Friday, March 1, 2013
My father's de facto nephew Charlie, a boisterous Irish lad in his mid-twenties, starts up a Hail Mary over the body of an atheist of Jewish extraction as if it might push life back into him. My aunt weeps. My half-sister in a red woolly hat, herself on six different types of medication, is on the phone to her mother, brightly telling her what she had for dinner. (It was stuffed aubergine.)
Charlie's younger brother Tommy, a sweet skinny boy of 20 who I last saw when he was a six-year-old potential serial killer, dissolves into my arms, sobbing. Positively radiating serenity, I stroke his head and let his grief wash over me. I have a headache from the scotch we've all been sneaking around the bed. I hate scotch. It was Bill's drink. It was Charlie's idea. I look at my father's body. He looks very dead, but then he has looked dead to me this last week, from the first time I saw him crumpled in the sheets, plastic tendrils curling from his head, one green eye stuck half-open.
I am quite aware as this is happening that it probably represents the single biggest headfuck and heartfuck of my life, and also that if it were happening in the US, the place of my father's birth, it would probably be considerably worse.
In the UK, we treat any old fucker for free. This is why that is important.
* * * *
The place of Bill's death is a foundation hospital, not directed by the government. It's a beautiful building, with open corridors around a vast central atrium filled with natural light and dotted with sculptures and fish tanks. You can't get lost in it, nor can you feel that antiseptic claustrophobia you get in hospitals.
The tax-funded UK National Health Service is now 65 years old. Foreign nationals get free treatment when they've been here for a year or otherwise have legal residency. A San Francisco native, Bill rocked up and made a home for himself in London in 1976. Since then he's had three (count 'em) artificial hips and been treated for cancer of the larynx, and is now spending his final week in intensive care. When I saw him last year for the first time in ten years, to interview him about the election for NSFWCORP, he mused on how much this country has shelled out to keep him upright: "Oh man, if you were to add up what the NHS has spent on me, it's phenomenal."
He was a charming, damaged, charismatic, fiercely intelligent, dissolute individual, who lived entirely on his own terms. As a professional gambler, it is unlikely he paid much if any tax in 37 years. He had no will, no funeral plan. He never did fill out the forms necessary to vote in the last election, or the one before that, as I discovered. He just hated forms. I could sympathise. Had he stayed in the US, it is – how you say – dollars to doughnuts he wouldn't have got it together to fill out the forms, and would have had no health insurance. He considered the US system "absolutely unmanageable".
* * * *
Bill goes into hospital on Tuesday complaining of dizziness and disorientation. We talk briefly on the phone and he sounds chipper as a chip. Some little heart arrhythmia thing, chest infection, in overnight for observation, no biggie. By Thursday he has plummeted into the subterranean limbo of the gravely ill, having most likely suffered a heart attack. He is being hauled from acute assessment up to the ICU.
Thursday afternoon I sit by his bed. Talk to him, say the nurses, he can probably hear you. With this type of sedation, the hearing is the last thing to go and the first to come back. I try. Hi, Bill. An inveterate gasbag, I find I've got nothing. I am accustomed to showers of aphorisms and miles of monologue from him. There's nothing to respond to.
An hour by a bed in the ICU is long. I bring some Vonnegut to read to him – I figure it's the sort of thing he might go for. I don't even open it. I just sit.
Late in the evening the doctor comes to talk to me. I'm the only one here so far. The friend who brought him in has yet to return, my aunt is on her way from Washington.
Bill's heart is fucked, hammering away at 150, 160, and it's fucked everything else. The kidneys are fucked. The liver is fucked. This could go on for days or weeks, the doctor says: "But my feeling is that he will pass away tonight."
So this is how it ends. I had always figured this fighty bastard – whose own father died two months ago almost to the day, aged 96 – was impervious to the usual quotidian sources of bodily doom. He beat cancer, shrugged off booze, swore that "when they come for me, which they will, I'll get 'em with my stick". When he goes, of course he's going down a manhole, under a Mercedes driven by a coked-up supermodel, into the belly of an escaped jaguar.
I'm prepared for this. I am sad, but ready. The distance from absence to departure doesn't seem so far, and it sucks, but it's OK. I go to bed in the small, snug visitors' room – the existence of which amazes me – in assurance they will wake me when it's time. Next morning he's still there. He will cling on for five more days. The notices will say 'a short illness', but they don't give any sense of how long and hard that can be.
