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Well: Ask Well: Weight Gain at Menopause

Written By Unknown on Jumat, 28 Maret 2014 | 13.57

Q

At menopause, I experienced a sudden and dramatic weight gain. I was healthy and exercised moderately five times a week for 30-plus years; I have always been careful about my diet, eating only healthy fresh food that I prepare myself. I am not sleep deprived. After trying various diets, I cannot get rid of this extra 15 pounds, and I've moved into the officially "overweight" category. What happened? Am I doomed to eat only lettuce in the future?

A

Is weight gain at menopause inevitable?

Many women in middle age complain about stubborn belly fat. Research suggests that this is indeed a common feature of menopause.

In a large study carried out by the International Menopause Society in 2012, researchers reviewed decades of research and concluded that the hormonal shifts of menopause change the distribution of body fat, making it more likely to accumulate in the abdomen. The drawbacks of this are more than just cosmetic: The accumulation can also increase the risk of insulin resistance and cardiovascular disease.

Last year, researchers at the Mayo Clinic took a closer look at the phenomenon by comparing fat tissue in pre- and post-menopausal women of similar ages. At the cellular level, they found that two enzymes that work to synthesize and store fat were more active in the postmenopausal women, which the researchers attributed to drops in estrogen.

Experts also say that decreases in metabolism mean that women gain an average of 10 pounds around menopause, but they can also lose weight through diet and exercise.

One study that underscored this was published in the journal Menopause in 2012. Researchers randomly assigned about 17,000 postmenopausal women who were not using hormone therapy to one of two conditions, either a control group, or another group that was put on a diet with increased intake of healthful foods like fruits, vegetables and whole grains. After a year, women in the diet group had fewer hot flashes and they were three times as likely to have lost weight.

In one randomized trial called the Women's Healthy Lifestyle Project, 535 premenopausal women were followed through menopause. About half of the women were assigned to follow a low-calorie diet (about 1,300 calories daily) and burn an extra 1,000 to 1,500 calories weekly through physical activity.

After five years, the women in the diet and exercise group saw greater reductions in their waistlines, and they were more likely to have remained at or below their baseline weight.

So while weight gain is common at midlife, it's not a foregone conclusion. That said, women who want to avoid midlife weight gain will have to work harder at keeping weight off by taking in fewer calories and burning more through exercise.


Do you have a health question? Submit your question to Ask Well.


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Well: The Workout: A Ref Keeps Up With March Madness

Written By Unknown on Kamis, 27 Maret 2014 | 13.57

The Workout

An inside look at fitness routines, by Anahad O'Connor.

As the big college basketball tournaments get underway, many eyes will be on the players scrambling up and down the courts in pursuit of a national championship.

But the players will not be the only ones breaking a sweat. The average college basketball official runs about four miles a game, and they are not taking their sweet time. The referees must race to keep up with the players, make split-second calls and decisions, and try to predict every play so they can get in the right position to have a clear view of the action.

To learn more about how these hardworking officials stay in shape for the job, we spoke with Deldre Carr, 34, who has spent time on the courts during the N.C.A.A. Men's Division 1 Basketball Championship, better known as March Madness.

Carr, who is from Las Vegas, has been officiating college and semi-professional basketball games for about a decade (he also has a full-time job, as an accounting clerk at a law firm). Recently, we caught up with him to talk about how a basketball ref keeps up with the players, how many miles he runs during an average game and what it's like drawing the ire of fans at every arena. Here are edited excerpts from our conversation.

Were you a basketball player yourself?

I've been playing since I was a child. I played soccer too, but basketball was my first love. I played in college for a Division I school, the University of Montana, and finished up my playing career there in 2002. I played shooting guard and small forward.

What made you want to become a basketball referee?

I'm roughly 6-foot-4 and 205 pounds. I thought about playing overseas, but if you're my height and you don't have a 40-inch vertical, you're not really going to be anything. So at the end of my college career, my father and I sat down and he said: "You need to find a hobby. Take up golf." I'm not a fan of golf. So he said I should try officiating. I gave him a funny look and said, "I hate referees — why would I want to become one? The referee is always the one you blame when you have problems."

But you tried it out anyway?

Yes. I reached out to my high school coach and I went to some local referee meetings here in Las Vegas. I saw some of the officials that worked my games in college and they took me under their wings and showed me the ropes. It felt like I was still part of the game, like I was still playing. You're not shooting and making jumpers, but you're out there making calls. I found a new love with officiating.

When did you start?

I started officiating in about 2003 or 2004. I refereed high school basketball for two years and moved up the ranks fairly quickly. My path went from high school to semi-pro and then to college.

Is officiating a physically demanding job?

I have a Nike FuelBand that I carry in my pocket. I run an average of 5.5 to six miles per game. We have to stay physically fit so you can get up and down the court and get into position to referee. You're running a lot and you're constantly making decisions. You have to think, "O.K., was this illegal contact? Was that marginal contact? Was this incidental contact?" These are things that can all become tiresome during a game. But if you take a break for a split second, you can miss something major like a flagrant foul.

Do you exercise during the season?

Yes. On my days off I like to get in the gym. During the season I like to save my legs because I know I'll do a lot of running during games. So when I go to the gym, I'll do the elliptical or stationary bike. I'll do 30 minutes of cardio, and then a little maintenance workout with weights that can range from 30 to 45 minutes. My heavy lifting is done in the off-season. That's when you try to get yourself in the best shape. During the season, it's all about maintaining.

What is your weight-lifting routine like?

I don't do legs during the season because of the burn that I get working games. But in the off-season, I do some light legwork. That's squats with no weight, leg curls and leg extensions to keep my quads and hamstrings in shape for the upcoming season. I'll also do bench press, pull-ups and military press for my shoulders.

How do you stay in shape in the off-season?

I do a mixture of cardio and weights. A couple of summers ago I was doing the Insanity Workout, which was tough and challenging. It's cardio and weights. I also like to do the treadmill. I like to run at least three times a week. I'd say I probably do about 15 miles a week on a treadmill or elliptical.

Do you exercise on game day too?

Yes. I have a routine that I do. I like to get up in the morning prior to the game, bike for 15 minutes, maybe four or five miles, not too hard. Then I'll grab a couple of weights and do some weight training. And then I'll go back to my room and relax until game time.

What is your typical schedule during the season?

In a typical week I'm home in Las Vegas Monday through Wednesday. On Thursday morning I'm usually out on the first plane. I work a game Thursday, sometimes Friday, and then Saturday. And I may get lucky here and there with a rare Sunday night game.

Do you still play basketball?

I stopped playing basketball about five years ago because I realized that referee running and playing basketball are two different things. You have to stay in shape for both of them, but basketball is a little more strenuous because you have to get into a defensive stance or do a lot of jumping and catching rebounds.

I heard the officiating schedule is sometimes stressful. Is that true?

For referees, the time off in between games is a lot shorter than it is for players. The players might do two games a week, whereas some referees with heavy schedules may do six games a week. You have to make sure your body is getting the proper nutrients and proper rest so you can be mentally strong and able to do this.

Do you follow a special diet?

The calories you put in your body are very important. My wife does a great spread. She keeps the meals very healthy. I eat a lot of chicken. She'll bake and grill chicken breasts. I eat brown rice at times, vegetables, and pastas as well. And I'll have the occasional fast food, especially when I'm on the road and I don't get out of a game until 10 o'clock. At that time, everything is closed so I might stop at Carl's Jr. and get a burger or a wrap.

Are there specific foods you like to eat before a game?

I always have a heavy breakfast in the morning. And then two hours before a game I'll have a soup and a salad. I like to keep it light.

Is it different working a March Madness game than a regular-season game?

The atmosphere is much different. Last year, I was selected to work a March Madness game in Dayton, Ohio. And at one point during a time out I had to take a step back and take it all in. And I thought, "This is a huge honor." Because you look up and there's not an empty seat in the house.

Are you ever bothered by taunts from the fans?

The fans pay money and they can boo, yell or whatever they want. They pay money to do that. I'm all for that. The things they do don't affect officials. In every arena we go into, we know we're going to be called terrible [by the fans]. I've yet to go to an arena where they're cheering us on. The only time you go into an arena and you're cheered is if you come out behind the home team. And after that, we know they're going to boo us.


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Well: Exercising for Healthier Eyes

Written By Unknown on Rabu, 26 Maret 2014 | 13.57

Phys Ed

Gretchen Reynolds on the science of fitness.

Age-related vision loss is common and devastating. But new research suggests that physical activity might protect our eyes as we age.

There have been suggestions that exercise might reduce the risk of macular degeneration, which occurs when neurons in the central part of the retina deteriorate. The disease robs millions of older Americans of clear vision. A 2009 study of more than 40,000 middle-aged distance runners, for instance, found that those covering the most miles had the least likelihood of developing the disease. But the study did not compare runners to non-runners, limiting its usefulness. It also did not try to explain how exercise might affect the incidence of an eye disease.

So, more recently, researchers at Emory University in Atlanta and the Atlanta Veterans Administration Medical Center in Decatur, Ga., took up that question for a study published last month in The Journal of Neuroscience. Their interest was motivated in part by animal research at the V.A. medical center. That work had determined that exercise increases the levels of substances known as growth factors in the animals' bloodstream and brains. These growth factors, especially one called brain-derived neurotrophic factor, or B.D.N.F., are known to contribute to the health and well-being of neurons and consequently, it is thought, to improvements in brain health and cognition after regular exercise.

But the brain is not the only body part to contain neurons, as the researchers behind the new study knew. The retina does as well, and the researchers wondered whether exercise might raise levels of B.D.N.F. there, too, potentially affecting retinal health and vision.

To test that possibility, the researchers gathered adult, healthy lab mice. Half of these were allowed to remain sedentary throughout the day, while the other animals began running on little treadmills at a gentle rodent pace for about an hour a day. After two weeks, half of the mice in each group were exposed to a searingly bright light for four hours. The other animals stayed in dimly lit cages. This light exposure is a widely used and accepted means of inducing macular degeneration in animals. It doesn't precisely mimic the slowly progressing disease in humans, obviously. But it causes a comparable if time-compressed loss of retinal neurons.

