Saturday, October 10, 2009
Chronic Fatigue Syndrome - Symptoms, Diagnosis, Treatment of Chronic Fatigue Syndrome - NY Times Health Information
Many people with chronic fatigue syndrome are infected with a little known virus that may cause or at least contribute to their illness, researchers are reporting.
The syndrome, which causes prolonged and severe fatigue, body aches and other symptoms, has long been a mystery ailment, and patients have sometimes been suspected of malingering or having psychiatric problems rather than genuine physical ones. Worldwide, 17 million people have the syndrome, including at least one million Americans.
An article published online Thursday in the journal Science reports that 68 of 101 patients with the syndrome, or 67 percent, were infected with an infectious virus, xenotropic murine leukemia virus-related virus, or XMRV. By contrast, only 3.7 percent of 218 healthy people were infected. Continuing work after the paper was published has found the virus in nearly 98 percent of about 300 patients with the syndrome, said Dr. Judy A. Mikovits, the lead author of the paper.
XMRV is a retrovirus, a member of the same family of viruses as the AIDS virus. These viruses carry their genetic information in RNA rather than DNA, and they insert themselves into their hosts' genetic material and stay for life.
Dr. Mikovits and other scientists cautioned that they had not yet proved that the virus causes the syndrome. In theory, people with the syndrome may have some other, underlying health problem that makes them prone to being infected by the virus, which could be just a bystander. More studies are needed to explain the connection.
But Dr. Mikovits said she thought the virus would turn out to be the cause, not just of chronic fatigue, but of other illnesses as well. Previous studies have found it in cells taken from prostate cancers.
"I think this establishes what had always been considered a psychiatric disease as an infectious disease," said Dr. Mikovits, who is research director at the Whittemore Peterson Institute in Reno, a nonprofit center created by the parents of a woman who has a severe case of the syndrome. Her co-authors include scientists from the National Cancer Institute and the Cleveland Clinic.
Dr. Mikovits said she and her colleagues were drawing up plans to test antiretroviral drugs — some of the same ones used to treat HIV infection — to see whether they could help patients with chronic fatigue. If the drugs work, that will help prove that the virus is causing the illness. She said patients and doctors should wait for the studies to be finished before trying the drugs.
Dr. William Schaffner, an infectious disease expert at Vanderbilt University, said the discovery was exciting and made sense.
"My first reaction is, 'At last,' " Dr. Schaffner said. "In interacting with patients with chronic fatigue syndrome, you get the distinct impression that there's got to be something there."
He said the illness is intensely frustrating to doctors because it is not understood, there is no effective treatment and many patients are sick for a long time.
He added, "This is going to create an avalanche of subsequent studies."
mutation and the life altering decisions I've had to make.
"I am more than boobs and tubes...I have a life to live!"
BRCA information from Memorial Sloan-Kettering Cancer Center:
What are the risks associated with a mutation in the BRCA1 gene?
Women with a mutation in the BRCA1 gene are at increased risk for
cancer of the breast and ovary. These risks may vary. Women with an
altered BRCA1 gene have a 50 to 85 percent risk of developing breast
cancer by age 70. Risk for cancer of the ovary is 40 to 60 percent by
A woman with cancer in one breast has a higher risk of developing
cancer in the other breast. Twenty-five to 30 percent of those with a
BRCA1 change may get a second breast cancer within ten years after
their first incidence of breast cancer.
Men and women with a BRCA1 change have an increased risk for certain
other cancers. Those with a BRCA1 mutation may get one or more
cancers, or none at all.
What are the risks associated with a mutation in the BRCA2 gene?
Both men and women with a change in the BRCA2 gene are at increased
risk for breast cancer. In women, the risks associated with a BRCA2
mutation appear to be about the same as those for BRCA1 mutations.
The risk for cancer of the ovary is also increased — between 16 and
27 percent by late age.
A male with a BRCA2 change has an increased risk for breast cancer.
Men with BRCA2 hanges also have a higher risk of prostate cancer. The
risk for pancreas cancer and melanoma also are increased in
individuals with BRCA2 changes.
