Showing posts with label Health. Show all posts
Showing posts with label Health. Show all posts

Well: Ask Well: Squats for Aging Knees

You are already doing many things right, in terms of taking care of your aging knees. In particular, it sounds as if you are keeping your weight under control. Carrying extra pounds undoubtedly strains knees and contributes to pain and eventually arthritis.

You mention weight training, too, which is also valuable. Sturdy leg muscles, particularly those at the front and back of the thighs, stabilize the knee, says Joseph Hart, an assistant professor of kinesiology and certified athletic trainer at the University of Virginia, who often works with patients with knee pain.

An easy exercise to target those muscles is the squat. Although many of us have heard that squats harm knees, the exercise is actually “quite good for the knees, if you do the squats correctly,” Dr. Hart says. Simply stand with your legs shoulder-width apart and bend your legs until your thighs are almost, but not completely, parallel to the ground. Keep your upper body straight. Don’t bend forward, he says, since that movement can strain the knees. Try to complete 20 squats, using no weight at first. When that becomes easy, Dr. Hart suggests, hold a barbell with weights attached. Or simply clutch a full milk carton, which is my cheapskate’s squats routine.

Straight leg lifts are also useful for knee health. Sit on the floor with your back straight and one leg extended and the other bent toward your chest. In this position, lift the straight leg slightly off the ground and hold for 10 seconds. Repeat 10 to 20 times and then switch legs.

You can also find other exercises that target the knees in this video, “Increasing Knee Stability.”

Of course, before starting any exercise program, consult a physician, especially, Dr. Hart says, if your knees often ache, feel stiff or emit a strange, clicking noise, which could be symptoms of arthritis.

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Personal Health: Keeping Blood Pressure in Check

Since the start of the 21st century, Americans have made great progress in controlling high blood pressure, though it remains a leading cause of heart attacks, strokes, congestive heart failure and kidney disease.

Now 48 percent of the more than 76 million adults with hypertension have it under control, up from 29 percent in 2000.

But that means more than half, including many receiving treatment, have blood pressure that remains too high to be healthy. (A normal blood pressure is lower than 120 over 80.) With a plethora of drugs available to normalize blood pressure, why are so many people still at increased risk of disease, disability and premature death? Hypertension experts offer a few common, and correctable, reasons:


Jane Brody speaks about hypertension.




¶ About 20 percent of affected adults don’t know they have high blood pressure, perhaps because they never or rarely see a doctor who checks their pressure.

¶ Of the 80 percent who are aware of their condition, some don’t appreciate how serious it can be and fail to get treated, even when their doctors say they should.

¶ Some who have been treated develop bothersome side effects, causing them to abandon therapy or to use it haphazardly.

¶ Many others do little to change lifestyle factors, like obesity, lack of exercise and a high-salt diet, that can make hypertension harder to control.

Dr. Samuel J. Mann, a hypertension specialist and professor of clinical medicine at Weill-Cornell Medical College, adds another factor that may be the most important. Of the 71 percent of people with hypertension who are currently being treated, too many are taking the wrong drugs or the wrong dosages of the right ones.

Dr. Mann, author of “Hypertension and You: Old Drugs, New Drugs, and the Right Drugs for Your High Blood Pressure,” says that doctors should take into account the underlying causes of each patient’s blood pressure problem and the side effects that may prompt patients to abandon therapy. He has found that when treatment is tailored to the individual, nearly all cases of high blood pressure can be brought and kept under control with available drugs.

Plus, he said in an interview, it can be done with minimal, if any, side effects and at a reasonable cost.

“For most people, no new drugs need to be developed,” Dr. Mann said. “What we need, in terms of medication, is already out there. We just need to use it better.”

But many doctors who are generalists do not understand the “intricacies and nuances” of the dozens of available medications to determine which is appropriate to a certain patient.

“Prescribing the same medication to patient after patient just does not cut it,” Dr. Mann wrote in his book.

The trick to prescribing the best treatment for each patient is to first determine which of three mechanisms, or combination of mechanisms, is responsible for a patient’s hypertension, he said.

¶ Salt-sensitive hypertension, more common in older people and African-Americans, responds well to diuretics and calcium channel blockers.

¶ Hypertension driven by the kidney hormone renin responds best to ACE inhibitors and angiotensin receptor blockers, as well as direct renin inhibitors and beta-blockers.

¶ Neurogenic hypertension is a product of the sympathetic nervous system and is best treated with beta-blockers, alpha-blockers and drugs like clonidine.

According to Dr. Mann, neurogenic hypertension results from repressed emotions. He has found that many patients with it suffered trauma early in life or abuse. They seem calm and content on the surface but continually suppress their distress, he said.

One of Dr. Mann’s patients had had high blood pressure since her late 20s that remained well-controlled by the three drugs her family doctor prescribed. Then in her 40s, periodic checks showed it was often too high. When taking more of the prescribed medication did not result in lasting control, she sought Dr. Mann’s help.

After a thorough work-up, he said she had a textbook case of neurogenic hypertension, was taking too much medication and needed different drugs. Her condition soon became far better managed, with side effects she could easily tolerate, and she no longer feared she would die young of a heart attack or stroke.

But most patients should not have to consult a specialist. They can be well-treated by an internist or family physician who approaches the condition systematically, Dr. Mann said. Patients should be started on low doses of one or more drugs, including a diuretic; the dosage or number of drugs can be slowly increased as needed to achieve a normal pressure.

Specialists, he said, are most useful for treating the 10 percent to 15 percent of patients with so-called resistant hypertension that remains uncontrolled despite treatment with three drugs, including a diuretic, and for those whose treatment is effective but causing distressing side effects.

Hypertension sometimes fails to respond to routine care, he noted, because it results from an underlying medical problem that needs to be addressed.

“Some patients are on a lot of blood pressure drugs — four or five — who probably don’t need so many, and if they do, the question is why,” Dr. Mann said.


How to Measure Your Blood Pressure

Mistaken readings, which can occur in doctors’ offices as well as at home, can result in misdiagnosis of hypertension and improper treatment. Dr. Samuel J. Mann, of Weill Cornell Medical College, suggests these guidelines to reduce the risk of errors:

¶ Use an automatic monitor rather than a manual one, and check the accuracy of your home monitor at the doctor’s office.

¶ Use a monitor with an arm cuff, not a wrist or finger cuff, and use a large cuff if you have a large arm.

¶ Sit quietly for a few minutes, without talking, after putting on the cuff and before checking your pressure.

¶ Check your pressure in one arm only, and take three readings (not more) one or two minutes apart.

¶ Measure your blood pressure no more than twice a week unless you have severe hypertension or are changing medications.

¶ Check your pressure at random, ordinary times of the day, not just when you think it is high.

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Ariel Sharon Brain Scan Shows Response to Stimuli





JERUSALEM — A brain scan performed on Ariel Sharon, the former Israeli prime minister who had a devastating stroke seven years ago and is presumed to be in a vegetative state, revealed significant brain activity in response to external stimuli, raising the chances that he is able to hear and understand, a scientist involved in the test said Sunday.




Scientists showed Mr. Sharon, 84, pictures of his family, had him listen to a recording of the voice of one of his sons and used tactile stimulation to assess the extent of his brain’s response.


“We were surprised that there was activity in the proper parts of the brain,” said Prof. Alon Friedman, a neuroscientist at Ben-Gurion University of the Negev and a member of the team that carried out the test. “It raises the chances that he hears and understands, but we cannot be sure. The test did not prove that.”


The activity in specific regions of the brain indicated appropriate processing of the stimulations, according to a statement from Ben-Gurion University, but additional tests to assess Mr. Sharon’s level of consciousness were less conclusive.


“While there were some encouraging signs, these were subtle and not as strong,” the statement added.


The test was carried out last week at the Soroka University Medical Center in the southern Israeli city of Beersheba using a state-of-the-art M.R.I. machine and methods recently developed by Prof. Martin M. Monti of the University of California, Los Angeles. Professor Monti took part in the test, which lasted approximately two hours.


Mr. Sharon’s son Gilad said in October 2011 that he believed that his father responded to some requests. “When he is awake, he looks at me and moves fingers when I ask him to,” he said at the time, adding, “I am sure he hears me.”


Professor Friedman said in a telephone interview that the test results “say nothing about the future” but may be of some help to the family and the regular medical staff caring for Mr. Sharon at a hospital outside Tel Aviv.


“There is a small chance that he is conscious but has no way of expressing it,” Professor Friedman said, but he added, “We do not know to what extent he is conscious.”


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Religious Groups and Employers Battle Contraception Mandate


Shawn Thew/European Pressphoto Agency


President Obama, with his health secretary, Kathleen Sebelius, offering a compromise on the contraception mandate last year.







In a flood of lawsuits, Roman Catholics, evangelicals and Mennonites are challenging a provision in the new health care law that requires employers to cover birth control in employee health plans — a high-stakes clash between religious freedom and health care access that appears headed to the Supreme Court.




In recent months, federal courts have seen dozens of lawsuits brought not only by religious institutions like Catholic dioceses but also by private employers ranging from a pizza mogul to produce transporters who say the government is forcing them to violate core tenets of their faith. Some have been turned away by judges convinced that access to contraception is a vital health need and a compelling state interest. Others have been told that their beliefs appear to outweigh any state interest and that they may hold off complying with the law until their cases have been judged. New suits are filed nearly weekly.


“This is highly likely to end up at the Supreme Court,” said Douglas Laycock, a law professor at the University of Virginia and one of the country’s top scholars on church-state conflicts. “There are so many cases, and we are already getting strong disagreements among the circuit courts.”


