Observatory - Hope for Human Fertility in Study of C. Elegans Worm

Now,a study in the journal Cellsuggests that one of the favorite animals for experiments in modern science, the tiny worm C. elegans, may provide new insight into female fertility. For the worm, as for women, it is diminished egg quality, not quantity, that marks the first sign of reproductive aging.

Coleen Murphy, a molecular biologist atPrinceton University, and colleagues found that as C. elegans ages, its oocytes, or unfertilized eggs, start to degrade because of increased secretion of a protein called transforming growth factor beta, or TGF-beta. The same protein is found in humans and other mammals.

The researchers also experimented with mutant worms that had low TGF-beta activity levels. In these worms, reproductive ability was lengthened and egg quality did not degrade.

In women, too, aging brings about a decline in the quality of oocytes, leading to a greater chance ofbirth defectslikeDown syndrome. Scientists have tested the protein in mice and found a similar effect, but in humans it may not play exactly the same role.

Still, this kind of research may eventually provide the knowledge to extend female fertility, Dr. Murphy said.

“The dream would be that you could give a woman in her early 30s a supplement or a drug to keep her oocytes healthy as long as possible,” she said.“We have treatments now that extend life span, but nothing extends our reproductive span.”

There are limits, as witnessed in some of the mutant worms. Although their reproductive ability increased, their life span did not, and reproducing in old age— 13 days for the worms— was fatal.

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Doctor and Patient - Sick Doctors, Sick Patients

Within days of the onset of my symptoms, other clinicians on my team were felled with the same. For weeks, we passed the cold back and forth in what became a viral game of hot potato. Even if I felt well enough one day to breathe through my nose, taste the nursing station holiday cookies and laugh without spiraling into a coughing fit, I knew that it would be only a matter of days, if not hours, before I would become sick again, invariably with a virus that had mutated just enough in the interim to dodge anyimmunitybuilt up during the last go-around.

The doctors and nurses on my team started referring to me as“the vector.”

Nonetheless, I continued to drag myself in to work each day. I didn’t want to desert the other doctors and nurses or my patients. And any time I was overtaken with a yearning to go home and crawl back in bed, one memory from medical school would quickly push that thought from my mind.

I had been a third-year medical student and had asked my senior doctor-in-training if I could go home because of anupset stomach.

“Sure, go on home,” he replied, an impassive look on his broad face.“Just remember that I’venevermissed a day at the hospital in my life. They’ll have to put me in the hospital to keep me from taking care of my patients.”

Hacking, febrile or racked with the sequelae of chronic illnesses, doctors who are sick have continued for generations to see their patients. Although published reports for over a decade have linked patient illnesses likethe flu,whooping coughand resistant bacterial infections to sick health care workers, as many as80 percent of physicians continue to work through their own ailments, even though they would have excused patients in the same condition.

For many doctors and other health care professionals, such self-sacrifice is proof of their dedication and professionalism. Moreover, in what are often precariously balancedhospitalsand practices, one individual’s absence can inflict tremendous stress upon others. Overstretched colleagues are forced to shoulder additional clinical responsibilities, supervisors must solve impossible staffing challenges and, worst of all, patients are left with inadequate care.

Being present— it seems, anyway— causes fewer problems than being absent.

But over the last few years, researchers in the business world have begun to question this assumption. Instead of focusing on problems incurred by absenteeism, these researchers have analyzed the impact of what’s been called presenteeism, or working despite being ill. And it turns out, at least in early studies, that those employees who choose to go to work sick are expensive. Presenteeism costs companiesmore than $150 billion a year in lost worker productivity.

Now, areport in the current issue of The Journal of General Internal Medicineexamines the impact of sick workers in health care. Anchoring their analysis with a description of a nursing home outbreak of norovirus gastroenteritis, an infection that causes nausea, vomiting anddiarrhea, researchers from theUniversity of California, San Francisco, address an issue that goes beyond the business school matter of worker productivity. They argue that in the health care setting what is important is that the decision to continue working while sick contradicts a core ethical principle of medicine: primum non nocere, or“First, do no harm.”

“The culture of medicine is so completely focused on self-sacrifice that when doctors come into work so sick they need intravenous fluids, it’s considered a badge of courage,” said Dr. Eric Widera, the study’s lead author and an assistant professor of geriatrics at the University of California, San Francisco.“No one is standing up for the patient and saying,‘This is wrong.’ ”

Initially the nursing home infection described by Dr. Widera and his co-authors affected only one staff member and three patients. But over the course of less than two weeks it spread to an additional 22 staff members and 30 patients despite restrictive— but voluntary— measures like stricter hand hygiene and disinfecting procedures, limiting visitors, closing down the dining hall and suspending group activities and outings. Only after the local health department required sick employees to be medically cleared before returning to work was the outbreak finally controlled.

“People probably felt they were showing up at work out of empathy for their patients and out of the kindness of their hearts,” Dr. Widera observed.“But they weren’t thinking about the risks.”

Resisting the pressure to go to work when ill can be particularly difficult for some health care professionals. Students, doctors-in-training and nurses may be afraid that their supervisors will frown upon any absence, regardless of the reason.“It’s a sign of being soft,” Dr. Widera said,“and they may get a tongue-lashing the next day from those in charge.”

Fully trained physicians or nurses who work in a small practice or who may be the only clinician available may feel a heightened sense of personal responsibility toward their colleagues and patients, and their decisions necessarily end up more complicated. For these individuals,“going into work sick becomes a risk-benefit analysis that must be weighed carefully,” Dr. Widera said. They may have to reschedule routine visits and limit patient contact to absolute emergencies, instead of what many clinicians have felt pressure to do in the past,“coming in then doing everything you would in a normal day because you are at work anyway.”

