New Developments in Dementia Treatment

For those who live with it, dementia can be devastating. But year by year, new drugs, technologies and techniques are being developed that not only reduce the likelihood of the condition occurring in the first place, but are also more effective in helping manage it if it does. This means that in terms of alleviating symptoms and slowing the progress of different types of dementia, doctors now have more treatment options than was thought possible, even just a few years ago.

These developments can involve looking at new ways to use existing drugs. For example, an American study has shown that beta-blockers, which are traditionally used to treat high blood pressure, might also be effective in lessening the onset of dementia. At the moment, because of the small size of the research sample, beta-blockers, can't as yet be prescribed for this purpose. However, a much larger study involving another type of blood pressure reducing drug, known as angiotensin receptor blocker (ARB), has been shown to have a similar benefits, which could lead to new range of medications becoming available.

Several other promising treatments are also in the late phases of testing. These include a drug that blocks the build-up of amyloid (the lumps of protein that can stop neurones in the brain from working properly together), while another is aimed at preventing the clumping of tau protein, a primary indicator of Alzheimer's. Initial results suggest that both could be effective lines of research.

While at the Massachusetts Institute of Technology (MIT) after 15 years of work, scientists have created 'Souvenaid'. This is a once-a-day drink they have developed to repair the damage done to neurones at the synapses, the point where they connect with each other in our brains. Tests have shown that Souvenaid does seem to help improve the memory of dementia sufferers.

Correct diagnosis of the exact nature and type of the dementia is of course important in the early stages of the disease if the best treatments are be given. In the past this could often involved some form of invasive treatment such as lumbar puncture. But now, American researchers have found that MRI scans can be used effectively in diagnosis, which means much less trauma for patients.

For younger sufferers in particular, being diagnosed with dementia can lead to the loss of employment and their independence. So in Hull, a two-year long pilot project is underway that will give those suffering from dementia the opportunity, with the support of a personal mentor, to do voluntary work in their own community. This positive and forward-thinking scheme will help demonstrate that those suffering from Alzheimer's and similar diseases are still able to make a contribution to society.

With other on-going trials of medications normally used in the treatment of high blood pressure and diabetes, as well as statins and even some antibiotics, there are definite signs that the light at the end of the tunnel is beginning to shine brighter for those suffering from the debilitating effects of dementia.

If you or someone you love is experiencing early signs of dementia, find out about the specialist dementia care options available to you.

What Housework Has to Do With Waistlines

Justin Pumfrey/Getty Images Gretchen Reynolds on the science of fitness.

One reason so many American women are overweight may be that we are vacuuming and doing laundry less often, according to a new study that, while scrupulously even-handed, is likely to stir controversy and emotions.

The study, published this month in PLoS One, is a follow-up to an influential 2011 report which used data from the U.S. Bureau of Labor Statistics to determine that, during the past 50 years, most American workers began sitting down on the job. Physical activity at work, such as walking or lifting, almost vanished, according to the data, with workers now spending most of their time seated before a computer or talking on the phone. Consequently, the authors found, the average American worker was burning almost 150 fewer calories daily at work than his or her employed parents had, a change that had materially contributed to the rise in obesity during the same time frame, especially among men, the authors concluded.

But that study, while fascinating, was narrow, focusing only on people with formal jobs. It overlooked a large segment of the population, namely a lot of women.

“Fifty years ago, a majority of women did not work outside of the home,” said Edward Archer, a research fellow with the Arnold School of Public Health at the University of South Carolina in Columbia, and lead author of the new study.

So, in collaboration with many of the authors of the earlier study of occupational physical activity, Dr. Archer set out to find data about how women had once spent their hours at home and whether and how their patterns of movement had changed over the years.

He found the information he needed in the American Heritage Time Use Study, a remarkable archive of “time-use diaries” provided by thousands of women beginning in 1965. Because Dr. Archer wished to examine how women in a variety of circumstances spent their time around the house, he gathered diaries from both working and non-employed women, starting with those in 1965 and extending through 2010.

He and his colleagues then pulled data from the diaries about how many hours the women were spending in various activities, how many calories they likely were expending in each of those tasks, and how the activities and associated energy expenditures changed over the years.

As it turned out, their findings broadly echoed those of the occupational time-use study. Women, they found, once had been quite physically active around the house, spending, in 1965, an average of 25.7 hours a week cleaning, cooking and doing laundry. Those activities, whatever their social freight, required the expenditure of considerable energy. (The authors did not include child care time in their calculations, since the women’s diary entries related to child care were inconsistent and often overlapped those of other activities.) In general at that time, working women devoted somewhat fewer hours to housework, while those not employed outside the home spent more.

Forty-five years later, in 2010, things had changed dramatically. By then, the time-use diaries showed, women were spending an average of 13.3 hours per week on housework.

More striking, the diary entries showed, women at home were now spending far more hours sitting in front of a screen. In 1965, women typically had spent about eight hours a week sitting and watching television. (Home computers weren’t invented yet.)

By 2010, those hours had more than doubled, to 16.5 hours per week. In essence, women had exchanged time spent in active pursuits, like vacuuming, for time spent being sedentary.

In the process, they had also greatly reduced the number of calories that they typically expended during their hours at home. According to the authors’ calculations, American women not employed outside the home were burning about 360 fewer calories every day in 2010 than they had in 1965, with working women burning about 132 fewer calories at home each day in 2010 than in 1965.

“Those are large reductions in energy expenditure,” Dr. Archer said, and would result, over the years, in significant weight gain without reductions in caloric intake.

What his study suggests, Dr. Archer continued, is that “we need to start finding ways to incorporate movement back into” the hours spent at home.

This does not mean, he said, that women — or men — should be doing more housework. For one thing, the effort involved is such activities today is less than it once was. Using modern, gliding vacuum cleaners is less taxing than struggling with the clunky, heavy machines once available, and thank goodness for that.

Nor is more time spent helping around the house a guarantee of more activity, over all. A telling 2012 study of television viewing habits found that when men increased the number of hours they spent on housework, they also greatly increased the hours they spent sitting in front of the TV, presumably because it was there and beckoning.