President Obama’s health care law, known as the Affordable Care Act, was the most fought-over piece of legislation in his first term and was the focus of a highly contentious Supreme Court decision last year that found it to be constitutional.


But a provision requiring the full coverage of contraception remains a matter of fierce controversy. The law says that companies must fully cover all “contraceptive methods and sterilization procedures” approved by the Food and Drug Administration, including “morning-after pills” and intrauterine devices whose effects some contend are akin to abortion.


As applied by the Health and Human Services Department, the law offers an exemption for “religious employers,” meaning those who meet a four-part test: that their purpose is to inculcate religious values, that they primarily employ and serve people who share their religious tenets, and that they are nonprofit groups under federal tax law.


But many institutions, including religious schools and colleges, do not meet those criteria because they employ and teach members of other religions and have a broader purpose than inculcating religious values.


“We represent a Catholic college founded by Benedictine monks,” said Kyle Duncan, general counsel of the Becket Fund for Religious Liberty, which has brought a number of the cases to court. “They don’t qualify as a house of worship and don’t turn away people in hiring or as students because they are not Catholic.”


In that case, involving Belmont Abbey College in North Carolina, a federal appeals court panel in Washington told the college last month that it could hold off on complying with the law while the federal government works on a promised exemption for religiously-affiliated institutions. The court told the government that it wanted an update by mid-February.


Defenders of the provision say employers may not be permitted to impose their views on employees, especially when something so central as health care is concerned.


“Ninety-nine percent of women use contraceptives at some time in their lives,” said Judy Waxman, a vice president of the National Women’s Law Center, which filed a brief supporting the government in one of the cases. “There is a strong and legitimate government interest because it affects the health of women and babies.”


She added, referring to the Centers for Disease Control and Prevention, “Contraception was declared by the C.D.C. to be one of the 10 greatest public health achievements of the 20th century.”


Officials at the Justice Department and the Health and Human Services Department declined to comment, saying the cases were pending.


A compromise for religious institutions may be worked out. The government hopes that by placing the burden on insurance companies rather than on the organizations, the objections will be overcome. Even more challenging cases involve private companies run by people who reject all or many forms of contraception.


The Alliance Defending Freedom — like Becket, a conservative group — has brought a case on behalf of Hercules Industries, a company in Denver that makes sheet metal products. It was granted an injunction by a judge in Colorado who said the religious values of the family owners were infringed by the law.


“Two-thirds of the cases have had injunctions against Obamacare, and most are headed to courts of appeals,” said Matt Bowman, senior legal counsel for the alliance. “It is clear that a substantial number of these cases will vindicate religious freedom over Obamacare. But it seems likely that the Supreme Court will ultimately resolve the dispute.”


The timing of these cases remains in flux. Half a dozen will probably be argued by this summer, perhaps in time for inclusion on the Supreme Court’s docket next term. So far, two- and three-judge panels on four federal appeals courts have weighed in, granting some injunctions while denying others.


One of the biggest cases involves Hobby Lobby, which started as a picture framing shop in an Oklahoma City garage with $600 and is now one of the country’s largest arts and crafts retailers, with more than 500 stores in 41 states.


David Green, the company’s founder, is an evangelical Christian who says he runs his company on biblical principles, including closing on Sunday so employees can be with their families, paying nearly double the minimum wage and providing employees with comprehensive health insurance.


Mr. Green does not object to covering contraception but considers morning-after pills to be abortion-inducing and therefore wrong.


“Our family is now being forced to choose between following the laws of the land that we love or maintaining the religious beliefs that have made our business successful and have supported our family and thousands of our employees and their families,” Mr. Green said in a statement. “We simply cannot abandon our religious beliefs to comply with this mandate.”


The United States Court of Appeals for the 10th Circuit last month turned down his family’s request for a preliminary injunction, but the company has found a legal way to delay compliance for some months.


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40 Years After Roe v. Wade, Thousands March to Oppose Abortion


Drew Angerer/The New York Times


Pro-life activists made their way down Constitution Avenue toward the Supreme Court during the March for Life in Washington on Friday.







WASHINGTON — Three days after the 40th anniversary of the decision in Roe v. Wade, the landmark Supreme Court case that legalized abortion, tens of thousands of abortion opponents from around the country came to the National Mall on Friday for the annual March for Life rally, which culminated in a demonstration in front of the Supreme Court building.




On a gray morning when the temperature was well below freezing, the crowd pressed in close against the stage to hear more than a dozen speakers, who included Tony Perkins, the president of the Family Research Council; Representative Diane Black, Republican of Tennessee, who recently introduced legislation to withhold financing from Planned Parenthood, and Senator Rand Paul, Republican of Kentucky; Cardinal Seán Patrick O’Malley of Boston; and Rick Santorum, the former senator from Pennsylvania and Republican presidential candidate.


Mr. Santorum spoke of his wife’s decision not to have an abortion after they learned that their child — their daughter Bella, now 4 — had a rare genetic disorder called Trisomy 18.


“We all know that death is never better, never better,” Mr. Santorum said. “Bella is better for us, and we are better because of Bella.”


Jeanne Monahan, the president of the March for Life Education and Defense Fund, said that the march was both somber and hopeful.


“We’ve lost 55 million Americans to abortion,” she said. “At the same time, I think we’re starting to win. We’re winning in the court of public opinion, we’re winning in the states with legislation.”


Though the main event officially started at noon, the day began much earlier for the participants, with groups in matching scarves engaged in excited chatter on the subway and gaggles of schoolchildren wearing name tags around their necks. Arriving on the Mall, attendees were greeted with free signs (“Defund Planned Parenthood” and “Personhood for Everyone”) and a man barking into a megaphone, “Ireland is on the brink of legalizing abortion, which is not good.”


The march came two months after the 2012 campaign season, in which social issues like abortion largely took a back seat to the focus on the economy. But the issue did come up in Congressional races in which Republican candidates made controversial statements about rape or abortion. In Indiana, Richard E. Mourdock, a Republican candidate for the Senate, said in a debate that he believed that pregnancies resulting from rape were something that “God intended,” and in Illinois, Representative Joe Walsh said in a debate that abortion was never necessary to save the life of the mother because of “advances in science and technology.” Both men lost, hurt by a backlash from female voters.


Recent polls show that while a majority of Americans do not want Roe v. Wade to be overturned entirely, many favor some restrictions. In a Gallup poll released this week, 52 percent of those surveyed said that abortions should be legal only under certain circumstances, while 28 percent said they should be legal under all circumstances, and 18 percent said they should be illegal under all circumstances. In a Pew poll this month, 63 percent of respondents said they did not want Roe v. Wade to be overturned completely, and 29 percent said they did — views largely consistent with surveys taken over the past two decades.


“Most Americans want some restrictions on abortion,” Ms. Monahan said. “We see abortion as the human rights abuse of today.”


Speaker John A. Boehner of Ohio, who spoke via a recorded video, called on the protest group, particularly the young people, to make abortion “a relic of the past.”


“Human life is not an economic or political commodity, and no government on earth has the right to treat it that way,” he said.


The crowd was dotted with large banners, many bearing the names of the attendees’ home states and churches and colleges. Gary Storey, 36, stood holding a handmade sign that read “I was adopted. Thanks Mom for my life.” Next to him stood his adoptive mother, Ellen Storey, 66, who held her own handmade sign with a picture of her six children and the words “To the mothers of our four adopted children, ‘Thank You’ for their lives.”


Mr. Storey said he was grateful for the decision by his biological mother to carry through with her pregnancy. “Beats the alternative,” he joked.


Last week, the Planned Parenthood Federation of America started a new Web site, and on Tuesday, its president, Cecile Richards, released a statement supporting abortion rights.


“Planned Parenthood understands that abortion is a deeply personal and often complex decision for a woman to consider, if and when she needs it,” she said. “A woman should have accurate information about all of her options around her pregnancy. To protect her health and the health of her family, a woman must have access to safe, legal abortion without interference from politicians, as protected by the Supreme Court for the last 40 years.”


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The New Old Age Blog: Grief Over New Depression Diagnosis

When the American Psychiatric Association unveils a proposed new version of its Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric diagnoses, it expects controversy. Illnesses get added or deleted, acquire new definitions or lists of symptoms. Everyone from advocacy groups to insurance companies to litigators — all have an interest in what’s defined as mental illness — pays close attention. Invariably, complaints ensue.

“We asked for commentary,” said David Kupfer, the University of Pittsburgh psychiatrist who has spent six years as chairman of the task force that is updating the handbook. He sounded unruffled. “We asked for it and we got it. This was not going to be done in a dark room somewhere.”

But the D.S.M. 5, to be published in May, has generated an unusual amount of heat. Two changes, in particular, could have considerable impact on older people and their families.

First, the new volume revises some of the criteria for major depressive disorder. The D.S.M. IV (among other changes, the new manual swaps Roman numerals for Arabic ones) set out a list of symptoms that over a two-week period would trigger a diagnosis of major depression: either feelings of sadness or emptiness, or a loss of interest or pleasure in most daily activities, plus sleep disturbances, weight loss, fatigue, distraction or other problems, to the extent that they impair someone’s functioning.

Traditionally, depression has been underdiagnosed in older adults. When people’s health suffers and they lose friends and loved ones, the sentiment went, why wouldn’t they be depressed? A few decades back, Dr. Kupfer said, “what was striking to me was the lack of anyone getting a depression diagnosis, because that was ‘normal aging.’” We don’t find depression in old age normal any longer.

But critics of the D.S.M. 5 now argue that depression may become overdiagnosed, because this version removes the so-called “bereavement exclusion.” That was a paragraph that cautioned against diagnosing depression in someone for at least two months after loss of a loved one, unless that patient had severe symptoms like suicidal thoughts.

