Type I and Type II Diabetes Cured In Mice

Tom Blackwell,

National Post

In a discovery that has stunned even those behind it, scientists at a Toronto hospital say they have proof the body's nervous system helps trigger diabetes, opening the door to a potential near-cure of the disease that affects millions of Canadians.

Diabetic mice became healthy virtually overnight after researchers injected a substance to counteract the effect of malfunctioning pain neurons in the pancreas.

"I couldn't believe it," said Dr. Michael Salter, a pain expert at the Hospital for Sick Children and one of the scientists. "Mice with diabetes suddenly didn't have diabetes any more."

The researchers caution they have yet to confirm their findings in people, but say they expect results from human studies within a year or so. Any treatment that may emerge to help at least some patients would likely be years away from hitting the market.

But the excitement of the team from Sick Kids, whose work is being published today in the journal Cell, is almost palpable.

"I've never seen anything like it," said Dr. Hans Michael Dosch, an immunologist at the hospital and a leader of the studies. "In my career, this is unique."

Their conclusions upset conventional wisdom that Type 1 diabetes, the most serious form of the illness that typically first appears in childhood, was solely caused by auto-immune responses -- the body's immune system turning on itself.

They also conclude that there are far more similarities than previously thought between Type 1 and Type 2 diabetes, and that nerves likely play a role in other chronic inflammatory conditions, such as asthma and Crohn's disease.

The "paradigm-changing" study opens "a novel, exciting door to address one of the diseases with large societal impact," said Dr. Christian Stohler, a leading U.S. pain specialist and dean of dentistry at the University of Maryland, who has reviewed the work.

"The treatment and diagnosis of neuropathic diseases is poised to take a dramatic leap forward because of the impressive research."

About two million Canadians suffer from diabetes, 10% of them with Type 1, contributing to 41,000 deaths a year.

Insulin replacement therapy is the only treatment of Type 1, and cannot prevent many of the side effects, from heart attacks to kidney failure.

In Type 1 diabetes, the pancreas does not produce enough insulin to shift glucose into the cells that need it. In Type 2 diabetes, the insulin that is produced is not used effectively -- something called insulin resistance -- also resulting in poor absorption of glucose.

The problems stem partly from inflammation -- and eventual death -- of insulin-producing islet cells in the pancreas.

Dr. Dosch had concluded in a 1999 paper that there were surprising similarities between diabetes and multiple sclerosis, a central nervous system disease. His interest was also piqued by the presence around the insulin-producing islets of an "enormous" number of nerves, pain neurons primarily used to signal the brain that tissue has been damaged.

Suspecting a link between the nerves and diabetes, he and Dr. Salter used an old experimental trick -- injecting capsaicin, the active ingredient in hot chili peppers, to kill the pancreatic sensory nerves in mice that had an equivalent of Type 1 diabetes.

"Then we had the biggest shock of our lives," Dr. Dosch said. Almost immediately, the islets began producing insulin normally "It was a shock ? really out of left field, because nothing in the literature was saying anything about this."

It turns out the nerves secrete neuropeptides that are instrumental in the proper functioning of the islets. Further study by the team, which also involved the University of Calgary and the Jackson Laboratory in Maine, found that the nerves in diabetic mice were releasing too little of the neuropeptides, resulting in a "vicious cycle" of stress on the islets.

So next they injected the neuropeptide "substance P" in the pancreases of diabetic mice, a demanding task given the tiny size of the rodent organs. The results were dramatic.

The islet inflammation cleared up and the diabetes was gone. Some have remained in that state for as long as four months, with just one injection.

They also discovered that their treatments curbed the insulin resistance that is the hallmark of Type 2 diabetes, and that insulin resistance is a major factor in Type 1 diabetes, suggesting the two illnesses are quite similar.

While pain scientists have been receptive to the research, immunologists have voiced skepticism at the idea of the nervous system playing such a major role in the disease. Editors of Cell put the Toronto researchers through vigorous review to prove the validity of their conclusions, though an editorial in the publication gives a positive review of the work.

"It will no doubt cause a great deal of consternation," said Dr. Salter about his paper.

The researchers are now setting out to confirm that the connection between sensory nerves and diabetes holds true in humans. If it does, they will see if their treatments have the same effects on people as they did on mice.

Nothing is for sure, but "there is a great deal of promise," Dr. Salter said.

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Christmas Cocktails: Dr. Manny's Tips for Responsible Holiday Drinking



Dr. Manny


As we head into the official holiday week, many of us have already enjoyed our fair share of fun, food and drinking--and many of us may also be feeling the early effects on our bodies of all that extra imbibing and ingesting.

But the office parties and Christmas events we've been attending all month are really just a warm up for a week that for most of us kicks off with lots of eating with family, and ends with lots of drinking with friends as we ring in the new year. Our shopping, decorating, planning and traveling has come to a close, and decompressing from the build up of holiday stress can itself motivate us to over-indulge.

No one wants to think about the negative effects of our food and alcohol consumption while we're trying to enjoy the holidays, but I've been talking and writing about this topic since Thanksgiving, along with my other medical colleagues at FOX. Chances are you'll eat too much this week, but the good news about overeating is that, unless you have a medical condition with dietary restrictions, the aftermath of too much turkey or cake may be some temporary digestive discomfort and weight gain. With a little post-holiday discipline and diligence, this can be reversed.

Over-consumption of alcohol, however, can pose more serious problems. It can negatively change our behavior, lead to unpleasant or dangerous situations, and for those with a history of alcohol abuse, this time of year can be very difficult. At the very least, drinking too much can ruin some of our holiday time if we have to spend it recovering from a hangover.

And, for those of us who are calorie conscious or trying to keep our weight gain under control, alcoholic drinks can pack a real caloric punch. Many people are unaware of just how fattening liquor is.

So while there is nothing wrong with enjoying a few holiday cocktails and toasting the new year, here is a recap of some of the tips I've been offering all month long on FOX on safe and responsible drinking:

--Never drink and drive. This is the most important piece of advice I can give. Never get behind the wheel of a car if you've been drinking, regardless of whether you think you're sober or not.

--Avoid diet mixers. The difference between drinking a rum and coke and a rum and diet coke is not just the calories saved by drinking diet soda. Mixing alcohol with a diet beverage results in a higher concentration of alcohol in the blood stream. Sugar metabolizes alcohol. In this instance, sugar is good for you.

--Do not mix alcohol with so-called "energy drinks." The high concentration of caffeine in energy drinks masks the effects of the alcohol. People think they are not drunk and drink considerably more. This leads to overdosing on alcohol and possibly alcohol poisoning. This is extremely dangerous, and can be deadly.

--Be aware of the caloric content of alcohol. We famously reported on FOX last week that a pina colada had about 700 calories, about the same as a Big Mac. A typical shot of alcohol has 90 calories. Mixers--juice, soda, etc.--can add significantly to this. For example, an average size vodka and orange juice has about 150 calories. Beer and wine are lower in calories than hard liquor. You may want to consider mixing your liquor with tomato juice. It is low in calories, very nutritious, but unlike diet soda, has the sugar necessary to metabolize alcohol.

--Alternate alcoholic drinks with non-alcoholic drinks, preferrably water. This will cut your alcohol consumption considerably, slow its affects on you, and help prevent the dehydration that causes hangovers.

--Drink out of a smaller glass. Size matters. Just as food portions have ballooned in this country, so has the size of drinks. Ask for a smaller glass.

--Beware mixing drinks. This age-old advice still rings true. Mixing different liquors is never a good idea.

Finally, have a safe, healthy, happy wonderful holiday!

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4 Tips for Lower Cholesterol Fast


R. Morgan Griffin

WebMD Medical News

Deepening smile lines and silver locks may be inevitable features of growing older, but rising cholesterol doesn't have to be.

And while higher cholesterol is often a consequence of aging, young people can have it too. But no matter your age, it poses a big health risk. That's because unhealthy cholesterol levels can boost your risk of heart attacks, strokes, and other problems.

Fortunately, you can do something about it.

"Unlike your age and your genes, cholesterol levels are risk factors that you can often change," says Jorge Plutzky MD, director of the Vascular Disease Prevention Program at Brigham and Women's Hospital in Boston.

Lower Cholesterol: 4 Ways to Fast Results

According to experts, there are four basic ways to get your cholesterol where you want it:

* Eating a healthy diet.
* Exercising
* Losing weight
* Taking medicine -- in some cases

While each of these works, some people have more success with one than another. Many need a combination of approaches.

No matter what your age or the state of your health, you can reduce your risks of serious problems by controlling your cholesterol -- and it's not as hard as you think.

Know Your Cholesterol Numbers

While Plutzky says that people are often alarmed when they find out they have high cholesterol, many are also confused.

"They don't understand what the numbers mean," he tells WebMD, "They don't know the difference between total cholesterol, LDL and HDL."

So let's start with some basics. Cholesterol is a fat-like substance that circulates in your blood. Some of it is made naturally by your body, and the rest comes from foods you eat. There are two main types: HDL and LDL.