Instead, Dr. Archer said, we should start consciously tracking what we do when we are at home and try to reduce the amount of time spent sitting. “Walk to the mailbox,” he said. Chop vegetables in the kitchen. Play ball with your, or a neighbor’s, dog. Chivvy your spouse into helping you fold sheets. “The data clearly shows,” Dr. Archer said, that even at home, we need to be in motion.

Gretchen Reynolds on the science of fitness.

Depression May Stifle Shingles Vaccine Response

Depression may lower the effectiveness of the shingles vaccine, a new study found.

The research showed that adults with untreated depression who received the vaccine mounted a relatively weak immune response. But those who were taking antidepressants showed a normal response to the vaccine, even when symptoms of depression persist.

Shingles, an acute and painful rash, strikes a million Americans each year, mostly older adults. Health officials recommend that those over 60 get vaccinated against the condition, which is caused by reactivation of the same virus that causes chickenpox, varicella-zoster.

In the new study, published in the journal Clinical Infectious Diseases, researchers followed a group of 92 older men and women for two years. Forty of the subjects had a major depressive disorder; they were matched with 52 control subjects of similar age. The researchers measured their immune responses to the shingles vaccine and a placebo shot.

Compared with the control patients, those with depression were poorly protected by the vaccine. But the patients who were being treated for their depression showed a boost in immunity — what the researchers called a “normalization” of the immune response. It is unclear why that was the case.

The authors of the study speculated that treatment of older people with depression might increase the effectiveness of the flu shot and other vaccines as well.

Ask Well: Exercises for Shoulder Pain

You are certainly right that sore shoulders are common, especially as a person ages. About half of all middle-aged tennis players suffer from shoulder pain, according to a 2012 study in The British Journal of Sports Medicine, and youngsters aren’t immune either. The same study reported that about a quarter of competitive tennis players under 20 hurt their shoulders every year.

Many of these injuries involve the rotator cuff, the group of muscles and tendons at the back of the shoulder that stabilize the joint. Studies show that forces equivalent to at least 120 percent of a person’s body weight slam through the rotator cuff during a typical tennis serve or baseball pitch. To withstand that pounding, the rotator cuff needs to be strong.

But many of us, including tennis players, have relatively weak rotator cuff muscles. “Playing tennis builds up the muscles in the front of the shoulder, but it doesn’t build up those in the back very much,” says Todd Ellenbecker, the clinic director at Physiotherapy Associates Scottsdale Sports Club in Scottsdale, Ariz., and senior director of medical services for the ATP World Tour, the men’s professional tennis circuit.

To isolate and strengthen the rotator cuff, Mr. Ellenbecker recommends simple exercises that you can do at home and that require only a stretchy exercise band or length of elastic tubing and a rolled-up towel. You can find step-by-step instructions for a number of these exercises, which Mr. Ellenbecker prescribes for professional tennis players, at “How to Fix a Bad Tennis Shoulder.”

Don’t wait to start the program, by the way, until your shoulders ache. “These exercises are excellent for preventing shoulder injuries,” Mr. Ellenbecker said, “in addition to rehabilitating injured shoulders.”

But of course, don’t start the program without first consulting a doctor, especially if you have shoulder pain. “See an orthopedic surgeon,” Mr. Ellenbecker said, “to have the shoulder carefully evaluated and maybe X-rayed to rule out injuries” more severe than a strained rotator cuff, he said.

Omega-3s May Lead to Healthier Babies

Pregnant women who took daily supplements of DHA, a type of omega-3 fatty acid, had longer gestations, bigger babies and fewer early preterm births, according to a new clinical trial.

In the double-blinded study, published online in The American Journal of Clinical Nutrition, researchers randomly assigned 154 healthy women to take 600 milligrams of DHA during the last half of pregnancy and 147 to take a placebo.

After adjusting for maternal education, socioeconomic status, prior pregnancy, smoking and other risk factors, they found that babies whose mothers took supplements were almost a half pound heavier than those of the mothers who took none, and they were slightly longer with larger head circumferences.

Almost 5 percent of mothers who took the placebo gave birth at 34 weeks’ gestation or less, compared with only 0.6 percent of the mothers who took DHA.

The lead author, Susan E. Carlson, a professor of nutrition at the University of Kansas, pointed out that the incidence of low birth weight and gestation shorter than 34 weeks in the placebo group is very similar to rates in the general population, while the DHA group had dramatic reductions. There were no adverse effects to taking the supplements.

Although a larger study is needed, she said, “women should be having a conversation with their doctors about whether they should be taking DHA during pregnancy.”

No Vitamin D and Calcium for Older Bones

A government task force formally recommended on Monday that healthy postmenopausal women avoid taking low daily doses of vitamin D and calcium to ward off bone fractures.

The group, the United States Preventive Services Task Force, an independent panel of experts in prevention and primary care, based its recommendations on extensive reviews of more than a hundred studies. They characterized low doses as 400 international units or less of vitamin D and 1,000 milligrams or less of calcium.

Taking those amounts daily, the task force wrote in its recommendations, “has no net benefit for the primary prevention of fractures.” But there is good evidence, the group said, that taking them could increase the likelihood of kidney stones.

The task force also looked at the use of the supplements in men and premenopausal women. The group concluded it was unable to “assess the balance of the benefits and harms” of using the supplements to prevent fractures in these groups.

The recommendations, however, do not apply to people with osteoporosis or vitamin D deficiencies, the task force said.

PMS Symptoms Linked to Diet

A 10-year study of more than 3,000 women has found that dietary iron may reduce the risk for premenstrual syndrome, while potassium intake may increase it.

Using data from a larger analysis of women’s health, researchers studied 1,057 women with PMS and 1,968 control subjects. They used questionnaires to establish their nutrient intake, both food and supplements, and established cases of PMS by clinical diagnosis.

After controlling for various health and dietary factors, they found that women in the highest 20 percent for iron intake were about 40 percent less likely to suffer PMS as those in the lowest 20 percent.

The study, published online in The American Journal of Epidemiology, found the opposite effect with potassium. Those in the highest 20 percent of intake had a 46 percent increased risk for PMS compared with those in the lowest 20 percent. There was no risk associated with intake of magnesium, zinc, manganese, copper or sodium.

