In Brachiopods’ Eyes, the Theory of Evolution

But Darwin dispelled that seeming absurdity by laying out a series of steps by which the evolution could take place. Making this sequence all the more plausible was the fact that some of the transitional forms Darwin described actually existed in living invertebrates.

Now, a team of American and European researchers report that they have discovered an eye that could represent the first step in this evolution. They have found, in effect, a swimming eyeball.

“This is in no way the ancestor of the human eye, but it’s the first time we have had a model of it,” said Yale Passamaneck, a postdoctoral researcher at theUniversity of Hawaii. He and his colleagues report the discovery in the online journalEvoDevo.

The researchers made the discovery while studying a species ofbrachiopods, or lamp shells, which live in shells but are marine worms unrelated to mollusks like clams and oysters. Lamp shells have existed for over half a billion years, but their biology has long remained a mystery— including the simple question of whether they can see.

Four-day-old lamp shell larvae, for example, have puzzling dark spots on either side of the front end of their bodies. Recently, Carsten Lüter, a biologist at the Berlin Museum of Natural History, and his colleagues dissected the eyespots of some lamp shell larvae. They discovered that each spot was actually a pair of neurons, one for capturing light and one containing pigment. The neurons connected to a brainlike clump of neurons inside the larva.

Their anatomy suggested the spots were simple eyes. So Dr. Lüter and his colleagues contacted Dr. Passamaneck and his colleagues at the University of Hawaii, who are experts on the genes for animal photoreceptors. The Hawaii researchers discovered that, indeed, photoreceptor genes were active in the dark spots.

But to be thorough, Dr. Passamaneck checked to see if the photoreceptor genes were active at other stages.“I thought,‘I’m just going to eliminate that possibility,’ ” he said.

Just the opposite happened. Dr. Passamaneck discovered that the genes were active much earlier, just 36 hours after fertilization, when the lamp shell embryo was merely a cup-shaped mass of a few hundred cells.

Dr. Passamaneck was baffled.“There are no neurons at that stage,” he said. Nevertheless, it was clear that the outer surface of the cup was covered with photoreceptors.

To see if the embryos were doing something with the light, Dr. Passamaneck and his colleagues put a light on one side of a dish of embryos. The lamp shell embryo is covered with tiny beating hairs, which it uses to swim in a spiral pattern. Dr. Passamaneck found that after 20 minutes, twice as many embryos would end up on the illuminated side of the dish as on the dark side.

Dr. Passamaneck and his colleagues hypothesize that the cells can detect the direction of light because it is blocked in some directions by the embryo’s yolk. It can then use this information to change the rhythm of its hair.

It is possible, Dr. Passamaneck said, that in the course of evolution, our own eyes started out as swimming eyeballs. Only later did the job of catching light get relegated to only some cells, which could send signals to their neighbors. And only much later did these specialist cells relay signals to brains.

Todd Oakley of theUniversity of California, Santa Barbara, an expert on the evolution of vision, called the results“tantalizing.” But he cautioned that just because the photoreceptor gene was active in the early embryo, that did not necessarily mean that the lamp shells were able to see.“Other possible photoreceptive mechanisms should also be ruled out,” Dr. Oakley said.“Correlation does not mean causation.”

Dr. Passamaneck is making plans for these sorts of studies. For now, though, he remains a bit stunned at what he has stumbled across.

“It’s likeYogi Berrasaid,” he said.“You can observe a lot by watching.”

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Digital Patient Data Holds Promise and Problems

Step back from the details and what emerges is a huge challenge in innovation design. What role should government have? What is the right mix of top-down and bottom-up efforts? Driving change through the system will involve shifts in technology, economic incentives and the culture of health care.

“This is a big social project, not just a technical endeavor,” saysDr. David Blumenthal,the Obama administration’s national coordinator for health information technology.

This year is when the project really takes off. In the 2009 economic recovery package, the administration and Congress allocated billions— the current estimate is $27 billion— in incentives for doctors and hospitals to adopt electronic records.

Now, a new Congress with Republicans looking for budget cuts could take back the money. Legislation has been introduced by Representative Tom Latham, an Iowa Republican, to reclaim unspent stimulus dollars— and money for accelerating the adoption of electronic health records could be a target.

Still, steps to encourage adoption of computerized health records have had bipartisan support over the years, though only the Obama administration has pushed for big financing. Most health policy analysts say it is unlikely that the legislation will be overturned.

When well designed and wisely used, computerized records have proved valuable in improving care. Doctors have more complete information in treating patients, reducing the chances of medical errors and unneeded tests.

But the success stories to date have come mainly from large health care providers, like Kaiser Permanente, theMayo Clinicand a handful of others. Most physicians are in small practices, lacking the financial and technical support the big groups provide for their doctors. So it is scarcely surprising that less than 30 percent of physicians nationwide now use digital records.

Late last year, the administration, working with health professionals and the technology industry, set out a roadmap for what digital records should include and how they should be used, for doctors to qualify for incentive payments, typically up to $44,000. The program begins this year, and the requirements for using the records to report and share health information increase in stages through 2015. After that, penalty payments fromMedicareandMedicaidkick in for doctors who don’t meet the use and reporting rules.

The initial requirements to qualify for“meaningful use” are minimal, including being able to collect and electronically report basic information, likevaccinationsfor children or blood glucose levels fordiabetespatients.

The long-range vision is that computerized patient data is a step toward what health care specialists call a“learning health system.” That means data across populations of patients can be analyzed to find what treatments are most effective or to get early warnings on dangerous drug interactions.

“Islands” of such learning networks already exist, notes Charles P. Friedman, chief scientist in the federal health information technology office. By mining its patient data, Kaiser, for example, was first to identify a link between the pain-relief drugVioxxand a higher risk ofheart failure, well beforeMerckpulled the drug off the market in 2004.

Yet the road to a national computer-enabled learning system, specialists agree, promises to be long. A major obstacle is that so many doctors, especially in small practices, are leery of technology they see as needlessly hard to use and time-consuming.“Doctors don’t want to become clerks,” says Dr. Isaac Kohane, a health technology specialist at the Harvard Medical School.

And complex technology— designed for big health groups, not small practices— could well increase medical mistakes, specialists say.

Such issues, Dr. Blumenthal says, are a reason that the government’s standards, and perhaps even the timetable for adopting electronic health records, will evolve and remain flexible.

The government, he adds, is looking closely at safety and usability. Dr. Blumenthal’s office gave theInstitute of Medicinea grant of nearly $1 million for a yearlong study of electronic health records and patient safety. And his office is working with theNational Institute of Standards and Technologyto develop a“usability assessment tool” that can be used to evaluate the digital records offered by different companies.

Under Dr. Blumenthal, the office has tried to gradually build consensus on policy and technical standards rather than issuing edicts. However, the President’s Council of Advisors on Science and Technology, an independent group of academic and industry experts, saidin a reportlast December that the time had come for more“top-down design choices,” which it called“an appropriate government role” and one that“requires a more aggressive approach than has been taken in the early stages.”

THIS month, the health information technology office announced a step that showed its preferred approach to setting standards, one that borrowed from the Internet model of open-source software development in an initiative called the Direct Project.

Many companies and groups contributed to the government-endorsed Internet-based tools for exchanging health data among institutions. Developers wrote code and suggested ideas, and a consensus built around an approach that was selected by the government. The design was inspired by the Web, with its minimal specifications that leave ample room for innovation, says Dr. Douglas Fridsma, head of standards at the health technology office.

Without a brisk market in information exchange, the campaign to adopt electronic records cannot really pay off. And more is needed than data-sharing standards and privacy and security protections, Dr. Blumenthal says.

