Unlikely Model for H.I.V. Prevention: Adult Film Industry

Stephanie Diani for The New York Times

INDUSTRY DATABASE Shylar Cobi, right, a film producer, confirmed test results of the actors who perform as James Deen and Stoya.

LOS ANGELES — Before they take off all their clothes, the actors who perform as James Deen and Stoya go through a ritual unique to the heterosexual adult film industry.

First, they show each other their cellphones: Each has an e-mail from a laboratory saying he or she just tested negative for H.I.V., syphilis, chlamydia and gonorrhea.

Then they sit beside the film’s producer, Shylar Cobi, as he checks an industry database with their real names to confirm that those negative tests are less than 15 days old.

Then, out on the pool terrace of the day’s set — a music producer’s hilltop home with a view of the Hollywood sign — they yank down their pants and stand around joking as Mr. Cobi quickly inspects their mouths, hands and genitals for sores.

“I’m not a doctor,” Mr. Cobi, who wears a pleasantly sheepish grin, says. “I’m only qualified to do this because I’ve been shooting porn since 1990 and I know what looks bad.”

Bizarre as the ritual is, it seems to work.

The industry’s medical consultants say that about 350,000 sex scenes have been shot without condoms since 2004, and H.I.V. has not been transmitted on a set once.

Outside the world of pornography, the industry’s testing regimen is not well known, and no serious academic study of it has ever been done. But when it was described to several AIDS experts, they all reacted by saying that there were far fewer infections than they would have expected, given how much high-risk sex takes place.

“I don’t think there’s any question that it works,” said Dr. Allan Ronald, a Canadian AIDS specialist who did landmark studies of the virus in prostitutes in a Nairobi slum. “I’m a little uncomfortable, because it’s giving the wrong message — that you can have multiple sex partners without condoms — but I can’t say it doesn’t work.”

Despite the regimen’s apparent success, California health officials and an advocacy group, the AIDS Healthcare Foundation, are trying to make it illegal to shoot without condoms. They argue that other sexually transmitted diseases are rampant in the industry, though the industry trade group disputes that.

In January, the city of Los Angeles passed a law requiring actors to wear condoms. A measure to do the same for the whole county is on the ballot on Tuesday.

Producers say the condom requirement will drive them out of business since consumers will not buy such films. Local newspapers like The Los Angeles Times oppose the ballot measure, calling it well-intentioned but unenforceable, and warning that it could drive up to 10,000 jobs out of state.

Very frequent testing makes it almost impossible for an actor to stay infected without being caught, said Dr. Jacques Pepin, the author of “The Origins of AIDS” and an expert on transmission rates. “And if you are having sex mostly with people who themselves are tested all the time, this must further reduce the risk.”

When the virus first enters a high-risk group like heroin users, urban prostitutes or habitués of gay bathhouses, it usually infects 30 to 60 percent of the cohort within a few years, studies have shown. The same would be expected in pornography, where performers can have more than a dozen partners a month, but the industry says self-policing has prevented it.

“Our talent base has sex exponentially more than other people, but we’re all on the same page about keeping it out,” said Steven Hirsch, the founder of Vivid Entertainment, one of the biggest studios.

Performers have to test negative every 28 days, although some studios recently switched to every 14.

If a test is positive, all the studios across the country that adhere to standards set by the Free Speech Coalition, an industry trade group, are obliged to stop filming until all the on-screen partners of that performer, all their partners, and all their partners’ partners, are found and retested. In 2004, the industry shut down for three months to do that.

It has had briefer shutdowns in each of the last four years.

In 2009 and 2010, no other infected performers were found. Coalition representatives said an infected woman in 2009, from Nevada, may have had an infected boyfriend, and offered evidence that a man infected in 2010 in Florida had worked outside the industry as a prostitute. The 2011 test was a false positive.

A shutdown in August came after several actors got syphilis, not H.I.V. All performers were given a choice: Take antibiotics, or pass two back-to-back syphilis tests 14 days apart.

Read More..

Unlikely Model for H.I.V. Prevention: Adult Film Industry

Stephanie Diani for The New York Times

INDUSTRY DATABASE Shylar Cobi, right, a film producer, confirmed test results of the actors who perform as James Deen and Stoya.

