The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

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

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Egypt’s President Said to Limit Scope of Judicial Decree

Tara Todras-Whitehill for The New York Times

Egyptians at a burned-out school in Cairo on Monday before the funeral of an activist who was injured in a clash and died Sunday.

CAIRO — With public pressure mounting, President Mohamed Morsi appeared to pull back Monday from his attempt to assert an authority beyond the reach of any court. His allies in the Muslim Brotherhood canceled plans for a large demonstration in his support, signaling a chance to calm an escalating battle that has paralyzed a divided nation.

After Mr. Morsi met for hours with the judges of Egypt’s Supreme Judicial Council, his spokesman read an “explanation” on television that appeared to backtrack from a presidential decree placing Mr. Morsi’s official edicts above judicial scrutiny — even while saying the president had not actually changed a word of the statement.

Though details of the talks remained hazy, and it was not clear whether the opposition or the court would accept his position, Mr. Morsi’s gesture was another demonstration that Egyptians would no longer allow their rulers to operate above the law. But there appeared little chance that the gesture alone would be enough to quell the crisis set off by his perceived power grab.

Hundreds of opponents of Mr. Morsi protested in Tahrir Square on Tuesday, Reuters reported, with the crowd expected to grow in the late afternoon.

The presidential spokesman, Yasser Ali, said for the first time that Mr. Morsi had sought only to assert pre-existing powers already approved by the courts under previous precedents, not to free himself from judicial oversight.

He said that the president meant all along to follow an established Egyptian legal doctrine suspending judicial scrutiny of presidential “acts of sovereignty” that work “to protect the main institutions of the state.” The judicial council had said Sunday that it could bless aspects of the decree deemed to qualify under the doctrine.

Mr. Morsi had maintained from the start that his purpose was to empower himself to prevent judges appointed by former President Hosni Mubarak from dissolving the constituent assembly, which is led by his fellow Islamists of the Muslim Brotherhood’s Freedom and Justice Party. The courts have already dissolved the Islamist-led Parliament and an earlier constituent assembly, and the Supreme Constitutional Court was widely expected to rule against this one next week.

But the text of the original decree had exempted all presidential edicts from judicial review until the ratification of a constitution, not just those edicts related to the assembly or justified as “acts of sovereignty.”

Legal experts said that the spokesman’s explanations of the president’s intentions, if put into effect, would amount to a revision of the decree Mr. Morsi issued last Thursday. But lawyers said that the verbal statements alone carried little legal weight.

How the courts would apply the doctrine remained hard to predict. And Mr. Morsi’s opposition indicated it was holding out for far greater concessions, including the breakup of the whole constituent assembly.

Speaking at a news conference while Mr. Morsi was meeting with the judges, the opposition activist and intellectual Abdel Haleem Qandeil called for “a long-term battle,” declaring that withdrawal of Mr. Morsi’s new powers was only the first step toward the opposition’s goal of “the withdrawal of the legitimacy of Morsi’s presence in the presidential palace.” Completely withdrawing the edict would be “a minimum,” he said.

Khaled Ali, a human rights lawyer and former presidential candidate, pointed to the growing crowd of protesters camped out in Tahrir Square for a fourth night. “The one who did the action has to take it back,” Mr. Ali said.

Moataz Abdel Fattah, a political scientist at Cairo University, said Mr. Morsi was saving face during a strategic retreat. “He is trying to simply say, ‘I am not a new pharaoh; I am just trying to stabilize the institutions that we already have,’ ” he said. “But for the liberals, this is now their moment, and for sure they are not going to waste it, because he has given them an excellent opportunity to score.”

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The Hard Road Back: Prosthetic Arms a Complex Test for Amputees

A Future Reset:
After losing his arm in an I.E.D. explosion in Afghanistan, Cpl. Sebastian Gallegos has adjusted to his prosthetic limb.

SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.

The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.

He had been blown up, and was drowning at the bottom of an irrigation ditch.

Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.

Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.

Success.

“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”

It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.

Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.

To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.

“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.

The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.

Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.

For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.

But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.

More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.

