Well: Shingles Can Increase Heart Attack Risk

A British study has found that having shingles can increase the risk for heart attacks.

The retrospective study, published in Neurology, included 106,601 shingles cases and 213,202 matched controls. The researchers followed the subjects for an average of 6.3 years after they contracted shingles.

After adjusting for body mass index, smoking, cholesterol, hypertension, diabetes and other vascular risk factors, they found that over all, having shingles increased the risk of a heart attack by 10 percent and the risk of a so-called mini-stroke, or transient ischemic attack, by 15 percent, though it did not alter the risk of having a major stroke.

But in people who developed shingles before age 40, the relative risks increased dramatically: a 2.4-fold increased risk for stroke, a 1.5-fold increase for transient ischemic attack, or T.I.A., and a 1.74-fold increase for heart attack.

The reasons are not completely clear, but the herpes zoster virus can spread to the blood vessels from the nerves and cause inflammation, which may lead to vascular disease.

"If you have shingles, get yourself checked for other vascular risks," said the lead author, Dr. Judith Breuer, a professor of virology at University College London. "We need to do more studies to figure out if preventing shingles is also a way of preventing stroke, heart attack and T.I.A.," she added. "But if you have other risk factors, you may want to consider the zoster vaccination."

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A Resisted Pill to Prevent H.I.V.

SAN FRANCISCO — Over a cup of tea at a downtown Starbucks, Michael Rubio recalled how four friends became H.I.V. positive through unprotected sex, all within a year. The news shocked Mr. Rubio, a 28-year-old gay man, into trying a controversial new form of H.I.V. prevention: a daily pill that studies show is highly effective in protecting people from infection.

"With my inner circle so affected in the last year, it was a no-brainer to consider this for my life right now," said Mr. Rubio, a front-office coordinator at the Positive Resource Center, a social service agency for people with H.I.V.

The very existence of that option represents a startling turn in the too-long history of the AIDS epidemic. Many health experts hoped that the medication — Truvada, a combination of two antiviral drugs that has been used to treat H.I.V. since 2004 — would be exuberantly embraced by H.I.V.-negative gay men. Instead, Truvada has been slow to catch on as an H.I.V. preventive in the 18 months since the strategy's approval by the Food and Drug Administration. In some quarters, the idea that healthy gay men should take a medication to prevent infection — an approach called pre-exposure prophylaxis, or PrEP — has met with hostility or indifference.

"It's gotten tons of attention at H.I.V. meetings as a new tool for prevention, and I consider it an important option for the right person," said Dr. Lisa Capaldini, a primary care doctor here who treats many gay men. "And yet there's been very little interest among my patients. There's a fascinating disconnect."

For 30 years, public health officials have aggressively promoted condom use during every sexual encounter as the only effective method, apart from abstinence, for preventing H.I.V. transmission. Still, 50,000 new infections are occurring annually in the United States; sexual transmission between men accounts for more than half of them, and a disproportionate number among African-Americans and other minorities.

Many experts hailed Truvada as an opportunity to reduce new infections among high-risk groups like young gay men, people in relationships with H.I.V.-positive partners, and prostitutes. The F.D.A. called for prescriptions to be accompanied by counseling, frequent H.I.V. testing, and continued promotion of safer sex, although research suggests that daily use of the pill alone confers close to full protection.

For many gay men, and for some public health officials, the new option has brought both hope and confusion.

"We've had several decades of the recommendation to use condoms," said Dr. Kenneth H. Mayer, a professor of medicine at Harvard University and the medical research director at Fenway Health, a community center in Boston with many lesbian and gay patients. "Now we're saying, 'Here's a pill that might protect you if you don't use condoms.' So it's flying in the face of community norms."

Certainly, fewer people have tried PrEP than many experts had anticipated. According to an analysis by Gilead Sciences, which makes the drug, data from more than half of retail pharmacies nationwide indicated that 1,774 people filled prescriptions for Truvada for H.I.V. prevention from January 2011 (it could be prescribed off-label before the F.D.A. approval) through March 2013. The numbers did not include the thousands already receiving the drug as research participants.

Almost half of the prescriptions were for women, a surprise to those who expected gay men to be the early adopters. Dr. Deborah Cohan, an obstetrician and gynecologist at the University of California, San Francisco, has prescribed it to several women with H.I.V.-positive partners, including one seeking to get pregnant.

"It's beautiful that we have this intervention that works for women who need it," Dr. Cohan said.

So why haven't more gay men signed up?

