The New Old Age Blog: A Community Time Bank

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Joan Black took a serious tumble two years ago, climbing up on a stepladder to reach for a punchbowl. She was about to host one of her frequent patio parties for a regional theater company in Montpelier, Vt.

Ms. Black had been doing quite well in her ground-floor apartment downtown. But the fall broke a vertebra, and since then she’s had trouble walking and standing for any extended period.

Daniel HechtCara Barbero shoveling snow at the home of her neighbor Joan Black.

Once she worked as an interior designer. “I take a great deal of pride in my home,” she told me in an interview. “But I couldn’t keep up with the vacuuming and dusting. I couldn’t garden. I used to start dreading winter in mid-July.” (She couldn’t shovel snow.) Living on Social Security payments since the recession plundered her savings, she couldn’t afford to hire helpers. “Seeing things in my life go downhill became very depressing,” said Ms. Black, now 80.

Happily, a city program called the Reach Service Exchange Network began operation in the fall of 2010, powered by a grant of $1 million from the federal Administration on Aging.

The network functions as a time bank. Montpelier residents of all ages join for $25 and get access to a site listing requests and offers: driving, pet care, reading aloud, help with grocery shopping, computer tutoring sessions and more. “We ask all members to provide services to the network,” explained Daniel Hecht, the network’s director. “We think people of any age or level of ability can contribute.”

We’ve talked here about various alternatives to assisted living and nursing homes that allow people to age in place, or at least age in place longer. Co-housing, shared housing, villages, N.O.R.C.’s — the approaches and the economics vary, but the goals of independence and interdependence, which aren’t contradictory in old age, are much the same. People want community, but they also want privacy; most try to maintain their own households for as long as they can. “I told my son and daughter-in-law that I want to be carried out of my apartment,” Ms. Black said, voicing a common sentiment.

Can an organization like Reach make that happen? “Volunteering and increased social interaction are known preventions that mean better health,” Mr. Hecht pointed out.

So far, 200 locals have joined Reach, half of them over age 58. The staff runs criminal background and sex-offense checks on each member and reviews the motor vehicle records of anyone who has volunteered to drive. “This sort of vetting means nobody’s going to come to your home and steal your jewelry,” Mr. Hecht said.

As a group, Reach members currently contribute 300 hours of services each month. Ms. Black, for instance, has arranged to have a member vacuum and dust her apartment each week, which takes about two hours.

Cara Barbero, who lives a block or so away, shows up to shovel snow, often before dawn. “I get up in the morning, and the path is already cleared and salted and the car is cleaned off, and I can get out and go,” Ms. Black said.

In exchange, she operates the Reach Network’s information table at the farmers’ market most summer weekends and works at the guided tour desk at the restored state Capitol building. She still hosts soirees to benefit the Lost Nation Theater — though someone else handles the punchbowl — and she arranges a high tea each March that supports a college art gallery. By helping Ms. Black, Ms. Barbero has earned hours that she uses to get child care.

Friendships develop. Ms. Barbero’s daughters came over to sing “Jingle Bells” and deliver Christmas cookies to Ms. Black last month; she invited them and their mother to her 80th-birthday celebration. She has signed up for classes that Reach is offering in the Alexander technique, which she thinks may ease her back pain.

As one downside of aging in place can be isolation and depression, “I’ve made it a point to get out and meet people,” Ms. Black said. “It keeps the juices going.”

But when the federal grant ends after three years, can Montpelier keep Reach going? It faces the same challenges as many elder care alternatives, including the much-touted village movement: It needs to raise money, if only for office space, Web site maintenance and at least a skeleton staff. And it needs to keep bringing in new members, including those younger and able-bodied. Its goal, in this small city of 7,500, is to attract 600 members who provide a collective 1,000 hours of service each month. That’s a far-off target.

Many of these experiments can keep older members in their homes when they need driving and dog-walking. As they age, a high proportion will eventually need help with the more basic activities of daily living — bathing, dressing, using a toilet. Few of these housing or community-building efforts are equipped to offer long-term care. “We can’t guarantee services to anyone,” Mr. Hecht acknowledged.

So Reach represents a model with limitations but also great benefits. “It reminds me of when I was growing up on Long Island and people just naturally helped and took care of each other,” Ms. Black said. “It’s tightened our community. I just hope it goes on forever.”

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

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Recipes for Health: Mashed Turnips and Potatoes With Turnip Greens — Recipes for Health

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2 bunches turnips with greens attached (1 3/4 to 2 pounds, including greens)

1 pound russet or Yukon gold potatoes, peeled and quartered

Salt to taste

1 to 2 tablespoons extra virgin olive oil

1 leek, white and light green parts only, finely chopped

2/3 cup low-fat milk, or as needed

Freshly ground pepper

1. Cut away the greens from the turnips. Peel the turnips and quarter if they’re large; cut in half if they’re small. Stem the greens and wash in 2 changes of water. Discard the stems.

2. Combine the turnips and potatoes in a steamer set above 2 inches of boiling water. Steam until tender, 20 to 25 minutes. Remove from the steamer and transfer to a bowl. Cover the bowl tightly and leave for 5 to 10 minutes so that the vegetables continue to steam and dry out.

3. Fill the bottom of the steamer with water and bring to a boil. Add salt to taste and add the greens. Blanch for 2 to 4 minutes, until tender. Transfer to a bowl of cold water using a slotted spoon or skimmer, then drain and squeeze out excess water. Chop fine. Drain the water from the saucepan, rinse and dry.

4. Heat 1 tablespoon of the olive oil over medium heat in the saucepan and add the leek and a pinch of salt. Cook, stirring, until leeks are tender and translucent but not colored. Add the milk to the saucepan, bring to a simmer and remove from the heat.

5. Using a potato masher, a fork or a standing mixer fitted with the paddle, mash the potatoes and turnips while still hot. Add the turnip greens and combine well. Beat in the hot milk and the additional tablespoon of olive oil if desired, and season to taste with salt and pepper. Serve hot, right away, or transfer to a buttered or oiled baking dish and heat through in a low oven when ready to serve.

Yield: Serves 4 to 6 as a side dish.

Advance preparation: You can make this several hours ahead and reheat as directed, or in a double boiler.

Nutritional information per serving: 208 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 3 grams monounsaturated fat; 3 milligrams cholesterol; 38 grams carbohydrates; 7 grams dietary fiber; 156 milligrams sodium (does not include salt to taste); 6 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Devices to Keep Track of Calories, Lost or Gained

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There is a simple reason for this. Everyone understands they have to burn more calories than they take in, said John Jakicic, a professor at the University of Pittsburgh and a researcher in the field of exercise and long-term weight control. But “most people don’t know how many calories they burn a day,” he said. “They have no clue.”

Getting a clue — or at least an accurate estimate — used to require a visit to a laboratory or the use of complex scientific equipment. Guess how often people took that approach?

Now though, there are simplified electronic monitors that are designed to accurately gauge physical activity and the calories burned, which is the silver bullet for weight loss. “There is a lot of evidence that shows they work,” Professor Jakicic said.

Some products in this area have fallen flat, like Jawbone’s Up, a wristband activity tracker that had so many technological problems that Jawbone is offering full refunds to dissatisfied customers. It is taking preorders for a new version.

How well a monitor works depends on how much it is used, which boils down to personal taste. Are you more likely to use one that offers games and challenges, one that just reports the numbers, or one that is inconspicuous? We tried four of the more common products.

STRIIV ($100) Just released in October, the Striiv may encourage even the most rooted sofa spud. Designed with the sedentary in mind, it is an ultra-simplified device that offers rewards and challenges to motivate users and keep them active.

The touch-screen device, about the size of a pack of Tic-Tacs, starts up with a jaunty song and a video with directions, though you hardly need them to operate it. Set-up is easy, and from there you wear it or carry it in a pocket to measure your steps when walking, running or climbing stairs. It was the one device tested that did not need to be synced with a computer.

Striiv has a number of ways to keep people engaged. It gives out trophies and points for accomplishments, like your record number of stairs climbed, and points can also be used to play MyLand, a game in which users build and explore an animated world.

Finally, you can choose one of three charities to receive a donation based on your activity (you’ll have to sync to a computer to make this happen). Walk 60,000 steps to immunize a child against polio. Fewer steps help provide clean water in South Africa or save a patch of rainforest. The Striiv is unique in that it offers both carrot and stick — it occasionally offers challenges, like “Do three minutes of activity.” Accept and you get a bonus 3,000 points; decline and you lose 300 points.

Striiv does suffer in a few regards. It measures only calories burned. You’ll need a separate app to measure calories consumed, like Livestrong.com’s MyPlate. And the device recognizes only the motions of walking, running and stair climbing, so it won’t spot an activity like weightlifting or cycling. That can throw off your calorie count.

FITBIT ULTRA WIRELESS ACTIVITY TRACKER ($100) Fitbit, a monitor about the size of a large nail clipper, has been around for a while, but the Fitbit Ultra brings some new features to the earlier version, which automatically transmits your data when you are within 15 feet of a Fitbit base connected to a computer.