In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.

But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.

Corporal Gallegos was not always that person.

His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.

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Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

Read More..

Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

Read More..

News Analysis: St. Jude Medical Suffers for Redacting a Product Name

Peter Muhly for The New York Times

Dr. Ernest Lau holds a Durata lead from a St. Jude Medical Fortify ICD, an implanted heart defibrillator.

IS covering a product’s name in a public document a sign that a company has something to hide? And how should doctors, patients and investors react if the product at issue is one on which peoples’ lives and a company’s fortunes depend?

Such questions now loom over St. Jude Medical after the disclosure last week that its executives had blacked out the name of a heart device component when they released a critical federal report involving the product. The value of St. Jude has since plummeted more than $1 billion, or 12 percent. But the company’s actions may have a more lasting impact on its reputation and the health of patients, some experts say.

Last week’s incident was the latest development in a controversy involving the component, an electrical wire that connects an implanted defibrillator to a patient’s heart. St. Jude officials say the wire, which is known as the Durata, is safe. But uncertainty about the company’s statements is growing, underscored by its handling of the report, which involved a Food and Drug Administration inspection of a plant that makes the Durata.

St. Jude released that report in October as part of a filing with the Securities and Exchange Commission. The F.D.A. provides device makers with the reports in an unaltered form, and they may contain criticisms of a company’s procedures.

But the version of the report that St. Jude filed with the S.E.C. left some doctors and analysts uncertain about which company product or products were at issue for a simple reason — St. Jude had redacted, or blocked out, all 20 references to the Durata in it.

Company executives said they had done so based on their “good faith” interpretation of how the F.D.A. would act if it publicly released the report under the Freedom of Information Act. But both an F.D.A spokeswoman and a lawyer who specializes in medical devices took exception with that view, saying that names of approved products typically do not qualify as the type of confidential business information that the F.D.A. would redact.

Among other things, F.D.A. inspectors found significant flaws in the company’s testing and oversight of the Durata. It was those revelations and the implications that the problems could lead to further F.D.A. action against St. Jude that led to the sharp fall last week in its stock price.

In 2005, Guidant, a device maker that no longer exists, also found itself under scrutiny. Back then, its executives decided not to tell doctors that one of its defibrillators could short-circuit when a patient needed an electrical jolt to save a life. The expert who brought the Guidant problem to light, Dr. Robert Hauser, a heart specialist in Minnesota, has also raised concerns about the St. Jude wires, adding that he believes that its executives have been less than forthright.

“Patients and physicians would appreciate more information,” Dr. Hauser said.

In an earlier interview, St. Jude’s chief executive, Daniel J. Starks, said the company had hidden nothing about the Durata or another heart wire named the Riata, which it stopped selling in 2010.

“We’ve been more transparent than others,” said Mr. Starks, referring to company competitors like Medtronic.

Still, some Wall Street analysts share Dr. Hauser’s view. And if one St. Jude executive can claim credit for shaping their opinion, it would be Mr. Starks.

Earlier this year, he sought, among other things, to have a medical journal retract an article written by Dr. Hauser that was critical of the Riata. The publication refused.

Now, after St. Jude’s latest misfire, Wall Street analysts, who usually agree more than disagree, are placing wildly differing bets on St. Jude, with some valuing it at $48 a share and others at $30. On Monday, St. Jude closed at $31.86 on the New York Stock Exchange.

One of those bearish analysts, Matthew Dodds of Citigroup, said he thought the Food and Drug Administration might act soon on Durata. “I believe that a lot of their actions have made the situation worse, ” he said of the company’s executives.

A St. Jude spokeswoman, Amy Jo Meyer, reiterated the company’s stance that it had interpreted agency rules in “good faith” when releasing the redacted report about the Durata. An F.D.A. spokeswoman, Mary Long, said the agency did not consider the names of approved products to be confidential. And a lawyer, William Vodra, said that while device makers try to make a confidentiality argument for product data they consider embarrassing, like injury reports, they rarely succeed.

“In my experience, the F.D.A. consistently rejects” such arguments, Mr. Vodra wrote in an e-mail.

