NYTimes
May 23, 2007
The Minimalist
For the Love of a Good Burger
By MARK BITTMAN
I’M sure you know how to make a burger. But do you make a burger you love, one that people notice, one that draws raves?
In a world where “burger” most often means a thin piece of meat whose flavor is overwhelmed by ketchup, mustard, pickle or onion, it doesn’t take much effort to make a better one. In fact, it’s almost as easy to cook a really great burger as it is to cook a mediocre one.
When I was young, my mother and her friends produced good burgers. They used different butchers (some were kosher), had different preferences (chuck, round or sirloin), and cooked either in a pan or the broiler (there was no grilling, except when we visited some relatives on Long Island).
A favorite recipe in the neighborhood called for garlic powder, an exotic ingredient in 1958; chopped onion; and — gasp! — Worcestershire sauce. This avant-garde recipe was treasured and shared sparingly.
What the burgers of my childhood all had in common was high-quality meat, and this is exactly what is missing from most of the backyard barbecues I visit. I see people buying everything from packaged ground meat to frozen patties. With these ingredients, the best they can hope for is to mimic fast food.
The key is to avoid packaged ground meat. When you buy it, you may know the cut of the meat — chuck, for example — and the fat content.
But you have no way of knowing whether the meat came from high- or low-quality animals. It could come from dozens of animals, and they could all be poor-quality animals — old dairy cows, for instance, rather than cattle raised for beef. The meat from these animals is ground together in huge quantities.
If the aesthetics of that don’t give you pause, consider the health concerns. Massive batches of ground meat carry the highest risk of salmonella and E. coli contamination, and have caused many authorities to recommend cooking burgers to the well-done stage. Forgive my snobbishness, but well-done meat is dry and flavorless, which is why burgers should be rare, or at most medium rare.
The only sensible solution: Grind your own. You will know the cut, you can see the fat and you have some notion of its quality.
“Grinding” may sound ominous, conjuring visions of a big old hand-cranked piece of steel clamped to the kitchen counter, but in fact it’s not that difficult. As the grinder was an innovation in its day, the food processor has taken over. It does nearly as good a job — not perfect, I’ll admit — in a couple of minutes or less.
Take a nice-looking chuck roast, or well-marbled sirloin steaks or some pork or lamb shoulder. Cut the meat into one- to two-inch cubes, and pulse it with the regular steel blade until it’s chopped.
If you have a 12-cup food processor, you can do a pound or a little more at a time; with a smaller machine, you’ll need to work in batches. You can do a few pounds at a time and freeze what you won’t use immediately, or you can grind the meat as you need it.
There are a few rules here. One, buy relatively fatty meat. If you start with meat that’s 95 percent lean — that’s hardly any fat at all — you are going to get the filet mignon of burgers: tender, but not especially tasty. If you use chuck or sirloin, with 15 to 20 percent fat — still quite lean by fast-food standards, by the way — you’re going to get meat that is really flavorful, along with the good mouth-feel that a bit of fat brings.
The same holds true with pork and lamb, though the selections are in fact easier, because the shoulder cuts of both animals contain enough internal fat that they’ll remain moist unless you overcook them horribly.
Next, don’t overprocess. You want the equivalent of chopped meat, not a meat purée. The finer you grind the meat, the more likely you are to pack it together too tightly, which will make the burger tough.
The patties should weigh about 6 ounces each: not small, but not huge, either. Handle the meat gently. Make the patties with a light hand, and don’t press on them with a spatula, like a hurried short-order cook.
Finally, season with salt and pepper aggressively. I’d start with a large pinch of salt and a bit of pepper and work up from there. If you grind your own beef, you can make a mixture and taste it raw.
(To reassure the queasy, there’s little difference, safety-wise, between raw beef and rare beef: salmonella is killed at 160 degrees, and rare beef is cooked to 125 degrees.)
If you are cautious, you can cook a little meat and then taste it. Though there are virtually no reported cases of trichinosis from commercial pork in the United States, few people will sample raw pork — or lamb, with which the danger is even less. So the thing to do is season the meat, then cook up a spoonful in a skillet, taste and season as necessary.
A final word about seasoning: Remember that the burger is the cousin not only of the steak — which often takes no seasoning beyond salt and pepper — but also of the meatloaf and the meatball, both of which are highly seasoned. Think about adding minced garlic in small quantities (we’ve moved beyond garlic powder, no?), chopped onion, herbs (especially parsley), grated Parmesan, minced ginger, the old reliable Worcestershire, hot sauce, good chili powder and so on. It’s hard to go wrong here.
Then there’s the grilling: Burgers cook so fast that the heat source doesn’t matter much. You want a hot fire, but not a blazing hot one; that fat, as we all know, is quick to ignite. The rack, which should be very clean, should be three or four inches above it.
Turn the burger only after the first side releases its grip on the grill, after a few minutes; if you don’t press with the spatula, you’ll get less sticking, too. Cooking time depends on the size of the burger, of course, but mine take about 6 to 8 minutes total, for rare to medium-rare. Pork takes a little longer, but not much.
The grilling is the easy part. The more important steps are shopping and grinding. The difference they make, you will find, is astonishing, and will change your burger-cooking forever.
Wednesday, May 23, 2007
Tuesday, May 22, 2007
Personality and narration about self
NYTimes
May 22, 2007
This Is Your Life (and How You Tell It)
By BENEDICT CAREY
For more than a century, researchers have been trying to work out the raw ingredients that account for personality, the sweetness and neuroses that make Anna Anna, the sluggishness and sensitivity that make Andrew Andrew. They have largely ignored the first-person explanation — the life story that people themselves tell about who they are, and why.
Stories are stories, after all. The attractive stranger at the airport bar hears one version, the parole officer another, and the P.T.A. board gets something entirely different. Moreover, the tone, the lessons, even the facts in a life story can all shift in the changing light of a person’s mood, its major notes turning minor, its depths appearing shallow.
Yet in the past decade or so a handful of psychologists have argued that the quicksilver elements of personal narrative belong in any three-dimensional picture of personality. And a burst of new findings are now helping them make the case. Generous, civic-minded adults from diverse backgrounds tell life stories with very similar and telling features, studies find; so likewise do people who have overcome mental distress through psychotherapy.
Every American may be working on a screenplay, but we are also continually updating a treatment of our own life — and the way in which we visualize each scene not only shapes how we think about ourselves, but how we behave, new studies find. By better understanding how life stories are built, this work suggests, people may be able to alter their own narrative, in small ways and perhaps large ones.
“When we first started studying life stories, people thought it was just idle curiosity — stories, isn’t that cool?” said Dan P. McAdams, a professor of psychology at Northwestern and author of the 2006 book, “The Redemptive Self.” “Well, we find that these narratives guide behavior in every moment, and frame not only how we see the past but how we see ourselves in the future.”
Researchers have found that the human brain has a natural affinity for narrative construction. People tend to remember facts more accurately if they encounter them in a story rather than in a list, studies find; and they rate legal arguments as more convincing when built into narrative tales rather than on legal precedent.
YouTube routines notwithstanding, most people do not begin to see themselves in the midst of a tale with a beginning, middle and eventual end until they are teenagers. “Younger kids see themselves in terms of broad, stable traits: ‘I like baseball but not soccer,’ ” said Kate McLean, a psychologist at the University of Toronto in Mississauga. “This meaning-making capability — to talk about growth, to explain what something says about who I am — develops across adolescence.”
Psychologists know what life stories look like when they are fully hatched, at least for some Americans. Over the years, Dr. McAdams and others have interviewed hundreds of men and women, most in their 30s and older.
During a standard life-story interview, people describe phases of their lives as if they were outlining chapters, from the sandlot years through adolescence and middle age. They also describe several crucial scenes in detail, including high points (the graduation speech, complete with verbal drum roll); low points (the college nervous breakdown, complete with the list of witnesses); and turning points. The entire two-hour session is recorded and transcribed.
In analyzing the texts, the researchers found strong correlations between the content of people’s current lives and the stories they tell. Those with mood problems have many good memories, but these scenes are usually tainted by some dark detail. The pride of college graduation is spoiled when a friend makes a cutting remark. The wedding party was wonderful until the best man collapsed from drink. A note of disappointment seems to close each narrative phrase.
By contrast, so-called generative adults — those who score highly on tests measuring civic-mindedness, and who are likely to be energetic and involved — tend to see many of the events in their life in the reverse order, as linked by themes of redemption. They flunked sixth grade but met a wonderful counselor and made honor roll in seventh. They were laid low by divorce, only to meet a wonderful new partner. Often, too, they say they felt singled out from very early in life — protected, even as others nearby suffered.
In broad outline, the researchers report, such tales express distinctly American cultural narratives, of emancipation or atonement, of Horatio Alger advancement, of epiphany and second chances. Depending on the person, the story itself might be nuanced or simplistic, powerfully dramatic or cloyingly pious. But the point is that the narrative themes are, as much as any other trait, driving factors in people’s behavior, the researchers say.
“We find that when it comes to the big choices people make — should I marry this person? should I take this job? should I move across the country? — they draw on these stories implicitly, whether they know they are working from them or not,” Dr. McAdams said.
Any life story is by definition a retrospective reconstruction, at least in part an outgrowth of native temperament. Yet the research so far suggests that people’s life stories are neither rigid nor wildly variable, but rather change gradually over time, in close tandem with meaningful life events.
Jonathan Adler, a researcher at Northwestern, has found that people’s accounts of their experiences in psychotherapy provide clues about the nature of their recovery. In a recent study presented at the annual meeting of the Society for Personality and Social Psychology in January, Mr. Adler reported on 180 adults from the Chicago area who had recently completed a course of talk therapy. They sought treatment for things like depression, anxiety, marital problems and fear of flying, and spent months to years in therapy.
At some level, talk therapy has always been an exercise in replaying and reinterpreting each person’s unique life story. Yet Mr. Adler found that in fact those former patients who scored highest on measures of well-being — who had recovered, by standard measures — told very similar tales about their experiences.
They described their problem, whether depression or an eating disorder, as coming on suddenly, as if out of nowhere. They characterized their difficulty as if it were an outside enemy, often giving it a name (the black dog, the walk of shame). And eventually they conquered it.
“The story is one of victorious battle: ‘I ended therapy because I could overcome this on my own,’ ” Mr. Adler said. Those in the study who scored lower on measures of psychological well-being were more likely to see their moods and behavior problems as a part of their own character, rather than as a villain to be defeated. To them, therapy was part of a continuing adaptation, not a decisive battle.
The findings suggest that psychotherapy, when it is effective, gives people who are feeling helpless a sense of their own power, in effect altering their life story even as they work to disarm their own demons, Mr. Adler said.
Mental resilience relies in part on exactly this kind of autobiographical storytelling, moment to moment, when navigating life’s stings and sorrows. To better understand how stories are built in real time, researchers have recently studied how people recall vivid scenes from recent memory. They find that one important factor is the perspective people take when they revisit the scene — whether in the first person, or in the third person, as if they were watching themselves in a movie.
In a 2005 study reported in the journal Psychological Science, researchers at Columbia University measured how student participants reacted to a bad memory, whether an argument or failed exam, when it was recalled in the third person. They tested levels of conscious and unconscious hostility after the recollections, using both standard questionnaires and students’ essays. The investigators found that the third-person scenes were significantly less upsetting, compared with bad memories recalled in the first person.
“What our experiment showed is that this shift in perspective, having this distance from yourself, allows you to relive the experience and focus on why you’re feeling upset,” instead of being immersed in it, said Ethan Kross, the study’s lead author. The emotional content of the memory is still felt, he said, but its sting is blunted as the brain frames its meaning, as it builds the story.
Taken together, these findings suggest a kind of give and take between life stories and individual memories, between the larger screenplay and the individual scenes. The way people replay and recast memories, day by day, deepens and reshapes their larger life story. And as it evolves, that larger story in turn colors the interpretation of the scenes.
Nic Weststrate, 23, a student living in Toronto, said he was able to reinterpret many of his most painful memories with more compassion after having come out as a gay man. He was very hard on himself, for instance, when at age 20 he misjudged a relationship with a friend who turned out to be straight.
He now sees the end of that relationship as both a painful lesson and part of a larger narrative. “I really had no meaningful story for my life then,” he said, “and I think if I had been open about being gay I might not have put myself in that position, and he probably wouldn’t have either.”
After coming out, he said: “I saw that there were other possibilities. I would be presenting myself openly to a gay audience, and just having a coherent story about who I am made a big difference. It affects how you see the past, but it also really affects your future.”
Psychologists have shown just how interpretations of memories can alter future behavior. In an experiment published in 2005, researchers had college students who described themselves as socially awkward in high school recall one of their most embarrassing moments. Half of the students reimagined the humiliation in the first person, and the other half pictured it in the third person.
Two clear differences emerged. Those who replayed the scene in the third person rated themselves as having changed significantly since high school — much more so than the first-person group did. The third-person perspective allowed people to reflect on the meaning of their social miscues, the authors suggest, and thus to perceive more psychological growth.
And their behavior changed, too. After completing the psychological questionnaires, each study participant spent time in a waiting room with another student, someone the research subject thought was taking part in the study. In fact the person was working for the research team, and secretly recorded the conversation between the pair, if any. This double agent had no idea which study participants had just relived a high school horror, and which had viewed theirs as a movie scene.
The recordings showed that members of the third-person group were much more sociable than the others. “They were more likely to initiate a conversation, after having perceived themselves as more changed,” said Lisa Libby, the lead author and a psychologist at Ohio State University. She added, “We think that feeling you have changed frees you up to behave as if you have; you think, ‘Wow, I’ve really made some progress’ and it gives you some real momentum.”
Dr. Libby and others have found that projecting future actions in the third person may also affect what people later do, as well. In another study, students who pictured themselves voting for president in the 2004 election, from a third-person perspective, were more likely to actually go to the polls than those imagining themselves casting votes in the first person.
The implications of these results for self-improvement, whether sticking to a diet or finishing a degree or a novel, are still unknown. Likewise, experts say, it is unclear whether such scene-making is more functional for some people, and some memories, than for others. And no one yet knows how fundamental personality factors, like neuroticism or extraversion, shape the content of life stories or their component scenes.
But the new research is giving narrative psychologists something they did not have before: a coherent story to tell. Seeing oneself as acting in a movie or a play is not merely fantasy or indulgence; it is fundamental to how people work out who it is they are, and may become.
“The idea that whoever appeared onstage would play not me but a character was central to imagining how to make the narrative: I would need to see myself from outside,” the writer Joan Didion has said of “The Year of Magical Thinking,” her autobiographical play about mourning the death of her husband and her daughter. “I would need to locate the dissonance between the person I thought I was and the person other people saw.”
May 22, 2007
This Is Your Life (and How You Tell It)
By BENEDICT CAREY
For more than a century, researchers have been trying to work out the raw ingredients that account for personality, the sweetness and neuroses that make Anna Anna, the sluggishness and sensitivity that make Andrew Andrew. They have largely ignored the first-person explanation — the life story that people themselves tell about who they are, and why.
Stories are stories, after all. The attractive stranger at the airport bar hears one version, the parole officer another, and the P.T.A. board gets something entirely different. Moreover, the tone, the lessons, even the facts in a life story can all shift in the changing light of a person’s mood, its major notes turning minor, its depths appearing shallow.
Yet in the past decade or so a handful of psychologists have argued that the quicksilver elements of personal narrative belong in any three-dimensional picture of personality. And a burst of new findings are now helping them make the case. Generous, civic-minded adults from diverse backgrounds tell life stories with very similar and telling features, studies find; so likewise do people who have overcome mental distress through psychotherapy.
Every American may be working on a screenplay, but we are also continually updating a treatment of our own life — and the way in which we visualize each scene not only shapes how we think about ourselves, but how we behave, new studies find. By better understanding how life stories are built, this work suggests, people may be able to alter their own narrative, in small ways and perhaps large ones.
“When we first started studying life stories, people thought it was just idle curiosity — stories, isn’t that cool?” said Dan P. McAdams, a professor of psychology at Northwestern and author of the 2006 book, “The Redemptive Self.” “Well, we find that these narratives guide behavior in every moment, and frame not only how we see the past but how we see ourselves in the future.”
Researchers have found that the human brain has a natural affinity for narrative construction. People tend to remember facts more accurately if they encounter them in a story rather than in a list, studies find; and they rate legal arguments as more convincing when built into narrative tales rather than on legal precedent.
YouTube routines notwithstanding, most people do not begin to see themselves in the midst of a tale with a beginning, middle and eventual end until they are teenagers. “Younger kids see themselves in terms of broad, stable traits: ‘I like baseball but not soccer,’ ” said Kate McLean, a psychologist at the University of Toronto in Mississauga. “This meaning-making capability — to talk about growth, to explain what something says about who I am — develops across adolescence.”
Psychologists know what life stories look like when they are fully hatched, at least for some Americans. Over the years, Dr. McAdams and others have interviewed hundreds of men and women, most in their 30s and older.
During a standard life-story interview, people describe phases of their lives as if they were outlining chapters, from the sandlot years through adolescence and middle age. They also describe several crucial scenes in detail, including high points (the graduation speech, complete with verbal drum roll); low points (the college nervous breakdown, complete with the list of witnesses); and turning points. The entire two-hour session is recorded and transcribed.
In analyzing the texts, the researchers found strong correlations between the content of people’s current lives and the stories they tell. Those with mood problems have many good memories, but these scenes are usually tainted by some dark detail. The pride of college graduation is spoiled when a friend makes a cutting remark. The wedding party was wonderful until the best man collapsed from drink. A note of disappointment seems to close each narrative phrase.
By contrast, so-called generative adults — those who score highly on tests measuring civic-mindedness, and who are likely to be energetic and involved — tend to see many of the events in their life in the reverse order, as linked by themes of redemption. They flunked sixth grade but met a wonderful counselor and made honor roll in seventh. They were laid low by divorce, only to meet a wonderful new partner. Often, too, they say they felt singled out from very early in life — protected, even as others nearby suffered.
In broad outline, the researchers report, such tales express distinctly American cultural narratives, of emancipation or atonement, of Horatio Alger advancement, of epiphany and second chances. Depending on the person, the story itself might be nuanced or simplistic, powerfully dramatic or cloyingly pious. But the point is that the narrative themes are, as much as any other trait, driving factors in people’s behavior, the researchers say.
