Durezol And Durasal, Don't Get Them Mixed Up, FDA Warns - MedWatch

Eye drug Durezol (difluprednate ophthalmic emulsion) and wart remover Durasal (salicylic acid) may sound similar, but getting them mixed up can happen, and with potentially serious consequences, the Food and Drug

Durezol is prescribed for patients with inflammation linked to eye surgery.

The FDA informs that it has received several reports of Durezol and Durasal mix-ups. Fortunately, the mistakes were spotted before the patient received their prescriptions in most cases.

The FDA adds that health care professionals have complained about the names of the two drugs, saying they sound too similar, and worry about potential medical errors.

Pharmacists should be especially vigilant when filling Durezol prescriptions, the Agency adds. The risk of injury is much greater if an eye-surgery patient gets the wart remover, than the other way round. Even so, errors in either direction should be avoided.

When drugs are submitted to the FDA for approval, the Agency carefully screens their proprietary names for similarities. However, Durasal (salicylic acid) is an OTC medication that did not undergo the approval process. That is why the two names exist side-by-side in the pharmacies.

Durasal came onto the market not long after the FDA approved Durezol.

The FDA has written to Elorac Inc. regarding removing Durasal from the market. Elorac has not responded, neither has it issued any kind of recall.

Pharmacists, doctors, other healthcare professionals and patients should check the drug's packaging and label information carefully.

Any medications that appear to have a potential for confusion regarding their names should be reported to theFDA's MedWatch Safety Information and Adverse Event Reporting program. Patients and doctors should also report any side effects linked to Durezol or Durasal usage to MedWatch.

http://www.medicalnewstoday.com/articles/239767.php

Chocolate bar for lunch? Is this an ‘occupational hazard’? - The Globe and Mail

You're working late, and eating dinner from a vending machine yet again.

Could your diet of Twinkies and Cheetos be a job hazard?

If you're a shift worker, it could well be, according to the medical journal PLoS Medicine.

An editorial in this month's issue of the journal makes a case for thinking about unhealthy eating as a new occupational health hazard. It highlights research that shows an association between shift work and an increased risk of type 2 diabetes.

While a disruption of circadian rhythms (which regulate one's metabolism) and a negative impact on sleep are contributing factors, workers' eating patterns "are obvious targets for intervention," the editorial says.

According to a press release, "Shift work is notoriously associated with poor patterns of eating, which is exacerbated by easier access to junk food compared with more healthy options."

The editorial points out that shift work is expected to become more common as the realm of work increasingly extends around the clock. And shift work, it says, has the potential to speed up the progression of the global epidemic of obesity and diabetes.

The editorial notes that employers and legislators have taken steps to reduce workers' exposure to tobacco smoke, suggesting they should tackle unhealthy eating in a similar manner, and make it easier and cheaper for workers to eat well. One workplace, the Cleveland Clinic, has taken a lead in this area, it says.

In an effort to keep health-care costs in check, the Cleveland Clinic in Ohio took a hard line to improve the health of its employees, The Washington Post reported earlier this year. It fired physicians who refused to quit smoking. It eliminated almost all fried foods, sugary sodas and trans fats from its campus. It offered free fitness and stress-management classes to its workers. And it began keeping track of its employees' blood pressure, lipids, blood sugar, weight and smoking habits. If any of these are "abnormal," the clinic requires that a doctor certify that the employee is taking measures to control them or else they don't receive an insurance rebate.

http://www.theglobeandmail.com/life/the-hot-button/chocolate-bar-for-lunch-is-this-an-occupational-hazard/article2285453/?cmpid=nl-news1

A young woman struggles with oxy addiction and recovery - Tampa Bay Times

ST. PETERSBURG, Florida

When her mom came to pick her up for drug court that morning, Stacy Nicholson was still high.

She staggered to the door, fumbled with the bungee cord that kept it closed, blinked back the sunlight.

"You ready?" asked her mom.