The Ultra adds an altimeter to count stairs climbed. Like the Striiv, it won’t recognize exercise other than walking, running and stair climbing, but you can use a new stopwatch feature to log a block of time that you can later assign to an activity, like a Zumba class, using the Fitbit Web page or the companion iPhone app.

The Ultra will help you track the amount and quality of your sleep, but you have to manually set the stopwatch to do that as well. Tracking sleep is worthwhile because research shows a correlation between adequate sleep and weight loss.

There is now added inducement for the lazy in the form of digital badges, and you can share your exercise progress on Facebook. As before you can also share challenges and encouragement on the Fitbit Web site by creating groups or joining public ones.

Fitbit has a food log where you can enter what you eat to see how your calorie intake stacks up against calories burned, as well as the percentage of fats, carbohydrates and proteins you’re eating. The list of foods leans heavily toward chain restaurant meals, so you may have to approximate for food you make yourself.

For an additional $50 a year, premium membership provides more detailed data and lets you anonymously compare your stats with other Fitbit users.

BODYMEDIA FIT LINK ($200 PLUS $7 A MONTH SUBSCRIPTION) BodyMedia’s monitors were originally built for researchers like Professor Jakicic. They are worn on the upper arm and they measure heat, moisture and movement to get a picture of activity. As with other monitors, BodyMedia’s wasn’t good at recognizing exercise other than walking or running (it recorded lifting heavy weights as “moderate” exercise, which it is not).

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F.D.A. Orders More Study on Surgical Mesh Risks

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The Food and Drug Administration issued an order on Wednesday requiring makers of implantable surgical mesh used to treat urinary incontinence in women to study its risks.

The move comes after years of reports of serious injuries linked to the devices, including infections, pain and other complications. It follows a recommendation in September by an F.D.A. advisory panel that the agency require such studies.

The move Wednesday by the agency is similar to one it took last year when it ordered producers of all-metal artificial hips to undertake patient studies. The mesh products and the hips belong to a class of implantable devices that manufacturers do not have to study in patients before they are marketed or closely follow in patients afterward.

Female incontinence is often caused by two conditions. One is called pelvic organ prolapse, in which muscles that support organs like the bladder weaken, allowing them to descend and press against the vaginal wall. The other, stress urinary incontinence, is also caused by muscle weakening.

In 2008, the F.D.A. issued a warning that the use of vaginal mesh was associated with complications but said at the time that such problems were rare. However, from 2008 to 2010 there was a fivefold increase in adverse event reports related to the use of vaginal mesh to treat pelvic organ prolapse, said Dr. William Maisel, the chief scientist of the F.D.A. division that oversees medical devices.

Dr. Maisel emphasized that the order Wednesday did not cover all uses of surgical mesh to treat incontinence. He added that the safety of such devices when surgically implanted through the abdomen was “well established.”

The top producers of vaginal mesh include Boston Scientific, C. R. Bard, Ethicon and W. L. Gore & Associates.

In 2010, about 185,000 women underwent procedures in which mesh was implanted vaginally to treat urinary incontinence.

That same year, researchers reported in a medical journal that about 15 percent of the women treated with vaginal mesh experienced potential complications. The study, which appeared in the journal Obstetrics and Gynecology, also concluded that mesh did not provide greater benefits than the traditional surgical treatment in which a patient’s own ligaments are used to strengthen the vaginal wall.

Dr. Maisel said he expects that mesh manufacturers, once studies are started, will follow patients for about three years to determine the frequency and severity of complications.

Over the last year, the F.D.A. has increasingly used its authority to order manufacturers to conduct emergency studies. But the effectiveness of that procedure in preventing patient injuries is questionable because by the time the agency acts, a device has been on the market for years and been implanted in hundreds of thousands of patients.

Also, while the F.D.A. in May ordered makers of all-metal hips to conduct postmarket studies of their risks, the agency and company officials are still discussing study designs, Dr. Maisel said.

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Marijuana Use Most Rampant in Australia, Study Finds

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The study, an analysis of global trends in illegal drugs and their effect on public health published in The Lancet, a prestigious journal, found that Australia and neighboring New Zealand topped the lists globally for consumption of both marijuana and amphetamines, a category of drugs whose use the study found to be growing rapidly around the world.

The study’s co-authors, Professors Louisa Degenhardt of the University of New South Wales and Wayne Hall of the University of Queensland, reported that as much as 15 percent of the populations of Australia and New Zealand between the ages of 15 and 64 had used some form of marijuana in 2009, the latest year for which data were available.

The Americas, by comparison, clocked in at 7 percent, although North America batted above the neighborhood average with nearly 11 percent of its population partaking. Asia demonstrated the lowest global marijuana use patterns at no more than 2.5 percent, the study said, although difficulties in obtaining accurate data in less developed countries were cited as one possible reason for the low figures.

The results were not surprising and reflected trends that have been in place for more than a decade, Mr. Hall said in an interview on Australian radio Friday. Despite the high figures in the report, he said, the rate of marijuana use in Australia has actually been dropping “steadily for the better part of a decade.”

Mr. Hall blamed both the ubiquity of the drug — Australia and New Zealand have no shortage of remote rural areas where policing is difficult and the plant grows like, well, a weed — and cultural mores that place the consumption of intoxicants at the center of social life.

“Just look at the way we take alcohol as an integral part of everyday life. I think a lot of young people see cannabis in the same way that we see alcohol: as no big deal, as a drug just to use to have a good time,” he said.

Stepping back for a global perspective, the study found that marijuana was the world’s most widely consumed illicit drug, with anywhere from 125 million to 203 million people partaking annually. Use of the drug far outstrips that of other illicit drugs globally, with 14 million to 56 million people estimated to use amphetamines, 14 million to 21 million estimated to use cocaine and 12 million to 21 million estimated to use opiates like heroin.

Still, despite marijuana’s significantly outpacing other illicit drugs in terms of the volume of use, the study found that it was the least likely of all illicit drugs to cause death. Additionally, barely 1 percent of deaths in Australia annually can be attributed to illegal drugs, the report said, compared with almost 12 percent from tobacco use.

The prevalence of marijuana use in Australia is widely accepted if not openly condoned, and at least three states have moved to decriminalize the possession of small quantities for personal use.

But the findings in the report most likely to cause concern to the Australian government were those relating to the use of amphetamines, and particularly methamphetamine, which has become a major public health concern over the past two decades. As much as 3 percent of the Australian population has used amphetamines like speed, compared with just 0.2 percent to 1.4 percent in Asia.

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British Seek Data to Help Decide on Breast Implant Removal

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“The question really comes down to the extent to which these implants fail relative to normal implants and the relative risks of their removal compared to the risk of having an operation,” Mr. Lansley told BBC radio.

Mr. Lansley was acknowledging that the British authorities did not have reliable statistics on ruptures or oozing of the implants, throwing into doubt the basis for their earlier recommendation that women with the implants in question not undergo “routine removal.”

The French government recommended on Dec. 23 that the 30,000 Frenchwomen with the implants have them removed, citing a failure rate of around 5 percent, a figure they have since raised to about 5.5 percent, calling it unacceptably high. The silicone gel inside them causes inflammation.

British officials at the time cited their own finding that the failure rate among more than 40,000 British women was closer to 1 percent to support their recommendation against removal, an operation performed under general anesthesia that carries its own potential risks.

Nigel Mercer, a former president of the British Association of Aesthetic Plastic Surgeons, said the government lacked data on how many British women have implants that have ruptured. But he said the real issue was not the numbers, but the risk posed by the implants’ use of industrial-grade, not surgical-grade, silicone.

“The British government is all hung up on the rupture rate, but that’s missing the point,” Dr. Mercer said. “It’s what’s inside the implants. It’s not fit to be inside a human being.”

The silicone gel inflames body tissues if it leaks, and the leaks also raised fears of a possible link to cancer. Health authorities around the world have issued statements saying no link has been found.

With British private clinics reportedly charging up to $4,690 to remove the implants, the overall cost could be more than $187 million for 40,000 patients, a burden the National Health Service is loath to bear.

The French government is paying the cost of removal for its citizens. The national health system estimated that it would cost about $77 million to treat all 30,000 French patients.

Mr. Lansley, the British health secretary, acknowledged in a statement that “this is a worrying time” for women who have implants made by Poly Implant Prothèse — known as PIP — and he sought to place the responsibility for care on the doctors who implanted the devices.

More than 300,000 women outside France — mostly in Western Europe and Latin America — also received PIP implants. None are known to have been sold in the United States.

The French daily Le Monde reported on Tuesday that TüV Rheinland, the German company responsible for assuring that PIP implants met European regulations, was being sued by distributors in Brazil, Bulgaria, Mexico, Thailand, Syria and Italy.

TüV Rheinland said last week that it had been deliberately deceived by PIP, which used high-grade silicone when TüV’s inspectors were present and returned to the substandard product after they left. It said it filed a criminal complaint against PIP.

French officials are also turning up their scrutiny of Jean-Claude Mas, the founder of PIP. Mr. Mas, who is already the subject of a fraud investigation by Marseille prosecutors over the implants, was questioned on Monday by the French agency that deals with the safety of health products, French news media reported.

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The New Old Age Blog: Happier Staffers at Nonprofit Nursing Homes

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Reading between the lines of a study published in The Gerontologist recently, I noticed another vote for nonprofit nursing homes.