For patients, the dilemma may become more excruciating. The company’s earlier heart wire, the Riata, has begun failing prematurely in some of the 128,000 patients worldwide who received it. And those patients and their doctors face a difficult decision: whether to leave it in place or have it surgically removed, a procedure that carries significant risks.

St. Jude executives say that the Durata, which uses a different type of insulation than the Riata, is not prone to such problems.

And with the Durata already implanted in 278,000 people, many heart specialists certainly hope they are right.

Read More..

As Rebels Gain, Congo Again Slips Into Chaos

GOMA, Democratic Republic of Congo — The lights are out in most of Goma. There is little water. The prison is an empty, garbage-strewn wasteland with its rusty front gate swinging wide open and a three-foot hole punched through the back wall, letting loose 1,200 killers, rapists, rogue soldiers and other criminals.

Now, rebel fighters are going house to house arresting people, many of whom have not been seen again by their families.

“You say the littlest thing and they disappear you,” said an unemployed man named Luke.

In the past week, the rebels have been unstoppable, steamrolling through one town after another, seizing this provincial capital, and eviscerating a dysfunctional Congolese Army whose drunken soldiers stumble around with rocket-propelled grenades and whose chief of staff was suspended for selling crates of ammunition to elephant poachers.

Riots are exploding across the country — in Bukavu, Butembo, Bunia, Kisangani and Kinshasa, the capital, a thousand miles away. Mobs are pouring into streets, burning down government buildings and demanding the ouster of Congo’s weak and widely despised president, Joseph Kabila.

Once again, chaos is courting Congo. And one pressing question is, why — after all the billions of dollars spent on peacekeepers, the recent legislation passed on Capitol Hill to cut the link between the illicit mineral trade and insurrection, and all the aid money and diplomatic capital — is this vast nation in the heart of Africa descending to where it was more than 10 years ago when foreign armies and marauding rebels carved it into fiefs?

“We haven’t really touched the root cause,” said Aloys Tegera, a director for the Pole Institute, a research institute in Goma.

He said Congo’s chronic instability is rooted in very local tensions over land, power and identity, especially along the Rwandan and Ugandan borders. “But no one wants to touch this because it’s too complicated,” he added.

The most realistic solution, said another Congo analyst, is not a formal peace process driven by diplomats but “a peace among all the dons, like Don Corleone imposed in New York.”

Congo’s problems have been festering for years, wounds that never quite scabbed over.

But last week there was new urgency after hundreds of rebel fighters, wearing rubber swamp boots and with belt-fed machine guns slung across their backs, marched into Goma, the capital of North Kivu Province and one of the country’s most important cities.

The rebels, called the M23, are a heavily armed paradox. On one hand, they are ruthless. Human rights groups have documented how they have slaughtered civilians, pulling confused villagers out of their huts in the middle of the night and shooting them in the head.

On the other hand, the M23 are able administrators — seemingly far better than the Congolese government, evidenced by a visit in recent days to their stronghold, Rutshuru, a small town about 45 miles from Goma.

In Rutshuru, there are none of those ubiquitous plastic bags twisted in the trees, like in so many other parts of Congo. The gravel roads have been swept clean and the government offices are spotless. Hand-painted signs read: “M23 Stop Corruption.” The rebels even have green thumbs, planting thousands of trees in recent months to fight soil erosion.

“We are not a rebellion,” said Benjamin Mbonimpa, an electrical engineer, a bush fighter and now a top rebel administrator. “We are a revolution.”

Their aims, he said, were to overthrow the government and set up a more equitable, decentralized political system. This is why the rebels have balked at negotiating with Mr. Kabila, though this weekend several rebels said that the pressure was increasing on them to compromise, especially coming from Western countries.

On Sunday, rebel forces and government troops were still squared off, just a few miles apart, down the road from Goma.

The M23 rebels are widely believed to be covertly supported by Rwanda, which has a long history of meddling in Congo, its neighbor blessed with gold, diamonds and other glittering mineral riches. The Rwandan government strenuously denies supplying weapons to the M23 or trying to annex eastern Congo. Rwanda has often denied any clandestine involvement in this country, only to have the denials later exposed as lies.