The mice then returned to their former routine — running or not exercising — for another two weeks, after which the scientists measured the number of neurons in each animal's eyes. The unexercised mice exposed to the bright light were experiencing, by then, severe macular degeneration. Almost 75 percent of the neurons in their retinas that detect light had died. The animals' vision was failing.

But the mice that had exercised before being exposed to the light retained about twice as many functioning retinal neurons as the sedentary animals; in addition, those cells were more responsive to normal light than the surviving retinal neurons in the unexercised mice. Exercise, it seems, had armored the runners' retinas.

Separately, the researchers had other mice run or sit around for two weeks, and then measured levels of B.D.N.F. in their eyes and bloodstreams. The runners had far more. Tellingly, when the scientists injected still other mice with a chemical that blocks the uptake of the growth factor before allowing them to run and exposing them to the bright light, their eyes deteriorated as badly as among sedentary rodents. When the mice could not process B.D.N.F., exercise did not safeguard their eyes.

Taken together, these experiments strongly suggest that "exercise protects vision, at least in mice, by increasing B.D.N.F. in the retina," said Jeffrey Boatright, an associate professor of ophthalmology at Emory University School of Medicine and a co-author of the study.

But obviously, mice are not people, so whether exercise can prevent or ameliorate macular degeneration in human eyes is "impossible to know, based on the data we have now," said Machelle Pardue, a research career scientist at the Atlanta Veterans Administration Medical Center, who is the senior author of the study. She and her colleagues are trying to find ways to determine the impact of exercise on human eyes. But such experiments will take years to return results.

For now, she and Dr. Boatright said, people who are concerned about their vision, and especially those with a family history of retinal degeneration, might want to discuss an exercise program with their doctor. "As potential treatments go," she said, "it's cheap, easy and safe."

Dr. Boatright agreed, adding that eye researchers have been trying for some time to find a way to externally deliver growth factors or drugs to aging eyes, but the available methods typically involve injections into the retina, a process that is complicated, chancy, pricey, and fundamentally objectionable.

Now, though, "it's beginning to look like we may have this other method" — exercise — "that costs almost nothing and results in you making your own growth factors, which is so much safer and more pleasant than having a needle stuck into your eyeball," he said, getting no disagreement from me.


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Books: “Caffeinated,” a History of Our Favorite Stimulant

Written By Unknown on Selasa, 25 Maret 2014 | 13.57

One legend says it all began when a North African herder saw his goats eat some wild berries, then frolic with unusual verve. Another story cites a few small leaves blown off a nearby bush into the Chinese emperor's mug of hot water. Either way, whether caffeine entered the life of man by coffee bean or tea leaf, happiness ensued.

Happiness, that is, for all but the poor souls charged with saving us from our drugs, for no regulatory challenge trumps the one posed by caffeine, molecule of elegant enjoyment and increasing abuse, man's best friend and occasional killer. As Murray Carpenter makes clear in his methodical review, our society's metrics are no match for this substance's nuances, whether among athletes, teenagers, experimental subjects or the average dependent Joe. (Read an excerpt of "Caffeinated.")

Pure caffeine is a bitter white powder. In the body it blocks the effects of the molecule adenosine, a crucial brake on many physiologic processes. With just enough caffeine in the system, the body's organs become a little more themselves: the brain a little brainier, the muscles a little springier, the blood vessels a little tighter, the digestion a little more efficient. With too much caffeine, all can accelerate into cardiac arrest.

It takes only about 30 milligrams of caffeine (less than a cup of coffee or can of cola) for stimulative effects to be noticeable. A hundred milligrams a day will hook most people: They feel immensely unhappy without their daily fix, and the organs all whine in protest for a few days. It takes more than 10 grams to kill you — a dose impossible to achieve with traditional beverages alone. However, the new caffeine-rich energy shots make it alarmingly easy for party-minded people to achieve the zone between enough and much too much.

A freelance journalist who has written for The New York Times, Mr. Carpenter dutifully circles the globe to visit the various landmarks of caffeine history: the birthplace of chocolate in the Soconusco region of Mexico's Pacific Coast; a tea shop in Beijing; a coffee plantation in Colombia (where the local brew is nothing special; most of the best beans are exported). Then it is off to some of the newer landmarks of the industry, including the Vermont headquarters of Green Mountain, pioneering developer of the individual K-Cups whose freshly brewed 10-ounce portions replaced the fetid pot of office coffee.

Mr. Carpenter has no luck in his efforts to tour some of the other new outposts, namely the factories in China and India that now supply soft-drink companies with synthesized caffeine powder. None of these plants would allow him in. (And none of the employees he found smoking outside the world's largest plant, in Shijiazhuang, China, had much to say — "When I asked if it was modern and sophisticated on the inside, they said, 'Yes, it is.' ")

This industrial caution is emblematic of the shuffle performed by the beverage industry over the last century around the subject of caffeine. From its beginnings in the late 19th century, Coca-Cola was advertised as a stimulant. In 1909 the federal government seized an interstate shipment of syrup, charging that the beverage's caffeine content violated the Pure Food and Drug Act. It took five years for the Coca-Cola Company to win that case, whereupon it promptly reduced the amount of caffeine in the proprietary formula. Industry policy began to emphasize the soda's taste over its buzz, with caffeine increasingly characterized, in the words of one corporate report, as a "flavor concentrate ingredient." In 2011 the American Beverage Association baldly stated in a news release, "Caffeine is not a drug."

But even while vigorously playing down the pharmaceutical qualities of their sodas, the big beverage makers now cheerfully bottle their own versions of concentrated caffeine-containing "energy" products, including some that have been associated with seizures and the rare death.

So what's a regulatory agency to do? Athletic organizations disagree: As of Mr. Carpenter's writing, the Olympic Committee no longer included caffeine in its drug screens, but the National Collegiate Athletic Association did. The Food and Drug Administration, faced with a huge array of caffeine-containing foods, beverages and supplements, leaves most of them alone, although it did recently crack down on a caffeine-containing gum.

The F.D.A.'s equivalents elsewhere in the world have imposed more stringent controls: Canada restricts the caffeine content of both energy drinks and sodas, while Europe mandates that the labels of high-caffeine beverages disclose the precise amount "in the same field of vision" as the brand name.

Mr. Carpenter packs all this and more into a data-heavy narrative that occasionally degenerates into regrettable summary moments, such as one chapter's finale: "Caffeine can really mess with your head."

The big numbers are all here: tons produced, cups consumed, dollars spent, along with the results of many, many studies of experimentally caffeinated athletes, soldiers and students.

But if you are a person whose best, most accepting, most forgiving friend in a cold world is all too often contained in a steaming 16-ounce mug, and you crave a few poetic words of tribute to the fragrant magic of your faithful companion, Mr. Carpenter never quite provides them. His best homage consists of the last line of his acknowledgments, when, finished with friends, family, sources and editors, he graciously thanks "the bitter white powder that inspired this book and provided the focus and stamina to write it."

A version of this article appears in print on 03/25/2014, on page D5 of the NewYork edition with the headline: A Brimming Cup of Addiction .

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Poison Pen: A Threat to Male Fertility

To study the impact of everyday chemicals on fertility, federal researchers recently spent four years tracking 501 couples as they tried to have children. One of the findings stood out: while both men and women were exposed to known toxic chemicals, men seemed much more likely to suffer fertility problems as a result.

The gender gap was particularly wide when it came to phthalates, those ubiquitous compounds used to make plastics more flexible and cosmetic lotions slide on more smoothly. Women who wore cosmetics often had higher levels of phthalates in their bodies, as measured by urinalysis. But only in their male partners were phthalate levels correlated with infertility.

"It's the males in the study that are driving the effect," said Germaine Buck Louis, an epidemiologist at the National Institute of Child Health and Human Development and lead author of the report, published in February in Fertility and Sterility. "They're the signal."

Poison Pen

Deborah Blum writes about chemicals and the environment.

Phthalates belong to a group of industrial compounds known as endocrine disruptors because they interfere with the endocrine system, which governs the production and distribution of hormones in the body. The chemicals have been implicated in a range of health problems, including birth defects, cancers and diabetes.

But it is their effect on the human reproductive system that has most worried researchers. A growing body of work over the last two decades suggests that phthalates can rewire the male reproductive system, interfering with the operation of androgenic hormones, such as testosterone, that play key roles in male development. That mechanism, some experts believe, explains findings that link phthalate exposure to changes in everything from testicular development to sperm quality.

"I wasn't surprised at all by this finding," Andrea Gore, a professor of pharmacology and toxicology at the University of Texas, and editor in chief of the journal Endocrinology, said of the new report. "We see the cell studies, the animal studies and now the human epidemiology work, and they are all showing us a similar picture."

The focus on male fertility dates back to the early 1990s, when researchers in the United States and Europe published a paper suggesting chemical exposures could be linked to a steady decline in semen quality. One of the authors, Niels Skakkebaek, a reproduction researcher at the University of Copenhagen, has since suggested that an increase in malformations in male reproductive systems, which he calls "testicular dysgenesis syndrome," may be linked to environmental exposure to compounds including endocrine disruptors like phthalates.

More recent studies in the United States have also suggested links between phthalate exposure and apparent sperm damage in men. The findings are supported by a host of animal studies, particularly in rats, which have shown that the compounds can interfere with masculinization of young animals and result in odd physical changes to male reproductive tracts.

"They interfere with how testosterone is made," explained Heather Patisaul, a biology professor at North Carolina State University who is studying the effect of endocrine-disrupting compounds during puberty. "Anything you can think of that's testosterone-dependent is likely to be affected."