* LDL is "bad cholesterol." It can clog your arteries, increasing the risk of heart attack and stroke. Healthy number: Less than 100mg/dL.
* HDL is "good cholesterol." What's good about it? HDL attaches to bad cholesterol and escorts it to the liver, which filters it out of the body. So HDL reduces the amount of bad cholesterol in your system. Healthy number: 60mg/dL or higher.
* Total cholesterol is the sum of all types of cholesterol in your blood. Although your doctor may still refer to this number, it's less significant than your HDL and LDL levels. Healthy number: Less than 200 mg/dL.
* Triglycerides, while not cholesterol, are another type of fat floating in your blood. Just as with bad cholesterol, having a high level of triglycerides increases your risk of cardiovascular problems. Healthy number: Less than 150 mg/dL.

Think you need to get a handle on your LDL, HDL, total cholesterol or triglycerides? Here's how to do it.

1. Lower Cholesterol by Eating Right

You've probably heard it before, but foods that are high in saturated fat and -- to a lesser extent -- high in cholesterol, boost your cholesterol levels. These include foods like egg yolks, fatty meats, and full-fat dairy products.

Plutzky recommends you also cut down on trans fatty acids as well, which are often found in processed and fried foods.

But eating a heart healthy diet isn't just about deprivation. In fact, some foods -- eaten in moderation -- can actually improve your cholesterol levels. They include:

* Fatty fish, like tuna and salmon
* Nuts, especially walnuts and almonds
* Oatmeal and oat bran
* Foods fortified with stanols, like some margarines and orange juices

How much does diet help? It depends.

"The effect of diet has a varying effect on people's cholesterol," says Roger Blumenthal MD, director of the Preventive Cardiology Center at Johns Hopkins Medical School in Baltimore. "Some people get a lot more benefit than others."

Blumenthal says diet tends to help people lower triglycerides and raise good HDL cholesterol, but it's less likely to have a big impact on bad LDL cholesterol.

2. Improving Cholesterol With Exercise

Exercise is another way to improve your cholesterol levels. Increased physical activity can have a modest effect on cholesterol, lowering triglycerides (and bad LDL cholesterol to a lesser extent), while boosting your good HDL cholesterol.

Of course, the type of exercise is up to you. Plotzky says just about any aerobic activity -- something that boosts your heart rate -- is good. Blumenthal says that walking is often the best way for people who are out of shape to get started.

"I encourage people to buy a $10 pedometer to count their steps," says Blumenthal. "It's a simple way to measure your progress, and it's easy to work in walking during the day."

3. Lose Weight: Lower Cholesterol

Being overweight tends to lead to unhealthy cholesterol levels. Losing weight can lower your bad LDL cholesterol and triglycerides. It also can raise your good HDL cholesterol.

Of course, weight loss is usually a product of a good diet and exercise. So what if you've already improved your diet and started exercising but still need to lose weight?

Then you need to make some further adjustments -- gradually. Once you've reduced your intake of saturated fats, trans fats, and cholesterol, you can focus on cutting out some calories. In the same way, once you've gotten into an exercise routine, you can step up the intensity to lose some pounds.

4. Controlling Cholesterol With Medication
So what happens if diet, exercise and weight loss aren't enough to bring your cholesterol under control? Your doctor might recommend medicine.

Medicine may also be a first choice for people who have other risk factors. "If you have high cholesterol and heart disease or diabetes," says Blumenthal, "the evidence is pretty clear that you should be on medication."

Medicine can have a dramatic effect both on your cholesterol levels and your overall health. "People need to understand that using medicine can lower your risk of heart attack and stroke by 30-40%," says Blumenthal.

Several types of medication can help, including:

* Statins, like Crestor, Lescol, Lipitor, Mevacor, Pravachol, and Zocor. Statins are usually the first choice for medicine. They block the effects of an enzyme that helps make cholesterol. They also lower bad cholesterol by a whopping 20-55%. They have a modest effect on triglycerides and give a mild boost to your good cholesterol.
* Ezetimibe (Zetia) is a newer cholesterol-reducing medication that decreases how much cholesterol the body absorbs. It can lower bad cholesterol by up to 25%. Ezetimibe may be combined with a statin to boost the cholesterol lowering effects. Vytorin is ezetimibe combined with the statin Zocor.
* Niacin, available as Niacor, Niaspan, and Nicolar (among others), lowers LDL cholesterol and triglycerides and raises HDL cholesterol. LDL levels are usually cut by 5-15% and may be reduced up to 25%.
* Bile acid resins like Colestid, Lo-Cholest, Prevalite, Questran, and WelChol. They stick to cholesterol in the intestines and prevent it from being absorbed. They can lower LDL cholesterol by 15-30%.
* Fibric acid like Atromid, Lopid, and Tricor. They mainly reduce your triglycerides and may also give a mild boost to your HDL. LDL is affected to a lesser extent.

Like any medicines, drugs to lower your cholesterol can have side effects. Talk to your health care provider about the risks.

If you wind up needing a medicine, don't feel like your lifestyle changes have failed. Some people have high cholesterol that just doesn't respond as well to exercise and diet, but keeping up your lifestyle changes may allow you to take lower doses of medicine.

Four Cholesterol Treatments: Which Is Best?

The best treatment varies from person to person. People at low risk may try lifestyle changes first and only move on to medication if they need it. Others who are at severe risk may need a medicine, like a statin, right away.

Admittedly, lifestyle changes may not be enough to drastically lower your bad LDL levels.

"Physical activity and improved diet can lower your triglycerides and raise your [good] HDL cholesterol," says Plutzky. "But it's pretty hard to eat or exercise your way to better LDL levels."

But that doesn't make lifestyle changes any less important or give you a free pass to loll about the house eating ice cream. You still need to keep eating well and exercising.

"Exercise and dietary changes have a lot of cardiovascular benefits that won't show up on a cholesterol test," says Plutzky. Exercise, eating well, and losing weight can lower blood pressure, lower your heart rate, and decrease your risk of diabetes and other diseases. And remember that your real goal is not merely better cholesterol numbers, but a lower risk of cardiovascular disease.

If your doctor does prescribe a statin, you may have mixed feelings. You may not like the idea of being on a medicine for the rest of your life. But Blumenthal and Plutzky urge people to think about the benefits.

"The safety and efficacy of statins is superb," says Plutzky. "They may be one of the greatest medical advances we've had in recent years."

And Blumenthal predicts that soon they may be taken like preventative aspirin is now -- even in people who don't have high cholesterol by today's standards.

Plutzky says that we've come a long way in our understanding and treatment of high cholesterol.

"We have excellent, safe treatments for high cholesterol now," says Plutzky, "Treatments that people in the past with high cholesterol would have given absolutely anything to have. So if you need them, it's a shame not to take advantage of them."

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Low-Cost Ways to Protect Your Bones


Gina Shaw
WebMD Feature

If you have osteoporosis -- or are at high risk -- odds are you're not getting the care you need.

A 2004 Stanford study determined that more than half of all people with osteoporosis remain undiagnosed. What's more, even high-risk patients -- such as those who have already had a hip fracture - often don't receive calcium and vitamin D supplements or antiosteoporosis drugs. The 2004 Surgeon General's Report on Bone Health adds that most physicians don't even discuss osteoporosis with their patients after a fracture.

Why is this the case? "I have no idea," says a baffled Michael Holick, MD, PhD, professor of medicine, physiology, and biophysics at Boston University Medical Center. "But the numbers are out there. Only one in four women between the ages of 45 and 75 will ever talk to a doctor about osteoporosis."

What's tragic about those numbers is that it's relatively easy and cost effective to take care of your bones -- but it can be devastating when you don't. Osteoporosis causes more than 1.5 million fractures every year. If you're a woman older than 50, you have 50-50 odds of having an osteoporosis-related fracture sometime in your remaining lifetime (don't stop reading if you're a man: your chance of a similar fracture is one in four).

Here are some things you can do to help protect your bones without breaking the bank -- especially if you're at high risk for osteoporosis, or nearing an age at which you will be.

* Get Cs and Ds: Calcium and vitamin D, that is. A recent study of postmenopausal women on osteoporosis treatment shows that 52% had vitamin D insufficiency -- even though they'd been told by their doctors to take calcium and vitamin D.

The National Osteoporosis Foundation recommends 400 to 800 IU of vitamin D every day, but Holick says that might not be enough now.

"To prevent skin cancer, we're avoiding sun exposure, which is a major source of vitamin D," he says. "If you're doing that, you should be making sure to get 1,000 IU of vitamin D daily." Fortified dairy products, egg yolks, fish, and liver contain vitamin D, but you'll probably need a supplement to ensure you get enough.

If you're postmenopausal, you should also be getting 1,200 milligrams of daily calcium, and 1,000 milligrams if you're pre-menopausal.
* Exercise: Here's the good news: The best exercise for maintaining your bone mass costs you nothing, other than maybe a good pair of shoes. It's walking, as little as 3-5 miles a week.

"The pounding on the pavement as you walk increases muscle tone and maintains bone density," says Holick. "No other type of exercise does this as well."

If you're looking to increase (not just maintain) bone density, you can't hope to increase your bone density through exercise -- not unless you stress yourself abnormally (think super weightlifter-type workouts) -- but it can help you keep the bone that you have. Jogging, stair climbing, and other types of weight-bearing exercise are also effective.

Strength training is the other half of the exercise equation. It maintains and possibly even improves bone mineral density, according to several studies, according to results from the Bone, Estrogen, and Strength (BEST) study funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

You don't have to join a pricey gym to get strength-training benefits. A few inexpensive hand weights or a rubber tubing used for resistance exercises are all you need. A simple program with one or two exercises for each muscle group is fine. Ask your doctor for some sample exercises.

