Personal Health: How CPR Can Save a Life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Global Health: Preserving Vaccines

Scientists studying microbes that live in volcanic hot springs have invented a way to preserve viruses that could someday change how vaccines are delivered in poor countries.

Much work remains to be done, but an intriguing study in The Journal of Virology describes how Portland State University scientists prevented several viruses from drying out by coating them with silica, the basic ingredient of glass, just as they are coated in hot springs. Once the silica coats were rinsed off, some of the viruses were able to infect cells again.

Most vaccines are made of weakened virus or viral bits, and many need refrigeration. Keeping them cold is a major challenge when it comes to protecting children living in villages without electricity.

"It's hard to put a fridge on the back of a donkey," said Kenneth M. Stedman, a biologist at Portland State and the lead author of the study.

By recreating the chemical-laden hot-spring environment, Dr. Stedman's team coated four types of virus with silica, stored them, then washed off the silica and tried to infect cells. One heavily studied virus, phage T4, which infects the cells of E. coli bacteria, retained 90 percent of its infectivity for almost a month. The virus used in smallpox vaccines also did well, but it is naturally able to be stored dry.

The team is now testing the technique on harder targets: flu virus and rotavirus, which can cause fatal childhood diarrhea. "And we're definitely interested in polio," he added.

Coating other viruses and testing them in animals instead of cells will require more work and more grants. Dr. Stedman's seed money came from NASA, which is interested in how viruses spewed by volcanoes survive in the upper atmosphere.

His team did one animal experiment: It injected the smallpox vaccine virus into mice still in the silica coating. Even then, it touched off their immune systems, suggesting that the body itself may be able to wash off the coating. DONALD G. McNEIL Jr.

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A Conversation With Holbrook Kohrt: A Doctor’s Intimate View of Hemophilia

By Jeffery DelViscio, Pedro Rafael Rosado, Kriston Lewis, Robin Lindsay and Abe Sater

Jim Wilson/The New York Times

When The Doctor Is Also a Patient: Holbrook Kohrt, a hematologist, talks about his own experiences as a hemophiliac.

Dr. Holbrook Kohrt is a physician and researcher who has spent a lifetime as a patient. A 36-year-old hematologist at the Stanford University School of Medicine, he has an extreme form of hemophilia, the bleeding disease. We spoke about his life and work for two hours in person, and later by telephone. An edited and condensed version of the conversations follows.

Hemophilia is thought to be hereditary. Do other members of your family have it?

No. None. When I was born in 1977, my parents didn't even know I had it. After circumcision, I bled profusely. And then, during the first month of life, I kept bleeding. Though my father was a pediatrician and my mother a nurse, they didn't even consider hemophilia.

They took me to the hospital, where the doctors thought my mother was abusing me — I had all these unexplained bruises. After some testing, it was determined that I had a very unusual type of hemophilia that comes from a random mutation.

Once that was known, my parents became centered on taking care of a child with severe hemophilia. So I grew up in a room that was padded so I wouldn't bleed to death if I fell. I wore a helmet every day. There were frequent trips to the children's hospital for emergencies, three hours from where we lived, in Lake Wallenpaupack, Pa.

Was it possible to have a normal childhood under those circumstances?

I wouldn't say so. We lived in a small town. Many people there did not understand about hemophilia.

To stay alive, I had to have transfusions of a blood product — clotting factor — every other day. We had neighbors who were members of a religion that opposed transfusions. People from that family would ring our doorbell and scream that we were going to hell.

On the school bus, the others made fun of me. This got even worse during my adolescence because people first began reading about AIDS. To uninformed people, AIDS and hemophilia were the same thing.

To make the situation even worse, large numbers of hemophiliacs developed H.I.V. At the beginning of the H.I.V. epidemic, the blood banks didn't test their donors for the virus. To stay alive, hemophiliacs often require transfusions of the clotting factor. It's a protein that our bodies can't make naturally, and it's made up from the blood of hundreds, perhaps thousands of donors. Well, if one of those donors had H.I.V., it could be transmitted to anyone who received the blood product. In those years, of the severe hemophiliacs, 95 percent died after contracting H.I.V. from transfusions.

I remember, from the time I was 8 years old, I went to this special summer camp for hemophiliac children. The first year I attended, there were about 200 campers. Eight years later, they stopped having the camp altogether because there were just two of us left.

I think that there's something very strong about the fact that I was a teenager at the time when all this was happening. When young kids encounter death, you don't understand the full magnitude of it. You experience it, but then you feel like life goes on.

Why didn't you contract H.I.V. like the others?

I was lucky. I did, at the age of 13, get hepatitis C, from contaminated blood. I was in the hospital for two months. And then something truly fortunate occurred. I had what's called a "full antibody response," which means that my immune system naturally cleared the infection.

Today, happily, the blood products hemophiliacs take are safer. Scientists have figured out a way to produce an engineered version of the clotting factor. That means that we don't have to go to hundreds of human donors for blood anymore. They take the protein we need, insert it into the ovary of a tiny hamster and make the clotting factor from that.

Did your childhood experiences lead you to become a hematologist?

Oh, absolutely. In my childhood, it was doctors who I related to more than my peers.

The thing that really attracted me, though, was seeing translational medicine happen in my lifetime. By the time I applied to medical school in 2000, the H.I.V. epidemic had become a chronic disease in the developed world. Breakthroughs in biochemistry promised the same for hemophilia. I wanted to help with that.

As you recall, I had this experience where my own immune system had naturally cleared a hepatitis C infection. I wondered if there might not be ways to get the immune system to respond to cancer in that same way. Today, that's the focus of my research.

Tell us about your research.

A few years ago, I joined the Stanford laboratory of Ron Levy, who developed the antilymphoma chemotherapy Rituxan. My focus there has been to try to get it to work better against non-Hodgkin's lymphoma by adding Rituxan to another antibody in the hope of finding a combination that attacks the cancer.

The experiment has been to inject mice with lymphoma, go down a couple days later, give the mice Rituxan, and then a couple days later, give them whatever molecule I choose. About four years ago we did this, and we had a whole cage full of mice where the tumor completely melted away.

Recently, we gave that combination to a human patient. And now, almost a year later, she has no evidence of the lymphoma whatsoever. Of course, one patient isn't enough to make for a clinical trial. So now we are going for full-scale trials to show that it is not only effective for lymphoma but, hopefully, for other cancers, too.

You've been doing a clinical trial in Cuba. Is that for the same therapy?

No. In Cuba, we've been taking little portions of cancer cells — the peptides — and vaccinating patients against them. Actually, we've taken this idea and applied it to cervical cancer in Cuba, ovarian cancer in Australia, leukemia in Europe, and at Stanford.

Our goal is to ultimately use this approach to teach transplanted bone marrow what the cancer looks like so when cancer attempts to come back, the immune system is smart enough to recognize and attack it.

