates from a time when citrus was a rare treat. We in the United States take our oranges and grapefruit for granted year round, but citrus really does have a season — winter — and it is welcome at this time of year, when we need all the vitamin C we can get.

My idea of a perfect Christmas gift is a big box of ruby red grapefruit. I have had the great fortune to live in two major citrus producing areas in my life, South Texas and now Los Angeles. I buy Valencia oranges by the bag and juice them until the end of their season, when navels come in (around now). I always have a big bowl of clementines on my annual New Year's Day buffet table, and they always disappear.

Around this time of year I start thinking about going beyond juice and unadorned fresh citrus. This year I have been adding oranges to salads, making vinaigrettes with grapefruit juice and experimenting with new desserts. The Culinary Institute of America is on the same wavelength: their latest Prochef newsletter carried the headline "The Professional Chef Discovers Specialty Citrus."

Beet, Orange and Arugula Salad: A colorful salad with sweet and sharp flavors.


Grapefruit and Navel Orange Gratin: This winter dessert is adapted from a recipe from the French chef Olympe Versini's cookbook, "Olympe."


Fennel and Orange Salad With Black Olives on a Bed of Couscous: A salad, modeled on a traditional North African one, that is great for buffets.


Gingered Winter Fruit Ambrosia: An old fashioned fruit ambrosia with a gingery kick.


Grapefruit Vinaigrette With Greens or Broccoli: This vinaigrette works with a variety of greens, like chard, beet greens or broccoli.



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The New Old Age Blog: Medicare to Cover More Mental Health Costs

For decades, older adults with depression, anxiety and other psychological conditions have received unequal treatment under Medicare. The program paid a smaller share of the bill for therapy from psychiatrists, psychologists or clinical social workers than it did for medical services. And Medicare imposed strict lifetime limits on stays in psychiatric hospitals, although no such limits applied to medical care received in inpatient facilities.

There was never a good rationale for this disparity, and in 2008 Congress passed the Medicare Improvements for Patients and Providers Act. The law required Medicare to begin covering a larger share of the cost of outpatient mental health services in 2010 and to phase in additional increases over time.

On Jan. 1, that process will be complete, and for the first time since Medicare's creation seniors who seek psychological therapy will be responsible for 20 percent of the bill while Medicare will pay 80 percent, the same percentage it covers for most medical services. (Payment kicks in once someone exhausts an annual deductible — $147 next year.)

In 2008, Medicare covered 50 percent of the cost of psychological treatment. Last year, it covered 65 percent.

The Medicare change follows new regulations issued last month by the administration for the Mental Health Parity and Addiction Equity Act, which expanded the principle of equal treatment for psychological illnesses to all forms health insurance. But that law does not apply to Medicare.

"Hopefully, older adults who previously were unable to afford to see a therapist will now be more likely to do so," said Andrea Callow, a policy lawyer with the Center for Medicare Advocacy.

But parity under Medicare remains incomplete, and hurdles still stand in the way of older adults receiving services. A 190-day lifetime limit on inpatient services at psychiatric hospitals is the most notable example. There is no similar cap on any other inpatient medical services provided through Medicare.

"It's just an arbitrary cap that targets people with serious mental illnesses who need care," Ms. Callow said.

Are mental health services covered under Medicare otherwise on equal footing with medical and surgical services? And do Medicare Advantage plans — private, managed-care-style arrangements that serve more than 14 million elderly people — apply the same sort of controls to mental health that they do to medical and surgical services?

Sadly, no one knows. "There are no analyses of this issue that I'm aware of," said Ron Manderscheid, a leading expert on mental health care and the executive director of the National Association of County Behavioral Health and Developmental Disability Directors.

By far the largest group of Medicare beneficiaries needing mental care have psychological conditions such as minor depression that, while painful, can be treated successfully and are not permanently disabling. But the move toward parity may not help many of them, because the law does little to remedy a lack of access to appropriately trained professionals.

"There are a lot of mental health providers out there, but very few have training to work with older adults," said Dr. Gary Kennedy, director of the division of geriatric psychiatry at Montefiore Medical Center in New York City. And there is little incentive for that to change, because Medicare reimbursement rates are relatively low, given the amount of time providers spend with patients.

A study published this month in JAMA Psychiatry reported an alarming trend: a nearly 20 percent decline in the number of psychiatrists willing to accept new patients covered by Medicare between 2005 and 2010. Just over half of psychiatrists (54.8 percent) reported being willing to take payments from Medicare in 2010, potentially compromising care for the elderly.