“We find that when it comes to the big choices people make — should I marry this person? should I take this job? should I move across the country? — they draw on these stories implicitly, whether they know they are working from them or not,” Dr. McAdams said.
Any life story is by definition a retrospective reconstruction, at least in part an outgrowth of native temperament. Yet the research so far suggests that people’s life stories are neither rigid nor wildly variable, but rather change gradually over time, in close tandem with meaningful life events.
Jonathan Adler, a researcher at Northwestern, has found that people’s accounts of their experiences in psychotherapy provide clues about the nature of their recovery. In a recent study presented at the annual meeting of the Society for Personality and Social Psychology in January, Mr. Adler reported on 180 adults from the Chicago area who had recently completed a course of talk therapy. They sought treatment for things like depression, anxiety, marital problems and fear of flying, and spent months to years in therapy.
At some level, talk therapy has always been an exercise in replaying and reinterpreting each person’s unique life story. Yet Mr. Adler found that in fact those former patients who scored highest on measures of well-being — who had recovered, by standard measures — told very similar tales about their experiences.
They described their problem, whether depression or an eating disorder, as coming on suddenly, as if out of nowhere. They characterized their difficulty as if it were an outside enemy, often giving it a name (the black dog, the walk of shame). And eventually they conquered it.
“The story is one of victorious battle: ‘I ended therapy because I could overcome this on my own,’ ” Mr. Adler said. Those in the study who scored lower on measures of psychological well-being were more likely to see their moods and behavior problems as a part of their own character, rather than as a villain to be defeated. To them, therapy was part of a continuing adaptation, not a decisive battle.
The findings suggest that psychotherapy, when it is effective, gives people who are feeling helpless a sense of their own power, in effect altering their life story even as they work to disarm their own demons, Mr. Adler said.
Mental resilience relies in part on exactly this kind of autobiographical storytelling, moment to moment, when navigating life’s stings and sorrows. To better understand how stories are built in real time, researchers have recently studied how people recall vivid scenes from recent memory. They find that one important factor is the perspective people take when they revisit the scene — whether in the first person, or in the third person, as if they were watching themselves in a movie.
In a 2005 study reported in the journal Psychological Science, researchers at Columbia University measured how student participants reacted to a bad memory, whether an argument or failed exam, when it was recalled in the third person. They tested levels of conscious and unconscious hostility after the recollections, using both standard questionnaires and students’ essays. The investigators found that the third-person scenes were significantly less upsetting, compared with bad memories recalled in the first person.
“What our experiment showed is that this shift in perspective, having this distance from yourself, allows you to relive the experience and focus on why you’re feeling upset,” instead of being immersed in it, said Ethan Kross, the study’s lead author. The emotional content of the memory is still felt, he said, but its sting is blunted as the brain frames its meaning, as it builds the story.
Taken together, these findings suggest a kind of give and take between life stories and individual memories, between the larger screenplay and the individual scenes. The way people replay and recast memories, day by day, deepens and reshapes their larger life story. And as it evolves, that larger story in turn colors the interpretation of the scenes.
Nic Weststrate, 23, a student living in Toronto, said he was able to reinterpret many of his most painful memories with more compassion after having come out as a gay man. He was very hard on himself, for instance, when at age 20 he misjudged a relationship with a friend who turned out to be straight.
He now sees the end of that relationship as both a painful lesson and part of a larger narrative. “I really had no meaningful story for my life then,” he said, “and I think if I had been open about being gay I might not have put myself in that position, and he probably wouldn’t have either.”
After coming out, he said: “I saw that there were other possibilities. I would be presenting myself openly to a gay audience, and just having a coherent story about who I am made a big difference. It affects how you see the past, but it also really affects your future.”
Psychologists have shown just how interpretations of memories can alter future behavior. In an experiment published in 2005, researchers had college students who described themselves as socially awkward in high school recall one of their most embarrassing moments. Half of the students reimagined the humiliation in the first person, and the other half pictured it in the third person.
Two clear differences emerged. Those who replayed the scene in the third person rated themselves as having changed significantly since high school — much more so than the first-person group did. The third-person perspective allowed people to reflect on the meaning of their social miscues, the authors suggest, and thus to perceive more psychological growth.
And their behavior changed, too. After completing the psychological questionnaires, each study participant spent time in a waiting room with another student, someone the research subject thought was taking part in the study. In fact the person was working for the research team, and secretly recorded the conversation between the pair, if any. This double agent had no idea which study participants had just relived a high school horror, and which had viewed theirs as a movie scene.
The recordings showed that members of the third-person group were much more sociable than the others. “They were more likely to initiate a conversation, after having perceived themselves as more changed,” said Lisa Libby, the lead author and a psychologist at Ohio State University. She added, “We think that feeling you have changed frees you up to behave as if you have; you think, ‘Wow, I’ve really made some progress’ and it gives you some real momentum.”
Dr. Libby and others have found that projecting future actions in the third person may also affect what people later do, as well. In another study, students who pictured themselves voting for president in the 2004 election, from a third-person perspective, were more likely to actually go to the polls than those imagining themselves casting votes in the first person.
The implications of these results for self-improvement, whether sticking to a diet or finishing a degree or a novel, are still unknown. Likewise, experts say, it is unclear whether such scene-making is more functional for some people, and some memories, than for others. And no one yet knows how fundamental personality factors, like neuroticism or extraversion, shape the content of life stories or their component scenes.
But the new research is giving narrative psychologists something they did not have before: a coherent story to tell. Seeing oneself as acting in a movie or a play is not merely fantasy or indulgence; it is fundamental to how people work out who it is they are, and may become.
“The idea that whoever appeared onstage would play not me but a character was central to imagining how to make the narrative: I would need to see myself from outside,” the writer Joan Didion has said of “The Year of Magical Thinking,” her autobiographical play about mourning the death of her husband and her daughter. “I would need to locate the dissonance between the person I thought I was and the person other people saw.”
Complete cancer care
NYTimes
May 22, 2007
Cancer Care Seeks to Take Patients Beyond Survival
By LESLIE BERGER
As a growing number of Americans are learning, surviving cancer can mean slipping into a rabbit hole of long-term medical problems — from premature menopause and sexual dysfunction to more debilitating side effects of chemotherapy and radiation, like heart disease and even new cancers.
The realization that cancer and its aftermath can go on for years has given rise to a medical specialty known as survivorship. At several major hospitals around the country, survivor programs financed by the Lance Armstrong Foundation are focusing on life after cancer.
“It’s no longer sufficient to say, ‘Well, you survived,’ ” said Mary S. McCabe, who directs the program at Memorial Sloan-Kettering Cancer Center in New York. “We need to maximize their recovery and quality of life.”
Cancer treatment and research are expanding to incorporate long-term postcancer care. With the number of survivors up to 10 million in the United States, from 3 million in the 1970s, cancer is increasingly being treated as a chronic disease, like diabetes or multiple sclerosis. As the presidential candidate John Edwards said in March after his wife, Elizabeth, learned that her breast cancer had returned and spread, the disease was “no longer curable” but “completely treatable.”
At U.C.L.A. Medical Center in Los Angeles, Dr. Patricia A. Ganz is helping patients like Tanya Saunders close gaps in their medical care. Staying healthy has become a full-time job for Ms. Saunders, who has endured one complication after another in the 15 years since she received her diagnosis of Hodgkin’s disease as a college student.
Radiation and chemotherapy thrust her into menopause. After a recurrence and a second round of treatments, she developed congestive heart failure. Last year, the bone tissue in one of her hips collapsed, forcing her to undergo a hip transplant.
Now 36, Ms. Saunders takes 11 medicines a day. She exercises three days a week with other cardiac patients, sees a much-loved psychotherapist (who is treating her free of charge) once a week and takes pottery and sailing classes. She lives on disability payments and qualifies for Medicare.
“It’s a kind of a renewal of spirit I would say I’m looking for while I try to get my strength back,” Ms. Saunders said.
Another patient of Dr. Ganz’s, Karen Huner, credits her with diagnosing and treating the hypothyroidism that was causing exhaustion and headaches months after she was cured of breast cancer. Other doctors had told her that the symptoms were effects of chemotherapy and that she should “just get used to it,” said Ms. Huner, a 44-year-old yoga and pilates instructor. In fact, she added, it was the radiation she received that probably disrupted her thyroid function.
She recently developed lymphodema, the painful swelling and water retention that can happen in the arm where lymph nodes were removed.
“My lymphodema doctor said to me, ‘Be happy you’re alive,’ ” Ms. Huner said. “I almost strangled her.”
The potential side effects of radiation and chemotherapy have been known for years, especially among survivors of childhood cancers. But the big push for awareness and support followed a strongly worded report in 2005 from the Institute of Medicine, part of the National Academy of Sciences.
“The transition from active treatment to post-treatment care is critical to long-term health,” it concluded. “If care is not planned and coordinated, cancer survivors are left without knowledge of their heightened risks and a follow-up plan of action.” Insurers, it added, “should recognize survivorship care as an essential part of cancer care.”
Another problem is that survivors may shy away from doctors, and not just because of the cost. Dr. Anna T. Meadows, a pediatric oncologist who directs the survivors’ program at the Children’s Hospital of Philadelphia, said people who got their diagnoses as children or teenagers were often wary of care that would force them to revisit a painful part of their past. These survivors do not necessarily need a cancer specialist for routine checkups and screening, she said, but rather someone who understands their previous treatment and its risks.
“A lot of cancer survivors have nothing wrong with them,” Dr. Meadows said. “But what is important is for anybody who’s had cancer is to know what treatment they received and what it’s likely to lead to in the future.” The program is adding two primary care doctors to encourage follow-up visits.
In the largest study so far of survivors of childhood or adolescent cancer, published last October in The New England Journal of Medicine, researchers documented a high rate of illness because of chronic conditions caused by life-saving treatments. The study tracked the health of nearly 10,400 adults now in their 20s, 30s and 40s who were treated for cancer between 1970 and 1986.
More than 62 percent of those survivors had at least one chronic condition; nearly 28 percent had a severe or life-threatening one. The survivors were more than three times as likely as their siblings to have a chronic health condition, and women were at greater risk than men. Survivors of bone tumors, central nervous system tumors and Hodgkin’s disease had the highest risk of a serious chronic condition.
The good news is that almost 80 percent of children and teenagers who get diagnoses of cancer today become long-term survivors. Moreover, treatments have changed to minimize the risks; the lowest effective doses of drugs and radiation are used.
“The silver lining of this is that we know what to expect a reasonable amount of the time,” said Dr. Kevin C. Oeffinger of Sloan-Kettering, a lead author of the report. While young cancer patients are more vulnerable to damage because their organs are still growing, Dr. Oeffinger said, the study has obvious implications for adults.
Age and type of treatment play a huge role in the experience of cancer survivors, several experts said. Many experience no side effects at all. Others, especially women of child-bearing age, face infertility and early menopause.
“Our research shows that younger patients have a harder time, both physically and emotionally,” said Dr. Ganz, of U.C.L.A. “It’s not something they’ve expected.”
At Sloan-Kettering, five social workers are assigned to concentrate exclusively on follow-up care for survivors. Part of the plan, at Sloan and other cancer centers, is to develop an online database of patient-care summaries — of the cancer treatment received, the potential risks and recommended follow-up care — that could be used by any physician.
The hospital also plans to open an off-campus outpatient center devoted to cancer survivors’ physical rehabilitation, in part with a donation from the media entrepreneur Robert F. X. Sillerman, who was treated at Sloan-Kettering six years ago for tongue cancer. He received chemotherapy and radiation and later began to suffer pain and muscle spasms in his shoulders and back, as well as increasing weakness in his left arm.
Today, Mr. Sillerman said, he has reversed the damage with a little bit of medication and a lot of physical therapy. He exercises six days a week with weights, bands and manual resistance, partly with a personal physical therapist whom he puts up in a Manhattan townhouse adjoining his family’s. He said he appreciated the fact that few have the same luxury.
“I was two years out from my cure before I was able to find the right protocol and treatment,” said Mr. Sillerman, 59. “Our hope is to eliminate that and provide access to rehabilitation right away, initially in the New York metropolitan area and eventually to make that a template nationally.”
For premature menopause in patients who can safely use estrogen, Dr. Mercedes Castiel likes to give teenagers and young women birth control pills to control hot flashes and bone loss. “It’s nicer to say I’m on the pill like my peers instead of hormones like my grandmother,” said Dr. Castiel, director of the Barbara White Fishman Women’s Health Center at Sloan.
Even sexual dysfunction, which for years was viewed as a small price to pay for survival, is now treated like any other side effect. Vaginal dryness and missed or blunted orgasms are among the most common complaints.
“We look at it in terms of enhancing intimacy,” said Dr. Michael L. Krychman, Sloan’s expert on the subject. “They want things to get back to normal.”
May 22, 2007
Cancer Care Seeks to Take Patients Beyond Survival
By LESLIE BERGER
As a growing number of Americans are learning, surviving cancer can mean slipping into a rabbit hole of long-term medical problems — from premature menopause and sexual dysfunction to more debilitating side effects of chemotherapy and radiation, like heart disease and even new cancers.
The realization that cancer and its aftermath can go on for years has given rise to a medical specialty known as survivorship. At several major hospitals around the country, survivor programs financed by the Lance Armstrong Foundation are focusing on life after cancer.
“It’s no longer sufficient to say, ‘Well, you survived,’ ” said Mary S. McCabe, who directs the program at Memorial Sloan-Kettering Cancer Center in New York. “We need to maximize their recovery and quality of life.”
Cancer treatment and research are expanding to incorporate long-term postcancer care. With the number of survivors up to 10 million in the United States, from 3 million in the 1970s, cancer is increasingly being treated as a chronic disease, like diabetes or multiple sclerosis. As the presidential candidate John Edwards said in March after his wife, Elizabeth, learned that her breast cancer had returned and spread, the disease was “no longer curable” but “completely treatable.”
At U.C.L.A. Medical Center in Los Angeles, Dr. Patricia A. Ganz is helping patients like Tanya Saunders close gaps in their medical care. Staying healthy has become a full-time job for Ms. Saunders, who has endured one complication after another in the 15 years since she received her diagnosis of Hodgkin’s disease as a college student.
Radiation and chemotherapy thrust her into menopause. After a recurrence and a second round of treatments, she developed congestive heart failure. Last year, the bone tissue in one of her hips collapsed, forcing her to undergo a hip transplant.
Now 36, Ms. Saunders takes 11 medicines a day. She exercises three days a week with other cardiac patients, sees a much-loved psychotherapist (who is treating her free of charge) once a week and takes pottery and sailing classes. She lives on disability payments and qualifies for Medicare.
“It’s a kind of a renewal of spirit I would say I’m looking for while I try to get my strength back,” Ms. Saunders said.
Another patient of Dr. Ganz’s, Karen Huner, credits her with diagnosing and treating the hypothyroidism that was causing exhaustion and headaches months after she was cured of breast cancer. Other doctors had told her that the symptoms were effects of chemotherapy and that she should “just get used to it,” said Ms. Huner, a 44-year-old yoga and pilates instructor. In fact, she added, it was the radiation she received that probably disrupted her thyroid function.
She recently developed lymphodema, the painful swelling and water retention that can happen in the arm where lymph nodes were removed.
“My lymphodema doctor said to me, ‘Be happy you’re alive,’ ” Ms. Huner said. “I almost strangled her.”
The potential side effects of radiation and chemotherapy have been known for years, especially among survivors of childhood cancers. But the big push for awareness and support followed a strongly worded report in 2005 from the Institute of Medicine, part of the National Academy of Sciences.
“The transition from active treatment to post-treatment care is critical to long-term health,” it concluded. “If care is not planned and coordinated, cancer survivors are left without knowledge of their heightened risks and a follow-up plan of action.” Insurers, it added, “should recognize survivorship care as an essential part of cancer care.”
Another problem is that survivors may shy away from doctors, and not just because of the cost. Dr. Anna T. Meadows, a pediatric oncologist who directs the survivors’ program at the Children’s Hospital of Philadelphia, said people who got their diagnoses as children or teenagers were often wary of care that would force them to revisit a painful part of their past. These survivors do not necessarily need a cancer specialist for routine checkups and screening, she said, but rather someone who understands their previous treatment and its risks.
“A lot of cancer survivors have nothing wrong with them,” Dr. Meadows said. “But what is important is for anybody who’s had cancer is to know what treatment they received and what it’s likely to lead to in the future.” The program is adding two primary care doctors to encourage follow-up visits.
In the largest study so far of survivors of childhood or adolescent cancer, published last October in The New England Journal of Medicine, researchers documented a high rate of illness because of chronic conditions caused by life-saving treatments. The study tracked the health of nearly 10,400 adults now in their 20s, 30s and 40s who were treated for cancer between 1970 and 1986.
More than 62 percent of those survivors had at least one chronic condition; nearly 28 percent had a severe or life-threatening one. The survivors were more than three times as likely as their siblings to have a chronic health condition, and women were at greater risk than men. Survivors of bone tumors, central nervous system tumors and Hodgkin’s disease had the highest risk of a serious chronic condition.
The good news is that almost 80 percent of children and teenagers who get diagnoses of cancer today become long-term survivors. Moreover, treatments have changed to minimize the risks; the lowest effective doses of drugs and radiation are used.
“The silver lining of this is that we know what to expect a reasonable amount of the time,” said Dr. Kevin C. Oeffinger of Sloan-Kettering, a lead author of the report. While young cancer patients are more vulnerable to damage because their organs are still growing, Dr. Oeffinger said, the study has obvious implications for adults.
Age and type of treatment play a huge role in the experience of cancer survivors, several experts said. Many experience no side effects at all. Others, especially women of child-bearing age, face infertility and early menopause.
“Our research shows that younger patients have a harder time, both physically and emotionally,” said Dr. Ganz, of U.C.L.A. “It’s not something they’ve expected.”
At Sloan-Kettering, five social workers are assigned to concentrate exclusively on follow-up care for survivors. Part of the plan, at Sloan and other cancer centers, is to develop an online database of patient-care summaries — of the cancer treatment received, the potential risks and recommended follow-up care — that could be used by any physician.