Why study this in Cuba?

There is a large population of underserved patients with cervical cancer there. They had doctors there who wanted to work with us. Right now, we're in Phase 1 of trials there, which means that we're testing for safety and the immune response. Patients who already have cancer receive the vaccine, and we'll see if the immune system responds and mobilizes.

Is there anything about your own condition that pushes you forward?

Oh, yes, but it's more philosophical than physical. I realized early on that I have to do everything I want to do as soon as possible because I didn't know what the future could be. That's been useful in terms of the research and the science. I have the stamina and the commitment to keep trying things.

It's not been so good in terms of personal relationships. I've been married twice. But that knowledge forces me to take the time I have to give the maximum to science and to my patients. Research requires great tenacity. When you've had a serious illness since infancy, you know to make the most of every single day.

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Mind: A New Focus on Depression

When will we ever get depression under control?

Of all the major illnesses, mental or physical, depression has been one of the toughest to subdue. Despite the ubiquity of antidepressant drugs — there are now 26 to choose from — only a third of patients with major depression will experience a full remission after the first round of treatment, and successive treatments with different drugs will give some relief to just 20 to 25 percent more.

About 30 percent of people with depression have some degree of treatment resistance. And the greater the degree of resistance, the more likely a future relapse, even if the patient continues taking the drug.

Although we have learned much about depression — for example, the recent research showing that the successful treatment of insomnia in depressed patients essentially doubles their response to a drug like Prozac — we still don't understand its fundamental cause. The old idea that the disease results from a deficiency of a single neurotransmitter like serotonin or dopamine is clearly simplistic and wrong.

Maybe psychiatrists and neuroscientists have something to learn from the successful hunt for the Higgs boson.

Of course a debilitating disease has nothing in common with a subatomic particle, except that both are mysterious and elusive. But it was those very qualities that inspired international teams of physicists to work together for years until they finally identified the boson last year.

Among biomedical scientists, who compete for the same research dollars and want to be first across the finish line with an important finding, such cooperation is hardly the norm. But there are signs that this is changing.

Not long ago, I sat in at a meeting of the Hope for Depression Research Foundation. Audrey Gruss, the knowledgeable and energetic philanthropist who started the foundation, has corralled a group of senior basic and clinical neuroscientists to look for solutions. (It is not the first to try a collaborative approach; others are being sponsored by the MacArthur Foundation and the Pritzker Consortium.)

"A complex problem like depression is much larger than one scientist or lab can handle," said the leader of the group at the Hope foundation, Huda Akil, a professor of neurosciences and psychiatry at the University of Michigan. "What is great about our collaboration is that we can think about big ideas and take risks without worrying about what grant reviewers" — like the National Institute of Mental Health, the major source of federal funding for psychiatric research — "might think."

A major goal is to understand which brain circuits and genes are altered by depression, how the environment interacts with these genes, and how to reverse the accumulated biological assaults of this disease. That will require the integration of a wide range of tools, she said: genomics, epigenetics, electrophysiology, animal models, clinical psychiatry.

A major drawback of our current antidepressants is that they rely on animal models that have been used for decades, yielding drugs that all work the same way. Novel drugs require identification of new targets in the brain and better animal models in which to screen them.

So one member of the group, Dr. Joshua Gordon, an associate professor of psychiatry at Columbia, studies new animal models of depression by recording activity in select brain regions in mice that are engaged in depressionlike behavior.

After talking with another group member, Dr. Helen S. Mayberg, a neuroscientist at Emory University, Dr. Gordon modified his approach. Dr. Mayberg has identified a target for deep brain stimulation in patients with treatment-resistant depression: a region called the subgenual cingulate cortex. When it is directly stimulated with electrodes in depressed patients who have failed to respond to nearly all other treatments, many show a brisk positive response.

Dr. Mayberg urged Dr. Gordon to extend the region of his recording to include the mouse analog of this human brain region, so he could more fully capture activity in these different areas of the cortex and understand how they individually contribute to depressionlike behavior in mice.

Another group member, Bruce McEwen, a neuroscientist at Rockefeller University who has done pioneering work on the effects of stress on the brain, is studying rats from Dr. Akil's lab that have been genetically selected for their propensity to show anxiety and depressionlike behavior.

Among other things, Dr. McEwen is using these rats to study the efficacy of drugs with the potential to act rapidly against depression. Such a drug would be a major boon to psychiatry: We need treatments that can ease the symptoms of depression, and its attendant risk of suicide, in far less time than the two to six weeks that all current antidepressants require to do their work.

Even a high-powered collaboration like this one offers no guarantee of finding effective weapons against intractable depression. After all, it took 50 years to smoke out the Higgs boson, and even at that, there are huge unanswered questions.

But at a time when federal research funds are shrinking and major drug companies have all but shuttered their brain research programs, enlightened philanthropists and entrepreneurs are helping to open a promising new pathway for neuroscience research: collaboration among researchers willing and able to take thoughtful risks and solve big problems.

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Dr. Richard A. Friedman is a professor of clinical psychiatry at Weill Cornell Medical College.

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Bearing Arms: When the Right to Bear Arms Includes the Mentally Ill

Last April, workers at Middlesex Hospital in Connecticut called the police to report that a psychiatric patient named Mark Russo had threatened to shoot his mother if officers tried to take the 18 rifles and shotguns he kept at her house. Mr. Russo, who was off his medication for paranoid schizophrenia, also talked about the recent elementary school massacre in Newtown and told a nurse that he "could take a chair and kill you or bash your head in between the eyes," court records show.

The police seized the firearms, as well as seven high-capacity magazines, but Mr. Russo, 55, was eventually allowed to return to the trailer in Middletown where he lives alone. In an interview there recently, he denied that he had schizophrenia but said he was taking his medication now — though only "the smallest dose," because he is forced to. His hospitalization, he explained, stemmed from a misunderstanding: Seeking a message from God on whether to dissociate himself from his family, he had stabbed a basketball and waited for it to reinflate itself. When it did, he told relatives they would not be seeing him again, prompting them to call the police.

As for his guns, Mr. Russo is scheduled to get them back in the spring, as mandated by Connecticut law.

"I don't think they ever should have been taken out of my house," he said. "I plan to get all my guns and ammo and knives back in April."

The Russo case highlights a central, unresolved issue in the debate over balancing public safety and the Second Amendment right to bear arms: just how powerless law enforcement can be when it comes to keeping firearms out of the hands of people who are mentally ill.

Connecticut's law giving the police broad leeway to seize and hold guns for up to a year is actually relatively strict. Most states simply adhere to the federal standard, banning gun possession only after someone is involuntarily committed to a psychiatric facility or designated as mentally ill or incompetent after a court proceeding or other formal legal process. Relatively few with mental health issues, even serious ones, reach this point.