A group of Italian researchers forced 21 surgical residents to play video games on a Nintendo Wii for an hour a day, five days a week, for four weeks. Whew!
Then the researchers had the residents perform a simulated keyhole surgery. They found that the gamers performed significantly better than another group of residents who didn't undergo this grueling video game training.
"We had a lot of fun," said Dr. Gregorio Patrizi, a professor at the University of Rome Medical School who worked on the study. "Research doesn't need to be boring."
Keyhole, or laparoscopic, surgery involves inserting tiny video cameras and instruments into your body so surgeons can operate without having to make a large incision. The approach reduces recovery times for patients, and the risk of infection goes down as well.
However, Patrizi said laparoscopy can be difficult for surgeons not used to staring at a video monitor during an operation. "You have to move in a three-dimensional space but you have a two-dimensional image on your screen," he said.
That's where the Wii comes in. Several earlier studies suggested that playing video games can boost laparoscopic skills, but those studies were largely based on surveys of surgeons' prior video gaming habits. Patrizi's study is one of the first randomized trials that had some surgeons undergo a structured game-playing routine and also maintained a separate control group.
Patrizi and his team had surgical residents play three Wii games — tennis, ping pong and one that involved shooting balloons from an aircraft. As the researchers write in their articlepublished online by PLOS ONE, they chose these games because they all required strong hand-eye coordination and three-dimensional visualization of a space.
Compared with the unlucky doctors in the control group, who didn't have an excuse to play video games for five hours a week, the residents who played the Wii games showed significantly more improvement on a laparoscopy simulator.
Though it might seem like this study was designed by Nintendo as an advertisement for the Wii, Patrizi said the video game maker had nothing to do with it. He said his team received no outside funding to conduct the experiment and didn't even notify Nintendo they were doing it.
In an email to Shots, a Nintendo spokeswoman said the company is "thrilled to hear" that the Wii might someday provide a benefit to medical science, even if that wasn't what its designers had in mind. "Did we think that the Wii would improve the performance of surgeons?" she writes. "No."
Patrizi said these results suggest that the Wii and other motion-sensing gaming consoles like Microsoft's Kinect could be used to supplement surgical training at a very low cost, especially when compared with expensive laparoscopy simulators.
To Dr. Brant Oelschlager, chief of the University of Washington's Center for Videoendoscopic Surgery, it makes sense that a video game would help a surgeon perform these procedures. "There's probably a lot of overlap in that bit of learning," he said. "Both are very unnatural environments to the novice."
But that doesn't mean hospitals should be putting Wii systems in the doctors lounge just yet. Oelschlager said video games would only be beneficial to inexperienced surgeons.
"I'm skeptical that at an advanced level that would help the surgeon become better," Oelschlager said. "At some point, it starts to have diminishing returns and you have to gain the rest of your skills in a real patient."
What's the rush? For all the white-knuckled wrangling over spending cuts set to start on Friday, the fundamental partisan argument over how to fix the government's finances is not about the immediate future. It is about the much longer term: how will the nation pay for the care of older Americans as the vast baby boom generation retires? Will the government keep Medicare spending in check by asking older Americans to shoulder more costs? Should we raise taxes instead?
It might not be a good idea to try to resolve these questions quite so urgently. Partisan bickering under the threat of automatic budget cuts is unlikely to produce a calm, thoughtful deal.
"We don't have to solve this tomorrow; not even next year," said Jonathan Gruber, an economist at the Massachusetts Institute of Technology who worked on the design of President Obama's health care reform.
More significantly perhaps, some economists point out that the problem may already be on the way toward largely fixing itself. The budget-busting rise in health care costs, it seems, is finally losing speed. While it would be foolhardy to assume that this alone will stabilize government's finances, the slowdown offers hope that the challenge may not be as daunting as the frenzied declarations from Washington make it seem.
The growth of the nation's spending slowed sharply over the last four years. This year, it is expected to increase only 3.8 percent, according to the Centers for Medicare and Medicaid Services, the slowest pace in four decades and slower than the rate of nominal economic growth.
Medicare spending is growing faster — stretched by baby boomers stepping out of the work force and into retirement. But its pace has slowed markedly, too. Earlier this month, the Congressional Budget Office said that by 2020 Medicare spending would be $126 billion less than it predicted three years ago. Spending over the coming decade, it added, would be $143 billion less than it forecast just last August.