You can also order the National Osteoporosis Foundation's BoneWise exercise video from its web site (www.nof.org) (be sure to check with your doctor before starting any exercise program, especially if you've had falls, fractures, or other injuries).
* Testing: Bone density screening is the best way to assess the health of your bones. But will your insurance coverage pay for it? The answer is yes and no, says Holick. "If you're 50 to 55 years of age and perimenopausal, bone density screening provides an important baseline, but insurance coverage is spotty."

Many insurers won't cover bone density screening for women under 65 (the age at which the National Osteoporosis Foundation recommends regular screening begin for all women) unless you have one or more additional risk factors. Be sure your doctor and your insurer know if you have any of these risk factors:
o Being postmenopausal, and/or early onset of menopause
o Smoking
o Family history of osteoporosis or fractures
o Low weight/having a thin frame
o Using corticosteroids for longer than three months
o Late onset of menstrual periods
o History of anorexia or bulimia
o Excessive alcohol intake
o Low intake of calcium or vitamin D
o Taking certain medications, such as some cancer drugs, thyroid drugs, and anticonvulsants-ask your doctor

If you already have osteoporosis, insurers generally cover prescribed medications such as bisphosphonates, although the monthly co-payments for a drug you will take for years can add up.

If these payments become a serious burden, or if you're uninsured, don't risk your bone health by dropping your medications -- explore these options:

* NeedyMeds (www.needymeds.com) is one of the best sources of information on the many drug assistance programs offered by states, localities, and pharmaceutical manufacturers themselves.
* AARP Bulletin online has a state-by-state, plan-by-plan guide to pharmacy assistance programs at http://www.aarp.org/bulletin/prescription/Articles/statebystate.html.
* Seniors Inc. (http://www.seniorsinc.org/medication.htm, or (303) 300-6945) and the Medicine Program (www.themedicineprogram.com) are both free services that help people enroll in medication assistance programs.
* Partnership for Prescription Assistance (www.pparx.org), a web site run by pharmaceutical companies, doctors, and patient advocacy groups that offers access to public and private patient assistance programs, including more than 150 programs offered by pharmaceutical companies.

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300 say they got ill at Olive Garden

More than 300 people say they became ill, and at least three have been hospitalized, after eating at an Olive Garden restaurant last weekend, health officials said Friday.

The restaurant has been closed while health officials and the company investigate what caused customers to complain of nausea, vomiting, fever and diarrhea, a company spokesman said.

Steve Coe, a spokesman for the Orlando, Fla.-based chain of Italian restaurants, said health officials are focusing on an employee who had flu-like symptoms similar to those patrons complained of.

Six restaurant workers reported Monday that they felt ill, said Marion County Health Department spokesman John Althardt.

"We're trying to isolate what the cause of the illness might be," he said.

Health officials have found no link to the E. coli outbreak that sickened dozens of people who ate at Taco Bell restaurants in the Northeast recently, Althardt said.

The reports have been isolated to the one restaurant, appearing to indicate the problem is not linked to any products used in the food, Coe said. Food suppliers typically supply the same products to many restaurants.

"We are taking this extremely seriously," he said. "But at this time there is no reason for us to believe that there is any connection with any E. coli outbreaks."

Health officials were collecting leftover food and stool samples from those stricken to pinpoint the source, Althardt said. Inspectors met with restaurant managers on Tuesday and found no health code violations.

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Germ outbreak reported at L.A. hospital

A hospital has closed its neonatal and pediatrics intensive care units to new admissions after a potentially fatal bacterium sickened seven children, including an infant who may have died from the infection, officials said.

White Memorial Medical Center shut down the neonatal unit on Dec. 4 following an outbreak of Pseudomonas aeruginosa, hospital officials said Friday.

The germ is believed to have infected five babies in the unit since it was detected on Nov. 30, said Dr. Laurene Mascola, director of the county's acute communicable disease control unit. One of the infants died, likely because of the pathogen, she said.

All infants who tested negative for the germ are being held in separate areas, officials said.

"These are very, very sick babies to begin with. (An infection) can increase their chance of dying," Mascola said.

On Friday, the hospital shuttered the pediatrics intensive care ward after discovering the bacterium had infected an infant and a toddler there, Dr. Rosalio Lopez, the hospital's chief medical officer, said in a statement.

Officials say they've identified the source of the outbreak — a medical instrument called a laryngoscope blade used to look at an infant's larynx that may not have been properly cleaned. Officials don't believe there is a danger to other babies, Lopez said.

Though common, the germ is particularly virulent in those with weak immune systems such as newborns who are premature or critically ill.

The hospital is working with county, state and federal health officials to investigate the outbreak, Lopez said.

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Circumcision Halves H.I.V. Risk, U.S. Agency Finds


DONALD G. McNEIL Jr.

Circumcision appears to reduce a man’s risk of contracting AIDS from heterosexual sex by half, United States government health officials said yesterday, and the directors of the two largest funds for fighting the disease said they would consider paying for circumcisions in high-risk countries.The announcement was made by officials of the National Institutes of Health as they halted two clinical trials, in Kenya and Uganda, on the ground that not offering circumcision to all the men taking part would be unethical. The success of the trials confirmed a study done last year in South Africa.
AIDS experts immediately hailed the finding. “This is very exciting news,” said Daniel Halperin, an H.I.V. specialist at the Harvard Center for Population and Development, who has argued that circumcision slows the spread of AIDS in the parts of Africa where it is common.
In an interview from Zimbabwe, he added, “I have no doubt that as word of this gets around, millions of African men will want to get circumcised, and that will save many lives.”
Uncircumcised men are thought to be more susceptible because the underside of the foreskin is rich in Langerhans cells, sentinel cells of the immune system, which attach easily to the human immunodeficiency virus, which causes AIDS. The foreskin also often suffers small tears during intercourse.
But experts also cautioned that circumcision is no cure-all. It only lessens the chances that a man will catch the virus; it is expensive compared to condoms, abstinence or other methods; and the surgery has serious risks if performed by folk healers using dirty blades, as often happens in rural Africa.
Circumcision is “not a magic bullet, but a potentially important intervention,” said Dr. Kevin M. De Cock, director of H.I.V./AIDS for the World Health Organization.
Sex education messages for young men need to make it clear that “this does not mean that you have an absolute protection,” said Dr. Anthony S. Fauci, an AIDS researcher and director of the National Institute of Allergy and Infectious Diseases.
Circumcision should be used with other prevention methods, he said, and it does nothing to prevent spread by anal sex or drug injection, ways in which the virus commonly spreads in the United States.
The two trials, conducted by researchers from universities in Illinois, Maryland, Canada, Uganda and Kenya, involved nearly 3,000 heterosexual men in Kisumu, Kenya, and nearly 5,000 in Rakai, Uganda. None were infected with H.I.V. They were divided into circumcised and uncircumcised groups, given safe sex advice (although many presumably did not take it), and retested regularly.
The trials were stopped this week by the N.I.H. Data Safety and Monitoring Board after data showed that the Kenyan men had a 53 percent reduction in new H.I.V. infection. Twenty-two of the 1,393 circumcised men in that study caught the disease, compared with 47 of the 1,391 uncircumcised men.
In Uganda, the reduction was 48 percent.
Those results echo the finding of a trial completed last year in Orange Farm, a township in South Africa, financed by the French government, which demonstrated a reduction of 60 percent among circumcised men.
The two largest agencies dedicated to fighting AIDS said they would now be willing to pay for circumcisions, which they have not before because there was too little evidence that it worked.
Dr. Richard G. A. Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has almost $5 billion in pledges, said in a television interview that if a country submitted plans to conduct sterile circumcisions, “I think it’s very likely that our technical panel would approve it.”
Dr. Mark Dybul, executive director of President Bush’s $15 billion Emergency Plan for AIDS Relief, said in a statement that his agency “will support implementation of safe medical male circumcision for H.I.V./AIDS prevention” if world health agencies recommend it.
He also warned that it was only one new weapon in the fight, adding, “Prevention efforts must reinforce the A.B.C. approach — abstain, be faithful, and correct and consistent use of condoms.”
Researchers have long noted that parts of Africa where circumcision is common — particularly the Muslim countries of West Africa — have much lower AIDS rates, while those in southern Africa, where circumcision is rare, have the highest.
But drawing conclusions was always confounded by other regional factors, like strict Shariah law in some Muslim areas, rape and genocide in East Africa, polygamy, rites that require widows to have sex with a relative, patronage of prostitutes by miners, and men’s insistence on dangerous “dry sex” — with the woman’s vaginal walls robbed of secretions with desiccating herbs.
Outside Muslim regions, circumcision is spotty. In South Africa, for example, the Xhosa people circumcise teenage boys, while Zulus do not. AIDS is common in both tribes.
Nelson Mandela’s autobiography, “Long Walk to Freedom,” contains an unnerving but hilarious account of his own Xhosa circumcision, by spear blade, as a teenager. Although he was supposed to shout, “I am a man!” he grimaced in pain, he wrote.
But not all initiation ceremonies are laughing matters. Every year, some South African teenagers die from infections, and the use of one blade on many young men may help spread AIDS.
In recent years, as word has spread that circumcision might be protective, many southern African men have sought it out. A Zambian hospital offered $3 circumcisions last year, and Swaziland trained 60 doctors to do them for $40 after waiting lists at its national hospital grew.
“Private practitioners also do it,” Dr. Halperin said. “In some places, it’s $20; in others, much more. Lots of the wealthy elite have already done it. It prevents S.T.D.’s, it’s seen as cleaner, sex is better, women like it. I predict that a lot of men who can’t afford private clinics will start clamoring for it.” (S.T.D.’s are sexually transmitted diseases.)
Male circumcision also benefits women. For example, a study of the medical records of 300 Ugandan couples last year estimated that circumcised men infected with H.I.V. were about 30 percent less likely to transmit it to their female partners.
Earlier studies on Western men have shown that circumcision significantly reduces the rate at which men infect women with the virus that causes cervical cancer. A study published in 2002 in The New England Journal of Medicine found that uncircumcised men were about three times as likely as circumcised ones with a similar number of sexual partners to carry the human papillomavirus.
The suspected mechanism was the same — cells on the inside of the foreskin were also more susceptible to that virus, which is not closely related to H.I.V.

