The decision affirms the original judgment by the FEMA Transitional Recovery Office in New Orleans that Charity was not more than half destroyed by Hurricane Katrina. FEMA has offered to pay Louisiana $150 million for storm damage to Charity, far short of what LSU needs as the cornerstone for its plan to build a new hospital complex in Mid-City.

Attorneys for the Louisiana Office of Facility Planning and Control and LSU now have 60 days to decide whether to appeal the decision by the regional office to FEMA headquarters in Washington and its new administrator, Craig Fugate.

Alternatively, the state could go through an arbitration process being created by the Department of Homeland Security as ordered by a provision in the stimulus package authored by Sen. Mary Landrieu, D-La.

The trick for the state, according to Mark Riley, deputy director of the Governor's Office of Homeland Security and Emergency Preparedness, is that the exact nature of the arbitration process is not final or public.

"We are going to press them to expose that process as soon as possible so we can make an informed decision," said Riley.

Homeland Security Secretary Janet Napolitano told Landrieu at a Senate Homeland Security Committee hearing Tuesday that department lawyers are putting the finishing touches on the arbitration plan. Napolitano will be pressed on the Charity issue when she appears today before the House Homeland Security Committee, on which Rep. Anh "Joseph" Cao, the freshman Republican from New Orleans, serves.

"We are extremely disappointed that they have denied this first appeal, but I hope to address this issue with Secretary Napolitano at the full committee hearing," Cao said.

At a White House reception April 23, Cao handed President Obama a letter asking for his help to resolve the Charity dispute.

"Charity Hospital was completely destroyed by Hurricane Katrina and has sat dormant since August 2005," Cao wrote. "For nearly four years, my constituents have been without the critical services offered by this facility, which is central to Orleans and Jefferson parishes' health-care delivery."

Cao's view on Charity's condition is disputed by a group of citizens who last month appealed to FEMA seeking to intervene in the Charity Hospital case on behalf of New Orleanians who they say have been denied adequate medical care in Charity's absence.

They claim that the state's case against FEMA is baseless, and attorneys for the group were delighted by word of FEMA's continued denial of the state's claims.

"They know the hospital was not irreparably damaged after the storm. We know the hospital was cleaned up, was ready to be reopened," said attorney Tracie Washington, who said that LSU and the state should drop their appeal and get about the business of reopening the historic hospital.

Efforts to gut and restore Charity, rather than build a new facility, also are supported by some historic preservationists and community groups, as well by Sen. David Vitter, R-La.

Vitter, according to spokesman Joel DiGrado, believes that a public hospital should have already been rebuilt downtown, that LSU has delayed that far too long, that its plan is too big and expensive and that "gutting the old Charity shell and rebuilding a state-of-the-art hospital in it could save a lot of money."

Riley and Paul Rainwater, executive director of the Louisiana Recovery Authority, said the latest FEMA decision was not unexpected and seemed pretty cursory and largely pro-forma in its review of the state's case.

Riley said that the arbitration route might require the state to waive further legal action, but might prove an attractive alternative if it allows the case to be decided by an administrative law judge.

If the state appeals to FEMA headquarters and loses, it could still take FEMA to court.

http://www.nola.com/news/t-p/frontpage/index.ssf?/base/news-12/1242192204131070.xml&coll=1

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LSU willing to share hospital power

The Times-Picayune | 05.13.09

By Jan Moller

Capital bureau

BATON ROUGE -- Louisiana State University officials said Tuesday they are willing to include Tulane, Xavier and other New Orleans institutions on the governing board of a proposed $1.2 billion teaching hospital, a move that could break a logjam that has divided the city's academic and medical communities for months.

The turnabout puts LSU in line with the position that Gov. Bobby Jindal's administration has advocated since last summer, when negotiations on the governing structure of the academic medical center kicked into overdrive. It also comes as the House prepares to vote on a proposal by House Speaker Jim Tucker, R-Algiers, that would remove or vastly reduce the universities' role in governing the New Orleans hospital.

LSU previously insisted that Tulane be excluded from the nonprofit corporation that would run the new hospital, arguing that it has a conflict of interest because Tulane University Hospital would be in direct competition. LSU System President John Lombardi said university officials "are going to have to live with that conflict of interest" if it means moving the project forward.

Governance issues and financing have become the biggest stumbling blocks as the state tries to build a state-of-the-art teaching hospital to replace Charity Hospital, which has been shuttered since Hurricane Katrina.

Lombardi said LSU also is willing to capitulate on the name of the new hospital, suggesting in a proposed memorandum of understanding that it be called the Avery C. Alexander Hospital, which is the formal name of the old Charity Hospital. But the broader academic medical complex planned for lower Mid-City would carry a different name that "shall reflect its relationship with LSU as well as recognition of other established affiliations," according to the proposal.

Ancillary buildings in the medical complex would be "available for naming by grateful patients" who donated money to the project, Lombardi said.

The hospital's name had become a point of contention, with Tulane saying LSU should not have its name affixed to a building that would host medical students and post-graduate residents from both institutions.

The memorandum calls for the new medical center to be run by an 11-member board, five of whose members would be appointed by the president of the LSU System. Tulane and Xavier universities each would have a board appointment, while another seat would rotate among Dillard, Delgado Community College and Southern University at New Orleans. Three members would be "non-permanent" and be "representative of the community."

Lombardi said LSU remains opposed to Tucker's House Bill 830, which in its current form would set up an independent board to run the hospital. Lombardi said the board that Tucker envisions would be overly political, have trouble issuing debt and would create the same conditions that led to the old Charity Hospital building falling into general disrepair.

By creating a state board, rather than one controlled by the university, the Tucker proposal "retreats to the old Charity model with every defect imaginable," Lombardi said.

Late Tuesday, Tucker said he has not seen LSU's memorandum and still plans to push his bill, which could come up for a floor vote early next week. He said it will be heavily amended and will include a governing board that gives equal weight to LSU, Tulane, Xavier, Dillard, Delgado and Southern. But the medical center would be owned by a separate board within the Department of Health and Hospitals that would have no university representation, Tucker said.

Health and Hospitals Secretary Alan Levine said the turnabout by LSU is a "good development" and said the administration remains in negotiations on Tucker's legislation. He said the administration is not ready to take a position on Tucker's bill until it sees the amendments and gets input from other affected parties.

"We're trying to be flexible. We're trying to work with everybody," Levine said.

Tulane University President Scott Cowen could not be reached for comment late Tuesday.

http://www.nola.com/news/t-p/frontpage/index.ssf?/base/news-12/1242192046131070.xml&coll=1

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LSU offers new plan for medical center

The Advocate | 05.13.09

By MARSHA SHULER

Advocate Capitol News Bureau

LSU executives Tuesday unveiled a revised plan to create a private, nonprofit organization to handle financing and operation of a proposed $1.2 billion academic medical center in New Orleans.

LSU System President John Lombardi said the revamp addresses problem areas that developed as LSU negotiated the proposal with Gov. Bobby Jindal’s administration, including the role Tulane University should play and the name of the new medical center.

“We are trying to get this thing off dead center,” Lombardi said.

State Department of Health and Hospitals Secretary Alan Levine called the new LSU proposal “a positive development.”

“If all parties are willing to endorse (it), we’d be prepared to,” Levine said.

The announcement came as LSU is fighting legislation by House Speaker Jim Tucker, R-Terrytown, that would move control of the hospital and other New Orleans health-care operations to a board of directors within the state Department of Health and Hospitals.

Lombardi said LSU’s private, not-for-profit model is one that has worked for other successful academic medical enterprises. He said it would help with financing of the project through use of its separate borrowing authority, such as that used by LSU’s Tiger Athletic Foundation to build sports facilities.

The new private entity would be created under LSU’s legal authority to affiliate with organizations in support of its educational mission.

Tucker’s proposal “retreats back to the old charity (hospital) with every defect imaginable,” including political interference, Lombardi said. “We are trying to take it out of politics and put it in academic medicine.”

LSU submitted its revamped proposal to Levine, who has been the administration’s point man in development of the plan, which is outlined in a “memorandum of understanding,” or MOU, Lombardi said.

A major stumbling block has been LSU’s resistance to Tulane having a seat on the board of directors of the not-for-profit corporation that would run the medical center. Tulane operates some of its physician training programs out of the LSU hospital in New Orleans today.

The new proposal would give Tulane a seat on the 11-member organization’s board. Lombardi continues to claim there is a “conflict of interest” because Tulane is affiliated with a private hospital that would be an LSU competitor.

The proposal also calls for naming the new hospital the Avery C. Alexander Hospital — after the late civil-rights leader and state legislator, Lombardi said. The name of the academic medical center development as a whole would be decided by the not-for-profit’s board, but it must reflect its relationship with LSU, he said.

Levine said he forwarded the new proposal to Tulane for input.

Levine said the administration is on board with the concept that LSU is advancing.

http://www.2theadvocate.com/news/44852202.html

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FEMA says it won't provide funds to replace Charity

WWLTV | 05.12.09

Susan Edwards / Eyewitness News

NEW ORLEANS – The state's top recovery official is outlining the next steps in the fight to get FEMA to reimburse the state millions for Charity Hospital.

Video: Watch the Story

On Tuesday FEMA denied the state's appeal for $492 million for the building as a result of damage from Hurricane Katrina.

The question now, is how that decision impacts the three-year debate on whether the hospital should be restored or rebuilt.

Paul Rainwater, director of the Louisiana Recovery Authority, disagrees with the FEMA response.

"We have three studies showing the facility was damaged more than 51 percent, so we obviously are making strong arguments, and will ask FEMA to look at three studies that prove our point," he said.

FEMA Denial Letter

http://www.wwltv.com/images09/0512fema.pdf

Those studies are not mentioned in the denial letter.

What is mentioned is the negligence on the state's behalf in not protecting the building to the fullest extent in the months after the storm, something the Eyewitness News cameras revealed during a tour of the building in January.

Rainwater said FEMA's mentioning that in the denial came as a surprise, because the former FEMA administration agreed that the damage, even if proven, was out of the state's control, because of Katrina and Rita's catastrophic nature.

Brad Ott, who co-chairs a committee to re-open Charity Hospital, said the failed appeal makes him cautiously optimistic that the hospital can be restored, and not replaced.

"We want the state to consider, LSU to consider to do the right thing and restore healthcare services quicker, faster and cheaper without destroying the neighborhood and dislocating residents who came back after the storm," Ott said.