Dr. Widera and his co-authors suggest that policy changes that include unrestricted paid leave and mandatory time off for sick health care workers, as well as increased redundancy in clinician staffing may help decrease presenteeism in health care.“We need to create a culture where patient safety is more important than making the ultimate sacrifice or maximizing efficiency,” he said.

“Patients are happy just to have gotten in to see a physician,” Dr. Widera added,“but they are basically cornered when that doctor is sick. The onus and responsibility for changing how we deal with presenteeism has to come from us. It has to come from within the health care system.”

After I had struggled for a couple of months with that cold, the chief of my division at the hospital ordered me to go home, turn off my beeper and stay away from the hospital for 48 hours. I protested at first, as did a fellow doctor who was quick to grouse about being left with all the work to do.

But I finally got better. And within days, everyone else did, too.

Join the discussion on the Well blog,“Why Doctors Should Take Sick Days.”

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Really? - The Claim -‘Brain Freeze’ Occurs Only on Warm Days - Question

The phenomenon, also known as ice creamheadache, occurs when a very cold substance touches the back of the palate,causing the rapid constriction and dilation of blood vessels in the head. According to some studies,this causes pain receptors to stimulate the trigeminal nerve, the major carrier of sensory information from the face to the brain, resulting in a stabbing pain in the face or head.

But it may not affect everyone. Researchers have found that only about a third of people experience it, and despite one common misconception stemming from early studies, it does not occur only on warm days.

In a report in the British journal BMJ in 2002, a scientist at McMaster University in Canada conducted a study involving 145 middle school students over two winter months. All— to their delight— were given moderate servings of ice cream. Some were randomly instructed to consume it slowly, while others were told to wolf it down in five seconds or less.

About 30 percent of students in the“accelerated eating” group developed the headache, compared with 13 percent in the“cautious eating” group.

“In contrast to previous studies,” the report said,“our results suggest that ice cream headache can be induced in cold weather even in subjects who eat their ice cream at a slow pace.”

Some studiesindicate that migraine sufferers may be more prone to these cold-induced headaches, thoughothers have disputed that finding.

THE BOTTOM LINEBrain freeze can occur in both warm and cold weather.

ANAHAD O’CONNOR

scitimes@nytimes.com

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Supreme Court to Consider Vaccine Case

At issue is whether a no-fault system established by Congress about 25 years ago to compensate children and others injured by commonly used vaccines should protect manufacturers from virtually all product liability lawsuits. The law was an effort to strike a balance between the need to provide care for those injured by vaccines, some of them severely, and the need to protect manufacturers from undue litigation.

Under the 1986 National Childhood Vaccine Injury Act, such claims typically proceed through an alternative legal system known as“vaccine court.” Under that system, a person is compensated if their injury is among those officially recognized as caused by a vaccine. That person, or their parents, can choose to reject that award and sue the vaccine’s manufacturer, but they then face severe legal hurdles created by law to deter such actions.

The case before theSupreme Courtis not related to autism. But the biggest effect of the court’s ruling, lawyers said, will be on hundreds of pending lawsuits that contend a link exists between childhood vaccines and autism. Repeated scientific studies have found no such connection.

Also, in several test case rulings over the last two years, administrative judges in vaccine court have held that autism-related cases did not qualify for compensation. During the last decade, about 5,800 of the 7,900 claims filed in vaccine court, or about 75 percent, have been autism-related, federal data show.

Federal data shows that $154 million was paid in fiscal 2010 to 154 claimants involved in vaccine court proceedings. That figure was significantly higher than in preceding years and reflected several unusually high awards, officials involved in the program said.

In the five preceding fiscal years, an average of $68 million in compensation was paid out on an annual basis, federal data indicates. A compensation fund is financed by an excise tax onvaccinations.

The case to be heard on Tuesday involves an 18-year-old woman, Hannah Bruesewitz, who sufferedseizureswhen she was 6 months old and subsequently suffered developmental problems, her parents say, after receiving a type of D.T.P. vaccine that is no longer sold. The D.T.P. vaccine protects against three potentially deadly childhood diseases:diphtheria;pertussis, which is also known as whooping cough; andtetanus.

Ms. Bruesewitz’s parents have contended in court papers that the vaccine’s manufacturer, which is now a part ofPfizer, knew at the time that their daughter was immunized that there was a safer version of the D.T.P. vaccine but did not produce it. The company rejected that contention

Initially, Ms. Bruesewitz’s parents brought a claim on her behalf to the vaccine court, but the severe injuries that she reportedly suffered were removed from the list of those that qualified for compensation a month before the case was heard. An administrative judge in vaccine court subsequently rejected her claim, so her parents filed a product liability lawsuit againstWyeth, a Pfizer unit that had acquired the vaccine’s manufacturer, Lederle Laboratories.

Lower court judges have ruled that her claims are barred by the federal Vaccine Act. As a result, Ms. Bruesewitz, who lives with her family in Pittsburgh and requires specialized care, has not received any compensation, her father, Russell Bruesewitz, said in a telephone interview.

“The cost of her care is an ongoing burden,” Mr. Bruesewitz said.

The Supreme Court review revolves around the narrow question of whether Congress in passing the Vaccine Act intended to bar lawsuits against vaccine manufacturers based on so-called design defect claims. A vaccine design defect claim essentially asserts that the manufacturer should have sold a different vaccine, which plaintiffs say would have been safer than the one used.

Those filing briefs arguing that Congress intended to permit such lawsuits include the American Association for Justice, a plaintiffs’ lawyers group, and the National Vaccine Information Center, an advocacy group.

Those filing briefs arguing that Congress intended to bar them include the solicitor general of the United States, the Chamber of Commerce and several professional medical groups, including theAmerican Academy of Pediatrics.

James M. Beck, a lawyer in Philadelphia who defends makers of drugs and medical devices, said in a phone interview that a ruling in favor of the Bruesewitzes would allow hundreds of lawsuits asserting a link between vaccines and autism to go forward.