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Gadgetwise Blog: A Phone Cradle for More GPS Power

Magellan may be best known for its dashboard GPS navigation products, particularly its oversize offerings like the Magellan RoadMate 9250T–LMB with its 7-inch screen.

But now it is making a product that helps bring a small screen to your dashboard, a GPS car kit that adds a more powerful antenna, speaker and charging for an iPhone 3GS, 4 and 4S, as well as the third- and fourth-generation iPod Touch.

The $100 cradle has a 30-pin connector at the bottom and a secure ratcheting clamp at the top. There is even an  adjustable bumper to push up against the back of the phone so it won’t rattle around. The whole assembly attaches to a suction cup mount that sticks on your windshield.

In a test using the car kit and a stand-alone iPhone, the car kit produced directions a little bit faster than the unmounted iPhone – and this was in an area with strong reception.

Of course, Magellan would like you to use it with its $50 navigation app — which happens to be quite good. But you are not limited to its app. The cradle will work with any navigation software you care to put on screen.

One thing that’s a bit quirky: Although the device plugs in, you still have to connect the audio wirelessly using Bluetooth, which appears to interfere with my car’s hands-free Bluetooth system.

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The New Old Age Blog: Turning a Home Into a Hospital

At age 96, my mother moved to New York City to live with me and my family in our two-bedroom Manhattan apartment after becoming increasingly isolated while living alone in Florida. She moved into my sons’ bedroom surrounded by all manner of adolescent paraphernalia, including every style of trendy sneakers, a giant papier-mâché statue of Michael Jordan and a poster of Bob Marley.

Three years later, at age 99, she was hospitalized and diagnosed with pancreatic cancer. Because of her advanced age, there was little to do to except make the last months of her life more comfortable. Her doctor arranged for home hospice care through Calvary. But part of me wanted to place her in a nursing home.

The idea of hospice care in my home overwhelmed me. I did not want my apartment to become a nursing facility, and the idea of personally taking care of my mother was frightening. I was preoccupied with thoughts and fears of losing her, and I was very afraid of witnessing her physical deterioration and her death.

As a psychotherapist in private practice, I treat people with emotional problems like anxiety and depression. I am introspective enough to know that I am comfortable with treating the mind, but squeamish about medical problems, especially serious medical issues.

Now my mother was dying, and I had to live with the uncertainty of what was going to happen. When would she no longer be able to bathe herself? Was she going to be bedridden? Incontinent?

Step by step, I overcame my fears, accepting the reality of our new situation. Looking back, the choice was inevitable — and I am grateful I took the steps of that life-changing journey.

My husband encouraged me to take on the challenge of caring for my mother in our home. He thought it would be cruel to put her in a nursing home. Easy for him to say, I thought, since my mother’s physical care would fall predominately on me.

Upset over my dilemma, I was crying. My mother, in her hospital bed, asked, “Why?”

“I don’t know how I can continue taking care of you in our home,” I told her. But I asked her what she wanted to do.

“I want to go home,” she said. “We will manage.”

So she left the hospital to again live with us.

The Calvary hospice nurse walked me through all the steps of home hospice care. After the first home visit, the nurse ordered an oxygen tank and told me there could be no smoking in the home or even in the hallway outside my apartment door, because the oxygen was flammable.

That made me uneasy. Although I was instructed how to use the tank, I was anxious that I would forget how to use it when the moment arrived that my mother had difficulty breathing. In my panic, I called the medical home care supply company to take the tank back. When my mother’s doctor told me that it was critical to have the oxygen available in case of an emergency, I relented. I was terrified that she might suffer.

My mother at that point had her full faculties and was able to get around. She could even walk, albeit very slowly, to the senior citizen’s center on our block and to the Jewish Community Center across the street, where she played mah-jongg and canasta. That stopped soon, however, and I had to order a wheelchair for her to use when she went out.