Rainwater said plans for an academic medical complex are moving forward, while the state has three options it can take in appealing the denial.

They could file a second appeal, which would involve an oral argument in Washington, D.C., go before an arbitration panel, or, ask Homeland Security Chief Janet Napolitano to review the claim. Rainwater said Napolitano would be willing to do that, based on previous discussions with her.

"What we will ask FEMA to do is provide them with 300 pages of documents, they gave us a 10 page document denying it, we want them to get in detail and show us what the issues are," said Rainwater.

Rainwater expects some sort of answer on what FEMA will owe the state in the next 90 to 120 days.

http://www.wwltv.com/topstories/stories/wwl051209cbfema.1c5939ca.html

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FEMA won't pay to replace New Orleans hospital

The Advertiser | 05.12.09

NEW ORLEANS (AP) — The Federal Emergency Management Agency said the state hasn't proven it's owed nearly half a billion dollars to replace a New Orleans hospital damaged by Hurricane Katrina, says a letter obtained Tuesday by The Associated Press.

Gary Jones, an acting regional administrator for the agency, said in a letter to the Governor's Office of Homeland Security and Emergency Preparedness that the state did not prove Charity Hospital was damaged so badly by the 2005 storm and flood waters that it merited the federal government pay to replace it.

FEMA is offering $150 million — $126 million for building damage and $24 million for damage to building contents — and Jones repeated the prior position of FEMA that not enough was done to guard the building against further decay after the storm.

The state has argued it is owed $492 million and believes it has the studies and documentation to back that up.

Christina Stephens, a spokeswoman for the Louisiana Recovery Authority, said the state intends to continue pressing its case and to exhaust all available options. Those include appealing to a higher level within FEMA or taking the matter to an arbitration panel that has been authorized but is not yet fully in place, she said.

U.S. Sen. Mary Landrieu, D-La., who pushed for the panel, has urged FEMA to finalize the details surrounding arbitration as soon as possible.

What FEMA ultimately allocates is likely to have a significant bearing on plans for a proposed $1.2 billion teaching and research hospital in New Orleans' Mid City neighborhood. The state has set aside $300 million, and even if FEMA ultimately grants all the state is seeking, there would still be a sizable hole to fill with as-yet unsecured bonds or other funds.

Stephens said talks so far have been focused on making the case to FEMA — not on pressing, say, for a congressional appropriation that would help cover the cost.

The proposed hospital would be built near a planned federal veterans' hospital in Mid City. State and local officials see the project as key to improving the city's still-ailing health care system and to creating jobs, attracting new residents and jolting the area economy.

But some question the need to clear land that includes homes rebuilt after Katrina and structures considered historic. Some preservationists argue the former Charity building, closed since the storm, could be revamped. Preservationists recently filed a lawsuit claiming federal agencies failed to adequately assess the effect of building two new hospitals in the neighborhood.

http://www.theadvertiser.com/article/20090512/NEWS01/90512042

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Letter: Rehab snags lurk at Charity

The Times-Picayune | 05.13.09

Steve Schmitt

For those who are not sure about the Charity Hospital renovation, I have two questions to ask you: 1) How much did they tell you, or someone you know, what it would cost to rebuild your home after Katrina? 2) How much did it actually cost?

Anyone who has been involved in a rebuilding or renovation is familiar with the term "unforeseen circumstances."

This is what the advocates of the old Charity renovation project don't want to acknowledge or talk about.

Those unforeseen circumstances always drive up the cost of a renovation, and they occur far more in renovation than in new construction.

Steve Schmitt

New Orleans

http://www.nola.com/news/t-p/letterstoeditor/index.ssf?/base/news-13/1242192232131070.xml&coll=1

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EDITORIAL: What about patients' rights?

The Times-Picayune | 05.13.09

State Rep. Bernard LeBas wants to protect health care workers from legal and job repercussions if they refuse to provide services on grounds of their moral beliefs, but House Bill 517 shields workers at the expense of patients.

This legislation also covers services that aren't even legal in Louisiana: euthanasia, physician-assisted suicide and human cloning. That's not necessary.

What is necessary is for Louisianians to have access to legitimate, legal health care services and information. This isn't only about doctors and nurses. Workers who refuse to schedule a service or process a claim or fill a prescription because they disagree with what's being done could end up depriving someone of care. This is particularly of concern in rural areas, where patients have fewer options.

HB 517 is not in the public interest. Louisiana residents shouldn't have to worry that their health care could be held hostage by someone else's beliefs. The bill has cleared the Civil Law & Procedure Committee, but the full House should consider the needs of patients and kill it.

http://www.nola.com/news/t-p/editorials/index.ssf?/base/news-5/1242192228131070.xml&coll=1

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New layer of Medicaid review sought

The Times-Picayune | 05.13.09

By Jan Moller

Capital bureau

BATON ROUGE -- The state Department of Health and Hospitals should be required to consult with an independent advisory group of doctors and dentists before it can make any changes to the Medicaid program, a House committee decided Tuesday.

The House Health and Welfare Committee voted 11-5 to send House Bill 717 to the floor, overriding objections from Gov. Bobby Jindal's administration, which said it would add an unnecessary layer of bureaucracy to the $6 billion-per-year program.

Supporters of the bill by Rep. Hunter Greene, R-Baton Rouge, said the eight-member advisory group -- which would consist of seven doctors and one dentist, all appointed by various medical societies -- is needed to guarantee that any changes to the Medicaid program are based on solid evidence.

"We're not here to take over DHH," Dr. Steven Spedale, a Baton Rouge pediatrician, said. "We're here to make sure that the clinical input on a policy is present."

Health and Hospitals Secretary Alan Levine said the advisory group, which would have the right to review changes in the rates paid to doctors, hospitals and other groups, could slow the rulemaking process and that policies already are in place to give doctors and others a chance to be heard.

He said the health agency issued 162 different rules last year, 95 percent of which pertained to the Medicaid program. All of the Medicaid rules would have to be reviewed by the new advisory committee.

"Sometimes what's in the best interest of public policy does not necessarily comport with what's in the best interest" of health-care providers, Levine said.

The vote was a rare setback for the Jindal administration in this young session, where the governor has been able to kill legislation not to his liking.

http://www.nola.com/news/t-p/capital/index.ssf?/base/news-7/1242192186131070.xml&coll=1

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Dental clinic bill clears House panel

The Times-Picayune | 05.13.09

By Jan Moller

Capital bureau

BATON ROUGE -- A controversial bid to outlaw school-based mobile dental clinics cleared its first legislative hurdle Tuesday after a House committee made changes that would allow some clinics to continue operating.

But opponents of House Bill 687 said the measure would still prevent many poor children from getting necessary dental care at school, and that regulation of mobile clinics is best left to professional licensing boards, not the Legislature.

As the bill by Rep. Kevin Pearson, R-Slidell, came to the committee, it would have barred virtually all mobile clinics, which critics say are unsanitary and don't provide for enough parental involvement.

"Full-service care is not generally going to be delivered in a mobile dental facility," Pearson said.

An amendment tacked on to the bill would make exceptions for mobile clinics operated by state or parish governments, or tied to federally qualified health centers that already are providing dental services. It also would allow school-based clinics in areas designated by the state dentistry board as being underserved, if local superintendents approve.

A divided House Health and Welfare Committee sent the bill to the floor moments after narrowly rejecting a motion that would have killed the bill and given the Louisiana Board of Dentistry one year to come up with new regulations for mobile clinics.

Mobile clinics -- where dentists set up temporary shop in a school gym, library or similar space -- have been a growing trend in Louisiana since the Legislature last year raised the Medicaid rates to the point where it became profitable for dentists to treat poor children. Before that, the few mobile clinics mainly catered to nursing homes.

While the Louisiana Dental Association backs the effort to curb the clinics, the bill has drawn opposition from some dentists, public health groups and the Federal Trade Commission.

Barry Ogden, executive director of the Louisiana Board of Dentistry, said there have not been any problems associated with the mobile clinics, but the 13-member licensing body is in the process of updating its regulations to reflect the changes represented by school-based mobile clinics.

"This is like a mushroom cloud in the dental community right now," Ogden said.

Dr. Herb Flood, a Mandeville dentist, said the bill would reduce access to care for the more than 400,000 Louisiana children who qualify for free care under Medicaid. He brushed off critics' concerns that "invasive procedures" shouldn't be done in schools, saying they are limited to filling cavities and pulling teeth.

"They're not doing brain surgery in the library," Flood said.

http://www.nola.com/news/t-p/capital/index.ssf?/base/news-7/1242192199131070.xml&coll=1

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Panel modifies ban on school dentistry

The Advocate | 05.13.09

By SARAH CHACKO

Advocate Capitol News Bureau

Legislation that would prohibit most dentistry services in public schools received approval from a Louisiana House committee Tuesday.

However, the panel did add some exceptions to a total ban.

State Rep. Kevin Pearson, R-Slidell and sponsor of House Bill 687, said full-service dental care is not always offered in mobile dental units.

“What we’re trying not to do is a commodity type dentistry,” Pearson told the House Health and Welfare Committee.

Of the 400 students last year who needed follow up treatments after in-school services, 310 did not get it, Pearson said.

Dr. Herb Flood, a dentist in Mandeville, said children across the state, particularly in impoverished, rural areas, are “dentally homeless.”

Of the 17 Medicaid providers in his area, only two are seeing new patients, he said.

“When we cannot get children to the care, we have to get the care to the children,” Flood said.

HB687 was amended to allow dentistry practiced in mobile dental units owned and operated by the state or local government, federally qualified health center mobile facilities, or a school-based health clinic with permanent facilities.

Those services would have to have been in place for at least six months in the past five years, according to the amendments brought by House Health and Welfare Committee Chairwoman Kay Katz, R-Monroe.

Katz said the language would be clarified on the House floor to allow for future programs by those agencies.

An exception was also added to allow the dentistry in schools in areas designated by the Louisiana State Board of Dentistry as underserved for dental care, with the approval of the school district superintendent.

State Board of Dentistry Executive Director Barry Ogden said the board has not yet taken a position on the bill but he has serious concerns about the safety of the services offered.

“How can you compare a gymnasium or school library to a dental office?” he asked.

But Ogden said he has not heard of any problems with mobile dentistry units and a dentistry-related death has not been reported in Louisiana in almost a decade.

Flood said doctors providing the mobile services do not use nitrous oxide and are qualified to handle emergency situations.

“They’re not doing brain surgery,” he said. “How many of you have removed a baby tooth in your living room?”