This isn’t a surprising finding, really. For years, researchers have reported that ownership status is one of the factors related to quality care. “Most studies show that nonprofits do a better job of caring for patients,” said JiSun Choi, a postdoctoral fellow in nursing and long-term care at the University of Kansas Medical Center School of Nursing. “But we’re not sure why that happens.”

We could speculate about the role that money plays, of course. A nonprofit nursing home doesn’t have to worry about paying shareholders dividends or keeping stock prices high. It can also rely on philanthropy to help bridge the gap between what it takes in from residents and government reimbursement and what it needs to spend.

But we also know that staff members’ feelings about their jobs appear to play a significant mediating role. Past studies have shown that in commercially operated homes, for instance, the certified nursing assistants who provide the bulk of the hands-on care are less satisfied with their jobs than those in nonprofits. Directors of nursing in commercial homes are less satisfied as well, and more likely to be planning to leave. In general, such homes are associated with higher — in some cases, shockingly high — staff turnover.

Dr. Choi and her colleagues, surveying nearly 900 registered nurses working in almost 300 skilled nursing facilities in New Jersey, found several characteristics that contributed to the nurses’ job satisfaction: their ability to help set the facility’s policies, their sense of having supportive managers, their feeling that they had adequate resources (translation: enough staff to get the job done well). “A more supportive practice environment,” the researchers called it.

At any rate, R.N.’s working in nonprofit nursing homes were significantly more satisfied with their jobs, the study showed.

Though turnover lay outside the scope of her study, Dr. Choi thought that greater satisfaction might keep them in their jobs longer and affect the work environment for the nursing aides and licensed practical nurses whom R.N.’s supervise. Those staff people would then also be less likely to leave, leading to better outcomes for the residents they come to know. Her next research project will look at the relationship between work force satisfaction and patient outcomes.

Trying to find the right nursing home is such a stressful and sometimes bewildering task that an industry has sprung up to try to guide, or steer, the adult children who often make the decisions.

Ownership isn’t a fail-safe way to choose, sadly. Good commercial homes do exist, and so do lousy nonprofits. In any case, there aren’t enough nonprofits for all the older people who will need long-term care.

But the evidence is mounting that as a group, they still do a better job. That’s where I would start, if I were beginning the search.

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

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Massachusetts Health Plan Extended to Immigrants

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The ruling said that a 2009 state budget that dropped about 29,000 legal immigrants who had lived in the United States for less than five years from Commonwealth Care, a subsidized health insurance program central to this state’s 2006 health care overhaul, violated the State Constitution.

“This appropriation discriminated on the basis of alienage and national origin,” wrote Justice Robert J. Cordy of the Supreme Judicial Court, ruling that the action “violates their rights to equal protection under the Massachusetts Constitution.”

In 2009, with Massachusetts in the grips of a budget crisis, the state legislature voted to eliminate these immigrants’ eligibility for the program, a move lawmakers said then would save about $130 million.

“Fiscal considerations alone cannot justify a state’s invidious discrimination against aliens,” Justice Cordy wrote.

He also dismissed the state’s argument that the cuts were in line with federal policies to deny Medicaid assistance to the same group of legal immigrants.

“The legislature may not lean on federal policy as a crutch to absolve it of examining whether its own invidious discrimination is truly necessary,” Justice Cordy wrote.

Gov. Deval Patrick initially opposed barring the immigrants’ from the program and worked with legislators to create an alternative — and more limited — program that cost about $40 million.

Wendy E. Parmet, a professor at Northeastern University School of Law who argued the case, said she hoped the ruling would mean a quick redemption of benefits for the immigrants who lost some or all of their health insurance coverage because of the money-saving measure.

“I think it sends a clear message that it is unconstitutional in the state of Massachusetts, that the state can’t deal with its budget problems on the backs of the legal immigrants,” Ms. Parmet said of the decision.

State officials say they will abide by the decision, although they are not yet sure how to pay for the change.

“This decision has significant fiscal impacts for the commonwealth, adding somewhere in the range of $150 million in annual costs to what is already a very challenging budget,” said Jay Gonzalez, secretary of administration and finance. But he added, “We will work expeditiously to identify the resources required and the operational steps that need to be taken to integrate all eligible, legal immigrants into the Commonwealth Care program in accordance with today’s decision.”

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Study of Medicare Patients Finds Most Hospital Errors Unreported

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WASHINGTON — Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.

Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the “adverse events,” according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.

In the report, being issued on Friday, Mr. Levinson notes that as a condition of being paid under Medicare, hospitals are to “track medical errors and adverse patient events, analyze their causes” and improve care.

Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care.

“Despite the existence of incident reporting systems,” Mr. Levinson said, “hospital staff did not report most events that harmed Medicare beneficiaries.” Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.

Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.

Federal investigators identified many unreported events by having independent doctors review patients’ records.

The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.

Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said.

When the National Academy of Sciences issued a landmark report on patient safety in 1999, many experts said that hospital employees were often afraid to admit mistakes. But that no longer appears to be the main obstacle to reporting, federal investigators said.

More often, Mr. Levinson said, the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported.

In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or “suspected that the events were isolated incidents unlikely to recur.”

To clear up confusion, Medicare officials said they would develop a list of “reportable events” that hospitals and their employees could use. In addition, the Medicare agency said, hospitals should give employees “detailed, unambiguous instructions on the types of events that should be reported.”

The Obama administration and hospital industry leaders have placed a high priority on reducing medical errors. But, the report said, at many hospitals, this high-level commitment has not been translated into practice.

The inspector general found that “hospitals made few changes to policies or practices” after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any “systemic quality problems.”

Organizations that inspect and accredit hospitals generally “do not scrutinize” how hospitals keep track of medical errors and other adverse events, the study said.

The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said.

More than 2,900 hospitals have joined the administration in a “partnership for patients” intended to reduce errors and save 60,000 lives in three years.

At least 27 states have laws that require hospitals to report publicly on infections that patients develop in the hospital, according to the National Conference of State Legislatures, up from 6 at the end of 2005.

In view of the state laws, Obama administration officials said they were not proposing new federal requirements for the public reporting of adverse events.

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Well: P.S.A. Test Does Not Save Lives

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Updated findings from one of the largest studies of prostate cancer screening show that the commonly used P.S.A. blood test did not save lives, although questions remain about whether younger men or those at very high risk for the disease might benefit.

Last fall, the United States Preventive Services Task Force concluded that healthy men should no longer be routinely screened for prostate cancer using the prostate-specific antigen, or P.S.A., blood test. That decision was based on findings from five well-controlled clinical trials, including a major American study called the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial, which studied P.S.A. testing in nearly 77,000 men ages 55 to 74.

In 2009, the PLCO trial reported that although annual P.S.A. screening did detect more cancers, it didn’t save more lives when compared with a group of men who were given routine medical care and tested for prostate cancer only when a problem was suspected. But at the time, the investigators had only 7 to 10 years of data. Because prostate cancer can take several years to develop, the investigators continued to collect data after reporting the initial findings.

In a new paper published today in The Journal of the National Cancer Institute, the scientists report that the additional follow-up time didn’t change the overall conclusion: that regular P.S.A. testing does not save lives and can lead to aggressive treatments that leave men impotent, incontinent or both.

The P.S.A. test, often given to men starting at age 50, detects a protein called prostate-specific antigen and can identify the presence of cancerous cells in the prostate. Although about 12 percent more cancers were found among men in the screening group, the risk of dying of prostate cancer in the study was about the same for each group, whether the cancer was detected through screening or because a man developed symptoms. The findings suggest that the type of cancer typically detected by screening is so slow-growing that it often is unlikely to cause harm before the man dies of another cause.

“Despite additional follow-up, there is no demonstrable mortality benefit for the men who had P.S.A. testing compared to the usual care group,’’ said Dr. Gerald L. Andriole, the lead author and chief of urology at Washington University School of Medicine in St. Louis.

Even so, the findings are unlikely to resolve the debate around P.S.A. testing. Many doctors argue that the trial was seriously flawed because about half the men in the non-screening group ended up getting one or more P.S.A. tests during the trial period, making it difficult to determine the real effect of screening.

After the study was finished, additional analysis also raised questions about whether certain younger, healthy men might benefit from P.S.A. testing. Although only about 300 men out of the 77,000 studied ended up dying of prostate cancer, the test appeared to have saved a few extra lives among younger men who didn’t have other health problems like diabetes or high blood pressure. While that doesn’t change the overall finding that the risks of P.S.A. testing outweigh the benefits, Dr. Andriole said it may prompt additional research into whether younger men should get a baseline P.S.A. test or whether certain groups at higher risk for prostate cancer, like African-Americans or men with a strong family history of the disease, may benefit from routine screening.

“I think it supports the recommendation that for the average man in the United States, mass screening is probably not beneficial at all,’’ Dr. Andriole said. “It also will keep the discussion open about whether there are indeed subsets of men who do potentially stand to benefit from P.S.A. screening.”

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China to Release More Data on Air Pollution in Beijing

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Beijing plans to publish hourly air quality reports based on an international standard known as PM 2.5, which measures tiny particles that are 2.5 microns or less in diameter, according to an announcement on the Web site of the Beijing municipal government. Those are the particles that are considered the most serious health hazard.