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How to Handle a Hangover

Hangovers seem to be the body’s way of reminding us about the hazards of overindulgence. Physiologically, it’s a group effort: Diarrhea, fatigue, headache, nausea, and shaking are the classic symptoms. Sometimes, systolic (the upper number) blood pressure goes up, the heart beats faster than normal, and sweat glands overproduce — evidence that the “fight or flight” response is revved up. Some people become sensitive to light or sound. Others suffer a spinning sensation (vertigo).

The causes are as varied as the symptoms. Alcohol is metabolized into acetaldehyde, a substance that’s toxic at high levels, although concentrations rarely get that high, so that’s not the complete explanation.

Drinking interferes with brain activity during sleep, so a hangover may be a form of sleep deprivation. Alcohol scrambles the hormones that regulate our biological clocks, which may be why a hangover can feel like jet lag, and vice versa. Alcohol can also trigger migraines, so some people may think they’re hung over when it’s really an alcohol-induced migraine they’re suffering.

Hangovers begin after blood alcohol levels start to fall. In fact, according to some experts, the worst symptoms occur when levels reach zero.

The key ingredient seems to be “drinking to intoxication”; how much you drank to get there is less important. In fact, several studies suggest that light and moderate drinkers are more vulnerable to getting a hangover than heavy drinkers. Yet there’s also seemingly contradictory research showing that people with a family history of alcoholism have worse hangovers. Researchers say some people may end up with drinking problems because they drink in an effort to relieve hangover symptoms.

Dr. Robert Swift, a researcher at the Providence Veterans Affairs Medical Center in Rhode Island, coauthored one of the few review papers on hangovers in 1998. It’s still one of the most frequently cited sources on the topic. The rundown on hangover remedies that follows is based on that review, an interview with Dr. Swift, and several other sources.

Hair of the dog.
Drinking to ease the symptoms of a hangover is sometimes called taking the hair of the dog, or hair of the dog that bit you. The notion is that hangovers are a form of alcohol withdrawal, so a drink or two will ease the withdrawal.

There may be something to it, says Dr. Swift. Both alcohol and short-acting sedatives, such as benzodiazepines like diazepam (Valium), interact with GABA receptors on brain cells, he explained, and it’s well documented that some people have withdrawal symptoms from short-acting sedatives as they wear off. Perhaps the brain reacts similarly as blood alcohol levels begin to drop.

Even so, Dr. Swift advises against using alcohol as a hangover remedy. “The hair of the dog just perpetuates a cycle,” he says. “It doesn’t allow you to recover.”

Drink fluids.
Alcohol promotes urination because it inhibits the release of vasopressin, a hormone that decreases the volume of urine made by the kidneys. If your hangover includes diarrhea, sweating, or vomiting, you may be even more dehydrated. Although nausea can make it difficult to get anything down, even just a few sips of water might help your hangover.

Get some carbohydrates into your system.
Drinking may lower blood sugar levels, so theoretically some of the fatigue and headaches of a hangover may be from a brain working without enough of its main fuel. Moreover, many people forget to eat when they drink, further lowering their blood sugar. Toast and juice is a way to gently nudge levels back to normal.

Avoid darker-colored alcoholic beverages.
Experiments have shown that clear liquors, such as vodka and gin, tend to cause hangovers less frequently than dark ones, such as whiskey, red wine, and tequila. The main form of alcohol in alcoholic beverages is ethanol, but the darker liquors contain chemically related compounds (congeners), including methanol. According to Dr. Swift’s review paper, the same enzymes process ethanol and methanol, but methanol metabolites are especially toxic, so they may cause a worse hangover.

Take a pain reliever, but not Tylenol.
Aspirin, ibuprofen (Motrin, other brands), and other nonsteroidal anti-inflammatory drugs (NSAIDs) may help with the headache and the overall achy feelings. NSAIDs, though, may irritate a stomach already irritated by alcohol. Don’t take acetaminophen (Tylenol). If alcohol is lingering in your system, it may accentuate acetaminophen’s toxic effects on the liver.

Drink coffee or tea.
Caffeine may not have any special anti-hangover powers, but as a stimulant, it could help with the grogginess. Coffee is a diuretic, though, so it may exacerbate dehydration.

Vitamin B6.
A study published over 30 years ago found that people had fewer hangover symptoms if they took a total of 1,200 milligrams of vitamin B6 before, during, and just after drinking to get drunk. But it was a small study and doesn’t seem to have been replicated.

Artichoke extract.
Supplement makers have promoted artichoke extract for a variety of ills, including hangovers, because it supposedly has beneficial effects on the liver. But a small study published in the Canadian Medical Association Journal in 2004 concluded that it isn’t effective for hangovers.

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Exercising may reduce lung cancer risk

KATHY MATHESON,

Associated Press Writer

Everyone knows smoking is a bad idea, but those who can't give it up may get a little protection from exercise, a study suggests. In a study of older women, researchers found that a physically active smoker had a 35 percent lower risk of lung cancer than a sedentary smoker.

Even so, one expert called that reduction trivial because smoking itself is so risky. And Dr. Kathryn Schmitz, the study's lead author, stressed that exercising does not give women a free pass to smoke.

"The most important thing that smokers can do to reduce the risk of lung cancer is quit smoking," said Schmitz, an assistant professor at the University of Pennsylvania's Center for Clinical Epidemiology and Biostatistics.

Those who quit smoking are 10 to 11 times less likely to develop lung cancer than those who smoke, she said.

The research, published in this month's issue of Cancer Epidemiology Biomarkers & Prevention, was based on information from the Iowa Women's Health Study. That project began in 1986 to follow nearly 42,000 older women. The women filled out health questionnaires over the years, including information about their smoking status and physical activity.

By the end of 2002, the data included 36,410 participants, and 777 had lung cancer.

Of those, 125 were non-smokers, 177 were former smokers, and 475 were current smokers.

Schmitz, who was then at the University of Minnesota's School of Public Health, worked with four colleagues to analyze the data.

Among smokers, the greatest number of cancer cases, 324, came from women who currently smoked and weren't very active. Among physically active smokers, there were 151 cases of lung cancer.

The greatest benefits went to those who had quit smoking and also exercised, with just 82 cancer cases compared to 95 in sedentary former smokers.

Among the exercisers, the lowest risk of lung cancer was found in those who had moderate workouts more than four times a week, or vigorous workouts two or more times a week.

It is still unclear why physical activity might have a preventive effect on lung cancer. Studies over the years have produced conflicting results on that subject. Researchers say it could be that improved pulmonary function reduces both the concentration of carcinogenic particles and the extent to which they are deposited in the lungs.

Also, being more physically active could make smokers more aware of the damage they have caused their lungs — leading them to smoke less or quit, Schmitz said.

Dr. Norman Edelman, chief medical officer for the American Lung Association, echoed Schmitz's comments that the report should not give physically active female smokers "a false sense of security."

"We don't want people to get the wrong message," Edelman said. "A regular smoker has a risk of lung cancer 10 times that of a nonsmoker, and 35 percent reduction in that risk is trivial."

He noted the study does not address the effect of exercise on other smoking-related health problems, such as emphysema and heart disease. He also said that because the active women were less likely to be overweight, it was unclear if the lower lung cancer rate was a result of their exercising or their weight. Some cancers are more common in the obese, Edelman said.

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French Toast for Dinner


Breakfast, that warm and comforting meal, is going prime time, as top chefs are inventing new gourmet variations on bacon and eggs.

Missed breakfast again today? No problem. Now you can savor the morning meal at night in the most elegant of settings — a gourmet restaurant. From Northern California's wine country to the dunes of Cape Cod, three-star chefs have begun whipping up surprising combinations like waffles with caviar, eggs benedict with truffles, and even French toast with chevre, and serving them well after dark. Long a staple of roadside diners and harried family cooks with no time to bake a lasagna, breakfast for dinner appeals to our cravings for soft, warm comfort foods that aren't heavy but still feel like a real meal.