Ogden said 10 mobile dentistry programs are permitted in the state.

State Rep. Fred Mills Jr., D-St. Martinville, tried to stop the measure from leaving the committee, asking the Board of Dentistry to make its own rules about the practice in schools within the next year.

Mills’ attempt failed, with six representatives voting to defer the bill and eight voting against the deferral.

HB687 then passed in the committee 12-2.

http://www.2theadvocate.com/news/44852207.html

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Letter: Ban dental care in La. schools

The Advocate | 05.13.09

Todd Herrington

The stated mission of the Louisiana state Department of Education is threefold: to ensure higher academic achievement for all students, to eliminate all achievement gaps and to prepare students to be effective citizens in a global market.

With a bloated state Department of Education budget of more than $4.5 billion and a per-student expenditure that would make many private schools blush, one might think these goals could be realized.

Sadly, according to our latest LEAP testing results, more than 85 percent of state children only score “basic,” “approaching basic” or “unsatisfactory” in all four main subjects of English, science, social studies and math.

Should not every moment in our schools be geared toward better academic results? Shouldn’t every administrator, teacher and student be driven for loftier achievement? Should not media outlets report the shortcomings and investigate how wisely our money is being spent and why results are so poor?

Unfortunately, it seems The Advocate has taken the position that part of the school day must now be spent away from instruction and in a dental chair, at an extra cost to the taxpayer, of course.

This position seems to think students in a captive environment should be subject to a state remedy for one of our many vast social problems. This type of social engineering is not part of the mission statement.

Schools already provide free breakfast and lunch for many; free and discounted before and after day care is also the norm; now it seems some would like to see doctors and dentists making house calls.

Free dental services are already available to those in need; it just requires making an appointment and showing up. Is the state not going to have a parent shoulder any responsibilities in the raising of the children they created?

Maybe the better solution would be to bring math and science instruction to the dentist office. Before receiving free care, the student must read the latest science chapter and pass an on-grade-level math test. Shouldn’t a dentist chair in the school library sound just as ridiculous?

Let us agree that the schools’ priority should be motivating children to learn in a safe environment. Is the self-esteem generated from clean teeth going to improve the core stated mission of the Department of Education and ensure highest academic achievement for all students?

I think we all know the answer.

I vote yes for House Bill 687 sponsored by Rep. Kevin Pearson, R-Slidell.

Todd Herrington

sales

Baton Rouge

http://www.2theadvocate.com/opinion/44850737.html

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Doctors would have new advisory role under bill that cleared committee

The Times-Picayune | 05.12.09

by Jan Moller, The Times-Picayune

"We're not here to take over DHH," Dr. Steven Spedale, a Baton Rouge pediatrician, said. "We're here to make sure that the clinical input on a policy is present."

"Sometimes what's in the best interest of public policy does not necessarily comport with what's in the best interest" of health-care providers, Levine said.

The vote was a rare setback for the Jindal administration in this young session, where the governor has been able to kill legislation not to his liking.

http://www.nola.com/politics/index.ssf/2009/05/doctors_would_have_new_advisor.html

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Annual report due for Social Security and Medicare

The Advocate | 05.12.09

By MARTIN CRUTSINGER

AP economics writer

WASHINGTON (AP) -- The financial health of the government's two biggest benefit programs may have slipped over the past year, reflecting the deep recession that has already bitten into other areas of the budget.

The trustees for Social Security and Medicare are scheduled to provide their annual report on the finances of both programs on Tuesday. In advance of the release, many private analysts said they expected both programs could run out of cash sooner than last predicted.

A year ago, the trustees projected that the Social Security trust fund would start paying out more in benefits than it collects in taxes in 2017 and that the trust fund would be depleted in 2041.

For the Medicare trust fund, which pays for hospital care, the situation was more urgent. It was projected to start paying more in benefits than it collects in taxes within a year, and the trustees forecast that it would be depleted by 2019.

But many analysts said the worst recession in decades will produce a bleaker forecast for both Social Security and Medicare in the new trustees' report. The downturn has resulted in a loss of 5.7 million payroll jobs since it began in December 2007 and an unemployment rate that hit a 25-year high of 8.9 percent in April.

Fewer people working means less being paid into the trust funds for Social Security and Medicare.

The Congressional Budget Office recently projected that Social Security will collect just $3 billion more in 2010 than it will pay out in benefits. A year ago, the CBO had projected that Social Security would have a much higher $86 billion cash surplus for the 2010 budget year, which begins Oct. 1. The difference in the two estimates is the result of the recession.

While the smaller surplus will not have any impact on Social Security benefit payments, the government will need to borrow more at a time when the federal deficit is already exploding because of the recession and the billions of dollars being spent to prop up a shaky banking system.

For years, the Social Security trust fund has taken in more than it spent on benefits, resulting in a cushion of billions of dollars that the government could spend on other programs while giving the trust fund an IOU.

Even with the big drop in the Social Security surplus, Medicare's condition is more precarious, reflecting the pressures from soaring health care costs as well as the drop in tax collections.

For that reason, President Barack Obama is expected to focus on Medicare before he addresses Social Security.

Obama on Monday praised a pledge by the health care industry to achieve $2 trillion in savings on health care costs over the next decade, but it was unclear how much help those pledges would be in achieving Obama's goal of extending coverage to some 50 million uninsured Americans. The administration is pushing Congress to pass legislation in this area this year, preferring to tackle health care before Social Security.

The trustees report is still expected to set off a heated debate over the government's two large benefit programs, with critics saying it will highlight the failure of the Obama administration to take on the most serious problems in the budget - soaring entitlement spending, before the retirement of 78 million baby boomers makes the problems even worse.

The administration on Monday revised its deficit forecasts upward to project an imbalance this year of $1.84 trillion, four times last year's record deficit, and said the deficits will remain above $500 billion every year over the next decade.

http://www.2theadvocate.com/news/44798062.html

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Medicare won't cover 'virtual colonoscopy'

The Times-Picayune | 05.12.09

The Associated Press

(AP) — WASHINGTON - Medicare won't pay for the so-called virtual colonoscopy procedure, concluding Tuesday that there's inadequate evidence to support the cheaper, less-intrusive alternative to the dreaded colonoscopy.

Some experts had hoped that popularizing the X-ray procedure would boost screening for colon cancer, the country's second leading cancer killer. Screening to spot early cancer or precancerous growths has resulted in fewer deaths over the last two decades.

But in a decision posted on its Web site, the Centers for Medicare and Medicaid Services said that the test does not qualify for Medicare coverage. The memo noted that the procedure is performed on people without symptoms and cannot, in itself, rid a patient of precancerous growths, like a regular colonoscopy can.

Medicare does cover regular colonoscopies, in which a long, thin tube equipped with a small video camera is snaked through the large intestine to view the lining. Any growth can be removed during the procedure.

CT colonography, also known as virtual colonoscopy, is a super X-ray of the colon that is quicker, cheaper and easier on the patient, but involves radiation.

http://www.nola.com/newsflash/index.ssf?/base/national-2/124218093471340.xml&storylist=health

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La. panel votes to outlaw human-animal hybrids

The Advocate | 05.12.09

Associated Press (AP)

A Louisiana Senate panel has voted to outlaw the creation of so-called "human-animal hybrids."

Scientific researchers in some areas have tried to create human embryonic stem cells by placing human DNA into animal cells. Harvard University researchers have tried to clone human embryonic cells in rabbit eggs. But the effectiveness and the ethics of such research are being hotly debated.

Sen. Danny Martiny's bill, approved Tuesday by a Senate judiciary committee, defines and outlaws such practices and several ways of making human-animal hybrids, including combination of human sperm and an animal egg, animal sperm with a human egg, or the use of human brain tissue or nerve tissue to develop a human brain in an animal.

The bill goes next to the full Senate.

http://www.2theadvocate.com/news/politics/44796042.html

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Panel backs bill to use other factors in layoffs

The Advocate | 05.13.09

By MARSHA SHULER

Advocate Capitol News Bureau

Liz Condo/The Advocate

Tim Barfield, executive director of the Louisiana Workforce Commission, left, testifies in favor of legislation by state Rep. Mike Danahay, D-Sulphur, right, encouraging state Civil Service to change layoff and pay rules governing more than 60,000 state employees.

A Louisiana House panel approved legislation Tuesday urging state Civil Service to move away from seniority as the sole factor in who goes and who stays when employee layoffs are required.

The House and Governmental Affairs Committee approved a resolution seeking use of other factors such as knowledge, performance and ability in the decision-making process.

The same measure — House Concurrent Resolution 6 — also requests that state government’s employment agency revise the system to give bosses “greater flexibility in compensating employees based on job duties and evaluations of performance.”

It’s part of a package of bills endorsed by the panel aimed at changing the layoff and pay policies of the agency that oversees more than 60,000 state employees.

“This is not an indictment of the state Civil Service system,” said state Rep. Mike Danahay, D-Sulphur, resolution sponsor. “It is an effort to bring resource management to the state Civil Service.”

Danahay said the current system provides “very little incentive (for employees) to strive to a higher level.” And he said executive officials are blocked from efficiently managing their agencies.

Danahay commended Civil Service for moving in the direction outlined in his resolution.

The employment agency’s staff is recommending to the state Civil Service Commission abandonment of using only seniority in layoff decisions in favor of job performance.

In the new rules, scheduled for final approval in June, there would be an end to “bumping rights,” which allows a more senior employee to move into another job and displace someone else when their job is eliminated in layoffs.

The Legislature can only recommend rule changes. The state Civil Service Commission is the constitutional body charged with overseeing state employment practices.

The proposed Civil Service rules drew the ire of some state employees and their representatives earlier this month for opening the door to the “spoils system” where favoritism and politics controlled hiring and firing.

Louisiana Workforce Commission Executive Director Tim Barfield testified in favor of the legislation, saying it would help advance work force reform efforts.

The panel also approved two other Danahay measures:

HCR98 which would require Civil Service to file an annual report with the Legislature about how many classified employees are required to be performance rated; the number of employees who received each of five different ratings; and the number of employees who received “merit” pay increases and the number who did not and their performance rating.

The report would be due Sept. 30 and annually thereafter.

House Bill 595 which would require the top executives in agencies across state government, including department secretaries, to get training in Civil Service rules and the personnel performance rating system within a year of when they take office.