What is needed to bring adequate mental health care to more older adults? Kimberly Williams, director of the Geriatric Mental Health Alliance in New York City, suggests that Medicare should pay more to providers who care for psychologically troubled homebound seniors. A wider range of therapists with varying levels of training should be approved to deliver services, she said.

And Medicare should pay for much-needed coordination between primary care doctors and psychiatrists, psychologists or social workers – something that rarely happens at present.

What problems have you observed with Medicare's coverage of mental health? And what kinds of changes do you think are necessary?


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Personal Health: How CPR Can Save a Life

Written By Unknown on Jumat, 27 Desember 2013 | 13.57

Millions of people have been trained in CPR in recent decades, yet when people who aren't in hospitals collapse from a sudden cardiac arrest, relatively few bystanders attempt resuscitation. Only one-fourth to one-third of those who might be helped by CPR receive it before paramedics arrive.

With so many people trained, why isn't bystander CPR done more often?

For one thing, people forget what to do: the panic that may ensue is not conducive to accurate recall. Even those with medical training often can't remember the steps just a few months after learning them. Rather than make a mistake, some bystanders simply do nothing beyond calling 911, even though emergency dispatchers often tell callers how to perform CPR.

Then there is the yuck factor: performing mouth-to-mouth resuscitation on a stranger. So pervasive is the feeling of reluctance that researchers decided to study whether rescue breathing is really necessary.

Two major studies, published in The New England Journal of Medicine in July 2010, clearly demonstrated that chest compressions alone were as good or even better than combining them with rescue breathing. In both studies, one conducted in Washington State and London and the other in Sweden, a slightly higher percentage of people who received only bystander chest compressions survived to be discharged from the hospital with good brain function.

When a person collapses suddenly because the heart's electrical function goes awry, it turned out, there is often enough air in the lungs to sustain heart and brain function for a few minutes, as long as blood is pumped continuously to those vital organs. In addition, some people gasp while in cardiac arrest, which can bring more oxygen into the lungs. Indeed, the studies strongly suggested that interrupting chest compressions to administer rescue breaths actually diminishes the effectiveness of CPR in these patients.

Based in part on these findings, the American Heart Association has removed rescue breathing from bystander CPR guidelines for teenagers and adults in sudden cardiac arrest.

About 900 Americans die every day because of sudden cardiac arrest. Nearly 383,000 of such episodes occur outside hospitals each year, 88 percent of them at home. Thus, the life you save with CPR may well be a relative's.

Sudden cardiac arrest is not the same as a heart attack. A victim of sudden cardiac arrest collapses suddenly, becomes unresponsive to gentle shaking and stops breathing normally. The arrest occurs when the heart's electrical system malfunctions, resulting in highly irregular signals that leave the heart unable to pump blood. After just four minutes of this, the brain's ability to recover from a lack of oxygen begins to seriously decline.

About 95 percent of people in sudden cardiac arrest die before reaching the hospital. Many of them were otherwise healthy. A victim's chances of survival fall by 7 percent to 10 percent every minute the heart fails to pump.

Since 2010, the heart association has advocated a simplified version of bystander CPR. When encountering a person who has collapsed and is unresponsive, the most important emergency action — after yelling for someone to call 911 — is to administer rapid, forceful chest compressions until medical help arrives or an automated external defibrillator, or A.E.D., can be used to shock the heart back into a normal rhythm.

Put one hand over the other, with fingers entwined, place them in the center of the chest between the victim's nipples, and press hard and fast. Each compression should depress the chest by about two inches and should be repeated about 100 times a minute. If done to the beat of "Stayin' Alive," the old Bee Gees song, the proper rhythm will be achieved. The chest should be allowed to rise up momentarily between compressions to allow the heart and lungs to refill.

You don't have to take a course to learn compression-only CPR. You can prepare by watching a video by the American Heart Association. Search online for "hands-only CPR instructional video," or check out the association's web page on the topic. There are also free mobile training apps available for iPhone and Android phones.

Chest compressions alone should be done only for teenagers and adults in sudden cardiac arrest. Conventional CPR, with rescue breathing, is still recommended for infants and younger children. The combination should also be used for teenagers and adults in cardiac arrest who collapsed unobserved and may not have any air left in their lungs, as well as for victims of drowning, drug overdose or collapse because of a breathing problem.