The hospital also plans to open an off-campus outpatient center devoted to cancer survivors’ physical rehabilitation, in part with a donation from the media entrepreneur Robert F. X. Sillerman, who was treated at Sloan-Kettering six years ago for tongue cancer. He received chemotherapy and radiation and later began to suffer pain and muscle spasms in his shoulders and back, as well as increasing weakness in his left arm.
Today, Mr. Sillerman said, he has reversed the damage with a little bit of medication and a lot of physical therapy. He exercises six days a week with weights, bands and manual resistance, partly with a personal physical therapist whom he puts up in a Manhattan townhouse adjoining his family’s. He said he appreciated the fact that few have the same luxury.
“I was two years out from my cure before I was able to find the right protocol and treatment,” said Mr. Sillerman, 59. “Our hope is to eliminate that and provide access to rehabilitation right away, initially in the New York metropolitan area and eventually to make that a template nationally.”
For premature menopause in patients who can safely use estrogen, Dr. Mercedes Castiel likes to give teenagers and young women birth control pills to control hot flashes and bone loss. “It’s nicer to say I’m on the pill like my peers instead of hormones like my grandmother,” said Dr. Castiel, director of the Barbara White Fishman Women’s Health Center at Sloan.
Even sexual dysfunction, which for years was viewed as a small price to pay for survival, is now treated like any other side effect. Vaginal dryness and missed or blunted orgasms are among the most common complaints.
“We look at it in terms of enhancing intimacy,” said Dr. Michael L. Krychman, Sloan’s expert on the subject. “They want things to get back to normal.”
Friday, May 18, 2007
Starting wine tasting
NYTimes
“To Study Wine, Buy and Drink”
By Eric Asimov, New York Times
April 11, 2007
New York Times, April 11, 2007
People ask me, more often than any other question by far, where to go to learn about wine.
Usually I tell them to go home.
No kidding. The best place to learn about wine is at home, particularly if you stop off at a good wine shop on the way.
What I’m about to propose is a do-it-yourself method that has a lot to offer to just about anybody who loves wine, or wants to learn about it. In fact, if you’ll join in with me, we will take this home wine class together and be the better for it. Let me explain.
Wine classes are best if you already know a little something and have decided that you are enthusiastic enough to pursue a passion. But for beginners they can be daunting, and they tend to teach more about how to describe wines rather than helping you learn what you like.
Books can be inspiring and entertaining, and at some point they are essential. But they pose similar problems for beginners. Do you think you can learn to play golf by reading a book? Of course not. You have to get out there and struggle, for years most likely.
Learning about wine is far more pleasant. All you have to do — almost — is drink it.
My approach does require a little thought and a modest bit of work, though, because you will learn only if you pursue wine systematically.
First, identify a good wine shop near you. If the answer isn’t obvious, ask a wine-obsessed friend for some recommendations. Second, find somebody at the shop with whom you seem to have a rapport and who is passionate about wine. Certain clues will help you gauge the passion. For example, if a salesperson tries to entice you by quoting scores from a consumer magazine, forget it. But if the salesperson explains why he or she loves a particular wine, it’s a very good sign.
Now you are ready to get down to business. Ask the salesperson for a mixed case — six red, six white — and give the shop a spending limit. You don’t need to be extravagant, but it’s not a time to stint, either. I suggest $250, give or take $50.
If the shop is a good one, you will be taking home a guide to the diverse and wonderful forms wine takes around the world. Some you will love, others you may detest. Either way, tasting a range is essential to learning about wine and about your own tastes.
Now comes the fun. Every night, or however often seems right, open one of the bottles with dinner. This is important. You want to drink a wine with food for the full experience.
Just the other night in a Spanish restaurant, I tasted a Rueda, a white wine made from the verdejo grape. On its own it was unexpectedly tart and pungent. With a bite of my shrimp-and-fig tapa, it was softer and more harmonious.
Over time you will gain a pretty good idea of which wines correspond with which foods. A really good wine shop may even have suggested general food pairings with the wines.
You will have to take some notes. Write down the name of the wine, the vintage, what you ate with it, and what you liked or didn’t like about it. It’s even easier than it sounds, especially if you don’t try to use the florid language of wine writers.
As you inhale the aromas and taste the flavors, think in general terms — was it sweet? Bitter? Did the aromas remind you of fruit, or maybe something else? Perhaps it didn’t taste like fruit at all, but like a beautiful sunset. Don’t know that I’ve had a sunset, but it’s evocative, at least.
The most important thing, though, is not how you describe the wine but whether you liked it or not, and whether you felt it enhanced what you ate or clashed with it. When you finish the case, return to the wine shop. Go over your list with the salesperson and, based on what you liked best, ask the shop to put together a second case of different bottles.
With this method you will gain a sense of what wines you like best. Eventually, if it’s fun, you may be motivated to find out even more.
That’s the time to buy a book or take a class, because now you have a context for organizing, understanding and digesting a blizzard of information. You may not be driving the ball 300 yards, or picking out Pomerols from Pommards, but you know what? Very few people do.
Now, as I said, I think this method is great not just for beginners but for anybody who wants to learn more about wine. So I’ve gone out and placed an order for a mixed case of wine on a $250 budget. In fact, I placed not just one order but two, from different shops, to see how the selection of the mixed case might differ and what that might mean. …
Out of curiosity, I… placed an order with… Sherry-Lehmann, the ultimate establishment wine shop. I spoke on the phone with Joy Land, a salesperson whom I didn’t know, but she knew exactly what I was after, and she quickly described her own palate.
“My background and my love is French wine,” Ms. Land said. “I like wines that are very elegant. I don’t like wines that are very big. I don’t like purple wines, or wines that stain your teeth.”
I’ll go along with that, though I do admit I kind of like purple.
I’ve now received both cases and they are similar conceptually, though they differ completely in the particulars. Both contain a Bordeaux, a red Burgundy and a white Burgundy. Both include a riesling and a zinfandel. Both include a sauvignon blanc, a Côtes du Rhône and a red from Italy. Both Lyle and Joy decided that one of the whites needed to be a Champagne.
I’ve got my work cut out for me, and I hope you’ll join me. I plan to keep you abreast of my progress on my blog, The Pour.
If you are newsprint-bound, check back here over the next couple of months and I’ll let you know what I’ve learned.
Homework
Your assignment: buy the following wines and drink them. Take notes. The [list was] compiled by… Joy Land of Sherry-Lehmann.
JOY’S CASE
* Deutz Brut NV $27.95
* Selbach-Oster Zeltinger, Schlossberg Spätlese 2002 $22.95
* Domaine Guy Roulot, Bourgogne Blanc 2004 $21.95
* Villa Maria Private Bin, Marlborough Sauvignon Blanc 2006 $12.95
* Salomon-Undhof Kremstal, Hochterrassen Grüner Veltliner 2005 $9.95
* Tablas Creek Paso Robles, Esprit de Beaucastel Blanc 2004 $29.95
* Mommessin Gevrey-Chambertin, 2003 $34.95
* Croix de Beaucaillou Saint-Julien 2003 $31.95
* Ridge Sonoma County, Three Valleys 2005 $19.95
* Guigal Côtes du Rhône 2003 $10.95
* Allegrini Palazzo della Torre IGT 2003 $16.95
* Enrique Foster Mendoza Malbec, Ique 2004 $8.95
“To Study Wine, Buy and Drink”
By Eric Asimov, New York Times
April 11, 2007
New York Times, April 11, 2007
People ask me, more often than any other question by far, where to go to learn about wine.
Usually I tell them to go home.
No kidding. The best place to learn about wine is at home, particularly if you stop off at a good wine shop on the way.
What I’m about to propose is a do-it-yourself method that has a lot to offer to just about anybody who loves wine, or wants to learn about it. In fact, if you’ll join in with me, we will take this home wine class together and be the better for it. Let me explain.
Wine classes are best if you already know a little something and have decided that you are enthusiastic enough to pursue a passion. But for beginners they can be daunting, and they tend to teach more about how to describe wines rather than helping you learn what you like.
Books can be inspiring and entertaining, and at some point they are essential. But they pose similar problems for beginners. Do you think you can learn to play golf by reading a book? Of course not. You have to get out there and struggle, for years most likely.
Learning about wine is far more pleasant. All you have to do — almost — is drink it.
My approach does require a little thought and a modest bit of work, though, because you will learn only if you pursue wine systematically.
First, identify a good wine shop near you. If the answer isn’t obvious, ask a wine-obsessed friend for some recommendations. Second, find somebody at the shop with whom you seem to have a rapport and who is passionate about wine. Certain clues will help you gauge the passion. For example, if a salesperson tries to entice you by quoting scores from a consumer magazine, forget it. But if the salesperson explains why he or she loves a particular wine, it’s a very good sign.
Now you are ready to get down to business. Ask the salesperson for a mixed case — six red, six white — and give the shop a spending limit. You don’t need to be extravagant, but it’s not a time to stint, either. I suggest $250, give or take $50.
If the shop is a good one, you will be taking home a guide to the diverse and wonderful forms wine takes around the world. Some you will love, others you may detest. Either way, tasting a range is essential to learning about wine and about your own tastes.
Now comes the fun. Every night, or however often seems right, open one of the bottles with dinner. This is important. You want to drink a wine with food for the full experience.
Just the other night in a Spanish restaurant, I tasted a Rueda, a white wine made from the verdejo grape. On its own it was unexpectedly tart and pungent. With a bite of my shrimp-and-fig tapa, it was softer and more harmonious.
Over time you will gain a pretty good idea of which wines correspond with which foods. A really good wine shop may even have suggested general food pairings with the wines.
You will have to take some notes. Write down the name of the wine, the vintage, what you ate with it, and what you liked or didn’t like about it. It’s even easier than it sounds, especially if you don’t try to use the florid language of wine writers.
As you inhale the aromas and taste the flavors, think in general terms — was it sweet? Bitter? Did the aromas remind you of fruit, or maybe something else? Perhaps it didn’t taste like fruit at all, but like a beautiful sunset. Don’t know that I’ve had a sunset, but it’s evocative, at least.
The most important thing, though, is not how you describe the wine but whether you liked it or not, and whether you felt it enhanced what you ate or clashed with it. When you finish the case, return to the wine shop. Go over your list with the salesperson and, based on what you liked best, ask the shop to put together a second case of different bottles.
With this method you will gain a sense of what wines you like best. Eventually, if it’s fun, you may be motivated to find out even more.
That’s the time to buy a book or take a class, because now you have a context for organizing, understanding and digesting a blizzard of information. You may not be driving the ball 300 yards, or picking out Pomerols from Pommards, but you know what? Very few people do.
Now, as I said, I think this method is great not just for beginners but for anybody who wants to learn more about wine. So I’ve gone out and placed an order for a mixed case of wine on a $250 budget. In fact, I placed not just one order but two, from different shops, to see how the selection of the mixed case might differ and what that might mean. …
Out of curiosity, I… placed an order with… Sherry-Lehmann, the ultimate establishment wine shop. I spoke on the phone with Joy Land, a salesperson whom I didn’t know, but she knew exactly what I was after, and she quickly described her own palate.
“My background and my love is French wine,” Ms. Land said. “I like wines that are very elegant. I don’t like wines that are very big. I don’t like purple wines, or wines that stain your teeth.”
I’ll go along with that, though I do admit I kind of like purple.
I’ve now received both cases and they are similar conceptually, though they differ completely in the particulars. Both contain a Bordeaux, a red Burgundy and a white Burgundy. Both include a riesling and a zinfandel. Both include a sauvignon blanc, a Côtes du Rhône and a red from Italy. Both Lyle and Joy decided that one of the whites needed to be a Champagne.
I’ve got my work cut out for me, and I hope you’ll join me. I plan to keep you abreast of my progress on my blog, The Pour.
If you are newsprint-bound, check back here over the next couple of months and I’ll let you know what I’ve learned.
Homework
Your assignment: buy the following wines and drink them. Take notes. The [list was] compiled by… Joy Land of Sherry-Lehmann.
JOY’S CASE
* Deutz Brut NV $27.95
* Selbach-Oster Zeltinger, Schlossberg Spätlese 2002 $22.95
* Domaine Guy Roulot, Bourgogne Blanc 2004 $21.95
* Villa Maria Private Bin, Marlborough Sauvignon Blanc 2006 $12.95
* Salomon-Undhof Kremstal, Hochterrassen Grüner Veltliner 2005 $9.95
* Tablas Creek Paso Robles, Esprit de Beaucastel Blanc 2004 $29.95
* Mommessin Gevrey-Chambertin, 2003 $34.95
* Croix de Beaucaillou Saint-Julien 2003 $31.95
* Ridge Sonoma County, Three Valleys 2005 $19.95
* Guigal Côtes du Rhône 2003 $10.95
* Allegrini Palazzo della Torre IGT 2003 $16.95
* Enrique Foster Mendoza Malbec, Ique 2004 $8.95
Med use in US kids
Link
Diabetes drug use spikes in young girlsReport: Pills for insomnia, psychotic behavior up among U.S. kids
Updated: 8:04 a.m. ET May 16, 2007
TRENTON, N.J. - The number of adolescent girls taking drugs for Type 2 diabetes nearly tripled in just five years, while use of chronic medicines for psychotic behavior and insomnia roughly doubled among boys and girls aged 10 to 19, a study shows.
Meanwhile, adolescents’ use of drugs for depression and attention deficit hyperactivity disorder, or ADHD, leveled off or dropped in the last two years, after widespread new warnings about safety concerns.
The study, an analysis of prescription drug use from 2001 to 2006 among 370,000 insured children aged 10 to 19, was conducted by Medco Health Inc. of Franklin Lakes, N.J., the country’s biggest prescription benefit manager, and released exclusively to The Associated Press.
Experts say the findings raise questions about physical and mental health problems in youth, the appropriateness of putting them on strong, long-term medicines mostly designed for adults, and whether it might be better to focus on other strategies, such as counseling, exercise and changes in diet, caffeine intake and bedtime routine.
“There’s increasing use of medication in children the last 20 years, but does that mean we’re treating them successfully or that we’re overmedicating?” said Dr. Thomas Insel, director of the National Institute of Mental Health. Probably both, he said, but some children aren’t getting needed help.
Dr. Wayne Snodgrass, chairman of the American Academy of Pediatrics’ committee on drugs, said the levels of medication usage found in the study might be appropriate, but it’s hard to know without details on why each prescription was written.
“It deserves watching,” he said, particularly because adolescents’ brains are still developing. Snodgrass said worried parents should question their child’s doctor about their treatment or seek a second opinion.
Striking diabetes trend
The most striking trend was a 167 percent spike in girls 10 to 19 taking pills for type 2 diabetes, formerly called adult-onset diabetes. Medco found it jumped from 0.1 percent in 2001 to 0.27 percent in 2006; among boys, prevalence up 33 percent, to 0.08 percent.
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“It’s really scary to think about people in their teens developing a disease that in the past only developed in the 40s, 50s and 60s,” Buse said.
The big gap between the sexes, he said, likely is partly due to girls taking a generic diabetes drug, metformin, linked to weight loss and also prescribed for a hormonal condition that involves abnormal insulin function, causes male sex traits and increases cancer risk.
Also, hormone changes in puberty can trigger insulin resistance, or prediabetes. Puberty starts a couple years earlier in girls, so many more girls than boys in the study were in puberty.
Medco found prevalence of kids taking antipsychotic drugs, once called major tranquilizers, roughly doubled, with about 1.2 percent of boys and 0.75 percent of girls taking them in 2006.
Widely used antipsychotic drugs — including Risperdal, Zyprexa, Seroquel and Clozaril — are approved for treating schizophrenia and bipolar disorder in adults, but not children.
Insel said the drugs often are prescribed for kids for disruptive behavior and other unapproved uses, particularly to kids previously on antidepressants and ADHD drugs.
A federal survey of doctors’ office practices estimated a sixfold jump from 1993 to 2002 in patients aged 20 or younger prescribed antipsychotic drugs, to 1.224 million. It found 38 percent of those prescriptions were for disruptive behavior such as ADHD, 32 percent were for mood disorders including depression, 17 percent were for developmental disorders such as mental retardation and autism, and 14 percent were for psychotic disorders such as schizophrenia.
Sleeping pills doubled
Meanwhile, Medco found use of prescription sleeping pills nearly doubled, to about 0.3 percent of boys and 0.44 percent of girls.
“The fact that these kids have to get a prescription pill to go to sleep at night is amazing,” said Dr. Robert Epstein, Medco’s chief medical official, adding parents should try slowing kids down at night with curfews on caffeine and computer use, for example.
He said Medco’s numbers reflect drug use among adolescents covered by private or government insurance, but in general kids in the Medicaid program use more prescription medications and those with no insurance take significantly less.
Use of ADHD drugs leveled off in girls in 2006 at 3.5 percent and dropped in boys to almost 8 percent, while antidepressant use dropped in both sexes in 2005 and 2006, to about 4 percent of girls and 3.2 percent of boys.
Insel said those trends make sense, given that after the drugs ago got stringent warnings about problems such as suicidal thoughts a couple years ago, many parents became concerned about side effects and pediatricians worried about their liability for prescribing the drugs.
Sleep and memory
Link
Good Sleep Wakes Up Memory
By Juhie Bhatia, HealthDay Reporter
HealthDay
(HealthDay News) -- Besides helping you feel well-rested, getting your zzz's may also sharpen your memory, a new study shows.
Researchers found that sleep not only protects memories from outside interferences, it also helps strengthen them.
"There was a very large benefit of sleep for memory consolidation, even larger than we were anticipating," said study author Dr. Jeffrey Ellenbogen, an associate neurologist at Brigham and Women's Hospital, Boston, and a postdoctoral fellow in sleep medicine at Harvard Medical School.
In the study, the researchers focused on sleep's impact on "declarative" memories, which are related to specific facts, episodes and events.
"We sought to explore whether sleep has any impact on memory consolidation, specifically the type of memory for facts and events and time," Ellenbogen said. "We know that sleep helps boost memory for procedural tests, such as learning a new piano sequence, but we're not sure, even though it's been debated for 100 years, whether sleep impacts declarative memory."