The incentives have to change as well. Two hospitals a few miles apart, he notes, do not now view themselves as allies, but as competitors. To a doctor or a hospital, a patient is, among other things, a financial asset— and holding a patient’s information is valuable.

Insurers, he suggests, will have to pay for providers to share data or penalize them if they don’t.“Information exchange has to be a business goal, rather than a competitive threat, for this to work,” he says.

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Book Review - Never Say Die - By Susan Jacoby

Jacoby sees a new ageism that doesn’t just stigmatize old people for their years, but blames them for physical ills that no lifestyle adjustments or medicine can yet forestall. In particular, she believes that our dreams of active, vital old age block a clear vision of“old old” age, the highly vulnerable stage that begins around a person’s 85th birthday. Among other perils, the“old old” have a roughly even chance of being counted among the mind-eaten ranks ofAlzheimer’svictims. We may not like to think that poverty, social isolation, crippling pain,dementiaand loss of autonomy are likely to come calling the longer we live, but it’s a fact.

Jacoby argues that Americans, and baby boomers especially, are blinded to the most regrettable facts of old age because we (I am 52, Jacoby is 65) have been steeped for decades in the national can-do, self-help, will-can-make-it-so stew. Boomers may believe they can reinvent life past 60 just as they reinventedadolescenceand young adulthood. They may think their late years will be filled with vigor, work, active social lives and“giving back.” And they may believe that medical science will transform human biology and spare us all from decrepitude. Dream on, Jacoby says. Or rather, don’t.

She digs deep to explain how America spawned such a self-confident, selfish, deluded horde. Wasn’t America founded and settled largely by people who left parents behind, she asks? To her, Laura Ingalls Wilder’s“Little House on the Prairie” series is a chronicle of elder abandonment. She reminds us that in 1905 one of the saints of American medicine, Dr. William Osler, gave a notorious farewell speech at Johns Hopkins claiming that human creativity peaked at 40 and that men over 60 were so useless they ought to be offered a“peaceful departure by chloroform.” (Osler, 56 at the time, later claimed he had been joking about the chloroform.) Jacoby also resurrects decades-old critiques of transactional analysis, EST and the Me Generation, and bemoans how today’s talk-show hosts, celebrity shrinks and medicine men pander to youth-obsessed fans.

These are not new arguments, but truth-tellers often must reiterate. It also helps if they have undergone a transformation themselves. Jacoby takes her younger self to task for once writing happy-talk articles on aging for AARP publications that rarely quoted anyone over 60. Boomers slightly younger than she is now, Jacoby observes, can imagine themselves easily enough as“young old,” but are not yet seasoned to empathize with the old old.

Even if we prolong our healthy lives, she writes, our last years are likely to be as full of handicaps as ever:“At 85 or 90— whatever satisfactions may still lie ahead— only a fool or someone who has led an extraordinarily unhappy life can imagine that the best years are still to come.” The advances of modern medicine may just draw out our unhappy ends even longer. Jacoby, an avowed atheist, argues that suicide is hardly immoral when one’s final days are an unbearable compound of physical and psychological insults.

Jacoby repeatedly hammers home the suffering of the very old, reminding readers how large the risk of dementia looms. Indeed, we need to face this individual truth in order to face the broader social one. By 2030, the 70 million aging boomers will nearly double the ranks of Americans over 65, strainingSocial Securityand, especially,Medicareto the breaking point (though Jacoby is quick to argue against the“greedy geezer” stereotype, which she sees as a half-truth pushed by conservatives who want to gut entitlement programs). Jacoby persuasively argues that the needs of the old old can be met only with a stronger government role, but that younger Americans would be unlikely to support this unless their health care needs were better met, too. She also notes that our insistence on personal choice in health care often leads to the obliteration of personal autonomy in late life, when the prohibitive cost of home care forces older people into low-rung institutions where they lose control of their lives.

For all Jacoby’s ultrarationalism,“Never Say Die” is not a perfectly reasoned manifesto. For a reader who agrees with her basic argument, confronting her lapses feels a little like colliding with one’s own teammate. One big stumble is equating the dream of an active late life with blindness to the common horrors of advanced old age. Might not the longing for activity be a kind of reckoning with the future? Recent surveys showing a large bump in the number of people near and at“retirement age” who expect to work for years to come reflect not just the hope of staying active, but a widespread fear of running out of money long before they run out of years. When asked about their greatest concerns about old age, 6 in 10 Americans cite the loss of mental capacity. And they may not be totally wrong in believing that healthy lifestyles can help. A 13-year study released last month by the University of Pittsburgh showed that those who walked six to nine miles a week appeared to maintain brain mass and stave off cognitive impairment better than those who were more sedentary.

Jacoby the rationalist allows only cursory glimpses at a few flesh-and-blood examples, including the man she“loved most in the world,” who died after battlingcancerand Alzheimer’s; her mother, who suffers agonizing osteoporotic pain; and her grandmother, who, at 99, lamented having“lived too long.” She does not look closely at the many programs and communities working hard to address the problems that haunt her. What of the neighborhoods that have banded together to deliver services to the old old who wish to stay in their homes? Or the many innovative group-living arrangements— like the“Green House” model, which puts 6 to 12 older adults in homes integrated into the surrounding community— that stress community but provide health care services, too? While Jacoby calls for big, preferably government-driven answers, the boomers she hopes to enlighten often turn to very local solutions for the age-related problems faced by their parents. It may be on this ground that the mood of our time changes.

Friends, Jacoby writes, urged her to end the book with a positive note and some practical advice. Hard pressed, she extols her home, New York City, with its public transportation, walkable streets and hustling delivery boys, as the best place in the world to age. She also advises people to stay busy.“And that,” she says,“just about sums up my‘positive advice.’” That is all sound and reasonable, but it lacks any hint of the passion of Jacoby the analytic assailer. Yes, the brute facts are the brute facts, but“Never Say Die” is ultimately— as Jacoby acknowledges in an aside late in the book— about her own fear of poverty, dementia and dependence. For all her doubts about the rest of the population’s grasp of reality, this fear is an increasingly common one. It took Jacoby until age 65 to collect her insights; her fellow boomers may be right behind.

Ted C. Fishman’s books include “China, Inc.” and, most recently, “Shock of Gray.”

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Newborn Mice’s Hearts Can Heal Themselves, Study Finds

Now researchers from the University of Texas Southwestern Medical Centerreport in the current issue of Sciencethat the mammalian newborn heart can fully heal itself.

Dr. Hesham Sadek, a cardiologist at the medical center, and his colleagues worked with mice and found that if a portion of the heart was removed within the first week of life, the heart grew back completely.

The researchers removed about 15 percent of lowest portion of the heart, known as the apex, in laboratory mice. Within three weeks, the lost tissue regenerated itself and the hearts were healed.

“But by seven days this remarkable regenerative is lost and instead of regrowing that tissue back, there isheart failure,” said Dr. Sadek said.“In humans, it may be a few months after birth that this is lost.”

The newborn’s uninjured beating heart cells, known as cardiomyocytes, may be the source of new cells. Orstem cellsmay be contributing to the process, according to the report.

The study offers hope that doctors will one day be able to cure heart disease. If newborn children are also able to regenerate their hearts, there may be a way to restart this ability in adults.

“We’re looking at a few genes that could regulate this process, and then we can look for drugs that activate the genes,” Dr. Sadek said.“Maybe we can remind the heart how to do this.”

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Tattoos as Permanent Makeup - Skin Deep

Though the procedure was“a little uncomfortable,” said Ms. Reynoso, now 39, she was delighted with the results.“Everything for beauty,” she said.“It’s amazing how you can wake up looking absolutely fabulous and get ready in five minutes. I just apply blush, lip gloss and mascara and I’m done.”