The senior author, Elizabeth R. Bertone-Johnson, an associate professor of epidemiology at the University of Massachusetts, cautioned women against taking too much iron, or consuming too little potassium, both of which can be harmful. “Eating a balanced diet with a variety of foods,” she said, “is a good way to ensure that women are consuming important vitamins and minerals.”

The Food and Nutrition Board of the Institute of Medicine recommends 18 milligrams of iron daily for women 19 to 50, and 4,700 milligrams of potassium a day for all adults.

Questions About Robotic Hysterectomy

Harry Campbell

Ever since it was approved by the Food and Drug Administration in 2005, robotic surgery for hysterectomy has been heavily advertised. Surgeons promise that using the da Vinci robotic device will bring better results and an easier recovery, and many hospitals claim that patients will experience less pain and fewer complications, getting back on their feet faster.

The company that makes da Vinci robotic surgery equipment promoted it last May at free health workshops organized by the federal Office on Womens’ Health. On Sunday, the Liberty Science Museum in Jersey City will host its first “Let’s Operate Day,” offering guests “hands-on” practice peering into video monitors and using da Vinci’s robot arms to pick up and manipulate small objects.

The cost of the new technology is rarely mentioned. But last week, a new study that evaluated outcomes in more than a quarter of a million American women raised questions about the manufacturer’s claims. The paper, published in The Journal of the American Medical Association, compared outcomes in 264,758 women who had either laparoscopic or robotically assisted hysterectomy at 441 hospitals between 2007 and 2010. Both methods are minimally invasive and involve smaller incisions than open abdominal surgery.

The researchers found no overall difference in complication rates between the two groups, and no difference in the rates of blood transfusion, even though one of the claims regarding robotic surgery is that it causes less blood loss.

But the researchers did find a big difference in cost. Robotically assisted surgery for hysterectomy costs on average about one-third more than laparoscopic surgery.

“It’s important to separate the marketing from the data,” said Dr. Jason D. Wright, the study’s lead author, an assistant professor of obstetrics and gynecology at Columbia University Medical Center. “For the surgeon, there is a greater degree of movement and control of the instruments and the visualization is better.

“But the ultimate question is, does this change outcomes for patients? This study suggests that there really is not a lot of difference as far as quantifiable outcomes.”

The majority of patients in both groups left the hospital in less than two days, though patients who had robotic surgery were slightly more likely to go home that early: 80 percent went home in less than two days, compared with 75 percent of those who had laparoscopic surgery.

But the cost of robotic surgeries was significantly higher, with a median cost to the hospital of $8,868, compared with $6,679 for laparoscopic hysterectomy. The study did not look at the difference in patients’ bills, but according to Newchoicehealth.com, the average patient price for a laparoscopic hysterectomy ranges from $7,700 in Dallas to $11,600 in Los Angeles.

With laparoscopic surgery — sometimes called keyhole surgery — narrow instruments and a small video camera are inserted through tiny incisions; the surgeon sees the image on a monitor and can cut and sew tissue with the instruments. With robotically assisted surgery, the surgeon sits at a console with a 3-dimensional view of the surgical site, and computer technology translates his or her hand movements into precise, scaled movements of the instruments.

Even without offering clear advantages the proportion of hysterectomies performed robotically has increased rapidly, up to nearly 10 percent of hysterectomies in 2010 from less than 1 percent in 2007, Dr. Wright said. Minimally invasive surgeries for hysterectomies are increasing across the board, he found, even at hospitals not performing robotic surgery.

Dr. Myriam J. Curet, chief medical adviser to Intuitive Surgical, which makes the da Vinci systems, did not dispute the study’s findings, but said the important message was that more women were able to receive minimally invasive surgeries because more options were available.

“That’s good for patients and for the health care system,” Dr. Curet said. Women who are not candidates for laparoscopic surgery might still be candidates for robotically-assisted surgery, she added.

Right now, however, it is not clear how to identify which women would benefit from robotic surgery and which would do well with a less expensive method.

The growing use of robotic surgery in hospitals will continue to drive up health costs, said Joel S. Weissman, of Brigham and Women’s Hospital and a co-author of an editorial published with the study.

“Once you have that robot, the tendency is to use it for all kinds of things, for which it may or may not have great value,” Dr. Weissman said. Studies like this one, he said, demonstrate the waste of health care dollars on “something that costs a lot more and doesn’t offer any added benefit over current treatment options.”

Each year approximately 600,000 American women have hysterectomies, according to the Centers for Disease Control and Prevention. By age 60, one in three American women has had her uterus removed, often along with her ovaries and cervix.

Critics who say far too many hysterectomies are done in the United States worry that all the attention to surgical method distracts from the question of whether patients should be having the surgery at all.

Most hysterectomies are prescribed for conditions that are not life-threatening, and advocates worry that women are not fully informed of the long-term harms, which may include a loss of sexual responsiveness, depression and chronic constipation, and higher risk for osteoporosis and heart disease, said Nora W. Coffey, the founder of the nonprofit Hysterectomy Educational Resources and Services Foundation.

“That’s the conversation we should be having,” Ms. Coffey said.

Nora W. Coffey and other experts emphasize that women considering a hysterectomy should discuss all options with their doctors.

¶Ask what the alternatives are and whether watchful waiting is an option. Remember that it is irreversible, regardless of how the surgery is done.

¶Learn about the nonreproductive functions of the uterus, ovaries and cervix, and the potential long-term consequences associated with their removal, as well as the function of the ovaries and cervix.

¶If you proceed, discuss the advantages and disadvantages of different surgical methods with your doctor. Interview several surgeons and inquire about the cost and how much insurance will cover. Your co-pay may vary depending on the surgical method.

¶Tell your surgeon if you do not want your ovaries and cervix removed.

A Rainbow of Root Vegetables

Andrew Scrivani for The New York Times

This week’s Recipes for Health is as much a treat for the eyes as the palate. Colorful root vegetables from bright orange carrots and red scallions to purple and yellow potatoes and pale green leeks will add color and flavor to your table.