Serving breakfast for dinner appeals to discerning customers and chefs alike. "When you look at most breakfast foods, they taste pretty darn good," says, John Nihoff, a professor of gastronomy at the Culinary Institute of America in Hyde Park, N.Y., who points to the growing interest in gourmet variations on breakfast stalwarts, such as the new Iberico ham from Spain, which comes from pigs that are fed only acorns. Meanwhile, more chefs are discovering that serving breakfast foods after noon doesn't have to mean going downscale. "Anyone can serve breakfast food at dinner. If I slapped French toast on the menu that wouldn't mean anything, but paired with figs and foie gras, it's like, wow," says Bill Brodsky, executive chef at the oceanside Twenty-Eight Atlantic (which recently earned a 3-star rating from the Boston Globe) in Chatham, Mass.

Perhaps most important, many people find a good breakfast to be satisfying for the soul as well as the stomach. "Breakfast has a better image than any other meal," says Leon Rappoport, who surveyed hundreds of diners on their feelings about food for his 2003 book How We Eat: Appetite, Culture and the Psychology of Food. He says that people generally associate the morning meal with family, coziness, and casualness, whereas dinner feels formal, heavy and even sad, particularly among young men. Thomas Keller, chef and owner of French Laundry in Yountville, Calif. and Per Se in New York City, (both of which won 3-star ratings from the Michelin guides) says happy childhood memories inspired his gourmet take on toad in the hole, which recently appeared on Per Se's vegetarian tasting menu. "That was what we used to have when we were kids. Mom would take a piece of bread, put a hole in it and cook it," he says. Per Se's iteration replaces white bread with brioche, and the hen egg with one from a pigeon or quail.

Many chefs also enjoy concocting endless riffs on basic breakfast foods like bread and eggs. "Bread goes with anything," says Keller, and "egg is the only protein that you use 24 hours a day in a savory and a sweet." That versatility explains why pain perdu — an authentically French version of French toast — makes a regular appearance on the French Laundry menu. But it's never ordinary. Cooked with bone marrow, tomatoes or truffles, it is hard to recognize as a variation on French toast in the first place. Other New York chefs' inspired takes on morning food range from the minimalist sable and coddled eggs, served as the second course at Telepan, to the spectacular sea scallops "benedict" appetizer at davidburke & donatella, which starts with a base of two hashed-brown potato cakes, then artfully piles them with sea scallops, poached quail eggs, chives and a cloud of lobster foam on top.

Sometimes what sounds like routine breakfast fare on the menu is really just the chef's way of making a little mischief. The newly renovated Picholine near Lincoln Center in Manhattan serves a dish called "bacon and eggs," in which the bacon is actually smoked tuna belly. And Brodsky once featured "green eggs and ham" in homage to Dr. Seuss, which was actually a truffled spring pea custard served with proscuitto chips and caviar. "I did it to have some fun and not take myself so seriously," he says. For diners too, lightening up about what to eat for dinner definitely hits the spot.

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12 Tips for a Better Night's Sleep


Michael Breus, AOL Wellness Coach and author of the book 'Good Night: The Sleep Doctor's 4-Week Program to Better Sleep and Better Health,' says a more restful night of sleep will give you more energy, help you lose weight and make you look younger.

Get Cool

Sleep in a cool environment. The ideal sleeping temperature is between 65 and 72 degrees. A mild drop in body temperature often induces sleep, which is why lying in a cool bed after a hot bath is so relaxing.

Reduce Your Anxiety Before Bed

Hide illuminated clocks from view to avoid clock-watching.
Avoid eating within three hours of bedtime.
Alcohol, tobacco and caffeine can exacerbate anxiety. Avoid these before bedtime.

Consider Possible Allergies

Look at pillows, sheets, fabric softeners and detergents, pets in the bed, dust, mold, perfume and so on, that can affect the bedroom environment. All of these can cause congestion, which can worsen snoring.

Watch the Caffeine

Get in tune with how your body responds to caffeine and make adjustments so that it's less likely to disrupt your sleep. Some people can drink several cups of coffee, tea or soft drinks within an hour of sleep and notice no effects, whereas others may feel stimulating effects after one cup.

Make Some Noise

Use a white noise machine or CD that is soothing to you. A cheaper alternative is to set the tuner of your FM radio between any two stations. The pseudo white noise you'll hear will do wonders to mask unwanted sounds. Ceiling fans or stand-alone fans can also provide a constant hum that can be sleep-friendly.

Let Each Other Sleep

Find your sleep schedule. With different work hours, social schedules and general lifestyles, couples typically need to go to bed and wake up at different times on different days. The trick is to maintain separate bedtimes and waking schedules without either one disturbing the other's sleep.

Prepare to Sleep

Relax before bedtime. Stress not only makes you miserable, it wreaks havoc on your sleep. Develop some kind of pre-sleep ritual like reading, light stretching or taking a hot bath to break the connection between all the day's stress and bedtime. These rituals can be as short as 10 minutes.

Make It Dark

Cover your windows. Consider blackout shades or heavy drapes -- these can also dampen sounds. Don't forget to use a drape clip, which will securely close the two sides of the drapery. (Start out by using a "chip clip," which works just as well.)

Rest Your Head

Buy a new pillow. If every night you scrunch up your pillow and fold it in half like a neck-roll just to get it to fit comfortably underneath your head, you're in dire need of a new pillow. If your pillow is dirty, stained, torn or if it smells bad, you also need a new bed pillow.

Set the Mood

Keep high-wattage lights away from the bedroom. Install low-wattage lights anywhere near the bed or add dimmers to all the switches and set the mood for sleep two to three hours before you retire.

Take a Nap

The 20-minute power nap has been talked about for years, but napping doesn't have to be so confined. You can gain a lot of benefits from as little as five minutes, and as much as two or more hours (but, please, no more than three). If you have real trouble sleeping at night, though, it's a no-napping policy during the day.

Evaluate Your Mattress

Test your mattress. If it hasn't been turned (rotated if it's a pillow top mattress) in a year, do it now. If it's older than seven years, it's time to buy a new one.

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Foods that are good for you -- and your sex life.


Amy Paturel


Mood Enhancers

Foods like oysters really can ignite passion in the bedroom. How? They're good for your heart. And what's good for your heart is good for your libido, too. After all, if your arteries are clogged, getting blood to flow down south can be problematic, says Bonnie Dix, M.A., R.D., of the American Dietetic Association. Here are some more romance-enhancing wonders:

Oysters

Since the tale of Aphrodite emerging from the sea on an oyster shell, this sexy shellfish has been hailed as an aphrodisiac. Oysters and other fatty fish such as salmon, scallops and sardines are loaded with healthful monounsaturated fats called Omega 3s. And they carry a hefty dose of testosterone-boosting zinc.

Champagne

So you've already heard the buzz that a daily glass of wine raises good cholesterol and helps prevent arteries from clogging. But alcohol, especially champagne, can also improve your health and your sex life. Like many mind altering substances, a glass or two of champagne will lower inhibitions and help ease any couple into an amorous mood.

Pine Nuts

Pine nuts have more protein than any other nut. Besides providing protein to help increase stamina, pine nuts are heavy in healthful monosaturated fats, zinc and other nutrients that are linked with increased sexual desire. Sexier than your average peanut, pine nuts are often present on many fine-dining menus.

Artichoke

This nutrient-dense, peculiar plant was once considered such a powerful aphrodisac that women were banned from eating it. According to Martha Hopkins, co-author of 'Inter-Courses: An Aphrodisiac Cookbook,' part of the appeal of the artichoke may be that you have to work hard to "get past the spiked leaves to get to the velvety-smooth heart."

Spices

The right spices not only heat things up on the tongue, but also in the bedroom. "Chili pepper and ginger help improve circulation," says Dix, "and hot spices like cayenne, curry and cumin help warm the body." The intoxicating aromas of exotic spices help infuse romance into the atmosphere.

Avocado

According to the Doctrine of Signatures, food aids the part of the body it resembles. In fact, the Aztecs valued the avocado as an aphrodisiac and named it ahuacale or testicle because they grow in pairs. Though science can neither confirm nor deny that this fruit will get your fire going, it will give you fuel in the form of healthy fats, protein and potassium.

Chocolate

Don't skip dessert: Eating chocolate causes the release of mood-boosting, stress-reducing serotonin. The sweet stuff also causes a release of phenylethylamine, which causes changes in blood pressure and blood-sugar levels leading to feelings of excitement. Just make sure to choose antioxidant-rich dark chocolate.

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Infant Car Seats Might Pose Breathing Risks

Ed Edelson

HealthDay Reporter

Babies should not be left alone to sleep in car safety seats, especially if they were born prematurely, New Zealand pediatricians report.

Their warning, published in this week's issue of the British Medical Journal, is based on a study of nine infants, aged 3 days to 6 months, who were referred to the Auckland Cot Monitoring Service by parents alarmed by what they described as infants who were "blue," "scrunched up" or "not breathing."

"All but one case occurred when the infants had been left in the car seats indoors, allowing them to fall asleep unrestrained in an upright position," said a report by the group, led by Dr. Alistair J. Gunn, an associate professor of physiology and pediatrics at the University of Auckland.

All the infants survived, but the parents were given advice on better positioning to prevent future problems, and warnings about not leaving the babies in the car seats for excessive periods of time.

It's a "fairly important paper," said Dr. Christopher Greeley, medical director of the newborn nursery at Vanderbilt Children's Hospital in Nashville, because it demonstrates the potential dangers of car seats, which are regarded as essential for protecting children if accidents occur.

"The take-home message is that parents should not leave babies unattended in car seats," Greeley said. "If you leave a very young baby in a car seat, the structure of the head, bigger in the back, can cause the airway, the trachea, to be narrowed."