While economists acknowledge that the recession accounts for part of the decline, depressing incomes and consumption, something else also seems to be going on: insurers, doctors, hospitals and other providers are experimenting with new, cheaper and more efficient ways to deliver care.
Prodded by President Obama's Affordable Care Act, which offers providers a share of savings reaped by Medicare from any efficiency gains, many doctors are dropping the costly practice of charging a fee for each service regardless of its contribution to patients' health. Doctors are joining hundreds of so-called Accountable Care Organizations, which are paid to maintain patients in good health and are thus encouraged to seek the most effective treatments at the lowest possible cost.
This has kindled hope among some scholars that Medicare could achieve the needed savings just by cleaning out the health care system's waste.
Elliott Fisher, who directs Dartmouth's Atlas of Health Care, which tracks disparities in medical practices and outcomes across the country, pointed out that Medicare spending per person varies widely regardless of quality — from $7,734 a year in Minneapolis to $11,646 in Chicago — even after correcting for the different age, sex and race profiles of their populations.
He noted that if hospital stays by Medicare enrollees across the country fell to the length prevailing in Oregon and Washington, hospital use — one of the biggest drivers of costs — would fall by almost a third.
"Twenty to 30 percent of Medicare spending is pure waste," Dr. Fisher argues. "The challenge of getting those savings is nontrivial. But those kinds of savings are not out of the question."
We could be disappointed, of course. Similar breakthroughs before have quickly fizzled. Just think back to that brief spell in the mid-1990s when health maintenance organizations seemed to beat health care inflation — until patients rebelled against being denied services and doctors dropped out of their networks rather than accept lower fees.
The Centers for Medicare and Medicaid Services already expects spending to rebound in coming years. Without tougher cost control devices, be it vouchers to limit government spending or direct government rationing, counting on savings of the scale needed to overcome the expected increase in Medicare rolls may be hoping for pie in the sky.
"It makes no sense," said Eugene Steuerle, an economist at the Urban Institute, to expect the government will reap vast Medicare savings without having an impact on the quality of care.
The Affordable Care Act already contemplates fairly big cuts to Medicare. In its latest long-term projections published last year, the Congressional Budget Office estimated that under current law, growth in spending per beneficiary over the coming decade would be about half a percentage point slower than the rate of economic growth per person.
To understand how ambitious this is, consider that Medicare spending per beneficiary since 1985 has exceeded the growth of gross domestic product per person by about 1.5 percentage points per year. Slowing down that spending would require deep cuts in doctor reimbursements that, though written into law, Congress has never allowed to happen — repeatedly voting to cancel or postpone them.
Under a more realistic situation, the Budget Office projected that the growth of Medicare spending per capita over the next 10 years would be in fact 0.6 percentage points higher than under current law and accelerate further after that.
Yet despite the ambition of these targets, they would not be enough to stabilize future Medicare spending as a share of the economy. A report by three health care policy experts, Michael Chernew and Richard Frank of Harvard Medical School, together with Stephen Parente of the University of Minnesota, concluded that to do that would require limiting the growth of spending per beneficiary at 1.25 percentage points less than the growth of our gross domestic product per person.
"The Affordable Care Act places Medicare spending on a trajectory that is historically low," Mr. Chernew said, noting his opinion was not an official statement as vice chairman of Medicare's Payment Advisory Commission, which advises Congress on Medicare. "Could we do better? Of course. Will we? That requires a little more skepticism."
Yet even if it is unrealistic to expect that newfound efficiencies will stabilize Medicare's finances, the slowdown in health care spending suggests that politicians in Washington calm down. It offers, at the very least, more breathing room to carefully consider reforms to the system to raise revenue or trim benefits in the least damaging way.
There are many ideas out there — from changing Medicare's premiums, deductibles and coinsurance to introducing a tax on carbon emissions to raise revenue. Some of them are not as good as others. Until recently, President Obama favored increasing the eligibility age for Medicare. Then research by the Kaiser Family Foundation concluded that raising the age would increase insurance premiums and cost businesses, beneficiaries and states more than the federal government would save. The nation would lose money in the deal.