As a result, the police often find themselves grappling with legal ambiguities when they encounter mentally unstable people with guns, unsure how far they can go in searching for and seizing firearms and then, in particular, how they should respond when the owners want them back.

"There is a big gap in the law," said Jeffrey Furbee, the chief legal adviser to the Police Department in Columbus, Ohio. "There is no common-sense middle ground to protect the public."

A vast majority of people with mental illnesses are not violent. But recent mass shootings — outside a Tucson supermarket in 2011, at a movie theater last year in Aurora, Colo., and at the Washington Navy Yard in September — have raised public awareness of the gray areas in the law. In each case, the gunman had been recognized as mentally disturbed but had never been barred from having firearms.

After the Newtown killings a year ago, state legislatures across the country debated measures that would have more strictly limited the gun rights of those with mental illness. But most of the bills failed amid resistance from both the gun lobby and mental health advocates concerned about unfairly stigmatizing people. In Washington, discussion of new mental health restrictions was conspicuously absent from the federal gun control debate.

What remains is the uncertain legal territory at the intersection of guns and mental illness. Examining it is difficult, because of privacy laws governing mental health and the limited availability of information on firearm ownership. But The New York Times obtained court and police records from more than 1,000 cases around the country in which guns were seized in mental-health-related episodes.

A systematic review of these cases — from cities and counties in California, Colorado, Connecticut, Florida, Indiana, Ohio and Tennessee — underscores how easy it is for people with serious mental health problems to have guns.

Over the past year in Connecticut, where The Times obtained some of the most extensive records of seizure cases, there were more than 180 instances of gun confiscations from people who appeared to pose a risk of "imminent personal injury to self or others." Close to 40 percent of these cases involved serious mental illness.

Perhaps most striking, in many of the cases examined across the country, the authorities said they had no choice under the law but to return the guns after an initial seizure for safekeeping.

For example, in Hillsborough County, Fla., 31 of 34 people who sought to reclaim seized firearms last year were able to do so after a brief court hearing, according to a count by The Times.

Among them was Ryan Piatt, an Afghanistan veteran with a history of treatment for depression, anxiety and paranoia. The police had descended on Mr. Piatt's workplace in November 2011, after mental health workers at the veterans hospital in Tampa reported that he had made intimations of violence to his psychiatrist and had tried to renounce his citizenship, mailing his Social Security card, birth certificate and other documents to a judge. Officers confiscated two guns from his car and one more from his toolbox; he got them back less than a year later.

Notes from Ryan Piatt's psychiatrist at a Florida veterans hospital, which alerted the police about him. (Handwriting in margins is Mr. Piatt's.)

Similarly, the sheriff in Arapahoe County, Colo., had to return a .45-caliber pistol last year that officers had seized four months earlier after receiving a call that Jose Reynaldo Santiago, an Army veteran with post-traumatic stress, was walking around his home in the middle of the night in a catatonic state with a gun in the pocket of his bathrobe.

Even in Indiana, one of the few states that have expanded the power of law enforcement to hold on to guns seized from people who are mentally ill, the examination revealed a significant loophole: there is nothing preventing them from going out and buying new guns.

The state's seizure law does not address the question, and as a result, records from gun confiscation cases are not entered into the federal background check database that dealers must consult when making sales, according to officials from the Indiana Supreme Court.

Connecticut had a similar vulnerability until this year. Unlike in Indiana, the Connecticut State Police handle gun background checks, running names in the federal system and checking its own records. Judicial officials are unsure, however, if the agency was receiving all gun seizure records. As a fail-safe and a way to prevent people from simply going to another state to buy a gun, the state has now begun submitting these records to the federal system.

Adding to the uncertainty for law enforcement, federal courts have ruled that an emergency involuntary psychiatric evaluation is not grounds to bar someone from possessing firearms.

The police in Caribou, Me., discovered this after repeated run-ins with a troubled resident, Curtis Zetterman, who was sent to a hospital after talking about shooting people; he was released, and was later accused of threatening a neighbor with a gun, according to court records.

Mr. Zetterman's conviction on a charge of illegally possessing a firearm was dismissed on appeal because his emergency hospitalization did not rise to the level of a formal involuntary commitment.

"We don't want to violate anybody's rights," said the Caribou police chief, Michael Gahagan. "But if you're in the apartment next door to this guy, what about your rights?"

Outliers Toughen Laws

It was the shock of a potentially avoidable tragedy that pushed Indiana lawmakers to act. Reports of gunfire brought Officer Timothy Laird to Indianapolis's south side one night in August 2004. Kenneth C. Anderson, a schizophrenic man who the police later learned had just killed his mother in her home, was stalking the block with an SKS assault rifle and two handguns. As Officer Laird stepped from his patrol car, he was fatally shot. Four other officers were wounded before one of them shot and killed Mr. Anderson.

At the beginning of that year, the police had seized nine guns from Mr. Anderson after being called to his home by paramedics because he was being combative. Deemed delusional and dangerous, he was taken to a hospital for a mental health evaluation. He was not, however, committed, and when he sought the return of his guns, police officials concluded that they had no legal grounds to keep them.

Several months after Officer Laird's death, the Indiana legislature passed its seizure bill, giving the police explicit authority to search for and confiscate guns from people who are considered dangerous or who are mentally ill and off their medication. The police can keep the guns, upon court approval, for five years.

Connecticut's law, passed in 1999, was also a response to a high-profile shooting rampage: a disgruntled employee with a history of psychiatric problems fatally shot four people at the state lottery offices before killing himself.

This year, in the wake of the Newtown shooting, in which 20 children and six adults were killed, the mental health debate in state legislatures focused largely on two areas: requiring mental health professionals to report dangerous people to the authorities and expanding the mental health criteria for revoking gun rights.

One legislature that ultimately did act was New York's, which passed a far-reaching — and controversial — measure that requires mental health professionals to report to county authorities anyone who "is likely to engage in conduct that would result in serious harm to self or others." If county officials agree with the assessment, they must submit the information to the state's Division of Criminal Justice Services, which alerts the local authorities to revoke the person's firearms license and confiscate weapons.

Maryland, too, amended its laws, barring anyone with a mental disorder who has a history of violence from having firearms.

And California adopted a five-year firearms ban for anyone who communicates a violent threat against a "reasonably identifiable victim" to a licensed psychotherapist. Previously, the ban was six months.

The state already had a five-year gun ban for anyone deemed to be a danger to himself or others and admitted on a 72-hour psychiatric hold for emergency evaluation and treatment or a longer 14-day hold. (Both steps fall short of the criteria for an involuntary commitment under federal law.) Even in cases where people are sent for emergency evaluations but not admitted, the police may confiscate their weapons and petition a court to keep them.

California, Maryland and New York, however, are outliers. (Hawaii and Illinois also stand out for their strict — some would argue onerous — mental health standards for gun ownership.) Most states have been content to follow the federal government's lead.