Some men have reported receiving negative reactions from their health care providers when they brought it up. Use of the drug as a preventive can be stigmatizing among gay men as well: the term "Truvada whore" has been bandied about on some social networks.

And many simply may not know much about the strategy. Gilead has not launched a public campaign to market Truvada for prevention, but has instead sponsored activities by other organizations. Fenway Health, for example, has received Gilead funding for some PrEP-related education and research.

Potential side effects like kidney damage and a loss of bone density, although rare, are also a concern. And Truvada is expensive: more than $1,000 a month. So far, private and public insurers, including state Medicaid programs, have generally covered the drug for prevention. (Gilead also provides it to some patients who cannot afford it.)

But a generational shift in attitudes toward H.I.V. among gay men may also be playing a role, some experts say. With advances in treatment, many younger men who did not experience the worst years of the epidemic are less fearful of the consequences of infection. Moreover, current medications can lower viral levels in H.I.V.-positive people to the point where the risk of transmission is negligible, further reducing the perceived need for PrEP among H.I.V.-negative partners.

Damon Jacobs, a New York psychotherapist, began taking Truvada following the breakup of a long-term relationship. "I found that I was no longer as consistent with condom use as I had been in earlier days, and that scared me greatly," said Mr. Jacobs, 42, who maintains a Facebook page promoting PrEP. He said that he has not missed a dose in two years; he also acknowledged that he was now much less likely to use condoms.

That sort of acknowledgment makes some health care experts nervous, despite Truvada's efficacy when used daily. The AIDS Healthcare Foundation, a major H.I.V. services provider based in Los Angeles, lobbied against F.D.A. approval of Truvada for H.I.V. prevention, arguing that men taking the medication would be likelier to pursue riskier sexual practices.

Certainly, "condom fatigue" among gay men is real. The proportion who reported unprotected anal sex in the previous year rose to 57 percent in 2011 from 48 percent in 2005, according to the Centers for Disease Control and Prevention.

But a recent study found that men in a large clinical trial who believed they were taking Truvada rather than placebo did not increase their risky behavior. For his part, Mr. Rubio, the San Francisco coordinator, said he remained "adamant" about using condoms. "For me, this is a whole other layer of protection," he said.

Adherence to the drug regimen is another thorny issue. The major trial that confirmed Truvada as an effective H.I.V. preventive among men who have sex with men, also found that many participants did not take the pill every day, leaving them more vulnerable to infection.

Michael Weinstein, president of the AIDS Healthcare Foundation, warned that drug adherence will continue to be a problem, likely leading to more infections and the emergence of drug-resistant H.I.V. strains. "If you don't take the medication every day and you don't use condoms, and you're highly sexually active, you're going to get infected," Mr. Weinstein said.

Advocates for PrEP argue, without substantial evidence to date, that people now taking and starting Truvada for prevention may be more likely to follow instructions because they know that it works, unlike participants in the early clinical trials.

In any event, the protocol for pre-exposure prophylaxis is itself likely to undergo significant changes as findings emerge from current and upcoming research into other formulations of Truvada such as gels or injectables, less frequent dosing regimens, and the use of other medications altogether.

"People are not lining up, but I'm not pessimistic," said Dr. Mayer of Fenway Health. "It's going to take time. It's really early days."

This article has been revised to reflect the following correction:

Correction: December 31, 2013

An earlier version of this article referred incorrectly to Michael Weinstein, president of the AIDS Healthcare Foundation. Though he has an honorary doctoral degree, he is not a medical doctor and therefore is not Dr. Michael Weinstein.

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Op-Ed Contributor: Can Animals Help Limit Concussions?

CINCINNATI — THE N.F.L. playoffs start tomorrow. During the regular season, the conversation about traumatic brain injuries in sports among doctors, players, league officials, politicians and parents seemed to gain in volume and intensity with each passing week. New revelations from retired N.F.L. players who announced that they had the progressive neurodegenerative brain disease chronic traumatic encephalopathy, or C.T.E., helped fuel these discussions.

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The key to beating the concussion crisis lies in dealing with what's happening inside the skull, not outside of it. Because the brain doesn't fill the skull, there's room for it to rattle, be bruised or sheared, not just with every collision but with every sudden stop and even start — a phenomenon sometimes described as "brain slosh." For athletes in contact sports, brain slosh has long been seen as inherent and unavoidable. But to make progress against concussions, we have to give priority in future research to minimizing brain slosh during game play. This means that we need sports leagues, policy makers and health care providers to emphasize primary prevention instead of damage control.