Women also have androgenic hormones, but to a lesser degree, and according to some theories this accounts for the smaller but still observable effects of phthalates on female fertility. (Testosterone, for instance, is part of the cascade of hormones that leads to egg production.)

There are plenty of uncertainties in this picture. The Centers for Disease Control and Prevention notes that while studies suggest that phthalate exposure is "widespread in the U.S. population," it's difficult to know what those levels are. Health effects from very low levels are still not well understood.

While the "evidence for an effect on male fertility is compelling," said Tracey Woodruff, director of the program on reproductive health and the environment at the University of California, San Francisco, it's still difficult to gauge the impact. "We are still pulling the tricky aspects together."

There are different kinds of phthalates complicating the picture; some seem to have a much larger effect than others. And these are far from the only factors, chemical and otherwise, that influence human fertility. Dr. Buck Louis's group is looking at a broad range of industrial compounds, including heavy metals like lead and cadmium, that tend to accumulate in the body.

Phthalates, by contrast, tend to be metabolized within a few hours. Their impact would not be so profound if it were not that people are constantly exposed from multiple sources.

These include not only cosmetics and plastics, but also packaging, textiles, detergents and other household products. Phthalates are found in the tubing used in hospitals to deliver medications; in water flowing through PVC pipes; enteric coatings on pills, including some aspirin; materials used to create time-release capsules; and countless other products. In 2008, the government banned them in children's toys, and the European Union is also moving forward on restrictions.

"The W.H.O. called them 'pseudopersistent' in one report," Dr. Woodruff said, because continued exposure keeps phthalates in the body. But here's the silver lining: the transient nature of these compounds also means that consumers can take fairly simple measures to reduce their phthalate levels.

One is to read the labels on cosmetics and other personal care products and to choose those without phthalates. Another is to be cautious with plastic food containers, and to avoid using them to heat food and drink, as the phthalates in them may get transferred to what you consume.

"These compounds leach from plastics," Dr. Buck Louis said. "You can switch to glass for drinking. You can cook your frozen dinners on paper plates."

Studies have shown that these kinds of actions do make a difference; experiments have found measurably lower levels within several days in people who make these changes.

"Lifestyle has an important place here," said Dr. Buck Louis.


This post has been revised to reflect the following correction:

Correction: March 24, 2014

A photograph of Tupperware food containers that accompanied an earlier version of this article was published in error. Tupperware says its containers are not manufactured with phthalates.

A version of this article appears in print on 03/25/2014, on page D3 of the NewYork edition with the headline: A Plastic Threat to Male Fertility.

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Making Vaccination Mandatory for All Children

Written By Unknown on Senin, 24 Maret 2014 | 13.57

An outbreak of measles in Manhattan showed that even doctors had overlooked the disease as childhood vaccination became widespread. But over the last decade more people have objected to immunization. Along with the religious exemptions that almost all states allow, 19 states allow exemptions for philosophical reasons.

But are broader outbreaks like those in Britain evidence that parents should no longer be allowed to get any exemption from having their children immunized?

Read the Discussion »
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Well: Stress May Affect Fertility

Can stress affect a woman's ability to become  pregnant? A new study says it may.

Over  four years, 401 women who were stopping  contraception and trying to have a baby  underwent saliva testing for two stress-related substances: the enzyme alpha-amylase, and the hormone cortisol. The women  provided a saliva sample upon enrollment in the study, and then another at their first observed menstrual period, so that comparisons between the women could be made from the same starting point.

Researchers analyzed the samples and then followed the women to see how long it took them to become pregnant. Women who became pregnant during the first month of the study (before they could give a second saliva sample) were also included in the analysis.

The scientists defined infertility as a failure to become pregnant after 12 months of unprotected intercourse. During the study, published Monday in Human Reproduction, 347 women became pregnant and 54 did not.

There was no association of cortisol with fertility. But those whose alpha-amylase   levels were in the highest third, a sign of longstanding stress, had more than double the risk of infertility. The scientists controlled for age, race, income and other health and socioeconomic factors.

The lead author, Courtney D. Lynch, director of reproductive epidemiology at Ohio State University, said that if a woman was having difficulty becoming pregnant, it would be harmless, and might be helpful, to consider stress-reduction techniques.

"Yoga, meditation, mindfulness have been successful in other health outcomes," she said, "and might be helpful for fertility as well."

 

 


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Well: A Viral Misery That Loves Company

Personal Health

Jane Brody on health and aging.

I have often felt sorry for people whose cruise ship vacations were marred by a nasty gastrointestinal virus that kept them quarantined in their cabins and sometimes cut short the trip.

But now that I've endured two separate bouts of this bug, formerly called Norwalk virus and now known as norovirus, my empathy has skyrocketed. Norovirus is, to put it mildly, misery incarnate. One minute you're fine, and the next you think you're dying — or that dying would be preferable.

My first infection was almost certainly acquired at a Hanukkah party several years ago; at least 23 attendees became ill. The next evening at a school event with my grandsons, I abruptly abandoned them to race to the restroom. I sweated through my clothes and could not stand unaided. I spent the night on my bathroom floor, with frequent intermissions on the toilet.

Fast forward to this February. The symptoms were virtually identical, but this time I could only guess at the source of my discomfort: a salmon-avocado sushi roll I had eaten for lunch 36 hours earlier.

Noroviruses have the dubious distinction of being the leading cause of gastrointestinal infections in the United States, where they account for an estimated half of all such ailments. The Centers for Disease Control and Prevention reports that each year noroviruses cause an estimated 21 million illnesses and 800 deaths.

About 80 percent of infections occur from November to April, when people tend to congregate in enclosed spaces with little fresh air circulating.

The current strain, first identified in Sydney in 2012, has been responsible for several outbreaks on cruise ships, where the highly contagious and difficult-to-kill virus can easily infect hundreds of passengers.

It has been nicknamed the Ferrari of viruses for the speed at which it can spread through groups. An outbreak on the Queen Mary 2 in December 2012 sickened 204 passengers and 16 crew members.

One infected traveler on the Royal Caribbean's Vision of the Seas, among 118 guests and three crew members similarly afflicted last March, reported being confined to his cabin for two days, during which time he counted 28 trips to the bathroom.

Nausea, vomiting and diarrhea are the usual symptoms. Others include stomach cramps, muscle aches, low-grade fever, headache and fatigue that can persist for days after the main symptoms abate. Although usually lasting just one to three days, a norovirus infection can be hazardous, particularly for infants, the elderly and people with compromised immunity. The greatest risk is dehydration stemming from vomiting and watery diarrhea.

The virus spreads readily in confined spaces like day care and retirement centers, schools, hotels and nursing homes, as well as on cruise ships. Most ships try hard to prevent outbreaks, providing alcohol-based hand sanitizers for passengers and crew, but the virus often persists despite such deterrents.

A case, or capsid, that surrounds the virus makes it especially hard to kill. It can even survive hand (and sometimes machine) dishwashing and laundering. And when a toilet with contaminated excretions is flushed, the virus can become airborne unless the lid is shut first.

Contaminated clothing, linens and towels should be handled carefully (preferably with gloves), machine-washed separately in hot water, and machine-dried. Contaminated toilets and other hard surfaces should be washed with a 10 percent bleach solution (one part bleach to nine parts water), hydrogen peroxide, Lysol or a commercial bleach-based cleaning product. Carpets and upholstered furniture need steam cleaning. No vaccine is yet available. One, developed by LigoCyte Pharmaceuticals, is being tested. In a randomized trial financed by the manufacturer, it reduced the risk of infection in 98 volunteers by 52 percent. The existence of at least five genetic groups and 31 subgroups of norovirus makes developing an effective vaccine difficult.

Meanwhile, frequent hand washing with soap and hot water for at least 30 seconds, especially after using the toilet, is the best preventive. Failing to do so risks transferring the virus to foods, drinks or utensils used by others. It takes only a small inoculation of norovirus to cause illness.

Furthermore, the virus can persist for days or weeks on hard surfaces, which speaks to the importance of thoroughly washing your hands before eating, preparing food and drinks or serving others. You can also infect yourself by touching your nose or mouth with virus-contaminated hands.

Anyone who becomes infected should refrain from handling food or drink to be consumed by others during the course of symptoms and for at least three days after. Occasionally, an infected person can spread the virus for a week or two after recovering, so diligent hand-washing after using the toilet is a must.

Restaurant workers, most of whom do not get paid sick leave, are a major concern; those who come in sick or too soon thereafter can spread the virus to hundreds of diners. Affected customers may label the ailment "food poisoning," which it is in a sense, but the real source is the handler.

Foods most often linked to norovirus outbreaks include raw shellfish, leafy greens, fresh fruits and ready-to-eat foods. Vegetables and fruits should be washed, and shellfish are safest when thoroughly cooked. Symptoms usually occur within 12 to 48 hours of ingesting norovirus.

As I experienced, the illness comes on suddenly: You're fine one minute then very sick the next, as if hit by a Mack truck. There is no treatment other than replacing lost fluids. If vomiting is severe, medications can reduce it, but experts advise against taking an antidiarrheal drug like Lomotil or Imodium, which can prolong the infection.

It is best to avoid sugary drinks, which can aggravate diarrhea. My doctor advised me to follow a so-called BRAT diet — bananas, rice, applesauce and toast — for a day or so, supplemented by plain fluids, broth or diluted juice.

Drink a cup of liquid to compensate for each large, loose stool. A rehydration drink like Pedialyte is suitable for adults as well as babies and children. But avoid foods high in fat and sugar, as well as spicy foods, alcohol and coffee, for about two days after symptoms are gone.


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Poison Pen: A Threat to Male Fertility

Written By Unknown on Sabtu, 22 Maret 2014 | 13.57

To study the impact of everyday chemicals on fertility, federal researchers recently spent four years tracking 501 couples as they tried to have children. One of the findings stood out: while both men and women were exposed to known toxic chemicals, men seemed much more likely to suffer fertility problems as a result.