"As we do this, there are smarter and dumber ways to do it," Mr. Gruber said. "It would be a problem if we were to do things in a panic mode that set us backward."http://www.nytimes.com/2013/02/27/business/medicare-needs-fixing-but-not-right-now.html?src=recg&pagewanted=print
The psychiatric illnesses seem very different — schizophrenia, bipolar disorder, autism, major depression and attention deficit hyperactivity disorder. Yet they share several genetic glitches that can nudge the brain along a path to mental illness, researchers report. Which disease, if any, develops is thought to depend on other genetic or environmental factors.
Their study, published online Wednesday in the Lancet, was based on an examination of genetic data from more than 60,000 people worldwide. Its authors say it is the largest genetic study yet of psychiatric disorders. The findings strengthen an emerging view of mental illness that aims to make diagnoses based on the genetic aberrations underlying diseases instead of on the disease symptoms.
Two of the aberrations discovered in the new study were in genes used in a major signaling system in the brain, giving clues to processes that might go awry and suggestions of how to treat the diseases.
"What we identified here is probably just the tip of an iceberg," said Dr. Jordan Smoller, lead author of the paper and a professor of psychiatry at Harvard Medical School and Massachusetts General Hospital. "As these studies grow we expect to find additional genes that might overlap."
The new study does not mean that the genetics of psychiatric disorders are simple. Researchers say there seem to be hundreds of genes involved and the gene variations discovered in the new study confer only a small risk of psychiatric disease.
Steven McCarroll, director of genetics for the Stanley Center for Psychiatric Research at the Broad Institute of Harvard and M.I.T., said it was significant that the researchers had found common genetic factors that pointed to a specific signaling system.
"It is very important that these were not just random hits on the dartboard of the genome," said Dr. McCarroll, who was not involved in the new study.
The work began in 2007 when a large group of researchers began investigating genetic data generated by studies in 19 countries and including 33,332 people with psychiatric illnesses and 27,888 people free of the illnesses for comparison. The researchers studied scans of people's DNA, looking for variations in any of several million places along the long stretch of genetic material containing three billion DNA letters. The question: Did people with psychiatric illnesses tend to have a distinctive DNA pattern in any of those locations?
Researchers had already seen some clues of overlapping genetic effects in identical twins. One twin might have schizophrenia while the other had bipolar disorder. About six years ago, around the time the new study began, researchers had examined the genes of a few rare families in which psychiatric disorders seemed especially prevalent. They found a few unusual disruptions of chromosomes that were linked to psychiatric illnesses. But what surprised them was that while one person with the aberration might get one disorder, a relative with the same mutation got a different one.
Jonathan Sebat, chief of the Beyster Center for Molecular Genomics of Neuropsychiatric Diseases at the University of California, San Diego, and one of the discoverers of this effect, said that work on these rare genetic aberrations had opened his eyes. "Two different diagnoses can have the same genetic risk factor," he said.
In fact, the new paper reports, distinguishing psychiatric diseases by their symptoms has long been difficult. Autism, for example, was once called childhood schizophrenia. It was not until the 1970s that autism was distinguished as a separate disorder.
But Dr. Sebat, who did not work on the new study, said that until now it was not clear whether the rare families he and others had studied were an exception or whether they were pointing to a rule about multiple disorders arising from a single genetic glitch.
"No one had systematically looked at the common variations," in DNA, he said. "We didn't know if this was particularly true for rare mutations or if it would be true for all genetic risk." The new study, he said, "shows all genetic risk is of this nature."
The new study found four DNA regions that conferred a small risk of psychiatric disorders. For two of them, it is not clear what genes are involved or what they do, Dr. Smoller said. The other two, though, involve genes that are part of calcium channels, which are used when neurons send signals in the brain.
"The calcium channel findings suggest that perhaps — and this is a big if — treatments to affect calcium channel functioning might have effects across a range of disorders," Dr. Smoller said.
There are drugs on the market that block calcium channels — they are used to treat high blood pressure — and researchers had already postulated that they might be useful for bipolar disorder even before the current findings.
One investigator, Dr. Roy Perlis of Massachusetts General Hospital, just completed a small study of a calcium channel blocker in 10 people with bipolar disorder and is about to expand it to a large randomized clinical trial. He also wants to study the drug in people with schizophrenia, in light of the new findings. He cautions, though, that people should not rush out to take a calcium channel blocker on their own.