At the National Conference on Youth Sports Safety in Washington in November, the approaches discussed were almost entirely focused on post-concussion management. The well-intentioned legislation currently under consideration in Congress is also too reactive. It should emphasize the critical role of primary prevention.

Newer helmets don't seem to make much of a difference, either. Studies appearing in the British Journal of Sports Medicine and the American Academy of Pediatrics found nearly identical rates of sports-related concussions among different helmet brands and models, including older helmets and new. Why? Think about shipping fragile porcelain — do we use steel or titanium containers, or Bubble Wrap?  The same principle applies when protecting the brain. Helmets fulfill their primary purpose of preventing skull fractures and lacerations, but they do not reduce concussions. It is the delicate brain within the skull that is damaged because it does not fit snugly. Athletes would benefit from a tighter fit for the brain — a Bubble Wrap effect — during play, but what are the factors within our control that might provide that effect? We have some leads.

At the Cincinnati Children's Hospital Medical Center, we released a study that found that high school football players who played at higher altitudes sustained a 30 percent reduction in total concussion incidence. We hypothesized that higher altitude increased the volume in the cerebral venous system, a natural Bubble Wrap that surrounds the brain, and that this created a snugger fit inside the skull that protected the athletes from sustaining concussions. We are currently analyzing N.F.L. concussion data from the 2012 and 2013 regular seasons to see if this effect obtains among professionals. 

There are also biomechanics in nature worth exploring for today's athletes.

Bighorn sheep ritually ram their heads into each other and woodpeckers slam their heads against trees thousands of times a day with neither species' sustaining concussions or even much of a headache, as far as we know. Meanwhile, much lesser forces result in a concussion, or worse, in humans. Our analysis suggests that both woodpeckers' and Bighorns' brains are naturally protected with mechanisms that slow the return of blood from the head to the body — increasing blood volume that fills their brains' vascular tree, creating the Bubble Wrap effect.

We have observed that the woodpecker uses muscles to do this, while the sheep has hollow pneumatic horn cores attached to its respiratory system that allow it to re-breathe its air and thus increase carbon dioxide in its bloodstream, expanding its intracranial vascular tree and enhancing the Bubble Wrap effect.

Every week the lights come on over fields of competition around the world, brightening the lives of players and their fans. Unfortunately, every week the lights dim for too many athletes who suffer the effects of concussions despite rule changes and newer helmets. What's troubling for sports enthusiasts is that parents and politicians may be making the decision to limit or remove the opportunity for young people to participate in contact sports. Although we cannot play every game in Denver, the winning strategies for defeating the concussion crisis may come from research focused on recreating the safe biomechanics already in use in the animal kingdom.

Gregory D. Myer is the director of research in sports medicine at Cincinnati Children's Hospital Medical Center.

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Emergency Visits Seen Increasing With Health Law

Thomas Patterson for The New York Times

A patient guide with a patient in a Portland, Ore., emergency room. When Medicaid reduced costs, more people went.

Supporters of President Obama's health care law had predicted that expanding insurance coverage for the poor would reduce costly emergency room visits because people would go to primary care doctors instead. But a rigorous new experiment in Oregon has raised questions about that assumption, finding that newly insured people actually went to the emergency room a good deal more often.

The study, published in the journal Science, compared thousands of low-income people in the Portland area who were randomly selected in a 2008 lottery to get Medicaid coverage with people who entered the lottery but remained uninsured. Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance.

The pattern was so strong that it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings.

The findings cast doubt on the hope that expanded insurance coverage will help rein in emergency room costs just as more than two million people are gaining coverage under the Affordable Care Act. And they go against one of the central arguments of the law's supporters, that extending insurance to large numbers of Americans would reduce emergency room use, and eventually save money.

In remarks in New Mexico in 2009, Mr. Obama said: "I think that it's very important that we provide coverage for all people because if everybody's got coverage, then they're not going to the emergency room for treatment."

The study suggests that the surge in the numbers of insured people may put even greater pressure on emergency rooms, at least in the short term. Nearly 25 million uninsured Americans could gain coverage under the law, about half of them through Medicaid. The first policies took effect on Wednesday.

"I suspect that the finding will be surprising to many in the policy debate," said Katherine Baicker, an economist at Harvard University's School of Public Health and one of the authors of the study.

An administration spokeswoman, Tara McGuinness, said that the time frame was too short to expect much of a change, and that over the longer term, use would most likely decline. She pointed to a longer-term study in Massachusetts, which expanded coverage for its residents in 2006, that found an 8 percent decline in emergency department use over a period of several years.