Without that exception, you could be diagnosed with this disorder if you are feeling empty, listless or distracted, a month after your parent or spouse dies.

“D.S.M. 5 is medicalizing the expected and probably necessary process of mourning that people go through,” said Allen Frances, a professor emeritus at Duke who chaired the D.S.M. IV task force and has denounced several of the changes in the new edition. “Most people get better with time and natural healing and resilience.”

If they are diagnosed with major depression before that can happen, he fears, they will be given antidepressants they may not need. “It gives the drug companies the right to peddle pills for grief,” he said.

An advisory committee to the Association for Death Education and Counseling also argued that bereaved people “will receive antidepressant medication because it is cheaper and ‘easier’ to medicate than to be involved therapeutically,” and noted that antidepressants, like all medications, have side effects.

“I can’t help but see this as a broad overreach by the APA,” Eric Widera, a geriatrician at the University of California, San Francisco, wrote on the GeriPal blog. “Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.”

But Dr. Kupfer said the panel worried that with the exclusion, too many cases of depression could be overlooked and go untreated. “If these things go on and get worse over time and begin to impair someone’s day to day function, we don’t want to use the excuse, ‘It’s bereavement — they’ll get over it,’” he said.

The new entry for major depressive disorder will include a note — the wording isn’t final — pointing out that while grief may be “understandable or appropriate” after a loss, professionals should also consider the possibility of a major depressive episode. Making that distinction, Dr. Kupfer said, will require “good solid clinical judgment.”

Initial field trials testing the reliability of D.S.M. 5 diagnoses, recently published in The American Journal of Psychiatry, don’t bolster confidence, however. An editorial remarked that “the end results are mixed, with both positive and disappointing findings.” Major depressive disorder, for instance, showed “questionable reliability.”

In an upcoming post, I’ll talk more about how patients might respond to the D.S.M. 5, and to a new diagnosis that might also affect a lot of older people — mild neurocognitive disorder.

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


This post has been revised to reflect the following correction:

Correction: January 24, 2013

An earlier version of this post misspelled the surname of a professor emeritus at Duke who chaired the D.S.M. IV task force. He is Allen Frances, not Francis.

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Well: Long Term Effects on Life Expectancy From Smoking

It is often said that smoking takes years off your life, and now a new study shows just how many: Longtime smokers can expect to lose about 10 years of life expectancy.

But amid those grim findings was some good news for former smokers. Those who quit before they turn 35 can gain most if not all of that decade back, and even those who wait until middle age to kick the habit can add about five years back to their life expectancies.

“There’s the old saw that everyone knows smoking is bad for you,” said Dr. Tim McAfee of the Centers for Disease Control and Prevention. “But this paints a much more dramatic picture of the horror of smoking. These are real people that are getting 10 years of life expectancy hacked off — and that’s just on average.”

The findings were part of research, published on Wednesday in The New England Journal of Medicine, that looked at government data on more than 200,000 Americans who were followed starting in 1997. Similar studies that were done in the 1980s and the decades prior had allowed scientists to predict the impact of smoking on mortality. But since then many population trends have changed, and it was unclear whether smokers today fared differently from smokers decades ago.

Since the 1960s, the prevalence of smoking over all has declined, falling from about 40 percent to 20 percent. Today more than half of people that ever smoked have quit, allowing researchers to compare the effects of stopping at various ages.

Modern cigarettes contain less tar and medical advances have cut the rates of death from vascular disease drastically. But have smokers benefited from these advances?

Women in the 1960s, ’70s and ’80s had lower rates of mortality from smoking than men. But it was largely unknown whether this was a biological difference or merely a matter of different habits: earlier generations of women smoked fewer cigarettes and tended to take up smoking at a later age than men.

Now that smoking habits among women today are similar to those of men, would mortality rates be the same as well?

“There was a big gap in our knowledge,” said Dr. McAfee, an author of the study and the director of the C.D.C.’s Office on Smoking and Public Health.

The new research showed that in fact women are no more protected from the consequences of smoking than men. The female smokers in the study represented the first generation of American women that generally began smoking early in life and continued the habit for decades, and the impact on life span was clear. The risk of death from smoking for these women was 50 percent higher than the risk reported for women in similar studies carried out in the 1980s.

“This sort of puts the nail in the coffin around the idea that women might somehow be different or that they suffer fewer effects of smoking,” Dr. McAfee said.

It also showed that differences between smokers and the population in general are becoming more and more stark. Over the last 20 years, advances in medicine and public health have improved life expectancy for the general public, but smokers have not benefited in the same way.

“If anything, this is accentuating the difference between being a smoker and a nonsmoker,” Dr. McAfee said.

The researchers had information about the participants’ smoking histories and other details about their health and backgrounds, including diet, alcohol consumption, education levels and weight and body fat. Using records from the National Death Index, they calculated their mortality rates over time.

People who had smoked fewer than 100 cigarettes in their lifetimes were not classified as smokers. Those who had smoked at least 100 cigarettes but had not had one within five years of the time the data was collected were classified as former smokers.

Not surprisingly, the study showed that the earlier a person quit smoking, the greater the impact. People who quit between 25 and 34 years of age gained about 10 years of life compared to those who continued to smoke. But there were benefits at many ages. People who quit between 35 and 44 gained about nine years, and those who stopped between 45 and 59 gained about four to six years of life expectancy.

From a public health perspective, those numbers are striking, particularly when juxtaposed with preventive measures like blood pressure screenings, colorectal screenings and mammography, the effects of which on life expectancy are more often viewed in terms of days or months, Dr. McAfee said.

“These things are very important, but the size of the benefit pales in comparison to what you can get from stopping smoking,” he said. “The notion that you could add 10 years to your life by something as straightforward as quitting smoking is just mind boggling.”

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The Well Column: Facing Cancer, a Stark Choice

In the 1970s, women’s health advocates were highly suspicious of mastectomies. They argued that surgeons — in those days, pretty much an all-male club — were far too quick to remove a breast after a diagnosis of cancer, with disfiguring results.

But today, the pendulum has swung the other way. A new generation of women want doctors to take a more aggressive approach, and more and more are asking that even healthy breasts be removed to ward off cancer before it can strike.

Researchers estimate that as many as 15 percent of women with breast cancer — 30,000 a year — opt to have both breasts removed, up from less than 3 percent in the late 1990s. Notably, it appears that the vast majority of these women have never received genetic testing or counseling and are basing the decision on exaggerated fears about their risk of recurrence.

In addition, doctors say an increasing number of women who have never had a cancer diagnosis are demanding mastectomies based on genetic risk. (Cancer databases don’t track these women, so their numbers are unknown.)

“We are confronting almost an epidemic of prophylactic mastectomy,” said Dr. Isabelle Bedrosian, a surgical oncologist at M. D. Anderson Cancer Center in Houston. “I think the medical community has taken notice. We don’t have data that say oncologically this is a necessity, so why are women making this choice?”

One reason may be the never-ending awareness campaigns that have left many women in perpetual fear of the disease. Improvements in breast reconstruction may also be driving the trend, along with celebrities who go public with their decision to undergo preventive mastectomy.

This month Allyn Rose, a 24-year-old Miss America contestant from Washington, D.C., made headlines when she announced plans to have both her healthy breasts removed after the pageant; both her mother and her grandmother died from breast cancer. The television personality Giuliana Rancic, 37, and the actress Christina Applegate, 41, also talked publicly about having double mastectomies after diagnoses of early-stage breast cancer.

“You’re not going to find other organs that people cut out of their bodies because they’re worried about disease,” said the medical historian Dr. Barron H. Lerner, author of “The Breast Cancer Wars” (2001). “Because breast cancer is a disease that is so emotionally charged and gets so much attention, I think at times women feel almost obligated to be as proactive as possible — that’s the culture of breast cancer.”

Most of the data on prophylactic mastectomy come from the University of Minnesota, where researchers tracked contralateral mastectomy trends (removing a healthy breast alongside one with cancer) from 1998 to 2006. Dr. Todd M. Tuttle, chief of surgical oncology, said double mastectomy rates more than doubled during that period and the rise showed no signs of slowing.

From those trends as well as anecdotal reports, Dr. Tuttle estimates that at least 15 percent of women who receive a breast cancer diagnosis will have the second, healthy breast removed. “It’s younger women who are doing it,” he said.

The risk that a woman with breast cancer will develop cancer in the other breast is about 5 percent over 10 years, Dr. Tuttle said. Yet a University of Minnesota study found that women estimated their risk to be more than 30 percent.

“I think there are women who markedly overestimate their risk of getting cancer,” he said.

Most experts agree that double mastectomy is a reasonable option for women who have a strong genetic risk and have tested positive for a breast cancer gene. That was the case with Allison Gilbert, 42, a writer in Westchester County who discovered her genetic risk after her grandmother died of breast cancer and her mother died of ovarian cancer.

Even so, she delayed the decision to get prophylactic mastectomy until her aunt died from an aggressive breast cancer. In August, she had a double mastectomy. (She had her ovaries removed earlier.)

“I feel the women in my family didn’t have a way to avoid their fate,” said Ms. Gilbert, author of the 2011 book “Parentless Parents,” about how losing a parent influences one’s own style of parenting. “Here I was given an incredible opportunity to know what I have and to do something about it and, God willing, be around for my kids longer.”

Even so, she said her decisions were not made lightly. The double mastectomy and reconstruction required an initial 11 1/2-hour surgery and an “intense” recovery. She got genetic counseling, joined support groups and researched her options.