Big cities in China, including Beijing, generally publish air quality data that measure particles that are up to 10 microns in diameter. Using that standard has allowed Beijing to record more than 250 “blue sky days” during each of the past two years.

China’s Ministry of Environmental Protection also said early Saturday that monitoring pollution levels using the PM 2.5 standard would be included in a newly amended draft of national air quality standards, according to Xinhua, the state news agency.

The public’s anger over declining air quality has been intensified by hourly readings released by the United States Embassy in Beijing. Those reports, released on a Twitter feed, use the 2.5 standard and paint a far grimmer picture of the city’s air problems, annoying Chinese officials and alarming residents who are aware of the feeds.

Beijing’s “blue sky days” have often turned up in United States Embassy readings as “unhealthy.”

In 2009, a Chinese Foreign Ministry official pressed the United States Embassy to stop reporting the data, saying the information was “confusing” and “insulting,” according to a State Department cable published by WikiLeaks. The embassy continues to release the readings via Twitter.

Twitter is blocked by the Chinese government, but some Chinese are able to access the site, and republish the data.

During the past year, smog has forced the city to periodically close highways, cancel flights and even cope with state-run media assaults on health problems caused by poor air quality.

Public anger over traffic jams and smog in the capital is doing economic and political damage to the city’s leaders. Some prominent bloggers, including the real estate tycoon Pan Shiyi, have sharply criticized the government’s official readings on microblogs and encouraged others to vote online about whether Beijing should publish more detailed air quality readings.

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Well Blog: Fussy Baby or a Sleep Disorder?

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One in 10 infants and toddlers have problems sleeping at night and may be at greater risk of developing a sleep disorder as they get older, a new study suggests.

The new research is a rare look at a problem that many parents and even pediatricians sometimes fail to notice. The study, which looked at children ages 6 months to 3 years, found that sleep problems were common in this age group. But parents did not always perceive red flags like loud and frequent snoring — which can be a risk factor for obstructive sleep apnea, a potentially serious breathing disorder — as problems that warranted mentioning to their pediatricians.

The findings also challenged a widespread notion that children who have sleep troubles early on tend to outgrow them. In the study, children who had one or more sleep problems at any point in early childhood were three to five times as likely to have a sleep problem later on.

“The data indicate that sleep problems in children are not an isolated phenomenon,” said Dr. Kelly Byars, an associate professor at the Cincinnati Children’s Hospital Medical Center and an author of the study, which was published in the journal Pediatrics. “If you have it early and it’s not remedied, then it’s likely to continue over time.”

The warning signs of a disorder can vary widely. But some indicators of a potential problem in children are loud snoring several nights a week, frequent bouts of getting up in the middle of the night, nightmares or night terrors, and routinely taking longer than 20 minutes to fall asleep.

Although serious sleep issues are more often thought of as a problem of adulthood, the National Sleep Foundation estimates that up to 69 percent of children younger than 11 have a sleep-related problem of some kind. Many parents, though, do not know what to look for or how to distinguish a true sleep disorder from the normal challenges of putting an infant or child to bed.

Pediatricians, too, may also overlook a child’s nighttime troubles. One report found that roughly half of all pediatricians do not ask about or screen for sleep disturbances when talking to parents about the health of a toddler or infant.

For the current study, Dr. Byars and his colleagues followed 359 infants, interviewing their mothers when the children were 6 months old, then again at 1, 2 and 3 years of age. Over all, about 10 percent of the parents reported that their children had problems like night awakenings, restlessness and trouble falling asleep.

Dr. Byars, who sees many children in his practice as a behavioral sleep medicine specialist, said parents often view a child’s difficulties at bedtime as a problem that goes away with age. “We hear that often in the clinic,” he said. “Parents will say, ‘We were told that Johnny or Suzy’s sleep problem was common and that this was just a phase.’ I think that’s true for probably the large majority of kids. But we’re finding that there’s a subset of kids that have a sleep problem that persists over time.”

The researchers, for example, found that up to 35 percent of the children who had trouble sleeping at the start of the study continued having problems over two years later. In comparison, less than 10 percent of the children who did not have sleep issues at the start of the study developed them later on.

Parents also tended to overlook potentially more serious problems. Between 12 and 20 percent of the children in the study snored most nights of the week, a possible sign of obstructive sleep apnea, but most parents did not report it as a problem. Although most children with sleep apnea outgrow it, the condition can result in failure to thrive, poor academic performance and behavior problems in some. The condition can usually be successfully treated with surgery to remove the tonsils and adenoids, or through weight loss and the use of continuous positive airway pressure, or CPAP, machines, which drive air into the lungs.

Dr. Byars said the best way parents can distinguish a true sleep disorder from a phase is to be on the lookout for problems that persist over time, and to raise any concerns with a pediatrician. “If a child has problems across two consecutive well-child visits” — at the 6-month checkup, for example, then again at 12 months, “then that is likely an indicator that this is a problem that should be addressed, as opposed to saying that it’s a problem the child will grow out of,” he said.

“As we say in our clinic, no sleep problem is insignificant if it’s having an impact on the family,” he added.

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News Analysis: Get a Midlife

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We are more accustomed to seeing the entry into middle age treated as a punch line or a cause for condolences. Despite admonishments that “50 is the new 30,” middle age continues to be used as a metaphor for decline or stasis. Having just completed a book about the history and culture of middle age, I found that the first question people asked me was, “When does it begin?” anxiously hoping to hear a number they hadn’t yet reached.

Elderly people who find middle age to be the most desirable period of life, however, are voicing what was a common sentiment in the 19th century, when the idea of a separate stage of development called “middle age” began to emerge. Although middle age may seem like a universal truth, it is actually as much of a manufactured creation as polyester or the rules of chess. And like all the other so-called stages into which we have divvied up the uninterrupted flow of life, middle age, too, is a cultural fiction, a story we tell about ourselves.

The story our great-great-great-grandparents told was that midlife was the prime of life. “Our powers are at the highest point of development,” The New York Times declared in 1881, “and our power of disciplining these powers should be at their best.”

Yes, yes, you think, bully for higher powers and all, but what about thickening waistlines, sagging skin, aching knees and multiplying responsibilities for aging, ailing parents? Is there anyone past 40 who, at one point or other, hasn’t pushed aside qualms and pushed back the skin above their cheekbones to smooth out those deepening nasolabial folds? Gym addicts aside, when it comes to face and physique, middle age doesn’t have a chance.

The problem with the physical inventory of middle age, though, is that it inevitably emphasizes loss — the end of fertility, decreased stamina, the absence of youth. Middle age begins, one cultural critic declared, the moment you think of yourself as “not young.” The approach is the same as that taken by physicians and psychologists, who have defined wellness and happiness in terms of what was missing: health was an absence of illness; a well-adjusted psyche meant an absence of depression and dysfunction.

The most recent research on middle age, by contrast, has looked at gains as well as deficits. To identify the things that contribute to feeling fulfilled and purposeful, Carol Ryff, the director of the Institute on Aging at the University of Wisconsin, Madison, developed a list of questions to measure well-being and divided them into six broad categories: personal growth (having new experiences that challenge how you think about yourself); autonomy (having confidence in your opinions even if they are contrary to the general consensus); supportive social relationships; self-regard (liking most aspects of your personality); control of your life; and a sense of purpose.

The survey questionnaire was meant to capture more than the fleeting pleasures of a few beers. It was designed to gauge whether an individual was functioning at full capacity or flourishing. The ancient Greeks called it eudaimonia, and positive psychologists have adopted the term to refer to the kind of profound satisfaction and meaning one derives from raising children, training for an Olympic event, completing a college degree or helping your neighbors rebuild after a disaster. The search for positive experiences showed researchers that a narrow focus on disease and dysfunction had skewed perceptions of midlife. For example, previous research had found that middle-aged women tended to have higher rates of depression than men. What they neglected to note was that women also reported better relationships and more personal growth, which strengthened their psychological resilience.

By the same token, researchers found that while stress reaches a high point in middle age, so does confidence in one’s own abilities. By midlife, most people said they felt better equipped to screen out petty annoyances and disappointments and juggle career and family. “Youth is the period in which a man can be hopeless. The end of every episode is the end of the world,” G. K. Chesterton wrote. “But the power of hoping through everything, the knowledge that the soul survives its adventures, that great inspiration comes to the middle-aged.”

A reporter who covers the arts and culture for The New York Times, and the author of “In Our Prime: The Invention of Middle Age.”

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Well: Think Like a Doctor: Ice Pick Pain Solved!

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On Wednesday, we challenged Well readers to figure out the diagnosis for a middle-aged woman with a pulsating whooshing sound in her head and a sharp stabbing pain on the left side of her neck and head. Nearly 400 readers wrote in with some very thoughtful assessments of this patient’s problem.