"Medicaid saves lives and improves health outcomes," Ms. McGuinness said. "Plenty of studies show that."

But many economists say that the emphasis on emergency room use, both in policy and in political speeches, is misplaced, as it makes up only a small part of health care costs in the United States. A federal government health survey found that emergency departments accounted for about 4 percent of total health spending in 2010, far less than inpatient hospital visits, which accounted for about 31 percent. Certain populations, however, like low-income people with chronic illnesses, have much higher rates of use.

Dr. Baicker and Amy Finkelstein, an economist at the Massachusetts Institute of Technology, another author, said the increased use of emergency rooms is driven by a basic economic principle: When services get less expensive, people use them more. Previous studies have found that uninsured people face substantial out-of-pocket costs that can put them in debt when they go to the emergency room. Medicaid reduces those costs.

Medicaid coverage also reduces the costs of going to a primary care doctor, and a previous analysis of data from the Oregon experiment found that such visits also increased substantially.

"This is just one piece of an increase we found across every type of care," said Bill J. Wright, an author of the new study who is the associate director of the Center for Outcomes Research and Education in Portland, a part of Providence Health and Services, a large health care provider.

The study's authors emphasized that Medicaid had many benefits. Previous analyses from the experiment found that gaining coverage reduced the incidence of depression and increased feelings of financial stability.

The study drew on data from the Oregon Health Insurance Experiment that included about 90,000 low-income Oregonians and randomly assigned about 30,000 of them access to Medicaid. Health experts say the experiment's design — random assignment of coverage through a lottery — allowed them to isolate and evaluate the effects of the program. Such designs are the gold standard in medical research, but are rarely used for domestic health care policy.

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Room for Debate: Thinking Beyond the Pill

Education First, Contraception Second

Natalie Rechberg, Valley Electronics AG

The debate about hormonal and alternative birth control must be engaged in order to gain traction against an entrenched Big Pharma establishment.

It Takes a Public-Private Partnership

Amy Ong Tsui, Bill & Melinda Gates Institute of Population and Reproductive Health

The stall on birth control innovation is largely due to muted enthusiasm for research and development by first world pharmaceuticals.

Men Deserve Options, Too

Elaine Lissner, Male Contraception Information Project

When it comes to male-oriented birth control, we need to see research through to the product development phase, not initiate more basic research.

A Different Kind of Pill

Evette Dionne, cultural critic

Oral pericoital contraceptives, taken before or after sex, are viable options for women who can't be anchored to the customary pill.

Options Exist, We Just Need to Use Them

Lawrence Finer, Guttmacher Institute

Don't dismiss I.U.D.s and implants, which are long-acting but easily reversible methods that are considerably more effective than the pill and condom.

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Op-Ed Contributor: Cold Turkey Isn’t the Only Route

THIS New Year's, a good number of those who struggle to control their drinking will resolve to abstain from alcohol. No halfway measures. Quitting is the only way.

The cold-turkey approach is deeply rooted in the United States, embraced by doctors, the multibillion-dollar treatment industry and popular culture. For nearly 80 years, our approach to drinking problems has been inspired by the 12 steps of Alcoholics Anonymous.

Developed in the 1930s by men who were "chronic inebriates," the A.A. program offers a single path to recovery: abstinence, surrendering one's ego and accepting one's "powerlessness" over alcohol.

But it's not the only way to change your drinking habits.

Bankole Johnson, an alcohol researcher and consultant to pharmaceutical companies who is also the chairman of the Department of Psychiatry at the University of Maryland School of Medicine, puts it this way: "We are wedded to the abstinence model as the goal, despite evidence that there can be many successful outcomes."

Because of the promise of anonymity, A.A. doesn't track its members or conduct research. Some studies have found that many members find support for healthier habits from a like-minded group of nondrinkers. But a systematic review found "no conclusive evidence to show that A.A. can help patients to achieve abstinence."

Research shows that many problem drinkers — those who repeatedly drink more than they intend, sometimes have physical or psychological consequences from overdrinking, and may have difficulty controlling themselves — could benefit from brief interventions and practical advice about how to set better limits and change their drinking by cutting back.

Women increasingly need help, as their drinking has escalated. Women are being stopped more for drunken driving than they were two decades ago. They're also the biggest consumers of wine, buying the larger share of the 856 million gallons sold in the United States in 2012. These women are drinking partly because alcohol is a socially respectable way to slog through the smartphone-tethered universe of managing demanding careers, aging parents, kids' activities and relationships at once. And while it's not healthy to pour yourself a third or fourth glass every night, it doesn't mean you're powerless to do anything about it.