Permanent makeup, also known as micropigmentation or cosmetic tattooing, dates back to the early 1980s, when it was developed to addressalopecia, a condition that causes hair loss (including eyebrows). Since then, the field has expanded to include burn victims andcancersurvivors, patients witharthritisandParkinson’s diseasewho have difficulty putting on makeup and people like Ms. Reynoso, who would simply rather limit the amount of time spent in front of a mirror.

But while many are thrilled with their outcomes, all is not rosy in the world of needles and ink. The word“permanent” is a misnomer because the color fades with time. Some patients develop granulomas,keloids, scars and blisters, and they report burning sensations when they undergo anM.R.I.

What’s more, although the inks used in permanent makeup and the pigments in these inks are subject to the scrutiny of theFood and Drug Administration, regulations for practitioners (electrologists, cosmetologists, doctors, nurses and tattoo artists) vary by state.“You can go on eBay and buy machines and pigment and go in the garage and set up shop,” said Dr. Charles Zwerling, an ophthalmologist in Goldsboro, N.C., and an author of the forthcoming book“Micropigmentation Millennium.” He founded the American Academy of Micropigmentation, a nonprofit professional organization that offers certification for practitioners, in 1992.

“We see thousands of faces being destroyed by people who don’t get trained properly, and that’s the biggest problem in permanent cosmetics,” said John Hashey, the owner of John Hashey’s Advanced School of Permanent Cosmetics in Oldsmar, Fla. Mr. Hashey said that 90 percent of his business is fixing mistakes.“Your average cosmetologist who cuts hair has to do 1,200 to 1,500 hours just to do that,” he said.“How is that any more important than taking a needle to someone’s eye?”

The adverse reactions to micropigmentation include infections likeH.I.V.,hepatitis, staph and strep from dirty needles, andallergic reactionsto the permanent dyes, said Dr. Jessica J. Krant, a dermatologist in Manhattan and an assistant clinical professor of dermatology at the SUNY Downstate Medical Center in New York.

A report in this month’s issue of Clinical Infectious Diseases reported an outbreak of mycobacterium haemophilum, a nontuberculous mycobacterium that causes skin, joint, bone and pulmonary infections, after permanent makeup was applied to patients’ brows. A study last September in ContactDermatitis, a medical journal, investigated severe adverse reactions likeswelling, burning, and the development of papules in four patients who had had at least two permanent-makeup procedures on their lips.“In light of the severe and often therapy-resistant skin reactions, we strongly recommend the regulation and control of the substances” used in the colorants, the authors wrote.

Nancy Erfan, a real estate agent in Monterey, Calif., had a bad experience. In November 2003, Ms. Erfan, now in her 30s, had permanent color applied to her lips and eyes. The technician told her she would be swollen for a few days, and gave her a cream to help. But the swelling worsened, Ms. Erfan said, and soon she had“big bumps” around her eyes and lips.

“I could barely open my mouth to eat or speak,” she said. She visited a variety of dermatologists and plastic surgeons, but found no remedy.“They said I was obviously having an allergic reaction, but they didn’t know what to do.”

It turned out that the colors used in one of the dyes by Premier Pigments, a manufacturer, was tainted; after the F.D.A. received more than 150 complaints, the company eventually recalled the entire line.

Finally Ms. Erfan found Dr. Mitchel Goldman, a dermatologist in San Diego who specializes in laser removal of tattoos. He did six treatments over a year, for a total of about $10,000, which insurance did not cover.Acupunctureand Chinese herbal medicine helped with facial pain and swelling, she said. Dr. Goldman would like greater F.D.A. supervision of permanent makeup.“I’ve had patients who have infections on their lips and eyebrows because these tattoo artists are totally not regulated,” he said.“They use equipment that’s not sterile. A lot of infections also come from the tap water. They dip their needles in and transfer infections. The pigment goes to lymph nodes. Who knows if 20 years down the line patients will have lymphoma or cancer because of these carcinogens in tattoo pigment?”

Mr. Hashey thinks practitioners should be regulated nationally and required to get 600 to 1,500 hours of training.

Elizabeth Finch-Howell, the owner and founder of Derma International, a permanent cosmetics manufacturer in Kempton, Pa., believes a minimum of 100 hours is enough. (She got a tattoo that matched her skin tone to cover up a port-wine colored birthmark on half of her face, performing the procedure herself because“I didn’t trust anyone else,” she said.)

As for Ms. Erfan, she is still angry, years later. It took her more than a year and a half to recover, she said, and she still has scars on her lips. She must wear makeup to cover the scars and white lines above her mouth, and the facial pain persists.“Applying makeup is one thing, but injecting it into your body? I feel stupid,” she said.“But everything I read about permanent makeup was positive, how even Cleopatra was tattooing her eye liner and lip liner. I thought it was safe.”

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Red and Black Rice With Leeks and Pea Tendrils - Recipes for Health

3 tablespoons extra virgin olive oil

2 leeks, white and light green parts only, halved lengthwise, cleaned and sliced thin

Salt to taste

2 teaspoons thyme leaves

3 cups cooked Wehani rice or Bhutanese red rice

1 cup cooked black rice, either Japonica or Chinese black rice

1 6-ounce bunch pea tendrils, ends trimmed, washed and spun dry, or 1 6-ounce bag baby spinach

Salt and freshly ground pepper

1.Heat 2 tablespoons of the olive oil over medium heat in a large, heavy skillet, and add the leek and a pinch of salt. Cook, stirring, until the leeks soften, about three minutes. Stir in the pea tendrils or spinach. Cook, stirring, until they wilt, about three minutes for pea tendrils and one minute for baby spinach. Season to taste. Add the thyme, the remaining olive oil and rice, and stir until the mixture is combined. Season with freshly ground pepper, adjust salt and serve.

Yield:Serves four to six.

Advance preparation:The dish will keep for three to four days in the refrigerator and can be frozen.

Nutritional information per serving (four servings):354calories; 2 gramssaturated fat; 2 grams polyunsaturated fat; 8 grams monounsaturated fat; 0 milligramscholesterol; 59 gramscarbohydrates; 5 gramsdietary fiber; 48 milligrams sodium (does not include salt to taste); 7 grams protein

Nutritional information per serving (six servings):236 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligrams cholesterol; 39 grams carbohydrates; 4 grams dietary fiber; 32 milligrams sodium (does not include salt to taste); 5 grams protein

Martha Rose Shulmanis the author of“The Very Best of Recipes for Health.”

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Fried Red Thai Jasmine Rice With Shrimp - Recipes for Health

2 tablespoons canola or peanut oil

8 garlic cloves, minced

1 large carrot, peeled and cut in 1-inch long julienne

8 medium or large shrimp (about 6 ounces), peeled, deveined and chopped

6 cups cooked ruby red jasmine rice, red Bhutanese or regular jasmine rice (2 cups uncooked)

1 bunch scallions, trimmed, cut in half lengthwise and then into 1-inch lengths

2 tablespoons Thai or Vietnamese fish sauce (omit if sodium is an issue; the high sodium content in this recipe comes from the fish sauce)

2 to 4 tablespoons chopped cilantro

For garnish (optional):

Chopped cilantro

Thinly sliced cucumber

Lime wedges

Scallions

Fish sauce with hot chilies (nam pla prik)

Chopped roasted peanuts

1.Heat a large wok or large, heavy nonstick skillet over medium-high heat until a drop of water evaporates upon contact. Add the oil, tilt to spread across the pan, and add the carrot and shrimp. Stir-fry until the shrimp is pink and opaque, about two minutes. Add the garlic, and stir-fry just until golden, 15 to 30 seconds. Add the rice. Stir-fry for about two minutes by scooping the rice up, then pressing it into the pan and scooping it up again. The rice should have a seared taste. Add the scallions and fish sauce, stir together for a half-minute to a minute and transfer to a platter. Sprinkle the cilantro over the top, and serve, passing the garnishes of your choice. Diners should squeeze lime juice onto their rice as they eat.