Stacy and two of her cousins had been holed up for months in this rundown house, shooting crushed-up pain pills. Used syringes littered an end table. Stacy's mom had kept telling her: Someone in this house is going to die.

Stacy, then 28, knew she was right. Days before, she had told her mom she was tired of stealing and doctor shopping to get pills. She was in trouble for skipping her last court date, so today, she planned to turn herself in.

"Okay," Stacy said. "Let's go."

She twisted her long, honey-colored hair into a knot. Zipped her sweatshirt. Underneath, she was wearing two bras, a tank top, two white T-shirts and three pairs of panties.

She wanted to be sure she would have a change of underwear in jail.

COURTROOM 10 WAS PACKED when Stacy and her mom, Sherry Alkire, slid into the back row. It was Feb. 1, a Tuesday.

More than 100 women, most 20 to 40 years old, filled the wooden benches. Some were visibly pregnant. Others trailed toddlers. Many of the women struggled to hold up their heads.

Just before 9 a.m., a thin, chestnut-haired woman in a black robe strode through the back door. "All rise!" called the bailiff. "The honorable Judge Dee Anna Farnell presiding."

The judge raised her arms and smiled. "Welcome to Ladies' Day," she said. America's first all-female drug court was in session.

Soon the judge called Stacy's name. Stacy slouched down the aisle, clasped her hands behind her back and hung her head.

Eighteen months earlier, she had been arrested for using a fake prescription to buy oxycodone, the painkiller she had been snorting or shooting for four years. The charge carried a possible five-year prison sentence.

The judge had offered a deal: Plead guilty and go on probation. If you go through rehab, if you go to 12-step meetings and get a job and stay sober, you can stay out of jail — and have your felony record wiped clean.

For a while, Stacy had tried. But then she failed a drug test, stopped going to counseling, started skipping court. Now she faced a sentence of 10 years instead of five.

The judge could send her to a long-term treatment facility or halfway house. Or she could put her in prison for violating her probation.

Farnell asked Stacy about her children. Stacy said her 12-year-old daughter had been staying with her paternal grandparents for almost a year. Her mom was taking care of her 2-year-old son.

"What are you going to test positive for today?" asked the judge.

Stacy shuffled her Air Jordan slides. "Well, I've been smoking and drinking. So marijuana and alcohol." She paused. "And benzos. And maybe …"

The judge shook her head. "Okay," she said. "What do you want to do? Do you want to opt out? Or keep trying?"

Stacy wanted what a lot of addicts want: to get clean, but also to get high. She wanted to have her kids back, but also to have no responsibility. She wanted to feel better, and to feel nothing.

She wiped her nose on her shoulder, looked up and said, "I want to keep trying."

PRESCRIPTION DRUG abuse kills 40 Americans every day. That's more than a threefold increase in the last decade, according to the U.S. Centers for Disease Control and Prevention.

Oxycodone is the deadliest drug of all. An opiate found in such painkillers as OxyContin and Percocet, it's prescribed after surgeries and car wrecks, and to people in chronic pain.

Others take it just for the high. The drug works by blocking the spinal cord's pain receptors. It doesn't make the pain go away, but prevents people from feeling it, creating a sense of euphoria. Soon, they need to take more to get the same pleasurable escape.

Oxy makes junkies out of people who would never buy from a street dealer. It is everyman's high, heroin in a pill.

Of all the oxycodone prescribed in America in the first half of last year, 98 percent was dispensed in Florida. According to the state medical examiner's office, an average of seven Floridians die from prescription drug overdoses every day — more than from car accidents.

In recent years, Pinellas has lost more people to prescription drugs than any other county in the state — 249 just last year. That's an increase of 60 over the year before.

"Everyone knows someone who has gone through this addiction and you just feel so helpless. It's a horrible, vicious disease," said Pinellas County sheriff's spokeswoman Marianne Pasha.