The gender gap was particularly wide when it came to phthalates, those ubiquitous compounds used to make plastics more flexible and cosmetic lotions slide on more smoothly. Women who wore cosmetics often had higher levels of phthalates in their bodies, as measured by urinalysis. But only in their male partners were phthalate levels correlated with infertility.

"It's the males in the study that are driving the effect," said Germaine Buck Louis, an epidemiologist at the National Institute of Child Health and Human Development and lead author of the report, published in February in Fertility and Sterility. "They're the signal."

Poison Pen

Deborah Blum writes about chemicals and the environment.

Phthalates belong to a group of industrial compounds known as endocrine disruptors because they interfere with the endocrine system, which governs the production and distribution of hormones in the body. The chemicals have been implicated in a range of health problems, including birth defects, cancers and diabetes.

But it is their effect on the human reproductive system that has most worried researchers. A growing body of work over the last two decades suggests that phthalates can rewire the male reproductive system, interfering with the operation of androgenic hormones, such as testosterone, that play key roles in male development. That mechanism, some experts believe, explains findings that link phthalate exposure to changes in everything from testicular development to sperm quality.

"I wasn't surprised at all by this finding," Andrea Gore, a professor of pharmacology and toxicology at the University of Texas, and editor in chief of the journal Endocrinology, said of the new report. "We see the cell studies, the animal studies and now the human epidemiology work, and they are all showing us a similar picture."

The focus on male fertility dates back to the early 1990s, when researchers in the United States and Europe published a paper suggesting chemical exposures could be linked to a steady decline in semen quality. One of the authors, Niels Skakkebaek, a reproduction researcher at the University of Copenhagen, has since suggested that an increase in malformations in male reproductive systems, which he calls "testicular dysgenesis syndrome," may be linked to environmental exposure to compounds including endocrine disruptors like phthalates.

More recent studies in the United States have also suggested links between phthalate exposure and apparent sperm damage in men. The findings are supported by a host of animal studies, particularly in rats, which have shown that the compounds can interfere with masculinization of young animals and result in odd physical changes to male reproductive tracts.

"They interfere with how testosterone is made," explained Heather Patisaul, a biology professor at North Carolina State University who is studying the effect of endocrine-disrupting compounds during puberty. "Anything you can think of that's testosterone-dependent is likely to be affected."

Women also have androgenic hormones, but to a lesser degree, and according to some theories this accounts for the smaller but still observable effects of phthalates on female fertility. (Testosterone, for instance, is part of the cascade of hormones that leads to egg production.)

There are plenty of uncertainties in this picture. The Centers for Disease Control and Prevention notes that while studies suggest that phthalate exposure is "widespread in the U.S. population," it's difficult to know what those levels are. Health effects from very low levels are still not well understood.

While the "evidence for an effect on male fertility is compelling," said Tracey Woodruff, director of the program on reproductive health and the environment at the University of California, San Francisco, it's still difficult to gauge the impact. "We are still pulling the tricky aspects together."

There are different kinds of phthalates complicating the picture; some seem to have a much larger effect than others. And these are far from the only factors, chemical and otherwise, that influence human fertility. Dr. Buck Louis's group is looking at a broad range of industrial compounds, including heavy metals like lead and cadmium, that tend to accumulate in the body.

Phthalates, by contrast, tend to be metabolized within a few hours. Their impact would not be so profound if it were not that people are constantly exposed from multiple sources.

These include not only cosmetics and plastics, but also packaging, textiles, detergents and other household products. Phthalates are found in the tubing used in hospitals to deliver medications; enteric coatings on pills, including some aspirin; materials used to create time-release capsules; and countless other products. In 2008, the government banned them in children's toys, and the European Union is also moving forward on restrictions.

"The W.H.O. called them 'pseudopersistent' in one report," Dr. Woodruff said, because continued exposure keeps phthalates in the body. But here's the silver lining: the transient nature of these compounds also means that consumers can take fairly simple measures to reduce their phthalate levels.

One is to read the labels on cosmetics and other personal care products and to choose those without phthalates. Another is to be cautious with plastic food containers, and to avoid using them to heat food and drink, as the phthalates in them may get transferred to what you consume.

"These compounds leach from plastics," Dr. Buck Louis said. "You can switch to glass for drinking. You can cook your frozen dinners on paper plates."

Studies have shown that these kinds of actions do make a difference; experiments have found measurably lower levels within several days in people who make these changes.

"Lifestyle has an important place here," said Dr. Buck Louis.


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The New Old Age Blog: In Many States, Few Legal Rights for C.C.R.C. Residents

"I'm not naïve about the corporate world," Burton Richter told me when we spoke about the class action lawsuit he and other residents are bringing against Vi at Palo Alto, a very upscale continuing care retirement community.

Dr. Richter, 83, has served on corporate boards. He directed the Stanford Linear Accelerator Center for 15 years, among his other faculty and administrative positions at the university. And his honors include the Nobel Prize in physics.

The five other named plaintiffs in the proposed suit have impressive resumes, too, with an abundance of advanced degrees. Yet when they grasped that Vi's management had not stashed their sizable entrance fees in a reserve account, "it astounded me and a lot of the residents," Dr. Richter said.

C.C.R.C.s are state regulated, and "there is no consistency from state to state as to what residents' rights are," said Katherine Pearson, a Penn State law professor and authority on this type of senior housing. Though such communities come in many configurations — some operate more like rentals, without big upfront fees — buying into a place like the Vi can take most of a resident's life savings.

Yet most state regulations, if they exist at all, emphasize disclosure more than consumer protection. "You can have a financial disclosure law that puts 99 percent of the burden on the resident to understand its significance," Ms. Pearson said. New York and New Jersey have strong C.C.R.C. regulations, she said; Virginia's are weak, and California's have serious gaps. Most don't require reserve funds for the eventual refunds of entrance fees.

So how can older people who aren't Nobel laureates, but are contemplating moving into a C.C.R.C., figure out whether a community is financially stable and smoothly run, whether residents' interests are protected, whether the investment makes sense?

The National Continuing Care Residents Association, incorporated in 1999, works to educate prospective residents and increase state oversight. With its 1,200 individual members, nine state associations and 38 member C.C.R.C.s, it probably represents close to 50,000 people, the group's incoming president, Dan Seeger, estimated.

One of its committees has drafted a national residents' "bill of rights" and expects to present it at the group's semi-annual meeting in Mystic, Conn., next month. Other committees are working on model laws to increase financial transparency and stability, which they hope state governments will adopt. The association also wants to develop an index of financial solvency, with which prospective residents can compare facilities.

"Right now, the average shopper is floundering," Mr. Seeger said. "This is a vulnerable population that probably believes there's more government regulation than there is."

Let me direct you to two association websites. The main site contains information about the organization, including a list of state associations. The site informally dubbed NaCCRA U takes a more educational approach. Jack Cumming, an actuary and the group's research director, has posted scads of videos and consumer guides, research documents and proposals.

Neither site is a model of user-friendly navigation; finding the information you want requires some poking around. To see court filings from C.C.R.C. litigation, including the Vi lawsuit, for instance, you need to look under the News tab on the NaCCRA U top menu bar. (Can't some semi-retired graphic designers and programmers design a snazzier and more serviceable website for these folks?) Nevertheless, novices in the world of C.C.R.C.s can learn a lot from what's there.

"They're a good group, very committed to C.C.R.C.s and wanting to do things to strengthen the industry," said Steve Maag, even though he's often on the other side of the fence as the director of residential communities for Leading Age, which represents nonprofit providers. "The stuff they put out is fairly accurate and well thought out."

Ms. Pearson also recommends an online tool called LifeSite Logics, started by a financial planner and an accountant who operate independently of C.C.R.C. developers and providers. LifeSite delivers financial data for hundreds of C.C.R.C.s — occupancy rates, operating margins, recent fee increases — for about $40 a search. Ms. Pearson discusses and links to LifeSite in a post on the Elder Law Prof Blog, which she writes and edits with other law professors.

People who live in these complexes tend to like them. "All of us believe in the C.C.R.C. way of life, the value and usefulness of seniors banding together to mutually help each other meet the contingencies of growing old," Mr. Seeger said.

But C.C.R.C.s essentially offer a form of long-term care insurance, in which seniors pay in advance to have care later on, with much less state regulation than insurance companies face.

"In boom times, they make so much sense," Ms. Pearson said of C.C.R.C.s. "With the slowdown in the economy, these issues have come about." Now that the recovery means more C.C.R.C.s on drawing boards, she doesn't want those issues forgotten.


Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."


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Well: Ha! The Quiz

Written By Unknown on Jumat, 21 Maret 2014 | 13.57

Laughter seems like the most natural response when something funny happens. But why don't we all laugh at the same thing? How the brain processes humor reveals some interesting truths about human nature. Take this quiz, based on the new book "Ha! The Science of When We Laugh and Why," by Scott Weems, to find out how much you know about your funny bone.



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Well: Ask Well: Exercises to Strengthen Bones

Q

What are good exercises to prevent osteoporosis?

What specific weight bearing or weight lifting exercises increase bone density in the spine?

A

In general, activities that involve impacts with the earth, such as running and jumping, are the most effective way to improve bone health, according to Dr. Jon Tobias, a professor of rheumatology at the University of Bristol who studies bone health. They create ground-reaction forces that move through your bones and stimulate them to "remodel" themselves and add density, he said. They also entail strong muscular contractions that tug at and slightly bend attached bones, redoubling the stimulating effects of the exercise.

Sprinting and hopping are the most obvious and well-studied examples of high-impact exercises. In one recent study, women ages 25 to 50 who leaped like fleas at least 10 times in a row, twice per day for four months, significantly increased the density of their hipbones. In another, more elaborate experiment from 2006, women who hopped and also lifted weights improved the density of their spines by about 2 percent compared to a control group, especially if the weight training targeted both the upper body and the legs. Women whose weight training focused only on the legs did not gain as much density in their spines.