The Danahay legislation advances to the House floor for debate.

http://www.2theadvocate.com/news/44852182.html

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John Maginnis: Jindal asserts his influence and authority over a resentful Legislature

The Times-Picayune | 05.13.09

by John Maginnis, Columnist

Oh, the world of hurt Bobby Jindal was supposed to be in by now.

A month ago, his constant coast-to-coast fundraising was straining the patience of even his friends, who wished aloud that he were spending more time at home dealing with the state's problems. And there were plenty of those, mostly linked to a gaping budget deficit, which promised to make his first legislative fiscal session a miserable one. Add to that, lawmakers, still harboring grudges for his vetoes of their pay raise and scores of local projects last year, were said to be lying in wait for payback.

It looked like an ominous session indeed for the governor, until it began, when the scene at the Capitol snapped back to the old reality. In the first two weeks, the governor's staff efficiently snuffed out or sidetracked bills the administration opposed, advanced ones it liked and easily fended off legislators' initial budget raids on his economic development mega-fund.

He also demonstrated a grasp for the art of the deal by proposing creative elements for a new long-term contract with the New Orleans Saints while at the same time pushing approval of spending $50 million to save a chicken-processing plant in Northeast Louisiana. The two are not connected, but politically they are wed, with regional support for each neutralizing opposition to the other. The unspoken linkage of the two makes for a pretty slick deal, worthy of Edwin Edwards, and it's even legal.

What did Jindal do to reassert his influence and authority over a resentful Legislature? Why, he showed up, which is pretty much all that's needed in a political system that affords so much power to a governor when he acts like one.

Democrats outnumber his Republicans, especially in the Senate, but partisanship has yet to come into play in this session. The most direct challenge to Gov. Jindal's fiscal policy, the proposed cigarette tax to restore health-care cuts, has not unified Democrats.

They will band together more to challenge his refusal to accept $98 million in added unemployment benefits from the federal stimulus package, but supporters concede it won't be enough to overcome his promised veto.

The issue that is causing Jindal the most trouble, at least in the public prints, comes at the hands of two Republicans. He has strongly opposed identical bills by Rep. Wayne Waddell of Shreveport and Sen. Robert Adley of Benton to make public more records in the governor's office, which is currently rated among the least transparent in the nation.

The governor's broad exemption from the public records act predates Jindal, but it perfectly suits his control personality that is reflected in his protective, insular staff.

Legislators and his contributors quickly learned not to expect return phone calls from the governor. He talks to people when he needs them, not the other way around.

Formalizing any more access to his office is not in his interest. The legal contortions New Orleans Mayor Ray Nagin is going through fighting the release of his schedule and e-mail probably make the governor all the more careful to not let down his public records shield.

Now if legislators were truly seeking revenge for Jindal's veto of their pay raise, they would pass a public records law opening up his office like a sardine can.

That they haven't suggests the notion of veto payback is vastly overstated. Legislators may still resent his nixing their raises, but some concede he did them a favor. What if they were pulling down $50,000-plus in total compensation while considering big budget cuts that would force layoffs in higher education and health care? Half of them would be facing recall petitions and harboring little hope of re-election. The mistake he and they both made was in forming their secret pact, which intense public anger, acting as a force majeure, nullified.

Lawmakers might still pass a public records bill Jindal doesn't like, or find some other vote on which to stick him. But most of them, when it gets right down to it, want to stay in the governor's good graces, even if he ignores them most of the time.

http://blog.nola.com/johnmaginnis/2009/05/what_payback_jindal_gets_his_w.html

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Inexpensive wrinkle cream praised

WWLTV | 05.11.09

By Meg Farris

NEW ORLEANS, LA (WWL-TV) - Some people are describing one anti-aging product as quick, easy, inexpensive, and with no downtime. Also, it's a product that dermatologists say works.

Like most women her age, Ashley Nelson let the damaging sun rays get the best years of her fair skin. "I would go to Destin for spring break with my girlfriends. I would get burned to a crisp and then I would stay inside and my friends would spray Solarcaine on me for the rest of the week," said Ashley Nelson, a professor at Tulane University.

Doctors have long warned burns and tans cause more of what we call skin aging than birthdays. And now at 44, Ashley wants to repair and reverse the damage. A friend told her to try Pro-X, a line of six different Oil of Olay products sold in the drug store. "I have noticed where I said the greatest reduction of wrinkles has been, mainly in my forehead area," adds Nelson.

Dermatologists are skin experts careful to recommend treatments from sound scientific evidence. They'll tell you nothing over the counter works like the well studied, FDA-approved retinoid creams and gels, those brands of prescription vitamin A creams such as Retin-A. But this time is different.

"This is probably one of the strongest non-prescription, over-the-counter, drug store products that you can get to improve the appearance of aging skin," said New Orleans dermatologist Dr. Mary P. Lupo. "I think the thing that makes Pro-X such a big story is that it actually has multiple cosmeceuticals actives. It is a wrinkle regimen, so it's like a system that has multiple products and it has some new active ingredients," said Metairie dermatologist Dr. Patricia Farris.

The doctors say Pro-X has combined several ingredients and technologies that are scientifically known to help the skin act younger. "The combination of these three ingredients sort of work synergistically to make the line a little bit more sophisticated than anything else that is currently available over-the-counter at the drug store," adds Dr. Lupo.

Here's what Pro-X is all about. First, three different anti-aging peptides. "Peptides boost collagen production. They've been shown in lots of studies to improve fine lines and wrinkles because of their ability to boost collagen production," said Dr. Farris.

Second, high levels of a type of vitamin B-3 called niacinamide. It improves the hydration of the skin, helps keep those damaging free radicals at bay and helps keep your immune system at a stronger level to fight off skin cancer. "The rationale behind it is very sound because there is tremendous data behind niacinamide as being anti-inflammatory and barrier repair. That's got the best science," said Dr. Lupo.

Third, there's a similar ingredient to what's in those well proven anti-aging prescription retinoids like Retin-A. It's called retinyl propionate to repair the skin. "It can help take away the brown spots. It can help stimulate new collagen. It can be used on very fine lines. Now, it's not the same as going to get a prescription for Retin-A, but it does offer our patients something that they can buy over the counter that's fairly easy to use," said LSU Health Sciences Center's Dr. Elizabeth McBurney, who is also a dermatologist in Slidell.

And because it's not as strong against photo aging as a prescription retinoids, more people will be able to tolerate it without the irritation. But what the doctors say is most impressive is the study that compared a regimen of three of the Pro-X creams in the line against one of those proven prescription retinoids. "This particular system was actually tested against Renova .02% and in 8-week studies and 24-week studies, they actually demonstrated equal efficacy to Renova which as you know is sort of the gold standard in dermatology for treating photo-aged skin," said Dr. Farris.

The study was funded by the makers of Pro-X in an independent lab and overseen by outside experts. Doctors consulted by WWL-TV say it was good science.

So the question is, if the Pro-X line is as good as the mildest prescription retinoid, should you use them both? Some of our doctors said yes. Use them both at night for maximum benefit. Others say no. The highest strength prescriptions are still better. And Pro-X is a good alternative for those who can't tolerate the prescriptions.

One of the Pro-X products has a day time sunscreen. "I didn't have any redness anywhere. It just really shielded me from the sun," said Nelson. And that's the most important anti-aging ingredient there is.

Each of the six products in the line run about $42. The Age Repair, the Wrinkle Smoother and the Deep Wrinkle creams were the three used in the study. The line also has an eye cream that doctors say helps puffiness because there is caffeine in it.

http://www.wafb.com/Global/story.asp?S=10341946

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Senate confirms FEMA chief after Sen. David Vitter ends delay

The Times-Picayune | 05.12.09

by Bruce Alpert, The Times-Picayune

WASHINGTON -- The Senate confirmed Craig Fugate as administrator of the Federal Emergency Management Agency on Tuesday, hours after Sen. David Vitter, R-La., dropped his hold on the nominee.

Vitter had stalled the nomination for the past 12 days, complaining that the agency is dragging its feet on key hurricane rebuilding projects in Grand Isle and in Cameron Parish. Under Senate rules, a single senator can hold up votes because most nominations are brought up under a procedure requiring unanimous consent of all senators.

Vitter relented after getting a letter from Nancy Ward, FEMA's acting administrator, saying, "We share your desire to achieve solutions that meet the needs and are in the best interests of those affected."

The impasse came over the agency's interpretation of rules that prohibit federal financing for construction projects in flood zones, or V-Zones, as they are referred to in agency rules.

"Louisianians have gotten way too many easy spoken assurances from FEMA over the last four years that didn't mean anything, " Vitter said. "Now that I've secured a specific written commitment from them on the V-Zone issue, we can move forward."

In selecting Fugate, who has run Florida's emergency management agency under two Republican governors, President Barack Obama described him as uniquely qualified to lead the country's emergency disaster response. He was confirmed late Tuesday by a voice vote.

With hurricane season beginning June 1, Vitter had come under pressure to drop his hold. Democrats accused him of posturing, and even some Republicans were impatient, including his Florida GOP colleague, Sen. Mel Martinez.

But in Grand Isle, where officials are eager to get a new fire station built -- a project that had been approved by FEMA and then later rejected -- Democratic Mayor David Camardelle expressed gratitude for Vitter's intervention.

"David Vitter went the extra mile to make sure he stood up for the people of Grand Isle, " Camardelle said.

He said all the projects supported by FEMA would be raised sufficiently to protect against flooding during future storms.

Sen. Mary Landrieu, D-La., questioned Department of Homeland Security Secretary Janet Napolitano on Tuesday about the V-Zone issue during a Senate Homeland Security and Governmental Affairs Committee.

Napolitano said the agency has, or is very close, to resolving matters in which the agency first approved a construction project and then pulled back because that isn't fair to the affected communities, she said.

She described the issue of V-Zones as having major national policy implications, with the federal government not wanting to spend taxpayers dollars on projects built in flood zones that could be vulnerable during the next hurricane.

Landrieu said the administration needs to understand that Grand Isle is "just not some vacation community, " but one whose recovery depends on having fire stations and other public buildings needed for it to function normally.

http://www.nola.com/news/index.ssf/2009/05/senate_confirms_fema_chief_aft.html

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Treatment of primates by researchers faulted

The Times-Picayune | 05.13.09

By Bruce Alpert

Washington bureau

WASHINGTON -- Treatment of chimpanzees and monkeys at the New Iberia Research Center failed to meet the standards of the Animal Welfare Act in several instances, according to a report released Tuesday by the U.S. Department of Agriculture.