Vanderbilt follows the recommendation of the American Academy of Pediatrics -- that all babies born before 37 weeks of pregnancy get a car seat test before they leave the hospital, he said.

"They get the test for the potentially longest duration of the ride home, so that they don't have this kind of positional occlusion," Greeley said. "The test is done for premature babies or full-term babies who have issues with their airways. If they are born really small, have poor nutrition or have poor neck control, we do the test."

When the children do get home, leaving them in car seats for a prolonged period is not a good idea, Greeley said. "The more they are left in, the more predisposed they are to have partial blockage of the airways," he noted. "Sleeping in a car seat is not necessarily a cause of death, but there is a higher likelihood that a baby somewhere will have difficulty with breathing."

"Car seats should only be used for transportation purposes," said Linda White, injury prevention coordinator at the Cincinnati Children's Hospital Medical Center. "Bringing one into the house and leaving a child in it, that is not what they are intended for."

Parents sometimes bring a car seat into the house and leave a baby in it "because they don't want to disturb them," White said. "But you don't want them [the babies] to be at that extended angle for a long period of time. We encourage families even when they are traveling to stop often and take the baby out of the car seat. The extended period of time is the key."

Marjorie Marciano, director of the safety education office at the New York City Department of Transportation, offers this advice: "We do know that using a car seat that is installed correctly can reduce the risk of injury significantly, for example by 70 percent for children under 1 year old," she said. "Installed correctly means that it should be at an angle of 45 degrees. When working with parents, we always say that it is important that the seat be at the right angle to keep the airway open."

More information

A parent's guide to car safety seats is provided by the American Academy of Pediatrics.

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Leading killer in Finland? Alcohol.

MATTI HUUHTANEN,

Associated Press Writer

Alcohol is now the leading killer of Finnish adults, with consumption reaching an all-time high last year in the Nordic nation, officials said Friday.

More than 2,000 people between the ages of 15 and 64 were killed by alcohol poisoning or illnesses caused by alcohol consumption last year, the government's leading welfare and health agency said. Nearly 1,000 people died in accidents or violent incidents caused by alcohol.

"This is truly a worrying trend," said Kristiina Kuussaari of the National Research and Development Center for Welfare and Health. "The serious negative effects will continue to grow for years to come."

Alcohol was responsible for 17 percent of all deaths among 15- to 64-year-old men, surpassing heart disease for the first time, the agency said. Alcohol also caused more than 10.5 percent of all deaths in adult women, alongside breast cancer, for the first time.

Since 2003, the cost of treating alcohol-related illnesses has grown by 14 percent, peaking at $1.1 billion last year in this nation of 5.2 million known for heavy drinking.

The government has traditionally kept a tight control on alcohol consumption with high prices in its Alko monopoly retail outlets, and supermarkets do not sell beer with higher alcohol content.

However, in March 2004 it slashed alcohol taxes by more than 40 percent to discourage growing "booze cruises" to Russia and neighboring Estonia, where alcohol is much cheaper.

The move caused an outcry from health officials who warned of negative health effects, and police who reported a rise in public drunkenness and anti-social behavior.

Officials reported a 10 percent growth in binge drinking among 17-year-olds in the first six months after the tax cut, and general consumption began to grow, reaching new records.

Last year, Finns drank the equivalent of 14.5 million gallons of pure grain alcohol — a 14 percent increase from 2003, just before the alcohol taxes were slashed.

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Smoking and the Knee


Smoking is the scourge that keeps on giving. To the long, long list of ways tobacco can do you harm, add yet one more: According to a study published in Annals of the Rheumatic Diseases, pain and cartilage damage may be worse in men suffering from osteoarthritis who also smoke than in those who don't smoke.

Investigators associated with the Mayo Clinic studied 159 male osteoarthritis patients, conducting magnetic resonance imaging scans of their knee cartilage and assessing their pain level, then following up on them 15 and 30 months later. In general, the smokers had a 2.3-fold greater chance of cartilage loss at the joint that connects the thigh and shin than the nonsmokers; and a 2.5-fold greater loss at the connection of knee cap and thigh. What's more, on a pain scale of 0 to 100, the smokers scored about 60 and the nonsmokers about 45, figures that remained essentially unchanged in the followups.

What it means: It's not certain how tobacco smoke can harm your knees, but the investigators have some theories. Substances in smoke carried through the bloodstream may stunt critical cell growth in knee cartilage, increase damage by oxidant radicals, and boost carbon dioxide levels, which essentially suffocates knee tissue. The increased pain may come from all of these kinds of damage as well as from the possibility that smoking simply lowers overall well-being and with it, pain tolerance. The solution is not one that should surprise you: Quit.

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Childbirth Linked to Mental Illness in New Moms


Danish researchers find that first-time mothers—but not first-time fathers—are at an increased risk for mental disorders, including schizophrenia, bipolar disorder and depression. The risk is greatest in the first three months following childbirth, according to a study published in this week’s issue of the Journal of the American Medical Association.

Postpartum depression affects between 10% and 15% of mothers and their families. Fortunately, severe psychoses are less common, affecting first-time moms in about one per 1,000 singleton births.

The JAMA study, which was based on data from 2,357,942 people in the Danish health and civil service registers, showed that the risk of postpartum mental illness remained statistically significant for up to three months after giving birth, regardless of the mother’s age.

More specifically, the study looked at 630,373 first-time mothers and 547,431 first-time fathers from 1973 to 2005. During that time, 1,171 women and 658 men developed mental disorders. The 10 to 19 days following childbirth were critical for new mothers and associated with the highest risk—7.3 times higher than women who had given birth previously.

Men and women (under about 25 years-old) who did not become parents during this time also had a lower incidence of hospital admission with a mental disorder.

What it Means: The study suggests that women may undergo physiological changes that increase their susceptibility to mental illness. The researchers call their results regarding risk of postpartum mental disorders an “underestimate” with the consideration that 40% to 50% of postnatal depression goes undetected. A related JAMA editorial stresses the importance of postpartum depression as a major public health problem.

At least one previous study has shown that some fathers, too, suffer from depression eight weeks after their child is born, but the current JAMA study argues against any association between fatherhood and the onset of mental disorders.

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The Hospital Wars

Surgery and imaging centers owned by doctors are swiping patients from traditional hospitals. Competition is good, right? Not always in health care, where an arms race keeps the costs rising.
Kevin Conlin has a problem. Physicians in Wichita have been catching a bug. An entrepreneurial bug. One that compels them to build highly specialized hospitals, diagnostic imaging facilities stocked with next-generation scanners, and same-day surgery centers that have hotel-like touches. Conlin, CEO of the $1.2 billion nonprofit Via Christi Health System in Kansas, complains that these outfits are competing unfairly against St. Francis and St. Joseph, his two general hospitals in Wichita. And he intends to do something about it. Via Christi provided Kansans with some $30 million in charity care and $33 million in unpaid Medicaid services this year. Conlin says Via Christi can no longer afford those costs if it keeps losing money to the new guys. "We're left with no option," says Conlin, "but to set a limit on how much of this kind of work we're going to do. Only then will we have a public conversation about the issues this phenomenon raises."

That phenomenon has sparked a war between hospitals and doctors across the country that is transforming the landscape of the U.S. health-care system--while not necessarily improving it. Hospital bosses say doctors, who wield huge influence over their patients, steer the most profitable procedures to facilities they own and shunt the least lucrative ones to the general hospital. This threatens the ability of the general hospital to provide money-losing services like emergency care, which it subsidizes in part with profits from procedures like cardiac surgery. The specialty competitors deny that they are the problem. Quite the opposite. "We raise the bar for the community," says Ed French, CEO of MedCath, which runs 12 specialty hospitals. "Everybody invests in more equipment and focuses more on nursing care because we set the competitive standard."

But researchers led by Paul Ginsburg at the Center for Studying Health System Change (HSC) in Washington find that this standard is fueling a de facto medical arms race, a competition that, perversely, increases health-care costs. Competition is not supposed to do that, but in the topsy-turvy U.S. health economy, excess supply often induces demand.

Hospital executives are responding to the assault of specialists by building and aggressively marketing profitable "service lines," like cancer, heart and brain centers. They're snapping up $1.4 million computed tomography (CT) scanners, which produce palpably detailed, 3-D pictures of bones and organs, and $2.2 million "high field" MRI machines that can watch the brain at work. The inflationary dynamic spawned by this expansion of health-care capacity exposes flaws in the payment system that sustains U.S. health care. Those flaws partly explain why Americans spend $2 trillion, or 16% of their GDP, for medical care, an outlay that's increasing roughly 7% annually.

There are only about 130 specialty hospitals in the U.S., compared with some 5,000 community hospitals, but dozens more are in the works since Congress this summer lifted a three-year moratorium on Medicare payments to new specialty hospitals. These typically focus on orthopedic and cardiac surgeries--which account for more than half the profits of many hospitals--and most lack costly emergency rooms. As these and other doctor-owned facilities spread and tensions soar, hospitals are finding it harder to get specialists on call in their ERs, reports HSC researcher Dr. Robert Berenson in a study published on the Web this week by Health Affairs.