In fact, the issue has long been a political quagmire.

Gun rights advocates worry that seizure laws will ensnare law-abiding citizens who pose no threat. In Connecticut, with its imminent-risk standard for seizure, the law sometimes "reaches pretty normal people," said Rachel Baird, a lawyer who has sued police departments over gun confiscations.

"People make comments all the time when they're angry or frustrated — 'I'm going to come down there, and it won't be pretty' — but if you say that and you own a firearm, it immediately takes on a context that it otherwise wouldn't," said Ms. Baird, a former prosecutor.

At the same time, mental health professionals worry that new seizure laws might stigmatize many people who have no greater propensity for violence than the broader population. They also fear that the laws will discourage people who need help from seeking treatment, while doing little to deter gun violence.

Research has shown, however, that people with serious mental illnesses, like schizophrenia, major depression or bipolar disorder, do pose an increased risk of violence. In one widely cited study, Jeffrey W. Swanson, now a psychiatry professor at Duke University, found that when substance abusers were excluded, 33 percent of people with a serious mental illness reported past violent behavior, compared with 15 percent of people without such a disorder. The study, based on epidemiological survey data from the 1980s, defined violent behavior as everything from taking part in more than one fistfight as an adult to using a weapon in a fight.

Substance abuse, the study found, was a powerful predictor of violence. The highest rate, 64 percent, was found among people who had major mental disorders as well as substance abuse issues. For substance abusers alone, the rate was 55 percent.

This month a consortium of mental health professionals, public health researchers and gun control advocates released a 52-page report containing a series of recommendations on improving state laws regarding mental health and guns. The group focused largely on the gray area beyond the narrow federal standard of involuntary commitment, recommending that people admitted for short-term involuntary hospitalizations lose their gun rights temporarily, and that the police be given a mechanism for removing guns from people they believe to be dangerous.

"That could save a lot of lives," said Dr. Swanson, a member of the consortium.

Varying Interpretations

One place that has an intimate awareness of the dangers of guns, especially in the hands of people struggling with mental illness, is Arapahoe County in Colorado, where 12 people died in the Aurora movie theater rampage last year. And at a high school there just this month, an 18-year-old gunman critically injured another student before taking his own life, though there has been no indication that mental illness was a factor.

Still, when it comes to seizing firearms, the sheriff there, Grayson Robinson, says he is also acutely aware of the legal limitations. If his deputies encountered a man on the street with a gun acting irrationally or suicidal, they would probably confiscate that weapon for safekeeping, he said. But they would not have the legal authority to enter his home and even temporarily take any other guns. Nor would the authorities hold on to the confiscated weapon, he said, unless the owner is expressly barred by law from having it.

"We understand property rights," he said. "We would return those weapons to him upon his request."

In the absence of specific guidance under federal and state laws, local police departments vary widely in how they deal with the issue, The Times found. Some hew to a strict interpretation. Others appear to be searching for a middle ground, fearful of what may happen if they return guns to dangerous people but also aware that they are on difficult legal terrain.

In Arapahoe County, the Sheriff's Department has confiscated weapons from just 13 people it sent for emergency psychiatric evaluations in the past two years, records show. In 10 of those cases, the guns were returned to their owners. (One gun was scheduled for destruction at the owner's request; another was given to a third party; one recent seizure was still in the department's possession.)

Among the guns seized was the pistol from the bathrobe pocket of Mr. Santiago, the veteran found walking around his home in a trance in November 2011. It took five minutes after deputies arrived for Mr. Santiago, then 23, to emerge from his catatonic state, according to the incident report. When he came to, he asked if he had hurt anyone. He also told deputies that he had post-traumatic stress from his deployment in Afghanistan and had experienced a similar episode before. The Fire Department took Mr. Santiago to the hospital for a brief stay to be examined, and sheriff's deputies took his gun. It was returned the following March.

A sheriff's report from Arapahoe County, Colo., on the department's encounter with Jose Reynaldo Santiago, which lead to his gun being confiscated.

In an interview, Mr. Santiago said he had "spaced out" after learning that an Army friend had died in a motorcycle accident. He said that the police had told him he could get his gun back right away but that he had decided to wait to "make sure I was all good." He had expected to have to answer questions about his mental health and was shocked when he only had to fill out some paperwork.

"All I did was I walked in, walked through the metal detectors, walked downstairs to their holding area where they keep evidence for safekeeping," he said. "They handed it right back to me, no questions asked."

In August 2012, Arapahoe deputies were called to the home of Jarrod Thoma, 29, another veteran, who was holed up in his bathroom with a newly purchased Ruger pistol pointed at his head. A SWAT team eventually talked him out. According to the incident report, his wife told deputies that he had been discharged from the Army because of a "personality disorder." (Mr. Thoma says it was actually adjustment disorder, from difficulty coping with stress.) His wife also told the police that he had tried to commit suicide twice before in 2011, once by overdosing on antidepressants and Tylenol and then in an episode involving a gun. The Sheriff's Department returned Mr. Thoma's gun three months later.

In an interview, Mr. Thoma said that after his encounter with the police, he voluntarily admitted himself to the hospital, where he remained for two and a half weeks, receiving counseling and medication. When he got his gun back, he said, his problems were under control.

"If I was a danger to others and if I was still suffering from some type of depression, I wouldn't have went back and claimed my gun," he said. "I've been through therapy. I put that stuff behind me."

A sheriff's report from Arapahoe County, detailing an episode in which Jarrod Thoma threatened suicide with a gun.

In Nashville, the police appear to be exercising greater discretion in returning seized firearms. Since 2010, they have confiscated weapons from 81 people in mental-health-related episodes, according to Don Aaron, a department spokesman. Guns were returned in just 18 of those cases.

Nashville police officials said they adhered to the same basic federal and state criteria as other departments. But because of problems obtaining full and accurate mental health records from the state's background-check database, officials said, the department will sometimes ask for a doctor's note certifying that the gun owner is no longer a danger or will agree to release guns only to a relative.

The Times found a similar rate of returns in Columbus. Last year, the police confiscated firearms from more than 40 people in mental-health-related episodes; in eight cases, the guns were returned.

Mr. Furbee, the Police Department's chief legal adviser, said the detectives who handled these releases were "very deliberate." Decisions can also be delayed, he said, because Ohio has no centralized registry of commitments to psychiatric institutions for the police to check. In addition, in several cases examined by The Times, the designation of the confiscated firearm was changed from "safekeeping" to "evidence," which would delay its release.

Among those who did get their guns back relatively quickly was Paul Colflesh, whose 9-millimeter Beretta was confiscated in May 2012 after his wife, Melody Bowman, called 911. She told the police that Mr. Colflesh had stopped taking his medication for depression two weeks earlier and had begun drinking heavily, according to the incident report. On this night, he had gone up to the bedroom, grabbed his gun and said he was going to kill himself. She added that he had once before put the gun in his mouth and threatened suicide. (In an interview, Ms. Bowman said this had been about a year earlier, also while he was drinking.) Mr. Colflesh was so drunk that the police could not interview him.