Interestingly, weight training on its own does not seem to be an effective way to improve bone density. A 2005 study of adult female athletes, for instance, found that those participating in the highest-impact sports, including volleyball, hurdling, squash, soccer and speed skating, had denser bones than those competing in weight lifting. But the weight lifters did have healthier bones than those in the no-impact sports of bicycling and swimming,

Thankfully for those of us reluctant to take up speed skating or hurdling later in life, the amount of pounding required to stimulate bone remodeling in older people is probably less than it is for the young. Walking may be sufficient, if it's speedy. In the large-scale Nurses' Health Study of more than 60,000 postmenopausal women, those who walked briskly at least four times per week were at much lower risk of hip fractures (an indirect but practical indicator of bone health) than the women who walked less often, more slowly, or not at all.

Had the walkers occasionally jigged backwards and sideways, all the better. So-called odd impacts, created when you move in a direction other than straight ahead, can initiate remodeling throughout the hipbone and spine in older people, a few recent studies suggest.

So, too, may shaking up the bones by standing on a whole-body vibration platform, available nowadays at many health clubs. In a 2013 study, 28 postmenopausal women were randomized to use a vibration platform for five minutes, three times a week, or not to shake and pulsate. After six months, the vibrating women had 2 percent more spinal bone, while the control group had lost about half a percent. Not all studies to date of vibration training show bone benefits, but none have found harms, so you might investigate the option if, because of your health, balance or natural sense of dignity, you do not hop.


Do you have a health question? Submit your question to Ask Well.


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Well: The Bugs in Your Home Quiz

Written By Unknown on Kamis, 20 Maret 2014 | 13.57

How familiar are you with the creepy, crawly critters that live under your roof?

Scientists from the North Carolina Museum of Natural Sciences and North Carolina State University scoured 50 homes in the Raleigh, N.C., area. They often found as many as 100 or more different species of arthropods in a single house, including all of those below.

Take our quiz to find out what may be living in your home.


Photos taken by Matt Bertone. Read about the study at "The Bugs in Our Homes."


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Well: The Bugs in Our Homes

We swat flies on our windowsills. Watch ants scramble for the crumbs on our kitchen counters. Bathe our pets to rid them of fleas. And all of us have crossed paths with the nasty cockroach.



But what most of us don't know is that our homes are filled with a profusion of insects and their relatives, collectively called arthropods, most of which we never see.

In the summer and fall of 2012, I embarked on a postdoctoral study with a team of fellow entomologists from the North Carolina Museum of Natural Sciences and North Carolina State University to discover what arthropods can be found in our homes. It was the first comprehensive study of its kind, with the aim to uncover what people could expect to find, and why they might be there.

From the attic to the basement, ceiling to floor, we collected over 10,000 specimens — dead or alive — in 50 houses (volunteered by the public) within 30 miles of downtown Raleigh, N.C. Homeowners were surveyed and extensive notes were taken at each location.

Our team, led by Michelle Trautwein from the Museum of Natural Sciences and Rob Dunn and Matthew Bertone from North Carolina State, organized, sorted and identified the collected specimens to the family taxonomic level (or further when possible) at the museum's Biodiversity Laboratory. Processing was time-consuming and intricate, often requiring the identification of a piece of leg or broken wing.

Our initial results were surprising: as many as 100 or more different species of arthropods were often found in a single house.

As entomologists we reveled in cataloging this relatively unexplored frontier of urban biodiversity. Within the phylum Arthropoda, most of our specimens belonged to class Insecta. But there were also arachnids (spiders and their relatives), myriapods (centipedes and millipedes) and crustaceans (generally consisting of isopods, also known as pill bugs or roly-polies) – indeed, nearly 300 families and an estimated 750 species.

Over all, arthropod groups with the most diversity in houses were flies and beetles (with over 40 different families collected), followed by ants and wasps, spiders, stink bugs and relatives, book lice, moths, isopods, millipedes, springtails, silverfish and cockroaches. Many arthropod families were collected as singletons – one species of a family collected one time in one room in one house.

Several families were found in more than 90 percent of homes: gall midges (Cecidomyiidae), ants (Formicidae) and carpet beetles (Dermestidae), along with cobweb spiders (Theridiidae), dark-winged fungus gnats (Sciaridae), cellar spiders (Pholcidae), scuttle flies (Phoridae) and book lice (Liposcelididae). Most houses also had dust mites (Pyroglyphidae).

The good news is that most of these species are harmless, living with us in harmony or at least unnoticed. Many are even doing our dirty work. Carpet beetle larvae are busy eating dead insects, spilled dog food, even our nail clippings, while dust mites are like tiny vacuum cleaners, eating the dead skin cells on our floors and in our beds.

Some curious discoveries included spitting spiders (Scytodidae, found in 10 percent of homes), which spit a venomous silk on prey up to two centimeters away, and ant-loving crickets (Myrmecophilidae) only a few millimeters in size found in five different kitchens that also had ant infestations. We also observed nature in action: a parasitic wasp hatching out of true bug's egg; a leaf-footed bug with a fly egg glued to its head that, if allowed to hatch, would have eaten its host alive; and flesh flies (Sarcophagidae) emerging from a cat's recent rodent kill.

As much as we were surprised by what we did find, we were also surprised by what we didn't find or found in very small numbers: no bedbugs, only a few German cockroaches, and just one black widow (residing in a basement).

An unexpected finding from our study is that book lice lived in just about every house. Recent molecular analyses, including research by Kevin Johnson at the Illinois Natural History Survey, have shown that book lice and head lice are more closely related to each other than previously thought. Together with bark lice, they are now joined in a single order, Psocodea. Our findings suggest that different lice are likely here to stay, whether parasitically living on our scalps in the perfect itchy storm or benignly eating mildew from our old books. As a parent who has experienced the head lice battle, I've come to the realization that I just have to accept there is no escaping these arthropods.

Indeed, we can conclude that having a diversity of insects and other arthropods in our homes is the norm, and there's not much we can do about it. Plenty of houses that were sprayed regularly to kill pests still contained a wealth of arthropods. No homes were bug-free. Far from it.

Insects live near us, with us and on us, innocuous roommates in our urban dwellings – a veritable natural history museum in our homes.


More about the bugs in your home and emerging results from this study are at YourWildLife.org.


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Well: Study Questions Fat and Heart Disease Link

Written By Unknown on Selasa, 18 Maret 2014 | 13.57

Many of us have long been told that saturated fat, the type found in meat, butter and cheese, causes heart disease. But a large and exhaustive new analysis by a team of international scientists found no evidence that eating saturated fat increased heart attacks and other cardiac events.

The new findings are part of a growing body of research that has challenged the accepted wisdom that saturated fat is inherently bad for you and will continue the debate about what foods are best to eat.

For decades, health officials have urged the public to avoid saturated fat as much as possible, saying it should be replaced with the unsaturated fats in foods like nuts, fish, seeds and vegetable oils.

But the new research, published on Monday in the journal Annals of Internal Medicine, did not find that people who ate higher levels of saturated fat had more heart disease than those who ate less. Nor did it find less disease in those eating higher amounts of unsaturated fat, including monounsaturated fat like olive oil or polyunsaturated fat like corn oil.

"My take on this would be that it's not saturated fat that we should worry about" in our diets, said Dr. Rajiv Chowdhury, the lead author of the new study and a cardiovascular epidemiologist in the department of public health and primary care at Cambridge University.

But Dr. Frank Hu, a professor of nutrition and epidemiology at the Harvard School of Public Health, said the findings should not be taken as "a green light" to eat more steak, butter and other foods rich in saturated fat. He said that looking at individual fats and other nutrient groups in isolation could be misleading, because when people cut down on fats they tend to eat more bread, cold cereal and other refined carbohydrates that can also be bad for cardiovascular health.

"The single macronutrient approach is outdated," said Dr. Hu, who was not involved in the study. "I think future dietary guidelines will put more and more emphasis on real food rather than giving an absolute upper limit or cutoff point for certain macronutrients."

He said people should try to eat foods that are typical of the Mediterranean diet, like nuts, fish, avocado, high-fiber grains and olive oil. A large clinical trial last year, which was not included in the current analysis, found that a Mediterranean diet with more nuts and extra virgin olive oil reduced heart attacks and strokes when compared with a lower fat diet with more starches.

Alice H. Lichtenstein, a nutritional biochemist at Tufts University, agreed that "it would be unfortunate if these results were interpreted to suggest that people can go back to eating butter and cheese with abandon," citing evidence that replacing saturated fat with foods that are high in polyunsaturated fats – instead of simply eating more carbohydrates – reduces cardiovascular risk.

Dr. Lichtenstein, who was not involved in the latest study, was the lead author of the American Heart Association's dietary guidelines, which recommend that people restrict saturated fat to as little as 5 percent of their daily calories, or roughly two tablespoons of butter or two ounces of Cheddar cheese for the typical person eating about 2,000 calories a day. The heart association states that restricting saturated fat and eating more unsaturated fat, beans and vegetables can protect against heart disease by lowering low-density lipoprotein or so-called bad cholesterol.

In the new research, Dr. Chowdhury and his colleagues sought to evaluate the best evidence to date, drawing on nearly 80 studies involving more than a half million people. They looked not only at what people reportedly ate, but at more objective measures such as the composition of fatty acids in their bloodstreams and in their fat tissue. The scientists also reviewed evidence from 27 randomized controlled trials – the gold standard in scientific research – that assessed whether taking polyunsaturated fat supplements like fish oil promoted heart health.

The researchers did find a link between trans fats, the now widely maligned partially hydrogenated oils that had long been added to processed foods, and heart disease. But they found no evidence of dangers from saturated fat, or benefits from other kinds of fats.

The primary reason saturated fat has historically had a bad reputation is that it increases low-density lipoprotein cholesterol, or LDL, the kind that raises the risk for heart attacks. But the relationship between saturated fat and LDL is complex, said Dr. Chowdhury. In addition to raising LDL cholesterol, saturated fat also increases high-density lipoprotein, or HDL, the so-called good cholesterol. And the LDL that it raises is a subtype of big, fluffy particles that are generally benign. Doctors refer to a preponderance of these particles as LDL pattern A.