"These aren't Dumpster-diving drug addicts," she said. "These people are getting their pills from doctors. It's the person in line beside you at Publix, the woman next to you in the pew at church."

A few years ago, drug court Judge Farnell started seeing more and more women charged with prescription drug abuse. By 2009, almost half of her drug court defendants were women.

That year, Pinellas County received a $900,000, three-year federal grant to fund substance abuse treatment for women in drug court.

That's how Tuesdays became "Ladies' Day."

Instead of punishing the women, the judge offers them a chance to start over. They come to court once a month. She creates incentives for them: Do yoga, run a 5K, quit smoking, and we'll waive your $52 monthly probation fee. She makes sure they know how to get a bus pass. If she gets a bad vibe about a boyfriend, she'll order a woman to steer clear of him.

She tells defendants, "You can do this. It's going to be hard. But it will be worth it."

When a woman slips, the judge scolds her and sends her back to jail to detox. Then she offers another chance.

About 500 defendants came to court on Ladies' Days this year. St. Petersburg Times journalists attended week after week. They interviewed dozens of women. They followed addicts as they bounced between jail and treatment, stayed in abandoned houses, looked for jobs and stumbled toward recovery or relapse.

One woman let the journalists follow her all year.

Stacy Nicholson grew up in St. Petersburg. A streetwise, Southern-fried tomboy, she loves the Florida Gators, Chevy pickups, Lil Wayne and Toby Keith. She believes in dream catchers and her Gemini horoscope, craves Cocoa Puffs and smokes Newports. She never wears makeup, always spritzes on Victoria's Secret body spray. When it comes to men, she likes the smell of trouble.

Her history of drug use and dysfunction stretches back to puberty. She tried marijuana at 13 and alcohol at 14, had her first baby at 16 and her second, with a different man, at 27.

But the pursuit of the oxy buzz erased any chance of a productive life.

For addicts, using quickly becomes a necessity, not a choice. Getting the next pill becomes more important than work, friends, family, even food. The addict's values shift to justify whatever it takes to get more oxys. Hard workers can no longer hold jobs. Smart students drop out. Good moms neglect their kids, drain their bank accounts, steal from family members.

If addicts stop using, they suffer horrible symptoms: vomiting, headaches, intense bone pain. That's why many are afraid to even try to get sober. They need to stay high so they don't crash.

After Stacy got hooked, she lost her personality, spark, motivation. Every new boyfriend was a red flag, but she never saw it. She dragged her kids from bad apartments to cheap motel rooms, and finally gave them up.

In Judge Farnell's court in February, Stacy entered what everyone agreed was a fight for her life. She could get better, or she could become one of Florida's seven a day.

She had a lot going for her: a mother who supported her even after all the times Stacy had broken her heart. Two children who desperately needed her love and attention. A treatment program backed by almost $1 million in taxpayer money. Drug counselors who wanted her to succeed. Other recovering addicts eager to share their experiences at 12-step meetings. An empathetic judge who was willing to give Stacy chance after chance, if only she would try.

Working against her: a little blue pill and Stacy's need to numb herself with it.

More ...

http://www.tampabay.com/features/humaninterest/article1206405.ece

The High Cost of Failing Artificial Hips - NYTimes.com

The most widespread medical implant failure in decades — involving thousands of all-metal artificial hips that need to be replaced prematurely — has entered the money phase.

Medical and legal experts estimate the hip failures may cost taxpayers, insurers, employers and others billions of dollars in coming years, contributing to the soaring cost of health care. The financial fallout is expected to be unusually large and complex because the episode involves a class of products, not a single device or just one company.

The case of Thomas Dougherty represents one particularly costly example. He spent five months this year without a left hip, largely stuck on a recliner watching his medical bills soar.

In August, Mr. Dougherty underwent an operation to replace a failed artificial hip, but his pelvis fractured soon afterward. The replacement hip was abandoned and then a serious infection set in. Some of the bills: $400,776 in charges related to hospitalizations, and $28,081 in doctors' bills.