Since root vegetables and tubers keep well and can be cooked up into something delicious even after they have begun to go limp in the refrigerator, this week’s Recipes for Health should be useful. Root vegetables, tubers (potatoes and sweet potatoes, which are called yams by most vendors – I mean the ones with dark orange flesh), winter squash and cabbages are the only local vegetables available during the winter months in colder regions, so these recipes will be timely for many readers.

Roasting is a good place to begin with most root vegetables. They sweeten as they caramelize in a hot oven. I roasted baby carrots and thick red scallions (they may have been baby onions; I didn’t get the information from the farmer, I just bought them because they were lush and pretty) together and seasoned them with fresh thyme leaves, then sprinkled them with chopped toasted hazelnuts. I also roasted a medley of potatoes, including sweet potatoes, after tossing them with olive oil and sage, and got a wonderful range of colors, textures and tastes ranging from sweet to savory.

Sweet winter vegetables also pair well with spicy seasonings. I like to combine sweet potatoes and chipotle peppers, and this time in a hearty lentil stew that we enjoyed all week.

Here are five colorful and delicious dishes made with root vegetables.

Spicy Lentil and Sweet Potato Stew With Chipotles: The combination of sweet potatoes and spicy chipotles with savory lentils is a winner.

Roasted Carrots and Scallions With Thyme and Hazelnuts: Toasted hazelnuts add a crunchy texture and nutty finish to this dish.

Carrot Wraps: A vegetarian sandwich that satisfies like a full meal.

Rainbow Potato Roast: A multicolored mix that can be vegan, or not.

Leek Quiche: A lighter version of a Flemish classic.

Martha Rose Shulman on healthful cooking.

Think Like a Doctor: The Man Who Wobbled

The Challenge: Can you solve the medical mystery of a man who suddenly becomes too dizzy to walk?

Solve a medical mystery with Dr. Lisa Sanders.

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a 56-year-old factory worker with dizziness and panic attacks. I have provided records from his two hospital visits that will give you all the information available to the doctor who finally made the diagnosis.

The first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped a roomful of specialists.

The Patient’s Story:

The middle-aged man clicked his way through the multiple reruns of late-late-night television. He should have been in bed hours ago, but lately he hadn’t been able to get to sleep. Suddenly his legs took on a life of their own. Stretched out halfway to the center of the room, they began to shake and twitch and jump around. The man watched helplessly as his legs disobeyed his mental orders to stop moving. He had no control over them. He felt nauseous, sweaty and out of breath, as if he had been running some kind of race. He called out to his wife. She hurried out of bed, took one look at him and called 911.

The Patient’s History:

By the time the man arrived at Huntsville Hospital, in Alabama, the twitching in his legs had subsided and his breathing had returned to normal. Still, he had been discharged from that same hospital for similar symptoms just two weeks earlier. They hadn’t figured out what was going on then, so they weren’t going to send him home now.

The patient considered himself pretty healthy, but the past year or so had been tough. In 2011, at the age of 54, he had had a mild stroke. He had no medical problems that put him at risk for stroke — no high blood pressure, no high cholesterol, no diabetes. A work-up at that time showed that he had a hole in his heart that allowed a tiny clot from somewhere in his body to travel to the brain and cause the stroke. He was discharged on a couple of blood thinners to keep his blood from making more clots. He hadn’t really felt completely well, though, ever since. His balance seemed a little off, and he was subject to these weird panic attacks, in which his heart would pound and he would feel short of breath whenever he got too stressed. Mostly he could manage them by just walking away and focusing on his breathing. Still, he never felt as if he was the kind of guy to panic.

And he had always been quick on his feet. The first half of his career he had been in the steel business — building huge metal trusses and supports. He and his team put together 60-plus tons of steel structures every day. For the past decade he had been machining car parts. After his stroke, work seemed to get a lot harder.

The Dizziness:

A few weeks ago, he stood up and wham — suddenly the whole world went off-kilter. He felt as if he was constantly about to fall over in a world that no longer lay down flat. His first thought was that he was having another stroke. He went straight to his doctor’s office. The doctor wasn’t sure what was going on and sent him to that same emergency room at Huntsville Hospital. After three days of testing and being evaluated by lots of specialists, his doctors still were not sure what was going on. He hadn’t had a heart attack; he hadn’t had a stroke. There was no sign of infection. All the tests they could think of were normal.

The only abnormal finding was that when he stood up, his blood pressure dropped. Why this happened wasn’t clear, but the doctors in the hospital gave him compression stockings and a pill — both could help keep his blood pressure in the normal range. Then they sent him home. He was also started on an antidepressant to help with the panic attacks he continued to have from time to time.

You can read the report from that hospital admission below.

You can also read the consultation and discharge notes from that hospital visit here.

He had been home for nearly two weeks and still he felt no better. He tried to go back to work after a week or so at home, but after driving for less than five miles, he felt he had to turn around. He wasn’t sure what was wrong; he just knew he didn’t feel right. Then his legs started jumping around, and he ended up back in the hospital.

The Doctor’s Exam:

It was nearly dawn by the time Dr. Jeremy Thompson, the first-year resident on duty that night, saw the patient. Awake but tired, the patient told his story one more time. He had been at home, watching TV, when his legs started jumping on their own and he started feeling short of breath. His wife sat at the bedside. She looked just as worried and exhausted as he did. She told the resident that when he spoke that night at home, his speech was slurred. And when the ambulance came, he could barely walk. He has never missed this much work, she told the young doctor. It’s not like him. Can’t you figure out what’s wrong?

The resident had already reviewed the records from the patient’s previous hospital admissions. He asked a few more questions: the patient had never smoked and rarely drank; his father died at age 80; his mother was still alive and well. The patient exam was normal, as were the studies done in the E.R.

The first E.R. doctor thought that his symptoms were a result of anxiety, culminating in a full-blown panic attack. The resident thought that was probably right. In any case he would discuss the case with the attending in a couple of hours during rounds on the new patients. Till then, he told the worried couple, they should just try to get a little sleep.