Yield:Serves four generously as a one-dish meal.

Advance preparation:Cooked rice will keep for three or four days in the refrigerator and can be frozen. The dish is a last-minute stir-fry.

Nutritional information per serving:484calories; 1 gramsaturated fat; 2 grams polyunsaturated fat; 4 grams monounsaturated fat; 68 milligramscholesterol; 82 gramscarbohydrates; 7 gramsdietary fiber; 900 milligrams sodium (does not include salt to taste); 16 grams protein

Martha Rose Shulmanis the author of“The Very Best of Recipes for Health.”

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A First in Sub-Saharan Africa - Methadone Maintenance Program Begins in Tanzania

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N.F.L. Players Shaken by Duerson’s Suicide Calculation

Football’s ramifications so concerned the former Chicago Bear Dave Duerson that, after deciding to kill himself last Thursday, he shot himself in the chest so that his brain could remain intact for similar examination.

This intent,strongly implied by text messages Duerson sent to family memberssoon before his death, has injected a new degree of fear in the minds of many football players and their families, according to interviews with them Sunday. To this point, the roughly 20N.F.L.veterans found to have chronic traumatic encephalopathy— several of whom committed suicide— died unaware of the disease clawing at their brains, how the protein deposits and damaged neurons contributed to their condition.

Duerson, 50, was the first player to die after implying that brain trauma experienced on the football field would be partly responsible for his death.

Retired and current players roundly noted on Sunday that they could not know what Duerson’s mind-set was and what other events in his life had contributed to his actions. Yet the gunshot from Duerson’s home in Sunny Isles Beach, Fla., and the final wishes for his brain shook players around the nation.

“Oh my God— he might have been aware of what was happening to himself?” the former Giants running backTiki Barbersaid when informed of the circumstances. After taking a moment to collect himself, Barber continued:“It feels like this was calculated and thought-out to some extent. It was almost with a purpose.”

Randy Cross, a formerSan Francisco 49erslineman, said,“It ought to terrify anyone that’s played the game.”

Players who began their careers knowing the likely costs to their knees and shoulders are only now learning about the cognitive risks, too. After years of denying or discrediting evidence of football’s impact on the brain— from C.T.E. in deceased players to an increasing number of retirees found to have dementia or other memory-related disease— the N.F.L. has spent the last year addressing the issue, mostly through changes in concussion management and playing rules.

The N.F.L. has also donated $1 milliontoBoston University’s Center for the Study of Traumatic Encephalopathy, the research group that will soon examine Duerson’s brain.

Duerson sent text messages to his family before he shot himself specifically requesting that his brain be examined for damage, two people aware of the messages said. Another person close to Duerson, who spoke on the condition of anonymity, said that Duerson had commented to him in recent months that he might have C.T.E., an incurable disease linked to depression, impaired impulse control and cognitive decline. Members of Duerson’s family declined an interview request through a family friend.

Duerson was a four-time Pro Bowl safety, primarily for the Bears. He was part of the 1985 team’s famed 46 defense that led the Bears to their onlySuper Bowlchampionship, and was a member of the Giants team that won the Super Bowl five years later. He retired in 1993.

For the past several years, Duerson served on the six-person panel that considers retired players’ claims through the league’s disability plan and the 88 Plan, a fund founded in 2007 to help defray families’ costs of caring for players with dementia. So Duerson would have been familiar with the stories of hundreds of retirees with mental issues ranging from impaired short-term memory to outright dementia.

“You know he’s been sitting in the disability meetings and the applications, so I’m sure he’s seen a lot of disability applications that have to do with brain injury,” said Ben Lynch, who played center for the 49ers from 1999 to 2002.“Having seen all those things come across in front of him, and for him to make the request about his brain, it’s something that must have been really on his mind. It’s unbelievable to me that this happened. The fact that he shot himself in chest, and not the head, it’s really eerie.”

Matt Birk, a center for theBaltimore Ravens, is one of 6 current N.F.L. players and 103 in all who have pledged to donate their brain to the Boston University center for analysis after their death. He said that Duerson’s requesting the same before shooting himself in a way punctuated the first era of the investigation.

“It’s almost now to the point that— not that it’s not tragic— but now it’s almost becoming common, some former players with some form of brain problems,” Birk said.“Is it something that I think about? Yeah, absolutely. There’s a little bit of,‘Well, it’s not going to happen to me.’ ”

Duerson was successful in private food-related business in the decade after he retired, but he had encountered significant financial and family problems in recent years. In 2005, he resigned from the Notre Dame board of trustees after he was charged with pushing his wife, Alicia. The next year, he sold most of his company’s assets at auction. In 2007, the Duersons filed for divorce, and their home in Highland Park, Ill., went into foreclosure,according to The Chicago Sun-Times.

Duerson relocated to South Florida and through his union activities remained heavily involved with issues regarding former N.F.L. players. Last spring, he attended a gathering of veterans in Fort Lauderdale held by theGay Culverhouse Players’ Outreach Program, an organization founded by Culverhouse, the formerTampa Bay Buccaneerspresident, to help league retirees apply for medical and pension benefits. Mitchell Welch, the organization’s vice president, said that when discussion that day turned to the88 Plan— the program for players with dementia— some veterans’ minds wandered, some appearing as if the topic of mental decline did not apply to them. Duerson walked to the front of the room and asked to say some words to the players, which Welch, in a telephone interview Sunday, said he now would never forget.

“I’m Dave Duerson,” Welch recalled Duerson saying.“Pay attention to what this guy’s telling you. Because it’s stuff you’re going to need to know.”

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Monkeys Fattened Up to Study Human Obesity

Shiva belongs to a colony of monkeys who have been fattened up to help scientists study the twin human epidemics ofobesityanddiabetes. The overweight monkeys also test new drugs aimed at treating those conditions.

“We are trying to induce the couch-potato style,” said Kevin L. Grove, who directs the“obese resource” at theOregon National Primate Research Centerhere.“We believe that mimics the health issues we face in the United States today.”

The corpulent primates serve as useful models, experts say, because they resemble humans much more than laboratory rats do, not only physiologically but in some of their feeding habits. They tend to eat when bored, even when they are not really hungry. And unlike human subjects who are notorious for fudging their daily calorie or carbohydrate counts, a caged monkey’s food intake is much easier for researchers to count and control.

“Nonhuman primates don’t lie to you,” said Dr. Grove, who is a neuroscientist.“We know exactly how much they are eating.”

To allow monitoring of their food intake, some of the obese monkeys are kept in individual cages for months or years, which also limits theirexercise. That is in contrast to most of the monkeys here who live in group indoor/outdoor cages with swings and things to climb on.

While this research is not entirely new and has been the target of some animal rights’ group complaints, demand for the overweight primates is growing as part of the battle against the nation’s obesity epidemic, according to Dr. Grove and other researchers working with such monkeys in Florida, Texas and North Carolina, and also overseas.

Some tests have already produced tangible results. Rhythm Pharmaceuticals, a start-up company in Boston, tested its experimentaldietdrug on some of the Oregon monkeys. After eight weeks, the animals reduced their food intake 40 percent and lost 13 percent of their weight, without apparent heart problems.

“We could get a much better readout on chronic safety and efficacy early,” said Bart Henderson, the president of Rhythm, which now plans to move into human testing.

In another study, a group of academic researchers is using the monkeys to compare gastric bypass surgery with weight loss from forced dieting. One goal is to try to figure out the hormonal mechanisms by which the surgery can quickly resolve diabetes, so that drugs might one day be developed to have the same effect. To that end, the study will do what cannot be done with people— kill some of the monkeys to examine their brains and pancreases.