The study involved 48 people between the ages of 18 and 30. These participants had normal, healthy sleep routines and were not taking any medications. They were all taught 20 pairs of words and asked to recall them 12 hours later. However, the participants were divided evenly into four groups with different circumstances for testing: sleep before testing, wake before testing, sleep before testing with interference, or wake before testing with interference.
Two of the groups (the wake groups) were taught the words at 9 a.m. and then tested on the pairings at 9 p.m., after being awake all day. The other two groups (the sleep groups) learned the words at 9 p.m., went to sleep, and were then tested at 9 a.m.
Also, prior to testing, one of the sleep groups and one of the wake groups were given a second list of 20 word pairs to remember. These groups were then tested on both lists to help determine memory recall with interference (competing information).
The result: Sleep appeared to help particpants recall their learned declarative memories, even when they were given competing information.
According to the researchers, people who slept after learning the information performed best, successfully recalling more words whether or not there was interference. Those in the sleep group without interference were able to recall 12 percent more word pairings from the first list than the wake group without interference (94 percent recall for the sleep group vs. 82 percent for the wake group).
When presented with interference, those who slept before testing did significantly better at remembering the words (76 percent for the sleep group vs. 32 percent for the wake group).
"We were surprised to find the order of magnitude by which the data demonstrated our effects," Ellenbogen said.
Jan Born, a professor of neuroendocrinology at the University of Lübeck in Germany, said the study offers more proof of the importance of sleep for memory consolidation.
"Considering that learning in every educational setting (schools, colleges, etc.), is centrally based on hippocampus-dependent memory function [declarative memories], people should realize that optimal learning conditions require proper sleep," he said.
Proper sleep may have other benefits, too, added Michael Perlis, director of the Sleep Research Laboratory at the University of Rochester in Rochester, NY. Research has shown that in addition to memory, sleep may be related to physical functioning, good immune function, physical and cognitive performance, and mood regulation, he said.
"These are all theories. The only thing we know is that when we're deprived of sleep, we do less well. Is that a lack of sleep or sustained wakefulness? It's very difficult to figure out how to crack that nut," he said. "We spend 30 percent of our time on sleep. What is sleep for? This is a riddle we're still working on."
SOURCES: Jeffrey Ellenbogen, M.D., associate neurologist, Brigham and Women's Hospital, postdoctoral fellow in sleep medicine, Harvard Medical School; Jan Born, Ph.D., professor, neuroendocrinology, University of Lübeck, Germany; Michael Perlis, Ph.D., director of the Sleep Research Laboratory, University of Rochester, N.Y.
Good Sleep Wakes Up Memory
By Juhie Bhatia, HealthDay Reporter
HealthDay
(HealthDay News) -- Besides helping you feel well-rested, getting your zzz's may also sharpen your memory, a new study shows.
Researchers found that sleep not only protects memories from outside interferences, it also helps strengthen them.
"There was a very large benefit of sleep for memory consolidation, even larger than we were anticipating," said study author Dr. Jeffrey Ellenbogen, an associate neurologist at Brigham and Women's Hospital, Boston, and a postdoctoral fellow in sleep medicine at Harvard Medical School.
In the study, the researchers focused on sleep's impact on "declarative" memories, which are related to specific facts, episodes and events.
"We sought to explore whether sleep has any impact on memory consolidation, specifically the type of memory for facts and events and time," Ellenbogen said. "We know that sleep helps boost memory for procedural tests, such as learning a new piano sequence, but we're not sure, even though it's been debated for 100 years, whether sleep impacts declarative memory."
The study involved 48 people between the ages of 18 and 30. These participants had normal, healthy sleep routines and were not taking any medications. They were all taught 20 pairs of words and asked to recall them 12 hours later. However, the participants were divided evenly into four groups with different circumstances for testing: sleep before testing, wake before testing, sleep before testing with interference, or wake before testing with interference.
Two of the groups (the wake groups) were taught the words at 9 a.m. and then tested on the pairings at 9 p.m., after being awake all day. The other two groups (the sleep groups) learned the words at 9 p.m., went to sleep, and were then tested at 9 a.m.
Also, prior to testing, one of the sleep groups and one of the wake groups were given a second list of 20 word pairs to remember. These groups were then tested on both lists to help determine memory recall with interference (competing information).
The result: Sleep appeared to help particpants recall their learned declarative memories, even when they were given competing information.
According to the researchers, people who slept after learning the information performed best, successfully recalling more words whether or not there was interference. Those in the sleep group without interference were able to recall 12 percent more word pairings from the first list than the wake group without interference (94 percent recall for the sleep group vs. 82 percent for the wake group).
When presented with interference, those who slept before testing did significantly better at remembering the words (76 percent for the sleep group vs. 32 percent for the wake group).
"We were surprised to find the order of magnitude by which the data demonstrated our effects," Ellenbogen said.
Jan Born, a professor of neuroendocrinology at the University of Lübeck in Germany, said the study offers more proof of the importance of sleep for memory consolidation.
"Considering that learning in every educational setting (schools, colleges, etc.), is centrally based on hippocampus-dependent memory function [declarative memories], people should realize that optimal learning conditions require proper sleep," he said.
Proper sleep may have other benefits, too, added Michael Perlis, director of the Sleep Research Laboratory at the University of Rochester in Rochester, NY. Research has shown that in addition to memory, sleep may be related to physical functioning, good immune function, physical and cognitive performance, and mood regulation, he said.
"These are all theories. The only thing we know is that when we're deprived of sleep, we do less well. Is that a lack of sleep or sustained wakefulness? It's very difficult to figure out how to crack that nut," he said. "We spend 30 percent of our time on sleep. What is sleep for? This is a riddle we're still working on."
SOURCES: Jeffrey Ellenbogen, M.D., associate neurologist, Brigham and Women's Hospital, postdoctoral fellow in sleep medicine, Harvard Medical School; Jan Born, Ph.D., professor, neuroendocrinology, University of Lübeck, Germany; Michael Perlis, Ph.D., director of the Sleep Research Laboratory, University of Rochester, N.Y.
Thursday, May 17, 2007
Triple Chocolate Brownies
Triple Chocolate Brownies
Recipe courtesy Nigella Lawson
3 sticks plus 2 tablespoons unsalted butter
12 ounces best-quality bittersweet chocolate
6 eggs
1 3/4 cups superfine sugar
1 tablespoon pure vanilla extract
1 1/2 cups plus 2 tablespoons all-purpose flour
1 teaspoon salt
1/2 cup white chocolate buttons, chips, or morsels
1/2 cup semisweet chocolate buttons, chips or morsels
Approximately 2 teaspoons confectioners' sugar, for garnish
Special equipment: Baking tin (approximately 11 1/4 inches by 9 inches by 2 inches), sides and base lined with baking parchment.
Preheat the oven to 350 degrees F.
Melt the butter and dark chocolate together in a large heavy based pan over a low heat.
In a bowl or large measuring jug, beat the eggs together with the superfine sugar and vanilla extract.
Allow the chocolate mixture to cool a little, then add the egg and sugar mixture and beat well. Fold in the flour and salt. Then stir in the white chocolate buttons or chips, and the semisweet chocolate buttons or chips. Beat to combine then scrape and pour the brownie mixture into the prepared tin.
Bake for about 25 minutes. You can see when the brownies are ready because the top dries to a slightly paler brown speckle, while the middle remains dark, dense and gooey. Even with such a big batch you do need to keep checking on it: the difference between gooey brownies and dry ones is only a few minutes. Remember, too, that they will continue to cook as they cool.
To serve, cut into squares while still warm and pile up on a large plate, sprinkling with confectioners' sugar pushed with a teaspoon through a small sieve.
Recipe courtesy Nigella Lawson
3 sticks plus 2 tablespoons unsalted butter
12 ounces best-quality bittersweet chocolate
6 eggs
1 3/4 cups superfine sugar
1 tablespoon pure vanilla extract
1 1/2 cups plus 2 tablespoons all-purpose flour
1 teaspoon salt
1/2 cup white chocolate buttons, chips, or morsels
1/2 cup semisweet chocolate buttons, chips or morsels
Approximately 2 teaspoons confectioners' sugar, for garnish
Special equipment: Baking tin (approximately 11 1/4 inches by 9 inches by 2 inches), sides and base lined with baking parchment.
Preheat the oven to 350 degrees F.
Melt the butter and dark chocolate together in a large heavy based pan over a low heat.
In a bowl or large measuring jug, beat the eggs together with the superfine sugar and vanilla extract.
Allow the chocolate mixture to cool a little, then add the egg and sugar mixture and beat well. Fold in the flour and salt. Then stir in the white chocolate buttons or chips, and the semisweet chocolate buttons or chips. Beat to combine then scrape and pour the brownie mixture into the prepared tin.
Bake for about 25 minutes. You can see when the brownies are ready because the top dries to a slightly paler brown speckle, while the middle remains dark, dense and gooey. Even with such a big batch you do need to keep checking on it: the difference between gooey brownies and dry ones is only a few minutes. Remember, too, that they will continue to cook as they cool.
To serve, cut into squares while still warm and pile up on a large plate, sprinkling with confectioners' sugar pushed with a teaspoon through a small sieve.
Tuesday, May 15, 2007
City rude driver rankings
May 15, 2007
Miami Holds Top Spot on Rude Driver List
By THE ASSOCIATED PRESS
Filed at 9:38 a.m. ET
MIAMI (AP) -- For the second straight year, rude Miami drivers have earned the city the title of worst road rage in a survey released Tuesday.
Miami motorists said they saw other drivers slam on their brakes, run red lights and talk on cell phones, according to AutoVantage, a Connecticut-based automobile membership club offering travel services and roadside assistance.
Other cities near the top of the rude drivers list were New York, Boston, Los Angeles and Washington, D.C.
South Miami resident Erik Pinto told The Associated Press he's probably seen every bad driving habit on Miami's roads.
''You don't want to know what I've seen,'' Pinto said. ''I've seen everything. I'm from L.A., and we don't see the crazy drivers that you see here.''
Portland, Ore., drivers were the least likely of the cities to see other motorists tailgating on the roadways, and St. Louis motorists were the least likely to swear at another driver, the survey found.
Minneapolis-St. Paul was rated the most courteous city in 2006 but slipped to the middle of the list this year.
The most frequent cause of road rage cited in the survey was impatient motorists. Drivers also cited poor driving in fast lanes and driving while stressed, frustrated or angry.
''The best piece of advice is to take a deep breath. Slow down, be aware and be careful,'' AutoVantage spokesman Todd Smith said, adding the aim of the survey is to increase driver safety across the nation.
More than 2,500 drivers who regularly commute in 25 major metropolitan areas were asked to rate road rage and rude driving in telephone surveys between January and March. The survey was conducted by Prince Market Research has a margin of error of plus or minus 2 percentage points.
The list, ranked from those reporting the most incidents of road rage to the fewest:
1. Miami
2. New York
3. Boston
4. Los Angeles
5. Washington, D.C.
6. Phoenix
7. Chicago
8. Sacramento, Calif.
9. Philadelphia
10. San Francisco
11. Houston
12. Atlanta
13. Detroit
14. Minneapolis-St. Paul
15. Baltimore
16. Tampa, Fla.
17. San Diego
18. Cincinnati
19. Cleveland
20. Denver
21. Dallas-Ft. Worth
22. St. Louis
23. Seattle-Tacoma
24. Pittsburgh
25. Portland, Ore.
Miami Holds Top Spot on Rude Driver List
By THE ASSOCIATED PRESS
Filed at 9:38 a.m. ET
MIAMI (AP) -- For the second straight year, rude Miami drivers have earned the city the title of worst road rage in a survey released Tuesday.
Miami motorists said they saw other drivers slam on their brakes, run red lights and talk on cell phones, according to AutoVantage, a Connecticut-based automobile membership club offering travel services and roadside assistance.
Other cities near the top of the rude drivers list were New York, Boston, Los Angeles and Washington, D.C.
South Miami resident Erik Pinto told The Associated Press he's probably seen every bad driving habit on Miami's roads.
''You don't want to know what I've seen,'' Pinto said. ''I've seen everything. I'm from L.A., and we don't see the crazy drivers that you see here.''
Portland, Ore., drivers were the least likely of the cities to see other motorists tailgating on the roadways, and St. Louis motorists were the least likely to swear at another driver, the survey found.
Minneapolis-St. Paul was rated the most courteous city in 2006 but slipped to the middle of the list this year.
The most frequent cause of road rage cited in the survey was impatient motorists. Drivers also cited poor driving in fast lanes and driving while stressed, frustrated or angry.
''The best piece of advice is to take a deep breath. Slow down, be aware and be careful,'' AutoVantage spokesman Todd Smith said, adding the aim of the survey is to increase driver safety across the nation.
More than 2,500 drivers who regularly commute in 25 major metropolitan areas were asked to rate road rage and rude driving in telephone surveys between January and March. The survey was conducted by Prince Market Research has a margin of error of plus or minus 2 percentage points.
The list, ranked from those reporting the most incidents of road rage to the fewest:
1. Miami
2. New York
3. Boston
4. Los Angeles
5. Washington, D.C.
6. Phoenix
7. Chicago
8. Sacramento, Calif.
9. Philadelphia
10. San Francisco
11. Houston
12. Atlanta
13. Detroit
14. Minneapolis-St. Paul
15. Baltimore
16. Tampa, Fla.
17. San Diego
18. Cincinnati
19. Cleveland
20. Denver
21. Dallas-Ft. Worth
22. St. Louis
23. Seattle-Tacoma
24. Pittsburgh
25. Portland, Ore.
America's Most Overpriced Real Estate Markets
Forbes
America's Most Overpriced Real Estate Markets
05.04.07, 12:01 AM ET
America's Most Overpriced Real Estate Markets
05.04.07, 12:01 AM ET
No matter the locale, its denizens almost always gripe about the stiff cost of living, housing and doing business. But in some places the financial pain is clearly more acute than others.
Take San Diego. A slumping housing market, where only 5% of residents can afford the median home, and a high price-to-earnings ratio made the oceanfront city our most overpriced real estate market. Had weather been included as a statistical measurement, there's no doubt San Diego would have avoided our list of top 10 most overpriced cities--but we didn't factor in sunshine.
Arriving at the relative value of a given market isn't as simple as calculating median home prices, income rates and cost of living. Instead, our list of most overpriced real estate markets incorporates a more meaningful methodology.
In Pictures: 10 Most Overpriced Real Estate Markets
In Pictures: 10 Least Overpriced Real Estate Markets
Behind The Numbers
Using the 40 largest metro areas, we started by estimating a "price-to-earnings" ratio for each market. (Like the P/E of a stock, this value attempts to measure the price a homeowner would pay for one dollar of return.) Using data from the National Association of Realtors (NAR), the U.S. Census Bureau and the Office of Federal Housing Enterprise Oversight, we took each market's median home price and divided it by annual rents minus taxes and insurance for those properties. (We assumed for this exercise that other costs don't vary drastically from city to city.)
The average P/E for the 40 markets is 28. Note: Unlike, say, the S&P 500 index of stocks, ours is not a weighted-average P/E. If it were, certain cities with greater overall sheer market value would carry more weight.
| In the market for a seven-figure home? How much domain your dollar will net depends on where you look. Find out how far your money will go--and where--here. |
We incorporated a second metric: an affordability index. Calculated from National Home Builder Association and
Consider Detroit. Almost 88% of its homes are available to those with a median income, and its 17.5 P/E ratio appears relatively low, but that doesn't make real estate in the Motor City a good investment. Already stagnant home prices have decreased at a rate of 1% over the last year and, of the major metros, Detroit is the only one on our list to have lost jobs since 2005 (other than New Orleans, which we left off; in the wake of Hurricane Katrina the city's statistical figures were such anomalies that it wasn't comparable to the rest of the cities).
| Related Stories Inside America's Super-Pricey Apartments World's Most Expensive Homes |
So which markets are in bubble territory? Look for a high P/E ratio, low affordability, low income growth and a high cost of living.
San Francisco, ranked fourth, fits that bill. Despite home prices growing at a 2% clip over last year, according to the NAR, the city by the bay ranks third to last in expected income growth, reports Moody's. Not good news in a market where only 7.5% of housing is affordable for the median-income earner. Combine that with a housing P/E ratio over 50, and it isn't difficult to imagine some softening on the horizon.
The usual suspects littered our list: Miami came in second, followed in order by: Sacramento, Calif.; San Francisco; Washington, D.C.; Honolulu; New York; Los Angeles; and Boston. San Jose, Calif., rounded out the top 10.
Sunday, May 13, 2007
Tourist in LA
NYTimes
May 13, 2007
Family Travel | Los Angeles
Adventures in Dreamland
By A. O. SCOTT
ONE pleasant April afternoon, I found myself, along with my wife and our two children, in the middle of a quintessential American scene. There was a quaint town square, a sturdy shade tree flanked by cozy shops and Victorian houses. As we surveyed this idyllic tableau, it was pointed out to us that many of the buildings were empty shells, and that the leaves on the trees were bits of green plastic wired to the branches.
The news was not altogether shocking. We had, after all, reached this New England hamlet via a five-minute drive from downtown Chicago, which was itself nestled up against a block of New York brownstones not far from an overgrown patch of jungle. The mountains in the distance seemed real enough. They were the Hollywood Hills, and our immediate surroundings, the Warner Brothers back lot in Burbank.
As a tourist destination, Hollywood is a bit of a tease, at once wide-open and hermetic. It's all around you — the magic of the movies, the homes of the stars, the big sign in the hills — but where, exactly, is it?
Before I became a film critic, I never spent much time in Los Angeles, and my subsequent acquaintance with the city has been colored, and perhaps distorted, by my job. It is all too easy, when you write about movies, to wrap yourself in a carapace of cynicism; you don't want to come off as too star-struck, too susceptible to the glamour that still emanates from Hollywood. And so you learn to inflect the word “Hollywood” with a certain disdain, to show that you don't buy all those clichés about Tinseltown and the Dream Factory. If you come from New York and have seen “Annie Hall” as many times as I have, you may also retain certain snobbish prejudices about the place.
But who am I kidding? Hollywood may connote shameless commercialism, but it also conjures a powerful, undimmed spell of romance. The paradoxical mystique of movie stars — we feel like we know them so well, even as their lives seem so fantastically distant from ours — extends to the place where they are hatched and raised.