An Important Clue:

Dr. Robert Centor was definitely a morning person. His cheerful enthusiasm about teaching and taking care of patients made him a favorite among residents. At 7:30 that morning, he stood outside the patient’s door as Dr. Thompson relayed the somewhat frustrating case of the middle-aged man with worsening dizziness and panic attacks. Then they went into the room to meet the patient. He was a big guy, tall and muscular with the first signs of middle-aged thickening around his middle. His complexion had the look of someone who spent a lot of time outdoors. Dr. Centor introduced himself and pulled up a chair as the rest of the team watched. He asked the patient what brought him to the hospital.

“Every time I get up, I get dizzy,” the man replied. Sure, he had had some balance problems ever since his stroke, he explained, but this felt different – somehow worse. He could hardly walk, he told the doctor. He just felt too unstable.

“Can you get up and show us how you walk?” Dr. Centor asked.

“Don’t let me fall,” the patient responded. He carefully swung his legs over the side of the bed. The resident and intern stood on either side as he slowly rose. He stood with his feet far apart. When asked to close his eyes as he stood there, he wobbled and nearly fell over. When he took a few steps, his heel and toes hit the ground at the same time, making a strange slapping sound.

Seeing that, Dr. Centor knew where the problem lay and ordered a few tests to confirm his diagnosis.

You can see the review report and notes for the patient’s second hospital visit below.

Solving the Mystery:

What tests did Dr. Centor order? Do you know what is making this middle-aged man wobble? Enter your guesses below. I’ll post the answer tomorrow.

Rules and Regulations: Post your questions and diagnosis in the Comments section below. The correct answer will appear tomorrow on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Friday March 1, 1:21 p.m. | Updated Thanks for all your responses! You can learn the correct diagnosis at “Think Like a Doctor: The Wobble Solved!”

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Solve a medical mystery with Dr. Lisa Sanders.

Why Failing Med Students Don’t Get Failing Grades

Doug Menuez/Getty Images

Tall and dark-haired, the third-year medical student always seemed to be the first to arrive at the hospital and the last to leave, her white coat perpetually weighed down by the books and notes she jammed into the pockets. She appeared totally absorbed by her work, even exhausted at times, and said little to anyone around her.

Except when she got frustrated.

I first noticed her when I overheard her quarreling with a nurse. A few months later I heard her accuse another student of sabotaging her work. And then one morning, I saw her storm off the wards after a senior doctor corrected a presentation she had just given. “The patient never told me that!” she cried. The nurses and I stood agape as we watched her stamp her foot and walk away.

“Why don’t you just fail her?” one of the nurses asked the doctor.

“I can’t,” she sighed, explaining that the student did extremely well on all her tests and worked harder than almost anyone in her class. “The problem,” she said, “is that we have no multiple choice exams when it comes to things like clinical intuition, communication skills and bedside manner.”

Medical educators have long understood that good doctoring, like ducks, elephants and obscenity, is easy to recognize but difficult to quantify. And nowhere is the need to catalog those qualities more explicit, and charged, than in the third year of medical school, when students leave the lecture halls and begin to work with patients and other clinicians in specialty-based courses referred to as “clerkships.” In these clerkships, students are evaluated by senior doctors and ranked on their nascent doctoring skills, with the highest-ranking students going on to the most competitive training programs and jobs.

A student’s performance at this early stage, the traditional thinking went, would be predictive of how good a doctor she or he would eventually become.

But in the mid-1990s, a group of researchers decided to examine grading criteria and asked directors of internal medicine clerkship courses across the country how accurate and consistent they believed their grading to be. Nearly half of the course directors believed that some form of grade inflation existed, even within their own courses. Many said they had increasing difficulty distinguishing students who could not achieve a “minimum standard,” whatever that might be. And over 40 percent admitted they had passed students who should have failed their course.

The study inspired a series of reforms aimed at improving how medical educators evaluated students at this critical juncture in their education. Some schools began instituting nifty mnemonics like RIME, or Reporter-Interpreter-Manager-Educator, for assessing progressive levels of student performance; others began to call regular meetings to discuss grades; still others compiled detailed evaluation forms that left little to the subjective imagination.

Now a new study published last month in the journal Teaching and Learning in Medicine looks at the effects of these many efforts on the grading process. And while the good news is that the rate of grade inflation in medical schools is slower than in colleges and universities, the not-so-good news is that little has changed. A majority of clerkship directors still believe that grade inflation is an issue even within their own courses; and over a third believe that students have passed their course who probably should have failed.

“Grades don’t have a lot of meaning,” said Dr. Sara B. Fazio, lead author of the paper and an associate professor of medicine at Harvard Medical School who leads the internal medicine clerkship at the Beth Israel Deaconess Medical Center in Boston. “‘Satisfactory’ is like the kiss of death.”

About a quarter of the course directors surveyed believed that grade inflation occurred because senior doctors were loath to deal with students who could become angry, upset or even turn litigious over grades. Some confessed to feeling pressure to help students get into more selective internships and training programs.

But for many of these educators, the real issue was not flunking the flagrantly unprofessional student, but rather evaluating and helping the student who only needed a little extra help in transitioning from classroom problem sets to real world patients. Most faculty received little or no training or support in evaluating students, few came from institutions that had remediation programs to which they could direct students, and all worked under grading systems that were subjective and not standardized.

Despite the disheartening findings, Dr. Fazio and her co-investigators believe that several continuing initiatives may address the evaluation issues. For example, residency training programs across the country will soon be assessing all doctors-in-training with a national standards list, a series of defined skills, or “competencies,” in areas like interpersonal communication, professional behavior and specialty-specific procedures. Over the next few years, medical schools will likely be adopting a similar system for medical students, creating a national standard for all institutions.

“There have to be unified, transparent and objective criteria,” Dr. Fazio said. “Everyone should know what it means when we talk about educating and training ‘good doctors.’”

“We will all be patients one day,” she added. “We have to think about what kind of doctors we want to have now and in the future.”

Dr. Pauline Chen on medical care.

The Roving Runner: There’s the Church, There’s the Steeple

Brian Fidelman/The New York Times

Pleasing scenery can punch up a routine run, and one recent Sunday I was treated to a majestic view of the Calvary-St. George’s Episcopal Church at Park Avenue and East 21st Street.