The primate center here, which is part of Oregon Health and Science University, has more than 4,000 monkeys, mostly rhesus macaques. About 150 of them are the rotund rhesuses. Some receive daily insulin shots to treat diabetes, and some have clogged arteries. One monkey died of aheart attacka few years ago at a fairly young age.

Shiva, a young adult, gained about 15 pounds in six months and weighs about 45 pounds, twice the normal weight for his age. Like other monkeys with a weight problem, he carries much of the excess in his belly, not his arms and legs.

The monkey’s daily diet consists of dried chow pellets, with about one-third of thecaloriescoming from fat, similar to a typical American diet, Dr. Grove said, though the diet also contains adequate protein and nutrients.

They can eat as many pellets as they want. They also snack daily on a 300-calorie chunk of peanut butter, and are sometimes treated to popcorn or peanuts. Gummy bears were abandoned because they stuck to the monkeys’ teeth.

They also drink a fruit-flavored punch with the fructose equivalent of about a can of soda a day. In all, they might consume about twice as many calories as a normal-weight monkey.

Dr. Grove and researchers at some other centers say the high-fructose corn syrup appears to accelerate the development of obesity and diabetes.

“It wasn’t until we added those carbs that we got all those other changes, including those changes in body fat,” said Anthony G. Comuzzie, who helped create an obese baboon colony at the Southwest National Primate Research Center in San Antonio.

Still, about 40 percent do not put on a lot of weight.

Barbara C. Hansen of the University of South Florida said calories, but not high fat, were important.“To suggest that humans and monkeys get fat because of a high-fat diet is not a good suggestion,” she said.

Dr. Hansen, who has been doing research on obese monkeys for four decades, prefers animals that become naturally obese with age, just as many humans do. Fat Albert, one of her monkeys who she said was at one time the world’s heaviest rhesus, at 70 pounds, ate“nothing but anAmerican Heart Association-recommended diet,” she said.

Mice and rats remain the main animals for medical research, but the effects on rodents often do not mirror those in people.

Rinat Neuroscience had an experimental drug that sharply reduced appetite in rodents. But obese baboons in San Antonio doubled or tripled their food intake when they got the drug.

The surprising result promptedPfizer, which acquired Rinat, to explore whether the drug instead could promote weight gain, perhaps forcancerpatients or others suffering fromwasting.

Some companies see no need to use primates to study obesity and diabetes, saying it is almost as easy to do human studies.

Monkey studies can cost up to several million dollars. The animals are so precious that only a small number can be used. And there are ethical reviews before a study can begin.

“Doing primate studies is about as difficult as doing human studies from an ethical standpoint,” said Dr. Lee M. Kaplan, director of the weight center atMassachusetts General Hospital, who is one of the researchers in the bariatric surgery study here.

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Diagnosis - An Unusual Rash, an Unusual Cause

The patient first saw the rash on Monday, and at that point, it was just a rash confined mostly to the back of her hands. It didn’t really hurt or itch. By the end of the day though, the rash had become redder and angrier-looking. Overnight, tiny blisters formed over the red regions. When her sister saw her hands, she was concerned.“You’ve got to see a doctor about this,” the sister urged. The patient was reluctant; she’d been laid off from her job at the local power company and now had nohealth insurance. Still, the rash on her hands looked pretty awful. And now it was painful as well. She called Larsen’s office, and they fit her into his schedule later that day.

At the first visit, Larsen immediately suspected that it was some kind of allergic contact dermatitis, probably from a plant like poison oak. Although it was late in the season for that kind of rash, this was a condition he knew a lot about. He had helped write a book on contact dermatitis. He asked the patient if she had been outdoors within the past few days. She told him she visited a friend’s farm and picked Swiss chard over the weekend, but she didn’t see any poison oak. Nevertheless, that seemed to cinch it— at least for the doctor.

The patient wasn’t convinced. She’d never had a reaction to poison oak before. And besides, wasn’t a poison-oak rash famously itchy? This rash was tender to the touch but not itchy at all. Still, the setting was right— she was out among plants— and the rash looked enough like poison oak at that first visit that it was hard for Larsen to discount it. He gave her asteroidcream to use and suggested that she come back in a couple of days so he could see how she was doing.

Now, two days later, she was back, and Larsen was stumped. The little blisters he noted on her hands initially had hardened, and the red streaks were much darker, almost purple, and raised. The way thoseweltsnow streaked across her neck, back, legs and abdomen made it look as if she had been flogged. Indeed, she told the doctor, she had started wearing gloves and long sleeves to hide the unsightly markings.

Had the rash starteditching? The red streaks looked like excoriations from vigorous scratching, but she told him that she hadn’t been. Besides, she had this rash on the middle of her back, where she couldn’t even reach. The doctor pulled a capped pen from his breast pocket and drew it lightly down her back, leaving a faint red line. As he did so, he explained that some people have a condition known as dermographism, in which the skin has an allergic reaction to being touched. With these patients, applying pressure as he just had could cause a red welt, like the ones she had on her body. He waited. The mark faded.

Had she started taking any new medicines recently? An allergic drug reaction could cause this kind of whole-body rash— though he had to admit he’d never seen one like this before. She shook her head: no new medications. There was nofever, no symptoms other than the rash? None, she told him. That made an infection unlikely.

“O.K.— it’s time to call in reinforcements.” Larsen asked if he could bring in a couple of colleagues and then disappeared from the room, returning a few minutes later with two of his younger partners. After a long moment, one of the partners, Dr. Michael Adler, broke the silence. He asked the patient whether she had eaten any shiitake mushrooms recently. The question surprised her.“How did you know?” she asked. On Friday, three days before the rash appeared, she was offered a sample of shiitakes cooked in oil and garlic at her local grocery store. They tasted fine, maybe a little chewier than usual, but she enjoyed them.

The young doctor thanked her, and then the three walked out of the room without telling her anything more. Finally Larsen returned.“We think this is a classic reaction to raw or undercooked shiitake mushrooms,” Larsen told her. Shiitake dermatitis, as it’s known in medical jargon, was first described in 1977. Since then, it has been frequently reported in Asia, though rarely, if ever, in the U.S. The rash is thought to be a toxic reaction to a starchlike component of the shiitake mushroom. This component, known as lentinan, breaks down with heat, and so this reaction is seen only when the mushrooms are eaten raw or partly cooked.

“So am I allergic to these mushrooms?” the patient asked. Well, it’s not a true allergy, Larsen explained. When someone is exposed to a substance and has a bad response, it’s considered allergic only when the immune system causes the reaction. Then you’ll gethivesorswellingor occasionallyanaphylaxis. But when people who get this rash are tested, there’s no sign of animmune response, so it’s considered a toxic, not allergic, reaction. The current thinking is that something in the lentinan triggers blood vessels to dilate and leak small amounts of inflammatory compounds just beneath the skin.

Not everyone has this kind of violent reaction to raw shiitakes. In one study, just over 500 patients were exposed to an intravenous version of lentinan. Nine developed this streaky rash. The other patients had no response. Perhaps that’s lucky for them, because this same component is thought to have important health benefits. Studies suggest that lentinan may be helpful in preventing diseases ranging from cavities tocolon cancer. Why it creates these whiplike streaks in some is not well understood. A rash with a similar pattern has been linked to bleomycin, a chemotherapeutic medication.

Larsen ordered abiopsyof the rash to make sure they weren’t missing anything, and he instructed the patient to continue to use the steroid cream at home. The cream helped, but it took weeks for the rash to fade completely.