A report from the Columbus, Ohio, police, describing the episode in which Paul Colflesh's gun was taken for safekeeping.

A few days after being taken to the emergency room, Mr. Colflesh gave the police a note from his doctor, who said Mr. Colflesh had been off his medication for a month but realized that it was the "wrong thing to have done." Mr. Colflesh, he concluded, "appears not in danger to himself or others since restarting his medications."

A detective, who later contacted the doctor directly, scrawled notes that Mr. Colflesh was "not suicidal or dangerous to others if he takes meds."

The police returned Mr. Colflesh's gun two months after they took it.

A letter from Mr. Colflesh's doctor, stating that he was not dangerous, as long as he was on his medication.

"When somebody comes here and demands their weapon back, and there is no legal disability, we give it back, even when it makes us uncomfortable," Mr. Furbee said.

Officials in Florida have also been grappling with ambiguities under the law. In 2009, the attorney general issued an advisory opinion saying that "in the absence of an arrest and criminal charge," the police could not hold on to firearms confiscated from people sent for mental health evaluations under the state's Baker Act, which authorizes the police to send mentally ill people who are potentially dangerous for involuntary examinations of up to 72 hours.

Across Florida, however, departments are still taking a variety of approaches, with some simply returning the weapons upon request — after performing the requisite checks — and others imposing additional hurdles.

This year, a judge ordered the Daytona Beach police to return 16 guns to Anthony Bontempo, 27, a veteran with a history of post-traumatic stress disorder and alcoholism. They had been confiscated after he called a suicide hotline in hysterics eight months earlier. A gun-rights group, Florida Carry, filed a lawsuit on behalf of Mr. Bontempo, arguing that the police had no right to hold on to the weapons.

In Hillsborough County, people whose weapons are seized in Baker Act proceedings are required to attend a brief court hearing, where a judge can confirm that they are not felons, have never been involuntarily committed and have nothing else on their records that bars them from having guns. Almost all walk out with orders allowing them to retrieve their guns.

Mr. Piatt, 30, whose guns were seized after the episode at the Tampa veterans hospital, said the police had overreacted by having a group of officers go to his workplace to take him forcibly into custody.

But his medical records, which he sent to The Times, show diagnoses for depression, generalized anxiety disorder, post-traumatic stress disorder and "psychotic disorder not otherwise specified." He had stopped taking his medication. Adding to his psychiatrist's concern, Mr. Piatt's roommate had called the veterans hospital worried about Mr. Piatt's stability, saying he seemed paranoid and had woken him up in the middle of the night, screaming.

In an interview, Mr. Piatt said the judge who presided over his firearms-return hearing focused not on establishing his mental state but primarily on ensuring that he would store his weapons safely because he has a young son.

The judge, Claudia R. Isom, who at the time was responsible for all gun-return petitions in the county, said she simply required gun owners to affirm under oath that they met the various legal requirements and then determined if the police or the clerk's office had found anything in their records checks. Judge Isom said she usually did not ask the petitioners if they were undergoing mental health treatment or taking their medication because "it was none of my business."

"I'm supposed to apply the law," she said. "If there's no legal objection, then there's no legal reason not to give a weapon back."

A Volatile Mix

It is impossible to know just how many gun owners have serious mental health issues. But an examination of gun seizure records in Connecticut and Indiana, where the police have been granted greater leeway to confiscate firearms, offers perhaps the best sense of just how frequently gun ownership and mental instability mix. Officials with the Connecticut court system have collected records on more than 700 gun seizure cases since the law was enacted in 1999. That probably represents a partial count at best, however, because court officials did not make a concerted effort to ensure that all cases were reported to them until this year, after the Newtown shooting.

The Times analyzed this year's cases in Connecticut and found that slightly more than half involved threats of suicide; 34 percent involved drugs or alcohol; and 42 percent clearly involved psychosis or some other serious mental health issue, such as bipolar disorder, schizophrenia or clinical depression. Just under 30 percent of the mental health cases also involved drugs or alcohol.

The results were similar in Marion County, Ind., which includes Indianapolis. In 2012, the police seized 67 guns from 30 people, according to court records. Documents in 40 percent of the cases mentioned some sort of mental illness; a quarter of those cases also involved substance abuse.

In one case in April, residents of Carlyle Place in Indianapolis flagged down a police cruiser because one of their neighbors, Michael Fishburn, 54, was screaming at cars and had pointed a handgun at a woman, according to a court affidavit. The day before, he had been strutting around his yard making rooster noises, they said. The police took Mr. Fishburn to the hospital and learned that he had been receiving mental health treatment there for the previous 10 years. They also discovered that he had a lifetime permit to carry a handgun. A judge ordered the police to retain Mr. Fishburn's pistol, as well as a shotgun, for five years.

A court affidavit filed by police in Marion County, Ind., on Michael Fishburn's threatening behavior, as reported by neighbors.

The case of James Serapilia of Bristol, Conn., illustrates just how challenging it can be to assess mental stability and predict violence. Shortly after midnight on March 19, 2004, the sound of breaking glass drew the police to a small ranch-style house, where they found Mr. Serapilia, then 41, standing amid the shattered remains of his living room window.

"In the name of Jesus Christ, I command you demons to leave," he yelled, according to a police report. As officers struggled to gain entry, Mr. Serapilia grabbed a shard of glass, held it to his throat and said, "This is it." He was stopped only after a sergeant fired a Taser through the broken window. Inside, the police found two rifles in the living room, along with several rounds of ammunition on a table and two handguns in an upstairs closet. Officers seized the weapons.

But as a local prosecutor explained in a court hearing, "the state has the burden of showing that he's in imminent danger to himself or others" or must eventually return the firearms. So 10 months after the episode, Mr. Serapilia, supported by a positive report from his psychiatrist, got his guns back.

But the police had not seen the last of him. Early on the morning of Sept. 25, 2010, they were at his house again, this time for a Lifeline medical alert for an older person in distress. Officers discovered Mr. Serapilia's mother lying in the entryway, unable to get up. She pointed to her son, who was sitting on the floor nearby, appearing pale, sweating profusely and surrounded by empty beer cans. "He wouldn't call an ambulance," she said, according to a police report.

A warrant from the Connecticut Superior Court describes James Serapilia referring to police officers as demons.

Mr. Serapilia bolted from the house, screaming that he was Jesus Christ, and proceeded to lead the police on a car chase through three towns before officers were able to deflate the tires of his Toyota Tacoma, smash a passenger-side window and drag him from the vehicle. He later told them that he had schizophrenia and depression, had stopped taking his medication and believed he was being chased by demons, the report said. This time, because Mr. Serapilia was criminally charged and his guns were seized as contraband, a judge ordered them destroyed. Mr. Serapilia, through his sister, declined to comment.