October is Breast Cancer Awareness Month, but what is it we need to be aware of? We know that for women, breast cancer is the most common cancer and, after lung cancer, the leading cause of cancer death. This month, pink ribbons and yogurt containers will remind us of the need to find a cure. But equally important is improving access to life-saving therapy for women already living with breast cancer — many of whom don't even know it.
Delayed diagnosis of breast cancer — measured from the first health care consultation for a breast complaint to a diagnosis of cancer — is the most common and the second most costly medical claim against American doctors. Moreover, the length of delays in breast cancer diagnosis in cases that lead to malpractice litigation has been increasing in recent years. According to a study by the Physician Insurers Association of America, in 1990 the average delay was 12.7 months; in 1995 it was 14 months. The most recent data, from 2002, showed the average delay had risen to 16.3 months.
Why are there such long delays, even for women who get regular examinations? The insurers association identifies five causes: a misreading of the mammogram, a false negative mammogram, findings that fail to impress the doctor, the doctor's failure to refer the patient to a specialist and poor communication between providers. Four of these five are preventable human errors (a false negative mammogram is a machine failure) and two — failure to make a referral and poor communication — are products of the way we organize health care.
The breast is something of an orphan in our health care system. We have cardiologists, nephrologists, hepatologists, proctologists and neurologists — but we have no "mammologists." How did the breast get lost?
To answer this question we need to look at the division of labor in medicine and the history of specialization. In 1940, 24 percent of doctors were specialists; by the late 1960s, nearly 90 percent of medical graduates were entering specialty residencies. In the 1930s, obstetrician-gynecologists attempted to define themselves as surgeons specializing in women's reproductive organs. But general surgeons had long considered all things surgical their exclusive turf, so obstetrician-gynecologists instead created a niche for themselves as "women's doctors," a kind of primary care specialty. They became the point of entry to health care for most women. Some were able to diagnose breast problems, but treatment of the breast remained for the most part with general surgeons.
When radiologists — specialists who can also diagnose breast cancer — appeared on the scene, another caregiver became involved in treatment. And radiologists were followed by radiation oncologists, medical oncologists, reconstructive surgeons and medical geneticists.
Women with breast cancer get lost in the mix, forced to make several different appointments, sit in various waiting rooms and see multiple doctors. In most cases, a woman with a breast problem will start with her obstetrician-gynecologist, who will then refer her to a surgeon (for a biopsy) or a radiologist (for a mammogram). The referring obstetrician-gynecologist may never see or hear from the patient again, and may not know if she kept her appointment or got adequate care.
Contrast this with the care given to women with gynecologic cancer. Because there is a subspecialty of gynecologic oncology, women see the same doctor from diagnosis to post-surgery follow-up. Breast malignancies outnumber gynecologic cancers 10 to one, and yet we have no subspecialty for breast care.
Why don't more obstetrician-gynecologists perform the initial, minimal surgery required to diagnose breast cancer? The answer lies in the training of medical residents. Three organizations oversee the education of future obstetrician-gynecologists: the Accreditation Council for Graduate Medical Education, the American College of Obstetricians and Gynecologists and the American Board of Obstetrics and Gynecology. All three have different requirements regarding training in breast care. At the end of their years as residents, some obstetrician-gynecologists have a great deal of experience with the minimally invasive diagnostic procedures needed to respond to breast complaints and others do not.
Women with breast cancer need obstetrician-gynecologists who have learned how to diagnose breast cancers and breast care specialists devoted to shepherding them through surgery, therapy and healing. Given the haphazard growth in medical specialties and varied training programs for obstetrician-gynecologists, it is no surprise that there is a mismatch between patient needs and caregiver skills. Campaigns to raise awareness of breast cancer must do more than push for a cure. They must also seek to improve the way we organize care for those who suffer from this illness.
Ann V. Bell is a graduate student in sociology at the University of Michigan. Mark Pearlman is a professor of obstetrics and gynecology and the director of the Breast Fellowship Program at the University of Michigan Medical School. Raymond De Vries is a professor of obstetrics and gynecology and bioethics there.
Ann V. Bell is a graduate student in sociology at the University of Michigan. Mark Pearlman is a professor of obstetrics and gynecology and the director of the Breast Fellowship Program at the University of Michigan Medical School. Raymond De Vries is a professor of obstetrics and gynecology and bioethics there.