"I'm sitting here on a La-Z-Boy meant for someone who is 80 and I'm 55," said Mr. Dougherty, who lives in Groveland, Ill., and works at Caterpillar, the heavy equipment manufacturer. His bills are "five times as much" as he paid for his home.

The so-called metal-on-metal hips like Mr. Dougherty's, ones in which a device's ball and joint are made of metal, are failing at high rates within a few years instead of lasting 15 years or more, as artificial joints normally do. The wear of metal parts against each other is generating debris that is damaging tissue and, in some cases, crippling patients.

The incidents have set off a financial scramble. Recently, lawsuits and complaints against makers of all-metal replacement hips passed the 5,000 mark. Insurers are alerting patients that they plan to recover their expenses from any settlement money that patients receive.Medicare is also expected to try to recover its costs.

While his insurer has covered his bills so far, Mr. Dougherty said he was preparing to sue his surgeon, who may have implanted the device incorrectly, and Johnson & Johnson, which produced his artificial hip, to help recoup some of the insurer's money.

"All these payers want to be paid back," said Matt Garretson, the founding partner of the Garretson Resolution Group, a firm in Cincinnati that manages product liability cases.

Until a recent sharp decline, all-metal implants accounted for nearly one-third of the estimated 250,000 hip replacements performed each year in the United States. Some 500,000 patients have received an all-metal replacement hip, according to one estimate. A new study found that no new artificial hip or knee introduced during a recent five-year period — implants that included some of the all-metal hips — were more durable than older devices, and 30 percent were worse.

One troubled all-metal model, implanted in 40,000 patients in the United States, was recalled last year by the DePuy division of Johnson & Johnson. As of October, some 3,500 patients had filed a lawsuit involving that device.

There is no data on the number of all-metal hips that have failed prematurely in this country because the outcomes of orthopedic procedures are not formally tracked by the government or private companies.

But extrapolating from overseas data and the estimate of metal hip use here, tens of thousands of patients in the United States may have to undergo operations over the next decade to replace the implants, said Dr. Art Sedrakyan, a researcher at Weill Cornell Medical College of Cornell University, who is studying the hip problem.

A decade ago, Sulzer Orthopedics paid a record $1 billion to settle claims by 6,800 patients who received artificial hips and knees that were contaminated with industrial oil during the manufacturing process. "We have been dwarfed by this," said Teresa Ford, a lawyer who worked at Sulzer at the time and is now in private practice.

Device producers have taken differing stances to covering patient expenses. Zimmer Holdings, which says its all-metal implants are safe, has settled hundreds of patient claims, lawyers involved in those cases say. Also, DePuy is covering costs related to the device it recalled last year, the A.S.R., or Articular Surface Replacement.

DePuy would not comment on how much it had paid in recall-related costs. But a spokeswoman, Mindy Tinsley, said in a statement that DePuy was working with patients and insurers.

Things have not gone smoothly for everyone who has taken DePuy's payment offer. One patient, Paula Laverty, received a hospital bill for $41,578 and a call from the facility warning her that the bill would be turned over soon to a collection agency.

Ms. Laverty, of Cape Elizabeth, Me., said she spent weeks calling the firm handling claims related to DePuy's A.S.R. She said she eventually learned that the implant maker had paid the hospital $18,000 for her replacement procedure and that the $41,578 represented the remaining charges.

This month, DePuy made an additional payment to the hospital, according to Ms. Tinsley, the company spokeswoman.

Along with A.S.R.-related cases, DePuy also faces over 560 lawsuits in connection with the all-metal version of another hip model, called the Pinnacle, the device that Mr. Dougherty received. Because the company says that the model is performing well, costs for its replacement are being borne by Medicare, insurers or patients themselves.