"We need to be sure it is safe and we need to be sure it works," Dr. Perlis said.
Thursday, February 28, 2013
In a major policy shift, the Icahn School of Medicine at Mount Sinai Wednesday announced that it will fill half of its entering class going forward by admitting college sophomores -- three years before they would enroll in medical school -- and will do so without requiring traditional pre-med course requirements and the Medical College Admission Test (MCAT).
In what a press release called the beginning of a "fundamental shift," sophomores will be admitted to"FlexMed,"  a new program in which they will spend the rest of their undergraduate time in tracks such as computational science/engineering, biomedical sciences and humanities/social sciences. Students will be encouraged to take courses in biostatistics, ethics, health policy and public health. These courses would replace the traditional pre-med science requirements .
Students will also be encouraged, but not required, to become proficient in Spanish or Mandarin.
David Muller, Mount Sinai's dean of medical education, said in an interview that although requirements issues had been "written about for years and years... there's been either an inertia or a reluctance to take a first step and break down the model and try something new. What I hope will happen is that this program will prove very successful and prove decisively that it's a viable alternative."
Mount Sinai has had a similar program  on a much smaller scale in the past, and says it has been a success.
Explaining the rationale behind the decision to take a small program and apply it to half of the class, Muller said that pre-med science requirements tend to be "science that is not the most applicable to current clinical or translational research; it's not unimportant science, but it's kind of outdated."
The announcement comes at a time that the MCAT itself is changing in ways that reflect some of the concerns raised by Mount Sinai; last year  saw the first major amendments made to the exam since 1991, with a plan to add sections on critical thinking and social sciences.
"I don't think of the MCAT as something that should be eliminated; I think the efforts to rethink the MCAT are admirable," Muller said. "[The revision] was a very thoughtful process, and yet the MCAT didn't eliminate some things that are really not that relevant to medical school. It really just sort of begins to scrape away at the iceberg of what we really need to do." Muller added that he thinks an over-reliance on the exams has developed. "The use of the MCAT, I think has really been warped over the course of time," he said.
Muller also said that the current medical education model fails to take into account changes in the medical and technological landscape. "All of science has changed, even if you went back 50 years," Muller said. "The science that has had the most impact… is completely different." For example, Muller said, when he was attending medical school, "the whole concept of information technology didn't exist… we trained at a time that there was no such thing as a computer that you had [personal] access to."
Robert Schaeffer, public education director of the National Center for Fair and Open Testing, which has been a frequent critic of the MCAT, and of standardized testing in general, called the move "definitely a step in the right direction." Schaeffer said that the alteration of requirements "moves Mount Sinai into the national leadership of medical school admissions reform. [The decision] indicates that they recognize the importance of multiple measures to assess for medical school."
Although he said it was hard to predict the best course of action before any data on the program was in, Muller said that "if we get to the point where we see that there is equivalence between the two groups… we might actually consider increasing it to a larger proportion of the class or the whole class."
"Medical schools can change their requirements at any time based on their environment and the mission of the institution," said Geoffrey Young of the Association of American Medical Colleges, which is responsible for the composition and administration of the MCAT. "The AAMC commends innovation in the medical school admissions process."
"Our hope is that this proves to be a viable alternative to the traditional path," Muller said. "It'll really all depend on the data."
Wednesday, February 27, 2013
People with fibromyalgia suffer from chronic widespread pain, sleep problems and fatigue. The illness affects more than 5 million Americans, 80 percent of whom are women. The cause of fibromyalgia is unknown and currently there is no cure. Using a Quality of Life (QOL) scale for fibromyalgia, the studies reviewed reported QOL ratings lower than 15 on a scale of 0 to 100 even among patients on medications. The two medications often prescribed to treat fibromalgia are duloxetine, known by the brand name Cymbalta or milnacipran, commonly known as Savella.
"A frank discussion between the physician and patient about the potential benefits and harms of both drugs should occur," noted the reviewers, led by Winfried Häuser, M.D. of Technische Universität München.
The authors reviewed 10 high-quality studies comprising more than 6,000 adults who received either duloxetine, milnacipran, or a placebo for up to six months. A substantial majority of study participants were middle-aged, white women.
"This is a very important study," says Fred Wolfe, M.D. of the National Data Bank for Rheumatic Diseases. "There's an enormous amount of advertising suggesting that these drugs really help, whereas the research data show that the improvement is really minimal."