The smallest and densest form of LDL is more dangerous. These particles are easily oxidized and are more likely to set off inflammation and contribute to the buildup of artery-narrowing plaque. An LDL profile that consists mostly of these particles, known as pattern B, usually coincides with high triglycerides and low levels of HDL, both risk factors for heart attacks and stroke.

The smaller, more artery-clogging particles are increased not by saturated fat, but by sugary foods and an excess of carbohydrates, Dr. Chowdhury said. "It's the high carbohydrate or sugary diet that should be the focus of dietary guidelines," he said. "If anything is driving your low-density lipoproteins in a more adverse way, it's carbohydrates."

While the new research showed no relationship overall between saturated or polyunsaturated fat intake and cardiac events, there are numerous unique fatty acids within these two groups, and there was some indication that they are not all equal.

When the researchers looked at fatty acids in the bloodstream, for example, they found that margaric acid, a saturated fat in milk and dairy products, was associated with lower cardiovascular risk. Two types of omega-3 fatty acids, the polyunsaturated fats found in fish, were also protective. But a number of the omega-6 polyunsaturated fatty acids, commonly found in vegetable oils and processed foods, may pose risks, the findings suggested.

The researchers then looked at data from the randomized trials to see if taking supplements like fish oil produced any cardiovascular benefits. It did not.

But Dr. Chowdhury said there might be a good explanation for this discrepancy. The supplement trials mostly involved people who had pre-existing heart disease or were at high risk of developing it, while the other studies involved generally healthy populations.

So it is possible that the benefits of omega-3 fatty acids lie in preventing heart disease, rather than treating or reversing it. At least two large clinical trials designed to see if this is the case are currently underway.


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Well: A Surgical Procedure’s Risks, Unmentioned

Written By Unknown on Senin, 17 Maret 2014 | 13.57

Personal Health

Jane Brody on health and aging.

Many patients assume that, like prescription drugs, surgical procedures and instruments undergo extensive testing and must be government-approved. It's not necessarily so.

Developers, of course, do test new instruments, and practitioners often train with an expert before using them unsupervised to treat patients. And the Food and Drug Administration must confirm an instrument's safety and effectiveness before it can be marketed — but only if the device is deemed significantly different from others already approved.

Surgical techniques, however, are not subject to the stringent approval process that drugs go through. And as with drugs, problems with new procedures may not become apparent until after they have been used many hundreds or thousands of times.

Such is the case with a popular treatment for a very common medical problem: uterine fibroids. The technique, called electric or power morcellation, has widespread appeal for both surgeons and patients. It is used during laparoscopic or robotic-assisted operations that are fast and effective, require only a tiny incision or none at all, and involve less pain, a shorter hospital stay and a quicker recovery. In most cases, these operations are safer than traditional surgery.

As recent reports have shown, however, power morcellation can also cause serious and sometimes life-threatening complications. Experts say that prospective patients are often not told about these risks before consenting to the operation.

The technique involves insertion of a tiny instrument with a rapidly rotating blade, the morcellator, that breaks up the fibroid so that it can be sucked out through the small opening of a laparoscope. But problems can arise months or years later if pieces of tissue escape into the pelvic cavity and seed themselves on other organs.

This problem is all the more serious if the fibroid that was morcellated happens to have contained a hidden cancer. Although the overwhelming majority of fibroids are benign, there is no certain way to tell before their removal if they harbor a cancer, which happens in 1 in 400 to 1 in 1,000 cases.

One such case involves a 41-year-old Bostonian, Dr. Amy J. Reed, an anesthesiologist and a mother of six, who now has a Stage 4 leiomyosarcoma after undergoing uterine morcellation. It is a rare but particularly aggressive uterine cancer. Dr. Reed and her husband, Dr. Hooman Noorchashm, a cardiothoracic surgeon, are waging a campaign through Change.org to halt use of the technique.

Despite several preoperative tests, neither Dr. Reed nor her surgeon suspected that cancer lurked within the fibroids that were removed. If she had had a traditional operation in which the fibroids were cut out or the entire uterus removed intact, it is highly unlikely that the cancer would have spread.

From 1983 through 2010, 13 unexpected uterine sarcomas were reported after uterine surgery on 5,666 patients. Among 1,192 women who underwent morcellation, two developed sarcoma that spread within the abdomen.

After reviewing the medical records of more than 1,000 women who received morcellation for fibroids, specialists at Brigham & Women's Hospital in Boston found a ninefold higher rate of unexpected sarcoma than is now quoted to patients considering the procedure.

"These data suggest uterine morcellation carries a risk of disseminating unexpected malignancy with apparent associated risk of mortality much higher than appreciated currently," the researchers wrote in the journal PLOS One in 2012.

Even benign uterine tissue, when it is spread to other parts of the abdomen during morcellation, can grow in places it doesn't belong and cause pain, infection or bowel obstruction.

There is a technique that could make morcellation safer: encasing the tissue to be removed in a bag before it is broken up. But thus far, the procedure is infrequently used, and few surgeons are skilled in the technique.

Other established ways to treat bothersome fibroids are free of this potential risk, though complications like wound infection are possible.

Fibroids are extremely common, affecting half or more women during their reproductive years, when hormones foster their growth. They develop from the smooth muscle tissue of the uterus, ranging in size from tiny to huge, and often shrink after pregnancy and menopause.

Most women with fibroids are unaware they have them, but others can experience symptoms like prolonged heavy periods, bleeding between periods, pelvic pressure, constipation, frequent urination, backaches and anemia. They can sometimes cause infertility or miscarriage.

Fibroids are typically detected through a pelvic exam, sonogram or M.R.I., sometimes with saline solution or a dye used to better define their size and location.

Nothing needs to be done about a fibroid that causes no distress. Large, bothersome fibroids can often be shrunk by several months of treatment with medications that block estrogen and progesterone, causing temporary menopause and its attendant symptoms.

The "morning after" pill, mifepristone (RU-486), also can shrink fibroids, and Evista may do likewise, but only in postmenopausal women. Sometimes a low-dose oral contraceptive is used to reduce bleeding caused by fibroids without shrinking their size.

Noninvasive ultrasound surgery under M.R.I. guidance can be used to heat and destroy a fibroid without damaging the uterus. A fibroid also can be destroyed by injecting small particles into uterine arteries to cut off its blood supply.

Fibroids can be removed laparoscopically or robotically without damaging the uterus. If the fibroid is contained within the uterus, it can often be removed with surgical instruments inserted through the vagina and cervix. Some fibroids may be destroyed by applying heat or electric current to the uterine lining.

Very large, multiple or deep fibroids may require more traditional surgery, called an abdominal myomectomy, that spares the uterus, or with a hysterectomy, a more serious operation involving removal of the entire uterus, ending a woman's menstrual periods and ability to bear children.

If you are contemplating treatment for symptomatic fibroids, your doctor should answer several important questions before you choose a method:

What is the nature of the problem, and how necessary is it to treat it?

What procedures are known to be effective, and what are the risks and benefits of each?

What is the approach you recommend, and how much experience do you have with it?

What are its possible complications, and how often do they occur?

Without a clear understanding of treatment options, their potential hazards as well as their effectiveness, it is not possible to for you to give informed consent.


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The New Old Age Blog: Mammography’s Limits, Seldom Understood

Written By Unknown on Sabtu, 15 Maret 2014 | 13.58

A sad fact: None of the eight major clinical trials looking at whether regular mammograms reduce a woman's risk of dying from breast cancer has included women over age 75.

Older adults are frequently excluded from trials, a problem for those trying to treat them based on information, not hunches. This helps explain why the United States Preventive Services Task Force says the current evidence is "insufficient" to assess mammography's value for those over age 75, and why the American Geriatrics Society cautions against it for women with limited life expectancies.

Not only may mammograms not help, like any medical procedure, they may also harm. Mammograms can result in false positives that require additional tests, including biopsies, and bring anxiety. The scans may identify small tumors that wouldn't have caused problems for years — or at all, since older women are far more likely to die from other causes.

Yet once a mammogram detects even a non-invasive cancer, "it's very hard to decide not to be treated," said Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston. Since most women over age 75 still get mammograms, thousands of them undergo unnecessary surgery, radiation and medication every year.

What women need, she and several colleagues agreed, is a "decision aid," a tool that clarifies a medical procedure and its likely results. Once they understand the pros and cons of mammograms, "women can make better decisions based on realistic information about their risks," she said. Dr. Schonberg, who has investigated breast cancer screening among older women for years, noted that women don't hear much about the cons.

She and her colleagues decided to put together an 11-page pamphlet, written clearly at a sixth-grade reading level. It points out that doctors don't know whether mammograms lower mortality in this age group. (Indeed, there is wide disagreement over whether regular mammograms lower mortality in any age group.) The guide estimates that out of 1,000 women over 75, three of those who get mammograms will die of breast cancer and so will four of those who don't, a tiny difference.

Its charts show that heart disease, other cancers, stroke and dementia are far greater threats to elderly women. It even helps women calculate their life expectancy, to see whether a mammogram is likely to extend their lives.

Then the researchers tried a small pilot study, asking 45 women aged 75 to 89 who'd had a mammogram within two years to use the pamphlet.

Did it help? Maybe. Sort of.

Yes, the information did significantly improve their knowledge, results published in the journal JAMA Internal Medicine show. The women scored higher on a true-false test about the benefits and risks of breast cancer screening after they read the pamphlet than they had beforehand.

Yes, it did lead to more conversations about the decision with primary care doctors: In the five years before this experiment, patient medical records showed, only 11 percent had had such discussions. In the six months after reading the guide, 53 percent did.