Elsewhere in the developed world, doctors treat drinking problems with evidence-based tools that best match the client's needs. Many are prescribed drugs such as naltrexone, an opioid antagonist approved by the Food and Drug Administration in 1994 to treat alcohol use disorders. It blocks the signals released when consuming alcohol.

American doctors typically prescribe drugs with the goal of abstinence. Yet in Finland, the American psychologist John David Sinclair pioneered a radically different protocol for naltrexone: he instructs patients to take the drug — which is available generically — an hour before drinking. Mr. Sinclair calls his method "pharmacological extinction." When people drink while taking naltrexone, the drug blocks the rewards produced by drinking and the cravings diminish. In published research, Mr. Sinclair has claimed a 78 percent success rate in reducing drinking. A drug similar to naltrexone, nalmefene, was recently approved in Europe to help heavy drinkers moderate their habits.

In reporting my book on women and drinking, I found that many women were successful in changing their drinking habits by using Moderation Management, a free nonprofit support group for nondependent problem drinkers who want to control their consumption. Using the techniques of cognitive behavioral therapy, M.M. encourages members to take "personal responsibility for choosing and maintaining their own path, whether moderation or abstinence." It instructs drinkers to abstain for 30 days, reintroduce alcohol while evaluating the effects of drinking, and then stick within limits (for women, that's nine drinks a week, no more than three on any day).

This approach isn't for severely dependent drinkers, for whom abstinence might be best. But it's been empirically shown to work for those on the more moderate end of the spectrum who outnumber dependent drinkers by about four to one — including the majority of women who drink too much. While the ratio of men to women in A.A. is roughly 2:1, that figure is reversed among users of an evidence-based Internet application at moderatedrinking.com. The website helps drinkers set limits, self-monitor while they're drinking, get feedback on their progress and identify and manage triggers to overdrinking. Reid K. Hester, director of research at Behavior Therapy Associates, which designed the program, says heavy drinkers are more likely to be honest about their consumption when they know they won't be reproached.

Few master these skills overnight, Mr. Hester says, but most learn healthier habits within six months. And mistakes can be lessons, not failures.

We don't treat cancer, depression or asthma with the same tools we used in 1935. We need to get away from the one-size-fits-all approach to drinking problems.

Gabrielle Glaser is the author, most recently, of "Her Best-Kept Secret: Why Women Drink — and How They Can Regain Control."

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Consumers Start Using Coverage Under Health Law

WASHINGTON — Kathy Hornbach of Tucson is not wasting any time before using her new health insurance coverage, which took effect on New Year's Day. Ms. Hornbach, 57, has an appointment with a cardiologist on Thursday for a stress test.

"I've had some heart palpitations, and my mom's side has a history of heart problems starting early," she said Wednesday in a telephone interview. "So it's mostly just to double-check that everything is O.K."

Ms. Hornbach, who has had breast cancer and retired early from the technology industry, said that insurance companies in Arizona had refused to cover her until about two years ago, when she got a policy with monthly premiums of $285 and a deductible of $5,500 a year. Last month, using the federal insurance exchange, she bought a midlevel silver plan with lower premiums and deductible.

"It's a better policy — lower out-of-pocket, more choice of doctors," she said. "This is a very happy day."

Consumers around the country began using coverage provided by the new health care law on Wednesday, the same day that Medicaid expanded to hundreds of thousands of people in about half the states. Many provisions of the 2010 health care law offering new benefits and protections to consumers, including those with pre-existing conditions, also took effect.

Hospitals said they were getting ready for an influx of newly insured patients, but many health care providers said the pace was slower than usual because of the New Year's holiday. In a typical report, Clay Holtzman, a spokesman for Swedish Medical Center in Seattle, said the system's hospitals were not seeing an immediate surge.

"We might at some point down the road, since we have spent a lot of time informing uninsured patients of their options under the exchange and expanded Medicaid," Mr. Holtzman said in an email. "But it depends on if those patients chose plans that include us."

Swedish is one of the largest hospital systems in the region, but Mr. Holtzman said it had been excluded from the networks of providers used by the two largest health plans on the state's insurance exchange.

Some people using their new insurance discovered that they could be responsible for substantial co-payments and other out-of-pocket costs.