SANTA FE, N.M. — The only person in America with a state license to distribute marijuana wants to keep her identity secret.
"I'm so totally paranoid I can't stand myself," said the distributor, who runs a nonprofit group here that grows and sells marijuana for medicinal purposes and who insisted on meeting in the privacy of a hotel room.
It was not meant to be this way.
New Mexico's new medical marijuana law was intended to provide safe, aboveboard access to the drug for hundreds of residents with chronic pain and other debilitating conditions. By licensing nonprofit distributors, New Mexico hoped to improve upon the free-for-all distribution systems in some states like California and Colorado, where hundreds of for-profit dispensaries have sprung up with virtually no state oversight.
But even in New Mexico, the process — from procuring the starter seed (in Amsterdam, via a middleman) to home delivery (by a former Marine) — is not for the faint of heart. Those engaged in the experiment here never know if they will be arrested, because growing, selling and using marijuana remain illegal under federal law. And robbery is always a fear.
In a reversal of Bush administration policy, Attorney General Eric H. Holder Jr. said in March that the government would not prosecute medical marijuana distributors who comply with state laws. That announcement has emboldened Rhode Island to adopt legislation similar to New Mexico's: it will license three nonprofit "compassion centers" to grow and dispense the drug by 2012. At least six other states are now considering the model.
But in recent weeks, law enforcement officers, some of them federal, have raided dispensaries in California and Washington State, and in the absence of any actual change in the federal law, many still fear prosecution.
Among New Mexican patients, demand has been great. In the two months since the Santa Fe Institute for Natural Medicine began dispensing marijuana, it has signed up about 400 clients, said Robert Pack, a patient on its board of directors who uses the drug to curb the side effects of epilepsy medication.
Eager patients depleted the initial supply, and the organization had to hurry to produce more marijuana this month, because weeks of rain hampered the drying and curing phase.
Twenty other nonprofit groups are seeking New Mexico's approval to grow and sell medical marijuana, but the state's Health Department will not identify them, citing privacy and safety concerns. Because the groups remain anonymous unless they identify themselves, other regulatory agencies — the Department of Agriculture, for example, which would inspect their growing techniques — will have no oversight.
Such secrecy seems out of keeping with the law's intent: to help medical marijuana patients emerge from the shadows and gain open access to the drug.
"I think what's appropriate is for this to be completely out in the open," said Len Goodman, a patient who started NewMexicann, a nonprofit group seeking state approval to distribute marijuana. "As long as you follow the rules, you should be able to come out of the closet and function with no fear or shame."
Friday, October 9, 2009
Thursday, October 8, 2009
Since August 23rd of this year I have interacted daily with our American Health Care system and often done so to the exclusion of virtually all other business. It is not undercover reporting, and it is not an expert study of the field, but since that day, when my father slid, seemingly benignly, out of his bed and onto the floor of his home, I have experienced with growing amazement and with multiplying anger, the true state of our hospitals, our doctor's offices, our insurance businesses, our pharmacies.
My father's story as a patient and mine as a secondary participant and a primary witness has been eye-opening and jaw-dropping. And we are among the utterly lucky ones, a fact that, by itself, is terrifying and infuriating.
And thus tonight, for all those who we have met along the way, those with whom we have shared the last two months inside the belly of the beast, and for everyone in this country who will be here and right soon tonight, Countdown will be devoted entirely to a Special Comment on the subject of health care reform in this country.
I do not want to yell. I feel like screaming but everybody is screaming, everybody is screaming that this is about rights or freedom or socialism or the president or the future or the past or a political failure or a political success. We have all been screaming, I have been screaming.
And we have all been screaming because we do not want to face, we cannot face, what is at the heart of all of this, what is the unspoken essence of every moment of this debate; what, about which, we are truly driven to such intense ineffable inchoate emotions. Because ultimately, in screaming about health care reform, pro or con, we are screaming about death. This, ultimately, is about death.
Tuesday, October 6, 2009
When Chad, a yellow Labrador retriever, moved in with Claire Vaccaro's family in Manhattan last spring, he already had an important role. As an autism service dog, he was joining the family to help protect Ms. Vaccaro's 11-year-old son, Milo — especially in public, where he often had tantrums or tried to run away.