Ambulatory Surgery Centers (ASCs), which compete with hospital outpatient departments for procedures that don't require overnight stays, like colonoscopies and some joint surgeries, are hollowing out hospitals as well. There are almost 5,000 ASCs today, nearly twice as many as a decade ago. Four in five are at least partly owned by physicians, many in partnership with hospitals seeking to minimize losses. The number of imaging centers has climbed to 6,037, up from 4,159 in 2001, according to the data firm Verispan. The scanning machines are costly to maintain, but once those costs are covered, the machines mint money. "There's an intense market-share competition taking place between hospital outpatient departments and imaging centers," says John Donahue, chairman of National Imaging Associates, which manages radiology for insurers in 36 states. "This battle is under way in Florida, Texas and virtually every state in which we operate."

Wichitans have had front- row seats to the war. In 1997, disgruntled cardiologists led by Dr. Gregory Duick approached Via Christi about establishing a heart hospital. "There was no grand conspiracy to make more dollars for doctors," says Duick. "It was fanned by frustration with the hospitals' inability to get things done and a lack of input from physicians on administration." When Via Christi declined, the doctors tapped local investors, and in 1999 opened the smartly designed, one-story Kansas Heart Hospital in a tony northeastern quadrant of town.

Kansas Heart triggered a cascade. This quiet, airy city of 540,000 already had--besides Via Christi's hospitals--the Wesley Medical Center, part of the for-profit HCA chain. Wichita now has five doctor-owned hospitals as well, along with a dozen ASCs and at least 10 free-standing diagnostic imaging centers, eight of which have physician investors. (Via Christi has a share in four of them, as it does in one ASC and a specialty hospital.) "The fear that emergency rooms and cardiovascular programs would close at community hospitals," says Duick, "has not been borne out over seven years in Wichita."

Money isn't the only motivator. Entrepreneurial physicians say they're tired of waiting for inefficiently scheduled hospital ORs to open up, that they're more productive and have better nursing support at their own facilities. Scott Barlow, CEO of the Central Utah Clinic in Provo, which runs an ASC, says that until the clinic bought its own imaging machines, patients had to wait up to 24 days to get a diagnostic scan at the nearby hospital. "This is about convenience, lower cost and higher quality," says Glen Tullman, CEO of Allscripts, an electronic-medical-records firm that works with ASCs and specialty hospitals. "Nobody in health care wants to be on the wrong side of that equation."

But is the competition fair? Within two years after Galichia Heart Hospital opened in Wichita in 2001, Wesley's net revenues from its cardiovascular program plummeted from a notch above $18 million to roughly $2 million. In 2003 the Kansas Spine Hospital opened, and in a year Wesley's neurosurgery revenues dropped $8.8 million, to roughly $1 million. Via Christi cardiovascular surgeries declined from 4,334 in 1998 to an estimated 2,950 this year. In that period, its executives say, the number of nonsurgically treated cardiac patients--who, say, have heart failure--remained relatively steady, around 4,300.

This matters, as Medicare reimburses most surgeries above the cost of care and nonsurgical treatments at lower rates, sometimes below cost. Hospitals make up the losses--and those from treating the uninsured--largely with profits from surgeries. They also hike the prices they charge insurers and employers, who give hospitals a 22% margin, according to researchers at the Lewin Group, a consultancy, helping cover overall losses of 5% or more from Medicare and Medicaid. That comes back to the rest of us as higher insurance premiums, making health care all the more costly to employers.

Physician-owned facilities do less charity care and treat fewer Medicaid patients than community hospitals do, government research shows. And they treat healthier (hence more profitable) patients, or--as in the case of heart hospitals--favor well-remunerated treatments. Not surprisingly, doctors who own a piece of the action are more likely to send patients to their own facilities.

The shift of patients can be devastating. Regionally owned Lincoln General Hospital in Ruston, La., lost about $2.5 million in business a year to imaging centers and an ASC, but was managing to stay afloat, according to CEO Tom Stone. Then, in 2003, the 40 physicians who ran the ASC opened the Green Clinic Surgical Hospital. Lincoln's inpatient and ambulatory surgeries halved, and by 2005 the hospital was $8 million in the red. "They've gone beyond cherry-picking," says Stone. "They've removed virtually everything they could take out of this facility." He is selling the hospital to a for-profit chain.

Green Clinic's CEO, Robert Goodwill, says Lincoln just screwed up. Its board declined an offer to invest in the specialty hospital, he says, and the hospital's losses stem from a "spending binge" Stone began in his attempt to compete. "Patients are choosing us because we're vastly superior," Goodwill says. But hospital bosses say this choice isn't a real one. "You're not going to disagree with the guy who's going to be cuttin' on you," says John Goodnow, CEO of Benefis Healthcare, a hospital system in Great Falls, Mont., that tried unsuccessfully to shut down a specialty hospital opened by half the city's doctors. "You can say patients have choice. Yes, theoretically. But c'mon, who's going to go against their own physician?"

Hospitals are fighting back in none-too-subtle ways. Some won't let an ASC physician-investor admit patients in their wards. And powerful health systems often use their leverage to lock physician-owned competitors out of preferred networks of insurers. Via Christi owns Kansas' largest managed-care plan; Wesley has an exclusive contract in Wichita with the state's leading insurer, Blue Cross and Blue Shield. "It's brutal competition," says David Laird, CEO of the Heart Hospital of Austin, which competes with the Texas nonprofit Seton Medical Center. "They act like they have a halo over their heads."

Such competition is fueling the arms race. Via Christi is counterattacking with a new neuromedicine service line. The weapons: a 64-slice CT scanner; and a brand-new $3.5 million CyberKnife, an X-ray gun that zaps tumors with pinpoint precision, housed in its own $1.5 million building. It has set up a stroke-treatment center and brain-aneurysm lab. "This is one of the areas that we've beefed up since all the specialty stuff happened," says Larry Schumacher, CEO of Via Christi's Wichita operations. "We're trying very hard to protect that." Wesley, for its part, has remodeled its operating rooms, opened a $54 million, four-story critical-care building and invested in its own gadgetry. "We compete on technology and have to stay state of the art," says Francie Ekengren, chief medical officer.

And if they build it, we'll fill it. The Medicare Payment Advisory Commission found that health-care markets with specialty hospitals have roughly 6% more cardiac surgeries and 9% more bypasses than markets without them. It's not that doctors deliberately push unnecessary surgery, but when a choice of treatments exists, capacity and monetary incentives have been known to influence the choices physicians make.

Nowhere is this more apparent than in diagnostic imaging. Last year Americans spent more than $100 billion on outpatient scans. Medicare's imaging costs have been growing 16% a year, much faster than the 9.6% rise for all physician services. The most lucrative--MRI and CT--climbed 25% last year. A third of the testing, says Donahue of National Imaging, is inappropriate; doctors order unnecessary scans, or two when one would suffice. "This is one of the most unsavory and concerning areas of how imaging is delivered," he says. "It's when imaging studies are not based upon clinical needs but on entrepreneurial requirements." Much of the growth is coming from cardiologists and orthopedists, who increasingly own such devices. It angers radiologists, who rely on referrals, and even imaging-center executives. "There should be some relief on the physician self-referral problem," says Bret Jorgensen, CEO of the chain InSight Health. "It's the single biggest reason imaging centers have been growing so rapidly." Physicians say much of the supposedly excessive testing is defensive. "If you fail to do a test and there's a bad outcome," says Dr. Kim Allan Williams, a nuclear cardiologist at the University of Chicago, "you will get sued in this country."

Congress and the Centers for Medicare and Medicaid Services (CMS) have taken steps to rein in imaging. Beginning next year, imaging centers will see payment cuts that the industry and its manufacturing allies--GE, Siemens, Phillips--say will reduce some payments to 20% of the cost of doing them. To level the specialty-hospital playing field, CMS will pay hospitals more for their more complex cases. Similarly it proposes to pay ASCs at 62% the rate of hospital outpatient departments. The industry is asking for 75%. Lobbyists are racing to the scene.

Though these changes are probably a step in the right direction, they do not directly address the problem of physician self-referral--or the distorted economics that underpin the rise of specialty facilities. Next year Medicare will pay physicians more for the time they spend on their patients' well-being, but, HSC researcher Dr. Hoangmai Pham notes, it still rewards them far more generously for procedures than for cognitive services like diagnosis and management of disease. So Wichita, which 15 years ago had seven psychiatric inpatient facilities, now has one, run by Via Christi. It has six that do heart surgeries.

Further, since physicians get paid through fee-for-service rather than, say, for curing their patients, their primary incentive is to do more stuff. CMS is starting to experiment with pay-for-performance programs that address this concern. But such measures can work only if they are remunerative enough to counter the base incentives that drive excess care. "A few pennies here and there is not going to change what physicians do every day," says Pham. "They're not stupid, and they have business managers."

And political clout. As do the manufacturers of medical technology. So creating a payment system that makes competition work as it ought to--reducing costs rather than inflating them--won't be easy. But the same can be said for living in a society that can't afford its sick and dying.


With reporting by Pat Dawson/Billings, Hilary Hylton/Austin

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Can a Fetus Feel Pain?



NANCY GIBBS

That’s the question at the heart of a new bill that uses pro-choice rhetoric to put another roadblock in the way of women seeking abortions.