The heart association has changed the recommended protocol for conventional CPR in hopes of improving its effectiveness. The current recommendation is to start with 30 chest compressions (at a rate of 100 a minute) followed by two one-second breaths, repeating this sequence until help arrives.

When providing breaths, the victim's head should be tilted back to open the airway. For an infant, the rescuer's mouth should completely cover the baby's nose and mouth. For children older than 1 and for adults, the victim's nose should be pinched and the mouth completely covered by the mouth of the rescuer, who should observe the chest rising with each rescue breath.


This post has been revised to reflect the following correction:

Correction: December 27, 2013

The Personal Health column on Tuesday, about CPR, rendered incorrectly the title of a song by the Bee Gees that provides a good rhythm for administering chest compressions. It is "Stayin' Alive," not "Staying Alive."


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Infection Resulting in Amputation Raises Questions About Asian Immigrants’ IV Use

On a recent afternoon, she gestured with her thumb to the spot where the fluid, which was probably dextrose, a form of glucose, or sugar, was inserted. It is the only digit Ms. Jang, 61, has left. Doctors amputated most of her hands and both her legs below the knee after she was taken by ambulance from the clinic to New York Hospital Queens, racked with septic shock.

And although it is not certain that the infection resulted from her procedure at the clinic, Ms. Jang's fate sent a scare through the Korean and Chinese hubs of New York City, where the use of intravenous solutions to combat even mild illnesses is something of a norm, a practice imported from home.

Though the zip glucose imparts is similar to that from consuming a sports drink, according to doctors, in China, IV solutions are dispensed so freely to healthy people that there have been calls by the government to halt the practice and stark warnings of IV overuse there from international health organizations.

In New York, some pharmacies sell IV bags illegally over the counter with whispers not to tell any "Westerners," off-duty nurses go door-to-door offering IV pick-me-ups, and there are private walk-in clinics where, patients say, for less than $100 they get a drip hooked up on request, no questions asked. Patients and staff at clinics and pharmacies described the drips and how they are given, but on a visit to the clinic where Ms. Jang said she received her IV, a reporter was forbidden from seeing the room beyond the drawn curtain where, a receptionist said, the drips were administered.

When Jia Ling had a persistent cough this summer, she sought out IV treatment. "I took medicine, American medicine — it didn't work," said Ms. Ling, 28, a former kindergarten assistant who emigrated from China four years ago. At the Flushing clinic a friend recommended, she paid $80 for the treatment, sitting beside several other people on a couch, each hooked up to an IV drip. She does not know what the solution was. "They are professionals, I trust them," she said.

Beyond improper sale and administration of the solution, there are other inherent dangers, said Ray Macioci, the chairman of the New York City Pharmacists Society, including that it may mean a patient does not seek "good professional help to see what is actually the problem."

Many who turn to IVs are uninsured, drawn by the relatively low price for a treatment. And while intravenous infusions are regularly prescribed by doctors and performed by medical professionals in the United States, because of the risk of infection they are used with reserve, for patients suffering from dehydration or who are unable to eat, for example.

Doctors have leeway to decide when a drip should be used, but prescribing it to, say, take the edge off jet lag is not medically indicated, said Dr. Perry Pong, the chief medical officer of the Charles B. Wang Community Health Center, a nonprofit facility based primarily in Manhattan's Chinatown.

Fielding and refusing requests for IV infusion at the Wang center is routine, according to the medical staff.

In China, however, drips are so commonly prescribed that the country's national health organization started public awareness campaigns to try to limit the practice. According to the World Health Organization, China is among the countries that use the most intravenous treatments; in 2010, the last year for which data is available, the region averaged 4.18 injections per person per year; the world average is just 2.88. The W.H.O. estimates that over a half-million new cases of hepatitis B were contracted there that year because of unsafe injection practices, and more than 6,000 new cases of H.I.V.


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Vista Workers Told Their U.S. Health Plan Fails Test

Cheryl Gerber for The New York Times

"It's as if the right hand does not know what the left hand is doing," said Abby Grosslein, a Vista volunteer in New Orleans.

WASHINGTON — The Obama administration has told Vista volunteers and other AmeriCorps workers that their government-provided health coverage does not measure up to the standards of the new health care law, and that they may be subject to financial penalties unless they obtain insurance elsewhere.

The notice has surprised and worried workers in AmeriCorps, the federal community service program that is often described as a domestic version of the Peace Corps.