The correct diagnosis is…

Hemicrania continua

The only right answer we got came in around 11:15 a.m. from Sashank Prasad, a neuro-ophthalmologist from Brigham and Women’s Hospital in Boston. He says he sees a lot of headache patients because eye involvement is a common feature in many chronic headaches. It was a comment I had made to another reader, noting that the patient didn’t require surgery to get better, that helped him focus on hemicrania continua as the cause of this patient’s pain. One of the characteristics of this syndrome is that it is usually very sensitive to indomethacin, a type of medicine in the same family as ibuprofen and naproxen.

The Diagnosis:

Hemicrania continua is a type of daily headache first described in the early 1980s. It is characterized by the symptoms noted by this patient: persistent pain on one side of the head interspersed with episodes of much more severe pain that is often described as sharp or stabbing. The episodes are usually accompanied by other facial symptoms, including watery eyes, runny nose, eyelid swelling or constriction of the pupil.

Most patients with this type of headache improve when treated with indomethacin. A hemicrania continua headache will sometimes respond to other anti-inflammatory drugs — but response to indomethacin, in particular, is a defining characteristic of the syndrome.

It’s seen more commonly in women than in men and most commonly comes on in a patient’s 20s, though these headaches can start at any age.

How the Diagnosis Was Made:

When the patient came back to the office a few weeks later, I examined her and told her that I thought that she had something known as carotidynia, a pain syndrome caused by inflammation of the tissues of the carotid artery. The cause is unknown, but the condition most frequently occurs in patients with a history of migraine headaches. It is sometimes associated with an injury to the carotid, like a dissection or tumor, but several scans had not detected a problem like that. I had also read that carotidynia and pulsatile tinnitus were more common in patients with abnormal carotid arteries, and this patient, as I described in my previous post, had unusual twisting and meandering carotid arteries.

Carotidynia can usually be treated with medications used to prevent migraine headaches. The patient had already tried beta blockers, the most commonly used migraine preventing drug, but hadn’t tolerated it, so I suggested she try Topamax, a medication developed to prevent seizures, which has also been used successfully to prevent migraines. If these types of medications didn’t work, I told her, we could consider trying a nerve-blocking injection to the region. The patient left my office optimistic that finally she might have found a diagnosis and a treatment. She made an appointment to come back in a month.

A Lucky Break:

Meanwhile, back at the ranch, I was busy studying. Every 10 years internists have to take a test to maintain our certification with the American Board of Internal Medicine. It’s one way the board has to make sure we all stay up to date on the newest medical practices. I had been studying for the past 18 months to take this daylong test in November 2011.

As I was reading, I came across a reference to an unusual disease with a Victorian-sounding name. I didn’t remember it and went to Google to read more about it: hemicrania continua. The first site I clicked on was written by a patient who suffered from this disorder.

And suffer she had. Reading her symptoms was like talking with my patient. The headache was unilateral, constant, stabbing. As I moved on to the medical literature, I saw that my patient’s symptoms fulfilled all the diagnostic criteria for the diagnosis except for one. Patients with this disorder usually have eye symptoms like watery eyes, swollen eyelids or a unilateral constriction of the pupil.

Talking With the Patient:

Excited by my discovery, I couldn’t wait until our next appointment, so I called the patient. How was the Topamax working? I asked. Not so well, she told me. She had stopped taking it after a couple of weeks. It didn’t help the pain, and when she took it she felt “dumb as a rock.”

I told her that I had some new ideas about what might be causing her pain, but first I had a couple of questions. Did she have any eye watering or eyelid swelling when the pain in her head was most intense? Yes, she told me. Sometimes she felt as if she had a cold, just in her left eye. And did she ever notice anything different about the pupil in that eye? Yes, she said. When the pain was most severe she noticed that her pupils were often not the same size. No one had asked her about these symptoms, and they were so mild she hadn’t thought to mention them.

Now I was really excited. I explained my incidental finding and started her on a two-week course of indomethacin. If this was hemicrania continua, she would get better with this medication. I hung up the phone and mentally crossed my fingers.

How the Patient Fared:

A few weeks later we spoke again. How was she feeling? How was her headache? She laughed at the question. She felt great, she told me. Her voice was excited. Her joy was audible.

The headache was gone. Completely gone. She had taken the medicine for almost a week with no effect and had almost given up, when suddenly the headache just disappeared. Just like that. It was amazing, she told me.
Strangely, for reasons I can’t explain, the whooshing sound in her head also disappeared. It had been diminishing over the past several weeks, even before she started the new medication, and now she heard it only occasionally when she held her head in certain positions.

She stopped the indomethacin after the two-week course. Her headaches hadn’t returned. But if they did, she told me, she knew what to do. She told me that she felt normal for the first time in years. Her blood pressure was well controlled on a single medication, but she’s hopeful that once she gets back into shape, she may not need it. In fact, she was getting ready to go for a hike. After not being able to exercise for years, she was working hard to get back into shape and back to her previous level of activity.

There’s a great line in baseball that I used to hear frequently quoted in my first career, when I was a television journalist. It was from Lefty Gomez, a New York Yankee. He said he’d rather be lucky than good. I guess that’s true in medicine. It was lucky I was studying. It was lucky I ran across this mention of this half-remembered disease. It’s humbling to know how easily I could have missed this diagnosis. Does it have to be a choice? Lucky or good? Frankly, I’d much rather be both.

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F.D.A. Restricts Cephalosporin Antibiotics in Livestock

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The medicines are known as cephalosporins and include brands like Cefzil and Keflex. They are among the most common antibiotics prescribed to treat pneumonia, strep throat, and skin and urinary tract infections. Surgeons also often use them before surgery, and they are particularly popular among pediatricians.

The drugs’ use in agriculture has, according to many microbiologists, led to the development of bacteria that are resistant to their effects, a development that many doctors say has cost thousands of lives.

Antibiotics were the wonder drugs of the 20th century, and their initial uses in both humans and animals were indiscriminate. Farmers became so enamored of the miraculous effects of penicillin and tetracycline on the robustness of cattle, chickens and pigs that the drugs were added in bulk to feed and water, with no need for prescriptions or any sign of sickness in the animals.

By the 1970s, public health officials had become worried that overuse was leading to the birth of killer infections resistant to treatment. Since then, the Food and Drug Administration has undertaken fitful efforts to wean farmers, ranchers and veterinarians from excessive use of the medicines, but the vast majority of antibiotics used in the United States still go to treat animals, not humans. Meanwhile, outbreaks of illnesses from antibiotic-resistant bacteria have grown in number and severity.

A decade ago, the F.D.A. banned indiscriminate agricultural uses of a powerful class of antibiotics, called fluoroquinolones, that includes the medicine Cipro. Wednesday’s announcement was another of the F.D.A.’s incremental steps.

“We believe this is an imperative step in preserving the effectiveness of this class of important antimicrobials that takes into account the need to protect the health of both humans and animals,” said Michael R. Taylor, deputy commissioner for foods at the agency.

Cephalosporins are not used as widely in livestock as penicillin, since they require a prescription from veterinarians. But the drugs are routinely injected into broiler eggs and used in large doses to treat infections in cattle and other animals.

The new rule will restrict only some of these uses and is therefore a modest step that, while applauded by consumer advocates, led many to call for far tougher measures.

“This is particularly important because cephalosporins are so important to human health, but it’s only a first step,” said Laura Rogers of the Pew Charitable Trusts, which has advocated restricting agricultural uses of antibiotics.

The F.D.A. initially proposed cephalosporin restrictions in 2008 but withdrew the rule before it could take effect because of opposition from veterinarians, farmers and drug companies. The rule announced Wednesday is less strict than that one, since it still allows veterinarians to use the drugs in to treat sick animals in some ways the F.D.A. has not specifically approved, and wide discretion to treat small-scale-production animals like ducks and rabbits. The rule bans routine injections of cephalosporins into chicken eggs and large and lengthy dosing in cattle and swine.

Dr. Christine Hoang, assistant director of scientific activities at the American Veterinary Medical Association, said the new rule was a vast improvement over the one proposed in 2008.

“We thought the original order was too broad and unnecessarily prohibited uses that were not likely to cause problems for human health,” Dr. Hoang said.

Dr. Scott A. Brown of Pfizer, which makes cephalosporins used in animals, said the company “acknowledges the intent of the proposed order to respect veterinary discretion in determining the appropriate and responsible use of cephalosporin antibiotic medicines in the interest of animal health and human health.”

The F.D.A. has yet to make final a guideline proposed in 2010 that would edge the agency closer to banning uses of penicillin and tetracycline in feed and water for the sole purpose of promoting the growth of animals or preventing illness that results from unsanitary living conditions. This issue has generated intense controversy among farmers and ranchers who contend that public health officials have exaggerated the danger of agricultural uses of antibiotics to humans.

When asked about the penicillin guideline, Mr. Taylor of the F.D.A. said, “We’re hopeful that in the coming months, we’ll be able to carry forward on that work.”

Representative Louise M. Slaughter, a Democrat from New York and a microbiologist, said the F.D.A. had been too slow and too timid. “We are staring at a massive public health threat in the rise of antibiotic-resistant superbugs,” she said. “We need to start acting with the swiftness and decisiveness this problem deserves.”

But Dr. Gatz Riddell, executive vice president of the American Association of Bovine Practitioners, a veterinarian group, said the dangers of agricultural uses of antibiotics had been greatly exaggerated. “It is highly misunderstood in the human-health community how much antibiotics are used in animals who are not sick or at risk of becoming sick,” he said.