And yes, the proportion of this small group who intended to continue screening dropped substantially, especially among those with a calculated life expectancy of nine years or less. In that group, 85 percent had earlier said they intended to get another mammogram; after the guide, 50 percent did. The guide didn't make a significant difference in the group with a longer life expectancy.

Women said they liked the pamphlet and found it useful. Their doctors said so, too.

And yet 60 percent of these older women went ahead and got another mammogram within 15 months, including more than half of those with a lower life expectancy.

It was tough to persuade women to start getting regular mammograms back in the 1970s, when the American Cancer Society and the former first lady Betty Ford began campaigning for annual screening. Decades later, it's tough to get older women to stop. Ditto for other cancer screenings — Pap tests, prostate tests, colonoscopies —among both older men and women.

These decisions involve more than a risk/reward calculation, clearly. When it comes to mammograms, "women go for reassurance, for affirmation of their health," Dr. Schonberg said. Her own studies show that "they felt this was the responsible thing to do," what Dr. Alexia Torke, associate director of the Indiana University Center for Aging Research, has termed "a moral obligation."

Some women don't recognize that there's a decision to be made at all. "Radiologists send you an annual reminder card," Dr. Schonberg said. "You're just told, 'go.'" (The Preventive Services Task Force recommendation is every two years, not annually, up to age 74.)

Still, this remains an individual decision. Women who see the whole picture and decide to continue with mammograms — Medicare pays for one each year — at least have reached an informed decision.

So I hope Dr. Schonberg's pamphlet gets widely circulated. She's about to test it with a much larger sample of about 500 women in Massachusetts and North Carolina, then report her findings.

And then we'll publish a link to the guide here, for anyone to use.


Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."


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Doctor and Patient: Emergency Rooms Are No Place for the Elderly

Written By Unknown on Jumat, 14 Maret 2014 | 13.58

Doctor and Patient

Dr. Pauline Chen on medical care.

The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who'd watched him hobble down the building's stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

"Of course, if things get worse before the week's up," I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, "come back here right away."

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man's face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. "Just admit him," she whispered. "It'll cost more, but it's the only way you'll be sure he's getting the right care."

I remembered the nurse's advice, and the patient I ended up admitting, when I came upon a recent paper and report on the care of elderly patients in American emergency rooms.

The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms.

But given longstanding trends in American medicine, it's hard to imagine a health care setting more ill suited for the elderly than today's emergency rooms.

Over the last five decades, quality emergency care has become synonymous with speed. Survival rates for patients in the throes of a stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. Even the physical environment where emergency care takes place has become a paragon of medical efficiency — large echoing spaces that can be divided at a moment's notice with panels of curtains, slick linoleum floors that can be mopped up in minutes and bright fluorescent lights.

More recently, as overcrowding has become a significant problem, the drive for efficiency has become more pronounced, with doctors and nurses having to work as quickly as possible simply to see all the patients.

But when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued by multiple chronic diseases like diabetes, high blood pressure and heart disease, take numerous prescription drugs that can cross-react in potentially dangerous ways and suffer from ills like dementia that can make the answer to even the simplest of questions – What brought you to the emergency room today? – difficult to understand.

For several years now, a small but dedicated group of emergency medicine and geriatrics specialists has been working to improve this situation. And over the last three months, first in an article published in the national health policy journal Health Affairs, then in an impressive set of evidence-based guidelines supported by several national professional medical and nursing organizations, they have issued a call to arms to the rest of the medical profession.

To meet the needs of the rapidly growing elderly population, these specialists assert, medical centers must "geriatricize" their emergency departments.

And they offer a plethora of practical advice for doing so. Among their suggestions: Hire providers trained in caring for older patients. Routinely administer quick but effective screening tests for dementia and other cognitive impairments. Install non-slip flooring and more sound-absorbing materials to decrease the risk of falls and dampen noise levels. And train all staff members to be more attuned to social factors that can affect care for the elderly, like the necessity of arranging for transportation to get to follow-up medical visits, the need for walkers, canes and other medical equipment to get around the home and for extra help to get prescriptions filled and taken correctly.

Similar changes have already been put in place to improve pediatric, trauma and cardiac emergency care. But a larger stumbling block remains: getting a greater proportion of hospital administrators, health care providers and the public at large to become interested in care for the elderly.

"Older adults aren't the kind of patients people gravitate toward," said Dr. Ula Hwang, lead author of the paper in Health Affairs, a member of the task force that compiled the guidelines and an associate professor of emergency medicine and geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai. "There's a reason you don't see the frail, cognitively and functionally impaired older patient on television medical shows."

Nonetheless, Dr. Hwang and her colleagues remain optimistic. About 50 medical centers have incorporated such changes into their emergency departments, a notable improvement from a decade ago, when none existed. And by emphasizing close attention to the individual's experience, many of these redesigned departments are not only improving care but also redefining what is possible for doctors and patients, even in one of the most critical of care settings.

"We can really become partners in improving care, instead of just putting a Band-Aid on the problem," Dr. Hwang said. "We can give our elderly patients, our parents and our grandparents the kind of respect and understanding that we owe them."


13.58 | 0 komentar | Read More

Well: To Keep Teenagers Alert, Schools Let Them Sleep In

COLUMBIA, Mo. – Jilly Dos Santos really did try to get to school on time. She set three successive alarms on her phone. Skipped breakfast. Hastily applied makeup while her fuming father drove. But last year she rarely made it into the frantic scrum at the doors of Rock Bridge High School here by the first bell, at 7:50 a.m.

Then she heard that the school board was about to make the day start even earlier, at 7:20 a.m.

"I thought, if that happens, I will die," recalled Jilly, 17. "I will drop out of school!"

That was when the sleep-deprived teenager turned into a sleep activist. She was determined to convince the board of a truth she knew in the core of her tired, lanky body: Teenagers are developmentally driven to be late to bed, late to rise. Could the board realign the first bell with that biological reality?

The sputtering, nearly 20-year movement to start high schools later has recently gained momentum in communities like this one, as hundreds of schools in dozens of districts across the country have bowed to the accumulating research on the adolescent body clock.

In just the last two years, high schools in Long Beach, Calif.; Stillwater, Okla.; Decatur, Ga.;, and Glens Falls, N.Y., have pushed back their first bells, joining early adopters in Connecticut, North Carolina, Kentucky and Minnesota. The Seattle school board will vote this month on whether to pursue the issue. The superintendent of Montgomery County, Md., supports the shift, and the school board for Fairfax County, Va., is working with consultants to develop options for starts after 8 a.m.

New evidence suggests that later high school starts have widespread benefits. Researchers at the University of Minnesota, funded by the Centers for Disease Control and Prevention, studied eight high schools in three states before and after they moved to later start times in recent years. In results released Wednesday they found that the later a school's start time, the better off the students were on many measures, including mental health, car crash rates, attendance and, in some schools, grades and standardized test scores.

Dr. Elizabeth Miller, chief of adolescent medicine at Children's Hospital of Pittsburgh, who was not involved in the research, noted that the study was not a randomized controlled trial, which would have compared schools that had changed times with similar schools that had not. But she said its methods were pragmatic and its findings promising.

"Even schools with limited resources can make this one policy change with what appears to be benefits for their students," Dr. Miller said.

Researchers have found that during adolescence, as hormones surge and the brain develops, teenagers who regularly sleep eight to nine hours a night learn better and are less likely to be tardy, get in fights or sustain athletic injuries. Sleeping well can also help moderate their tendency toward impulsive or risky decision-making.

During puberty, teenagers have a later release of the "sleep" hormone melatonin, which means they tend not to feel drowsy until around 11 p.m. That inclination can be further delayed by the stimulating blue light from electronic devices, which tricks the brain into sensing wakeful daylight, slowing the release of melatonin and the onset of sleep. The Minnesota study noted that 88 percent of the students kept a cellphone in their bedroom.

But many parents, and some students, object to shifting the start of the day later. They say doing so makes sports practices end late, jeopardizes student jobs, bites into time for homework and extracurricular activities, and upsets the morning routine for working parents and younger children.

At heart, though, experts say, the resistance is driven by skepticism about the primacy of sleep.

"It's still a badge of honor to get five hours of sleep," said Dr. Judith Owens, a sleep expert at the Children's National Medical Center in Washington. "It supposedly means you're working harder, and that's a good thing. So there has to be a cultural shift around sleep."

Last January, Jilly decided she would try to make that change happen in the Columbia school district, which sprawls across 300 square miles of flatland, with 18,000 students and 458 bus routes. But before she could make the case for a later bell, she had to show why an earlier one just would not do.

She got the idea in her team-taught Advanced Placement world history class, which explores the role of leadership. Students were urged to find a contemporary topic that ignited their passion. One morning, the teachers mentioned that a school board committee had recommended an earlier start time to solve logistical problems in scheduling bus routes. The issue would be discussed at a school board hearing in five days. If you do not like it, the teachers said, do something.

Jilly did the ugly math: A first bell at 7:20 a.m. meant she would have to wake up at 6 a.m.

She had found her passion.

She seemed an unlikely choice to halt what was almost a done deal. She was just a sophomore, and did not particularly relish conflict. But Jilly, the youngest of seven children, had learned to be independent early on: Her mother died when she was 9.

And she is energetic and forthright. That year, she had interned on a voter turnout drive for Missouri Democrats, volunteered in a French-immersion prekindergarten class, written for the student newspaper, worked at a fast-food pizza restaurant and maintained an A average in French, Spanish and Latin.

"It's about time management," she explained one recent afternoon, curled up in an armchair at home.

That Wednesday, she pulled an all-nighter. She created a Facebook page and set up a Twitter account, alerting hundreds of students about the school board meeting: "Be there to have a say in your school district's decisions on school start times!"

She then got in touch with Start School Later, a nonprofit group that provided her with scientific ammunition. She recruited friends and divided up sleep-research topics. With a blast of emails, she tried to enlist the help of every high school teacher in the district. She started an online petition.