Luckily, my children, now 8 and 10 years old, provide an antidote to my put-on professional world-weariness. They are voracious, indiscriminate consumers of popular culture, and while I can't always share their enthusiasm — in the interests of family harmony, we tacitly agree not to bring up my reviews of “Madagascar” or “Chicken Little” — I am always happy to feed it.
And so when work calls me out to Southern California, I try whenever possible to take the family along. Over the last few years, the four of us have developed a collective crush on Los Angeles.
Earlier this spring, I left behind my critical agenda and, inspired by “Little Miss Sunshine,” the National Lampoon “Vacation” movies and a half-dozen relevant episodes of “The Simpsons,” assumed the role of affable tourist doofus dad. In this script my wife, Justine, was perfectly typecast as the voice of skepticism and good sense. Our children adopted pseudonyms, both to protect their anonymity in the newspaper and to pay tribute to the local tradition of self-reinvention that turned Issur Danielovich Demsky into Kirk Douglas and Norma Jeane Baker into Marilyn Monroe. The boy renamed himself Wayne Bruce, in triple tribute to Batman, the Duke and the star of “Die Hard,” which he'd recently seen part of on cable and which is, not coincidentally, a movie about a New Yorker coping with life in Los Angeles. His younger sister chose to inscribe herself in the tradition of single-named divas; we'll call her Melody.
We took an afternoon flight to LAX and found ourselves in the rental car lot just in time for rush hour. Wayne Bruce, true to action-hero form, wanted to roll out in the red Hummer. I'll admit to ogling the Dodge Magnum. Half an hour later, thrift and good sense prevailed and we were crawling north on the 405 in a silver Impala under a disconcertingly cloudy sky. We checked into our cozy suite in West Hollywood, ordered hamburgers and quesadillas and set about storyboarding the days ahead.
The plan was to balance present and past, sensation and education, indoors and out. We wanted not only to explore movie-related tourist sites, but also to score a vicarious taste of what our movie-saturated imaginations pictured as a Hollywood lifestyle. Thus a certain amount of time would be allotted for lounging beside the pool, for being seen in trendy restaurants, for driving aimlessly in the hills, for staring at the Pacific Ocean.
“Will we see any celebrities?” Melody wondered. As it happened, we would not. There was one of those I-know-I've-seen-him-somewhere encounters, in an aisle of the Whole Foods in Santa Monica, with an actor who had the good grace to show up in a rerun on the hotel TV that night. And our guide on the Warner Brothers studio tour did make eye contact with me in his rear view mirror and ask, “Did anyone ever tell you you look like Paul Giamatti?”
But I'm ahead of the story. A studio tour was to be the first order of business. We had done Universal Studios — more of a theme park ride than a tour — on a previous visit; Disney doesn't offer tours of its studio lot, and neither does Fox (D'oh!). Paramount and Sony don't accommodate children under 12. That left Warner Brothers. The voice message said that reservations were accepted for the first tours of the morning (at 8:30 and 9), and that the rest of the day was first come first served.
So after a leisurely breakfast at the Urth Caffé on Melrose in West Hollywood, surrounded by script-readers and -writers and other aspirants to Hollywood glory, we made it to Burbank by 10:30. “Do you have a reservation?” we were asked. Well, no we didn't. Rather than wait three hours, we made reservations for the next afternoon and headed back over the hills, touching down at the intersection of Hollywood and Highland.
This turned out to be a good place to start — the epicenter of Hollywood tourism, an open-air theme park and pilgrimage site. Grauman's Chinese Theater, the Walk of Fame, the Kodak Theater shopping-mall complex where the Oscars are handed out: they're all right here.
We began with the Hollywood History Museum, which occupies a handsome Art Deco building that used to house the Max Factor makeup company. As I bought tickets, Justine pointed her digital camera at a poster in the lobby — an advertisement for the museum itself — and was immediately accosted by a man who seemed more like a junior production executive than the security guard he apparently was. “Ma'am, I'll have to ask you to erase that picture,” he said, explaining that “everything in this museum is a copyrighted piece of intellectual property.”
This was a useful object lesson, a reminder that we were visitors in a company town. We tend to think of movies as public property. Who do they belong to, if not the fans? But of course they are made, distributed, owned and fiercely protected by large commercial interests. And so we checked the camera at the front desk and worked our way through the jumble of memorabilia that is the Hollywood History Museum.
History is not, in that museum or anywhere else in Hollywood, a sequential, chronological affair. The Max Factor Building has been made over into a glorious attic, where posters, costumes, autographs and props line walls and fill vitrines according to no discernable principles of organization. John Garfield, John Wayne, Bruce Willis, Johnny Depp, Elvis Presley, Janet Gaynor, Jodie Foster — they're all thrown together, along with thousands more, just as they would be on the shelves of an especially chaotic video store. That may be the idea: movies exist in an eternal present, which is to say whenever you happen to watch them. And who has ever watched them in chronological — or any other logical — order?
My favorite room was filled with pictures of old-time stars, and also of the city itself, taken at various points in its evolution from a sleepy Western outpost into a sprawling postmodern metropolis. But the feeling was less one of nostalgia than of continuity and equivalence.
The Hollywood tourist experience creates the impression that legends of the past are equal to the glories of the present. This is quite deliberate. If the golden age were located too firmly in the past, then how could the appetite for novelty on which the entertainment industry depends be sustained? Wayne and Melody, big fans of “Some Like It Hot,” were happy to see Marilyn Monroe at the Hollywood Wax Museum (our next stop), but they were more excited by Spiderman and Freddy and Jason and the crew of the Black Pearl.
And the Walk of Fame, which stretches along Hollywood Boulevard in both directions, expands on this happy heterogeneity. Critics and historians can evaluate quality and importance, but the sun shines on the legendary and the forgotten, the great and the awful — Judy Garland's square of pavement and Mary-Kate and Ashley Olsen's — alike. You can follow their names from the Chinese to the Egyptian, home of the American Cinematheque, a shrine to serious cinema art, and stop on the way to have your picture taken with a guy dressed as SpongeBob or Homer Simpson (him again!) and buy a hollow replica of an Oscar statuette with the inscription Best Dad.
As we walked east, the homogenized atmosphere of chain restaurants and licensed merchandise turned seedy, as if the New Times Square were adjacent to the old one, rather than on top of it. We debated joining an organized walking tour of Hollywood sites, or boarding a bus that would take us past movie star homes, but decided to wander instead. We gazed at windows full of wigs and costumes, and were happy, for most of an hour, to trade the magic of Hollywood for Hollywood Magic, a marvelous old-style novelty shop. There, a man behind the counter performed card and coin tricks, much to the delight of Wayne and Melody, who spent some of her allowance on a Whoopee Cushion.
BY dinnertime, we were ready for more refined amusement, or at least a good dinner. Did we have a reservation? No, but when we called Lucques, a highly rated restaurant a short walk from the hotel, we were told that a party of four had just canceled. Justine and Melody shared the seared breast of duck, and Wayne polished off a plate of short ribs.
Justine likes movies, but she loves birds and trees, and so the next day, on our way to Warner Brothers, we drove into Griffith Park, where trails wind through the wooded hillsides toward the Hollywood sign and the Observatory. Scrambling through brush and the rocks, we could imagine ourselves in the Old West, or deep in the jungle, or, once we reached the Observatory terrace, in “Rebel Without a Cause.” All of which were perfectly apt. The varied natural and human topography of greater Los Angeles — desert, forest, suburb, seaside, slum — has made it almost infinitely adaptable. One of the reasons so many movies are made here is that it can so easily pass for just about anywhere.
And what Hollywood cannot find, it builds and recycles. This was the theme of the Warner Brothers tour, which took us through empty back lots and sound stages, further scrambling our sense of location and history. Since it was a holiday, no one was working except the tour guide, who talked as if he was not an employee of Time Warner but one of the original Brothers. As he drove us past the bungalows that once housed writers and actors on contract, he recounted that Bette Davis had once demanded an entire building to herself. “She was one of our biggest stars,” he said, “and since she'd made us so much money we were happy to give her whatever she wanted.” I'm sure he was.
But the tour, in keeping with the endless scrambling of past and present, was less about Bette Davis than “The Gilmore Girls.” We stopped in Stars Hollow to take permitted photographs, and wandered through the Gilmore mansion, which is housed in a sound stage. But Stars Hollow used to be Walton's Mountain, and before that, part of it was Kings Row, where Ronald Reagan lived before he went into politics. And the “Gilmore Girls” sound stage used to be “Casablanca.” Much of the lot was built in the early years of the sound era, and its city streets and country towns have been used hundreds of times — in bad and good movies and (more frequently now) in television shows — ever since.
It began to occur to us that what we were encountering was raw materials and byproducts, none of which were quite as satisfying as the movies themselves. It isn't so much that Los Angeles saves its best face for the camera, but more that its ubiquity on screen creates a strange sense of familiarity. The Richard Neutra houses and Spanish-style bungalows; the Capitol Records Building and the Santa Monica Pier; Rodeo Drive and Skid Row — I see them every week, juxtaposed in ways forbidden by traffic and geography, and framed and filtered by more evocative lenses than the ones on my glasses.
Happy as we were to be in the real Los Angeles, we found that what we really wanted to do was go to the movies, and our attempt was thwarted in a quintessentially Hollywood fashion. According to the papers, there was an early-evening screening in the Cinerama Dome, a refurbished 1950s showpiece (now part of the Arclight complex) built for the three-projector wide-screen spectaculars that were meant to save the movies from television. But the Dome is a popular place for premieres, and when we arrived the red carpet and velvet ropes were being prepared for that night's “Entourage” gala.
The next day, Melody and Justine, having decided that some movie-star-grade pampering was in order, went for hot stone massages at a day spa. Wayne and I took a power breakfast in Larchmont Village, a neighborhood that seemed eerily familiar. Dads pushing jogging strollers; moms lugging yoga mats: it was Park Slope, but with palm trees.
Then, hungering for a glimpse of the ocean, even through the persistent cloud cover, the four of us drove up the Pacific Coast Highway to Malibu, and pushed the Impala through hairpin turns into the Santa Monica Mountains, where we found the Paramount Ranch. Now part of a national park, the ranch was where the studio shot many of its westerns. The Western Town, most recently home of “Dr. Quinn, Medicine Woman,” is still there, and Wayne shot me down, just as if I was Liberty Valance, on its dusty main street. The town wasn't big enough for the both of us.
We wound along Mulholland and then turned toward the Pacific, to follow our western with a surfing movie. At Point Dume State Beach we dug our toes into the sand, stared dreamily into the distance and spotted dolphins frolicking not far from shore, a sight more thrilling than any movie.
As the sun set, we turned off the highway onto Sunset Boulevard. The sandy children dozed in the back and I could sense the glow of a Hollywood feeling I had sought without quite knowing it. Maybe it was the feeling of finding myself in a perfectly cinematic moment, as the road snaked through Pacific Palisades, Brentwood and Beverly Hills, past the grand, gated homes, the hand-lettered signs advertising Star Maps and the bored dreamers selling them. The drive was mundane and romantic at the same time, and as we descended onto the Sunset Strip in search of dinner (which we found, without reservations, at a Japanese restaurant where Jim Jarmusch's “Dead Man” was silently projected on a courtyard wall), we felt lost and completely at home.
A few weeks later, back in her third-grade classroom, Melody wrote an essay about her trip “to a place I like to call Hollywood.” I'm not sure exactly which place she meant, but I like to call it that too.
VISITOR INFORMATION
The unassuming Le Parc Suite Hotel blends into its quiet residential block in West Hollywood. Its spacious, reasonably priced suites, which make the hotel popular with musicians and film crews in town for extended stays, also make it appealing for families. The studio and one-bedroom suites can sleep four people comfortably, with varying degrees of privacy, and have kitchenettes and small balconies. Meals can be taken at the Knoll restaurant on the third floor; you can also order food on the rooftop terrace, where there is a small heated pool, a hot tub and tennis courts. (733 North West Knoll Drive; 310-855-8888; www.leparcsuites.com. Rates vary seasonally. Current rates begin at $229 for a studio.)
Groceries can be purchased at Trader Joe's, a 10-minute walk from Le Parc at 8611 Santa Monica Boulevard. Urth Caffé, not far away at 8565 Melrose Avenue, has excellent coffee, healthy and generous breakfast and lunch offerings and good opportunities for movie-industry eavesdropping. Le Parc is also within walking distance of the trendy Melrose shopping district, and from Lucques (8474 Melrose; 323-655-6277; www.lucques.com), which serves creative and thoughtfully prepared Cal-French cuisine in a carriage house once owned by the silent-film star Harold Lloyd. Another memorable meal was at Yatai (8535 Sunset Boulevard; 310-289-0030; www.yatai-bar.com), an Asian tapas bar whose sleek, dark ambience seemed much less child-friendly than its selection of small dishes (including satay, vegetable rolls and addictive nuggets of fried chicken) turned out to be. The mojitos are good, too.
Reservations for the Warner Brothers VIP studio tours can be made by calling (818) 972-8687 or at www.warnerbros.com. The tours last a little more than two hours; children must be at least 8 years old. Tickets are $42 a person.
Tickets for the various sites near Hollywood and Highland can be purchased individually. Or, at any of them, you can buy a Walk of Fame City Pass that includes the Hollywood History Museum or the Kodak Theater, the Hollywood Wax Museum, the Hollywood Behind-the-Scenes Walking Tour and the Starline bus tour. It costs $49.95 and is valid for nine days. Star Maps can be purchased for $5 from anyone sitting in a folding chair under a sign that says “Star Maps, $5.”
Griffith Park is open daily from 6 a.m. to 10 p.m. (Park information is at www.lacity.org/rap/dos/parks/griffithPK or 323-913-4688). Admission to the Observatory (www.griffithobs.org) requires a timed ticket ($8 for adults; $4 for children 5-12) and a shuttle bus ride from Hollywood and Highland. Reservations: (888) 695-0888. The Paramount Ranch is part of the Santa Monica Mountains National Recreation Area (805-370-2301; www.nps.gov/samo) in Thousand Oaks. It is open daily from 9 to 5. There is a covered picnic area and a performance stage behind the Western Town.
Hollywood Magic is at 6614 Hollywood Boulevard (323-464-5610). Collectors, souvenir hunters and comic-book geeks should not miss Meltdown (7522 Sunset Boulevard; 323-851-7223; www.meltcomics.com), which has an impressive and eclectic selection of action-figures, memorabilia, comics and graphic novels.
May 13, 2007
Family Travel | Los Angeles
Adventures in Dreamland
By A. O. SCOTT
ONE pleasant April afternoon, I found myself, along with my wife and our two children, in the middle of a quintessential American scene. There was a quaint town square, a sturdy shade tree flanked by cozy shops and Victorian houses. As we surveyed this idyllic tableau, it was pointed out to us that many of the buildings were empty shells, and that the leaves on the trees were bits of green plastic wired to the branches.
The news was not altogether shocking. We had, after all, reached this New England hamlet via a five-minute drive from downtown Chicago, which was itself nestled up against a block of New York brownstones not far from an overgrown patch of jungle. The mountains in the distance seemed real enough. They were the Hollywood Hills, and our immediate surroundings, the Warner Brothers back lot in Burbank.
As a tourist destination, Hollywood is a bit of a tease, at once wide-open and hermetic. It's all around you — the magic of the movies, the homes of the stars, the big sign in the hills — but where, exactly, is it?
Before I became a film critic, I never spent much time in Los Angeles, and my subsequent acquaintance with the city has been colored, and perhaps distorted, by my job. It is all too easy, when you write about movies, to wrap yourself in a carapace of cynicism; you don't want to come off as too star-struck, too susceptible to the glamour that still emanates from Hollywood. And so you learn to inflect the word “Hollywood” with a certain disdain, to show that you don't buy all those clichés about Tinseltown and the Dream Factory. If you come from New York and have seen “Annie Hall” as many times as I have, you may also retain certain snobbish prejudices about the place.
But who am I kidding? Hollywood may connote shameless commercialism, but it also conjures a powerful, undimmed spell of romance. The paradoxical mystique of movie stars — we feel like we know them so well, even as their lives seem so fantastically distant from ours — extends to the place where they are hatched and raised.
Luckily, my children, now 8 and 10 years old, provide an antidote to my put-on professional world-weariness. They are voracious, indiscriminate consumers of popular culture, and while I can't always share their enthusiasm — in the interests of family harmony, we tacitly agree not to bring up my reviews of “Madagascar” or “Chicken Little” — I am always happy to feed it.
And so when work calls me out to Southern California, I try whenever possible to take the family along. Over the last few years, the four of us have developed a collective crush on Los Angeles.
Earlier this spring, I left behind my critical agenda and, inspired by “Little Miss Sunshine,” the National Lampoon “Vacation” movies and a half-dozen relevant episodes of “The Simpsons,” assumed the role of affable tourist doofus dad. In this script my wife, Justine, was perfectly typecast as the voice of skepticism and good sense. Our children adopted pseudonyms, both to protect their anonymity in the newspaper and to pay tribute to the local tradition of self-reinvention that turned Issur Danielovich Demsky into Kirk Douglas and Norma Jeane Baker into Marilyn Monroe. The boy renamed himself Wayne Bruce, in triple tribute to Batman, the Duke and the star of “Die Hard,” which he'd recently seen part of on cable and which is, not coincidentally, a movie about a New Yorker coping with life in Los Angeles. His younger sister chose to inscribe herself in the tradition of single-named divas; we'll call her Melody.
We took an afternoon flight to LAX and found ourselves in the rental car lot just in time for rush hour. Wayne Bruce, true to action-hero form, wanted to roll out in the red Hummer. I'll admit to ogling the Dodge Magnum. Half an hour later, thrift and good sense prevailed and we were crawling north on the 405 in a silver Impala under a disconcertingly cloudy sky. We checked into our cozy suite in West Hollywood, ordered hamburgers and quesadillas and set about storyboarding the days ahead.
The plan was to balance present and past, sensation and education, indoors and out. We wanted not only to explore movie-related tourist sites, but also to score a vicarious taste of what our movie-saturated imaginations pictured as a Hollywood lifestyle. Thus a certain amount of time would be allotted for lounging beside the pool, for being seen in trendy restaurants, for driving aimlessly in the hills, for staring at the Pacific Ocean.