Calvary provided me with a home health aide for five hours a day and a social worker. That was helpful but stressful. Because of my work as a therapist, coordinating schedules was a challenge.

As she grew more ill, my mother became too weak to shower, dress or go to bathroom by herself. I had to hire an additional home health aide for the afternoon and for full days on weekends. Eventually, I needed to get an overnight aide.

I was surrounded by an army of hospital-like caretakers who used hand sanitizer immediately upon entering the apartment, ate in our kitchen, showered in the bathroom and slept with my mother in one of our two bedrooms. I felt the loss of control and a sense of chaos, which was made worse when my youngest son returned home after graduating from college and underwent emergency surgery for a torn A.C.L. He generously gave up his bedroom to my mother (and to the aide who slept there at night) and camped out in the living room.

My house had truly been turned upside down. But what kept me sane was knowing that the chaos was temporary, and that we were providing my mother with the care she needed, in the setting that had been her choice.

I had to learn to trust that the aides would act in my mother’s best interest. In fact, most of them were generous and devoted to my mother’s care to the end.

Her last days were not without a touch of humor. One night, the aide called me into the room telling me that my mother, still with her full faculties, was “seeing smoke.” I thought, “Is she hallucinating?”

I sat down on the bed. My mother pointed to the Bob Marley poster. She asked, “Is that famous man smoking?” She had looked at that poster for three years and never asked until then.

But another night, around 1 a.m., my son overheard my mother yelling, “Don’t touch me.” He found the nighttime aide pushing my mother back into bed. The aide wanted to sleep through the night and did not want to be bothered taking my mother to the bathroom. I fired the aide the next day.

Gradually, I surrendered to the reality that my apartment had been turned into a nursing home. My mother now had an oxygen tank, a walker, a wheelchair, a shower chair, a commode, Depends and bed pads.

Still, I had said from the beginning that I did not want a hospital bed in my home. Its name alone symbolized the transformation of my home into a hospital. But two days before my mother’s death, I relented. My mother could not get up from the bed that she had been using. She needed the adjustable bed to lift and transfer her.

With the arrival of that bed, I finally accepted the new reality: my home was indeed transformed into a nursing home, despite all my initial fears about living with my dying mother in that environment.

At 99, just 8 months short of a century, my mother died in my home surrounded by family and the Bob Marley poster. It was a peaceful passage. She died with grace and dignity.

As I reflect on the experience, I am glad that I was able to be with my mother through the end of her journey. It was tough to watch this once strong, vital woman become thin and fragile. And as my last living parent, she was the buffer between myself and the reality of my mortality.

Still, the experience was emotionally rich and liberating. And, in the end, we were both at peace.

Linda G. Beeler is a psychotherapist in private practice in Manhattan.

Read More..

The New Old Age Blog: Turning a Home Into a Hospital

At age 96, my mother moved to New York City to live with me and my family in our two-bedroom Manhattan apartment after becoming increasingly isolated while living alone in Florida. She moved into my sons’ bedroom surrounded by all manner of adolescent paraphernalia, including every style of trendy sneakers, a giant papier-mâché statue of Michael Jordan and a poster of Bob Marley.

Three years later, at age 99, she was hospitalized and diagnosed with pancreatic cancer. Because of her advanced age, there was little to do to except make the last months of her life more comfortable. Her doctor arranged for home hospice care through Calvary. But part of me wanted to place her in a nursing home.

The idea of hospice care in my home overwhelmed me. I did not want my apartment to become a nursing facility, and the idea of personally taking care of my mother was frightening. I was preoccupied with thoughts and fears of losing her, and I was very afraid of witnessing her physical deterioration and her death.

As a psychotherapist in private practice, I treat people with emotional problems like anxiety and depression. I am introspective enough to know that I am comfortable with treating the mind, but squeamish about medical problems, especially serious medical issues.

Now my mother was dying, and I had to live with the uncertainty of what was going to happen. When would she no longer be able to bathe herself? Was she going to be bedridden? Incontinent?

Step by step, I overcame my fears, accepting the reality of our new situation. Looking back, the choice was inevitable — and I am grateful I took the steps of that life-changing journey.