The students she organized made hundreds of posters and fliers, and posted advice on Twitter: "If you are going to be attending the board meeting tomorrow we recommend that you dress up!"

The testy school board meeting that Monday was packed. Jilly, wearing a demure, ruffled white blouse and skirt, addressed the board, blinking owl-like. The dignitaries' faces were a blur to her because while nervously rubbing her eyes, she had removed her contact lenses. But she spoke coolly about the adolescent sleep cycle: "You know, kids don't want to get up," she said. "I know I don't. Biologically, we've looked into that."

The board heatedly debated the issue and decided against the earlier start time.

The next day Jilly turned to campaigning for a later start time, joining a movement that has been gaining support. A 2011 report by the Brookings Institution recommended later start times for high schools, and last summer Arne Duncan, the secretary of education, posted his endorsement of the idea on Twitter.

The University of Minnesota study tracked 9,000 high school students in five districts in Colorado, Wyoming and Minnesota before and after schools shifted start times. In those that originally started at 7:30 a.m., only a third of students said they were able to get eight or more hours of sleep. Students who got less than that reported significantly more symptoms of depression, and greater use of caffeine, alcohol and illegal drugs than better-rested peers.

"It's biological — the mental health outcomes were identical from inner-city kids and affluent kids," said Kyla Wahlstrom, a professor of educational research at the University of Minnesota and the lead author of the study.

In schools that now start at 8:35 a.m., nearly 60 percent of students reported getting eight hours of sleep nightly.

In 2012, the high school in Jackson, Wyo., moved the first bell to 8:55 a.m. from 7:35 a.m. During that academic year, car crashes by drivers 16 to 18 years old dropped to seven from 23 the year before. Academic results improved, though not across the board.

After high schools in the South Washington County district, outside Minneapolis, switched to an 8:35 a.m. start, grades in some first- and third-period classes rose between half a point and a full grade point. And the study found that composite scores on national tests such as the ACT rose significantly in two of the five districts.

Many researchers say that quality sleep directly affects learning because people store new facts during deep-sleep cycles. During the rapid-eye-movement phases, the brain is wildly active, sorting and categorizing the day's data. The more sleep a teenager gets, the better the information is absorbed.

"Without enough sleep," said Jessica Payne, a sleep researcher and assistant professor of psychology at the University of Notre Dame, "teenagers are losing the ability not only to solidify information but to transform and restructure it, extracting inferences and insights into problems."

Last February, the school board in Columbia met to consider later start times. "It is really reassuring to know that students can have a say in the matter," Jilly told them. "So thank you, guys, for that."

The moment of decision arrived at the board's next meeting in March. Jilly sat in the front row, posting on Twitter, and addressed the board one last time. "I know it's not the most conventional thing and it's going to get some pushback," she said, referring to the later time. "But it is the right decision."

The board voted, 6 to 1, to push back the high school start time to 9 a.m. "Jilly kicked it over the edge for us," said Chris Belcher, the superintendent.

It is now seven months into the new normal. At Rock Bridge High School, the later end to the day, at 4:05 p.m., is problematic for some, including athletes who often miss the last period to make their away games.

"After doing homework, it gets to be 11:30 p.m. pretty quickly," said Brayden Parker, a senior varsity football player. "I would prefer to get home by dark and have more time to chill out."

The high schools in the district have tried to adjust, for example by adding Wi-Fi access to buses so athletes can do homework on the road. Some classes meet only one or two days a week, and are supplemented with online instruction. More sports practices and clubs convene before school.

Some parents and first-period teachers are seeing a payoff in students who are more rested and alert.

At 7:45 a.m. on a recent school day, Rock Bridge High, a long, one-story building with skylights and wide hallways, was sun-drenched and almost silent.

Then, like an orchestra tuning up, students gradually started arriving, some for debate club and choir, others to meet in the cafeteria for breakfast and gossip. Laughter crackled across the lobby, as buses dropped off more students, and others drifted in from the parking lots. The growing crowds could almost be described as civilized.

At 8:53 a.m., Jilly burst through the north entrance door, long hair uncombed and flyaway, wearing no makeup, lugging her backpack.

"Even when I am late to school now," she said, dashing down a corridor to make that 8:55 bell, "it's only by three or four minutes."

A version of this article appears in print on 03/14/2014, on page A1 of the NewYork edition with the headline: To Keep Teenagers Alert, Schools Start to Let Them Sleep In.

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Well: Ask Well: Laser Treatments for Nail Fungus

Q

How effective are laser treatments for toe nail fungus?

Is there any medical evidence suggesting that laser treatments actually work for fungal infections in toenails?

A

Laser treatments for nail fungus have become fairly common since the procedure was approved by the Food and Drug Administration four years ago. Several kinds of laser therapies are now available, but there is limited evidence that the treatments work.

The appeal of lasers is that they selectively heat and destroy harmful fungi while sparing healthy surrounding tissue. And some small studies and lab tests suggest they can kill the fungi and cure the condition.

But in one of the best studies to date, published last year in The Journal of the American Academy of Dermatology, researchers at the University of Alabama at Birmingham found that laser treatments produced no improvements in patients with toenail fungus, even after five sessions.

The procedures are generally not covered by insurance, and a course of treatment typically involves multiple sessions, each costing hundreds of dollars, said Dr. Andrea Bershow, the director of the nail procedure clinic at the Minneapolis VA Health Care System.

"I think we want it to work, but the evidence just isn't quite there yet," said Dr. Bershow, who published a report last year that reviewed current research. "The studies that have shown efficacy have been small, they haven't been randomized controlled trials, and most of them have been funded by the actual laser companies themselves."

Dr. Bershow says she frequently treats patients with the oral drug Lamisil because it is cheap, it works and it is generally very safe. But many people are reluctant to take it because in very rare cases it may cause liver damage. When all else fails, some patients elect to have their toenail removed and the nail matrix medically destroyed to prevent the nail from growing back.

Dr. Bershow is frequently asked about laser treatments, but she never recommends them.

"The reason is that I don't know if it works, but it does cost a lot of money," she said. "I would hate to tell someone to go try something that insurance doesn't cover, that could cost them thousands of dollars, and that may or may not work."


Do you have a health question? Submit your question to Ask Well.


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Doctor and Patient: Emergency Rooms Are No Place for the Elderly

Doctor and Patient

Dr. Pauline Chen on medical care.

The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who'd watched him hobble down the building's stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

"Of course, if things get worse before the week's up," I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, "come back here right away."

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man's face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. "Just admit him," she whispered. "It'll cost more, but it's the only way you'll be sure he's getting the right care."

I remembered the nurse's advice, and the patient I ended up admitting, when I came upon a recent paper and report on the care of elderly patients in American emergency rooms.

The number of older people seeking health care is expected to increase significantly over the next 40 years, doubling in the case of those older than 65, potentially tripling among those over 85. In a health care system already critically short of primary care providers and geriatrics specialists, many of these older patients will likely end up in emergency rooms.

But given longstanding trends in American medicine, it's hard to imagine a health care setting more ill suited for the elderly than today's emergency rooms.

Over the last five decades, quality emergency care has become synonymous with speed. Survival rates for patients in the throes of a stroke, heart attack or traumatic injury depend on the number of minutes needed to triage, diagnose and treat. Even the physical environment where emergency care takes place has become a paragon of medical efficiency — large echoing spaces that can be divided at a moment's notice with panels of curtains, slick linoleum floors that can be mopped up in minutes and bright fluorescent lights.

More recently, as overcrowding has become a significant problem, the drive for efficiency has become more pronounced, with doctors and nurses having to work as quickly as possible simply to see all the patients.

But when it comes to elderly patients, it is nearly impossible to work quickly. Many are plagued by multiple chronic diseases like diabetes, high blood pressure and heart disease, take numerous prescription drugs that can cross-react in potentially dangerous ways and suffer from ills like dementia that can make the answer to even the simplest of questions – What brought you to the emergency room today? – difficult to understand.

For several years now, a small but dedicated group of emergency medicine and geriatrics specialists has been working to improve this situation. And over the last three months, first in an article published in the national health policy journal Health Affairs, then in an impressive set of evidence-based guidelines supported by several national professional medical and nursing organizations, they have issued a call to arms to the rest of the medical profession.

To meet the needs of the rapidly growing elderly population, these specialists assert, medical centers must "geriatricize" their emergency departments.

And they offer a plethora of practical advice for doing so. Among their suggestions: Hire providers trained in caring for older patients. Routinely administer quick but effective screening tests for dementia and other cognitive impairments. Install non-slip flooring and more sound-absorbing materials to decrease the risk of falls and dampen noise levels. And train all staff members to be more attuned to social factors that can affect care for the elderly, like the necessity of arranging for transportation to get to follow-up medical visits, the need for walkers, canes and other medical equipment to get around the home and for extra help to get prescriptions filled and taken correctly.

Similar changes have already been put in place to improve pediatric, trauma and cardiac emergency care. But a larger stumbling block remains: getting a greater proportion of hospital administrators, health care providers and the public at large to become interested in care for the elderly.

"Older adults aren't the kind of patients people gravitate toward," said Dr. Ula Hwang, lead author of the paper in Health Affairs, a member of the task force that compiled the guidelines and an associate professor of emergency medicine and geriatrics and palliative care at the Icahn School of Medicine at Mount Sinai. "There's a reason you don't see the frail, cognitively and functionally impaired older patient on television medical shows."

Nonetheless, Dr. Hwang and her colleagues remain optimistic. About 50 medical centers have incorporated such changes into their emergency departments, a notable improvement from a decade ago, when none existed. And by emphasizing close attention to the individual's experience, many of these redesigned departments are not only improving care but also redefining what is possible for doctors and patients, even in one of the most critical of care settings.

"We can really become partners in improving care, instead of just putting a Band-Aid on the problem," Dr. Hwang said. "We can give our elderly patients, our parents and our grandparents the kind of respect and understanding that we owe them."


13.58 | 0 komentar | Read More
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