Larsen recommended she avoid uncooked shiitakes.“I’m never going to touch another shiitake,” the patient told him.“I don’t care if they are good for you. One of theserasheswas enough.”

So how was Adler able to recognize this obscure rash when his older, more experienced colleague was not? I put the question to Adler. He laughed.“I’m not usually the guy who gets the off-the-wall diagnosis,” he told me.“It was really just luck.” He had read a case report of a patient who developed this crazy-looking rash after eating shiitakes. The picture in the journal was so striking that as soon as he saw the patient, it all came back in a flash.“That’s what is so great about working in a group. When you get stumped, you just call for help, and chances are, one of these guys will know the answer. It’s like doing the crossword puzzle with a friend. With any luck, the other guy fills in your gaps in knowledge. This time I got to be that guy.”

Lisa Sanders is the author of“Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis.”

If you have a solved case to share with Dr. Sanders, you can e-mail her atlisa.sandersmd@gmail.com. She is unable to respond to all e-mail messages.

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Kickboxing Express and Other 30-Minute Workouts

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Four States Given Waivers for Rules in Health Care Law

The states are Florida, New Jersey, Ohio and Tennessee, the administration told Congress.

Lawmakers said that many other states, insurers and employers needed similar exemptions from some of the law’s requirements and would seek waivers if they knew of the option.

Steven B. Larsen, a top federal insurance regulator, said the waivers would allow many consumers to keep the coverage they had, a goal often espoused byPresident Obama.

Under the law and rules issued by the administration, health plans this year must generally provide at least $750,000 in coverage for essential benefits like hospital care, doctors’ services and prescription drugs. In states granted the waivers, many health plans with much lower annual limits on coverage may continue to operate.

“Unfortunately, limited benefit plans, or mini-med plans, are often the only type of insurance offered to some workers,” said Mr. Larsen, who is director of the federalCenter for Consumer Information and Insurance Oversight. It was to protect such coverage that the administration granted the waivers, he said.

To qualify for a waiver, a state, an employer or an insurer must show that compliance with the federal requirement would cause“a significant increase in premiums or a decrease in access to benefits.”

Mr. Larsen said the administration had granted temporary waivers to the four states and to more than 900 health plans covering 2.4 million people, or fewer than 2 percent of all those with employer-sponsored insurance.

Each of the states had a law, policy or program that required or encouraged health plans to offer limited-benefit coverage, Mr. Larsen said.

At a hearing of a House Energy and Commerce subcommittee, Republicans repeatedly asked: if the new law is so good, why have so many waivers been granted?

Representative Fred Upton, Republican of Michigan and chairman of the House Energy and Commerce Committee, said the waivers showed that the law, approved by Congress without any Republican votes, was“fundamentally flawed.” Without the waivers, Mr. Upton said, hundreds of thousands of people would have lost insurance or experienced a reduction in benefits.

RepresentativeHenry A. Waxmanof California, the senior Democrat on the committee, said the limited-benefit plans were clearly inadequate. But he said the waivers would allow“a smooth transition between now and 2014,” when insurers and employers will be forbidden to impose limits on the dollar value of benefits.

The hearing gave Republicans their first opportunity to investigate the activities of the federal office that regulates private insurance and has dozens of other important duties under the new health law. In his 2012 budget, Mr. Obama requested more than $93 million for the office, which has 252 employees.

The insurance office originally reported directly toKathleen Sebelius, the secretary of health and human services. In early January, she moved it into the Centers for Medicare and Medicaid Services, whose programs insure more than 100 million people.

House Republicans expressed concern that power over public and private health insurance programs was concentrated in one agency led by an official, Dr.Donald M. Berwick, who had not been confirmed by the Senate.

“He is in charge of almost all insurance coverage in the United States,” said Representative Michael C. Burgess, Republican of Texas.

Jay Angoff, former director of the insurance regulation office, said,“There are efficiencies to be gained by merging it” with the agency that runsMedicareandMedicaid. However, in response to questions, Mr. Larsen said,“We do not anticipate laying people off.”

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Beet Greens and Potato Hash - Recipes for Health

1 pound red boiling potatoes or baby Yukon golds, cut in small dice (about 1/2 inch)

1 bunch beets, roasted, peeled and cut in small dice (about 1/2 inch)

1 generous bunch of beet greens, stemmed and cleaned in 2 changes of water

2 tablespoons extra virgin olive oil

2 garlic cloves, minced

1 teaspoon fresh thyme leaves

Salt and freshly ground pepper

1 tablespoon vinegar— sherry, red wine or Champagne (optional)

Poached eggs, if desired, for serving (optional)

1.Place the diced potatoes in a steamer above an inch of boiling water. Cover and steam for 10 minutes. Add the beet greens to the steamer, and steam for five minutes until wilted; turn them halfway through so they cook evenly. Turn off the heat underneath the steamer. With tongs, remove the greens to a bowl, and rinse them with cold water. Drain, squeeze out excess water and chop. Set the potatoes aside.

2.Heat the olive oil over medium heat in a large, heavy nonstick skillet. Add the potatoes, turn the heat to medium-high, and cook, stirring from time to time, until the potatoes are lightly browned, about five minutes. Stir in the garlic, beets, greens, thyme, salt and pepper. Cook, stirring often, for another five minutes, pressing the mixture down into the pan so the edges brown. Taste, and adjust salt and pepper. Stir in the vinegar if using. Serve, topped with a poached egg if desired.

Yield:Serves four to six.

Advance preparation:This will keep for three or four days in the refrigerator, and it reheats well.

Variation:You can add a finely chopped onion to this dish to make it more like a traditional hash. Cook for about five minutes in the oil, until tender, before adding the potatoes in Step 2.

Nutritional information per serving (four servings):221calories; 1 gramsaturated fat; 1 gram polyunsaturated fat; 5 grams monounsaturated fat; 0 milligramscholesterol; 36 gramscarbohydrates; 9 gramsdietary fiber; 295 milligrams sodium (does not include salt to taste); 6 grams protein

Nutritional information per serving (sox servings):147 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 3 grams monounsaturated fat; 0 milligrams cholesterol; 24 grams carbohydrates; 6 grams dietary fiber; 197 milligrams sodium (does not include salt to taste); 4 grams protein

Nutritional information per poached egg:71 calories; 2 grams saturated fat; 1 gram polyunsaturated fat; 2 grams monounsaturated fat; 186 milligrams cholesterol; 0 grams carbohydrates; 0 grams dietary fiber; 81 milligrams sodium; 6 grams protein

Martha Rose Shulmanis the author of“The Very Best of Recipes for Health.”

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Global Update - H.I.V. Rate Plummets in Zimbabwe

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Vibrations’ Effect on Athletic Ability Is Still in Question

But maybe it’s not so silly, exercise physiologists say. Although they don’t really know why vibrations should work, researchers report that they actually seem to slightly improve performance in the few minutes after a person gets off the machine.

The problem, though, is that there is little consensus on how fast the vibrations should be or in what direction platforms are supposed to vibrate. Some studies have failed to show any effects from vibrations. And then there is the question of what exactly vibrations are doing to muscles and nerves.

“It certainly is intriguing, and a large portion of the evidence would support that something is happening,” said Lee E. Brown, director of the Center for Sports Performance at California State University, Fullerton. But he added,“We are still trying to figure out exactly what the mechanism is.”

Meanwhile, several companies make the vibrating platforms, and they are being used at gyms and by some athletes.

One company, Power Plate, proclaims that stars like Serena Williams and the Minnesota Twins’Justin Morneautrain with its device. A testimonial for another company, Wave, says the United States ski and snowboard teams used its vibrating plates in training for the 2010 Winter Olympics.

But researcher are wary.