This 1848 brownstone beauty, situated just a block from Gramercy Park, is straight out of an Edith Wharton novel. No, really. She belonged to this church, and the Web site claims it was a setting for “The Age of Innocence.” The Roosevelt family worshiped there as well.

Designed by James Renwick Jr. in the Gothic Revival style, the church was not just the finest sight on my run. It was the only sight. I was on a treadmill at the New York Health & Racquet Club across the street, staring out the window as I ran.

Not everyone is a fan of the treadmill. Some of my Times colleagues would sooner suck in subzero air for an hour than run in place for 10 minutes. The dreadmill, one called it. A recent Times column by Gretchen Reynolds backed them up, concluding that exercising inside just isn’t the same.

Even so, when it’s cold I opt for the temperate air, predictable terrain and precise pacing of — O.K., fine — the hamster wheel.

As I migrate back outdoors, my go-to route will be along the Hudson River. But whenever I can I will take my unlimited MetroCard and a $10 bill and go somewhere. Anywhere. My goal is to explore unfamiliar places, or familiar places from a new perspective.

I did this in 2009, recording my observations in a column called the Roving Runner, and I had a blast. I ran laps around Governors Island and Roosevelt Island. I got lost in Inwood Hill Park and went barefoot in Central Park. There was a tennis run and a baseball run and an unforgettable jog along Chicago’s waterfront. It’s urban exploring and heart-thumping workout, all in one.

Back inside, I’ve been building a base of fitness for the coming outdoor adventures. The treadmills at some gyms, including some in this chain, leave you staring at the wall or a mirror or the television. The sight of the church across the street, however, is hypnotic. The second-floor view encourages a runner to get lost in the exterior details, the clerestory windows, the red doors, the little annex to the left.

On this particular Sunday I started quite slowly, not much faster than a walk. But each minute I hit the up arrow to increase my speed slightly. I could barely tell the difference from one minute to the next, but over time I went from too slow to just right to faster than my comfort zone.

For the first couple of miles I had the TV on and was half tuned in to a Sunday morning talk show, which featured two politicians debating Washington’s automatic spending cuts, known as the sequester (turns out I wasn’t the only one spinning furiously and getting nowhere). Once I reached warp speed, or my own personal version of warp speed, I removed the headphones and focused ahead.

As my legs moved faster and my stride lengthened I tried to visualize some of my favorite runners — Haile Gebrselassie of Ethiopia, Paul Tergat of Kenya — and how they seem to glide effortlessly at impossibly blistering paces. Even though I was now moving quickly, I tried to imagine that I was still jogging, keeping my upper body relaxed. My goal is to make this faster pace second nature in races.

There was a light reflection on the window, not enough to see my tired eyes, but enough to keep my form honest and allow me to self-correct should my legs or arms start swinging out.

Every minute I went a tenth of a mile per hour faster. I zeroed in on the roof of the church, zipping along and feeling a bit of a rush from churning my legs so fast.

At last I hit 4.5 miles, and pressed the cool-down button to wrap up the run over the next few minutes.

After I left the gym I crossed Park Avenue to catch an uptown bus. There is a speaker by the door of the church, right at the bus stop. As I waited I heard the pastor concluding his sermon, which was about salvation. Next, the choir sang a sweet hymn. I looked back across the street at the runners in the window above. New Yorkers — parishioners and runners alike — were making something out of their Sunday morning.

The M3 bus pulled up, and off to work I went.

What are your favorite runs? Please share the best trails, neighborhoods and routes below.

Really? Annoying Songs Get Stuck in Our Heads

Anahad O’Connor tackles health myths.

THE FACTS

Virtually everyone experiences them, and rarely are they thought of fondly. They are earworms, the tunes that burrow into our consciousness and play on repeat.

In a recent study involving hundreds of people, Ira Hyman Jr. of Western Washington University and colleagues looked at what made songs most likely to stick, exposing unsuspecting subjects to popular songs and then asking them to complete various tasks.

Previous research showed that people can recall the first verse of a song they like, but after the chorus stumble over the lyrics. At this point the song becomes incomplete — a conflict without closure — and that is one way that it becomes an intrusive thought, Dr. Hyman said.

“You get to the chorus, and then it’s looping right there, and you’re kind of doomed at that point,” he said.

The study found that songs typically intrude during tasks that are either too difficult, which causes the mind to wander, or too easy, which creates a mental opening for repetitive thoughts. The trick to flushing out an earworm, Dr. Hyman said, is to find a task that is engaging and that requires the auditory and verbal components of your working memory — like reading a good book or watching a favorite show.

THE BOTTOM LINE

Research suggests that songs we like, not ones we despise, are most likely to form intrusive thoughts.

Anahad O'Connor tackles health myths.

Too Many Pills in Pregnancy

Katherine Streeter Jane Brody on health and aging.

The thalidomide disaster of the early 1960s left thousands of babies with deformed limbs because their mothers innocently took a sleeping pill thought to be safe during pregnancy,

In its well-publicized wake, countless pregnant women avoided all medications, fearing that any drug they took could jeopardize their babies’ development.

I was terrified in December 1968 when, during the first weeks of my pregnancy, I developed double pneumonia and was treated with antibiotics and codeine. Before swallowing a single dose, I called my obstetrician, who told me to take what was prescribed, “reassuring” me that if I died of pneumonia I wouldn’t have a baby at all.

In the decades that followed, pregnancy-related hazards were linked to many medicinal substances: prescription and over-the-counter drugs and herbal remedies, as well as abused drugs and even some vitamins.

Now, however, the latest findings about drug use during pregnancy have ignited new concerns among experts who monitor the effects of medications on the developing fetus and pregnancy itself.

During the last 30 years, use of prescription drugs during the first trimester of pregnancy, when fetal organs are forming, has grown by more than 60 percent.

About 90 percent of pregnant women take at least one medication, and 70 percent take at least one prescription drug, according to the Centers for Disease Control and Prevention.

Since the late 1970s, the proportion of pregnant women taking four or more medications has more than doubled.

Nearly one woman in 10 takes an herbal remedy during the first trimester.