“If these cases go forward, it will make it economically unfeasible for anyone to make vaccines in this country,” said Mr. Beck.

Mr. Bruesewitz said that he and his wife were not opposed to vaccination. Instead, he said they pressed his daughter’s claim because he thought that vaccine producers needed to face the threat of litigation to produce safer medications.

“What we want and are concerned about is to make sure that the safety of vaccines in this country is constantly enhanced,” Mr. Bruesewitz said.

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Ratatouillelike Dishes Find a Welcome on Many Global Tables

It was true in my kitchen for a long time, too. But when I began exploring the cuisines of the Mediterranean, I discovered that beloved ratatouillelike dishes exist just about everywhere you go. It’s no coincidence: Mediterranean cuisines have long had an affinity for eggplant, and eggplant has an affinity for olive oil, garlic and onions. When the new foods that came from the Americas— peppers, summer squash and especiallytomatoes— took hold in the region, a number of closely related dishes were born, including what we call ratatouille— and a man from La Mancha calls pisto, an Ikarian Greek calls soufiko and a Turk calls turlu.

The dishes are all made with abundant olive oil and simmered slowly and for a long time, traditionally in earthenware pots. They are recognizably different, though, because of their seasonings. The beguiling sweet and savory flavors in a Turkish turlu— cinnamon and coriander, fenugreek, mint and dill— are nothing like the earthy flavors in the layered parsley and oregano-seasoned Greek briam, the paprika and vinegar-spiked juices of an Andalusian alboronía or the thyme-scented essence of a ratatouille.

The dishes vary in other ways. In Majorca and Greece, potatoes are added to the mix, which makes these medleys substantial enough to serve as a main dish. You find additional summer vegetables like green beans and okra in the stews from Greece and Turkey. One of my favorites, Catalan samfaina, is often used as a sauce for rabbit, chicken or salt cod. The ingredients are chopped very small, tossed with olive oil and cooked for hours until the mixture is so thick and caramelized that it’s described as a vegetable marmalade. Ligurian rattatuia, almost identical to its cousin and near namesake across the border, can also be classified as a sauce, to accompany gnocchi,pastaor fish.

When you get into the kitchen, know that no two Mediterranean cooks make the same dish exactly the same way. Some Turkish cooks use up to a cup of olive oil when they make turlu, while others rely on a mixture of water, olive oil and tomato purée as a cooking medium. One cook will layer the vegetables after first cooking them in olive oil, then finish the dish in the oven or on a slow burner while another will stir everything together. Majorcan cooks from one village or restaurant may use a pungent tomato sauce in their layered vegetable tumbet; others use simple chopped tomatoes.

In my kitchen, I stray from the authentic recipes. If one-quarter or one-third cup of olive oil will work for a recipe that calls for one-half to one cup, I’ll always go for the lesser amount. You can use more if you prefer the robust flavor, texture and heft of abundant olive oil.

And when I want to brown eggplant, I don’t fry it in batches in oil; I know how thirsty eggplant can be. Instead, I toss all of the eggplant with a couple of tablespoons of olive oil and either roast it in the oven or brown it in a heavy nonstick pan.

Sometimes the stews can be watery at the end of cooking. One solution is to wait; time and again, I’ve left turlu or ratatouille overnight to find the juices reabsorbed, the stew thick and satiny the next day. You can also drain the cooked vegetables in a colander set over a bowl and reduce the juices to a thick, intensely flavored syrup that you then pour back over the stew.

These aren’t dishes that you throw together for supper after work. There are a lot of vegetables to chop (and in some cases to sauté) before the long simmer on the stove or in the oven. The simmering is pretty much unattended— an occasional stir if it’s not a layered dish— but you do have to be around.

Your efforts, however, can yield dinner for the rest of the week. The stews always taste better the next day (and the next— you can keep them in the refrigerator for about five days), as the flavors meld and ripen. They’re delicious hot or cold, and they freeze well. Leftovers become new meals as they’re mixed with scrambled or poached eggs (traditional especially in Spain and North Africa), spooned over a piece of fish or mounded onto a bruschetta.

This is time well spent.

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Advertising - Some of Sharecare.com’s Health Advice Will Be From Advertisers

Starting on Thursday, theWeb siteSharecare.comis to arrive, offering what its proprietors call an interactive social Q.&A. platform to provide consumers with what they want to know on health and wellness subjects— with the A’s being contributed by, among others, marketers.

Those behind Sharecare, a company formed last year to operate Sharecare.com, hope its features will enable the new Web site to thrive in a crowded field. Others in the online health care category includeAbout.com,AOL, CNN, eHow, Everyday Health,Health.com, MSN,WebMDandYahoo.

Sharecare.com will begin with content contributed by organizations likeAARP, theAmerican Cancer Society, theAmerican Heart Association, theAmerican Red Cross, theCleveland Clinic, Johns Hopkins and the National Academy of Sports Medicine, along with medical professionals like Dr.Mehmet Oz.

Those contributors are to be known as experts on the site. There is another label, knowledge partners, for marketers that are paying an estimated $1 million to $7 million to become sponsors of Sharecare.com. The initial roster is composed ofColgate-Palmolive, for Colgate oral care products; the Ortho-McNeil-Janssen Pharmaceuticals division ofJohnson&Johnson; theMedicines Company, a drug maker;Pfizer;Unilever, for Dove skin-care products; UnitedHealthcare, the health insurer; andWalgreen, for its Walgreens drug stores.

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Plans call for the content provided by the sponsors to be labeled, bearing their names and logos, so that visitors to Sharecare.com can distinguish their contributions from those of other sources.