The report was ordered by Agriculture Secretary Tom Vilsack after an undercover investigation by the Humane Society of the United States alleged mistreatment of primates at the facility, operated by the University of Louisiana at Lafayette.

The report found six violations of federal standards for animal research facilities, although center officials say it has since corrected five of the deficiencies and will correct the sixth.

Among the problems cited during a March 17 inspection by officials from the Agriculture Department's Animal and Plant Health Inspection Service:

-- The center oversedated three of its female adult monkeys to the point they were unresponsive to the "vigorous attempts" of their infants to arouse them.

-- Methods of transporting sedated primates could cause "unnecessary discomfort, physical harm, or trauma." It said some primates were lifted by all four limbs while placed into a vehicle.

-- Some sedated primates were kept on an unsecured table, with a risk of falling and injuring themselves.

-- Some primates were kept in outdoor shelters without adequate heating. Some African green monkeys had portions of their tails amputated, some as a result of frostbite, according to the report.

In a statement, Dr. Thomas Rowell, director of the New Iberia Research Center, said that the facility "cooperated fully" during the March 17 inspection.

He said five of the six deficiencies found during the inspection "have been completely addressed," and that the sixth, providing additional heat for African green monkeys housed outdoors, would be resolved by the Oct. 30 deadline set by the Agriculture Department.

The Humane Society of the United States praised the Agriculture Department for quickly following up on its undercover investigation, though noting that a 2008 inspection by the agency had failed to uncover "none of the long-standing problems" found in the March inspection.

"It should not have taken an undercover investigation to prove that chimpanzees and other primates at New Iberia were suffering from chronic psychological distress, self-mutilation, neglect and boredom," said Martin Stephens, the society's vice president for animal research issues.

http://www.nola.com/news/t-p/washington/index.ssf?/base/news-3/1242192230131070.xml&coll=1

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Why a calorie isn't just a calorie

The Boston Globe | 05.13.09

By M.E. Malone, Globe Correspondent

Count the calories. Watch the carbs. No, just the fat. Actually, pay attention to the protein instead. Scratch that. Go back to what we said before. Just count the calories.

Back in ancient times, say the 1950s, dieting advice was almost universally limited to slashing calories. Our mothers bought countertop scales and booklets listing the calories in common foods with nary a mention of fat, saturated fat, carbohydrate content, or grams of protein.

Then, in the 1970s, the diet docs shifted our attention away from calories and promoted what were perceived to be more effective ways to lose weight by using the body's natural metabolic habits to burn our excess fat. Eating foods without carbohydrates, skipping animal fats, adding more protein, or consuming only "good" fats would lead us to leaner times.

Now, with a more recent, expansive two-year study of weight loss methods, the advice has come full circle: just count the calories. And on the heels of the results come experts who don't agree.

If you consider that a vegetable stir-fry with brown rice contains the same number of calories as a slice of lemon-meringue pie (around 350 apiece), does it matter if you skip the healthy meal and go straight to dessert? Or if you choose two apples over a Hostess Twinkie for a little 150-calorie pick-me-up, are you really better off? Some experts say that a calorie from fruit is essentially a "better" calorie than one from the carbohydrates in processed sugar and flour, not only because the fruit contains a variety of nutrients, but also because the volume and fiber of fruit will keep hunger at bay.

The study in question was conducted at Brigham and Women's Hospital as well as the Pennington Biomedical Research Center in Louisiana over two years with results published in the New England Journal of Medicine in February. It was considered an improvement over past diet studies because it was longer - many studies are conducted for just six or 12 months - and involved more than 800 participants, including a larger percentage of male dieters than is the norm.

There was no meaningful difference in weight loss among the participants, no matter which of four diets they were assigned to follow. The diets were based on nutritious foods with similar calories, but the ratio of fat, carbohydrates, and protein in the diets varied by group. The study's results, its authors note, prove that people should pick a diet they can stick with rather than take a one-size-fits-all weight loss approach.

"I'm not convinced that we know that a calorie is just a calorie," says Barbara J. Rolls, professor and Guthrie Chair of Nutrition at Penn State University. She and others in the diet field believe the study was too narrow in focus, sending mixed signals to do-it-yourself dieters.

Rolls and others note that while the study was published this year, it was actually designed many years ago amidst battles over the effectiveness of high-protein/low-carbohydrate diets such as Atkins and South Beach when compared with more traditional low-fat diets.

In the interim, numerous studies have been done on more effective ways to lose weight that focus on the regulation of hunger - a dieter's greatest obstacle - which can vary dramatically by the type of fat or carb in a food, the water and fiber content of what we eat, and possibly the timing and spacing of meals throughout the day. What triggers hunger signals to the brain is a lot more complex than the calorie counts in the foods we eat.

"I think the field has moved beyond thinking about macronutrients" - the primary sources of calories, namely carbohydrates, proteins, and fats, says Rolls, author of "The Volumetrics Eating Plan." Alcohol is considered the fourth micronutrient.

For example, her work focuses on the water content of food. Apples are a better snack choice than Twinkies not because your mother said so, but because fruits and vegetables have a higher water content, or lower energy density, than high-fat, high-sugar foods. Energy density is a measure of the calories per gram of food.

Research shows that people tend to eat about the same weight of food each day, she says in a telephone interview. If you choose water-rich foods, such as fruits, vegetables, soups, and nonfat milk, you will feel more full with fewer calories for the same weight of food.

Susan Roberts, senior scientist at Tufts University's Energy Metabolism Laboratory, agrees that there is more to the science of losing weight than just counting calories. In addition, she notes, a large number of the dieters who participated in the two-year weight-loss study regained a portion of their lost weight at about the same rate, no matter which diet they tried.

"The real goal is to lose weight and never gain it back. Without doing it in a way that's sustainable is a waste of time," she says.

Roberts has developed a weight-loss plan based on research into the role of fiber in the diet, particularly its effect on hunger. Research at Tufts has shown that people who eat 35 to 45 grams of fiber a day are less hungry when losing weight and lose more weight than those who eat less fiber. The typical American diet contains only about 15 grams of fiber a day. So, for the same number of calories (about 550), you can have salmon, broccoli, lentils, and wine for dinner (about 14 grams of fiber), or two slices of pepperoni pizza (about 2 grams of fiber).

Alicia Hutton of Waltham, who is participating in a study of Roberts's fiber-rich diet plan and hopes to lose 50 pounds, remembers going to Weight Watchers with her mother at the age of 14. It was the beginning of a life of yo-yo dieting. "I would try whatever the latest study said or the latest fad," says Hutton, 35, who has followed the Atkins and South Beach diets, Jenny Craig, and the 5 Day Miracle Diet.

On each one, she was always driven to eat as much food as possible for the lowest number of calories without focusing on how quickly her hunger might return. "Not to pick on Weight Watchers," she says, "but I would eat one of their two-point ice cream bars. Ten minutes later, I'd want another bar."

At age 52, Marcia Schurer decided to take charge of her health and lose the 35 pounds she'd gained when she was in her 40s. With a background in food product development, she channeled her nutrition knowledge and lost the weight she'd gained in just six months, and has managed to keep it all off for four years.

She believes that news accounts of weight-loss studies are often oversimplified and can do more harm than good to those trying to lose weight on their own. "They are really turned into sound bites that make the message sound attractive," she says. She chronicled her experience and weight-loss methods in a book, "FitDelicious," which includes tools to help dieters know more about the foods they eat.

The book provides the nutritional data of foods based on the weight of their components rather than serving size.

For instance, you can quickly compare how sprinkling 3.5 ounces of dried cranberries on your salad instead of the same amount of deli ham will affect your diet. Items that typically go into a sandwich are grouped together, allowing you to glance at the calorie count of a meal you're creating from fresh ingredients.

"Sure, any calorie reduction helps to lose weight. But if you can't sustain that kind of eating pattern, it all comes back," says Schurer, who lives in Chicago. She has saved the packaging and nutrition labels from every food she's eaten in the last three years to study and categorize them. "It's one thing to cut calories. You have to have a good, healthy food plan if you're going to lose weight and keep it from coming back."

So that Twinkie might satisfy the urge the moment you devour it. But a little while later, you may find yourself reaching for another.

Mom was right. Go for the apples.

http://www.boston.com/lifestyle/food/articles/2009/05/13/why_a_calorie_isnt_just_a_calorie/

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Health Care, a Lesson in Pain

The New York Times | 05.12.09

By DAVID LEONHARDT

The events of the last few weeks have raised the odds that a health care overhaul will really happen this year.

Democrats have suggested that they are willing to play hardball and pass a bill without Republican support. Arlen Specter, the senior Pennsylvania senator, became a Democrat, potentially adding one more vote. At the White House on Monday, lobbyists for doctors, insurers and other industry groups pledged to reduce the growth of medical spending.

Yet none of these developments has removed the main hurdle to health care reform: the matter of the missing $90 billion.

Providing health insurance to the roughly 50 million people without it will cost something like $120 billion a year. President Obama has proposed $60 billion or so in new revenue for this purpose — a “down payment,” his advisers say. But Congress seems set to reject about half of the down payment (a plan to limit high-income families’ tax deductions for charitable giving and other such things). That makes for the $90 billion health care hole.

And no one is quite sure how to fill it.

Because Mr. Obama has made it clear that health care is his top legislative priority, the $90 billion hole has become one of the biggest political issues of 2009. The Obama administration’s health care team is now preoccupied by it. On Tuesday, the Senate began to consider it, at a packed round-table discussion among 13 prominent health experts and members of the finance committee.

“Now it’s time to think about money,” said Max Baucus, the Montana Democrat who heads the committee.

The experts at the round table — liberal and conservative — actually agreed to an impressive degree about the best way to fill the hole. They urged the senators to limit the tax deduction for employer-provided health insurance.

The deduction may seem a wonderful thing, but it isn’t. It benefits the wealthy more than anyone else. It encourages employers to overspend on health insurance, because $100 in untaxed medical benefits is more valuable to workers than $100 in taxed income. And, as Mr. Baucus said, the deduction has a certain Willie Sutton appeal for Congress: it’s where the money is.

The government forgoes $250 billion a year in taxes because of the deduction. Capping it, to apply only to reasonably priced health plans, would bring in enough money to fill most of the $90 billion hole.

The idea seems to be classic Obama: empirical, pragmatic, bipartisan. Unfortunately, it happens to be an idea that John McCain campaigned on last year and that Mr. Obama, sensing a political opening, blasted as a tax increase. “Taxing health care instead of fixing it,” intoned the narrator in an Obama campaign advertisement, with ominous music playing in the background. “We can’t afford John McCain.”