Like many companion animals, whether service dogs or pets, Chad had an immediate effect — the kind of effect that is noticeable but has yet to be fully understood through scientific study. And it went beyond the tether that connects dog and boy in public.
"Within, I would say, a week, I noticed enormous changes," Ms. Vaccaro said of Milo, whose autism impairs his ability to communicate and form social bonds. "More and more changes have happened over the months as their bond has grown. He's much calmer. He can concentrate for much longer periods of time. It's almost like a cloud has lifted."
Dr. Melissa A. Nishawala, clinical director of the autism-spectrum service at the Child Study Center at New York University, said she saw "a prominent and noticeable change" in Milo, even though the dog just sat quietly in the room. "He started to give me narratives in a way he never did," she said, adding that most of them were about the dog.
The changes have been so profound that Ms. Vaccaro and Dr. Nishawala are starting to talk about weaning Milo from some of his medication.
Anecdotes abound on the benefits of companion animals — whether service and therapy animals or family pets — on human health. But in-depth studies have been rare. Now the Eunice Kennedy Shriver National Institute of Child Health and Human Development, part of the National Institutes of Health, is embarking on an effort to study whether these animals can have a tangible effect on children's well-being.
In partnership with the Waltham Center for Pet Nutrition in England (part of the Mars candy and pet food company), the child health institute is seeking proposals that "focus on the interaction between humans and animals." In particular, it is looking for studies on how these interactions affect typical development and health, and whether they have therapeutic and public-health benefits. It also invites applications for studies that "address why relationships with pets are more important to some children than to others" and that "explore the quality of child-pet relationships, noting variability of human-animal relationships within a family."
The national institutes' interest in this type of research goes back at least two decades. Valerie Maholmes, who directs research on child development and behavior at the children's health institute, said that at a broad-ranging meeting in 1987 on the health benefits of pets, the N.I.H. "concluded that there needed to be much more research," especially on child development.
Other sessions confirmed the need for research, but most studies focused on negative interactions, like the ways pets could spread disease, said James A. Griffin, the institute's deputy chief of child development and behavior.
Meanwhile, the Waltham Center was expanding its own research to do some small studies about human-animal interaction, said Catherine E. Woteki, global director of scientific affairs for Mars Inc. "We are a pet food company and pet care company," Dr. Woteki said, "and we're interested in seeing that that relationship stays a strong one."
The fear of swine flu is being compounded by new worries, this time among primary care doctors who say that they are swamped by calls from patients seeking the new vaccine, and that they are ill-prepared to cope with the nationwide drive to immunize everyone, particularly children and chronically ill adults.
The federal Centers for Disease Control and Prevention released the first doses of vaccine on Monday. But many doctors, especially pediatricians, say they know little about the program and have been deluged with questions.
At the same time, the pediatricians are struggling to figure out how to administer perhaps thousands of doses quickly in small offices with limited staff, while still dealing with other illnesses.
Some said they were considering hiring nurses just for the vaccinations and setting aside days when children would be vaccinated in alphabetical order.
At Westchester Pediatrics, an office with 6,000 to 8,000 families in Hartsdale, N.Y., exasperated doctors have added a new choice to the office answering machine: "If you have a question about the flu vaccine, please dial 6." Pressing 6 produces a further message saying that the swine flu vaccine is not yet available, and to keep checking the CDC.gov Web site for updates.
For those who are not satisfied, a sign in the office waiting room counsels patience.
Kathryn Paterno, the office manager, summed up the situation as "a nightmare."
"People want it," Ms. Paterno said of the swine flu vaccine. "When they listen to news reports, they pick out bits and pieces — 'swine flu, get it' — but they don't quite comprehend that we don't have it yet, and we're dealing with a quite affluent socioeconomic group here."
When asked whether his office had received vaccine inquiries, Dr. Herbert Lazarus, a pediatrician on the Upper West Side, said only half-jokingly: "Do you think that's accounting for two-thirds of our phone calls, or three-quarters?"
the fictional doctor of Fox's House, M.D.
But when you consider how much unnecessary testing is already going
on, can this be a good idea.