“There is something to it,” said William J. Kraemer, a professor ofkinesiologyat the University of Connecticut and the editor in chief of The Journal of Strength&Conditioning Research, calling it“another tool” for athletic conditioning. But he added that other conditioning methods might yield the same or better results.

“If you think of conditioning as a toolbox, there are lots of tools,” he said.“But when companies are selling something, they want to pretend that one tool does everything.”

Experts who have tried the platforms describe them in different ways. The sensation is nothing like using a jackhammer, said Hugh Lamont, a sports biomechanist at Eastern Tennessee State University. Most vibration plates move no more than 50 times a secon and feel like the vibrations in a seat over the wheel hub on a bus, Dr. Lamont said.

Others say the vibrations remind them of downhill skiing— they get the same sort of the rattling in their legs and feet. For Jeffrey M. McBride, an associate professor ofbiomechanicswho is director of the neuromuscular laboratory at Appalachian State University in Boone, N.C., the word that comes to mind is“weird.”

“You can feel your muscles contract,” he said.“It sort of fatigues you.”

But if there is an effect, the researchers said, it seems to be short-lived. People seem to be slightly faster sprinters immediately after standing on a platform. They also seem to be able to jump a bit higher. Vibrations also seem to help people warm up before more strenuous exercise.

“The effect wears off very quickly,” Dr. Brown said.“We are not talking about using this to play a 90-minute soccer match. One sprint and the effect would be gone. You’d play for one minute and still have 89 minutes to go.”

But it could make a difference, he said, if an athlete is about to try a penalty kick in soccer or swing a bat in baseball.

And Michael G. Bemben, chairman of exercise science at the University of Oklahoma, said that“one thought was if you were, say, a high jumper on your third trial in the Olympics and you are at 7 feet 2 inches and need to get to 7 feet 3, this might give you the power for that jump.”

Investigators say they can only guess why vibrations might improve performance. Their leading hypothesis is that it somehow mimics the effect of following a difficult task with an easier one— a simple technique that has been in use for years.

“If you pick up something heavy and then pick up something considerably lighter,” Dr. Lamont explained,“you might be able to throw the lighter weight farther.”

Or if you want to jump, he continued, you might first put a huge weight on a training rack, do a quarter squat, partway down, and then, for three to five seconds, try to push up and lift the weight. You would be doing an isometric contraction of your leg muscles. After that, you might jump higher.

But does it matter? Why not just warm up in the normal way, or do isometric contractions before jumping, or pick up a heavy weight before trying to throw a lighter one?

Or why not combine everything and do warm-ups on a vibrating platform, or try isometric contractions between periods of vibration?

Researchers have thought of that, and say they are investigating. Meanwhile, they say, people should be appropriately skeptical about the effects of standing on a vibrating platform.

“We don’t know a lot about prescribing it,” Dr. Kraemer said.“There’s the rub.”

And yet it is being used many times without an understanding of how to do it best or what the long-term training effects will be.

“Research,” Dr. Kraemer said,“is trying to catch up.”

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Risk and Reward in Utero - Ethics of Spina Bifida Clinical Trial

Their only access was through a clinical trial testing whether risky prenatal surgery was better than standard surgery after birth. Participating meant being randomly assigned to one surgery or the other.

“They take you to a room and a paper tells you what part of the trial you were randomized to,” said Jessica Thomas, 26, of Stansbury Park, Utah, assigned to prenatal surgery when pregnant with her son Tyson.“It was my only sense of hope to try to give him a better life.”

Amy Shapiro, 40, of Leander, Tex., was assigned to postnatal surgery, performed on her son Zachary the day after he was born.

“It was one of the hardest decisions I had to make to be in the study,” said Ms. Shapiro, who knew how disabling spina bifida was because her sister-in-law has it.“It was a big disappointment that we didn’t get the prenatal surgery because I knew that that was the surgery that was most likely going to help him the most, because otherwise why would they be doing the study? But at the same time, he could have died or been born prematurely from prenatal surgery. When they explained everything to us, I wanted to be in it regardless.”

Now, results are in: Fetal surgery, while increasing premature births and causing tearing at some mother’s incisions,made babies more likely to walkand less likely to have neurological problems or need shunts to drain brain fluid.

Besides the groundbreaking results, the seven-year study spotlights ethical dilemmas in research.

The surgery was becoming popular in the 1990s, even appearing on a Time magazine cover, and some experts believed that it might eventually eliminate most symptoms. But given the risks, others wanted proof that it was better than postnatal surgery.

“There were no systematic data regarding safety and efficacy,” said Dr. Jeremy Sugarman, a bioethicist at Johns Hopkins University who participated in early discussions.“Many things we believe to be true and right and appropriate ultimately are shown to be harmful and ineffective.” Spina bifida researchers believed that few women would participate if the surgery were available elsewhere, so they persuaded all but the three hospitals in the trial to stop doing the procedure, an unusual agreement.

“I frankly have a lot of problems when a group of physicians get together and in effect shut down everything so they can have a trial,” said Baruch A. Brody, director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine.“For physicians who believe in it, why should they be pressured into stopping? For families who believe they should have the surgery, why should they be told they can’t?”

But several ethicists praised the pause.“It’s impressive to see that kind of collaboration,” said Dr. Jeffrey R. Botkin, a pediatric ethicist at the University of Utah.“The sophistication surgeons need to do this is so high, it makes sense to answer research questions by allowing it only at a few centers.”

The surgery proved beneficial enough that an independent monitoring board stopped the trial, not wanting to deny more women the opportunity for prenatal surgery. But stopping trials early sometimes limits the information researchers can collect that might benefit future patients.

Monitoring boards“walk a very fine line,” said Dr. Steven Goodman, an epidemiologist at Johns Hopkins and editor of the journal Clinical Trials.“At what point is the benefit of getting more information outweighed by the consequences of not releasing results and continuing to randomize patients?”

In some trials, if one treatment proves superior, other participants can then receive that treatment. But with prenatal surgery, that isn’t possible, said Jeffrey Kahn, director of the University of Minnesota’s bioethics center.“Some people are accepting risk for the benefit of those who will come after them.”

Still, regardless of therapy,“people who enroll in clinical trials, for the most part, do better than people who don’t, because care is controlled and monitored,” Dr. Goodman said.“You simply can’t go back and say,‘In every trial people who didn’t get the winning therapy were deprived.’”

Tyson Thomas emerged from prenatal surgery with no need for a shunt and, at 22 months old, uses a walker but is almost walking independently. Zachary Shapiro, 6, has a shunt, walks with braces, and has some attention problems. Both boys, who received their surgery at the University of California, San Francisco, need catheters.

Ms. Shapiro, a kindergarten teacher, said of her son,“I do feel like he benefited, even though he didn’t benefit from the actual surgery.”

She added,“He benefited from the research that has happened about his disability.”

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Tiptoeing Out of One’s Comfort Zone (and of Course, Back In)

First, I spoke to a group of middle-school students about journalism. It was a day when parents were supposed to come and talk about their work and discuss why what you learned in middle school was actually important in real life.

I am fairly self-confident about talking to a roomful of adults. But 12- and 13-year-old children made me sweat. Some looked at me intently, but others stared out the window, played with their pencils or poked their neighbors. Suddenly, I was pulled back to my middle-school years, trying to entertain the“popular” kids. I was most uncomfortable.

A few days later, we had some workers in to paint a few rooms in the house. No big deal, I thought. Except that as more rooms were draped in drop cloths and living room furniture crowded the dining room, our entire family— and two befuddled cats— retreated upstairs.

No one could find anything. Everyone was out of sorts. We were feeling decidedly uncomfortable.

Moving out of our comfort zones is supposed to be a good thing. We challenge ourselves, we grow and take on new risks. But is this always true? After all, over the last few years, many of us have been pushed out of our comfort zones, forced to seek new jobs, even careers.