Mr. Obama’s economic advisers would be happy to see him reverse his position. But his political advisers remember that ad and know it could be used against him. Further complicating matters, labor unions and Charles Rangel, the influential Democratic House member, say they remain firmly opposed to capping the deduction.

All of which means that filling the $90 billion hole is going to be very tricky.

If the tax deduction can’t be touched, the first alternative is simply to add the $90 billion a year to the deficit, to cover the uninsured now and pay for it later, as President George W. Bush did with his tax cuts, the Iraq war and the Medicare prescription drug benefit. In another time, this might have been politically palatable. But it isn’t now, not when this year’s deficit is projected to be larger than any since the end of World War II.

That leaves two ways to pay for an expansion of health insurance: raise taxes or cut health spending.

Economically, spending cuts have a lot to recommend them. The United States spends vastly more per person on medical care than any other country. Much of that spending does nothing to improve health, as chronicled in this newspaper’s recent “Evidence Gap” series. Getting rid of such waste could pay for universal health insurance, several times over, and prevent Medicare from going bankrupt.

The $30 billion that remains of Mr. Obama’s down payment plucks the low-hanging fruit of cost reduction, like the subsidies for private insurers to provide the same coverage as Medicare at a higher cost. But the precise strategy for finding a lot more savings is still murky. “Reducing spending without also affecting services that do improve health,” says Douglas Elmendorf, director of the Congressional Budget Office, “is challenging.”

The Obama administration is laying the groundwork for a more efficient system by pushing for more research into medical effectiveness. But we’re not there yet, and getting there won’t be easy. Consider that some of the same industry groups that pledged to reduce medical spending this week are also trying to block effectiveness research — the very thing that would tell us how to reduce spending without damaging people’s health.

So over the short term, tax increases are probably necessary, though they have their own problems. Will the 85 percent of people with health insurance be willing to pay higher taxes for something approaching universal coverage?

Congress has already rejected several of Mr. Obama’s proposals to reduce the budget deficit, including the plan to limit charitable deductions for the affluent. The other ideas that have been floated, like taxing high-calorie sodas, wouldn’t raise anywhere near $90 billion a year.

You can imagine a bill that mixes together lots of different revenue sources, in typical sausage-making style. But it’s hard to get to $90 billion without changing the deduction for employer-provided health insurance. “I just don’t know where else you get enough money,” says Jonathan Gruber, an M.I.T. economist and one of the round-table panelists.

One possibility is that Congress will pass a bill capping the deduction, and Mr. Obama will be able to claim that he is signing it reluctantly. Another possibility, however, is that we need to begin thinking about whether health care reform is possible even if some significant number of people remain uninsured.

What might that look like?

The subsidies for insurance, which make up most of the $120 billion price tag, would have to be reduced, leaving some people unable to afford coverage but also cutting the bill’s cost. That would be the painful compromise.

The second, crucial step would be doing everything possible to get rid of wasteful medical spending: using the force of law to hold medical providers to their cost-reduction pledges; moving Medicare away from a fee-for-service model that pays for quantity, not quality; encouraging low-cost hospitals to grow and high-cost hospitals to change — or shrink.

During the campaign, Mr. Obama emphasized universal insurance more than costs. Since taking office, he has shifted his focus somewhat. “What we have done,” Rahm Emanuel, the White House chief of staff, told me this week, “is raise cost control to the same level as expanded coverage.”

Cost control has the political benefit of appealing to the 85 percent of people with insurance. And it has enormous economic benefits, too. If costs can be reduced, the price of covering the uninsured will come way down. Put differently, the only way to have a sustainable universal health care system is to control costs.

In an ideal world, Congress and Mr. Obama would find the $90 billion to cover all the uninsured now. But if they don’t, health care reform is not an all-or-nothing proposition.

http://www.nytimes.com/2009/05/13/business/economy/13leonhardt.html

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Cancer Patients Challenge the Patenting of a Gene

The New York Times | 05.12.09

By JOHN SCHWARTZ

Benjamin Sklar for The New York Times

Genae Girard, 39, is suing Myriad Genetics and the Patent Office over the granting of a patent on a gene. Myriad also has patented the only test that measures the risk of breast and ovarian cancer.

When Genae Girard received a diagnosis of breast cancer in 2006, she knew she would be facing medical challenges and high expenses. But she did not expect to run into patent problems.

Ms. Girard took a genetic test to see if her genes also put her at increased risk for ovarian cancer, which might require the removal of her ovaries. The test came back positive, so she wanted a second opinion from another test. But there can be no second opinion. A decision by the government more than 10 years ago allowed a single company, Myriad Genetics, to own the patent on two genes that are closely associated with increased risk for breast cancer and ovarian cancer, and on the testing that measures that risk.

On Tuesday, Ms. Girard, 39, who lives in the Austin, Tex., area, filed a lawsuit against Myriad and the Patent Office, challenging the decision to grant a patent on a gene to Myriad and companies like it. She was joined by four other cancer patients, by professional organizations of pathologists with more than 100,000 members and by several individual pathologists and genetic researchers.

The lawsuit, believed to be the first of its kind, was organized by the American Civil Liberties Union and filed in federal court in New York. It blends patent law, medical science, breast cancer activism and an unusual civil liberties argument in ways that could make it a landmark case.

Companies like Myriad, based in Salt Lake City, have argued that the patent system promotes innovation by giving companies the temporary monopoly that rewards their substantial investment in research and development.

Richard Marsh, Myriad’s general counsel, said company officials would not be able to comment on the lawsuit until they had fully reviewed the complaint.

The coalition of plaintiffs argues that gene patents actually restrict the practice of medicine and new research.

“With a sole provider, there’s mediocrity,” said Wendy K. Chung, the director of clinical genetics at Columbia University and a plaintiff in the case.

Dr. Chung and others involved with the suit do not accuse Myriad of being a poor steward of the information concerning the two genes at issue in the suit, known as BRCA1 and BRCA2, but they argue that BRCA testing would improve if market forces were allowed to work.

Harry Ostrer, director of the human genetics program at the New York University School of Medicine and a plaintiff in the case, said that many laboratories could perform the BRCA tests faster than Myriad, and for less money than the more than $3,000 the company charged.

Laboratories like his, he said, could focus on the mysteries still unsolved in gene variants. But if he tried to offer such services today, he said, he would be risking a patent infringement lawsuit from Myriad.

Christopher A. Hansen, senior national staff counsel for the civil liberties union, said the problem was with the patent office, not the company. He recalled that when he first heard that the office had granted a patent for a gene, “I said that can’t be true.”

As the A.C.L.U. explored the restrictions on competition that companies like Myriad had put in place — blocking alternatives to the patented tests, and even the practice of interpreting or comparing gene sequences that involved those genes — the restrictions started to look like not just a question of patent law, Mr. Hansen said, but of the First Amendment’s guarantee of free speech as well.

“What they have really patented,” he said, “is knowledge.”

A patent was also granted to a single company for genetic testing on long QT syndrome, which can lead to heart arrhythmias and sudden death, and to the HFE gene, linked to hereditary hemochromatosis, a condition in which iron accumulates in the blood and can cause organ damage. Doctors and scientists have complained about both patents.

On the other hand, the company that owns the patent to the gene CFTR, which has been linked to cystic fibrosis, has licensed the testing to dozens of laboratories, drawing praise from the medical world.

The decision to allow gene patents was controversial from the start; patents are normally not granted for products of nature or laws of nature. The companies successfully argued that they had done something that made the genes more than nature’s work: they had isolated and purified the DNA, and thus had patented something they had created — even though it corresponded to the sequence of an actual gene.

The argument may have convinced patent examiners, but it has long been a sore point for many scientists. “You can’t patent my DNA, any more than you can patent my right arm, or patent my blood,” said Jan A. Nowak, president of the Association for Molecular Pathology, a plaintiff in the case.

So far, however, two panels of government experts who have looked at the issue have not found significant impediments to research or medical care caused by gene patents. A 2006 report from the National Research Council found that patented biomedical research “rarely imposes a significant burden for biomedical researchers.”

That report and others, however, warn that the patent landscape “could become considerably more complex and burdensome over time.”

In the future, genetic tests are likely to involve the analysis of many genes at once, or even of a person’s full set of genes. Some 20 percent of the human genome is already included in patent claims, amounting to thousands of individual genes, says a draft report from the National Institutes of Health. The report warns that “it may be difficult for any one developer to obtain all the needed licenses” to develop the next generations of tests.

For Lisbeth Ceriani, a single mother from Newton, Mass., and a plaintiff in the case against Myriad, the biggest obstacle that gene patents present is one of cost. She has had breast cancer and a double mastectomy, but wants to have BRCA testing to determine her risk of ovarian cancer and help her decide whether to have her ovaries removed. But Myriad has refused to work with her insurance plan, Mass Health, and paying for the test herself is beyond her means.

She is reluctant to have surgery that might prove unnecessary, she said, but she also worries about her 8-year-old daughter and the inherited risk she might face. Which is why, Ms. Ceriani said, she wants to “find out if I have the mutation, so I can take the necessary steps to stay on the planet.”

“I want to be here,” she said, “to make sure she does her screening by the time she’s 30.”

http://www.nytimes.com/pages/health/index.html

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Drugs Urged for Swine Flu in Pregnancy

The New York Times | 05.12.09

By DONALD G. McNEIL Jr.

Pregnant women who get swine flu are at such high risk of complications like pneumonia, dehydration and premature labor that they should be treated at once with the antiviral drug Tamiflu — even though it is not normally recommended in pregnancy, the Centers for Disease Control and Prevention said Tuesday.

Because a positive test for the new H1N1 flu can take days, the agency said, Tamiflu should be given to any pregnant patient with flu symptoms and a history of likely contact with someone else with swine flu.

“If I’m thinking influenza — the classic symptoms, febrile, aching all over, came on all of a sudden — and this flu is in the community, and I’d otherwise give the patient Tamiflu if she wasn’t pregnant, we’re saying, ‘Don’t delay because she’s pregnant,’ ” said Dr. Denise Jamieson, a C.D.C. medical officer. “At that point, the benefit of giving Tamiflu outweighs the risk.”

Tamiflu is not normally recommended for use by pregnant women because the effects on the unborn child are unknown, according to its maker, Roche.

Dr. Jamieson, an obstetrician, said most medicines had insufficient safety data for pregnancy “because you don’t do clinical trials in pregnant women.” But she added, “Tamiflu and Relenza are fairly safe in pregnancy.”