A growing number of pregnant women, naïvely assuming safety, self-medicate with over-the-counter drugs that were once sold only by prescription.

While many commonly taken medications are considered safe for unborn babies, the Food and Drug Administration estimates that 10 percent or more of birth defects result from medications taken during pregnancy. “We seem to have forgotten as a society that drugs pose risks,” Dr. Allen A. Mitchell, professor of epidemiology and pediatrics at Boston University Schools of Public Health and Medicine, said in an interview. “Many over-the-counter drugs were grandfathered in with no studies of their possible effects during pregnancy.”

Medical progress has contributed to the rising use of medications during pregnancy, Dr. Mitchell said. Various conditions, like depression, are now recognized as diseases that warrant treatment; drugs have been developed to treat conditions for which no treatment was previously available, and some conditions, like Type 2 diabetes and hypertension, have become more prevalent.

Misled by the Web

Now a new concern has surfaced: Bypassing their doctors, more and more women are using the Internet to determine whether the medication they are taking or are about to take is safe for an unborn baby.

A study, published online last month in Pharmacoepidemiology and Drug Safety, of so-called “safe lists for medications in pregnancy” found at 25 Web sites revealed glaring inconsistencies and sometimes false reassurances or alarms based on “inadequate evidence.”

The report was prepared by Cheryl S. Broussard of the Centers for Disease Control and Prevention with co-authors from Emory, Georgia State University, the University of British Columbia and the Food and Drug Administration.

“Among medications approved for use in the U.S.A. from 2000 to 2010, over 79% had no published human data on which to assess teratogenic risk (potential to cause birth defects), and 98% had insufficient published data to characterize such risk,” the authors wrote.

But that did not stop the 25 Web sites from characterizing 245 medications as “safe” for use by pregnant women, which “might encourage use of medications during pregnancy even when they are not necessary,” the authors suggested.

Furthermore, the information found online was sometimes contradictory. “Twenty-two of the products listed as safe by one or more sites were stated not to be safe by one or more of the other sites,” the study found.

The question of timing was often ignored. A drug that could interfere with fetal organ development might be safe to take later in pregnancy. Or one (for example, ibuprofen) that is safe early in pregnancy could become a hazard later if it raises the risk of excessive bleeding or premature delivery.

Fewer than half the sites advised taking medication only when necessary, and only 13 sites encouraged pregnant women to consult their doctors before stopping or starting a medication.

Doctors, too, are often poorly informed about pregnancy-related hazards of various medications, the authors noted. One woman I know was advised to wean off an antidepressant before she became pregnant, but another was told to continue taking the same drug throughout her pregnancy.

“In many instances the best bet is for mom to stay on her medication,” said Dr. Siobhan M. Dolan, an obstetrician and geneticist at Albert Einstein College of Medicine. She said that if a woman is depressed during pregnancy, her risk of postpartum depression is greater and she may have difficulty bonding with her baby.

Dr. Dolan, who is author, with Alice Lesch Kelly, of the March of Dimes’ newest book, “Healthy Mom Healthy Baby,” emphasized the importance of weighing benefits and risks in deciding whether to take medication during pregnancy and which drugs to take.

“In anticipation of pregnancy, a woman taking more than one drug to treat her condition should try to get down to a single agent,” Dr. Dolan said in an interview. “Of the various medications available to treat a condition, is there a best choice — one least likely to cause a problem for either the baby or the mother?”

She cautioned against sharing medications prescribed for someone else and assuming that a remedy labeled “natural” or “herbal” is safe. Virtually none have been tested for safety in pregnancy.

Among medications a woman should be certain to avoid, in some cases starting three months before becoming pregnant, are isotretinoin (Accutane and others) for acne; valproic acid for seizure disorders; lithium for bipolar disorder; tetracycline for infections, and angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor antagonists for hypertension, Dr. Dolan said.

“Many medications that are not recommended during pregnancy can be replaced with low-risk alternatives,” she wrote.

Dr. Broussard, who did the “safe lists” study, said in an interview, “We’ve heard about women seeing medications on these lists and deciding on their own that it’s O.K. to take them. “Women who are pregnant or even thinking about getting pregnant should talk directly to their doctors before taking anything. They should be sure they’re taking only what’s necessary for their health condition.”

A reliable online resource for both women and their doctors, Dr. Mitchell said, are fact sheets prepared by OTIS, the Organization of Teratology Information Specialists, which are continually updated as new facts become available: http://www.otispregnancy.org.

Jane Brody on health and aging.

What I'm loving Wednesday: Fashion and beauty!

We could, and keep this beauty and fashion theme going, right? Wine and Food Festival is this weekend, so I assure you I get some food-heavy posts next week!

1. last week at Ulta, I bought an awesome OPI Polish duo. Bubble Bath has long been a favorite of mine, and I'm not really a waitress is a really beautiful red. They are both so feminine.

2. I can't stop admiring my C. Wonder purchases from their flash sales. I squealed when I opened my package to find this beautiful calf hair wallet. It is even better in person.

I also purchased these earrings. They are large and in charge, that is certain.

3. Since I became mildly obsessed with the color of my wallet, I was, I needed a matching top. I can't wait to wear this with white jeans. Hurry up, spring! It is now for sale at Old Navy.
4. Last Friday both Courtney and Megan posted on this gorgeous bracelet at Groopdealz. I have a feeling I would want to wear it every day. It looks as if it could not also double as protection?

5. the weather here has been disgusting. Rain, rain everywhere. I feel that I have the dressing like a hood rat everywhere I go. I have not make hoodrat stuff, but. I assure you. 6. I have fallen in love. With a foot washing. Crest recently sent me a package of smile-clarification goodies and I are already occupied with the Arctic fresh whitening rinse.

You know what I love? They sent me enough to host a GIVEAWAY! In some toothbrushes, toothpaste and this awesome rinse? Come back tomorrow for a chance to win!

25 Day alcohol Detox overview

First of all, I would like to thank each of you for your support over the last month. Your encouragement convinced me that I would get through 25 days just fine. After reading every single comment and email, I knew there was no way I would let myself or any of you down. I was particularly pleased to know that more of them participated in the detox as well as. Cong rats to you! I used 25 without drinks, and I am very glad I did.