But doctors say many women are not making such informed decisions. Last month, University of Michigan researchers reported on a study of more than 1,446 women who had breast cancer. Four years after their diagnosis, 35 percent were considering removing their healthy breast and 7 percent had already done so.

Notably, most of the women who had a double mastectomy were not at high risk for a cancer recurrence. In fact, studies suggest that most women who have double mastectomies never seek genetic testing or counseling.

“Breast cancer becomes very emotional for people, and they view a breast differently than an arm or a required body part that you use every day,” said Sarah T. Hawley, an associate professor of internal medicine at the University of Michigan. “Women feel like it’s a body part over which they totally have a choice, and they say, ‘I want to put this behind me — I don’t want to worry about it anymore.’ ”


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Well: An Unexpected Road Hazard: Obesity

Obesity carries yet another surprising risk, according to a new study: obese drivers are more likely than normal weight drivers to die in a car crash.

Researchers reviewed data on accidents recorded in the Fatality Analysis Reporting System, managed by the National Highway Traffic Safety Administration. Beginning with 41,283 collisions, the scientists selected accidents in which the cars, trucks or minivans were the same size.

Then the investigators gathered statistics on height and weight from driver’s licenses and categorized the drivers of wrecked cars into four groups based on body mass index. The study, published online Monday in the Emergency Medicine Journal, also recorded information on seat-belt use, time of day of the accident, driver sex, driver alcohol use, air bag deployment and collision type.

In the analysis, there were 6,806 drivers involved in 3,403 accidents, all of which involved at least one fatality. Among the 5,225 drivers for whom the researchers had complete information, 3 percent were underweight (a B.M.I of less than 18.5), 46 percent were of normal weight (18.5 to 24.9), 33 percent were overweight (25 to 29.9) and 18 percent were obese (a B.M.I. above 30).

Drivers with a B.M.I. under 18 and those between 25 and 29.9 had death rates about the same as people of normal weight, the researchers found. But among the obese, the higher the B.M.I., the more likely a driver was to die in an accident.

A B.M.I. of 30 to 34.9 was linked to a 21 percent increase in risk of death, and a number between 35 and 39.9 to a 51 percent increase. Drivers with a B.M.I. above 40 were 81 percent more likely to die than those of normal weight in similar accidents.

The reasons for the association are unclear, but they probably involve both vehicle design and the poorer health of obese people. The authors cite one study using obese and normal cadavers, in which obese people had significantly more forward movement away from the vehicle seat before the seat belt engaged because the additional soft tissue prevented the belt from fitting tightly.

“This adds one more item to the long list of negative consequences of obesity,” said the lead author, Thomas M. Rice, an epidemiologist with the Transportation Research and Education Center of the University of California, Berkeley. “It’s one more reason to lose weight.”

Other factors that might have affected fatality rates — the age and sex of the driver, the vehicle type, seat-belt use, alcohol use, air bag deployment and whether the collision was head-on or not — did not explain the differences between obese and normal weight drivers.

“Vehicle designers are teaching to the test — designing so that crash-test dummies do well,” Dr. Rice said. “But crash-test dummies are typically normal size adults and children. They’re not designed to account for our nation’s changing body types.”

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Well: Holly the Cat's Incredible Journey

Nobody knows how it happened: an indoor housecat who got lost on a family excursion managing, after two months and about 200 miles, to return to her hometown.

Even scientists are baffled by how Holly, a 4-year-old tortoiseshell who in early November became separated from Jacob and Bonnie Richter at an R.V. rally in Daytona Beach, Fla., appeared on New Year’s Eve — staggering, weak and emaciated — in a backyard about a mile from the Richters’ house in West Palm Beach.

“Are you sure it’s the same cat?” wondered John Bradshaw, director of the University of Bristol’s Anthrozoology Institute. In other cases, he has suspected, “the cats are just strays, and the people have got kind of a mental justification for expecting it to be the same cat.”

But Holly not only had distinctive black-and-brown harlequin patterns on her fur, but also an implanted microchip to identify her.

“I really believe these stories, but they’re just hard to explain,” said Marc Bekoff, a behavioral ecologist at the University of Colorado. “Maybe being street-smart, maybe reading animal cues, maybe being able to read cars, maybe being a good hunter. I have no data for this.”

There is, in fact, little scientific dogma on cat navigation. Migratory animals like birds, turtles and insects have been studied more closely, and use magnetic fields, olfactory cues, or orientation by the sun.

Scientists say it is more common, although still rare, to hear of dogs returning home, perhaps suggesting, Dr. Bradshaw said, that they have inherited wolves’ ability to navigate using magnetic clues. But it’s also possible that dogs get taken on more family trips, and that lost dogs are more easily noticed or helped by people along the way.

Cats navigate well around familiar landscapes, memorizing locations by sight and smell, and easily figuring out shortcuts, Dr. Bradshaw said.

Strange, faraway locations would seem problematic, although he and Patrick Bateson, a behavioral biologist at Cambridge University, say that cats can sense smells across long distances. “Let’s say they associate the smell of pine with wind coming from the north, so they move in a southerly direction,” Dr. Bateson said.

Peter Borchelt, a New York animal behaviorist, wondered if Holly followed the Florida coast by sight or sound, tracking Interstate 95 and deciding to “keep that to the right and keep the ocean to the left.”

But, he said, “nobody’s going to do an experiment and take a bunch of cats in different directions and see which ones get home.”

The closest, said Roger Tabor, a British cat biologist, may have been a 1954 study in Germany which cats placed in a covered circular maze with exits every 15 degrees most often exited in the direction of their homes, but more reliably if their homes were less than five kilometers away.

New research by the National Geographic and University of Georgia’s Kitty Cams Project, using video footage from 55 pet cats wearing video cameras on their collars, suggests cat behavior is exceedingly complex.

For example, the Kitty Cams study found that four of the cats were two-timing their owners, visiting other homes for food and affection. Not every cat, it seems, shares Holly’s loyalty.

KittyCams also showed most of the cats engaging in risky behavior, including crossing roads and “eating and drinking substances away from home,” risks Holly undoubtedly experienced and seems lucky to have survived.

But there have been other cats who made unexpected comebacks.

“It’s actually happened to me,” said Jackson Galaxy, a cat behaviorist who hosts “My Cat From Hell” on Animal Planet. While living in Boulder, Colo., he moved across town, whereupon his indoor cat, Rabbi, fled and appeared 10 days later at the previous house, “walking five miles through an area he had never been before,” Mr. Galaxy said.

Professor Tabor cited longer-distance reports he considered credible: Murka, a tortoiseshell in Russia, traveling about 325 miles home to Moscow from her owner’s mother’s house in Voronezh in 1989; Ninja, who returned to Farmington, Utah, in 1997, a year after her family moved from there to Mill Creek, Wash.; and Howie, an indoor Persian cat in Australia who in 1978 ran away from relatives his vacationing family left him with and eventually traveled 1,000 miles to his family’s home.

Professor Tabor also said a Siamese in the English village of Black Notley repeatedly hopped a train, disembarked at White Notley, and walked several miles back to Black Notley.

Still, explaining such journeys is not black and white.

In the Florida case, one glimpse through the factual fog comes on the little cat’s feet. While Dr. Bradshaw speculated Holly might have gotten a lift, perhaps sneaking under the hood of a truck heading down I-95, her paws suggest she was not driven all the way, nor did Holly go lightly.

“Her pads on her feet were bleeding,” Ms. Richter said. “Her claws are worn weird. The front ones are really sharp, the back ones worn down to nothing.”

Scientists say that is consistent with a long walk, since back feet provide propulsion, while front claws engage in activities like tearing. The Richters also said Holly had gone from 13.5 to 7 pounds.

Holly hardly seemed an adventurous wanderer, though her background might have given her a genetic advantage. Her mother was a feral cat roaming the Richters’ mobile home park, and Holly was born inside somebody’s air-conditioner, Ms. Richter said. When, at about six weeks old, Holly padded into their carport and jumped into the lap of Mr. Richter’s mother, there were “scars on her belly from when the air conditioner was turned on,” Ms. Richter said.

Scientists say that such early experience was too brief to explain how Holly might have been comfortable in the wild — after all, she spent most of her life as an indoor cat, except for occasionally running outside to chase lizards. But it might imply innate personality traits like nimbleness or toughness.

“You’ve got these real variations in temperament,” Dr. Bekoff said. “Fish can by shy or bold; there seem to be shy and bold spiders. This cat, it could be she has the personality of a survivor.”

He said being an indoor cat would not extinguish survivalist behaviors, like hunting mice or being aware of the sun’s orientation.

The Richters — Bonnie, 63, a retired nurse, and Jacob, 70, a retired airline mechanics’ supervisor and accomplished bowler — began traveling with Holly only last year, and she easily tolerated a hotel, a cabin or the R.V.

But during the Good Sam R.V. Rally in Daytona, when they were camping near the speedway with 3,000 other motor homes, Holly bolted when Ms. Richter’s mother opened the door one night. Fireworks the next day may have further spooked her, and, after searching for days, alerting animal agencies and posting fliers, the Richters returned home catless.

Two weeks later, an animal rescue worker called the Richters to say a cat resembling Holly had been spotted eating behind the Daytona franchise of Hooters, where employees put out food for feral cats.

Then, on New Year’s Eve, Barb Mazzola, a 52-year-old university executive assistant, noticed a cat “barely standing” in her backyard in West Palm Beach, struggling even to meow. Over six days, Ms. Mazzola and her children cared for the cat, putting out food, including special milk for cats, and eventually the cat came inside.