Tamiflu and Relenza are in the same class of drugs. But Tamiflu is a pill and liquid, while Relenza is a powder that must be inhaled, so it is prescribed much less often.

The C.D.C. and the World Health Organization said case histories in Mexico and the United States suggested that pregnancy was emerging as a risk factor rivaling asthma, diabetes, immunosuppression and cardiovascular disease.

One of the three deaths in the United States involved a pregnant Texas woman who was on no medication other than prenatal vitamins, the disease centers said. The agency knows of 20 confirmed or probable swine flu infections in pregnant Americans, and “a few have had severe complications,” said Dr. Anne Schuchat, the interim deputy director for public health.

American doctors are often reluctant to prescribe flu drugs for pregnant women unless they develop severe symptoms like pneumonia. Pregnant women are often reluctant to take medication. A pregnant woman is at higher risk from flu because hormonal changes depress the immune system to protect the fetus.

Details about the death of the pregnant woman in Texas emerged Friday in the disease centers’ weekly morbidity and mortality report. Dr. Jamieson said the woman had mild asthma and psoriasis, but was relatively healthy. The woman has been widely identified as Judy Trunnell, 33.

Mrs. Trunnell was eight months pregnant when she entered the hospital with pneumonia on April 19, five days after flu symptoms began and she had been found flu-positive in a doctor’s office test. Her baby was delivered by Caesarean section and is healthy. She developed acute respiratory distress on April 21 and needed mechanical ventilation. She did not get Tamiflu until April 28. She died May 4.

It is becoming clear that the epidemic in the United States will mirror the epidemic in Mexico, and similar rates of severe illness should be expected. The outbreak across Europe is still spreading slowly because the Europeans aggressively treat every suspected mild case with Tamiflu, health officials said.

The United States now has more than 3,000 confirmed cases — two-thirds in people younger than 18 — but only 116 hospitalizations. But officials note that hospitalizations take slightly longer to appear in statistics and deaths take much longer.

http://www.nytimes.com/2009/05/13/health/research/13flu.html?ref=health

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Doctor Falsified Study on Injured G.I.’s, Army Says

The New York Times | 05.12.09

By DUFF WILSON and BARRY MEIER

A former surgeon at Walter Reed Army Medical Center, who is a paid consultant for a medical company, published a study that made false claims and overstated the benefits of the company’s product in treating soldiers severely injured in Iraq, the hospital’s commander said Tuesday.

An investigation by Walter Reed found that the study cited higher numbers of patients and injuries than the hospital could account for, said the commander, Col. Norvell V. Coots.

“It’s like a ghost population that were reported in the article as having been treated that we have no record of ever having existed,” Colonel Coots said in a telephone interview on Tuesday. “So this really was all falsified information.”

The former Army surgeon, Dr. Timothy R. Kuklo, reported that a bone-growth product sold by Medtronic Inc. had much higher success in healing the shattered legs of wounded soldiers at Walter Reed than other doctors there had experienced, according to Colonel Coots and a summary of an Army investigation of the matter.

Dr. Kuklo, 48, now an associate professor at the Washington University medical school in St. Louis, did not respond to numerous e-mail messages and telephone calls to his office and home seeking comment over the last two weeks. Walter Reed officials say he did not respond to their inquiries during their investigation.

Army investigators found that Dr. Kuklo forged the signatures of four Walter Reed doctors on the article before submitting it last year to a British medical journal, falsely claiming them as co-authors. He also did not obtain the Army’s required permission to conduct the study.

“This was a real letdown for us to have one of our former members do something like this,” one of those doctors, Lt. Col. Romney C. Andersen, wrote in an e-mail message Tuesday. Dr. Andersen, now posted at a combat hospital in Baghdad, said he could not comment further without the permission of his commanders.

It was Dr. Andersen who brought the problem to the Army’s attention last year, prompting the inquiry. In its March edition, at the Army’s request, the journal retracted the article — something that has gone largely unnoticed outside orthopedic circles.

The Army released an executive summary of its investigation to The New York Times last Friday in response to a reporter’s questions, followed by the Tuesday interview with Colonel Coots.

A West Point graduate who also has a law degree from Georgetown University, Dr. Kuklo worked at Walter Reed from early 2003 until he retired from the Army in March 2007.

While at Walter Reed and since, Dr. Kuklo has given talks to other doctors around the country about the bone-growth product, a protein called Infuse, according to meeting agendas and published documents.

A Medtronic spokeswoman, Marybeth Thorsgaard, confirmed that Dr. Kuklo was a paid consultant to the company and that the company financially supported some of his research at Walter Reed, through a foundation affiliated with the hospital.

But she said Medtronic did not finance or review the Infuse study, which was published in Britain last August in The Journal of Bone and Joint Surgery. She declined to say when Medtronic had hired Dr. Kuklo or how much it had paid him over the years.

Infuse is widely used in civilian hospitals and trauma centers around the country for spinal surgeries and to treat broken bones. The Food and Drug Administration issued a safety alert last year that Infuse, if used in neck surgeries — for which it has not been approved — could cause breathing difficulties.

Since last year, the Justice Department and Senator Charles E. Grassley of Iowa, ranking Republican on the Senate Finance Committee, have been investigating whether Medtronic illegally promoted unapproved uses of Infuse by paying doctors, among other measures. The company has denied those charges.

During the six-month period ending last October, sales of Medtronic’s bioengineered products, principally Infuse, reached $419 million, according to a company filing.

Dr. Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said he was unaware of any previous cases in which medical studies involving injured soldiers had been retracted because of such allegations. “People are very careful when they deal with this patient population,” he said. “I think they understand that the stakes are pretty high.”

The study claimed to be a review of soldiers who were treated at Walter Reed for gaping lower-leg wounds with open fractures caused by explosions in the Iraq war from March 2003 to March 2005.

Colonel Coots said that Walter Reed surgeons had used Infuse with good results on some soldiers — but not at the 92 percent success rate Dr. Kuklo claimed.

Several colleagues of Dr. Kuklo, who has published more than 100 articles on orthopedic topics, said they had recently become aware of the allegations and they were not in keeping with what they know of his work.

“It surprises me to hear this swirling around him,” said Dr. Todd J. Albert, chairman of orthopedic surgery at Thomas Jefferson University Hospital in Philadelphia. “He’s a guy, anything he tells me, I take to the bank.”

A former Walter Reed colleague, Dr. David W. Polly Jr., who is also a Medtronic consultant, said he believed that Dr. Kuklo’s data was “strong” and the episode had been overblown.

Army officials said that Colonel Coots sent the results of their investigation late last year to Medtronic’s chief executive and to the dean of the Washington University School of Medicine. A university official declined to say whether it was investigating Dr. Kuklo but added that he remained on the faculty.

Colonel Coots said he decided to handle the matter by notifying the journal, university and Medtronic, as well as several orthopedics professional groups, rather than recalling Dr. Kuklo from retirement to face possible Army discipline.

As recently as February, two months after Medtronic received the findings of the Army’s investigation, Dr. Kuklo made a general presentation about Infuse at the orthopedic academy’s national meeting in Las Vegas. In a disclosure filing for the event, he noted that he was a paid consultant, speaker and researcher for Medtronic. The filing did not specify any dollar amounts.

Back in 2005, while still at Walter Reed, Dr. Kuklo listed Medtronic as a financial supporter “in excess of $500” in a disclosure statement accompanying a preliminary report about the use of Infuse on American soldiers injured in Iraq. The Army is not disputing those early results.

Infuse was approved by the F.D.A. in 2002 for use in the lower spine and in 2004 for fractures of the shinbone. The studies on which the F.D.A. approved shin-bone treatment involved patients injured in accidents like car crashes and falls.

But because doctors are free to use any product approved by the F.D.A. for whatever purposes they see fit, surgeons at Walter Reed used the product to see if it could help soldiers with far more severe, combat-related injuries.

During his time at Walter Reed Dr. Kuklo was extensively involved in research and writing about various Medtronic products, including editing two books published by the company and conducting three studies that were approved by his Army superiors, according to his list of publications and an Army report.

The results reported by Dr. Kuklo in his Infuse study “suggested a much higher efficacy of the product being researched in the article than is supported by the experience of the purported co-authors,” according to the Army’s investigation.

Colonel Coots said Tuesday that the total number of patients Dr. Kuklo reported as having been treated for extensive lower leg wounds at Walter Reed during the study period — 138 soldiers — was greater than the number for which the hospital could find records.

“It is a significant breach of academic protocol,” Colonel Coots said. “It’s a breach of trust.”

http://www.nytimes.com/2009/05/13/business/13surgeon.html?ref=health

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The Marks of Childhood or the Marks of Abuse?

The New York Times | 05.11.09

By PERRI KLASS, M.D.

I had just started out in practice when one day I examined a little boy, maybe 4 years old, and discovered around his neck the clear mark of a noose. I asked him what had happened; he said he didn’t know. I asked his mother; she said she didn’t know, but it was the fault of her ex-husband. I had to tell her I was filing a report with the Department of Social Services — the child had clearly suffered an inflicted injury.

My training had included many slide shows about the stigmata of cigarette burns, belt marks and other suspicious injuries, but it was the first time I had been the person alone on the front line, looking at a mark on a child, knowing something was wrong.

My colleague Dr. Lori Legano is a pediatrician who specializes in child abuse at the Frances L. Loeb Child Protection and Development Center at Bellevue Hospital. Part of her job is to testify in court and to speak to judges and juries about a range of marks and bruises and what they indicate.

She has to integrate a pediatrician’s understanding of child development and behavior with a growing body of forensic information about child abuse. Bumps and bruises, after all, can be expected in any young child who is learning to walk. But some injuries are inconsistent with developmental stage: “If you don’t cruise, you don’t bruise.”

So a child who isn’t mobile shouldn’t have those marks, let alone broken bones. And then there are intrinsically suspicious marks, or marks in the wrong places.

This year, the study of child abuse is coming of age as a medical specialty. In November, the first medical board exam will be offered in a new official specialty, child abuse pediatrics. Knowledge and research that have accumulated over decades about the effects of physical abuse and sexual abuse are being codified into a curriculum; fellowship training in the field will have to meet certain standards; an expert, testifying in court, can expect to be questioned about being board-certified.