As for Mark Russo, the Middletown man who is looking forward to reclaiming his 18 guns in April, he acknowledged that public records indicated that he had made threats of violence, but he said they were untrue. He said he had had difficulty getting doctors to understand the real nature of his problem, which is not mental illness but paranormal activities that have afflicted him since his youth, including objects disappearing from his home and a bird once flying out of his forehead.

"I've offered to take a lie-detector test to prove what I'm saying is true," he said. "But psychiatrists, they don't want to hear about God and demons and all that."

At the Middletown Police Department, Lt. Heather Desmond said there was little her agency could do to avoid returning guns to someone who is mentally ill, unless "there are new incidents or concerns that would justify seeking another risk warrant." The police check their records for that before handing over the firearms, she said.

"But if a year has gone by and nothing new has happened, there's nothing we can do," Lieutenant Desmond said. "It's unfortunate, and it's something that has to be addressed."

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Michiaki Takahashi, 85, Who Tamed Chickenpox, Dies

Dr. Michiaki Takahashi, whose experience caring for his 3-year-old son after the boy contracted chickenpox led him to develop a vaccine for the virus that is now used all over the world, died on Monday in Osaka, Japan. He was 85.

The cause was heart failure, said his longtime secretary, Maki Fukui.

In 1964 Dr. Takahashi, who had spent several years studying the measles and polio viruses in Japan, was on a research fellowship at Baylor Medical College in Houston when his son, Teruyuki, came down with a severe case of chickenpox after playing with a friend who had the virus.

"My son developed a rash on his face that quickly spread across his body," Dr. Takahashi recalled in a 2011 interview with The Financial Times. "His symptoms progressed quickly and severely. His temperature shot up and he began to have trouble breathing. He was in a terrible way, and all my wife and I could do was to watch him day and night. We didn't sleep. He seemed so ill that I remember worrying about what would happen to him."

"But gradually, the symptoms lessened and my son recovered," he added. "I realized then that I should use my knowledge of viruses to develop a chickenpox vaccine."

He returned to Japan in 1965 and within five years had developed an early version of the vaccine. By 1972 he was experimenting with it in clinical trials. Within a few years, Japan and some other countries had begun widespread vaccination programs. Yet the Food and Drug Administration did not approve the United States' first chickenpox vaccine until 1995.

The delay was caused by several factors, including concerns that the immunity created by the vaccine might not last long enough, that there could be unwanted side effects and, more generally, that chickenpox might not be a serious enough disease to warrant a vaccination program.

Chickenpox is caused by the varicella-zoster virus, a form of herpes. If a person contracts the virus, has an active infection and then recovers, the virus is not actually gone from the body. It can hide in nerve cells for years or decades, then emerge again to cause shingles, a painful condition that causes a skin rash and occurs mostly in adults.

Dr. Takahashi developed his vaccine by growing live but weakened versions of the virus in animal and human cells. The vaccine did not cause the disease, but it prompted immune systems to produce antibodies.

"It fools the immune system into thinking it has seen this disease before," said Dr. Anne A. Gershon, the director of the Division of Pediatric Infectious Disease at Columbia University Medical Center and a friend of Dr. Takahashi's.

Dr. Gershon said Dr. Takahashi's is "the only vaccine successful against any of the human herpes viruses."

In 2006, the Centers for Disease Control and Prevention began recommending a second dose of the vaccine. The C.D.C. recommends that children receive their first dose when they are 12 to 15 months old and a second dose when they are 4 to 6 years old.

"Prior to the licensing of the chickenpox vaccine in 1995," the agency said, "almost all persons in the United States had suffered from chickenpox by adulthood. Each year, the virus caused an estimated four million cases of chickenpox, 11,000 hospitalizations, and 100 to 150 deaths."

Today, chickenpox — like other childhood diseases for which vaccines had been developed earlier, including measles, mumps, rubella and polio — is largely a thing of the past. A large long-term study published this year found that a very small percentage of children who receive one dose of the vaccine still get the virus, and that most of those cases are mild or moderate. Among children in the study who received a second dose, none contracted the disease.

Dr. Takahashi was born on Feb. 17, 1928, in Osaka. He received his medical degree from Osaka University in 1954. Before his work on the chickenpox vaccine, he collaborated on mumps and rubella vaccines. He later served on the board of directors of the Research Foundation for Microbial Diseases of Osaka University.

His survivors include his wife, Hiroko, and his son.

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Hypertension Guide May Affect 7.4 Million

With two-thirds of Americans over 60 experiencing high blood pressure, new treatment guidelines released on Wednesday might mean fewer medications, lower doses or even none at all for millions of people.

But the committee that released the guidelines did not have data to answer one fundamental question: How many people are affected by the change?

On Thursday, Paul Muntner, a professor of epidemiology at the University of Alabama at Birmingham, came up with an answer: 7.4 million Americans out of the 51 million over 60 are in the newly defined safe range, which is blood pressure of between 140/90 and 149/90.

The old guidelines urge treatment if the systolic blood pressure — the top number — is 140 or higher. The new guidelines state that the goal for people over 60 is a systolic pressure of less than 150. In both cases the recommended diastolic pressure — the bottom number — should be lower than 90.

Dr. Muntner's figure was derived in response to an inquiry on Wednesday from a reporter. It was based on his analysis of data from the National Health and Nutrition Survey, a federal study that combines interviews and health exams to gather information on the health of Americans.

More than half of those 7.4 million people — 4.2 million — are currently taking medications to lower their blood pressure, yet still remain over 140/90. Under the old guidelines, that often led to more treatment, with doctors urging additional medications or higher doses to bring systolic pressure down. Under the new guidelines, that is no longer recommended.

The other 3.2 million can continue without treatment, though in the past they were often warned that no treatment would put them at risk of a stroke or heart attack. The committee said that anyone over 60 with pressure below 140/90 after treatment can stay on the medications, as long as there are no side effects.

Many doctors take issue with the new targets, saying a systolic pressure goal of 150 is too high. They say that the committee, composed of 17 academics, was too narrowly focused on data from randomized trials and that it should have considered other forms of evidence.

But the committee said it was convinced by rigorous studies that failed to find an advantage for people over 60 having pressure lower than 150.

A lower pressure, without medications, is certainly healthier, the group said. But achieving a lower pressure by using medications is not the same as having it naturally, it said, as medications can have side effects.

"When you are taking an asymptomatic person and putting them on medication, you want to be sure you are doing good," said Dr. Paul A. James, the chairman of the department of family medicine at the University of Iowa and co-chairman of the guidelines committee.

This article has been revised to reflect the following correction:

Correction: December 23, 2013

An article on Friday about new blood pressure treatment guidelines misstated the surname of the doctor whose analysis determined how many Americans would be affected by the changes. He is Paul Muntner, not Munter.