Nancy M. Schlichting, the chief executive of the Henry Ford Health System in Detroit, said that one patient who visited the emergency room of the system's flagship hospital on Wednesday tried to fill a prescription and found that the co-payment would be $84 — more than she was accustomed to paying. She got a similar drug with a lower co-payment, illustrating the need for patients to pay close attention to details of their drug coverage, Ms. Schlichting said.

In San Antonio, at a 24-hour Walgreens store, only a few vehicles were lined up at the drive-through window at midday, and no one was waiting in line to pick up prescriptions at the indoor pharmacy counter.

"It's dead," said Leslie Castillo, a pharmacist on duty. "We've had a few regulars come by, but no one has come in today with a new insurance card or wanting us to look up their benefits under Obamacare."

One reason, Ms. Castillo said, was that most doctors were not seeing patients on the New Year's holiday. But she added, "We'll probably be packed tomorrow."

Kenneth E. Raske, the president of the Greater New York Hospital Association, said: "Today is a historic occasion for the health care community. The coverage expansion kicks in for hundreds of thousands of people in New York State and millions across the country, who will enjoy the comfort of knowing they won't have to worry about health care bills if they get sick."

Danny Cottrell, the owner of a pharmacy in Brewton, Ala., said he had helped several people sign up for coverage. One customer, who has $3,500 to $4,000 a year in prescription drug costs, qualified for federal subsidies and chose a plan with a premium of about $300 a month and an annual deductible of $500.

"He will definitely come out ahead," Mr. Cottrell said. "He will save at least $7,500 a year on medical bills."

Dr. Michael W. Cropp, the president of Independent Health, an insurer in Buffalo, said, "I anticipate a lot of uncertainty and confusion and some frustration" as consumers begin to use their new insurance policies.

"The website for the New York exchange is now working for most enrollment purposes," Dr. Cropp said. "But I have concerns about how funds will flow from the federal government to health plans for members receiving federal subsidies."

Expecting a continued battle over health care, the White House moved Wednesday to recruit volunteers for its campaign to defend and promote the law, which is likely to be a defining issue in many congressional races this year. A White House website invites supporters and beneficiaries of the law to provide their names, email addresses and personal experiences.

"Whether you have new coverage today or know someone who does, we want to hear your story," David Simas, an aide to President Obama, said in an email to people who had expressed interest in the issue.

Jessica Santillo, a White House spokeswoman, said the invitation was part of a systematic new effort by the administration to "highlight stories of everyday Americans benefiting from the law."

The administration hopes to encourage enrollment and reverse public opinion polls that show approval of the health care law lagging behind disapproval.

Lisa Maria Garza contributed reporting from San Antonio, and Kimiya Shokoohi from Los Angeles.

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Well: Ask Well: Is Nail Polish Harmful?

A

The idea of nail polish as a risky substance gained traction in 2006 when public health advocates began a nationwide protest concerning three compounds — often referred to as "the toxic trio" — in leading nail polish brands.

The trio consisted of a known carcinogen, formaldehyde, used as a hardening agent, and two materials linked to developmental defects: toluene, to evenly suspend color, and the plasticizer dibutyl phthalate, or DBP, to add flexibility and sheen.

Since then, many companies have voluntarily removed these compounds from their products, although, as a 2012 investigation by the California Department of Toxic Substances Control found, some simply changed their labels while continuing to use them. While the European Union has banned the use of DBP in cosmetics, the United States Food and Drug Administration has not taken any comparable regulatory action.

Janet Nudelman, co-founder of the Campaign for Safe Cosmetics, an advocacy group, said the concern was that trace amounts of these materials would be absorbed through the skin or nail or that vapors would be inhaled. "No one is saying that occasional application of nail polish will cause long-term health consequences," she said. But certain groups may be at higher risk.

Researchers have raised direct health concerns for those who work in nail salons, for instance, leading salon operators to organize for better regulation.

Children, too, may be particularly susceptible to phthalates like DBP that pose developmental risks, and some pediatricians now warn against letting young girls, especially those young enough to chew on their fingers, wear polish.

For dedicated polish enthusiasts, Ms. Nudelman recommends doing research to find the safest brands. The Environmental Working Group maintains a searchable cosmetics database at www.ewg.org/skindeep.

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

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

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

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

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

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

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

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

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

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

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

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

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

Developments

Orthopedics

Doubts About a Knee Operation

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

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

Genetics

An Ancient Link for Diabetes

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

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

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

Energy

A Plant Fuels Energy Hopes

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

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

Psychology

For Anxiety, Don't Keep Calm

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

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

Coming Up

Technology

Dry Cleaning Challenge

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

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

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