In the rhetorical trenches of the culture wars, sometimes the best way to ambush your enemies is to echo them. Read some of the arguments in support of the Federal Unborn Child Pain Awareness Act, which the lame duck Congress debated on Wednesday, and you’ll be forgiven if you think they were drafted by a liberal crusader for women's rights. The law is presented as protecting a woman's right to know, and to make an informed consent. "Women should not be kept in the dark," argues Kansas Senator Sam Brownback, a sponsor of the bill whose stated purpose is "to ensure that women seeking an abortion are fully informed regarding the pain experienced by their unborn child."

Lawmakers and activists opposed to abortion naturally want to make sure that women know as much as possible about the procedure, the risks, and the alternatives. Each layer of restriction, from waiting periods to parental notification, reinforces the message that this is not a decision to be made lightly. The movement to make ultrasounds more available reflects the belief that women who see an image, watch a heart beat, are much less likely to go through with an abortion. More than 20 years ago, the video The Silent Scream helped to shift the public focus from the horror stories of women who had suffered back-alley abortions to the horror movie of a fetus undergoing one.

Now it all comes together: Brownback and Congressman Chris Smith argue for a woman's right to understand the experience of the fetus. Their bill would require abortion providers to tell patients that by 20 weeks after fertilization a fetus can feel pain, and to ask if she would like anesthesia for the baby. If she refuses, she would have to sign a waiver. Doctors who fail to follow the rules could face fines up to $250,000. "There is substantial evidence that by this point, unborn children draw away from surgical instruments in a manner which in an infant or an adult would be interpreted as a response to pain," the text of the bill states. "Congress finds that there is substantial evidence that the process of being killed in an abortion will cause the unborn child pain, even though you receive a pain-reducing drug or drugs."

It's hard to argue with a bill that aims to reduce suffering; but in this case it's also easy to sense an ulterior motive. The bill's supporters, which include most anti-abortion lawmakers and organizations, can argue that so long as abortion remains legal, the least we can do is make it merciful. But the bill's language makes it clear that in this case mercy is for monsters: it invites women to request pain relief for her baby, so that it will hurt less when, as the law states, "the unborn child's body parts are grasped at random with a long-toothed clamp. The fetal body parts are then torn off of the body and pulled out of the vaginal canal." The text notes that this concern for the unborn child's possible pain is in keeping with laws having to do with the humane slaughter of livestock and lab animals.

Most people have no problem with pain being part of the abortion discussion: a Zogby poll found that 77% of the public supported the idea of giving pregnant women information about fetal pain. Even NARAL Pro-Choice America, issued a statement saying it would not oppose the measure: "Pro-choice Americans have always believed that women deserve access to all the information relevant to their reproductive health decisions. For some women, that includes information related to fetal anesthesia options."

The question, however, is what information. Already the two sides of the abortion wars argue over state laws requiring doctors to warn of a heightened risk of breast cancer linked to abortion, despite something like a medical consensus that this link has not been proven. In this case there is dispute among researchers about when a fetus's nervous system and brain are mature enough to allow for pain, with some saying this occurs around 26 weeks, not the 20 weeks the bill stipulates. (An article in the Journal of the American Medical Association suggested pain was unlikely before 29 weeks; but the bill's defenders pointed out that some of the paper's authors were abortion rights activists with a clear conflict of interest.)

Another point of contention is that the law dates a pregnancy as beginning at the moment an egg is fertilized, as opposed to the standard definition, the point at which it implants in the womb. Were that to become a legally accepted definition, then those forms of contraception that may prevent a fertilized egg from implanting could be categorized as a form of abortion. That belief is what propels opposition to emergency contraception like Plan B.

Finally, the value of protecting a fetus from possible pain will in practice be balanced against the cost to the woman. A great many abortion providers would probably not be trained, equipped or insured to provide the kind of anesthesia the law gives women to right to demand. While it may reduce a fetus' pain, it also increases the woman's risk. Some women who might not be able to afford the added cost would be left only with the added guilt.

While the National Organization for Women denounced "this deceptive bill [that] will put women's health at risk and add one more barrier to abortion access," even some abortion foes questioned this particular strategy. Douglas R. Scott, president of Life Decisions International, worried that the offer of anesthesia might make women more likely to go through with an abortion. "The mother can believe she is making a benevolent choice, even as she simultaneously participates in a heinous act," he wrote on Christian Newswire. "I can hear it now. 'At least the fetus didn't feel pain...'"

There's nothing wrong with people opposed to abortion trying to discourage women from having them. But when the discouragement carries the force of law, it must be based on fact. Pain in adults is something of a mystery and a quandary; aware and articulate, we can describe what we feel — a sharp stab, a dull ache, a twinge, a pang, an agony — and yet still physicians argue over what to do and how to treat. Unlocking the secrets of the womb is surely harder, and the stakes for the mother high as well.

All those who have grown weary of these wars will be grateful that this may be the last for a while. With the G.O.P. still in control of Congress these last few weeks, they were eager to bring this to a vote; the activists believe in the value of the issue, the strategists in the value of forcing Democrats to vote against proposals that large majorities of Americans support. In the new Congress, the Democrats' agenda does not include placing new restrictions on abortion or making women think harder before having one. But that just means the argument will be moving to new battlegrounds.

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Danger in Toyland




San Francisco's ban on toxic toys - including such classics as the rubber ducky - highlights the lurking danger of plastic contaminants.

They line the nursery section of children's toy stores like brightly colored candies: rubber duckies for bathtime, chewable rings for teething, soft-covered books for pawing and mouthing. Parents shopping for their babies can be forgiven if they assume that everything on those shelves is 100% child safe. So why did the city of San Francisco issue a ban last week on the sale of certain plastic toys aimed at children under 3? And why are activists warning holiday shoppers in the most alarming terms against buying them?

"Sucking on some of these teethers and toys," says Rachel Gibson of Environment California, a nonprofit, "is like sucking on a toxic lollipop." At issue are contaminants in plastics used to make the toys. Environmentalists have long argued that some of these chemicals can leach out and harm children, pointing to animal studies that link the substances to birth defects, cancer and developmental abnormalities. Those warnings are hotly disputed by the chemical industry and toy manufacturers, which cite stacks of scientific studies that have found the plastics to be safe at federally approved levels. But the issue has gained traction on the strength of new evidence from independent and university-sponsored studies. The European Union has banned some chemicals in toys since 1999, and now half a dozen state legislatures are considering similar laws.

The controversy centers on a family of chemicals called phthalates (pronounced "thalates"), which are used to soften vinyl, and on bisphenol A (BPA), a substance used to make clear and shatterproof plastic. Most are known to be so-called endocrine disrupters, capable of interfering with the hormones that regulate masculinity and femininity. Several hundred animal studies have linked phthalates to prostate and breast cancers, abnormal genitals, early puberty onset and obesity. More recently, they've been shown to affect humans as well. In a paper published last year in the journal Environmental Health Perspectives, scientists from the Centers for Disease Control and Prevention and several universities found that boys born to mothers with higher phthalate levels are far more likely to show altered genital development, linked to incomplete testicular descent. Harvard School of Public Health studies report that men with higher phthalate levels have lower sperm counts and damaged sperm dna.

The American Chemistry Council (ACC), which represents manufacturers such as ExxonMobil and Dow Chemical, says the crackdowns on toys are not justified by the science. "The E.U. aims to ban products that show adverse effect at very high doses in rats," says the acc's Marian Stanley. "Many essential products are made from starting materials that can be quite toxic at high doses. This does not mean that the final consumer products are toxic." As for recent phthalate studies on humans, she says, they are either preliminary or "overhyped." Meanwhile, toy companies are relying on a 2001 review by a Consumer Product Safety Commission panel that found "no demonstrated health risk" in toys made with dinp—one of the phthalates used in vinyl. Critics fault the panel for failing to examine the effect of dinp when combined with other phthalates.

The focus on bpa is new. Its use is widespread—it's found in dental sealants and the epoxy linings on food cans as well as in baby bottles. Studies in animals over the past five years have found that the substance, which mimics the human hormone estrogen, alters brain structure and chemistry as well as the immune system and reproductive organs. Some of these effects show up at extremely low doses, in some cases 2,000 times below the Environmental Protection Agency (EPA) safety guideline, according to Frederick vom Saal, a University of Missouri endocrinologist. Chemical companies say the findings are not applicable to humans, but the federal National Toxicology Program has launched a reassessment of the safety standard. "The literature around bpa is very controversial," warns epa scientist Earl Gray. "Next year's review should clarify things."

The problem for retailers—and parents—is that the U.S. does not require manufacturers to disclose ingredients in most consumer products. How can you tell which contain the contaminants when chemical companies guard the information as proprietary? "Stores have products stacked to the ceiling for the holidays," says Daniel Grossman, ceo of San Francisco's Wild Planet Toys. "They have no idea what has phthalates and what doesn't."

They may soon find out. The San Francisco Chronicle recently had 16 toys tested in a private lab. One rubber ducky contained the phthalate dehp at 13 times San Francisco's allowed level. A teether contained another phthalate at five times the limit. Meanwhile, a rattle, two waterproof books and a doll contained bpa, which is prohibited by the city at any level. Although the products comply with U.S. law, some toymakers, including Goldberger Doll, are cutting out phthalates. Richard Woo, owner of a local store called Citikids, estimates that he might have to pull a third of his items off the shelves. Next month manufacturers will go to court to block the new law. Whatever the ruling, parents will be left wondering how safe their children's toys really are.

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