They named her Cosette after the orphan in Les Misérables, and took her to a veterinarian, Dr. Sara Beg at Paws2Help. Dr. Beg said the cat was underweight and dehydrated, had “back claws and nail beds worn down, probably from all that walking on pavement,” but was “bright and alert” and had no parasites, heartworm or viruses. “She was hesitant and scared around people she didn’t know, so I don’t think she went up to people and got a lift,” Dr. Beg said. “I think she made the journey on her own.”

At Paws2Help, Ms. Mazzola said, “I almost didn’t want to ask, because I wanted to keep her, but I said, ‘Just check and make sure she doesn’t have a microchip.’” When told the cat did, “I just cried.”

The Richters cried, too upon seeing Holly, who instantly relaxed when placed on Mr. Richter’s shoulder. Re-entry is proceeding well, but the mystery persists.

“We haven’t the slightest idea how they do this,” Mr. Galaxy said. “Anybody who says they do is lying, and, if you find it, please God, tell me what it is.”

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Personal Health: That Loving Feeling Takes a Lot of Work

When people fall in love and decide to marry, the expectation is nearly always that love and marriage and the happiness they bring will last; as the vows say, till death do us part. Only the most cynical among us would think, walking down the aisle, that if things don’t work out, “We can always split.”

But the divorce rate in the United States is half the marriage rate, and that does not bode well for this cherished institution.

While some divorces are clearly justified by physical or emotional abuse, intolerable infidelity, addictive behavior or irreconcilable incompatibility, experts say many severed marriages seem to have just withered and died from a lack of effort to keep the embers of love alive.


Jane Brody speaks about love and marriage.



I say “embers” because the flame of love — the feelings that prompt people to forget all their troubles and fly down the street with wings on their feet — does not last very long, and cannot if lovers are ever to get anything done. The passion ignited by a new love inevitably cools and must mature into the caring, compassion and companionship that can sustain a long-lasting relationship.

Studies by Richard E. Lucas and colleagues at Michigan State University have shown that the happiness boost that occurs with marriage lasts only about two years, after which people revert to their former levels of happiness — or unhappiness.

Infatuation and passion have even shorter life spans, and must evolve into “companionate love, composed more of deep affection, connection and liking,” according to Sonja Lyubomirsky, a professor of psychology at the University of California, Riverside.

In her new book, “The Myths of Happiness,” Dr. Lyubomirsky describes a slew of research-tested actions and words that can do wonders to keep love alive.

She points out that the natural human tendency to become “habituated” to positive circumstances — to get so used to things that make us feel good that they no longer do — can be the death knell of marital happiness. Psychologists call it “hedonic adaptation”: things that thrill us tend to be short-lived.

So Dr. Lyubomirsky’s first suggestion is to adopt measures to avert, or at least slow down, the habituation that can lead to boredom and marital dissatisfaction. While her methods may seem obvious, many married couples forget to put them into practice.

Building Companionship

Steps to slow, prevent or counteract hedonic adaptation and rescue a so-so marriage should be taken long before the union is in trouble, Dr. Lyubomirsky urges. Her recommended strategies include making time to be together and talk, truly listening to each other, and expressing admiration and affection.

Dr. Lyubomirsky emphasizes “the importance of appreciation”: count your blessings and resist taking a spouse for granted. Routinely remind yourself and your partner of what you appreciate about the person and the marriage.

Also important is variety, which is innately stimulating and rewarding and “critical if we want to stave off adaptation,” the psychologist writes. Mix things up, be spontaneous, change how you do things with your partner to keep your relationship “fresh, meaningful and positive.”

Novelty is a powerful aphrodisiac that can also enhance the pleasures of marital sex. But Dr. Lyubomirsky admits that “science has uncovered precious little about how to sustain passionate love.” She likens its decline to growing up or growing old, “simply part of being human.”

Variety goes hand in hand with another tip: surprise. With time, partners tend to get to know each other all too well, and they can fall into routines that become stultifying. Shake it up. Try new activities, new places, new friends. Learn new skills together.

Although I’ve been a “water bug” my whole life, my husband could swim only as far as he could hold his breath. We were able to enjoy the water together when we both learned to kayak.

“A pat on the back, a squeeze of the hand, a hug, an arm around the shoulder — the science of touch suggests that it can save a so-so marriage,” Dr. Lyubomirsky writes. “Introducing more (nonsexual) touching and affection on a daily basis will go a long way in rekindling the warmth and tenderness.”

She suggests “increasing the amount of physical contact in your relationship by a set amount each week” within the comfort level of the spouses’ personalities, backgrounds and openness to nonsexual touch.

Positive Energy

A long-married friend recently told me that her husband said he missed being touched and hugged. And she wondered what the two of them would talk about when they became empty-nesters. Now is the time, dear friend, to work on a more mutually rewarding relationship if you want your marriage to last.

Support your partner’s values, goals and dreams, and greet his or her good news with interest and delight. My husband’s passion lay in writing for the musical theater. When his day job moved to a different city, I suggested that rather than looking for a new one, he pursue his dream. It never became monetarily rewarding, but his vocation fulfilled him and thrilled me. He left a legacy of marvelous lyrics for more than a dozen shows.

Even a marriage that has been marred by negative, angry or hurtful remarks can often be rescued by filling the home with words and actions that elicit positive emotions, psychology research has shown.

According to studies by Barbara L. Fredrickson, a social psychologist and professor at the University of North Carolina at Chapel Hill, a flourishing relationship needs three times as many positive emotions as negative ones. In her forthcoming book, “Love 2.0,” Dr. Fredrickson says that cultivating positive energy everyday “motivates us to reach out for a hug more often or share and inspiring or silly idea or image.”

Dr. Lyubomirsky reports that happily married couples average five positive verbal and emotional expressions toward one another for every negative expression, but “very unhappy couples display ratios of less than one to one.”

To help get your relationship on a happier track, the psychologist suggests keeping a diary of positive and negative events that occur between you and your partner, and striving to increase the ratio of positive to negative.

She suggests asking yourself each morning, “What can I do for five minutes today to make my partner’s life better?” The simplest acts, like sharing an amusing event, smiling, or being playful, can enhance marital happiness.


This post has been revised to reflect the following correction:

Correction: January 18, 2013

The Personal Health column on Tuesday, about making marriages last, misspelled the given name of a professor of psychology at the University of California, Riverside, who studies happiness. She is Sonja Lyubomirsky, not Sonya.

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Well: A Great Grain Adventure

This week, the Recipes for Health columnist Martha Rose Shulman asks readers to go beyond wild rice and get adventurous with their grains. She offers new recipes with some unusual grains you may not have ever cooked or eaten. Her recipes this week include:

Millet: Millet can be used in bird seed and animal feed, but the grain is enjoying a renaissance in the United States right now as a great source of gluten-free nutrition. It can be used in savory or sweet foods and, depending on how it’s cooked, can be crunchy or creamy. To avoid mushy millet, Ms. Shulman advises cooking no more than 2/3 cup at a time. Toast the seeds in a little oil first and take care not to stir the millet once you have added the water so you will get a fluffy result.

Triticale: This hearty, toothsome grain is a hybrid made from wheat and rye. It is a good source of phosphorus and a very good source of magnesium. It has a chewy texture and earthy flavor, similar to wheatberries.

Farro: Farro has a nutty flavor and a chewy texture, and holds up well in cooking because it doesn’t get mushy. When using farro in a salad, cook it until you see that the grains have begun to splay so they won’t be too chewy and can absorb the dressing properly.

Buckwheat: Buckwheat isn’t related to wheat and is actually a great gluten-free alternative. Ms. Shulman uses buckwheat soba noodles to add a nutty flavor and wholesomeness to her Skillet Soba Salad.

Here are five new ways to cook with grains.

Skillet Brown Rice, Barley or Triticale Salad With Mushrooms and Endive: Triticale is a hybrid grain made from wheat and rye, but any hearty grain would work in this salad.


Skillet Beet and Farro Salad: This hearty winter salad can be a meal or a side dish, and warming it in the skillet makes it particularly comforting.


Warm Millet, Carrot and Kale Salad With Curry-Scented Dressing: Millet can be tricky to cook, but if you are careful, you will be rewarded with a fluffy and delicious salad.


Skillet Wild Rice, Walnut and Broccoli Salad: Broccoli flowers catch the nutty, lemony dressing in this winter salad.


Skillet Soba, Baked Tofu and Green Bean Salad With Spicy Dressing: The nutty flavor of buckwheat soba noodles makes for a delicious salad.


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Life, Interrupted: Brotherly Love

Life, Interrupted

Suleika Jaouad writes about her experiences as a young adult with cancer.

There are a lot of things about having cancer in your 20s that feel absurd. One of those instances was when I found myself calling my brother Adam on Skype while he was studying abroad in Argentina to tell him that I had just been diagnosed with leukemia and that — no pressure — he was my only hope for a cure.

Today, my brother and I share almost identical DNA, the result of a successful bone marrow transplant I had last April using his healthy stem cells. But Adam and I couldn’t be more different. Like a lot of siblings, we got along swimmingly at one moment and were in each other’s hair the next. My younger brother by two years, he said I was a bossy older sister. I, of course, thought I knew best for my little brother and wanted him to see the world how I did. My brother is quieter, more reflective. I’m a chronic social butterfly who is probably a bit too impulsive and self-serious. I dreamed of dancing in the New York City Ballet, and he imagined himself playing in the N.B.A. While the sounds of the rapper Mos Def blared from Adam’s room growing up, I practiced for concerto competitions. Friends joked that one of us had to be adopted. We even look different, some people say. But really, we’re just siblings like any others.