Treatment with drugs alone "should be discouraged," the reviewers added. Instead, the review authors recommend a multi-faceted treatment approach including medications for those who find them helpful, exercises to improve mobility and psychological counseling to improve coping skills.
"The medical field does poorly with the treatment of fibromyalgia in general," says Brian Walitt, M.D., M.P.H., a co-author of the review and an expert in pain syndromes at Washington Hospital Center in Washington, D.C. "Chasing [a cure] with medicine doesn't seem to work.The people who seem to me to do best sort of figure it out on their own by thinking about things, getting to know themselves, and making changes in their lives to accommodate who they've become," concludes Walitt.
The only other medication approved for fibromyalgia treatment in the U.S. is the anti-convulsant pregabalin, known by the brand name Lyrica. The Cochrane Library plans to publish a review of its effectiveness later this year.
Intensive neuroscientific research is needed to reveal the underlying causes of fibromyalgia and other pain syndromes, say the researchers. In the meantime, combinations of various medications as well as combinations of drug and non-drug treatments may offer better symptom control for sufferers.
"Remember when they burnt those people's house down?" Spencer Cox asks.
We are at a reunion dinner for about half a dozen people at a restaurant on the edge of Soho. I haven't seen him since the mid-1990s. He looks unwell. It's late September, 2012. On Nov. 30 we're on a panel together for World AIDS Day at St. Luke's-Roosevelt Hospital Center. By Dec. 18 he is dead.
I don't remember, so I look it up when I get back to D.C. In 1987, in Arcadia, Florida, Clifford and Louise Ray's house mysteriously burned to the ground after a court ordered the local schools had to admit their HIV-positive hemopheliac sons, despite community objections. Other families had already been pulling their kids out of the school, which also faced multiple phoned-in bomb threats. The family decided their only option was to give up and leave town.
This was right around the same time homophobia in America peaked, according to Gallup polling of the 1986-87 period. It was Reagan's second term, there were no AIDS treatments (AZT wasn't approved until March 1987), the Supreme Court had recently upheld state laws making gay sex a crime in the June 1986Bowers v. Hardwick ruling, and 57 percent of those surveyed answered yes when asked if gay and lesbian relations should be illegal. Several states were actively considering quarantine measures for people with AIDS, which is to say, tearing some of their most marginalized and frightened citizens away from the only people who loved them and locking them up with strangers who considered them freaks and pariahs, until they died.
It's no wonder that when Nora Ephron had to cancel a speech at the Lesbian and Gay Community Services Center of New York in Greenwich Village, Manhattan, in March 1987, leading to playwright Larry Kramer subbing in for her, the gay and lesbian community in what was then the epicenter of the emerging global pandemic exploded. ACT UP, the AIDS Coalition to Unleash Power, was born out of Larry's call to action.
"Others would talk about such experiences all the time," a friend IMed me after the September release ofHow to Survive a Plague, which tells the story of the ACT UP Treatment + Data Committee (of which I was the youngest member) and the Treatment Action Group (of which I was a founding member) and how they worked to transform the drug-approval process and AIDS research in this country, leading eventually to the availability of the only successful antiretrovirals in existence and, once the U.S. and other governments decided to put some money behind drug distribution, the saving of millions of lives around the world.
My only response to that expectation of chattiness is: not if you lived through it. I've written only one reflection on that era previously, for a book a decade ago; it took me two months to squeeze out about 1,200 words, because every time I turned to the subject I either developed such a colossal headache I had to stop, or burst into tears.
Many people who were part of ACT UP have tried to write about it in retrospect, but it took an outsider who was also invested in the story, journalist-turned-filmmaker David France, to bring the story to the mainstream, to the extent that has happened over the past year. France was one of the earliest chroniclers of the epidemic, first in the gay press and later for New York and national media outlets, and a man whose partner Doug Gould, to whom the film is dedicated, died of AIDS in 1992. France's documentary, distributed by IFC and Sundance Selects, has won a slew of awards since premiering in January 2012 in the documentary competition in Sundance, and then in theaters in September. (It's also now available on iTunes and Netflix). It's even been nominated for an Academy Award in the Documentary Feature category.The movie focuses on three HIV-positive men to tell the larger story of the early years of AIDS treatment activism, when death came quick and violently: Peter Staley, a dynamic former bond trader who in his late 20s was given two years to live before joining ACT UP and undertaking some of its most daring and theatrical actions (if an action involved scaling part of a building or bolting yourself in somewhere with power tools, Peter was likely involved); film archivist and later MacArthur genius award-grantee Mark Harrington, the chain-smoking intellectual force behind T+D on whose amber-screened 286 computer most of T+D's giant technical documents were tapped out; and the late Bob Rafsky, a publicist turned ACT UPper who famously heckled then-candidate Bill Clinton in 1992 and was told in reply a line that would come to define the president, "I feel your pain."