“Will we see any celebrities?” Melody wondered. As it happened, we would not. There was one of those I-know-I've-seen-him-somewhere encounters, in an aisle of the Whole Foods in Santa Monica, with an actor who had the good grace to show up in a rerun on the hotel TV that night. And our guide on the Warner Brothers studio tour did make eye contact with me in his rear view mirror and ask, “Did anyone ever tell you you look like Paul Giamatti?”
But I'm ahead of the story. A studio tour was to be the first order of business. We had done Universal Studios — more of a theme park ride than a tour — on a previous visit; Disney doesn't offer tours of its studio lot, and neither does Fox (D'oh!). Paramount and Sony don't accommodate children under 12. That left Warner Brothers. The voice message said that reservations were accepted for the first tours of the morning (at 8:30 and 9), and that the rest of the day was first come first served.
So after a leisurely breakfast at the Urth Caffé on Melrose in West Hollywood, surrounded by script-readers and -writers and other aspirants to Hollywood glory, we made it to Burbank by 10:30. “Do you have a reservation?” we were asked. Well, no we didn't. Rather than wait three hours, we made reservations for the next afternoon and headed back over the hills, touching down at the intersection of Hollywood and Highland.
This turned out to be a good place to start — the epicenter of Hollywood tourism, an open-air theme park and pilgrimage site. Grauman's Chinese Theater, the Walk of Fame, the Kodak Theater shopping-mall complex where the Oscars are handed out: they're all right here.
We began with the Hollywood History Museum, which occupies a handsome Art Deco building that used to house the Max Factor makeup company. As I bought tickets, Justine pointed her digital camera at a poster in the lobby — an advertisement for the museum itself — and was immediately accosted by a man who seemed more like a junior production executive than the security guard he apparently was. “Ma'am, I'll have to ask you to erase that picture,” he said, explaining that “everything in this museum is a copyrighted piece of intellectual property.”
This was a useful object lesson, a reminder that we were visitors in a company town. We tend to think of movies as public property. Who do they belong to, if not the fans? But of course they are made, distributed, owned and fiercely protected by large commercial interests. And so we checked the camera at the front desk and worked our way through the jumble of memorabilia that is the Hollywood History Museum.
History is not, in that museum or anywhere else in Hollywood, a sequential, chronological affair. The Max Factor Building has been made over into a glorious attic, where posters, costumes, autographs and props line walls and fill vitrines according to no discernable principles of organization. John Garfield, John Wayne, Bruce Willis, Johnny Depp, Elvis Presley, Janet Gaynor, Jodie Foster — they're all thrown together, along with thousands more, just as they would be on the shelves of an especially chaotic video store. That may be the idea: movies exist in an eternal present, which is to say whenever you happen to watch them. And who has ever watched them in chronological — or any other logical — order?
My favorite room was filled with pictures of old-time stars, and also of the city itself, taken at various points in its evolution from a sleepy Western outpost into a sprawling postmodern metropolis. But the feeling was less one of nostalgia than of continuity and equivalence.
The Hollywood tourist experience creates the impression that legends of the past are equal to the glories of the present. This is quite deliberate. If the golden age were located too firmly in the past, then how could the appetite for novelty on which the entertainment industry depends be sustained? Wayne and Melody, big fans of “Some Like It Hot,” were happy to see Marilyn Monroe at the Hollywood Wax Museum (our next stop), but they were more excited by Spiderman and Freddy and Jason and the crew of the Black Pearl.
And the Walk of Fame, which stretches along Hollywood Boulevard in both directions, expands on this happy heterogeneity. Critics and historians can evaluate quality and importance, but the sun shines on the legendary and the forgotten, the great and the awful — Judy Garland's square of pavement and Mary-Kate and Ashley Olsen's — alike. You can follow their names from the Chinese to the Egyptian, home of the American Cinematheque, a shrine to serious cinema art, and stop on the way to have your picture taken with a guy dressed as SpongeBob or Homer Simpson (him again!) and buy a hollow replica of an Oscar statuette with the inscription Best Dad.
As we walked east, the homogenized atmosphere of chain restaurants and licensed merchandise turned seedy, as if the New Times Square were adjacent to the old one, rather than on top of it. We debated joining an organized walking tour of Hollywood sites, or boarding a bus that would take us past movie star homes, but decided to wander instead. We gazed at windows full of wigs and costumes, and were happy, for most of an hour, to trade the magic of Hollywood for Hollywood Magic, a marvelous old-style novelty shop. There, a man behind the counter performed card and coin tricks, much to the delight of Wayne and Melody, who spent some of her allowance on a Whoopee Cushion.
BY dinnertime, we were ready for more refined amusement, or at least a good dinner. Did we have a reservation? No, but when we called Lucques, a highly rated restaurant a short walk from the hotel, we were told that a party of four had just canceled. Justine and Melody shared the seared breast of duck, and Wayne polished off a plate of short ribs.
Justine likes movies, but she loves birds and trees, and so the next day, on our way to Warner Brothers, we drove into Griffith Park, where trails wind through the wooded hillsides toward the Hollywood sign and the Observatory. Scrambling through brush and the rocks, we could imagine ourselves in the Old West, or deep in the jungle, or, once we reached the Observatory terrace, in “Rebel Without a Cause.” All of which were perfectly apt. The varied natural and human topography of greater Los Angeles — desert, forest, suburb, seaside, slum — has made it almost infinitely adaptable. One of the reasons so many movies are made here is that it can so easily pass for just about anywhere.
And what Hollywood cannot find, it builds and recycles. This was the theme of the Warner Brothers tour, which took us through empty back lots and sound stages, further scrambling our sense of location and history. Since it was a holiday, no one was working except the tour guide, who talked as if he was not an employee of Time Warner but one of the original Brothers. As he drove us past the bungalows that once housed writers and actors on contract, he recounted that Bette Davis had once demanded an entire building to herself. “She was one of our biggest stars,” he said, “and since she'd made us so much money we were happy to give her whatever she wanted.” I'm sure he was.
But the tour, in keeping with the endless scrambling of past and present, was less about Bette Davis than “The Gilmore Girls.” We stopped in Stars Hollow to take permitted photographs, and wandered through the Gilmore mansion, which is housed in a sound stage. But Stars Hollow used to be Walton's Mountain, and before that, part of it was Kings Row, where Ronald Reagan lived before he went into politics. And the “Gilmore Girls” sound stage used to be “Casablanca.” Much of the lot was built in the early years of the sound era, and its city streets and country towns have been used hundreds of times — in bad and good movies and (more frequently now) in television shows — ever since.
It began to occur to us that what we were encountering was raw materials and byproducts, none of which were quite as satisfying as the movies themselves. It isn't so much that Los Angeles saves its best face for the camera, but more that its ubiquity on screen creates a strange sense of familiarity. The Richard Neutra houses and Spanish-style bungalows; the Capitol Records Building and the Santa Monica Pier; Rodeo Drive and Skid Row — I see them every week, juxtaposed in ways forbidden by traffic and geography, and framed and filtered by more evocative lenses than the ones on my glasses.
Happy as we were to be in the real Los Angeles, we found that what we really wanted to do was go to the movies, and our attempt was thwarted in a quintessentially Hollywood fashion. According to the papers, there was an early-evening screening in the Cinerama Dome, a refurbished 1950s showpiece (now part of the Arclight complex) built for the three-projector wide-screen spectaculars that were meant to save the movies from television. But the Dome is a popular place for premieres, and when we arrived the red carpet and velvet ropes were being prepared for that night's “Entourage” gala.
The next day, Melody and Justine, having decided that some movie-star-grade pampering was in order, went for hot stone massages at a day spa. Wayne and I took a power breakfast in Larchmont Village, a neighborhood that seemed eerily familiar. Dads pushing jogging strollers; moms lugging yoga mats: it was Park Slope, but with palm trees.
Then, hungering for a glimpse of the ocean, even through the persistent cloud cover, the four of us drove up the Pacific Coast Highway to Malibu, and pushed the Impala through hairpin turns into the Santa Monica Mountains, where we found the Paramount Ranch. Now part of a national park, the ranch was where the studio shot many of its westerns. The Western Town, most recently home of “Dr. Quinn, Medicine Woman,” is still there, and Wayne shot me down, just as if I was Liberty Valance, on its dusty main street. The town wasn't big enough for the both of us.
We wound along Mulholland and then turned toward the Pacific, to follow our western with a surfing movie. At Point Dume State Beach we dug our toes into the sand, stared dreamily into the distance and spotted dolphins frolicking not far from shore, a sight more thrilling than any movie.
As the sun set, we turned off the highway onto Sunset Boulevard. The sandy children dozed in the back and I could sense the glow of a Hollywood feeling I had sought without quite knowing it. Maybe it was the feeling of finding myself in a perfectly cinematic moment, as the road snaked through Pacific Palisades, Brentwood and Beverly Hills, past the grand, gated homes, the hand-lettered signs advertising Star Maps and the bored dreamers selling them. The drive was mundane and romantic at the same time, and as we descended onto the Sunset Strip in search of dinner (which we found, without reservations, at a Japanese restaurant where Jim Jarmusch's “Dead Man” was silently projected on a courtyard wall), we felt lost and completely at home.
A few weeks later, back in her third-grade classroom, Melody wrote an essay about her trip “to a place I like to call Hollywood.” I'm not sure exactly which place she meant, but I like to call it that too.
VISITOR INFORMATION
The unassuming Le Parc Suite Hotel blends into its quiet residential block in West Hollywood. Its spacious, reasonably priced suites, which make the hotel popular with musicians and film crews in town for extended stays, also make it appealing for families. The studio and one-bedroom suites can sleep four people comfortably, with varying degrees of privacy, and have kitchenettes and small balconies. Meals can be taken at the Knoll restaurant on the third floor; you can also order food on the rooftop terrace, where there is a small heated pool, a hot tub and tennis courts. (733 North West Knoll Drive; 310-855-8888; www.leparcsuites.com. Rates vary seasonally. Current rates begin at $229 for a studio.)
Groceries can be purchased at Trader Joe's, a 10-minute walk from Le Parc at 8611 Santa Monica Boulevard. Urth Caffé, not far away at 8565 Melrose Avenue, has excellent coffee, healthy and generous breakfast and lunch offerings and good opportunities for movie-industry eavesdropping. Le Parc is also within walking distance of the trendy Melrose shopping district, and from Lucques (8474 Melrose; 323-655-6277; www.lucques.com), which serves creative and thoughtfully prepared Cal-French cuisine in a carriage house once owned by the silent-film star Harold Lloyd. Another memorable meal was at Yatai (8535 Sunset Boulevard; 310-289-0030; www.yatai-bar.com), an Asian tapas bar whose sleek, dark ambience seemed much less child-friendly than its selection of small dishes (including satay, vegetable rolls and addictive nuggets of fried chicken) turned out to be. The mojitos are good, too.
Reservations for the Warner Brothers VIP studio tours can be made by calling (818) 972-8687 or at www.warnerbros.com. The tours last a little more than two hours; children must be at least 8 years old. Tickets are $42 a person.
Tickets for the various sites near Hollywood and Highland can be purchased individually. Or, at any of them, you can buy a Walk of Fame City Pass that includes the Hollywood History Museum or the Kodak Theater, the Hollywood Wax Museum, the Hollywood Behind-the-Scenes Walking Tour and the Starline bus tour. It costs $49.95 and is valid for nine days. Star Maps can be purchased for $5 from anyone sitting in a folding chair under a sign that says “Star Maps, $5.”
Griffith Park is open daily from 6 a.m. to 10 p.m. (Park information is at www.lacity.org/rap/dos/parks/griffithPK or 323-913-4688). Admission to the Observatory (www.griffithobs.org) requires a timed ticket ($8 for adults; $4 for children 5-12) and a shuttle bus ride from Hollywood and Highland. Reservations: (888) 695-0888. The Paramount Ranch is part of the Santa Monica Mountains National Recreation Area (805-370-2301; www.nps.gov/samo) in Thousand Oaks. It is open daily from 9 to 5. There is a covered picnic area and a performance stage behind the Western Town.
Hollywood Magic is at 6614 Hollywood Boulevard (323-464-5610). Collectors, souvenir hunters and comic-book geeks should not miss Meltdown (7522 Sunset Boulevard; 323-851-7223; www.meltcomics.com), which has an impressive and eclectic selection of action-figures, memorabilia, comics and graphic novels.
Thursday, May 10, 2007
Pharma and antipsychotic prescribing
NYTimes
May 10, 2007
Industry’s Role in Childrens’ Antipsychotics
By GARDINER HARRIS, BENEDICT CAREY and JANET ROBERTS
When Anya Bailey developed an eating disorder after her 12th birthday, her mother took her to a psychiatrist at the University of Minnesota who prescribed a powerful antipsychotic drug called Risperdal.
Created for schizophrenia, Risperdal is not approved to treat eating disorders, but increased appetite is a common side effect and doctors may prescribe drugs as they see fit. Anya gained weight but within two years developed a crippling knot in her back. She now receives regular injections of Botox to unclench her back muscles. She often awakens crying in pain.
Isabella Bailey, Anya’s mother, said she had no idea that children might be especially susceptible to Risperdal’s side effects. Nor did she know that Risperdal and similar medicines were not approved at the time to treat children, or that medical trials often cited to justify the use of such drugs had as few as eight children taking the drug by the end.
Just as surprising, Ms. Bailey said, was learning that the university psychiatrist who supervised Anya’s care received more than $7,000 from 2003 to 2004 from Johnson & Johnson, Risperdal’s maker, in return for lectures about one of the company’s drugs.
Doctors, including Anya Bailey’s, maintain that payments from drug companies do not influence what they prescribe for patients.
But the intersection of money and medicine, and its effect on the well-being of patients, has become one of the most contentious issues in health care. Nowhere is that more true than in psychiatry, where increasing payments to doctors have coincided with the growing use in children of a relatively new class of drugs known as atypical antipsychotics.
These best-selling drugs, including Risperdal, Seroquel, Zyprexa, Abilify and Geodon, are now being prescribed to more than half a million children in the United States to help parents deal with behavior problems despite profound risks and almost no approved uses for minors.
A New York Times analysis of records in Minnesota, the only state that requires public reports of all drug company marketing payments to doctors, provides rare documentation of how financial relationships between doctors and drug makers correspond to the growing use of atypicals in children.
From 2000 to 2005, drug maker payments to Minnesota psychiatrists rose more than sixfold, to $1.6 million. During those same years, prescriptions of antipsychotics for children in Minnesota’s Medicaid program rose more than ninefold.
Those who took the most money from makers of atypicals tended to prescribe the drugs to children the most often, the data suggest. On average, Minnesota psychiatrists who received at least $5,000 from atypical makers from 2000 to 2005 appear to have written three times as many atypical prescriptions for children as psychiatrists who received less or no money.
The Times analysis focused on prescriptions written for about one-third of Minnesota’s Medicaid population, almost all of whom are disabled. Some doctors were misidentified by pharmacists, but the information provides a rough guide to prescribing patterns in the state.
Drug makers underwrite decision makers at every level of care. They pay doctors who prescribe and recommend drugs, teach about the underlying diseases, perform studies and write guidelines that other doctors often feel bound to follow.
But studies present strong evidence that financial interests can affect decisions, often without people knowing it.
In Minnesota, psychiatrists collected more money from drug makers from 2000 to 2005 than doctors in any other specialty. Total payments to individual psychiatrists ranged from $51 to more than $689,000, with a median of $1,750. Since the records are incomplete, these figures probably underestimate doctors’ actual incomes.
Such payments could encourage psychiatrists to use drugs in ways that endanger patients’ physical health, said Dr. Steven E. Hyman, the provost of Harvard University and former director of the National Institute of Mental Health. The growing use of atypicals in children is the most troubling example of this, Dr. Hyman said.
“There’s an irony that psychiatrists ask patients to have insights into themselves, but we don’t connect the wires in our own lives about how money is affecting our profession and putting our patients at risk,” he said.
The Prescription
Anya Bailey is a 15-year-old high school freshman from East Grand Forks, Minn., with pictures of the actor Chad Michael Murray on her bedroom wall. She has constant discomfort in her neck that leads her to twist it in a birdlike fashion. Last year, a boy mimicked her in the lunch room.
“The first time, I laughed it off,” Anya said. “I said: ‘That’s so funny. I think I’ll laugh with you.’ Then it got annoying, and I decided to hide it. I don’t want to be made fun of.”
Now she slumps when seated at school to pressure her clenched muscles, she said.
It all began in 2003 when Anya became dangerously thin. “Nothing tasted good to her,” Ms. Bailey said.
Psychiatrists at the University of Minnesota, overseen by Dr. George M. Realmuto, settled on Risperdal, not for its calming effects but for its normally unwelcome side effect of increasing appetite and weight gain, Ms. Bailey said. Anya had other issues that may have recommended Risperdal to doctors, including occasional angry outbursts and having twice heard voices over the previous five years, Ms. Bailey said.
Dr. Realmuto said he did not remember Anya’s case, but speaking generally he defended his unapproved use of Risperdal to counter an eating disorder despite the drug’s risks. “When things are dangerous, you use extraordinary measures,” he said.
Ten years ago, Dr. Realmuto helped conduct a study of Concerta, an attention deficit hyperactivity disorder drug marketed by Johnson & Johnson, which also makes Risperdal. When Concerta was approved, the company hired him to lecture about it.
He said he gives marketing lectures for several reasons.
“To the extent that a drug is useful, I want to be seen as a leader in my specialty and that I was involved in a scientific study,” he said.
The money is nice, too, he said. Dr. Realmuto’s university salary is $196,310.
“Academics don’t get paid very much,” he said. “If I was an entertainer, I think I would certainly do a lot better.”
In 2003, the year Anya came to his clinic, Dr. Realmuto earned $5,000 from Johnson & Johnson for giving three talks about Concerta. Dr. Realmuto said he could understand someone’s worrying that his Concerta lecture fees would influence him to prescribe Concerta but not a different drug from the same company, like Risperdal.
In general, he conceded, his relationship with a drug company might prompt him to try a drug. Whether he continued to use it, though, would depend entirely on the results.