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Phys Ed: Phys Ed: Icing Can Make Sore Muscles Worse

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Patrik Giardino/Getty ImagesIs ice the best remedy for an aching muscle?

Already, the benches in gym locker rooms and beside basketball courts are filling with 2012’s early casualties, those of us who, goaded by New Year’s resolutions, are exercising a bit too enthusiastically and developing sore muscles. Many of us will then drape ice packs over our aching muscles. But a new review article published this month in the journal Sports Medicine suggests that for sore muscles, ice is not always the panacea that most of us believe it to be and that, in some instances, it can be counterproductive.

For the study, researchers at the University of Ulster and University of Limerick in Ireland reviewed almost three dozen earlier studies of the effects of using ice to combat sore muscles, a practice that many who exercise often employ. Ice is, after all, the “I” in the acronym RICE (rest, ice, compression, elevation), which remains the standard first-aid protocol for dealing with a sports-related injury. Icing is also widely used to deal with muscles that twinge but aren’t formally injured. Watch almost any football, basketball or soccer game, at any level, and you’ll likely see many of the players icing body parts during halftime, preparing to return to play.

But there has been surprisingly little science to support the practice. A 2004 review of icing-related studies published to that point concluded that while cold packs did seem to reduce pain in injured tissues, icing’s overall effects on sore muscles had “not been fully elucidated” and far more study was needed.

Last year, a small-scale randomized trial found no discernible benefits from icing leg muscle tears. The cooled muscles did not heal faster or feel less painful than the untreated tissues. But, as the researchers point out, it is difficult to scientifically study icing, since you can’t blind people to whether they are receiving the therapy or a placebo. People generally can tell if their muscles are getting cold or not.

Which leaves the findings of the new review about icing by athletes as the best overview we may have for now. And the findings are not altogether comforting.

The authors write that, in a majority of the studies they looked at, icing was quite effective at numbing soreness. But it also significantly reduced muscle strength and power for up to 15 minutes after the icing had ended. It also tended to lessen fine motor coordination. Some of the reviewed studies found that people experienced impaired limb proprioception, or their sense of where their limb was in space after it had been iced.

The result was frequently, at least in the short term, poorer athletic performance. Volunteers were not able to jump as high, sprint as fast, or throw or strike a ball as well after 20 minutes of icing.

“The current evidence base suggests that the performance of athletes will probably be adversely affected should they return to activity immediately after cooling,” the authors conclude.

Why an ice pack before exercise should depress performance isn’t fully understood, though there are several theories. “The most likely reason is that ice reduces nerve conduction velocity,” said Chris M. Bleakley, a research associate at the University of Ulster who led the study. “Nerve impulses in the muscle slow down.” Cooling, he said, also probably “affects the mechanical properties of the muscle tendon unit,” meaning that the muscles and tendons, which should work together seamlessly, do not.

There’s also the possibility that icing sore muscles may increase the risk of injury, though the studies did not examine this issue directly. If your iced shoulder or legs feel sluggish during a tennis match or run, the authors suggest, you presumably will push harder, even as the iced muscle, being numb, doesn’t alert you to the beginnings of a more severe injury. The risk really applies “to situations where athletes are returning to competition immediately after icing,” like when you apply a cold pack before a run or “ice on the sidelines or at halftime to treat pain and discomfort,” Dr. Bleakley said. That means for most of us, there may be times when it’s fine to ice sore muscles – like after a hard workout or when we experience serious injury — provided we do not jump back into the field.

Most earlier studies have found little benefit from icing after exercise, but also few negative side effects. And if we must resume activity, the negative effects of icing are thankfully short-lived, usually disappearing within about 15 minutes. They also were less severe if the icing time was shortened, Dr. Bleakley says. “Application times of three to five minutes had much less of an adverse effect on performance” than keeping the ice pack in place for 20 minutes or more, he said.

The fundamental lesson of the review is clear. “Ice has many benefits,” Dr. Bleakley says. “It is cheap and remains an excellent method of numbing pain.”

Ice remains an accepted therapy for an acute injury and is popular with many athletes to help them to recover after exercise. But relying on ice to get you back into that senior-league basketball game or onto the running track when you’re already sore is inadvisable. “Athletes should consider that pain is usually a sign that something is wrong with your body,” Dr. Bleakley says. Listen, and stay out of the second half of the senior-league basketball game or skip a day’s run. You have the rest of 2012 to fulfill your resolution.

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The Bay Citizen: Unreported Food Poisoning at San Francisco Restaurant Spotlights Absence of Law

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But in December, its many accolades could not protect Delfina from an unusual incident. On a night the restaurant was booked solely for a private party, about two dozen patrons were sickened by food poisoning.

The staff determined what each victim ate, and since a vegetarian was among those sickened, oysters, beef tartar and other foods were eliminated as the sources of illness.

“We narrowed things down to the most common denominator,” Mr. Stoll said. Their conclusion: Tainted produce, most likely salad greens.

The restaurant contacted its suppliers, but no alert went out to the public, and there was no government investigation. The San Francisco Department of Public Health had not heard of the incident until contacted by The Bay Citizen.

In what appears to be a gap in the food supply safety net, there is no requirement for restaurants to report when their diners are affected by food-borne illnesses even when large numbers of people get sick.

“They are not obligated to report it,” said Richard Lee, director of environmental health regulatory programs for the city.

Mandatory reporting is not required at the state level either, according to the California Department of Public Health. Under both state and local laws, reporting is required only when restaurant workers become sick.

While city health officials have embarked on a high-profile crackdown of popular unlicensed food sales — including the closing last year of the Underground Market and recent action to regulate pop-up dining events like the ForageSF’s Wild Kitchen — the Delfina incident shows that health officials are sometimes unaware of actual cases of food-borne illness.

Dr. Rajiv Bhatia, the city’s director of environmental health, said the Delfina incident was now under investigation, but added that it was highly unusual for health officials to be unaware of a case involving so many diners.

“Over the past 13 years, I have not encountered a case where an?outbreak of this magnitude was not reported directly by an ill consumer?or a medical provider to the department,” Dr. Bhatia said.

He suggested a need for stricter rules. “I believe that reporting of potential outbreaks should be mandatory for supermarkets, restaurants, schools and workplace cafeterias, even though this is not a requirement under current law,” he said.

The city has approximately 4,500 licensed food establishments, and reported illness outbreaks are rare.

Dr. Nathan Wolfe, a visiting professor in human biology at Stanford University and director of the Global Viral Forecasting Initiative in San Francisco, said that better systems for reporting food-related illnesses were essential.

In his new book, “The Viral Storm: The Dawn of a New Pandemic Age,” Dr. Wolfe writes that many illnesses, including viruses, make the jump to humans from animals when used for food, with transmission possible during hunting, butchering or consumption.

A worst-case scenario was portrayed in the recent film “Contagion,” on which Dr. Wolfe served as a consultant. Spoiler alert: The movie’s fictional pandemic starts in a restaurant kitchen.

“Early detection can play a huge role” in treating and containing outbreaks, Dr. Wolfe said in an interview, but “we still have not largely cracked the problem of biosurveillance.”

An increasingly interconnected and complex food chain makes that task daunting. “With the advent of processed meats,” Dr. Wolfe wrote in the book, “a single hot dog at a baseball game can consist of multiple species (pig, turkey, cattle) and contain meat derived from hundreds of animals.” Typical meat eaters “will consume bits of millions of animals in their lifetimes.”

Vegetarians are also at risk since animal waste can taint produce at farms.

The World Health Organization, governments and private companies are developing elaborate efforts to catch outbreaks early, including the monitoring of key words in Google searches — for example, a sudden spike in queries for a symptom — that could pinpoint emerging illnesses in specific regions. Yet here in San Francisco and California, no law requires restaurants even to pick up the phone and report when diners are sickened.

At Delfina, which consistently achieves high scores on health inspections, Mr. Stoll said there had not been an illness before or since that night, but he wants the mystery solved.

“We’re not positive what it was,” he said.

Scott James is an Emmy-winning television journalist and novelist who lives in San Francisco.

sjames@baycitizen.org

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Recipes for Health: Soba With Black-Eyed Peas and Spinach — Recipes for Health

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1 cup (6 ounces) black-eyed peas, rinsed

1 quart water

1 onion, cut in half

3 garlic cloves, minced

A bouquet garni made with a bay leaf, a Parmesan rind and a sprig each of parsley and thyme

Salt to taste

2 tablespoons extra virgin olive oil

1 red bell pepper, cut in small (1/4-inch) dice

1 12-ounce bunch spinach, stemmed and washed, or a 6-ounce bag of baby spinach

Freshly ground pepper

8 ounces soba

Freshly grated Parmesan

1. Combine the black-eyed peas and water in a large saucepan or soup pot and bring to a gentle boil over medium-high heat. Skim off any foam, then add the onion, 2 of the minced garlic cloves, the bouquet garni and salt to taste. Reduce the heat to low, cover and simmer 40 minutes, or until the beans are thoroughly tender but intact. Taste the broth and adjust salt. Remove the onion and bouquet garni and discard.