Still, some visitors looking for objective answers to questions on health matters may raise their eyebrows at the presence of marketers. For instance, in a demonstration of the Web site on Wednesday, a reporter saw that among the questions being answered by Dove, on topics like treatingvaricose veinsand the effects of tanning beds, was one asking why good skin care is important.

“I’m sure there will be people who do that,” Jeff Arnold, chairman and chief architect at Sharecare in Atlanta, said of potential eyebrow-lifters. But in tests of the Web site in the last year,“the brand answers were read as much as the expert answers,” he added.

“It’s interesting to see how seriously the brands are taking their answers,” Mr. Arnold said, because they know their replies will not be far from those of the experts. There are more than 100,000 answers to questions on Sharecare.com, he added, with a goal of“a million by the end of the year.”

Paul Ewing, senior director for patient marketing at the United States primary-care business unit of Pfizer in New York, said his company would provide answers to questions“in the areas offibromyalgiaandsmoking cessation” but“not around any products we offer” in those areas, which are, respectively, the prescription drugs Lyrica and Chantix.

Anyone who reads content on Sharecare.com, whatever the source, will“have to work with their health care providers to make sure they’re making the best decisions about what the next steps would be” for any condition they want treated, Mr. Ewing said.

Pfizer’s interest in taking part in the Web site stems from a belief that“informed people make better decisions about their health,” he added,“and have better interactions with their health care providers.”

Christine Kubisztal, director for media services at Walgreen in Deerfield, Ill., said she would“be curious to see if” users of Sharecare.com perceived the answers from sponsors differently from the others.

“Yes, we are a retail place to go to,” she said of the Walgreens stores,“but we are also a brand trusted for 109 years.”

People are looking to“consume health care online in a much more user-friendly way,” Ms. Kubisztal said, and the“very individualized, very localized” answers to be provided by Sharecare.com are part of how Walgreen wants to demonstrate that its pharmacists“can be experts, providing answers and advice beyond 30 pills in a bottle.”

Sharecare was formed by a consortium that includes Mr. Arnold, who founded WebMD and later was chief executive ofHowStuffWorks.comwhen it was sold toDiscovery Communications; Dr. Oz, whose career as a health care arbiter was made byOprah Winfrey; Harpo Productions, Ms. Winfrey’s company;SonyPictures Television, a unit of the Sony Corporation that co-owns“The Dr. Oz Show” with Ms. Winfrey; and Discovery, a partner with Ms. Winfrey in OWN: the Oprah Winfrey Network, a cable channel to be introduced in January.

In a sort of soft debut for Sharecare.com, the Q.&A. section of Dr. Oz’sWeb site(doctoroz.com) bears the words“powered by Sharecare.”

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Sony Pictures Television is handling the search for sponsors for Sharecare.com.“Their answers are never‘This dental floss brand is better than that dental floss brand,’ ” said Amy Carney, president for advertising sales at Sony Pictures Television in New York.

“When the answers are as high quality as they will be,” she added,“if there is an initial skepticism on the part of the consumer it will quickly go away.”

According tocomScore, the top health information Web site in the United States in August wasEverydayhealth.com, with 25.7 million unique visitors, followed by WebMD, with 23.3 million. Of the total American Internet audience that month of 212.6 million, comScore reported, 96.6 million, or 45.4 percent, sought health information.

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Keeping Henhouses Free of Disease

In Henhouse No. 1 at the Hi-Grade Egg Farm here, the droppings from 381,000 chickens are carried off along a zig-zagging system of stacked conveyor belts with powerful fans blowing across them.

The excrement takes three days to travel more than a mile back and forth, and when it is finally deposited on a gray, 20-foot high mountain of manure, it has been thoroughly dried out, making it of little interest to the flies and rodents that can spread diseases likesalmonellapoisoning.

Standing by the manure pile on a recent afternoon, Robert L. Krouse, the president of Midwest Poultry Services, the company that owns the Hi-Grade farm, took a deep breath. The droppings, he declared, smelled sweet, like chocolate.

“This is the kind of thing that gets egg farmers excited,” Mr. Krouse said.

Controlling manure and keeping henhouses clean is essential to combating the toxic strain of salmonella that sickened thousands of people this year and prompted the recall of more than half a billion eggs produced by two companies in Iowa.

Chocolaty smells or not, the Hi-Grade facility appeared very different from the descriptions released by federal investigators of the Iowa farms that produced the recalled eggs. Those farms, most of them owned byAustin J. DeCoster, one of the country’s largest egg producers, were portrayed as filthy and badly maintained, with manure piles teeming with maggots and overflowing from pits beneath henhouses.

Those are not the images the egg industry wants consumers to have. Nor are they necessarily representative of most egg farms, federal regulators and industry officials agree.

Mr. Krouse’s farms were not associated with the recall, and a tour of one of them here in northern Indiana shows that much is being done in the egg industry to fight salmonella.

“We’ve had to completely change the way we look at things,” said Mr. Krouse, who is also chairman of the United Egg Producers, an industry association.“Thirty years ago, farms had flies and farms had mice, everything was exposed to everything else. They just all happily lived together. You can’t work that way anymore.”

Today the hens on Mr. Krouse’s farms come from hatcheries certified to provide chicks free of salmonella. The young birds are vaccinated to create resistance to the bacteria. And then steps are taken to keep them from being exposed to it, primarily by controlling mice and flies that may carry salmonella or spread it around.

That is where the manure drying comes in, although it has other benefits, like preventing bad smells that can bother neighbors.

Many of the henhouses have been built or refurbished in recent years. Henhouse No. 1 is three years old. On the newer henhouses, the bottom two feet of the outer walls are concrete, to make it harder for mice to get inside. The buildings are surrounded by a perimeter of stone and gravel, and the grass between buildings is cut short, to eliminate rodent habitats.

The doors seal tightly, like doors in a modern home rather than old-style barn doors. Bait containers and traps are placed along the walls, and the number of trapped mice is tracked closely to spot any increase in activity.