As the lockout dragged on for more than four months, though, the conversation shifted from player safety to revenue percentages and competitive balance. The first few weeks of the shortened 48-game season passed without much talk of concussions.
But in the past two weeks, 11 N.H.L. players are believed to have sustained them, among them Crosby's teammate and the reigning most valuable player, Evgeni Malkin, thrusting the issue of head injuries back into the spotlight.
Concussions continue to plague the league, despite its increased emphasis on reducing them. For the second season, the N.H.L. is playing under its broadened version of Rule 48, which penalizes hits that target an opponent's head or make the head the principal point of contact. But many of the recent injuries, including Malkin's, were not caused by hits deemed worthy of fines or suspensions.
Last season, according to CBC network estimates, about 90 players missed games because of concussions, about 13 percent of N.H.L. players on active rosters on a given night. Crosby missed 60 games while recovering from a concussion he sustained in the 2011 Winter Classic.
Malkin, who has 4 goals and 17 assists in 18 games this season, received a concussion diagnosis Sunday, two days after he fell awkwardly into the end boards following a routine shove from Florida's Erik Gudbranson. Malkin slid back-first into the boards, causing his head to snap sharply backward and strike the boards.
Penguins Coach Dan Bylsma said Malkin initially had short-term memory loss but was improving. The team placed Malkin on injured reserve Monday, retroactive to Sunday. A player on injured reserve is ineligible to play for a minimum of seven days, meaning the soonest Malkin can be reactivated is next Sunday.
"There's not a specific schedule for that right now in terms of physical activity," Bylsma told reporters Tuesday in Sunrise, Fla., where the Penguins played the Panthers again.
"The protocol and resting with a concussion, he's following that right now," Bylsma added.
The Penguins, who lead the Atlantic Division, have a new medical team this season, headed by Dr. Christopher Harner of the University of Pittsburgh Medical Center, where the team is planning to open a training, sports medicine and performance facility. The Penguins announced in the summer that they had ended their association with their longtime team doctor, Charles Burke.
The team and Burke said that their parting was amicable and not related to Crosby's 14-month concussion saga. Penguins President David Morehouse said the team "wanted to have enhanced medical coverage for our players," which included having doctors travel with the team.
Perhaps because of their history with Crosby, the Penguins are among the N.H.L.'s most transparent teams in disclosing concussions, and General Manager Ray Shero is considered a progressive voice in support of tighter rules governing hits to the head and concussion protocol.
A lack of openness about concussions can make it difficult to have an accurate accounting of head injuries. Among the other players with recently announced head injuries are the 20-year-old Carolina forward Jeff Skinner, who missed 16 games last season with a concussion; St. Louis's high-scoring rookie Vladimir Tarasenko; another top rookie, Brendan Gallagher of Montreal; and Devils winger Ryan Carter.
Under N.H.L. regulations, clubs are not required to disclose the specific nature of a player's injury. But they are not permitted to give out false or misleading information about an injury.
The Columbus Blue Jackets' announcement that Artem Anisimov is out with an "upper body injury" is allowed under those guidelines, even though he was taken off the ice in Detroit on a stretcher Thursday after his head was driven into the ice by the elbow of a falling Red Wing, Kyle Quincey.
The Rangers do not always disclose players' concussions. Rick Nash and Ryan McDonagh are believed to be out of the lineup with concussions, but the team has issued no details regarding their conditions. Forward Darroll Powe was sidelined with a confirmed concussion Feb. 17, but returned to play on Tuesday.
Nash, who has missed four games, returned to practice Tuesday and told reporters that his absence was because of a "number of things." He declined to confirm or deny that a concussion was among the injuries.