2. Fill a large pot two-thirds of the way full with water (soba will bubble up, and if you fill the pot too full the foamy water will overflow) and bring to a boil.

3. Meanwhile, heat the olive oil over medium heat in a large, heavy skillet and add the red pepper. Cook, stirring often, until it is just tender, 3 to 5 minutes. Add the garlic and cook, stirring, until it is fragrant, 30 seconds to a minute. Add the beans with their liquid to the pan and bring to a boil. Boil over medium-high heat until the broth reduces a bit, and stir in the spinach. Stir just until it is wilted, and remove the pan from the heat. Add salt and freshly ground pepper to taste.

4. When the soba water comes to a boil, add salt to taste and the soba. Let the water bubble up until it is just about to reach the top of the pot, then turn the heat down to low so that the water retreats. Turn the heat up again and let the water come back up, then turn the heat back down. Repeat one more time. The soba should be cooked by the end of the third round. If it is not, repeat one more time. Drain and toss with the bean and spinach mixture, either in the pan or in a wide bowl. Serve with freshly grated Parmesan.

Yield: 4 servings.

Advance preparation: The black-eyed peas can be cooked ahead through Step 1 up to 4 days ahead and stored in the refrigerator.

Nutritional information per serving (4 servings): 410 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligrams cholesterol; 71 grams carbohydrates; 12 grams dietary fiber; 124 milligrams sodium (does not include salt to taste); 19 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Well: Think Like a Doctor: An Ice Pick in the Head

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The Challenge: Can you solve a medical mystery involving a middle-aged woman with a pulsing noise in her ear and a stabbing pain in her head?

The Diagnosis column of The New York Times Magazine regularly asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case that left a previously healthy, active woman nearly crippled by pain. The lab results, consultation notes and images obtained over the two-and-a-half-year course of the illness will give you the same information available to the doctor who made the diagnosis. As it happens, I was that doctor and found it to be a tough diagnosis. Will you?

The first reader to figure out this case will get a signed copy of my book “Every Patient Tells a Story,” along with the satisfaction of knowing you could outdiagnose the Diagnosis columnist. Good luck.

The Presenting Problem:

A healthy and active 53-year-old woman complains of severe pain on the left side of her head and a “swooshing” sound in her left ear.

The Patient’s Story:

“It all started at the chiropractor’s,” the patient told me at her first appointment. It was a hot August day, and she had brought to my office a friend, a huge stack of old medical records and a complicated story.

Her story began two and a half years earlier. She was at the chiropractor, getting a chiropractic treatment on her neck when, suddenly, a loud whooshing noise filled her left ear. The noise pounded against her eardrum like some sound-effect machine gone mad. It scared her, and she told the chiropractor about it right away. The chiropractor stopped immediately, but the noise didn’t. Indeed, the patient told me, it hadn’t stopped for even a moment ever since.

The noise seemed to get worse when she lay down or turned her head a certain way. Usually it was just annoying, but sometimes it was so loud she had trouble hearing voices over the “whoosh, whoosh, whoosh.” She was a social worker, and listening was a big part of her job. Still, it seemed manageable, at least at first.

The headaches started six weeks after the noise. She was talking with a client when suddenly she felt as if she had been hit on the left side of the head with a brick. The pain was blinding, excruciating. She had to leave work and go home to lie in a dark room.

The next morning her doctor, suspecting a migraine, gave her a drug called Zomig and ordered an M.R.I. and then a CT scan of her brain. The medicine didn’t help, and the scans didn’t reveal any useful information. The headache lasted two more days. After that, the left-side headaches came every few weeks, requiring her to take off work; the whooshing noise remained her constant companion.

You can see the M.R.I. report here, part of the patient’s thick stack of medical records she brought to me that first visit.

She saw a neurologist, who ordered an M.R.A. scan, which is an M.R.I. that focuses on the arteries of the brain. It was normal, and the doctor told her she had tinnitus and migraine headaches. An ear, nose and throat specialist ordered a hearing test and an M.R.V., which is an M.R.I. that focuses on the anatomy of the venous system of the brain. A second E.N.T. reviewed the studies that had already been done and suggested a diagnosis of pulsatile tinnitus, mild hearing loss and eustachian tube dysfunction. None of the doctors had advice on how to get rid of the noise or the headaches.

You can see the M.R.A. and M.R.V. reports in her chart.

The Pain Gets Worse:

A few months later, the patient read an article about a disorder that she thought might explain the constant noise in her head and the occasional migraine that still trapped her in a dark room for a couple of days at a time. The disease was called fibromuscular dysplasia, or FMD, an unusual disorder in which the walls of arteries become narrow and restrict blood flow to essential organs, most commonly the kidneys and brain.

She made an appointment with Dr. Jeffrey Olin, director of vascular medicine at the Mount Sinai Medical Center in New York, who was quoted in the article. Dr. Olin thought that the woman’s symptoms, while not classic, could very well be a result of FMD, so he arranged for detailed imaging of the carotid arteries, the vessels that carry blood from the heart to the brain.

As the technician was injecting contrast dye into her veins, the patient felt an ice pick of pain shoot from the top of her skull past her ears and down to her clavicle. It was all she could do not to scream, the pain was so intense. Dr. Olin was immediately concerned. This kind of pain can be seen when arteries tear. Could the slightly increased pressure caused by the injection of dye into the bloodstream have torn a fragile segment of the patient’s carotid artery? Dr. Olin examined the CT scan closely for any evidence of a torn or dissected artery. He didn’t see that, but as he looked at the images of her carotids, it was clear that they were not normal.

Usually the carotid arteries make a straight line from where they take off from the aorta, the large vessel that leaves the heart, to where they deliver blood deep into the brain. This patient’s carotids seemed to meander up the neck, wending their way to the brain like some lazy river. On the left side, where the pain and noise were, the vessel made a 360 degree loop-de-loop on the way.

Here are images from the CT (left) and M.R.I. (right) of the patient’s neck.

Looking at the images, Dr. Olin could tell that the patient didn’t have FMD, but he was fascinated by the baroque configuration of her carotid arteries. Although the situation was rare, Dr. Olin had seen other patients with similarly twisted blood vessels. Many had complained of a pulsating tinnitus like hers, as well as migrainelike headaches. But no one else had complained of the sharp ice-pick pain that now dominated her daily life.

You can read more of Dr. Olin’s reports here.

Treatment Efforts:

Muscle relaxants prescribed by a neurologist didn’t help. Although the patient had been treated for invasive thyroid cancer several years earlier, an oncologist’s evaluation revealed no evidence of recurrent tumor. A vascular surgeon gave a diagnosis of temporal arteritis, an inflammatory disease of the arteries of the head, eyes and face that can cause blindness and stroke. The patient was started on high-dose steroids, but an ultrasound and a biopsy of the artery were normal, and the patient was weaned off the potent drugs.

On top of all this, the patient had made several trips to the emergency room when the pain in her head became too intense to tolerate. She was given a variety of painkillers and had several imaging studies done on her neck, brain and chest. None revealed anything new. At several of those visits her blood pressure, normally low, had been quite elevated. The E.R. docs thought it might have been a response to pain.

The patient used to be an athlete. Now just walking up a flight of stairs could trigger the stabbing pains on top of the steady daily pain. Simply trying to maintain the appearance of a normal life with this constant pain was exhausting. The pain, she told me, was sapping all the pleasure from her life

The Doctor’s Exam:

Start to finish, it took over half an hour for this patient to tell me her story. Then she handed me her thick sheaf of medical records. On top was a seven-page summary of all the doctors she’d seen and tests she’d had done. I looked through it quickly and put it aside. It was far too much to review in the time I had left.

The examination was mostly normal. The patient did have some tenderness over the carotid artery on her left side. And there was a soft tissue mass at the base of the neck that measured 10 centimeters in diameter and was raised a couple of centimeters. The patient told me that this had been biopsied and PET scanned, because of concern about a possible recurrence of her thyroid cancer. No cancer had been found, and the biopsy suggested it was a lipoma, a benign fatty tumor. The records are all there, the patient assured me, waving to the pile of papers she’d given me.

I knew I couldn’t make a diagnosis based on the information I had so far. I thought it was possible that some part of her carotid artery had been injured by the chiropractic manipulation, but I was baffled as to why she would develop such terrible pain when contrast dye was injected for imaging. I would need to review the records she had brought in and try to figure out what her problem might be. I asked her to return in a week or two and told her I would have a plan of action at that point.

You can read my summary notes here, as well as the extensive patient chart below. (Click on the lower left for a full-screen version.)

Solving the Medical Mystery:

Now I turn the question over to you, my readers. What do you think the patient has? Or if a diagnosis cannot be made based on the information you have here, what additional studies would you want to get? How can you help this middle-aged woman get back to a normal life without the pain and pulsations that plague her?

Rules and Regulations: Post your diagnosis and questions for Dr. Sanders in the Comments section below. The correct answer will appear tomorrow on the Well blog. The winner will be contacted. Comments may also appear in a coming issue of The New York Times Magazine.