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Well: Life, Interrupted: By a Dog

Life, Interrupted

Suleika Jaouad writes about her experiences as a young adult with cancer.

Ever since a therapy dog visited me in the hospital during my first cycle of chemotherapy in May 2011, I became fixated on the idea of having a dog of my own one day.

When you are talking to a dog about cancer, there are no judgments or taboos. The therapy dog, a small energetic King Charles Spaniel, jumped around on my hospital bed playfully tugging at the blanket on my lap. For the first time since I had fallen ill, I didn't feel like I was being treated as if I were made of porcelain. The therapy dog made me feel like a human first, and a cancer patient second.

During the first year of my cancer treatment, adopting a dog was out of the question. I spent more time in the hospital than out. And in the time I was able to spend at home, I had to live in a germ-free bubble to protect my fragile immune system. As a substitute for a real dog, my mom found "Sleepy," my childhood stuffed dog in the attic. As embarrassing as it was for me to be toting a stuffed animal at age 22, Sleepy was the next best thing to a real puppy. He made me feel like a kid again, safe and innocent to the cruelties of the world.

Six months after my bone marrow transplant, I finally got the green light from my doctors to get a real puppy. I promised my parents that I would take numerous precautions to protect my health. The dog would wear disposable booties on walks, to keep his paws as germ-free as possible. I promised to wear gloves when walking and feeding him, vowed that he would never sleep in my bed and lined up four friends to help take care of him when I lacked the energy.

I spent months trolling animal adoption websites for the perfect furry companion but as soon as I saw Oscar, I knew I had to bring all four, wiggling pounds of him home with me. With his soft white fur, tiny heart-shaped nose, and hazel eyes, it was love at first sight.

But within 72 hours of living with Oscar, I began to wonder if I had made a huge mistake. I had meticulously geared up for his arrival (teething toys, a crate, and an armload of cleaning products and stain removers: check, check, and check). But nothing could have prepared me for the task of sprinting outside of my apartment building at the crack of dawn with a peeing 8-week-old schnauzer-poodle mix. After a bone-marrow transplant and two and a half years of ongoing chemotherapy, my muscles were weak and my energy nonexistent.

Walking Oscar quickly became the most dreaded part of my day. After a few blocks, he was warmed up and ready for a run in the park. I, on the other hand, couldn't wait to crawl back into bed.

When my boyfriend Seamus is home from work, he shares the responsibilities of taking care of Oscar. But during the day, it's just me and the dog.

Oscar, unlike my caregivers, doesn't care that I'm tired, feeling nauseous after my chemotherapy treatments. Every morning between 6 and 7, Oscar scoots over to my side of the bed and begins the process of baptizing me with his tongue until I wake up.

Caring for Oscar is not always easy, but trying to keep up with him has been some of the best medicine I've received since my cancer diagnosis. Oscar and I have even shared similar experiences, and together, we've slowly matured and grown more disciplined. He no longer pees on the Oriental rug in my living room, and I have stopped sleeping in until noon. Oscar just finished getting his booster shots, and I will soon be getting all of my childhood vaccinations for the second time (a patient's immunizations are lost during a bone marrow transplant).

Walking up and down stairs used to be a challenge for us. I felt weak and unstable on my feet after spending so much time on bed rest. And Oscar's short, stubby legs meant that more often than not, he would end up tumbling rather than walking down the stairs. Now, we bound up and down the stairs with ease, taking them two by two.

I've found that I do some of my best thinking during our early morning walks — those few hours after the garbage trucks have gone and before the coffee shops open when Manhattan is as asleep as it ever will be. For that one hour each morning, I'm focused on the now.

Because of Oscar, I have discovered the Tompkins Square Park dog run where we've made lots of new friends. There's Mochi, the terrier mix who likes to wrestle in the sand with Oscar. And Thelma and Louise, the shy brother and sister beagle duo who prefer to watch the other dogs play from a distance. I get my morning comic relief from watching Max, a giant hound, whose favorite extracurricular activity is attacking the fur trim on women's winter coats.

As for the dog precautions that I promised my parents, we have tried to stick to most of them. I wash my hands regularly, and as my immune system has grown stronger, we've graduated to wiping down Oscar's paws each time he enters the apartment. It won't surprise any dog owner that Oscar has wriggled his way into the bed, but at least he sleeps at the foot of it.

Although I was the one who rescued Oscar from an animal shelter, it has become clear that he's done most of the rescuing in our relationship. We're still working on "heel" and other basic commands. When we leave my apartment, Oscar bounds ahead of me, tugging at his leash as he guides me toward the dog park. For the first time in a very long time, it's not the cancer that leads. It's Oscar.

---

Suleika Jaouad (pronounced su-LAKE-uh ja-WAD) is a 25-year-old writer who lives in New York City. Her column, "Life, Interrupted," chronicling her experiences as a young woman with cancer, appears regularly on Well. Follow her updates on Twitter or Facebook.

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Judge Orders Girl Be Kept on Ventilator

OAKLAND, Calif. — A 13-year-old girl who was declared brain-dead after complications from a tonsillectomy should be kept on life support for the time being, a judge has ruled.

The family of the girl, Jahi McMath, says doctors at Children's Hospital Oakland wanted to disconnect life support after she was declared brain-dead on Dec. 12.

A ruling on Friday by Judge Evelio Grillo of Superior Court came as both sides in the case agreed to get together and choose a neurologist to further examine Jahi and determine her condition. The judge scheduled a hearing on Monday to appoint a physician.

After Jahi underwent what the family called a routine tonsillectomy to help with her sleep apnea and was moved to a recovery room, her mother, Nailah Winkfield, began to fear that something was going wrong.

Jahi was sitting up in bed, her hospital gown bloody, and was holding a cup full of blood, she said. "Is this normal?" Ms. Winkfield repeatedly asked nurses.

With her family and hospital staff members trying to help and comfort her, Jahi bled profusely for the next few hours and then went into cardiac arrest, her mother said.

Despite the family's description of the operation as routine, the hospital said in a memorandum presented to the court on Friday that the procedure was "complicated."

"Ms. McMath is dead and cannot be brought back to life," the hospital said in the memo.

"Children's is under no legal obligation to provide medical or other intervention for a deceased person," it added.

The family said hospital officials told them in a meeting on Thursday that they wanted to take Jahi off life support quickly.

The family filed a request on Friday for a temporary restraining order prohibiting the hospital from taking her off life support or any of her other treatments.

At the hearing later, the hospital's lawyer, Doug Straus, said two doctors unaffiliated with the hospital had examined Jahi and concluded that she was brain-dead.

But he said, "We're happy to cooperate with the judge's suggestion that an independent expert be provided to confirm yet again that brain death is the outcome that has occurred here."