Visitors are made to dress in head-to-toe white coveralls made of a disposable material— evoking images of workers on the sterile floor of a semiconductor factory, only here there are downy feathers in the air and the racket made by hundreds of thousands of birds in cages stacked to the ceiling.

The suits are meant to keep out germs that visitors may track in from off the farm. They may protect against salmonella, but they are mostly aimed at pathogens that can ravage flocks with diseases likeavian influenzaand could be tracked in from other farms or places like golf courses that are home to wild geese.

The long, gray, tin-sided henhouses, about two football fields long, have no windows. Surrounded by fields of corn and soybeans, they hum softly with the sound of giant fans.

But everything here is not as modern as the manure drying contraption in Henhouse No. 1.

Nearby is a 12-year-old building, Henhouse No. 6.

Here more than 200,000 birds live on the house’s second floor, in cages stacked in an A-frame configuration, with an opening at the center that allows the droppings to fall into a cavernous ground floor space below.

Mr. Krouse said that just a few years ago this design was considered the most advanced, and it is still prevalent throughout the egg industry, including the henhouses at the Iowa farms involved in the recall.

At the farms in Iowa, inspectors found manure piles eight feet deep in some barns, with the manure overflowing and bursting through doors. Escaped chickens were seen loose in the manure and there were flies and maggots, according to theFood and Drug Administrationinspection reports.

Once again, the picture was very different here. At the Hi-Grade barn, the manure was only about six inches deep, lying in five mounds, about four feet wide and 600 feet long, on the floor beneath the long arrays of cages. Mr. Krouse said the houses were cleaned out in early August.

Here, there was no suggestion of chocolate smells. The air had an ammonia bite, although it was far from overpowering. And there were flies, though not in large numbers (in part because of plenty of fly traps).

Gary E. Casper, a farm manager, said the key to controlling flies and rodents in this type of barn was to keep the manure dry. Large fans around the room kept the air moving. And he said it was crucial to watch for problems in the system that carries water to the birds in the cages above, and to stop leaks before they can soak the manure piles.

Many egg producers have been working for years to keep salmonella out of their flocks. Midwest Poultry began testing barns for salmonella in the late 1990s and has never found the toxic strain that can infect eggs.

In July, the F.D.A. put in place a set of egg safety rules that all producers must follow, with an emphasis on testing and rodent control. For companies like Midwest, that has meant only minor adjustments. The company, which has a total of six million laying hens in three states, spent about $200,000 upgrading refrigeration equipment to meet stricter rules for cooling eggs to prevent the growth of bacteria.

Mr. Krouse sells eggs to the large supermarket chains Kroger andWal-Mart, and he says that those stores now scrutinize their farm suppliers much as they would a food manufacturing company.

“They’re looking at us as just another part of their food production system,” he said.

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Recipes for Health - Apple Crumble

2 quarts thinly sliced apples (about 2 1/2 pounds)

2 tablespoons raw brown (turbinado) sugar, preferably organic

1 tablespoon fresh lemon juice

1/2 teaspoon cinnamon

1/4 teaspoon nutmeg

1 teaspoon vanilla extract

1 batchquinoa-oat crumble topping

1.Preheat the oven to 375 degrees. Butter a two-quart baking dish. Slice the apples thin. (I don’t peel them, but if you’d rather, go ahead.) Toss them in a large bowl with the sugar, lemon juice, cinnamon, nutmeg and vanilla. Transfer to the baking dish, and place in the oven. Bake 30 minutes, stirring every 10 minutes until the apples are tender. Remove from the heat.

2.Top the apples with the crumble topping, and return to the oven. Bake 15 to 20 minutes until bubbling and the top is nicely browned. Allow to cool for at least 10 minutes before serving.

Yield:Serves eight.

Advance preparation:The crumble topping keeps for several months in the freezer. The recipe can be made through Step 1 several hours before the final baking.

Nutritional information per serving:265calories; 10 grams fat; 6 gramssaturated fat; 23 milligramscholesterol; 42 gramscarbohydrates; 5 gramsdietary fiber; 104 milligrams sodium; 3 grams protein

Martha Rose Shulman can be reached atmartha-rose-shulman.com. Her latest book,"The Very Best of Recipes for Health,"was published in August by Rodale Books.

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U.S. Waivers After Threats of Lost Health Coverage

The waivers have been issued in the last several weeks as part of a broader strategic effort to stave off threats by some health insurers to abandon markets, drop out of the business altogether or refuse to sell certain policies.

Among those that administration officials hoped to mollify with waivers were some big insurers, some smaller employers and McDonald’s, which went so far as to warn that the regulations could force it to strip workers of existing coverage.

At a time when the midterm elections are looming and Republicans have been vocal in campaigning against the law, reaction to the rollout has been closely watched.

To date, the administration has given about 30 insurers, employers and union plans, responsible for covering about one million people, one-year waivers on the new rules that phase out annual limits on coverage for limited-benefit plans, also known as“mini-meds.” Applicants said their premiums would increase significantly, in some cases doubling or more.

These early exemptions offer the first signs of how the administration may tackle an even more difficult hurdle: the resistance from insurers and others against proposed regulations that will determine how much insurers spend on consumers’ health care versus administrative overhead, a major cornerstone of the law.

Several leading insurers, including WellPoint,AetnaandCigna, have also objected to new rules requiring them to cover even those children who are seriously ill, warning that they will stop selling new policies in some states because the rules do not protect them from having to cover too many sick children.

“The hardest part of health reform is always going to be the transition,” said Peter T. Harbage, a former state health official who is a policy consultant in Sacramento. He predicts more insurers and employers will lean on the government to delay or weaken the new regulations.“I think this pressure just increases until we get to 2014,” he said, referring to the year that the law will fully go into effect.