As the interview continued, Dr. Realmuto said that upon reflection his payments from drug companies had probably opened his door to useless visits from a drug salesman, and he said he would stop giving sponsored lectures in the future.
Kara Russell, a Johnson & Johnson spokeswoman, said that the company selects speakers who have used the drug in patients and have either undertaken research or are aware of the studies. “Dr. Realmuto met these criteria,” Ms. Russell said.
When asked whether these payments may influence doctors’ prescribing habits, Ms. Russell said that the talks “provide an educational opportunity for physicians.”
No one has proved that psychiatrists prescribe atypicals to children because of drug company payments. Indeed, some who frequently prescribe the drugs to children earn no drug industry money. And nearly all psychiatrists who accept payments say they remain independent. Some say they prescribed and extolled the benefits of such drugs before ever receiving payments to speak to other doctors about them.
“If someone takes the point of view that your doctor can be bought, why would you go to an E. R. with your injured child and say, ‘Can you help me?’ ” said Dr. Suzanne A. Albrecht, a psychiatrist from Edina, Minn., who earned more than $188,000 from 2002 to 2005 giving drug marketing talks.
The Industry Campaign
It is illegal for drug makers to pay doctors directly to prescribe specific products. Federal rules also bar manufacturers from promoting unapproved, or off-label, uses for drugs.
But doctors are free to prescribe as they see fit, and drug companies can sidestep marketing prohibitions by paying doctors to give lectures in which, if asked, they may discuss unapproved uses.
The drug industry and many doctors say that these promotional lectures provide the field with invaluable education. Critics say the payments and lectures, often at expensive restaurants, are disguised kickbacks that encourage potentially dangerous drug uses. The issue is particularly important in psychiatry, because mental problems are not well understood, treatment often involves trial and error, and off-label prescribing is common.
The analysis of Minnesota records shows that from 1997 through 2005, more than a third of Minnesota’s licensed psychiatrists took money from drug makers, including the last eight presidents of the Minnesota Psychiatric Society.
The psychiatrist receiving the most from drug companies was Dr. Annette M. Smick, who lives outside Rochester, Minn., and was paid more than $689,000 by drug makers from 1998 to 2004. At one point Dr. Smick was doing so many sponsored talks that “it was hard for me to find time to see patients in my clinical practice,” she said.
“I was providing an educational benefit, and I like teaching,” Dr. Smick said.
Dr. Steven S. Sharfstein, immediate past president of the American Psychiatric Association, said psychiatrists have become too cozy with drug makers. One example of this, he said, involves Lexapro, made by Forest Laboratories, which is now the most widely used antidepressant in the country even though there are cheaper alternatives, including generic versions of Prozac.
“Prozac is just as good if not better, and yet we are migrating to the expensive drug instead of the generics,” Dr. Sharfstein said. “I think it’s the marketing.”
Atypicals have become popular because they can settle almost any extreme behavior, often in minutes, and doctors have few other answers for desperate families.
Their growing use in children is closely tied to the increasingly common and controversial diagnosis of pediatric bipolar disorder, a mood problem marked by aggravation, euphoria, depression and, in some cases, violent outbursts. The drugs, sometimes called major tranquilizers, act by numbing brain cells to surges of dopamine, a chemical that has been linked to euphoria and psychotic delusions.
Suzette Scheele of Burnsville, Minn., said her 17-year-old son, Matt, was given a diagnosis of bipolar disorder four years ago because of intense mood swings, and now takes Seroquel and Abilify, which have caused substantial weight gain.
“But I don’t have to worry about his rages; he’s appropriate; he’s pleasant to be around,” Ms. Scheele said.
The sudden popularity of pediatric bipolar diagnosis has coincided with a shift from antidepressants like Prozac to far more expensive atypicals. In 2000, Minnesota spent more than $521,000 buying antipsychotic drugs, most of it on atypicals, for children on Medicaid. In 2005, the cost was more than $7.1 million, a 14-fold increase.
The drugs, which can cost $1,000 to $8,000 for a year’s supply, are huge sellers worldwide. In 2006, Zyprexa, made by Eli Lilly, had $4.36 billion in sales, Risperdal $4.18 billion and Seroquel, made by AstraZeneca, $3.42 billion.
Many Minnesota doctors, including the president of the Minnesota Psychiatric Society, said drug makers and their intermediaries are now paying them almost exclusively to talk about bipolar disorder.
The Diagnoses
Yet childhood bipolar disorder is an increasingly controversial diagnosis. Even doctors who believe it is common disagree about its telltale symptoms. Others suspect it is a fad. And the scientific evidence that atypicals improve these children’s lives is scarce.
One of the first and perhaps most influential studies was financed by AstraZeneca and performed by Dr. Melissa DelBello, a child and adult psychiatrist at the University of Cincinnati.
Dr. DelBello led a research team that tracked for six weeks the moods of 30 adolescents who had received diagnoses of bipolar disorder. Half of the teenagers took Depakote, an antiseizure drug used to treat epilepsy and bipolar disorder in adults. The other half took Seroquel and Depakote.
The two groups did about equally well until the last few days of the study, when those in the Seroquel group scored lower on a standard measure of mania. By then, almost half of the teenagers getting Seroquel had dropped out because they missed appointments or the drugs did not work. Just eight of them completed the trial.
In an interview, Dr. DelBello acknowledged that the study was not conclusive. In the 2002 published paper, however, she and her co-authors reported that Seroquel in combination with Depakote “is more effective for the treatment of adolescent bipolar mania” than Depakote alone.
In 2005, a committee of prominent experts from across the country examined all of the studies of treatment for pediatric bipolar disorder and decided that Dr. DelBello’s was the only study involving atypicals in bipolar children that deserved its highest rating for scientific rigor. The panel concluded that doctors should consider atypicals as a first-line treatment for some children. The guidelines were published in The Journal of the American Academy of Child and Adolescent Psychiatry.
Three of the four doctors on the panel served as speakers or consultants to makers of atypicals, according to disclosures in the guidelines. In an interview, Dr. Robert A. Kowatch, a psychiatrist at Cincinnati Children’s Hospital and the lead author of the guidelines, said the drug makers’ support had no influence on the conclusions.
AstraZeneca hired Dr. DelBello and Dr. Kowatch to give sponsored talks. They later undertook another study comparing Seroquel and Depakote in bipolar children and found no difference. Dr. DelBello, who earns $183,500 annually from the University of Cincinnati, would not discuss how much she is paid by AstraZeneca.
“Trust me, I don’t make much,” she said. Drug company payments did not affect her study or her talks, she said. In a recent disclosure, Dr. DelBello said that she received marketing or consulting income from eight drug companies, including all five makers of atypicals.
Dr. Realmuto has heard Dr. DelBello speak several times, and her talks persuaded him to use combinations of Depakote and atypicals in bipolar children, he said. “She’s the leader in terms of doing studies on bipolar,” Dr. Realmuto said.
Some psychiatrists who advocate use of atypicals in children acknowledge that the evidence supporting this use is thin. But they say children should not go untreated simply because scientists have failed to confirm what clinicians already know.
“We don’t have time to wait for them to prove us right,” said Dr. Kent G. Brockmann, a psychiatrist from the Twin Cities who made more than $16,000 from 2003 to 2005 doing drug talks and one-on-one sales meetings, and last year was a leading prescriber of atypicals to Medicaid children.
The Reaction
For Anya Bailey, treatment with an atypical helped her regain her appetite and put on weight, but also heavily sedated her, her mother said. She developed the disabling knot in her back, the result of a nerve condition called dystonia, in 2005.
The reaction was rare but not unknown. Atypicals have side effects that are not easy to predict in any one patient. These include rapid weight gain and blood sugar problems, both risk factors for diabetes; disfiguring tics, dystonia and in rare cases heart attacks and sudden death in the elderly.
In 2006, the Food and Drug Administration received reports of at least 29 children dying and at least 165 more suffering serious side effects in which an antipsychotic was listed as the “primary suspect.” That was a substantial jump from 2000, when there were at least 10 deaths and 85 serious side effects among children linked to the drugs. Since reporting of bad drug effects is mostly voluntary, these numbers likely represent a fraction of the toll.
Jim Minnick, a spokesman for AstraZeneca, said that the company carefully monitors reported problems with Seroquel. “AstraZeneca believes that Seroquel is safe,” Mr. Minnick said.
Other psychiatrists renewed Anya’s prescriptions for Risperdal until Ms. Bailey took Anya last year to the Mayo Clinic, where a doctor insisted that Ms. Bailey stop the drug. Unlike most universities and hospitals, the Mayo Clinic restricts doctors from giving drug marketing lectures.
Ms. Bailey said she wished she had waited to see whether counseling would help Anya before trying drugs. Anya’s weight is now normal without the help of drugs, and her counseling ended in March. An experimental drug, her mother said, has recently helped the pain in her back.
May 10, 2007
Industry’s Role in Childrens’ Antipsychotics
By GARDINER HARRIS, BENEDICT CAREY and JANET ROBERTS
When Anya Bailey developed an eating disorder after her 12th birthday, her mother took her to a psychiatrist at the University of Minnesota who prescribed a powerful antipsychotic drug called Risperdal.
Created for schizophrenia, Risperdal is not approved to treat eating disorders, but increased appetite is a common side effect and doctors may prescribe drugs as they see fit. Anya gained weight but within two years developed a crippling knot in her back. She now receives regular injections of Botox to unclench her back muscles. She often awakens crying in pain.
Isabella Bailey, Anya’s mother, said she had no idea that children might be especially susceptible to Risperdal’s side effects. Nor did she know that Risperdal and similar medicines were not approved at the time to treat children, or that medical trials often cited to justify the use of such drugs had as few as eight children taking the drug by the end.
Just as surprising, Ms. Bailey said, was learning that the university psychiatrist who supervised Anya’s care received more than $7,000 from 2003 to 2004 from Johnson & Johnson, Risperdal’s maker, in return for lectures about one of the company’s drugs.
Doctors, including Anya Bailey’s, maintain that payments from drug companies do not influence what they prescribe for patients.
But the intersection of money and medicine, and its effect on the well-being of patients, has become one of the most contentious issues in health care. Nowhere is that more true than in psychiatry, where increasing payments to doctors have coincided with the growing use in children of a relatively new class of drugs known as atypical antipsychotics.
These best-selling drugs, including Risperdal, Seroquel, Zyprexa, Abilify and Geodon, are now being prescribed to more than half a million children in the United States to help parents deal with behavior problems despite profound risks and almost no approved uses for minors.
A New York Times analysis of records in Minnesota, the only state that requires public reports of all drug company marketing payments to doctors, provides rare documentation of how financial relationships between doctors and drug makers correspond to the growing use of atypicals in children.
From 2000 to 2005, drug maker payments to Minnesota psychiatrists rose more than sixfold, to $1.6 million. During those same years, prescriptions of antipsychotics for children in Minnesota’s Medicaid program rose more than ninefold.
Those who took the most money from makers of atypicals tended to prescribe the drugs to children the most often, the data suggest. On average, Minnesota psychiatrists who received at least $5,000 from atypical makers from 2000 to 2005 appear to have written three times as many atypical prescriptions for children as psychiatrists who received less or no money.
The Times analysis focused on prescriptions written for about one-third of Minnesota’s Medicaid population, almost all of whom are disabled. Some doctors were misidentified by pharmacists, but the information provides a rough guide to prescribing patterns in the state.
Drug makers underwrite decision makers at every level of care. They pay doctors who prescribe and recommend drugs, teach about the underlying diseases, perform studies and write guidelines that other doctors often feel bound to follow.
But studies present strong evidence that financial interests can affect decisions, often without people knowing it.
In Minnesota, psychiatrists collected more money from drug makers from 2000 to 2005 than doctors in any other specialty. Total payments to individual psychiatrists ranged from $51 to more than $689,000, with a median of $1,750. Since the records are incomplete, these figures probably underestimate doctors’ actual incomes.
Such payments could encourage psychiatrists to use drugs in ways that endanger patients’ physical health, said Dr. Steven E. Hyman, the provost of Harvard University and former director of the National Institute of Mental Health. The growing use of atypicals in children is the most troubling example of this, Dr. Hyman said.
“There’s an irony that psychiatrists ask patients to have insights into themselves, but we don’t connect the wires in our own lives about how money is affecting our profession and putting our patients at risk,” he said.
The Prescription
Anya Bailey is a 15-year-old high school freshman from East Grand Forks, Minn., with pictures of the actor Chad Michael Murray on her bedroom wall. She has constant discomfort in her neck that leads her to twist it in a birdlike fashion. Last year, a boy mimicked her in the lunch room.
“The first time, I laughed it off,” Anya said. “I said: ‘That’s so funny. I think I’ll laugh with you.’ Then it got annoying, and I decided to hide it. I don’t want to be made fun of.”
Now she slumps when seated at school to pressure her clenched muscles, she said.
It all began in 2003 when Anya became dangerously thin. “Nothing tasted good to her,” Ms. Bailey said.
Psychiatrists at the University of Minnesota, overseen by Dr. George M. Realmuto, settled on Risperdal, not for its calming effects but for its normally unwelcome side effect of increasing appetite and weight gain, Ms. Bailey said. Anya had other issues that may have recommended Risperdal to doctors, including occasional angry outbursts and having twice heard voices over the previous five years, Ms. Bailey said.
Dr. Realmuto said he did not remember Anya’s case, but speaking generally he defended his unapproved use of Risperdal to counter an eating disorder despite the drug’s risks. “When things are dangerous, you use extraordinary measures,” he said.
Ten years ago, Dr. Realmuto helped conduct a study of Concerta, an attention deficit hyperactivity disorder drug marketed by Johnson & Johnson, which also makes Risperdal. When Concerta was approved, the company hired him to lecture about it.
He said he gives marketing lectures for several reasons.
“To the extent that a drug is useful, I want to be seen as a leader in my specialty and that I was involved in a scientific study,” he said.
The money is nice, too, he said. Dr. Realmuto’s university salary is $196,310.
“Academics don’t get paid very much,” he said. “If I was an entertainer, I think I would certainly do a lot better.”
In 2003, the year Anya came to his clinic, Dr. Realmuto earned $5,000 from Johnson & Johnson for giving three talks about Concerta. Dr. Realmuto said he could understand someone’s worrying that his Concerta lecture fees would influence him to prescribe Concerta but not a different drug from the same company, like Risperdal.
In general, he conceded, his relationship with a drug company might prompt him to try a drug. Whether he continued to use it, though, would depend entirely on the results.
As the interview continued, Dr. Realmuto said that upon reflection his payments from drug companies had probably opened his door to useless visits from a drug salesman, and he said he would stop giving sponsored lectures in the future.
Kara Russell, a Johnson & Johnson spokeswoman, said that the company selects speakers who have used the drug in patients and have either undertaken research or are aware of the studies. “Dr. Realmuto met these criteria,” Ms. Russell said.
When asked whether these payments may influence doctors’ prescribing habits, Ms. Russell said that the talks “provide an educational opportunity for physicians.”
No one has proved that psychiatrists prescribe atypicals to children because of drug company payments. Indeed, some who frequently prescribe the drugs to children earn no drug industry money. And nearly all psychiatrists who accept payments say they remain independent. Some say they prescribed and extolled the benefits of such drugs before ever receiving payments to speak to other doctors about them.
“If someone takes the point of view that your doctor can be bought, why would you go to an E. R. with your injured child and say, ‘Can you help me?’ ” said Dr. Suzanne A. Albrecht, a psychiatrist from Edina, Minn., who earned more than $188,000 from 2002 to 2005 giving drug marketing talks.
The Industry Campaign
It is illegal for drug makers to pay doctors directly to prescribe specific products. Federal rules also bar manufacturers from promoting unapproved, or off-label, uses for drugs.
But doctors are free to prescribe as they see fit, and drug companies can sidestep marketing prohibitions by paying doctors to give lectures in which, if asked, they may discuss unapproved uses.
The drug industry and many doctors say that these promotional lectures provide the field with invaluable education. Critics say the payments and lectures, often at expensive restaurants, are disguised kickbacks that encourage potentially dangerous drug uses. The issue is particularly important in psychiatry, because mental problems are not well understood, treatment often involves trial and error, and off-label prescribing is common.
The analysis of Minnesota records shows that from 1997 through 2005, more than a third of Minnesota’s licensed psychiatrists took money from drug makers, including the last eight presidents of the Minnesota Psychiatric Society.
The psychiatrist receiving the most from drug companies was Dr. Annette M. Smick, who lives outside Rochester, Minn., and was paid more than $689,000 by drug makers from 1998 to 2004. At one point Dr. Smick was doing so many sponsored talks that “it was hard for me to find time to see patients in my clinical practice,” she said.
“I was providing an educational benefit, and I like teaching,” Dr. Smick said.
Dr. Steven S. Sharfstein, immediate past president of the American Psychiatric Association, said psychiatrists have become too cozy with drug makers. One example of this, he said, involves Lexapro, made by Forest Laboratories, which is now the most widely used antidepressant in the country even though there are cheaper alternatives, including generic versions of Prozac.
“Prozac is just as good if not better, and yet we are migrating to the expensive drug instead of the generics,” Dr. Sharfstein said. “I think it’s the marketing.”
Atypicals have become popular because they can settle almost any extreme behavior, often in minutes, and doctors have few other answers for desperate families.
Their growing use in children is closely tied to the increasingly common and controversial diagnosis of pediatric bipolar disorder, a mood problem marked by aggravation, euphoria, depression and, in some cases, violent outbursts. The drugs, sometimes called major tranquilizers, act by numbing brain cells to surges of dopamine, a chemical that has been linked to euphoria and psychotic delusions.
Suzette Scheele of Burnsville, Minn., said her 17-year-old son, Matt, was given a diagnosis of bipolar disorder four years ago because of intense mood swings, and now takes Seroquel and Abilify, which have caused substantial weight gain.
“But I don’t have to worry about his rages; he’s appropriate; he’s pleasant to be around,” Ms. Scheele said.
The sudden popularity of pediatric bipolar diagnosis has coincided with a shift from antidepressants like Prozac to far more expensive atypicals. In 2000, Minnesota spent more than $521,000 buying antipsychotic drugs, most of it on atypicals, for children on Medicaid. In 2005, the cost was more than $7.1 million, a 14-fold increase.