My husband encouraged me to take on the challenge of caring for my mother in our home. He thought it would be cruel to put her in a nursing home. Easy for him to say, I thought, since my mother’s physical care would fall predominately on me.

Upset over my dilemma, I was crying. My mother, in her hospital bed, asked, “Why?”

“I don’t know how I can continue taking care of you in our home,” I told her. But I asked her what she wanted to do.

“I want to go home,” she said. “We will manage.”

So she left the hospital to again live with us.

The Calvary hospice nurse walked me through all the steps of home hospice care. After the first home visit, the nurse ordered an oxygen tank and told me there could be no smoking in the home or even in the hallway outside my apartment door, because the oxygen was flammable.

That made me uneasy. Although I was instructed how to use the tank, I was anxious that I would forget how to use it when the moment arrived that my mother had difficulty breathing. In my panic, I called the medical home care supply company to take the tank back. When my mother’s doctor told me that it was critical to have the oxygen available in case of an emergency, I relented. I was terrified that she might suffer.

My mother at that point had her full faculties and was able to get around. She could even walk, albeit very slowly, to the senior citizen’s center on our block and to the Jewish Community Center across the street, where she played mah-jongg and canasta. That stopped soon, however, and I had to order a wheelchair for her to use when she went out.

Calvary provided me with a home health aide for five hours a day and a social worker. That was helpful but stressful. Because of my work as a therapist, coordinating schedules was a challenge.

As she grew more ill, my mother became too weak to shower, dress or go to bathroom by herself. I had to hire an additional home health aide for the afternoon and for full days on weekends. Eventually, I needed to get an overnight aide.

I was surrounded by an army of hospital-like caretakers who used hand sanitizer immediately upon entering the apartment, ate in our kitchen, showered in the bathroom and slept with my mother in one of our two bedrooms. I felt the loss of control and a sense of chaos, which was made worse when my youngest son returned home after graduating from college and underwent emergency surgery for a torn A.C.L. He generously gave up his bedroom to my mother (and to the aide who slept there at night) and camped out in the living room.

My house had truly been turned upside down. But what kept me sane was knowing that the chaos was temporary, and that we were providing my mother with the care she needed, in the setting that had been her choice.

I had to learn to trust that the aides would act in my mother’s best interest. In fact, most of them were generous and devoted to my mother’s care to the end.

Her last days were not without a touch of humor. One night, the aide called me into the room telling me that my mother, still with her full faculties, was “seeing smoke.” I thought, “Is she hallucinating?”

I sat down on the bed. My mother pointed to the Bob Marley poster. She asked, “Is that famous man smoking?” She had looked at that poster for three years and never asked until then.

But another night, around 1 a.m., my son overheard my mother yelling, “Don’t touch me.” He found the nighttime aide pushing my mother back into bed. The aide wanted to sleep through the night and did not want to be bothered taking my mother to the bathroom. I fired the aide the next day.

Gradually, I surrendered to the reality that my apartment had been turned into a nursing home. My mother now had an oxygen tank, a walker, a wheelchair, a shower chair, a commode, Depends and bed pads.

Still, I had said from the beginning that I did not want a hospital bed in my home. Its name alone symbolized the transformation of my home into a hospital. But two days before my mother’s death, I relented. My mother could not get up from the bed that she had been using. She needed the adjustable bed to lift and transfer her.

With the arrival of that bed, I finally accepted the new reality: my home was indeed transformed into a nursing home, despite all my initial fears about living with my dying mother in that environment.

At 99, just 8 months short of a century, my mother died in my home surrounded by family and the Bob Marley poster. It was a peaceful passage. She died with grace and dignity.

As I reflect on the experience, I am glad that I was able to be with my mother through the end of her journey. It was tough to watch this once strong, vital woman become thin and fragile. And as my last living parent, she was the buffer between myself and the reality of my mortality.

Still, the experience was emotionally rich and liberating. And, in the end, we were both at peace.

Linda G. Beeler is a psychotherapist in private practice in Manhattan.

Read More..