How much the administration can, or should, compromise in ways that could dilute the effect of the new law in the next few years is a subject of much debate, depending on the politics from state to state or the economic dynamics in a particular market.

Policy experts say much of the authority to enforce the new law rests with the states, and they say the federal government may have little ultimate control over whether insurers will keep offering coverage in specific markets.

Nancy-Ann DeParle, the director of the Office of Health Reform at the White House, acknowledged that the concessions given to companies and insurers reflected attempts to avoid having people lose their current coverage before the full law goes into effect while meeting the aim of improving that coverage.

“It is a balancing act,” Ms. DeParle said.“The president wants to have a smooth glide path to 2014.”

The waivers issued so far include the policies offered by McDonald’s to its fast-food workers, typically capped at just a few thousand dollars, sold by a profit-making company owned by Blue Cross and Blue Shield plans. As a result of the administration’s efforts, McDonald’s says it is“confident that we’ll continue to provide health care coverage for our 30,000 hourly restaurant employees.”

Aetna and Cigna have also received waivers to continue selling limited-benefit policies, according to the list released by theDepartment of Health and Human Services, as have small employers like Sanderson Plumbing Products and Guy C. Lee Manufacturing. HealthMarkets, which offers policies through MEGA Life and Health and other insurers, says it also plans to apply for a waiver for some of its plans.

Some states, like Iowa and Maine, have already said they might seek additional authority from federal officials to exempt some insurers, at least for a time, because of the potential disruption if carriers leave the market over the new standards on medical spending.

“We have some very small carriers in the state,” said Susan E. Voss, the Iowa insurance commissioner, who said she favored letting state regulators decide whether some carriers should be given more leeway. The state has already lost some carriers, including thePrincipal Financial Group, which announced its decision last week.

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In Crick’s Letters, Rivalry Among DNA Sleuths Comes to Life

The letters were written during a 26-year period when Crick informally guided the progress of molecular biologists around the world in establishing how DNA operates in living cells. An article on the letters was published Wednesday in the journal Nature, focusing on those related to the discovery of DNA’s double helix structure in 1953.

“We are really between forces that may grind all of us to pieces,” the physicist Maurice Wilkins wrote after a disastrous attempt by Crick and his colleagueJames D. Watsonto build a model of DNA based in part on data gathered by Rosalind Franklin.

Ignoring the intimations of doom, Crick responded to Dr. Wilkins in flippant style, referring to his poaching another lab’s problem and to his friend’s inability to get along with his colleague Dr. Franklin.“So cheer up and take it from us that even if we kicked you in the pants it was between friends,” Crick wrote in December 1951.“We hope our burglary will at least produce a united front in your group!”

Crick’s scientific career was delayed by wartime work designing mines, and at the time he was studying for his Ph.D. atCambridge Universityand was not supposed to be working on DNA at all. The problem belonged to Dr. Wilkins at the University of London. But he, too, was sidelined because the head of his laboratory, John Randall, had made him give up his DNA material and graduate student to a new hire, Dr. Franklin.

The debacle of the wrong structure was set up by Dr. Watson, who had attended a lecture Dr. Franklin gave about her work on DNA but misremembered a critical measurement. Based on it, he and Crick built a model of DNA’s structure and proudly invited the London group up to Cambridge to inspect it.

Dr. Franklin saw immediately that it was mistaken and pointed out the error. Worse consequences were to follow. Hearing of the failed attempt, Dr. Randall complained to Lawrence Bragg, the head of Crick’s laboratory. Dr. Wilkins’s fear of“forces that may grind all of us to pieces” was not misplaced: Dr. Bragg told Crick to get back to his thesis work and stop building models of DNA. The ban was reversed a year later only when Dr. Bragg learned that Pauling, his longtime rival, was also hot on the trail of the DNA structure.

Crick’s correspondence during the formative years of molecular biology was long thought to have been destroyed. Crick told others in 1976 that an overly tidy secretary had thrown all his early letters away. His colleague Sydney Brenner, with whom he shared an office in Cambridge for 21 years, believed the same. Dr. Brenner once showed the author Horace Judson boxes of his unsorted correspondence, explaining it had survived, unlike Crick’s, only because he had been too lazy to file it.“And that’s why the girl never destroyed it,” he said, Mr. Judson reports in his book“The Eighth Day of Creation.”

But it turned out the secretary did not destroy Crick’s correspondence. Dr. Brenner, who is now at the Salk Institute in La Jolla, Calif., recently donated all his files to the Cold Spring Harbor Laboratory on Long Island, where Dr. Watson still works. Looking through Dr. Brenner’s archives, Alex Gann, director of the laboratory’s publishing unit, recognized that they included Crick’s missing correspondence, which evidently had not been discarded but merely was commingled with Dr. Brenner’s papers.

Dr. Gann and Jan Witkowski, director of the Banbury Center at Cold Spring Harbor, write in their article in Nature that the recovered correspondence“gives us a more nuanced sense of the interactions between the principal players in this most famous of scientific stories.”

Robert Olby, a historian of science at theUniversity of Pittsburghand Crick’s authorized biographer, called the rediscovered trove“a rich source of passages that are the live words of the actors at the time, spoken in the heat of the moment.” Dr. Olby’s biography,“Francis Crick, Hunter of Life’s Secrets,” was published last year, its subject having forbade its appearance during his lifetime.

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Really? - Should You Clean Produce With Soap and Water? - Question

Scientists have found some effective household measures that can eliminate germs and pesticides. The simplest? Rinsing with tap water, which works as well as a mild soap solution or fruit and vegetable washes.