The drugs, which can cost $1,000 to $8,000 for a year’s supply, are huge sellers worldwide. In 2006, Zyprexa, made by Eli Lilly, had $4.36 billion in sales, Risperdal $4.18 billion and Seroquel, made by AstraZeneca, $3.42 billion.
Many Minnesota doctors, including the president of the Minnesota Psychiatric Society, said drug makers and their intermediaries are now paying them almost exclusively to talk about bipolar disorder.
The Diagnoses
Yet childhood bipolar disorder is an increasingly controversial diagnosis. Even doctors who believe it is common disagree about its telltale symptoms. Others suspect it is a fad. And the scientific evidence that atypicals improve these children’s lives is scarce.
One of the first and perhaps most influential studies was financed by AstraZeneca and performed by Dr. Melissa DelBello, a child and adult psychiatrist at the University of Cincinnati.
Dr. DelBello led a research team that tracked for six weeks the moods of 30 adolescents who had received diagnoses of bipolar disorder. Half of the teenagers took Depakote, an antiseizure drug used to treat epilepsy and bipolar disorder in adults. The other half took Seroquel and Depakote.
The two groups did about equally well until the last few days of the study, when those in the Seroquel group scored lower on a standard measure of mania. By then, almost half of the teenagers getting Seroquel had dropped out because they missed appointments or the drugs did not work. Just eight of them completed the trial.
In an interview, Dr. DelBello acknowledged that the study was not conclusive. In the 2002 published paper, however, she and her co-authors reported that Seroquel in combination with Depakote “is more effective for the treatment of adolescent bipolar mania” than Depakote alone.
In 2005, a committee of prominent experts from across the country examined all of the studies of treatment for pediatric bipolar disorder and decided that Dr. DelBello’s was the only study involving atypicals in bipolar children that deserved its highest rating for scientific rigor. The panel concluded that doctors should consider atypicals as a first-line treatment for some children. The guidelines were published in The Journal of the American Academy of Child and Adolescent Psychiatry.
Three of the four doctors on the panel served as speakers or consultants to makers of atypicals, according to disclosures in the guidelines. In an interview, Dr. Robert A. Kowatch, a psychiatrist at Cincinnati Children’s Hospital and the lead author of the guidelines, said the drug makers’ support had no influence on the conclusions.
AstraZeneca hired Dr. DelBello and Dr. Kowatch to give sponsored talks. They later undertook another study comparing Seroquel and Depakote in bipolar children and found no difference. Dr. DelBello, who earns $183,500 annually from the University of Cincinnati, would not discuss how much she is paid by AstraZeneca.
“Trust me, I don’t make much,” she said. Drug company payments did not affect her study or her talks, she said. In a recent disclosure, Dr. DelBello said that she received marketing or consulting income from eight drug companies, including all five makers of atypicals.
Dr. Realmuto has heard Dr. DelBello speak several times, and her talks persuaded him to use combinations of Depakote and atypicals in bipolar children, he said. “She’s the leader in terms of doing studies on bipolar,” Dr. Realmuto said.
Some psychiatrists who advocate use of atypicals in children acknowledge that the evidence supporting this use is thin. But they say children should not go untreated simply because scientists have failed to confirm what clinicians already know.
“We don’t have time to wait for them to prove us right,” said Dr. Kent G. Brockmann, a psychiatrist from the Twin Cities who made more than $16,000 from 2003 to 2005 doing drug talks and one-on-one sales meetings, and last year was a leading prescriber of atypicals to Medicaid children.
The Reaction
For Anya Bailey, treatment with an atypical helped her regain her appetite and put on weight, but also heavily sedated her, her mother said. She developed the disabling knot in her back, the result of a nerve condition called dystonia, in 2005.
The reaction was rare but not unknown. Atypicals have side effects that are not easy to predict in any one patient. These include rapid weight gain and blood sugar problems, both risk factors for diabetes; disfiguring tics, dystonia and in rare cases heart attacks and sudden death in the elderly.
In 2006, the Food and Drug Administration received reports of at least 29 children dying and at least 165 more suffering serious side effects in which an antipsychotic was listed as the “primary suspect.” That was a substantial jump from 2000, when there were at least 10 deaths and 85 serious side effects among children linked to the drugs. Since reporting of bad drug effects is mostly voluntary, these numbers likely represent a fraction of the toll.
Jim Minnick, a spokesman for AstraZeneca, said that the company carefully monitors reported problems with Seroquel. “AstraZeneca believes that Seroquel is safe,” Mr. Minnick said.
Other psychiatrists renewed Anya’s prescriptions for Risperdal until Ms. Bailey took Anya last year to the Mayo Clinic, where a doctor insisted that Ms. Bailey stop the drug. Unlike most universities and hospitals, the Mayo Clinic restricts doctors from giving drug marketing lectures.
Ms. Bailey said she wished she had waited to see whether counseling would help Anya before trying drugs. Anya’s weight is now normal without the help of drugs, and her counseling ended in March. An experimental drug, her mother said, has recently helped the pain in her back.
Tuesday, May 08, 2007
Basic kitchen essentials
NYTimes
May 9, 2007
The Minimalist
A No-Frills Kitchen Still Cooks
By MARK BITTMAN
THE question I’m asked more often than any other is, “What kitchen equipment should I buy?”
Like cookbooks, kitchen equipment is a talisman; people believe that buying the right kind will make them good cooks. Yet some of the best cooks I’ve known worked with a battered batterie de cuisine: dented pots and pans scarred beyond recognition, an old steak knife turned into an all-purpose tool, a pot lid held just so to strain pasta when the colander was missing, a food processor with a busted switch. They didn’t complain and they didn’t apologize; they just cooked.
But famous TV chefs use gorgeous name-brand equipment, you might say. And you’d be right. But a.) they get much of that stuff free, the manufacturers hoping that placing it in the hands of a well-known chef will make you think it’s essential; b.) they want their equipment to be pretty, so you’ll think they’re important; and c.) see above: a costly knife is not a talisman and you are not a TV chef.
Finally (and this is crucial), the best chefs may use the best-looking equipment when they are in public view, but when it is time to buy equipment for the people who actually prepare those $200 restaurant meals, they go to a restaurant supply house to shop for the everyday cookware I recommend to people all the time.
In fact, I contend that with a bit of savvy, patience and a willingness to forgo steel-handle knives, copper pots and other extravagant items, $200 can equip a basic kitchen that will be adequate for just about any task, and $300 can equip one quite well.
To prove my point I put together a list of everything needed for almost any cooking task. I bought most of the equipment at Bowery Restaurant Supply, 183 Bowery Street (Delancey Street), where the bill came to just about $200. Throw in a few items the store didn’t have and a few extras, and the total would be about $300. (New York happens to have scores of restaurant supply shops, but every metropolitan area has at least one.)
I started with an eight-inch, plastic-handle stainless alloy chef’s knife for $10. This is probably the most essential tool in the kitchen. People not only obsess about knives (and write entire articles about them), but you can easily spend over $100 on just one. Yet go into any restaurant kitchen and you will see most of the cooks using this same plastic-handle Dexter-Russell tool. (Go to the wrong store and you’ll spend $20 or even $30 on the same knife.)
I found an instant-read thermometer, a necessity for beginning cooks and obsessive-compulsives, for $5. Three stainless steel bowls — not gorgeous and maybe a little thin — set me back about $5. You are reading that right. Sturdy tongs, an underappreciated tool: $3.50 (don’t buy them too long, make sure the spring is nice and tight, and don’t shop for them at a “culinary” store, where they’ll cost four times as much).
For less than $6 I picked up a sturdy sheet pan. It’s not an ideal cookie sheet but it’s useful for roasting and baking (not a bad tray, either, and one of the more common items in restaurant kitchens). A plastic cutting board was about the same price. For aesthetic purposes I’d rather have wood, but plastic can go into the dishwasher.
At $3, a paring knife was so cheap I could replace it every year or two. I splurged on a Japanese mandoline for $25. (It’s not indispensable, but since my knife skills are pathetic, I use mine whenever I want thin, even slices or a real julienne.)
You, or the college graduate you are thinking of, might own some of the things I bought: a $4 can opener; a vegetable peeler (I like the U-shaped type, which cost me $3); a colander ($7, and I probably could’ve gotten one cheaper).
You are thinking to yourself: “Humph. He’s ignoring pots and pans, the most expensive items of all.” Au contraire, my friend; I bought five, and I could live with four (though I’d rather have six): a small, medium and large cast-aluminum saucepan (total: about $30); a medium nonstick cast aluminum pan (10-inch; $13); and a large steep-sided, heavier duty steel pan (14-inch; $25). I bought a single lid ($5; I often use plates or whatever’s handy for lids because I can never find the right one anyway).
I like cast iron, and I have used it in some kitchens for nearly everything; but it can be more expensive than this quite decent cheap stuff, and it’s very heavy. What you don’t want is the awful wafer thin (and relatively more expensive) sets of stainless or aluminum ones sold in big-box stores.
Other things, like the mandoline, are almost luxury items: a skimmer (I like these for removing dumplings or gnocchi); a slotted spoon; a heat-resistant rubber spatula (which can replace the classic wooden spoon); a bread knife (good for crusty loaves and ripe tomatoes); and a big whisk (which I might use three times a year).
You should also have a food processor (you want 12-cup capacity, and Amazon.com, for example, has an adequate 14-cup Hamilton Beach for $60); a salad spinner (the one at Bowery Restaurant Supply was as big as my kitchen; you will find one for $15 somewhere); a Microplane grater (the old box graters have been largely replaced by the food processor, but you’ll need something for cheese, nutmeg and your oft-used asafetida; it’ll set you back less than $10). A coffee and spice grinder is another $10 item.
A blender is a bit more optional. An immersion one is nice, but standard ones are more useful, and you can find them for as little as $15.
And, finally, something with which to keep those knives sharp. A whetstone costs about $6, and if you use it, it will work fine; a decent steel is expensive enough that you may as well graduate to an electric sharpener. Though sharpeners take up counter space and cost at least $30, they work well.
The point is not so much that you can equip a real kitchen without much money, but that the fear of buying the wrong kind of equipment is unfounded. It needs only to be functional, not prestigious, lavish or expensive.
Keep that in mind, stay out of the fancy places and find a good restaurant supply house. If you make a mistake — something is the wrong size or of such lousy quality you can’t bear it — you can spend 20 bucks more another time. Meanwhile, you’ll be cooking.
The Inessentials
YOU can live without these 10 kitchen items:
BREAD MACHINE You can buy mediocre bread easily enough, or make the real thing without much practice.
MICROWAVE If you do a lot of reheating or fast (and damaging) defrosting, you may want one. But essential? No. And think about that counter space!
STAND MIXER Unless you’re a baking fanatic, it takes up too much room to justify it. A good whisk or a crummy handheld mixer will do fine.
BONING/FILLETING KNIVES Really? You’re a butcher now? Or a fishmonger? If so, go ahead, by all means. But I haven’t used my boning knife in years. (It’s pretty, though.)
WOK Counterproductive without a good wok station equipped with a high-B.T.U. burner. (There’s a nice setup at Bowery Restaurant Supply for $1,400 if you have the cash and the space.)
STOCKPOT The pot you use for boiling pasta will suffice, until you start making gallons of stock at a time.
PRESSURE COOKER It’s useful, but do you need one? No.
ANYTHING MADE OF COPPER More trouble than it’s worth, unless you have a pine-paneled wall you want to decorate.
RICE COOKER Yes, if you eat rice twice daily. Otherwise, no.
COUNTERTOP CONVECTION OVEN, ROTISSERIE, OR “ROASTER” Only if you’re a sucker for late-night cooking infomercials.
May 9, 2007
The Minimalist
A No-Frills Kitchen Still Cooks
By MARK BITTMAN
THE question I’m asked more often than any other is, “What kitchen equipment should I buy?”
Like cookbooks, kitchen equipment is a talisman; people believe that buying the right kind will make them good cooks. Yet some of the best cooks I’ve known worked with a battered batterie de cuisine: dented pots and pans scarred beyond recognition, an old steak knife turned into an all-purpose tool, a pot lid held just so to strain pasta when the colander was missing, a food processor with a busted switch. They didn’t complain and they didn’t apologize; they just cooked.
But famous TV chefs use gorgeous name-brand equipment, you might say. And you’d be right. But a.) they get much of that stuff free, the manufacturers hoping that placing it in the hands of a well-known chef will make you think it’s essential; b.) they want their equipment to be pretty, so you’ll think they’re important; and c.) see above: a costly knife is not a talisman and you are not a TV chef.
Finally (and this is crucial), the best chefs may use the best-looking equipment when they are in public view, but when it is time to buy equipment for the people who actually prepare those $200 restaurant meals, they go to a restaurant supply house to shop for the everyday cookware I recommend to people all the time.
In fact, I contend that with a bit of savvy, patience and a willingness to forgo steel-handle knives, copper pots and other extravagant items, $200 can equip a basic kitchen that will be adequate for just about any task, and $300 can equip one quite well.
To prove my point I put together a list of everything needed for almost any cooking task. I bought most of the equipment at Bowery Restaurant Supply, 183 Bowery Street (Delancey Street), where the bill came to just about $200. Throw in a few items the store didn’t have and a few extras, and the total would be about $300. (New York happens to have scores of restaurant supply shops, but every metropolitan area has at least one.)
I started with an eight-inch, plastic-handle stainless alloy chef’s knife for $10. This is probably the most essential tool in the kitchen. People not only obsess about knives (and write entire articles about them), but you can easily spend over $100 on just one. Yet go into any restaurant kitchen and you will see most of the cooks using this same plastic-handle Dexter-Russell tool. (Go to the wrong store and you’ll spend $20 or even $30 on the same knife.)
I found an instant-read thermometer, a necessity for beginning cooks and obsessive-compulsives, for $5. Three stainless steel bowls — not gorgeous and maybe a little thin — set me back about $5. You are reading that right. Sturdy tongs, an underappreciated tool: $3.50 (don’t buy them too long, make sure the spring is nice and tight, and don’t shop for them at a “culinary” store, where they’ll cost four times as much).
For less than $6 I picked up a sturdy sheet pan. It’s not an ideal cookie sheet but it’s useful for roasting and baking (not a bad tray, either, and one of the more common items in restaurant kitchens). A plastic cutting board was about the same price. For aesthetic purposes I’d rather have wood, but plastic can go into the dishwasher.
At $3, a paring knife was so cheap I could replace it every year or two. I splurged on a Japanese mandoline for $25. (It’s not indispensable, but since my knife skills are pathetic, I use mine whenever I want thin, even slices or a real julienne.)
You, or the college graduate you are thinking of, might own some of the things I bought: a $4 can opener; a vegetable peeler (I like the U-shaped type, which cost me $3); a colander ($7, and I probably could’ve gotten one cheaper).
You are thinking to yourself: “Humph. He’s ignoring pots and pans, the most expensive items of all.” Au contraire, my friend; I bought five, and I could live with four (though I’d rather have six): a small, medium and large cast-aluminum saucepan (total: about $30); a medium nonstick cast aluminum pan (10-inch; $13); and a large steep-sided, heavier duty steel pan (14-inch; $25). I bought a single lid ($5; I often use plates or whatever’s handy for lids because I can never find the right one anyway).
I like cast iron, and I have used it in some kitchens for nearly everything; but it can be more expensive than this quite decent cheap stuff, and it’s very heavy. What you don’t want is the awful wafer thin (and relatively more expensive) sets of stainless or aluminum ones sold in big-box stores.
Other things, like the mandoline, are almost luxury items: a skimmer (I like these for removing dumplings or gnocchi); a slotted spoon; a heat-resistant rubber spatula (which can replace the classic wooden spoon); a bread knife (good for crusty loaves and ripe tomatoes); and a big whisk (which I might use three times a year).
You should also have a food processor (you want 12-cup capacity, and Amazon.com, for example, has an adequate 14-cup Hamilton Beach for $60); a salad spinner (the one at Bowery Restaurant Supply was as big as my kitchen; you will find one for $15 somewhere); a Microplane grater (the old box graters have been largely replaced by the food processor, but you’ll need something for cheese, nutmeg and your oft-used asafetida; it’ll set you back less than $10). A coffee and spice grinder is another $10 item.
A blender is a bit more optional. An immersion one is nice, but standard ones are more useful, and you can find them for as little as $15.
And, finally, something with which to keep those knives sharp. A whetstone costs about $6, and if you use it, it will work fine; a decent steel is expensive enough that you may as well graduate to an electric sharpener. Though sharpeners take up counter space and cost at least $30, they work well.
The point is not so much that you can equip a real kitchen without much money, but that the fear of buying the wrong kind of equipment is unfounded. It needs only to be functional, not prestigious, lavish or expensive.
Keep that in mind, stay out of the fancy places and find a good restaurant supply house. If you make a mistake — something is the wrong size or of such lousy quality you can’t bear it — you can spend 20 bucks more another time. Meanwhile, you’ll be cooking.
The Inessentials
YOU can live without these 10 kitchen items:
BREAD MACHINE You can buy mediocre bread easily enough, or make the real thing without much practice.
MICROWAVE If you do a lot of reheating or fast (and damaging) defrosting, you may want one. But essential? No. And think about that counter space!
STAND MIXER Unless you’re a baking fanatic, it takes up too much room to justify it. A good whisk or a crummy handheld mixer will do fine.
BONING/FILLETING KNIVES Really? You’re a butcher now? Or a fishmonger? If so, go ahead, by all means. But I haven’t used my boning knife in years. (It’s pretty, though.)
WOK Counterproductive without a good wok station equipped with a high-B.T.U. burner. (There’s a nice setup at Bowery Restaurant Supply for $1,400 if you have the cash and the space.)
STOCKPOT The pot you use for boiling pasta will suffice, until you start making gallons of stock at a time.
PRESSURE COOKER It’s useful, but do you need one? No.
ANYTHING MADE OF COPPER More trouble than it’s worth, unless you have a pine-paneled wall you want to decorate.
RICE COOKER Yes, if you eat rice twice daily. Otherwise, no.
COUNTERTOP CONVECTION OVEN, ROTISSERIE, OR “ROASTER” Only if you’re a sucker for late-night cooking infomercials.
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