Mary Strasser, the director of AmeriCorps' Vista program, described the changes in a bulletin to members on Dec. 16.

The coverage provided by the agency — the AmeriCorps Health Care Benefits Plan — "does not satisfy the individual responsibility requirement of the Affordable Care Act," which takes effect on Jan. 1, Ms. Strasser said. Accordingly, she said, Vista members may be required to pay a tax penalty if they do not have other coverage and do not receive an exemption.

The impact on community service workers is another unanticipated consequence of the health care law, which is making coverage available at little or no cost to many uninsured people but disrupting coverage for others who already had it.

Abby Grosslein, a Vista member in New Orleans, said she thought it was strange that the health benefits provided by a federal agency did not meet the standards of a law adopted more than three and a half years ago. "It would be nice if the government waived the penalty because we are a federally funded program," said Ms. Grosslein, 24, who is completing her third year of service with AmeriCorps. "It's as if the right hand does not know what the left hand is doing."

Moreover, she said: "The Affordable Care Act has been on the books since 2010. Why are we hearing only now that our health plan is not compliant?"

Thousands of private employers and state and local government agencies have revamped their employee health plans to meet the law's requirements. But AmeriCorps says that its members are technically not employees, and that it does not have to provide them with the "minimum essential coverage" they need to comply with the individual mandate. "There will be no changes to the AmeriCorps Health Care Benefits Plan," Ms. Strasser wrote.

Vista, or Volunteers in Service to America, was proposed by President John F. Kennedy in 1963, authorized by Congress in 1964 and folded into the AmeriCorps network of programs in 1993. Its members work in education, housing, jobs and social service programs.

President Obama — a onetime community organizer — is a big supporter, and he has called public service "a central cause" of his administration. In March, the White House said that "AmeriCorps may be one of America's best assets," transforming communities every day.

Rick Christman of Lexington, Ky., a former member of the board of AmeriCorps' parent organization, the Corporation for National and Community Service, said no one expected that Vista workers would be subject to penalties because their health coverage was inadequate.

"It's unfortunate," Mr. Christman said.

Samantha Jo Warfield, a spokeswoman for the agency, said AmeriCorps members had several options: They can keep their current coverage; they can shop for coverage on the new insurance exchanges, including HealthCare.gov; and if they are under 26, they may be able to stay on their parents' insurance. In addition, some might be eligible for Medicaid, the federal-state program for low-income people, which is being expanded in about half the states.

AmeriCorps members say their existing coverage, which pays for doctors' services, hospital care and prescription drugs, meets most of their needs. However, according to the members' handbook, "AmeriCorps does not provide benefits for any diagnosis that is considered a pre-existing condition," and the coverage for preventive care appears to be less than the law requires.

Sarah L. Sklaw, a 22-year-old Vista member from New York City, said: "I really support the Affordable Care Act, and I don't want to be a naysayer. But it was surprising and frustrating to be told that our health coverage would not meet the law's standards, especially because the Corporation for National and Community Service told us at orientation in August that we did not need to worry about the issue."

Other AmeriCorps members said they occasionally needed more extensive coverage to pay for treatment of pre-existing conditions or injuries requiring specialty care, and they noted that some members did dangerous work, such as fighting wildfires or building trails on steep mountains.

The AmeriCorps health plan is available at no cost to members of Vista and the National Civilian Community Corps, a residential program for young men and women, who help build homes, tutor children and provide disaster relief and other services.

Vista officials said that some members might qualify for exemptions from the individual mandate penalty because of their low incomes. Vista members receive allowances to cover the cost of food, housing and other basic necessities. But the amounts are low because members are expected to live at approximately the same economic level as those they serve.


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Well: Ask Well: Is It Good to Sweat?

A

"There's this entrenched idea that it's good to 'sweat things out,'" said Oliver Jay, an associate professor of exercise physiology and director of the Thermal Ergonomics Laboratory at the University of Ottawa in Canada, and by extension, that sweating heavily during exercise is somehow healthier than misting daintily. But in fact, "sweating, per se, provides no health benefits," Dr. Jay said, apart from preventing overheating. The benefits derive from the exercise itself, and the more intense, generally, the greater the health benefits.

Core temperature rises during prolonged and vigorous physical activity, though, and your body must shed that heat. It does so in large part by sweating. The more vigorously you exert yourself, the more internal heat you produce, and the more you must sweat. Such strenuous exercise improves health through many different physiological mechanisms. But perspiring, in and of itself, does not provide or amplify those effects, Dr. Jay said.