Well, no. But that doesn't stop a handful of patients with rare
diseases to implore that their doctors do more testing: "Doctors say
they're seeing a rise in patients who've self-diagnosed a condition
they saw on 'House.' . . . few are usually right, doctors say, but
that doesn't stop patients from expecting that physicians will run
the complex and costly tests, such as those House routinely runs in
the pursuit of a diagnosis. Not only are those tests often unneeded,
doctors say, they can drive up the overall cost of health care."
In reality, those with rare diseases take years to diagnose, and
certainly not within the confines of a one hour television drama.
It's also important to note that it's frustrating for doctors as well
when patients cannot be diagnosed. After all, we'd like to know what
the answer is as well.
Part of the difficulty lies in the fact that some answers are
infrequently black and white. Unlike television, there is no moment
of revelation at the 55-minute mark. There's a reason why rare
diseases are difficult to diagnose.
And television shows like House, M.D. is doing real-life physicians a
disservice by unreasonable ratcheting up patients' expectations of
what medical technology can do.
Sunday, October 4, 2009
It was the third week of the fall semester. I was teaching two courses, and I'd already been absent twice. I was trying to figure out how to carry my book bag.
A few months earlier, I flunked a genetic test and learned that I inherited a mutant protein from my father. He was 44 when he died. I was 45 and healthy by conventional cardiovascular measures, so the first symptom would probably be my sudden death.
I opted for an implanted defibrillator. As a bonus, I was given a staph infection. In September, I puffed up, my surface temperature soared and an emergency explant surgery (the defibrillator was contaminated) left me once again at risk of sudden death. In a few months, the doctors would stuff another device into me — which also had to be yanked out (product recall). But for the moment, I just had a hole in my chest, a catheter sticking out of my forearm and a month's supply of syringes and antibiotics. I couldn't use either hand for lifting.
For one week, illness trumped every topic. Even the visiting nurses started dropping hints like, How about those Red Sox? My partner, Peter, offered to sling my bag over my shoulder and get me out of the house.
I occasionally shoved myself aside to think about Binny, the sister of a friend. I met her only once, but I was bowled over by her spirit. Binny's own adventures in medicine culminated in a heart transplant — and she became one of the first transplant survivors to bear a child. Then her second heart failed, and her only hope was another heart and everything that surgery entailed. While I was in a hospital in Boston, Binny was in a hospital in New Hampshire, choosing not to undergo another transplantation. She died.
Peter was recalibrating my injection schedule so I wouldn't have to shoot up on campus when I said, Binny.
I said, It's hard to say if she chose to die, or if she chose her life. Peter didn't say anything.
I said, I know I can't imagine what she endured, but I think I got a little taste. It's intolerable, and yet you can tolerate it. That's what I learned. But tolerance is a failure to respond. And if you don't respond to most of what you feel, what makes you know you are alive?
I could not articulate exactly what I knew, but I was certain I knew it.
I drove to campus, parked and grabbed my bag. I felt a sting in my arm near the catheter. To get the book bag on, I knelt beside the car and looped the strap over my shoulder. When I stood up, I was sweating.
Students streamed by. Maybe it was the expectant air they gave off, or maybe cooler weather was blowing in, but the breeze dried me out. I looked up at the true-blue autumn sky through the limbs of a midlife maple, its still-green leaves quivering like jazz hands, and I didn't think, I just said, Oh, Binny.
Maybe life is not a lesson, or maybe I am a bad student, but I knew nothing but how sweet it is to catch an unexpected breeze.
I was early to class. One young man was there to watch me shrug off my bag. He said, I'm glad you're back.
I said, I'm happy you turned up again, too.
He smiled. He was wearing shorts. Maybe he'd had an accident, or maybe he'd also inherited his loss. Somewhere above the shin, most of one of his original legs was missing. He had a handsome steel prosthetic.
I said, Is that as good as it looks?
This one is good, he said, as if he'd had a few.
As class ended, I saw a former student. I waved her in. When we were alone, she said, Are you O.K.?
I said, I'm fine.
Oh, not your operation, she said. I mean the blood.
During class, I'd shoved the cuffs of my sweater past the catheter. A streak of dried blood ran from my elbow to my wrist. I remembered that jab of pain when I'd grabbed my bag. It's O.K., I said.