To recoup their expenses, insurers typically notify patients through lawyers that they expect to be reimbursed from any settlement money that patients receive, rather than pursue their own lawsuits with the device makers. Also, Medicare is expected to enforce new laws next year that will make it easier for the agency to recover taxpayer dollars spent treating patients injured by problem drugs and medical devices, legal experts said.

Still, some patients are weathering some of the financial impacts on their own. While Charmin McCune, a teacher in Wylie, Tex., is recuperating well from a recent replacement operation, she said that she and her husband, also a teacher, have had more than $12,000 in expenses that have not been covered by insurance.

Mr. Dougherty, the Illinois patient, underwent a procedure this month to get a new hip implant. All went well, he said, so he hopes to spend next year back on his feet and at work.

"You can't do anything," he said of his current situation. "You see your wife doing everything for you. It is just not right."

http://www.nytimes.com/2011/12/28/business/the-high-cost-of-failing-artificial-hips.html?_r=1&nl=todaysheadlines&emc=tha2&pagewanted=print

Robert Ader, Who Linked Stress and Illness, Dies at 79 - NYTimes.com

Dr. Robert Ader, an experimental psychologist who was among the first scientists to show how mental processes influence the body's immune system, a finding that changed modern medicine, died on Tuesday in Pittsford, N.Y. He was 79.

His death followed a long illness and complications of a fracture suffered in a fall, his daughter Deborah Ader said.

Dr. Ader, who spent his entire career as a professor of psychiatry and psychology at the University of Rochester School of Medicine and Dentistry, conducted some of the original experiments in a field he named himself, psychoneuroimmunology.

His initial research, in the 1970s, became a touchstone for studies that have since mapped the vast communications network among immune cells, hormones and neurotransmitters. It introduced a field of research that nailed down the science behind notions once considered magical thinking: that meditation helps reduce arterial plaque; that social bonds improve cancer survival; that people under stress catch more colds; and that placebos work not only on the human mind but also on supposedly insentient cells.

At the core of Dr. Ader's breakthrough research was an insight already obvious to any grandmother who ever said, "Stop worrying or you'll make yourself sick." He demonstrated scientifically that stress worsens illness — sometimes even triggering it — and that reducing stress is essential to health care.

That idea, now widely accepted among medical researchers, contradicted a previous principle of biochemistry, which said that the immune system was autonomous. As late as 1985, the idea of a connection between the brain and the immune system was dismissed in an editorial in The New England Journal of Medicine as "folklore."

"Today there is not a physician in the country who does not accept the science Bob Ader set in motion," said Dr. Bruce Rabin, founder of the Brain, Behavior and Immunity Center at the University of Pittsburgh Medical Center, who considered Dr. Ader a mentor. "He attracted interest in the field and made it possible to prove that 'mind-body' is real."

Dr. Ader said his breakthrough began in 1975 with what he called "scientific serendipity."

He and a fellow researcher, Dr. Nicholas Cohen, were conducting an unrelated experiment about taste aversion involving rats and saccharine-sweetened water when they stumbled on a mysterious phenomenon.

In the experiment, one group of rats was given sweetened water accompanied by an injection that caused stomach aches. (A control group got only the sweetened water.) When the injections stopped, and the rats that had experienced stomach aches refused to drink the water, researchers force-fed them with eye-droppers in order to complete the experiment's protocols.

Dr. Ader and Dr. Cohen had expected the conditioned rats to refuse the drink. They had not anticipated that forcing them to drink would eventually kill them, however, which it did, some time afterward.

The two reviewed their protocols and guessed that the drugs used in the injections might have had some bearing on the deaths. They could have used any drug that caused stomach pain without doing serious harm. But the researchers discovered that they had unwittingly picked Cytoxan, which besides causing stomach aches suppresses the immune system. At first they suspected that the rats had died from an overdose of Cytoxan. Then they determined that the dosage the rats received had been too low to support that explanation.