First of all, I wondered, how did the term originate? In my research, I came across one theory that comfort zone was the temperature range— about 67 to 78 degrees, depending on the season— at which people were neither too hot nor too cold.

All right. I can’t test that with snow on the ground. But if we transfer that to a psychological comfort zone, it makes sense— it’s where we’re completely at home. Or as Judith M. Bardwick, author of“Danger in the Comfort Zone” (American Management Association, 1991), writes,“The comfort zone is a behavioral state within which a person operates in an anxiety-neutral position.”

She cites afamous experimentconducted by the psychologists Robert M. Yerkes and John D. Dodson, way back in 1908. Using mice, they found that stimulation improved performance, up to a certain level— what is now known as optimal anxiety. When that level is passed, and we’re under too much stress, performance deteriorates.

“We need a place of productive discomfort,” said Daniel H. Pink, author of“Drive: The Surprising Truth About What Motivates Us” (Riverhead, 2009).“If you’re too comfortable, you’re not productive. And if you’re too uncomfortable, you’re not productive. Like Goldilocks, we can’t be too hot or too cold.”

Everyone’s reaction to stress is different, of course— your comfort zone is not mine.

The objective is to reach that optimal level so that our skills increase and we become comfortable with that new level of anxiety— then we’re in an expanded comfort zone. And ideally, we will get more used to those feelings of“productive discomfort” and won’t be so scared to try new things in the future.

Brené Brown, a research professor at theUniversity of HoustonGraduate College of Social Work and author of“The Gifts of Imperfection” (Hazelden, 2010), has another definition of comfort zone:“Where our uncertainty, scarcity and vulnerability are minimized— where we believe we’ll have access to enough love, food, talent, time, admiration. Where we feel we have some control.”

The trouble is, Ms. Brown said,“When we get into times of social, political or financial instability, our comfort zones get smaller.” The more afraid we are, she said,“the more impenetrable our comfort zones buffers become.”

There was a huge shift after 9/11, she said, in just how vulnerable people were willing to be in their personal and work lives. When we feel vulnerable, she added, we often feel fear and shame.

And,“since those are some of our most difficult emotions, we want to avoid them,” she said.

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Are Doctors Too Quick to Cut? - Room for Debate

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Mustard Vinaigrette - Recipes for Health

1 rounded tablespoon Dijon mustard

1 1/2 tablespoons red wine vinegar or sherry vinegar

1 tablespoon fresh lemon juice

Salt and freshly ground pepper

1/2 cup extra virgin olive oil, or use half olive oil and half canola or grapeseed oil

1 small garlic clove

1.In a small bowl or measuring cup, combine the mustard, vinegar, lemon juice, salt and pepper. Whisk in the oil.

2.Peel the garlic clove and lightly crush, or cut down to the root end with a paring knife, keeping the garlic clove intact. Place in the dressing and allow to marinate for at least 30 minutes. Remove from the dressing before serving.

Yield:About 2/3 cup.

Advance preparation:This dressing will keep well in the refrigerator for a few days. Remove the garlic clove before storing.

Nutritional information per 2 tablespoons:184calories; 3 gramssaturated fat; 2 grams unsaturated fat; 15 grams monounsaturated fat; 0 milligramscholesterol; 1 gramcarbohydrates; 0 gramsdietary fiber; 58 milligrams sodium (does not include salt to taste); 0 grams protein

Martha Rose Shulmanis the author of“The Very Best of Recipes for Health.”

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G.O.P. Sponsoring Bills to Expand Abortion Restrictions

Invoking the mantra of fiscal restraint that has dominated House action since lawmakers reconvened last month, Republicans began committee work this week on two bills that would greatly expand restrictions on financing for and access to abortions. Another bill, one that would cut off federal dollars to women’s health care clinics that offer abortions, is expected to surface later this year.

“This House is more pro-life than it’s ever been,” said Representative Joe Pitts, Republican of Pennsylvania and the author of one of the bills to limit money for abortions.

Democrats in both the House and Senate immediately fought back Tuesday, working closely with reproductive rights advocates. They have appropriated the Republican charge from last year that Democrats were working on a liberal policy agenda instead of on job creation and the economy, and turned it on its head.

“This election was about the economy,” said SenatorKirsten Gillibrandof New York, who joined with other Democratic senators Tuesday to decry the House bills Tuesday as needless and intrusive.

Over and over, Democrats said that by bringing up the abortion issue now, Republicans were going back on their word to focus on the budget.

Yet the bills that have surfaced on the House floor this year have been fiscal in nature, including the repeal of the health care law, which was later rejected by the Senate, and some measures designed to cut spending.

“Republicans are focused on creating a better environment for economic growth and job creation,” said Kevin Smith, a spokesman for SpeakerJohn A. Boehner,“and that is reflected in the legislation the House is passing,”

Still, Republicans in the House are clearly energized about using their new majority to reopen debate on an important issue for conservatives, especially in the context of the health care overhaul.

On Tuesday, RepresentativeEric Cantor, the Republican majority leader, described the new measures as“obviously very important in terms of the priorities we set out initially in our pledge to America.”

He indicated that he expected the first version of a House bill to finance the government through the rest of the year to bar spending to carry out the health care law. That provision is likely to also be attacked by the Senate and the Obama administration.

One bill, the“No Taxpayer Funding for Abortion Act,”would eliminate tax breaks for private employers who provide health coverage if their plans offer abortion services, and would forbid women who use a flexible spending plan to use pre-tax dollars for abortions. Those restrictions would go well beyond current law prohibiting the use of federal money for abortion services.

The bill, sponsored by RepresentativeChristopher H. Smith, Republican of New Jersey, has drawn fire over language that undercuts a longstanding exemption on the ban on using federal money for abortions in the case ofrapeor incest; the measure narrows the definition of rape to“forcible rape,” a term that his office has never defined. Democratic lawmakers and others repeatedly hammered on the term, saying it suggested that victims of statutory rape and other crimes could not get abortions paid for with federal money.

While Mr. Smith’s staff said last week that the term"forcible rape"would be removed from the bill, the staff of RepresentativeJerrold Nadler of New York, the top Democrat on the Judiciary Subcommittee on the Constitution, said that language remained intact as of Tuesday.

Another bill, sponsored by Mr. Pitts, addresses the health care overhaul head-on by prohibiting Americans who receive insurance through state exchanges from purchasing abortion coverage, even with their own money. The bill is essentially a resurrection of a provision in the House version of the health care law but was not in the Senate version.

The bill would also permithospitalsto refuse abortions to women, even in emergency situations, if such care would offend the conscience of the health care providers.

“Both bills are designed to drive coverage for abortion out ofhealth insuranceplans, period,” said Nancy Northup, president of theCenter for Reproductive Rights.

The bills drew immediate fire from House and Senate Democrats.“We are sending a clear message to House Republicans that their agenda on women’s health is extreme,” SenatorBarbara Boxerof California said at a news conference.“It breaks faith with a decades-long bipartisan compromise, and it risks the health and lives of women. It also punishes women and businesses with a tax hike if they wish to keep or buy insurance that covers a full range of reproductive health care.”

SenatorFrank R. Lautenbergof New Jersey, another Democrat who joined the news conference, compared the proposals to“a Third World country that’s requiring women to wear head shawls to cover their faces even if they don’t want to do it.”

As Mr. Smith’s bill provoked a spirited back and forth at a hearing of a subcommittee of the House Judiciary Committee, it also drew praise from some outside supporters.

“The federal government should not use tax dollars to support or promoteelective abortion,” Richard Doerflinger, associate director of theSecretariat of Pro-Life Activitiesof theUnited States Conference of Catholic Bishops, said in a news release.

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