The family's lawyer, Christopher Dolan, said the family wanted tests of their own because they did not believe that the hospital's physicians were sufficiently independent.

"There is mistrust, and there is a conflict of interest," he said.

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Spike in Harm to Liver Is Tied to Dietary Aids

When Christopher Herrera, 17, walked into the emergency room at Texas Children's Hospital one morning last year, his chest, face and eyes were bright yellow — "almost highlighter yellow," recalled Dr. Shreena S. Patel, the pediatric resident who treated him.

Christopher, a high school student from Katy, Tex., suffered severe liver damage after using a concentrated green tea extract he bought at a nutrition store as a "fat burning" supplement. The damage was so extensive that he was put on the waiting list for a liver transplant.

"It was terrifying," he said in an interview. "They kept telling me they had the best surgeons, and they were trying to comfort me. But they were saying that I needed a new liver and that my body could reject it."

New data suggests that his is not an isolated case. Dietary supplements account for nearly 20 percent of drug-related liver injuries that turn up in hospitals, up from 7 percent a decade ago, according to an analysis by a national network of liver specialists. The research included only the most severe cases of liver damage referred to a representative group of hospitals around the country, and the investigators said they were undercounting the actual number of cases.

While many patients recover once they stop taking the supplements and receive treatment, a few require liver transplants or die because of liver failure. Naïve teenagers are not the only consumers at risk, the researchers said. Many are middle-aged women who turn to dietary supplements that promise to burn fat or speed up weight loss.

"It's really the Wild West," said Dr. Herbert L. Bonkovsky, the director of the liver, digestive and metabolic disorders laboratory at Carolinas HealthCare System in Charlotte, N.C. "When people buy these dietary supplements, it's anybody's guess as to what they're getting."

Though doctors were able to save his liver, Christopher can no longer play sports, spend much time outdoors or exert himself, lest he strain the organ. He must make monthly visits to a doctor to assess his liver function.

Americans spend an estimated $32 billion on dietary supplements every year, attracted by unproven claims that various pills and powders will help them lose weight, build muscle and fight off everything from colds to chronic illnesses. About half of Americans use dietary supplements, and most of them take more than one product at a time.

Dr. Victor Navarro, the chairman of the hepatology division at Einstein Healthcare Network in Philadelphia, said that while liver injuries linked to supplements were alarming, he believed that a majority of supplements were generally safe. Most of the liver injuries tracked by a network of medical officials are caused by prescription drugs used to treat things like cancer, diabetes and heart disease, he said.

But the supplement business is largely unregulated. In recent years, critics of the industry have called for measures that would force companies to prove that their products are safe, genuine and made in accordance with strict manufacturing standards before they reach the market.

But a federal law enacted in 1994, the Dietary Supplement Health and Education Act, prevents the Food and Drug Administration from approving or evaluating most supplements before they are sold. Usually the agency must wait until consumers are harmed before officials can remove products from stores. Because the supplement industry operates on the honor system, studies show, the market has been flooded with products that are adulterated, mislabeled or packaged in dosages that have not been studied for safety.

The new research found that many of the products implicated in liver injuries were bodybuilding supplements spiked with unlisted steroids, and herbal pills and powders promising to increase energy and help consumers lose weight.

"There unfortunately are criminals that feel it's a business opportunity to spike some products and sell them as dietary supplements," said Duffy MacKay, a spokesman for the Council for Responsible Nutrition, a supplement industry trade group. "It's the fringe of the industry, but as you can see, it is affecting some consumers." More popular supplements like vitamins, minerals, probiotics and fish oil had not been linked to "patterns of adverse effects," he said.

The F.D.A. estimates that 70 percent of dietary supplement companies are not following basic quality control standards that would help prevent adulteration of their products. Of about 55,000 supplements that are sold in the United States, only 170 — about 0.3 percent — have been studied closely enough to determine their common side effects, said Dr. Paul A. Offit, the chief of infectious diseases at the Children's Hospital of Philadelphia and an expert on dietary supplements.

"When a product is regulated, you know the benefits and the risks and you can make an informed decision about whether or not to take it," he said. "With supplements, you don't have efficacy data and you don't have safety data, so it's just a black box."

Since 2008, the F.D.A. has been taking action against companies whose supplements are found to contain prescription drugs and controlled substances, said Daniel Fabricant, the director of the division of dietary supplement programs in the agency's Center for Food Safety and Applied Nutrition. For example, the agency recently took steps to remove one "fat burning" product from shelves, OxyElite Pro, that was linked to one death and dozens of cases of hepatitis and liver injury in Hawaii and other states.

The new research, presented last month at a conference in Washington, was produced by the Drug-Induced Liver Injury Network, which was established by the National Institutes of Health to track patients who suffer liver damage from certain drugs and alternative medicines. It includes doctors at eight major hospitals throughout the country.

The investigators looked at 845 patients with severe, drug-induced liver damage who were treated at hospitals in the network from 2004 to 2012. It focused only on cases where the investigators ruled out other causes and blamed a drug or a supplement with a high degree of certainty.

When the network began tracking liver injuries in 2004, supplements accounted for 7 percent of the 115 severe cases. But the percentage has steadily risen, reaching 20 percent of the 313 cases recorded from 2010 to 2012.

Those patients included dozens of young men who were sickened by bodybuilding supplements. The patients all fit a similar profile, said Dr. Navarro, an investigator with the network.

"They become very jaundiced for long periods of time," he said. "They itch really badly, to the point where they can't sleep. They lose weight. They lose work. I had one patient who was jaundiced for six months."

Tests showed that a third of the implicated products contained steroids not listed on their labels.

A second trend emerged when Dr. Navarro and his colleagues studied 85 patients with liver injuries linked to herbal pills and powders. Two-thirds were middle-aged women, on average 48 years old, who often used the supplements to lose weight or increase energy. Nearly a dozen of those patients required liver transplants, and three died.

It was not always clear what the underlying causes of injury were in those cases, in part because patients frequently combined multiple supplements and used products with up to 30 ingredients, said Dr. Bonkovsky, an investigator with the network.

But one product that patients used frequently was green tea extract, which contains catechins, a group of potent antioxidants that reputedly increase metabolism. The extracts are often marketed as fat burners, and catechins are often added to weight-loss products and energy boosters. Most green tea pills are highly concentrated, containing many times the amount of catechins found in a single cup of green tea, Dr. Bonkovsky said. In high doses, catechins can be toxic to the liver, he said, and a small percentage of people appear to be particularly susceptible.

But liver injuries attributed to herbal supplements are more likely to be severe and to result in liver transplants, Dr. Navarro said. And unlike prescription drugs, which are tightly regulated, dietary supplements typically carry no information about side effects. Consumers assume they have been studied and tested, Dr. Bonkovsky said. But that is rarely the case. "There is this belief that if something is natural, then it must be safe and it must be good," he said.

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