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Recipes for Health: Frittata With Turnips and Olives — Recipes for Health

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AppId is over the quota

1 pound firm medium-size or small turnips

Salt

2 tablespoons extra virgin olive oil

2 teaspoons fresh thyme leaves, chopped

6 eggs

1 tablespoon milk

Freshly ground pepper

1/2 cup chopped flat-leaf parsley

1 ounce imported black olives, pitted and chopped, about 1/3 cup (optional)

1 or 2 garlic cloves, minced or puréed (optional)

1. Peel the turnips and grate on the large holes of a box grater or with a food processor. Salt generously and leave to drain in a colander for 30 minutes. Take up handfuls and squeeze tightly to rid the turnips of excess water.

2. Heat 1 tablespoon of the olive oil over medium-low heat in a wide saucepan or skillet and add the turnips and the thyme. When the turnips are sizzling, cover and cook gently, stirring often, for about 15 minutes, until they are tender. If they begin to stick to the pan or brown, add a tablespoon of water. Season to taste with salt and pepper. Remove from the heat and allow to cool slightly.

3. Beat the eggs and milk in a bowl and season to taste with salt and pepper. Stir in the parsley, chopped olives and garlic. Add the turnips and mix together.

4. Heat the remaining olive oil over medium-high heat in a heavy 10-inch skillet, preferably nonstick. Hold your hand above it; it should feel hot. Drop a bit of egg into the pan, and if it sizzles and cooks at once, the pan is ready. Pour in the egg mixture. Swirl the pan to distribute the eggs and filling evenly over the surface. Shake the pan gently, tilting it slightly with one hand while lifting up the edges of the frittata with a spatula in your other hand, to let the eggs run underneath during the first few minutes of cooking. Once a few layers of egg have cooked during the first couple of minutes of cooking, turn the heat down to very low, cover (use a pizza pan if you don’t have a lid that will fit your skillet) and cook 10 minutes, shaking the pan gently every once in a while. From time to time, remove the lid and loosen the bottom of the frittata with a spatula, tilting the pan, so that the bottom doesn’t burn.

5. Meanwhile, heat the broiler. Uncover the pan and place under the broiler, not too close to the heat, for 1 to 3 minutes, watching very carefully to make sure the top doesn’t burn (at most, it should brown very slightly and puff under the broiler). Remove from the heat, shake the pan to make sure the frittata isn’t sticking and allow it to cool for at least 5 minutes (the frittata is traditionally eaten warm or at room temperature). Loosen the edges with a spatula. Carefully slide from the pan onto a large round platter. Cut into wedges or into smaller bite-size diamonds. Serve warm, at room temperature or cold.

Yield: 6 servings.

Advance preparation: In Mediterranean countries, flat omelets are served at room temperature, which makes them perfect do-ahead dishes. They’ll keep in the refrigerator for a few days, and they make terrific lunchbox fare. They do not reheat well.

Nutritional information per serving: 132 calories; 2 grams saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 186 milligrams cholesterol; 5 grams carbohydrates; 1 gram dietary fiber; 113 milligrams sodium (does not include salt to taste); 7 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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British Statement on Defective Implants Offers Limited Help

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“It is undeniably the case that these implants are made up of non-medical-grade silicone and therefore should not have been implanted in women in the first place,” the health secretary, Andrew Lansley, said in a statement.

His remarks did little to assuage the fears of about 40,000 other British women who unwittingly paid for the poor quality implants during cosmetic surgery in dozens of private clinics where the bulk of the implants here were done. Responding to the announcement, which was supposed to clarify the government’s position on the growing breast-implant scandal, many women said they were more confused and frightened than ever.

Mr. Lansley urged those clinics to follow the health service’s example, saying they had a “a moral duty to offer the same service to their patients that we will offer to N.H.S. patients: free information, consultations, scans and removal if necessary.”

But while he said the government would pursue the clinics “with all means at its disposal to avoid the taxpayer picking up the bill,” Mr. Lansley offered no indication that the government could force the clinics to do anything.

Kevin Timms, a lawyer at Garden House Solicitors who is representing a number of women with the implants, manufactured by Poly Implants Prothèses, or PIP, said that the statement had not cleared up the concerns of his clients.

“The guidance, if you can call it that, doesn’t change the government’s position at all,” he said. “The government is taking the moral high ground in respect to N.H.S. patients, but all they’ve done is suggest that the private clinics follow suit.”

Rowena Mackintosh, 30, who has PIP implants, has already come up against the intransigence of the clinic that put them in. She paid $6,500 for the implants in 2008 after being assured that they would not rupture or leak. Eight months later, she began to feel aching and burning in her left breast, and developed a lump — a classic sign that silicone was oozing out of the implant.

An ultrasound then found a “black mass” near the breast, Ms. Mackintosh said. But after determining that it was not cancer, she said, her National Health Service doctor “stuck his nose in the air” and told her to consult the private clinic again. When she called, though, the clinic refused even to test whether the implants had ruptured.

“They were rude; they were obnoxious,” she said. “I have not had a single word from them — no support, no nothing.”

Until now, most private clinics have refused to pay to remove and replace their former patients’ PIP implants, saying that they installed the devices in good faith and that redoing all that surgery would prove ruinously expensive. But on Friday, several clinics changed their minds and said that free consultations, at least, would be made available to worried patients.

But it is unclear which clinics will be willing to replace implants that have not begun to leak but whose presence is frightening to the women who have them.

“Obviously, there’s differing opinions in some companies,” said Sally Taber, director of the Independent Healthcare Advisory Services, which represents a majority of private clinics.

Some clinics have gone out of business since installing the implants, and the government said it would allow those women to seek treatment from the health service.

Britain banned the PIP implants in 2010 when it became clear that the company was using silicone intended for industrial, not human, use. It urged clinics using the implants to contact any patients who had them, but it appears that few, if any, took that advice.

Meanwhile, it emerged on Friday that PIP’s chief executive, Jean-Claude Mas, admitted to the police last October that the company used the low-grade material “because it was less expensive,” according to a police transcript first published by Agence France-Presse. Mr. Mas also told his staff to “hide the truth” from German inspectors responsible for ensuring that the implants met European regulations by concealing documents and making containers “disappear.”

Doctors and patients began reporting leaks and ruptures in PIP implants, often accompanied by symptoms like fibromyalgia, a musculoskeletal pain and fatigue disorder, as early as 2005, but the implants were still widely used in Britain.

In his statement, Mr. Lansley also admitted that the government did not have adequate information about the safety risks associated with the implants, despite ordering the private clinics to provide data on ruptures and other complications earlier this week.

Many prominent plastic surgeons here have said publicly that the implants should be removed as a matter of course because they are unfit for use in humans, but the government has failed to follow suit, saying it was waiting for data from the clinics.

“Throughout this process we have followed expert advice,” Mr. Lansley said. “The data available to the experts has not been good enough to enable them to give a clear recommendation of the risk posed by PIP implants.”

The French government, which apparently keeps better records, says the rupture rate for the PIP devices is about 5.5 percent, more than five times the industry standard. It has said it will pay to have them removed from women, but will not pay for replacement implants.

The authorities in Germany and the Czech Republic recommended Friday that women with PIP implants in those countries should have them removed, too.

Mark Harvey, who is head of litigation at the Hugh James law firm and is representing about 600 women seeking to sue the clinics that gave them the implants, said that Friday’s statement showed how little authority the government had over the cosmetics industry.

“By only making a suggestion that the cosmetic industry should follow the example of the N.H.S., the government again leaves women vulnerable,” he said in a statement.

“From our clients’ experiences with many of these clinics to date, they have shown affected women no sympathy or support,” he said. “We are extremely concerned that this announcement will again allow cosmetic clinics to leave women to try to sort out this serious problem alone.”

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Recipes for Health: Turnip Gratin — Recipes for Health

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AppId is over the quota

Butter or olive oil for the baking dish

1 garlic clove, cut in half

2 pounds turnips, preferably small ones, peeled and sliced in thin rounds

Salt and freshly ground pepper

4 ounces Gruyère cheese, grated (about 1 cup tightly packed)

2 1/2 cups low-fat milk (1 percent or 2 percent)

1 teaspoon fresh thyme leaves, roughly chopped

1. Preheat the oven to 400 degrees. Butter or oil a 2-quart baking dish or gratin dish. Rub the sides and bottom with the cut clove of garlic.

2. Place the sliced turnips in a bowl and season generously with salt and pepper. Add half the cheese and the thyme and toss together, then transfer to the gratin dish and pour on the milk. It should just cover the turnips.

3. Place in the oven and bake 30 minutes. Push the turnips down into the milk with the back of a large spoon. Sprinkle the remaining cheese over the top and return to the oven. Bake another 40 to 50 minutes, until all of the milk is absorbed, the turnips are soft and the dish is nicely browned on top and around the edges.

Yield: 4 servings.

Advance preparation: You can assemble this several hours before baking, but don’t add the milk until you’re ready to bake. You can bake it several hours ahead and reheat in a medium oven.

Nutritional information per serving: 258 calories; 7 grams saturated fat; 1 gram polyunsaturated fat; 4 grams monounsaturated fat; 43 milligrams cholesterol; 22 grams carbohydrates; 4 grams dietary fiber; 319 milligrams sodium (does not include salt to taste); 16 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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