So they developed a theory, which became a landmark of medical science as further experiments proved it correct: The rats died because the mere taste of saccharine-laced water was enough to trigger neurological signals that did indeed suppress their immune systems — exactly as if they had been overdosed with Cytoxan. The rats succumbed to bacterial and viral infections they were unable to fight off. It was an example of the so-called placebo effect, only in this case it did not fool the brain into thinking it had been given something beneficial but rather the opposite.

The findings were "incontrovertible," Anne Harrington, a Harvard professor of the history of science, wrote in the 1997 book "The Placebo Effect."

"The fact that he had achieved this in rats rather than humans was a further blockbuster," she continued, "because it undermined the frequent assumption that placebo effects were a product of peculiarly human interpersonal processes."

Robert Ader was born on Feb. 20, 1932, in the Bronx, the older of two sons of Mae and Nathan Ader. His father, who owned a liquor wholesale company, died in a car accident in 1945 when Robert was a teenager. After graduating from the private Horace Mann School in the Riverdale section of the Bronx, he received his bachelor's degree from Tulane University and, in 1957, his Ph.D. in psychology from Cornell.

Soon after, he became an assistant professor in the department of psychology at the University of Rochester, where he went on to hold many teaching and research posts. He retired in July as a professor emeritus of psychosocial medicine.

Besides his daughter Deborah, he is survived by his wife, Gayle; three other daughters, Janet, Rini and Leslie Ader; and a grandson.

Since he inaugurated the study of psychoneuroimmunology (usually referred to as PNI), Dr. Ader had to defend its premise against doubters in the medical establishment and later to disassociate it from New Age therapies that he called "flaky" because they had not been grounded in solid scientific experimentation.

Deborah Ader, a psychology researcher, said a sense of modesty had been at the core of her father's curiosity as a scientist.

"My father used to say, 'I just didn't know any better,' " she said, recounting how he had described his pioneering research.

He told her, she recalled, "I didn't know the immune system wasn't supposed to be connected to the brain."

http://www.nytimes.com/2011/12/26/science/robert-ader-who-linked-stress-and-illness-dies-at-79.html?pagewanted=print

Affluent Children Are More Physically Fit Than Poor Ones - NYTimes.com

Every Monday, Sycamore Valley Elementary in Danville challenges its students to run a "Smile Mile" together after school. Some parents even run with their children. Photos of the student joggers' grinning faces are posted in the cafeteria. On a recent Monday afternoon, there were 41 smiling faces on the wall.

Students at Sycamore Valley have a lot to be happy about when it comes to their physical fitness. Fifth graders there got the best scores among all of their Bay Area peers on the 2011 statewide Physical Fitness Test.

Eighty-three percent of the fifth graders tested at Sycamore Valley aced the test by receiving healthy scores on all six different measurements — of aerobic capacity, abdominal strength, upper body strength, trunk strength, body composition and flexibility, most of them gauged through physical activity. One part of the Physical Fitness Test measures a child's body composition, usually through body mass index, which is calculated using weight and height and is used to determine who is overweight.

Statewide, only 31 percent of public school students performed as well, according to the California Department of Education.

An analysis of state data by The Bay Citizen revealed a large variation in how fifth graders in Bay Area elementary schools perform on the test. The schools that performed the best have few students from low-income families, for reasons that experts say are not surprising. At Sycamore Valley Elementary, in an affluent suburban community, not a single student was eligible to receive a free or reduced-price lunch because of low family income last year, according to the state's data.

Across the Bay, in San Francisco's Mission district, none of the fifth graders at Cesar Chavez Elementary School received six healthy scores on the test. More than a quarter of them were found to "need improvement" on every measure of fitness.

At Cesar Chavez, where Spanish is the first language for many, more than 85 percent of the students are eligible to receive free or reduced-price school lunches. In the school district that includes Cesar Chavez, Hispanic and black students are less likely to receive healthy scores than their Asian and white peers, the state data show.