“When I started doing this in 1984, nothing that I do now was even known,” said Dr. Carole Jenny, a professor of pediatrics at Brown and the director of the child protection team at Hasbro Children’s Hospital in Providence, R.I. “The first week I was working in the field, it was a child who had reportedly had a torn hymen or no hymen, and the defense attorney said, ‘But doctor, aren’t some children born without hymens?’ and I said, ‘I don’t know!’ And we initiated a study in the newborn nursery and we counted 1,100 baby girls.” Every one had a hymen.

Like most pediatricians, I am intimidated by the idea of testifying in court. But all of these specialists have answered questions from lawyers on many occasions; the witness box is a basic part of the landscape of the new specialty.

“So many of these victims are children who could never explain to us what happened to them — they’re not swearable,” said Marjory D. Fisher, chief of the special victims bureau in the Queens district attorney’s office. Without pediatricians trained in child abuse, she continued, “we would never be able to prevail in these cases because the victims are too young; they don’t possess the ability to testify.”

In my training, from the beginning, I was taught to worry about burns. Cigarette burns were always suspicious; immersion burns suggested that a child might have been punished by being dunked in too-hot water. So, of course, it was cigarette burns that brought my own young son to the emergency room one night during my residency when I was on call; he had run full tilt into a stranger in a restaurant who was holding a lighted cigarette. (Yes, I trained so long ago that people could smoke in restaurants.)

Dr. Philip Hyden, medical director of the Kapi’olani Child Protection Center in Honolulu, is an expert on burns. To help figure out whether a burn could have occurred accidentally (as in an apartment building in which someone in another apartment flushed a toilet and the bath water suddenly turned scalding hot), he asks detectives to check the water temperature at the same time on the same day of the week that the injury occurred.

Go to the home, turn on the hot water, wait to see how hot it gets — and then you’ll have an idea how long the child would need to have been in contact with the water for the burn. Could it have happened with a single splash, or was the child held in hot water?

“If Mom says the kid fell into the tub and you go into the bathroom and the water won’t go higher than 125,” Dr. Hyden told me, “you know that water can burn that kid, but it’s going to take a lot of time to do it.”

Regularly, he says, he finds himself trying to explain the physics of burns to a judge or jury: “The hotter the water, the much quicker the burn is, exponentially quicker rather than just linear.”

When my son came to the emergency room with cigarette burns, I found out what it was like for a parent to watch doctors suspect child abuse. Did this story make sense? (Yes.) Did the child confirm it? (Yes.)

But the incident made enough of an impression on my colleagues that a year or so later, when the same child came back with a broken femur at age 4, an attending doctor said to me, with the harsh humor of the emergency room: “I don’t know, Perri. First cigarette burns, now a major fracture — doesn’t look so good for you.” (I knew enough to be theoretically glad that abuse was on his mind; on the other hand, 20 years later, I haven’t forgotten or forgiven the remark.)

To be board-certified in this new specialty will also mean thoroughly understanding the medical conditions that are sometimes mistaken for child abuse — the easily broken bones of osteogenesis imperfecta, for example, or the dramatic bruising that can happen with hemophilia. The parents of children with these medical conditions are often themselves traumatized when the suspicion of child abuse is raised, and one role for a specialist is to make sure that even esoteric alternative explanations are considered.

“We spend a lot of time ruling out abuse,” Dr. Jenny said. Forty percent of the children referred to her for evaluation turn out, in her best judgment, not to have been abused.

The child abuse experts don’t want the rest of us in the profession to stop thinking about the subject. “I think the average pediatrician can diagnose this, even though it’s becoming a specialty,” Dr. Legano said.

But it’s an emotionally difficult diagnosis for a pediatrician to contemplate, especially when it concerns a family you feel you know well. And all too often, it is a diagnosis we fail to consider in families that don’t match our mental profiles of abusers. That’s why pediatricians and parents alike need all the clinical experience and all the science we can get, deployed on the side of the children.

http://www.nytimes.com/2009/05/12/health/12klas.html?_r=1&ref=health

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Vitamins Found to Curb Exercise Benefits

The New York Times | 05.11.09

By NICHOLAS WADE

If you exercise to improve your metabolism and prevent diabetes, you may want to avoid antioxidants like vitamins C and E.

That is the message of a surprising new look at the body’s reaction to exercise, reported on Monday by researchers in Germany and Boston.

Exercise is known to have many beneficial effects on health, including on the body’s sensitivity to insulin. “Get more exercise” is often among the first recommendations given by doctors to people at risk of diabetes.

But exercise makes the muscle cells metabolize glucose, by combining its carbon atoms with oxygen and extracting the energy that is released. In the process, some highly reactive oxygen molecules escape and make chemical attacks on anything in sight.

These reactive oxygen compounds are known to damage the body’s tissues. The amount of oxidative damage increases with age, and according to one theory of aging it is a major cause of the body’s decline.

The body has its own defense system for combating oxidative damage, but it does not always do enough. So antioxidants, which mop up the reactive oxygen compounds, may seem like a logical solution.

The researchers, led by Dr. Michael Ristow, a nutritionist at the University of Jena in Germany, tested this proposition by having young men exercise, giving half of them moderate doses of vitamins C and E and measuring sensitivity to insulin as well as indicators of the body’s natural defenses to oxidative damage.

The Jena team found that in the group taking the vitamins there was no improvement in insulin sensitivity and almost no activation of the body’s natural defense mechanism against oxidative damage.

The reason, they suggest, is that the reactive oxygen compounds, inevitable byproducts of exercise, are a natural trigger for both of these responses. The vitamins, by efficiently destroying the reactive oxygen, short-circuit the body’s natural response to exercise.

“If you exercise to promote health, you shouldn’t take large amounts of antioxidants,” Dr. Ristow said. A second message of the study, he said, “is that antioxidants in general cause certain effects that inhibit otherwise positive effects of exercise, dieting and other interventions.” The findings appear in this week’s issue of The Proceedings of the National Academy of Sciences.

The effect of vitamins on exercise and glucose metabolism “is really quite significant,” said Dr. C. Ronald Kahn of the Joslin Diabetes Center in Boston, a co-author of the report. “If people are trying to exercise, this is blocking the effects of insulin on the metabolic response.”

The advice does not apply to fruits and vegetables, Dr. Ristow said; even though they are high in antioxidants, the many other substances they contain presumably outweigh any negative effect.

Dr. Kahn said it might be that reactive oxygen is beneficial in small doses, because it touches off the body’s natural defense system, but harmful in higher doses.

Andrew Shao of the Council for Responsible Nutrition, a trade association of dietary supplement makers, said the new study was well designed but was just one bit of evidence in a complex issue. Most available evidence points to the opposite conclusion, that antioxidants benefit health by reducing oxidative stress, he said.

“I wouldn’t change recommendations for anyone based on one study,” he said. “This is one small piece of the puzzle.”

http://www.nytimes.com/2009/05/12/health/research/12exer.html?ref=health

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Intensive Medical Intervention Successful in Primary Care Setting for Patients With Extreme Obesity

Doctors Guide | 05.08.09

By Shazia Qureshi

AMSTERDAM, Netherlands -- May 8, 2009 -- Patients with extreme obesity achieved 8.3% weight loss after 2 years of intensive medical intervention compared with 0.5% in a control group, according to research reported here at the 17th European Congress on Obesity (ECO).

The investigators found that at the 2-year mark, 31%, 21%, 10%, and 7% of patients in an intensive intervention group reached a 5%, 10%, 15%, and 20% weight loss, respectively, based on an intention-to-treat (ITT) analysis. In a usual-care group, the respective numbers were 10%, 4%, 2%, and 2%.

The intensive medical intervention included weight-loss medications, calorie-restricted and structured diets, and group behavioural counselling.

Lead author Donna Ryan, MD, Associate Director for Clinical Research, Pennington Biomedical Research Center, Baton Rouge, Louisiana, presented the results of this 2-year, randomised, pragmatic clinical trial here on May 7.

Dr. Ryan described a pragmatic clinical trial as one that "selects clinically relevant alternative interventions to compare against." A pragmatic trial is "designed to mimic real-world protocols, with both the physician and the patient having leeway in making treatment choices," she said.

The study included 393 of 597 individuals screened. Individuals who were currently taking weight-loss medications were excluded.

Patients had a body-mass index (BMI) >=40 kg/m2. Women comprised 83% of the group.

The patients were randomised to either usual care (n = 193) or intensive medical intervention (n = 200). Both treatment groups were balanced for gender, ethnicity, age, and BMI.

Usual care consisted of access to a self-guided, internet-based weight management program (through the Mayo Clinic Web site).

Patients in the intensive medical intervention group received treatment in 3 stages. The first stage lasted 3 months, during which patients consumed a liquid diet of 900 kcal/day.

In the second stage, during months 4-8, the intensive intervention consisted of weekly sessions of group behavioural counselling plus a structured diet and pharmacotherapy. The medications included sibutramine, orlistat, and diethylpropion.

The third stage, from months 8-24, saw the patients continuing on the medications, having monthly counselling sessions, and being free to return to the liquid diet or structured diet.

Using a last observation carried forward analysis, the researchers showed that the mean weight loss after 2 years in the intensive intervention group was 8.3% (+- 0.79%) and in the usual-care group was 0.5% (+- 0.46%).

At the 1-year follow-up, 60% of patients in the intensive intervention group and 47% of patients in the usual care group were still participating in the study. At 2 years, it was 51% and 45%, respectively (P = NS). A US$100 Wal-Mart gift card was given to encourage attendance at the 2-year visit.

Among the 119 patients who were still in the intensive intervention group at the 1-year follow-up, the mean weight loss was 9.7% (+- 1.3%), a reduction of 12.7 kg (+- 1.7 kg) (P < .0001 vs baseline).

Mean weight loss among the 92 patients who were still receiving usual care at 1 year was 1.5% (+- 0.8%) or 1.7 kg (+- 0.9 kg) lost (P = .28 vs baseline).

Twenty serious adverse events were seen in the intensive intervention group and 12 in the usual care group. None were judged to be related to treatment.

Dr. Ryan said that the next follow-up will be at the 5-year mark. She concluded, "trained primary care physicians can be successful in helping a subset of patients with severe obesity achieve meaningful weight loss."

The study was funded by the Office of Group Benefits, a health insurance provider for government employees (including Dr. Ryan) in Louisiana. A portion of the sibutramine was donated by Abbott Laboratories.

http://www.docguide.com/news/content.nsf/news/852571020057CCF6852575B0007664E7

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Please email questions and comments to lsuhospitals@lsuhsc.edu.