That situation doesn't change if you're sweating due to a hot environment. "Sweat is sweat," he said. You will perspire more if the air is humid, he said, because sweat doesn't evaporate efficiently in humidity, and it's evaporation that actually cools your body. But you aren't gaining extra health benefits from drenching your clothing with perspiration; you're only ensuring that you'll need to sip from your water bottle more often to avoid losing too much fluid.

As a rule of thumb, drink when you feel thirsty, so that sweating doesn't become actually unhealthy.


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Well: For Fitness, Intensity Matters

Written By Unknown on Rabu, 25 Desember 2013 | 13.57

Phys Ed

Gretchen Reynolds on the science of fitness.

This year, exercise science expanded and fine-tuned our understanding of how physical activity affects our brains, joints, hearts, and even genes, beginning before birth and continuing throughout our lifespans, which can be lengthened, it seems, by exercise, especially if we pick up the pace.

This year's fitness news, as a look back through 2013's Phys Ed columns shows, was variously enlightening, validating (if, like me, you never bothered cooling down after a workout anyway), and practical (D.I.Y. concussion testing, anyone?). It was also occasionally deflating, at least if you hoped that barefoot running invariably would reduce the risk of injury, gentle exercise would quash your appetite, or training for a marathon would automatically exempt you from being a couch potato.

But the lesson that seemed to emerge most persistently from the fitness-related studies published this year was that intensity matters, especially if you wish to complete your workout quickly. The most popular column that I wrote this year, by a wide margin, detailed "The Scientific 7-Minute Workout," a concept that appealed, I have no doubt, because the time commitment was so slight. But the vigor required was considerable; to gain health benefits from those seven minutes, you needed to maintain a thumping heart rate and spray sweat droplets around the room.

Almost halving the time spent exercising was also effective, a later and likewise popular column showed. In that study, out-of-shape volunteers who ran on a treadmill for a mere four minutes three times a week for 10 weeks raised their maximal oxygen uptake, or endurance capacity, by about 10 percent and significantly improved their blood sugar control and blood pressure profiles.

The results undercut a common excuse for skipping workouts. "One of the main reasons people give" for not exercising is that they don't have time, said Arnt Erik Tjonna, a postdoctoral fellow at the Norwegian University of Science and Technology, who led the study.

But they emphasize, too, the potency of hard effort. The volunteers ran at 90 percent of their maximum aerobic capacity for those four minutes, a level that is frankly unpleasant. But, in four minutes, they were done.

There were other hints throughout the year that exerting yourself vigorously may have unique payoffs, compared with less strenuous exercise. In a study that I wrote about a few weeks ago, for instance, people who walked briskly, at a pace of 17 minutes per mile or less, generally lived longer than those men and women who strolled during their walks, at a pace of 20 minutes per mile or slower, although the study was not designed to determine why the intensity of the exercise mattered.

And in September, I wrote about two studies showing that strenuous exercise blunted volunteers' appetites after workouts more effectively than longer sessions of easy exercise did. The studies were small, though, and involved only young-ish, overweight men. Whether the results are applicable to other people, including those of us who are not male, requires additional experiments. I expect to be covering the results in 2014.

Meanwhile, other studies that I wrote about this year emphasize how pervasive the impacts of any amount and type of exercise can be. One of my favorite experiments of 2013 detailed how rodents that ran on wheels for several weeks responded far better to stressful situations than sedentary animals, in large part, it seems, because their brains contained specialized cells that dampened unnecessary anxiety. At a molecular level, the runners' brains were calmer than those of their sedentary lab mates.

But perhaps the most remarkable studies of the year examined the effect of exercise on our DNA. In several experiments, which I wrote about in July, scientists found that exercise reshapes genes in human cells, changing how atoms attach to the outside of individual portions of our DNA. As a result, I wrote, the behavior of the gene changes. In one of the studies, researchers found that six months of moderate exercise profoundly remodeled genes related to the risk for diabetes and heart disease. But for those of us too impatient to wait six months, the other study found that a single session of bike riding altered genes in volunteers' muscle cells. The effects showed up whether the pedaling was easy or strenuous, but, in line with so much of this year's exercise science, were more pronounced when cyclists rode vigorously.

Still, for everyone, as one of the scientists told me, the studies are an important and inspirational reminder of "the robust effect exercise can have on the human body, even at the level of our DNA."


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