Students at Sycamore Elementary have a dedicated "physical education specialist" on campus to help them train for the test. Those at Cesar Chavez do not.

"There is an inequity problem with the availability of quality physical education between schools of varying socioeconomic status," said Drisha Leggitt, executive director of the California Association for Health, Physical Education, Recreation and Dance, a nonprofit organization.

Robert O'Brien, Sycamore Valley's physical education specialist, who favors shorts even when the temperature dips into the 40s, is fond of slogans like "exercise, not extra fries." He leads students as young as 6 in sit-ups, jumping jacks, push-ups and running, striving to get all of them moving, while giving their classroom teachers time to prepare other lessons.

All 21 of the elementary schools in the San Ramon Valley Unified School District, in which Sycamore Valley is located, have a physical education specialist like Mr. O'Brien.

"Having dedicated physical education teachers can make a big difference in students' performance on the test," said Linda Hooper, an education, research and evaluation consultant for the California Department of Education.

The San Francisco Unified School District has just 15 physical education specialists for all 76 of its elementary schools. Spread thin, they work with about half the schools at any time. According to Michelle Zapata, the physical education program administrator for the district, Cesar Chavez was among the 38 schools that had no physical education specialist on campus.

Advocates for child health warn that failing to teach children how to be active and healthy will have long-term consequences.

"It comes as no surprise whatsoever that such enormous inequities would be present," said Dr. Harold Goldstein, executive director of the California Center for Public Health Advocacy, a nonprofit organization. "It is grossly unjust and will have health and economic impacts on the state of California for generations to come."

Sycamore Valley Elementary maintains a focus on health outside of physical education class time. Parents are not allowed to bring in cupcakes or other potentially fattening treats to celebrate birthdays. Instead, gifts of pencils or erasers to classmates are substituted.

Parents also contribute financially. Fund-raising pays for a twice-a-week movement class for kindergarteners that is not required by the state. In the fall, the school's Parent Teacher Association gave Mr. O'Brien a $375 grant to buy new basketball hoops, and he also leads an after-school sports camp that helps raise money to buy sports equipment.

Each fall, the PTA holds a "fun run" fund-raiser, in which students are sponsored to run laps during school. It raised nearly $10,000 this year.

Even the school's location supports fitness. It is next to a park, near a sweeping open space of rolling hills dotted with oaks. The park features a play structure, a basketball court, a bocce court and athletic fields, where Mr. O'Brien sometimes holds physical education lessons.

Many elementary school students in the suburbs also play sports outside school, including basketball and lacrosse.

Rebecca Adams, president of the Sycamore Valley Elementary PTA, said her children, who are in the first and third grades, participate in indoor soccer, swimming, gymnastics, baseball and softball, depending on the season.

Not all their activities are organized by adults. "A lot of kids play outside in their front yard," said Ms. Adams, who lives less than a mile from the school. In-line skating, biking and tag are popular.

"My kids play outside all the time," she said.

At Cesar Chavez Elementary School, physical education lessons, taught by classroom teachers, are held on a fenced-in blacktop lot below a huge, colorful mural of the school's namesake. In the mural, Mr. Chavez, the late civil rights leader, is surrounded by a crowd of children as he carries a banner that reads "Help me take responsibility for my own life so I can be free at last."

On the urban school's blacktop, the basketball rims have no nets. "We don't have a field or a park next door," said Catalina Rico, the school's principal.

Most of the students' parents, many of whom are immigrants, cannot give extra money to help beef up its programs. Some families are homeless, and many others are struggling financially.

"A lot of our kids have been traumatized by poverty, violence, their parents being deported," Ms. Rico said.

For those families, regular exercise in a safe place after school may be out of reach.

If parents are working two jobs, Ms. Rico said, "who is going to take them to the park?"

http://www.nytimes.com/2011/12/25/us/affluent-children-are-more-physically-fit-than-poor-ones.html?hpw=&pagewanted=print