In studies at the Connecticut Agricultural Experiment Station in 2000, for example, scientists compared pesticide removal methods on 196 samples of lettuce, strawberries and tomatoes. Some were rinsed under tap water for a minute; others were treated with either a 1 percent solution of Palmolive or a fruit and vegetable wash. Tap water“significantly reduced” residues of 9 of 12 pesticides, and it worked as well as soap and wash products, the studies found.

Water temperature was not the key; friction was.“The mechanical action of rubbing the produce under tap water is likely responsible for removing pesticide residues,”scientists wrote.

For micro-organisms, try rinsing produce with a mild solution of vinegar, about 10 percent. Ina 2003 studyat theUniversity of Florida, researchers tested disinfectants on strawberries contaminated with E. coli and other germs. They found the vinegar mixture reduced bacteria by 90 percent and viruses by about 95 percent.

THE BOTTOM LINETo remove pesticides and germs, rinse produce with a vinegar solution, then wash with tap water for at least 30 seconds.

ANAHAD O’CONNORscitimes@nytimes.com

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Personal Health - Vegetable Consumption Lags, Despite Benefits

For many of us, that was a litany of childhood, an 11th commandment— often followed by“or no dessert.” I even know a mother who tried reversepsychologyon her son—“You can’t have your vegetables until you’ve finished your meat” (or chicken or fish)— though I can’t testify to its success.

As evidence of the health benefits of vegetables has accumulated, public health scientists, nutritionists, federal health experts, growers and marketers, teachers and physicians have been urging— and urging and urging— that Americans eat more of them.

Producers have gone to great lengths to encourage vegetable consumption by a public increasingly pressed for time and overly focused on fast food and takeout. Farmers’ markets are springing up all over the country, with enticing displays of locally grown produce. Supermarkets feature ready-to-eat and ready-to-cook vegetables— spinach, salad greens, complete salads, broccoli florets, peeled baby carrots. Simple, tasty recipes are often part of the produce display. Even the major fast-food purveyors have made an effort, introducing salads as side and main dishes; McDonald’s now sells more salads than any other eating establishment.

Yet last month came the discouraging word from the nationalCenters for Disease Control and Preventionthat Americans have fallen far short of the goals set a decade ago to increase consumption of vegetables. In 2009, just 26 percent of adults had three or more servings a day (including those who count a tomato slice and a lettuce leaf on a burger as a vegetable serving). That was half the percentage public health officials had hoped for.

And it falls even shorter if you look at the current recommendations: at least four to five vegetable servings daily. Please note the definition of a serving: half a cup of cut-up or cooked vegetables, one cup of fresh greens, half a cup of cooked dried beans, or, if you must, six ounces of vegetable juice.

So what’s so good about vegetables anyway? First, vegetables are loaded with vital nutrients: potassium,beta-carotene(the precursor of vitamin A), magnesium,calcium, iron,folate(a B vitamin) andvitaminsC, E and K, as well as antioxidants andfiber. Despite an ill-conceived effort years ago to“package” vegetables’ nutrients in a supplement, there is no good way to consume them short of eating the foods that contain them.

And unless they are drowned in butter or a high-calorie sauce or dressing, vegetables provide those nutrients at minimal caloric cost, an important attribute in a society whereobesityis ballooning out of control.

Curbing weight gain can reduce the risk ofType 2 diabetes, now rampant in America and an important cause of heart disease,kidney failureand premature death.

Fiber, Potassium and More

Vegetables provide dietary bulk, filling the stomach and reducing the appetite for higher-calorie foods. The fiber in vegetables helps reduce blood levels of heart-damagingcholesteroland is a major antidote forconstipationanddiverticulosis.

The potassium in tomato products, dried beans, sweet potatoes, spinach, Swiss chard and winter squash can easehigh blood pressure, a major risk factor for heart disease and stroke, and may also reduce the risk of developingkidney stonesand bone loss.

Folate is a critical nutrient duringpregnancyto prevent spinal cord defects; it also helps the body form red blood cells.Vitamin E, an antioxidant, protects against the deterioration of essential fatty acids and premature cell aging, andvitamin Cis important for healthy gums and teeth, healing of wounds and absorption of iron.Vitamin Kaids in blood clotting (note, however, that people taking blood thinners must curb their intake of foods rich in this nutrient).

The vitamin A formed from beta-carotene is vital to the health of the eyes and skin and may help prevent infections.A Harvard study of 73,000 nurses, published in 2003 in The American Journal of Clinical Nutrition, linked a carotenoid-richdietto a reduced risk of coronary artery disease, anda Swedish studyfound that it cut the risk ofstomach cancerin half.

Two othercarotenoids, lutein and zeaxanthin, can reduce the risks ofmacular degenerationandcataracts, common causes of vision loss as people age. These nutrients are found in dark green leafy vegetables, like spinach and kale, which are packed with other valuable vitamins and minerals.

Lycopene, another carotenoid, may reduce the risk ofprostate cancerandwas also linked to a reduced risk of cardiovascular disease in women. Lycopene is best obtained from processed tomato products. (Tomatoes, of course, are technically fruits, as are squash and other“vegetables” with seeds. The foods we usually think of as fruit have plenty of nutritional value but tend to have morecaloriesthan vegetables— and may not supply all the same nutrients.)

Several other vegetables, not all of them popular among Americans, have also been linked to protection againstcancer. These are the so-called cruciferous vegetables: broccoli, cauliflower, cabbage, kale, collard greens and brussels sprouts.

Then there are the allium vegetables, onions and garlic, thatresearchers in Milan have linkedto protection against cancers of the colon and rectum, ovary, prostate, breast, kidney, esophagus, mouth and throat.

Last year The Nutrition Action Healthletter, published by theCenter for Science in the Public Interest, an advocacy group based in Washington, ranked vegetables according to nutrient content. Kale led the list, followed by spinach, collard greens, turnip greens, Swiss chard, canned pumpkin, mustard greens, sweet potato, broccoli and carrots.