She said, Do you need a tissue?
I said, It's not bleeding now.
She seemed nervous, as if she were responsible for my well-being. I was sure she was going to offer to walk me to my car.
Anyway, she said, could you write a recommendation letter for me? No rush. It's for study abroad.
I don't remember where in the world she wanted to go, but I do remember how happy I was to be there.
Michael Downing is the author of "Life With Sudden Death: A Tale of Moral Hazard and Medical Misadventure." This essay is adapted from the book, due out this month.
Stephanie Smith, a children's dance instructor, thought she had a stomach virus. The aches and cramping were tolerable that first day, and she finished her classes.
Then her diarrhea turned bloody. Her kidneys shut down. Seizures knocked her unconscious. The convulsions grew so relentless that doctors had to put her in a coma for nine weeks. When she emerged, she could no longer walk. The affliction had ravaged her nervous system and left her paralyzed.
Ms. Smith, 22, was found to have a severe form of food-borne illness caused by E. coli, which Minnesota officials traced to the hamburger that her mother had grilled for their Sunday dinner in early fall 2007.
"I ask myself every day, 'Why me?' and 'Why from a hamburger?' "Ms. Smith said. In the simplest terms, she ran out of luck in a food-safety game of chance whose rules and risks are not widely known.
Meat companies and grocers have been barred from selling ground beef tainted by the virulent strain of E. coli known as O157:H7 since 1994, after an outbreak at Jack in the Box restaurants left four children dead. Yet tens of thousands of people are still sickened annually by this pathogen, federal health officials estimate, with hamburger being the biggest culprit. Ground beef has been blamed for 16 outbreaks in the last three years alone, including the one that left Ms. Smith paralyzed from the waist down. This summer, contamination led to the recall of beef from nearly 3,000 grocers in 41 states.
Ms. Smith's reaction to the virulent strain of E. coli was extreme, but tracing the story of her burger, through interviews and government and corporate records obtained by The New York Times, shows why eating ground beef is still a gamble. Neither the system meant to make the meat safe, nor the meat itself, is what consumers have been led to believe.
Ground beef is usually not simply a chunk of meat run through a grinder. Instead, records and interviews show, a single portion of hamburger meat is often an amalgam of various grades of meat from different parts of cows and even from different slaughterhouses. These cuts of meat are particularly vulnerable to E. coli contamination, food experts and officials say. Despite this, there is no federal requirement for grinders to test their ingredients for the pathogen.
The frozen hamburgers that the Smiths ate, which were made by the food giant Cargill, were labeled "American Chef's Selection Angus Beef Patties." Yet confidential grinding logs and other Cargill records show that the hamburgers were made from a mix of slaughterhouse trimmings and a mash-like product derived from scraps that were ground together at a plant in Wisconsin. The ingredients came from slaughterhouses in Nebraska, Texas and Uruguay, and from a South Dakota company that processes fatty trimmings and treats them with ammonia to kill bacteria.
Using a combination of sources — a practice followed by most large producers of fresh and packaged hamburger — allowed Cargill to spend about 25 percent less than it would have for cuts of whole meat.
Those low-grade ingredients are cut from areas of the cow that are more likely to have had contact with feces, which carries E. coli, industry research shows. Yet Cargill, like most meat companies, relies on its suppliers to check for the bacteria and does its own testing only after the ingredients are ground together. The United States Department of Agriculture, which allows grinders to devise their own safety plans, has encouraged them to test ingredients first as a way of increasing the chance of finding contamination.
Unwritten agreements between some companies appear to stand in the way of ingredient testing. Many big slaughterhouses will sell only to grinders who agree not to test their shipments for E. coli, according to officials at two large grinding companies. Slaughterhouses fear that one grinder's discovery of E. coli will set off a recall of ingredients they sold to others.
"Ground beef is not a completely safe product," said Dr. Jeffrey Bender, a food safety expert at the University of Minnesota who helped develop systems for tracing E. coli contamination. He said that while outbreaks had been on the decline, "unfortunately it looks like we are going a bit in the opposite direction."