My results:

I felt much more alert, had more energy and was more productive. Have no hangover or foggy morning was great.I started the detox weighs 113.6. When it was over, weighed in 109.4. No joke. This can be from nixing alcohol, or a combination of, and to be more productive/eat healthier. In the first week, there were 3 or 4 times when I said aloud, ' Oooh, I want some wine, "or felt like having a glass with dinner. It was just me acting out of habit. Although it was a bit of a bummer, I never felt it was that big of a deal. Downloads, was my sugar cravings also crazy. I wanted chocolate more than ever. That finally disappeared after the second week. And in remission means I eat the chocolate once a day, just like normal, instead of my new all day habit. Towards the end of the other Ha downloads, I really do not remember not to have alcohol because of how much better I felt.By the third week, I knew that I had achieved my goal. I could recognize when I using alcohol as a stress zapper and how there are a million other ways to deal with it in a healthy way.The last few days were really exciting. I felt such a sense of achievement and was ready to celebrate. I knew that I would be able to go out with friends and know my limits.The most interesting that happened was this: I had a nightmare about 3-4 times a week since last summer event. During the detox, I had not a single one. The first night I decided to have the wine again, Carter and I had one regular medium-sized glass of red wine. A. Night, I had the nightmare again.

As I have just said, the first night, I had a glass of wine. I wanted to see how I felt after a drink before jumping in to the wine and Food Festival open bar party. The night of the event, I limited myself to have a sip or two of specialty drinks, and then had just two beers. When we were in the bars later, I only had beer.  No shots, no fluid, no wine … no problems. Believe me, I am wearing a pair of 5-inch heels, and both of us survived.

Because of how much better I felt without alcohol, I have made a decision on how the transition into March. I have chosen to save the booze for weekends only. There should be a special occasion during the week, Yes, I get a drink to celebrate. No big deal there.

If you are interested in doing a detox yourself, here are some tips:

Tell family and friends what you are doing. I guarantee that you will have at least one person's support. You can always tell me also — I will help you!Write down why you are doing this. When you get the courage, look at your reasons to detox to remember your goals.Take note, when you feel the need to drink. Recognize if it is because you want to enjoy it, or if you feel that you need it. Learn the difference.Keep track of your mood and energy levels. You will be surprised how these will improve.DO order a water or non-alcoholic drinks when you are around friends who drink. Sometimes it is weird not keep something and you want to avoid the dreaded question, "Why don't you drink!?" from all around you.DO stock up on seltzer or flavored water. You it.Have a reward for yourself in the end. I knew mine would not only be a sense of accomplishment, but that I would get to celebrate with friends on wine and Food Festival. Worth it!

Again, I am so so I did and I strongly encourage any of you to try this If you feel that the alcohol has been a problem in your life. If you have any questions, please leave me a comment or email me. I would be pleased to answer them and support them!

In other news, I have verrrryyyyyy exciting blog news to share with you on Wednesday. More reasons to celebrate!

Skønhed er magt: Min Makeup rutine

It took me a long, long time to get into makeup. I wore it rarely in high school and was still not interested in college. Even now, I just a few times a week. Boding likes to joke, when I actually right up my hair and put on makeup, I have a date or an interview. Pssh. that being said, I enjoy wearing it because it reinforces my confidence and I have a lot of fun playing with all the colors and techniques that we can use to transform our faces. Let us take a look at the products I use most often.

I wash my face with Neutrogenas oil free Acne Wash Pink bottle sucked me and pink. grapefruit scent has me connected.

A couple of times a week, do I use the foaming scrub. It is a really light scrub, which is perfect for skin that tends to be dry.

Next step is moisturizing. I have used Olays full all day pore space with SPF 15.

I am neurotic about using my eye cream day and night. I only benefits it is potent Eye Cream. My eyes get so puffy after a night without sleep/too much alcohol.

If someone recommends something else, please Let me know! Someone told me recently about the use of preparation H to depuff. Have any of the tested this?

Makeup!

I cannot stress the importance of using a primer in the shadow. It sets the shade in place of a lasting effect. I swear by Mac's primer. I'm not even kidding, your makeup within 48 hours If you choose not to wash your face. Not that I recommend, but still, it is nice. I switch between Painterly (nude beige) for a basic look and bare study (soft beige with gold Pearl) to a shimmery look. Mac's eyeshadows are equally fantastic. They are mixed well and stay put. My three favorites are Retrospeck, Tempting and Woodwinked.

A few months ago, my life changed when I discovered the incredible MUAS eyeshadow palettes. I kid you not, they are my favorite eyeshadows of all time. Palettes has so many beautiful colors all blend well with each other. Yes, MUA is a British company and you will suffer a currency exchange rate and shipping fee, but it is worth every DOLLAR! They are super cheap anyway, so 1 pallete with shipping will only set you back about $ 17. Buy in bulk, my friends! My favorite is the heaven and the Earth. The Naked Palette UD'S kicks ass.

I cannot believe it took me 28 years to realize the power of an eyebrow pencil. For those of us who have lighter hair, makes it amazing things for our face. A pencil can really make your eyes pop. I use Revlon's Brown Fantasy in dark blond.

Like my girl Amy, I am a mascara junkie and have tried so many forms. My go to his is …

Cheap: Rimmel Scandaleyes.

Moderate: MAC Plush Lash.

Expensive: Christian Dior Diorshow.

Thank God I don't have to use a concealer or foundation, so I Pat just on a good quantity of MACS clean/Pressed powder.

Blush are like mascara, my other necessity to feel alive. I love Mac's Fleur power and Pinch Me.

I am still not a fan of lipstick, but has a zillion chap sticks and lip glosses floating around my purse and bathroom. I like Maybelline Baby lips in chapstick Peppermint (probably BC it is lime green):

Revlon's lip gloss in the Pink whisper:

and Mac's lip glass in Viva Glam VI.

You know anybody yet? I am. I seriously wonder if this seems to be a ton of make-up for some of them, and not so much to others. Do what you think? What is your go to products? I want some new Favorites! Tell me everything.