Others among the“superstars” listed were romaine lettuce, red bell pepper, curly endive, brussels sprouts, butternut squash, green pepper, peas and bok choy.

Except for sweet potato (100 calories in one medium potato) and peas (70 calories per half cup), none of these (when unadorned by fat) have more than 40 calories a serving, and most have only 20 or 30 calories.

Suggestions Welcome

Given that so many professionals have failed to raise the consumption of vegetables among not-so-health-conscious Americans, how can we make a difference? Fresh ideas are needed, and I invite readers to e-mail suggestions toscitimes@nytimes.comfor possible inclusion in a future column. (Please include the word“Brody” in the subject line.)

Who knows? One of you may succeed in keeping Americans healthier and curbing our runaway health care costs.

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Noticed - Yoga Mats Falling Out of Favor

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Antipsychotic Drugs - Side Effects May Include Lawsuits

While the effectiveness of antipsychotic drugs in some patients remains a matter of great debate, how these drugs became so ubiquitous and profitable is not. Big Pharma got behind them in the 1990s, when they were still seen as treatments for the most serious mental illnesses, like hallucinatoryschizophrenia, and recast them for much broader uses, according to previously confidential industry documents that have been produced in a variety of court cases.

Anointed with names like Abilify and Geodon, the drugs were given to a broad swath of patients, from preschoolers to octogenarians. Today, more thana half-million youthstake antipsychotic drugs, and fullyone-quarter of nursing-home residentshave used them. Yet recent governmentwarnings saythe drugs may be fatal to some older patients and have unknown effects on children.

The new generation of antipsychotics has also become the single biggest target of theFalse Claims Act, a federal law once largely aimed at fraud among military contractors. Every major company selling the drugs—Bristol-Myers Squibb,Eli Lilly,Pfizer,AstraZenecaandJohnson&Johnson— has either settled recent government cases for hundreds of millions of dollars or is currently under investigation for possible health care fraud.

Two of the settlements, involving charges of illegal marketing, set records last year for the largest criminal fines ever imposed on corporations. One involved Eli Lilly’s antipsychotic, Zyprexa; the other involved a guilty plea for Pfizer’s marketing of a pain pill,Bextra. In the Bextra case, the government also charged Pfizer with illegally marketing another antipsychotic, Geodon; Pfizer settled that part of the claim for $301 million, without admitting any wrongdoing.

The companies all say their antipsychotics are safe and effective in treating the conditions for which theFood and Drug Administrationhas approved them— mostly, schizophrenia andbipolarmania— and say they adhere to tight ethical guidelines in sales practices. The drug makers also say that there is a large population of patients who still haven’t taken the drugs but could benefit from them.

AstraZeneca, which markets Seroquel, the top-selling antipsychotic since 2005, says it developed such drugs because they have fewer side effects than older versions.

“It’s a drug that’s been studied in multiple clinical trials in various indications,” says Dr. Howard Hutchinson, AstraZeneca’s chief medical officer.“Getting these patients to be functioning members of society has a tremendous benefit in terms of their overall well-being and how they look at themselves, and to get that benefit, the patients are willing to accept some level of side effects.”

The industry continues to market antipsychotics aggressively, leading analysts to question how drugs approved by the Food and Drug Administration for about 1 percent of the population have become the pharmaceutical industry’s biggest sellers— despite recent crackdowns.

Some say the answer to that question isn’t complicated.

“It’s the money,” says Dr. Jerome L. Avorn, aHarvardmedical professor and researcher.“When you’re selling $1 billion a year or more of a drug, it’s very tempting for a company to just ignore the traffic ticket and keep speeding.”

NEUROLEPTIC drugs— now known as antipsychotics— were first developed in the 1950s for use inanesthesiaand then as powerfulsedativesfor patients with schizophrenia and other severepsychoticdisorders, who previously might have received surgical lobotomies.

But patients often stopped taking those drugs, like Thorazine and Haldol, because they could cause a range ofinvoluntary body movements,ticsandrestlessness.

A second generation of drugs, called atypical antipsychotics, was introduced in the’90s and sold to doctors more broadly, on the basis that they were safer than the old ones— an assertion that regulators and researchers are continuing to review because the newer drugs appear to cause a range of other side effects, even if they cause fewer tics.

Contentions that the new drugs are superior have been“greatly exaggerated,” says Dr. Jeffrey A. Lieberman, chairman of thepsychiatrydepartment atColumbia University. Such assertions, he says,“may have been encouraged by an overly expectant community of clinicians and patients eager to believe in the power of new medications.”

“At the same time,” he adds,“the aggressive marketing of these drugs may have contributed to this enhanced perception of their effectiveness in the absence of empirical evidence.”

Others agree.“They sold the story they’re more safe, when they aren’t,” says Robert Whitaker, a journalist who has writtentwo booksabout psychiatric medicines.“They had to cover up the problems. Right from the start, we got this false story.”

The drug companies say all the possible side effects are fully disclosed to the F.D.A., doctors and patients. Side effects likedrowsiness, nausea,weight gain, involuntary body movements and links todiabetesare listed on the label. The companies say they have a generally safe record in treating a difficult disease and are fighting lawsuits in which some patients claim harm.

The cases, both civil and criminal, against many of the world’s largest drug makers have unveiled hundreds of previously confidential documents showing that some company officials were aware they were using questionable tactics when they marketed these powerful, expensive drugs.

Such marketing, according to analysts and court documents, included payments, gifts, meals and trips for doctors, biased studies, ghostwritten medical journal articles, promotional conference appearances, and payments for postgraduate medical education that encourages a pro-drug outlook among doctors. All of these are tools that federal investigators say companies have used to exaggerate benefits, play down risks and promote off-label uses, meaning those the F.D.A. hasn’t approved.

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Mammogram Benefit Is Seen for Women in Their 40s

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