Food scientists have registered increasing concern about the virulence of this pathogen since only a few stray cells can make someone sick, and they warn that federal guidance to cook meat thoroughly and to wash up afterward is not sufficient. A test by The Times found that the safe handling instructions are not enough to prevent the bacteria from spreading in the kitchen.
Cargill, whose $116.6 billion in revenues last year made it the country's largest private company, declined requests to interview company officials or visit its facilities. "Cargill is not in a position to answer your specific questions, other than to state that we are committed to continuous improvement in the area of food safety," the company said, citing continuing litigation.
The meat industry treats much of its practices and the ingredients in ground beef as trade secrets. While the Department of Agriculture has inspectors posted in plants and has access to production records, it also guards those secrets. Federal records released by the department through the Freedom of Information Act blacked out details of Cargill's grinding operation that could be learned only through copies of the documents obtained from other sources. Those documents illustrate the restrained approach to enforcement by a department whose missions include ensuring meat safety and promoting agriculture markets.
Within weeks of the Cargill outbreak in 2007, U.S.D.A. officials swept across the country, conducting spot checks at 224 meat plants to assess their efforts to combat E. coli. Although inspectors had been monitoring these plants all along, officials found serious problems at 55 that were failing to follow their own safety plans.
"Every time we look, we find out that things are not what we hoped they would be," said Loren D. Lange, an executive associate in the Agriculture Department's food safety division.
In the weeks before Ms. Smith's patty was made, federal inspectors had repeatedly found that Cargill was violating its own safety procedures in handling ground beef, but they imposed no fines or sanctions, records show. After the outbreak, the department threatened to withhold the seal of approval that declares "U.S. Inspected and Passed by the Department of Agriculture."
In the end, though, the agency accepted Cargill's proposal to increase its scrutiny of suppliers. That agreement came early last year after contentious negotiations, records show. When Cargill defended its safety system and initially resisted making some changes, an agency official wrote back: "How is food safety not the ultimate issue?"
"Honey, Dr. Wolffe wants to take a look at you," the father said as he turned off the television. The 18-month-old toddler scrambled up from the floor and walked over to the familiar figure now sitting at his dining-room table. The child looked up into the round, friendly face of Dr. Wolffe Nadoolman. The pediatrician immediately noticed that the whites of the boy's eyes were bright pink — a nearly uniform tint everywhere except for a slender band of normal white surrounding the iris. Unlike in a typical case of pinkeye, there was no crusting or discharge from the eyes, no tearing. The pink eyes didn't seem to bother the boy, and yet this was why the doctor was making a house call. He was worried when the boy's parents called to report one more new and unusual symptom.
Nadoolman saw the toddler the day before in his Berkeley office. His parents brought him in because he'd had a high fever for nearly a week with no other symptoms. The fever would spike to 103 degrees, and though the acetaminophen and ibuprofen would bring it down, his temperature never returned to normal. Neither had the boy: for the past week he had been tired and cranky. His appetite was gone, and he had been waking up at night, something he hadn't done for nearly a year. Did he have meningitis? the mother worried.
How is your older child? Nadoolman asked about the boy's 5-year-old brother. He had a couple of days of fever the week before, the mother reported, and now had a couple of canker sores in his mouth, but otherwise he was fine.
On examination, the younger boy had a low-grade temperature of 100.6 despite the acetaminophen and ibuprofen he was given a couple of hours earlier, but other than that, the exam was unremarkable.
Five days of fever is unusual for most childhood illnesses, and although Nadoolman often sent kids for lab work at this point, this child didn't appear sick enough to need that. It was likely that he had what his brother had the week before. The combination of fever and canker sores made Nadoolman suspect a coxsackievirus — one of the most common causes of fever in very young children. It could also be roseola — another common childhood viral illness. Roseola is caused by a herpesvirus and is characterized by several days of high fever followed by a bright pink rash that usually starts as the fever begins to subside. Neither of these infections needed treatment other than the fever reducers they were already giving the toddler.
The doctor paused. There was another possibility — Kawasaki disease. Although rare, it was most common in boys of Asian descent — as this child was — and in this age group. Kawasaki, he explained, is an inflammatory disease of the blood vessels. No one understands what causes it, but the disease, if not diagnosed and treated promptly, can cause permanent damage to the heart and early death. The most common symptom was a prolonged fever accompanied by a rash. Typically the rash affected the fingers and toes, causing them to swell and then peel. In his office, he told the boy's parents that they should call him if he developed any kind of rash at all. Pink eyes or lips were another frequent symptom.