When I was diagnosed with cancer at age 22, I learned just how much cancer affects families when it affects individuals. My doctors informed me that I had a high-risk form of leukemia and that a bone marrow transplant was my only shot at a cure. ‘Did I have any siblings?’ the doctors asked immediately. That would be my best chance to find a bone marrow match. Suddenly, everyone in our family was leaning on the little brother. He was in his last semester of college, and while his friends were applying to jobs and partying the final weeks of the school year away, he was soon shuttling from upstate New York to New York City for appointments with the transplant doctors.

I’d heard of organ transplants before, but what was a bone marrow transplant? The extent of my knowledge about bone marrow came from French cuisine: the fancy dish occasionally served with a side of toasted baguette.

Jokes aside, I learned that cancer patients become quick studies in the human body and how cancer treatment works. The thought of going through a bone marrow transplant, which in my case called for a life-threatening dose of chemotherapy followed by a total replacement of my body’s bone marrow, was scary enough. But then I learned that finding a donor can be the scariest part of all.

It turns out that not all transplants are created equal. Without a match, the path to a cure becomes much less certain, in many cases even impossible. This is particularly true for minorities and people from mixed ethnic backgrounds, groups that are severely underrepresented in bone marrow registries. As a first generation American, the child of a Swiss mother and Tunisian father, I suddenly found myself in a scary place. My doctors worried that a global, harried search for a bone marrow match would delay critical treatment for my fast-moving leukemia.

That meant that my younger brother was my best hope — but my doctors were careful to measure hope with reality. Siblings are the best chance for a match, but a match only happens about 25 percent of the time.

To our relief, results showed that my brother was a perfect match: a 10-out-of-10 on the donor scale. It was only then that it struck me how lucky I had been. Doctors never said it this way, but without a match, my chances of living through the next year were low. I have met many people since who, after dozens of efforts to encourage potential bone marrow donors to sign up, still have not found a match. Adding your name to the bone marrow registry is quick, easy and painless — you can sign up at marrow.org — and it just takes a swab of a Q-tip to get your DNA. For cancer patients around the world, it could mean a cure.

The bone marrow transplant procedure itself can be dangerous, but it is swift, which makes it feel strangely anti-climactic. On “Day Zero,” my brother’s stem cells dripped into my veins from a hanging I.V. bag, and it was all over in minutes. Doctors tell me that the hardest part of the transplant is recovering from it. I’ve found that to be true, and I’ve also recognized that the same is true for Adam. As I slowly grow stronger, my little brother has assumed a caretaker role in my life. I carry his blood cells — the ones keeping me alive — and he is carrying the responsibility, and often fear and anxiety, of the loving onlooker. He tells me I’m still a bossy older sister. But our relationship is now changed forever. I have to look to him for support and guidance more than I ever have. He’ll always be my little brother, but he’s growing up fast.


Suleika Jaouad (pronounced su-LAKE-uh ja-WAD) is a 24-year-old writer who lives in New York City. Her column, “Life, Interrupted,” chronicling her experiences as a young adult with cancer, appears regularly on Well. Follow @suleikajaouad on Twitter.

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Study Confirms Benefits of Flu Vaccine for Pregnant Women


While everyone is being urged to get the flu vaccine as soon as possible, some pregnant women avoid it in the belief that it may harm their babies. A large new study confirms that they should be much more afraid of the flu than the vaccine.


Norwegian researchers studied fetal death among 113,331 women pregnant during the H1N1 flu pandemic of 2009-2010. Some 54,065 women were unvaccinated, 31,912 were vaccinated during pregnancy, and 27,354 were vaccinated after delivery. The scientists then reviewed hospitalizations and doctor visits for the flu among the women.


The results were published on Thursday in The New England Journal of Medicine.


The flu vaccine was not associated with an increased risk for fetal death, the researchers found, and getting the shot during pregnancy reduced the risk of the mother getting the flu by about 70 percent. That was important, because fetuses whose mothers got the flu were much more likely to die.


Unvaccinated women had a 25 percent higher risk of fetal death during the pandemic than those who had had the shot. Among pregnant women with a clinical diagnosis of influenza, the risk of fetal death was nearly doubled. In all, there were 16 fetal deaths among the 2,278 women who were diagnosed with influenza during pregnancy.


Dr. Marian Knight, a professor at the perinatal epidemiology unit of the University of Oxford, who was not involved in the research, called it “a high-quality national study” that shows “there is no evidence of an increased risk of fetal death in women who have been immunized. Clinicians and women can be reassured about the safety of the vaccine in the second and third trimesters of pregnancy.”


The Norwegian health system records vaccinations of individuals and maintains linked registries to track effects and side effects. The lead author, Dr. Camilla Stoltenberg, director of the Norwegian Institute of Public Health, said that there are few countries with such complete records.


“This is a great study,” said Dr. Denise J. Jamieson, an obstetrician and a medical officer at the Centers for Disease Control and Prevention, who was not involved in the work. “It’s nicely done, with good data, and it’s additional information about the importance of the flu vaccine for pregnant women. It shows that it’s effective and might reduce the risk for fetal death.”


In Norway, the vaccine is recommended only in the second and third trimesters, so the study includes little data on vaccination in the first trimester. The C.D.C. recommends the vaccine for all pregnant women, regardless of trimester.


“We knew from other studies that the vaccine protects the woman and the newborn,” Dr. Stoltenberg said. “This study clearly indicates that it protects fetuses as well. I seriously suggest that pregnant women get vaccinated during every flu season.”


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Well: How to Go Vegan

When I first heard former President Bill Clinton talk about his vegan diet, I was inspired to make the switch myself. After all, if a man with a penchant for fast-food burgers and Southern cooking could go vegan, surely I could too.

At the grocery store, I stocked up on vegan foods, including almond milk (that was the presidential recommendation), and faux turkey and cheese to replicate my daughter’s favorite sandwich. But despite my good intentions, my cold-turkey attempt to give up, well, turkey (as well as other meats, dairy and eggs) didn’t go well. My daughter and I couldn’t stand the taste of almond milk, and the fake meat and cheese were unappealing.

Since then, I’ve spoken with numerous vegan chefs and diners who say it can be a challenge to change a lifetime of eating habits overnight. They offer the following advice for stocking your vegan pantry and finding replacements for key foods like cheese and other dairy products.

NONDAIRY MILK Taste all of them to find your favorite. Coconut and almond milks (particularly canned coconut milk) are thicker and good to use in cooking, while rice milk is thinner and is good for people who are allergic to nuts or soy. My daughter and I both prefer the taste of soy milk and use it in regular or vanilla flavor for fruit smoothies and breakfast cereal.

NONDAIRY CHEESE Cheese substitutes are available under the brand names Daiya, Tofutti and Follow Your Heart, among others, but many vegans say there’s no fake cheese that satisfies as well as the real thing. Rather than use a packaged product, vegan chefs prefer to make homemade substitutes using cashews, tofu, miso or nutritional yeast. At Candle 79, a popular New York vegan restaurant, the filling for saffron ravioli with wild mushrooms and cashew cheese is made with cashews soaked overnight and then blended with lemon juice, olive oil, water and salt.

THINK CREAMY, NOT CHEESY Creaminess and richness can often be achieved without a cheese substitute. For instance, Chloe Coscarelli, a vegan chef and the author of “Chloe’s Kitchen,” has created a pizza with caramelized onion and butternut squash that will make you forget it doesn’t have cheese; the secret is white-bean and garlic purée. She also offers a creamy, but dairy-free, avocado pesto pasta. My daughter and I have discovered we actually prefer the rich flavor of butternut squash ravioli, which can be found frozen and fresh in supermarkets, to cheese-filled ravioli.

NUTRITIONAL YEAST The name is unappetizing, but many vegan chefs swear by it: it’s a natural food with a roasted, nutty, cheeselike flavor. Ms. Coscarelli uses nutritional yeast flakes in her “best ever” baked macaroni and cheese (found in her cookbook). “I’ve served this to die-hard cheese lovers,” she told me, “and everyone agrees it is comparable, if not better.”

Susan Voisin’s Web site, Fat Free Vegan Kitchen, offers a nice primer on nutritional yeast, noting that it’s a fungus (think mushrooms!) that is grown on molasses and then harvested and dried with heat. (Baking yeast is an entirely different product.) Nutritional yeasts can be an acquired taste, she said, so start with small amounts, sprinkling on popcorn, stirring into mashed potatoes, grinding with almonds for a Parmesan substitute or combining with tofu to make an eggless omelet. It can be found in Whole Foods, in the bulk aisle of natural-foods markets or online.

BUTTER This is an easy fix. Vegan margarines like Earth Balance are made from a blend of oils and are free of trans fats. Varieties include soy-free, whipped and olive oil.

EGGS Ms. Coscarelli, who won the Food Network’s Cupcake Wars with vegan cupcakes, says vinegar and baking soda can help baked goods bind together and rise, creating a moist and fluffy cake without eggs. Cornstarch can substitute for eggs to thicken puddings and sauces. Vegan pancakes are made with a tablespoon of baking powder instead of eggs. Frittatas and omelets can be replicated with tofu.

Finally, don’t try to replicate your favorite meaty foods right away. If you love a juicy hamburger, meatloaf or ham sandwich, you are not going to find a meat-free version that tastes the same. Ms. Voisin advises new vegans to start slow and eat a few vegan meals a week. Stock your pantry with lots of grains, lentils and beans and pile your plate with vegetables. To veganize a recipe, start with a dish that is mostly vegan already — like spaghetti — and use vegetables or a meat substitute for the sauce.