The Rangers have been reluctant to disclose concussions in the recent past. In January 2011, they revealed that the enforcer Derek Boogaard had sustained a concussion in a fight about a month earlier, and in September 2011 they disclosed that defenseman Marc Staal had played more than two months at the end of the previous season with concussion symptoms. Staal did not return to game action until the 2012 Winter Classic.
"Where are we?" "Who did we play in the last game?" "What is the date today?"
Those are some of the questions N.F.L. players are asked after they are hit in the head during a game. Next season, they are coming to an iPad.
The mandatory postinjury sideline concussion assessment tool, instituted for the 2012 season along with a baseline test done during physicals at the start of preseason, will now be used in app form by all 32 teams, a method that was tried by a handful of teams in a pilot program last season. The hope is that being able to compare the results of a baseline test and a postinjury test side by side in real time will speed diagnosis and help doctors and trainers recognize when a player should be removed from a game. The league also plans to have independent neurological consultants on the sideline during each game to assist the team physician in diagnosing and treating players.
The players union, which had pushed strongly for independent doctors to be on the sideline, said it was encouraged by the technological advance the new test represented, but it still had questions about how much power the independent consultants would have to make decisions about players. The union wants the independent sideline concussion experts to have almost exclusive authority in detecting concussions and administering tests, in part because it believes team doctors are often busy attending to other injured players, while the concussion experts are there for one reason.
"If you're busy and didn't see the play, how do you know you need us?" said Dr. Thomas Mayer, the union's medical director. "This is a big enough issue we need an extra set of eyes, an extra judgment."
The postinjury test is quick — it takes about six to eight minutes — and shares many elements with the baseline test to allow a comparison that might indicate a decline in function. Both include a section on the players' concussion history and a 24-symptom checklist; players are asked to score themselves on a scale of 1 to 6 in categories like dizziness, confusion, irritability and sleep problems. Both note any abnormal pupil reaction or neck pain. There is a balance test and a concentration test, in which players, who are usually brought to the locker room to be evaluated, are asked to say the months of the year in reverse order, to recite a string of numbers backward and to remember a collection of words three times. Then they are asked to recall them again, without warning, at least five minutes later. The words and sequence of numbers may be changed from test to test, so players cannot memorize them from a previous test to mask concussion symptoms — a fact that has annoyed players, according to Dr. Margot Putukian, the director of athletic medicine at Princeton University Health Services and a member of the N.F.L.'s Head, Neck and Spine Committee.
On the postinjury tests, there is one different element: a series of five questions designed to test orientation and glean how confused a player might be at that moment. They are: Where are we? What quarter is it right now? Who scored last in the practice or game? Did we win the last game? Those questions, known as Maddocks questions, were developed in the 1990s by an Australian doctor who worked with players in Australian rules football.
"What the application does, when you are evaluating the athlete, you actually see — as they are doing their word recall — his baseline," said Putukian, who added that it was her understanding that team doctors would administer the tests. "He was able to remember 15 out of 15 words, and now he's having trouble giving you five back right away? Maybe he's only able to remember two? It gives you real-time information."
The tests are far from perfect tools for diagnosing concussions. Some doctors are concerned the N.F.L. tests are trying to reduce concussion evaluation to ticking items off a checklist, a problem Putukian acknowledged, emphasizing the importance of having doctors familiar with the players evaluate them. Last season, Jets running back Shonn Greene took a hit to his helmet in a game and walked unsteadily back toward the huddle before quarterback Mark Sanchez sent him off. Greene later returned to the game, and the Jets said he had passed concussion tests given in the locker room. Also last season, San Francisco quarterback Alex Smith took a hit that caused blurred vision, but he remained in the game for several plays and completed a touchdown pass before being removed. He was subsequently found to have a concussion. While he was out, the backup Colin Kaepernick took over, and Smith effectively lost his starting job.
"I think we have to be careful," Putukian said. "The tool, it's not the be-all, end-all. There are going to be athletes who have concussions that this tool does not pick up. It's not a perfect test. Nor is there one. We don't have one that is a perfect test."
She added: "Athletes may take this and perform this test and do fine on it. But you may know the athlete, athletes will stumble through it — 'Yeah, we played the Seawhawks' — you know they are struggling. It's not bang, bang, bang. They'll give you the right answers, but they are struggling. If you know that athlete, you say: 'I know you passed the test, but I know you. You're not O.K.' "