When the doctor called the next morning, the boy still had the fever, but no rash, no redness, no other new symptoms. Then late that afternoon the boy's mother noticed that his eyes were pink. When Nadoolman heard about the eyes, he told the parents he would make a house call at the end of the day. Now he was worried.
After looking at the boy's eyes, the doctor moved on to examine the rest of the child's body. The only new finding was a single canker sore on the inside of the boy's lower lip.
In medicine we are taught that any given collection of symptoms is far more likely to be an unusual presentation of a common disease than even a classic presentation of a rare one. So was this an unusual case of a coxsackievirus infection? Or was this early Kawasaki disease? The prolonged fever, the pink eyes and the presence of only a single ulcer — usually there are several — would make this an unusual case of coxsackie. As for Kawasaki — there is no definitive test. Doctors use clusters of symptoms to make the diagnosis. While the boy had two of the symptoms of Kawasaki disease — prolonged fever and pink eyes — you needed at least five to diagnose this disease definitively. But damage to the heart could occur even without a full-blown presentation of the disease. And Kawasaki was thought to be widely underdiagnosed. Postponing treatment beyond 10 days after the start of the fever significantly increased the risk of heart damage.
Let's give it another day, he told the parents.
The nation's nursing homes are perilously close to laying off workers, cutting services -- possibly even closing -- because of a perfect storm wallop from the recession and deep federal and state government spending cuts, industry experts say.
A Medicare rate adjustment that cuts an estimated $16 billion in nursing home funding over the next 10 years was enacted at week's end by the federal Centers for Medicare and Medicaid Services -- on top of state-level cuts or flat-funding that already had the industry reeling.
And Congress is debating slashing billions more in Medicare funding as part of health care reform.
Add it all up, and the nursing home industry is headed for a crisis, industry officials say.
''We can foresee the possibility of nursing homes having to close their doors,'' said David Hebert, a senior vice president at the American Health Care Association. ''I certainly foresee that we'll have to let staff go.''
The funding crisis comes as the nation's baby boomers age ever closer toward needing nursing home care. The nation's 16,000 nursing homes housed 1.85 million people last year, up from 1.79 million in 2007, U.S. Census Bureau figures show.
Already this year, 24 states have cut funding for nursing home care and other health services needed by low-income people who are elderly or disabled, according to the Center on Budget and Policy Priorities, a nonprofit research firm based in Washington, D.C.
Some facilities are now closed because of money problems -- including four in Connecticut -- and others have laid off workers because of what industry officials say are inadequate Medicaid reimbursement rates. Medicare cuts are troubling, they say, because the higher Medicare reimbursements have been used to compensate for the lower Medicaid rates.
In Griswold, Conn., the community's only nursing home shut down earlier this year because of rising costs and an inability to pay for $4.9 million in needed renovations for the 90-bed facility.
''A 92-year-old woman was screaming and crying as she was loaded into the ambulance, saying 'This is my home,''' Griswold First Selectman Philip Anthony said. His 88-year-old mother was a resident of the same home at the time.
Anthony sought and found a new facility for his mother, but she died of pneumonia before the Griswold Health and Rehabilitation Center closed in the spring.
''To be hit with a sudden and deliberate closure like this, it just drained the heart right out of you,'' Anthony said.
Convenience and necessity. Drug companies cater to their clients' preferences. Adults prefer popping pills, so most medicines for adults come in small capsules. Kids, by contrast, often dislike swallowing tablets, so companies manufacture liquid alternatives. But not every drug can be taken any which way. It's better to take certain cancer medications—like the red-blood-cell booster Epogen—intravenously rather than via intramuscular injection, since the drugs may irritate tissue. Proteins such as human growth hormone or insulin can't be taken orally, since the stomach's acids and digestive enzymes would break these down as if they were food. Other drugs have to be taken orally. For example, if you're trying to treat gastrointestinal issues like heartburn, you're going to want a pill rather than an ointment or an IV drip.