“Trying to recapture something and find an exact substitute is really hard,” she said. “A lot of people will try a vegetarian meatloaf right after they become vegetarian, and they hate it. But after you get away from eating meat for a while, you’ll find you start to develop other tastes, and the flavor of a lentil loaf with seasonings will taste great to you. It won’t taste like meat loaf, but you’ll appreciate it for itself.”

Ms. Voisin notes that she became a vegetarian and then vegan while living in a small town in South Carolina; she now lives in Jackson, Miss.

“If I can be a vegan in these not-quite-vegan-centric places, you can do it anywhere,” she said. “I think people who try to do it all at once overnight are more apt to fail. It’s a learning process.”


What are your tips for vegan cooking and eating? Share your suggestions on ingredients, recipes and strategies by posting a comment below or tweeting with the hashtag #vegantips.

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Well: How to Go Vegan

When I first heard former President Bill Clinton talk about his vegan diet, I was inspired to make the switch myself. After all, if a man with a penchant for fast-food burgers and Southern cooking could go vegan, surely I could too.

At the grocery store, I stocked up on vegan foods, including almond milk (that was the presidential recommendation), and faux turkey and cheese to replicate my daughter’s favorite sandwich. But despite my good intentions, my cold-turkey attempt to give up, well, turkey (as well as other meats, dairy and eggs) didn’t go well. My daughter and I couldn’t stand the taste of almond milk, and the fake meat and cheese were unappealing.

Since then, I’ve spoken with numerous vegan chefs and diners who say it can be a challenge to change a lifetime of eating habits overnight. They offer the following advice for stocking your vegan pantry and finding replacements for key foods like cheese and other dairy products.

NONDAIRY MILK Taste all of them to find your favorite. Coconut and almond milks (particularly canned coconut milk) are thicker and good to use in cooking, while rice milk is thinner and is good for people who are allergic to nuts or soy. My daughter and I both prefer the taste of soy milk and use it in regular or vanilla flavor for fruit smoothies and breakfast cereal.

NONDAIRY CHEESE Cheese substitutes are available under the brand names Daiya, Tofutti and Follow Your Heart, among others, but many vegans say there’s no fake cheese that satisfies as well as the real thing. Rather than use a packaged product, vegan chefs prefer to make homemade substitutes using cashews, tofu, miso or nutritional yeast. At Candle 79, a popular New York vegan restaurant, the filling for saffron ravioli with wild mushrooms and cashew cheese is made with cashews soaked overnight and then blended with lemon juice, olive oil, water and salt.

THINK CREAMY, NOT CHEESY Creaminess and richness can often be achieved without a cheese substitute. For instance, Chloe Coscarelli, a vegan chef and the author of “Chloe’s Kitchen,” has created a pizza with caramelized onion and butternut squash that will make you forget it doesn’t have cheese; the secret is white-bean and garlic purée. She also offers a creamy, but dairy-free, avocado pesto pasta. My daughter and I have discovered we actually prefer the rich flavor of butternut squash ravioli, which can be found frozen and fresh in supermarkets, to cheese-filled ravioli.

NUTRITIONAL YEAST The name is unappetizing, but many vegan chefs swear by it: it’s a natural food with a roasted, nutty, cheeselike flavor. Ms. Coscarelli uses nutritional yeast flakes in her “best ever” baked macaroni and cheese (found in her cookbook). “I’ve served this to die-hard cheese lovers,” she told me, “and everyone agrees it is comparable, if not better.”

Susan Voisin’s Web site, Fat Free Vegan Kitchen, offers a nice primer on nutritional yeast, noting that it’s a fungus (think mushrooms!) that is grown on molasses and then harvested and dried with heat. (Baking yeast is an entirely different product.) Nutritional yeasts can be an acquired taste, she said, so start with small amounts, sprinkling on popcorn, stirring into mashed potatoes, grinding with almonds for a Parmesan substitute or combining with tofu to make an eggless omelet. It can be found in Whole Foods, in the bulk aisle of natural-foods markets or online.

BUTTER This is an easy fix. Vegan margarines like Earth Balance are made from a blend of oils and are free of trans fats. Varieties include soy-free, whipped and olive oil.

EGGS Ms. Coscarelli, who won the Food Network’s Cupcake Wars with vegan cupcakes, says vinegar and baking soda can help baked goods bind together and rise, creating a moist and fluffy cake without eggs. Cornstarch can substitute for eggs to thicken puddings and sauces. Vegan pancakes are made with a tablespoon of baking powder instead of eggs. Frittatas and omelets can be replicated with tofu.

Finally, don’t try to replicate your favorite meaty foods right away. If you love a juicy hamburger, meatloaf or ham sandwich, you are not going to find a meat-free version that tastes the same. Ms. Voisin advises new vegans to start slow and eat a few vegan meals a week. Stock your pantry with lots of grains, lentils and beans and pile your plate with vegetables. To veganize a recipe, start with a dish that is mostly vegan already — like spaghetti — and use vegetables or a meat substitute for the sauce.

“Trying to recapture something and find an exact substitute is really hard,” she said. “A lot of people will try a vegetarian meatloaf right after they become vegetarian, and they hate it. But after you get away from eating meat for a while, you’ll find you start to develop other tastes, and the flavor of a lentil loaf with seasonings will taste great to you. It won’t taste like meat loaf, but you’ll appreciate it for itself.”

Ms. Voisin notes that she became a vegetarian and then vegan while living in a small town in South Carolina; she now lives in Jackson, Miss.

“If I can be a vegan in these not-quite-vegan-centric places, you can do it anywhere,” she said. “I think people who try to do it all at once overnight are more apt to fail. It’s a learning process.”


What are your vegantips? We’re collecting suggestions on ingredients, recipes and strategies.

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City Room: Cuomo Declares Public Health Emergency Over Flu Outbreak

With the nation in the grip of a severe influenza outbreak that has seen deaths reach epidemic levels, New York State declared a public health emergency on Saturday, making access to vaccines more easily available.

There have been nearly 20,000 cases of flu reported across the state so far this season, officials said. Last season, 4,400 positive laboratory tests were reported.

“We are experiencing the worst flu season since at least 2009, and influenza activity in New York State is widespread, with cases reported in all 57 counties and all five boroughs of New York City,” Gov. Andrew M. Cuomo said in a statement.

Under the order, pharmacists will be allowed to administer flu vaccinations to patients between 6 months and 18 years old, temporarily suspending a state law that prohibits pharmacists from administering immunizations to children.

While children and older people tend to be the most likely to become seriously ill from the flu, Mr. Cuomo urged all New Yorkers to get vaccinated.

On Friday, the Centers for Disease Control and Prevention in Atlanta said that deaths from the flu had reached epidemic levels, with at least 20 children having died nationwide. Officials cautioned that deaths from pneumonia and the flu typically reach epidemic levels for a week or two every year. The severity of the outbreak will be determined by how long the death toll remains high or if it climbs higher.

There was some evidence that caseloads may be peaking, federal officials said on Friday.

In New York City, public health officials announced on Thursday that flu-related illnesses had reached epidemic levels, and they joined the chorus of authorities urging people to get vaccinated.

“It’s a bad year,” the city’s health commissioner, Dr. Thomas A. Farley, told reporters on Thursday. “We’ve got lots of flu, it’s mainly type AH3N2, which tends to be a little more severe. So we’re seeing plenty of cases of flu and plenty of people sick with flu. Our message for any people who are listening to this is it’s still not too late to get your flu shot.”

There has been a spike in the number of people going to emergency rooms over the past two weeks with flulike symptoms – including fever, fatigue and coughing – Dr. Farley said.

Mayor Michael R. Bloomberg and Mr. Cuomo made a public display of getting shots this past week.

In a briefing with reporters on Friday, officials from the C.D.C. said that this year’s vaccine was effective in 62 percent of cases.

As officials have stepped up their efforts encouraging vaccinations, there have been scattered reports of shortages. But officials said plenty of the vaccine was available.

According to the C.D.C., makers of the flu vaccine produced about 135 million doses for this year. As of early this month, 128 million doses had been distributed. While that would not be enough for every American, only 37 percent of the population get a flu shot each year.

Federal health officials said they would be happy if that number rose to 50 percent, which would mean that there would be more than enough vaccine for anyone who wanted to be immunized.

Two other diseases – norovirus and whooping cough – are also widespread this winter and are contributing to the number of people getting sick.

The flu can resemble a cold, though the symptoms come on more rapidly and are more severe.

A version of this article appeared in print on 01/13/2013, on page A21 of the NewYork edition with the headline: New York Declares Health Emergency.
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‘Bodega Clinicas’ Draw Interest of Health Officials


HUNTINGTON PARK, Calif. — The “bodega clinicas” that line the bustling commercial streets of immigrant neighborhoods around Los Angeles are wedged between money order kiosks and pawnshops. These storefront offices, staffed with Spanish-speaking medical providers, treat ailments for cash: a doctor’s visit is $20 to $40; a cardiology exam is $120; and at one bustling clinic, a colonoscopy is advertised on an erasable board for $700.


County health officials describe the clinics as a parallel health care system, serving a vast number of uninsured Latino residents. Yet they say they have little understanding of who owns and operates them, how they are regulated and what quality of medical care they provide. Few of these low-rent corner clinics accept private insurance or participate in Medicaid managed care plans.


“Someone has to figure out if there’s a basic level of competence,” said Dr. Patrick Dowling, the chairman of the family medicine department at the David Geffen School of Medicine at the University of California, Los Angeles.


Not that researchers have not tried. Dr. Dowling, for one, has canvassed the clinics for years to document physician shortages as part of his research for the state. What he and others found was that the owners were reluctant to answer questions. Indeed, multiple attempts in recent weeks to interview owners and employees at a half-dozen of the clinics in Southern California proved fruitless.


What is certain, however, is that despite their name, many of these clinics are actually private doctor’s offices, not licensed clinics, which are required to report regularly to federal and state oversight bodies.


It is a distinction that deeply concerns Kimberly Wyard, the chief executive of the Northeast Valley Health Corporation, a nonprofit group that runs 13 accredited health clinics for low-income Southern Californians. “They are off the radar screen,” said Ms. Wyard of the bodega clinicas, “and it’s unclear what they’re doing.”


But with deadlines set by the federal Affordable Care Act quickly approaching, health officials in Los Angeles are vexed over whether to embrace the clinics and bring them — selectively and gingerly — into the network of tightly regulated public and nonprofit health centers that are driven more by mission than by profit to serve the uninsured.


Health officials see in the clinics an opportunity to fill persistent and profound gaps in the county’s strained safety net, including a chronic shortage of primary care physicians. By January 2014, up to two million uninsured Angelenos will need to enroll in Medicaid or buy insurance and find primary care.


And the clinics, public health officials point out, are already well established in the county’s poorest neighborhoods, where they are meeting the needs of Spanish-speaking residents. The clinics also could continue to serve a market that the Affordable Care Act does not touch: illegal immigrants who are prohibited from getting health insurance under the law.


Dr. Mark Ghaly, the deputy director of community health for the Los Angeles County Department of Health Services, said bodega clinicas — a term he seems to have coined — that agree to some scrutiny could be a good way of addressing the physician shortage in those neighborhoods.


“Where are we going to find those providers?” he said. “One logical place to consider looking is these clinics.”


Los Angeles is not the only city with a sizable Latino population where the clinics have become a part of the streetscape. Health care providers in Phoenix and Miami say there are clinics in many Latino neighborhoods.


But their presence in parts of the Los Angeles area can be striking, with dozens in certain areas. Visits to more than two dozen clinics in South Los Angeles and the San Fernando Valley found Latino women in brightly colored scrubs handing out cards and coupons that promised a range of services like pregnancy tests and endoscopies. Others advertised evening and weekend hours, and some were open around the clock.


Such all-hours access and upfront pricing are critical, Latino health experts say, to a population that often works around the clock for low wages.


Also important, officials say, is that new immigrants from Mexico and Central America are more accustomed to corner clinics, which are common in their home countries, than to the sprawling medical complexes or large community health centers found in the United States. And they can get the kind of medical treatments — including injections of hypertension drugs, intravenous vitamins and liberally dispensed antibiotics — that are frowned upon in traditional American medicine.


The waiting rooms at the clinics reflected the everyday maladies of peoples’ lives: a glassy-eyed child resting listlessly on his mother’s lap, a fit-looking young woman waiting with a bag of ice on her wrist, a pensive middle-aged man in work boots staring straight ahead.


For many ordinary complaints, the medical care at these clinics may be suitable, county health officials and medical experts say. But they say problems arise when an illness exceeds the boundaries of a physician’s skills or the patient’s ability to pay cash.


Dr. Raul Joaquin Bendana, who has been practicing general medicine in South Los Angeles for more than 20 years, said the clinics would refer patients to him when, for example, they had uncontrolled diabetes. “They refer to me because they don’t know how to handle the situation,” he said.


The clinic physicians by and large appear to have current medical licenses, a sample showed, but experts say they are unlikely to be board certified or have admitting privileges at area hospitals. That can mean that some clinics try to treat patients who face serious illness.


Olivia Cardenas, 40, a restaurant worker who lives in Woodland Hills, Calif., got a free Pap smear at a clinic that advertises “especialistas,” including in gynecology. The test came back abnormal, and the doctor told Ms. Cardenas that she had cervical cancer. “Come back in a week with $5,000 in cash, and I’ll operate on you,” Ms. Cardenas said the doctor told her. “Otherwise you could die.”


She declined to pay the $5,000. Instead, a family friend helped her apply for Medicaid, and she went to a hospital. The diagnosis, it turned out, was correct.


Health care experts say the clinics’ medical practices would come under greater scrutiny if they were brought closer into the fold.


But being connected would mean the clinics’ cash-only business model would need to change. Dr. Dowling said the lure of newly insured patients in 2014 might draw them in. “To the extent there are payments available,” he said, “the legitimate ones might step up to the plate.”


This article was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.



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The New Old Age Blog: As Flu Rages, Caregiving Suffers

The flu started in the personal care center at Masonic Village in Elizabethtown, Pa., then moved to the nursing home. Within a few days, seven older adults had taken ill.

Administrators moved quickly: they shut down two floors of the buildings and told all visitors to stay away. All social activities stopped, and residents were asked to stay in their rooms.

The phones began to ring. “How is my wife doing?” an older spouse would ask. “What’s Mom eating?” a concerned daughter would inquire.

As the flu sweeps across the country, all kinds of issues are arising as institutions serving the elderly cope with outbreaks and nurses, home health aides and family members fall ill and can’t attend to the older people under their care.

One of the residents of Masonic Village was the mother-in-law of Joyce Heisey, director of nursing at this continuing care retirement community. She had come to the nursing home after a nasty fall and a subsequent hospitalization for rehabilitation.

“It was hard for her because she wasn’t accustomed to being in this kind of setting, and my father-in-law couldn’t visit,” said Ms. Heisey, who talked to her in-laws about their experiences. They declined to speak directly to a reporter.

Worried about isolation, the home sent recreation therapists into residents’ rooms for a few minutes each day and directed physical therapists to continue working with those undergoing rehabilitation, again in their rooms when possible.

In Collinsville, Ill., a city of about 42,000 that is 23 miles east of St. Louis, 20 percent of the staff at Home Instead Senior Care have called in sick, either struck by the flu themselves or at home taking care of a sick child.

“We’ve never seen it as bad as it is this year,” said Skip Brown, the agency’s owner. In previous years, about 5 percent of the staff have taken ill during flu season.

“It’s really hard for our clients, most of whom are elderly,” Mr. Brown said. “All of a sudden you have another person coming in to your home that you’re not familiar with. That’s really hard for seniors, and we have to make sure they’re comfortable.”

One client, a 92-year-old woman with diabetes, was insistent that a stranger not come to help when her usual caregiver became sick and stayed home.

“The problem that we’re always concerned with is, what if an older person doesn’t eat and what if they don’t take their medication?” Mr. Brown said. Concerned, he called his client’s out-of-town daughter, who called an elderly neighbor, who agreed to accompany someone from the agency to make sure the older woman was all right.

As it turned out, she hadn’t taken insulin for a full day and was at risk of a diabetic crisis, which was averted when the agency worker intervened.

Things got bad so fast that after the second week of December, Mr. Brown required all staff members to get flu shots – and still they became ill. This year, the flu shot is effective about 62 percent of the time, the Centers for Disease Control and Prevention said on Friday.

Nationally, about 60 percent of health care workers get flu vaccines, which are voluntary in most hospitals, nursing homes and assisted-living facilities, according to Dr. Gregory Poland, director of the Mayo Clinic Vaccine Research Group. And when workers are struck by the flu, infections among residents can follow.

“The disruptions, the costs, the complications from this virus, no one should confuse it with a minor illness,” said Dr. Poland, who has advocated for mandatory immunizations for health care workers.

According to New York’s statewide influenza report for the week ended Jan. 5, 179 outbreaks have hit nursing homes this flu season — 57 of them during the week covered by the report alone. The state health department defines an outbreak as one confirmed case or two suspected cases of flu that are contracted in a nursing home.

Allison Chisholm, a nurse with Partners in Care, a home care agency operated by the Visiting Nurse Service of New York, had a flu shot on Dec. 27 and a week later took to bed with a fever and chills.

“It was so bad, my toenails were hurting. I had no appetite. I couldn’t move, I was so sore,” she said. “I knew it was the flu because I’m not a sickly person. I’ve never felt like that for 30 years.”

Ms. Chisholm had been seeing a woman in her 70s every day since October to treat a bone infection with intravenous antibiotics. “When I called her she could hear immediately that something was wrong,” Ms. Chisholm said. “She was concerned and said, ‘If you’re sick like that, don’t come – I don’t want to get what you have.’ ” A week later, the nurse said she got a phone call from the older woman checking in to see if she was better.

In this case, the client was due to end treatment the day after Ms. Chisholm fell ill, and she agreed to have a worker from the company that supplied her intravenous supplies administer her last IV therapy.

At the Martha Stewart Living Center, an outpatient center for older patients at Mount Sinai Medical Center, Dr. Audrey Chun, medical director, has been telling caregivers and other people who have any kind of upper respiratory problems — a cough, constant sniffles – to stay away from older people’s homes because of the risk of passing on an infection.

But do be sure to call in regularly to ask how your older relative or friend is feeling and whether they have unusual lethargy, breathing problems or disabling fatigue, said Jennifer Leeflang, senior director of private care services for Partners in Care. The agency has been getting about 10 requests a week for flu shots for homebound elderly ($100 for the visit and the shot). Other hospitals, like Montefiore Medical Center in the Bronx, are providing a similar service for home care agency patients.

New data released Friday by the federal Centers for Disease Control and Prevention underscores how vulnerable older adults are to flu and how many are being affected by the current outbreak. In the week ended Jan. 5, the rate of flu-related hospitalizations for people 65 and older was 53.4 per 100,000, more than twice that of another vulnerable group, newborns and children up to 4 years old. Hospitalizations are an indicator of the most serious flu cases.

That’s a big jump from the week before, when the rate of flu-related hospitalizations for people 65 and older stood at 29.3 per 100,000.

How has flu season affected your ability to provide — or get care — for your elderly relative? Share your experiences and advice here.

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