LOS ANGELES — Before they take off all their clothes, the actors who perform as James Deen and Stoya go through a ritual unique to the heterosexual adult film industry.

First, they show each other their cellphones: Each has an e-mail from a laboratory saying he or she just tested negative for H.I.V., syphilis, chlamydia and gonorrhea.

Then they sit beside the film’s producer, Shylar Cobi, as he checks an industry database with their real names to confirm that those negative tests are less than 15 days old.

Then, out on the pool terrace of the day’s set — a music producer’s hilltop home with a view of the Hollywood sign — they yank down their pants and stand around joking as Mr. Cobi quickly inspects their mouths, hands and genitals for sores.

“I’m not a doctor,” Mr. Cobi, who wears a pleasantly sheepish grin, says. “I’m only qualified to do this because I’ve been shooting porn since 1990 and I know what looks bad.”

Bizarre as the ritual is, it seems to work.

The industry’s medical consultants say that about 350,000 sex scenes have been shot without condoms since 2004, and H.I.V. has not been transmitted on a set once.

Outside the world of pornography, the industry’s testing regimen is not well known, and no serious academic study of it has ever been done. But when it was described to several AIDS experts, they all reacted by saying that there were far fewer infections than they would have expected, given how much high-risk sex takes place.

“I don’t think there’s any question that it works,” said Dr. Allan Ronald, a Canadian AIDS specialist who did landmark studies of the virus in prostitutes in a Nairobi slum. “I’m a little uncomfortable, because it’s giving the wrong message — that you can have multiple sex partners without condoms — but I can’t say it doesn’t work.”

Despite the regimen’s apparent success, California health officials and an advocacy group, the AIDS Healthcare Foundation, are trying to make it illegal to shoot without condoms. They argue that other sexually transmitted diseases are rampant in the industry, though the industry trade group disputes that.

In January, the city of Los Angeles passed a law requiring actors to wear condoms. A measure to do the same for the whole county is on the ballot on Tuesday.

Producers say the condom requirement will drive them out of business since consumers will not buy such films. Local newspapers like The Los Angeles Times oppose the ballot measure, calling it well-intentioned but unenforceable, and warning that it could drive up to 10,000 jobs out of state.

Very frequent testing makes it almost impossible for an actor to stay infected without being caught, said Dr. Jacques Pepin, the author of “The Origins of AIDS” and an expert on transmission rates. “And if you are having sex mostly with people who themselves are tested all the time, this must further reduce the risk.”

When the virus first enters a high-risk group like heroin users, urban prostitutes or habitués of gay bathhouses, it usually infects 30 to 60 percent of the cohort within a few years, studies have shown. The same would be expected in pornography, where performers can have more than a dozen partners a month, but the industry says self-policing has prevented it.

“Our talent base has sex exponentially more than other people, but we’re all on the same page about keeping it out,” said Steven Hirsch, the founder of Vivid Entertainment, one of the biggest studios.

Performers have to test negative every 28 days, although some studios recently switched to every 14.

If a test is positive, all the studios across the country that adhere to standards set by the Free Speech Coalition, an industry trade group, are obliged to stop filming until all the on-screen partners of that performer, all their partners, and all their partners’ partners, are found and retested. In 2004, the industry shut down for three months to do that.

It has had briefer shutdowns in each of the last four years.

In 2009 and 2010, no other infected performers were found. Coalition representatives said an infected woman in 2009, from Nevada, may have had an infected boyfriend, and offered evidence that a man infected in 2010 in Florida had worked outside the industry as a prostitute. The 2011 test was a false positive.

A shutdown in August came after several actors got syphilis, not H.I.V. All performers were given a choice: Take antibiotics, or pass two back-to-back syphilis tests 14 days apart.

Read More..

DealBook Column: The Election Won't Solve All Puzzles

Here comes more uncertainty.

It may sound counterintuitive, but whatever the outcome of the election — whether President Obama or Mitt Romney wins — the economy and markets are likely to face more uncertainty, not less, over the coming year.

“Uncertainty” has become the watchword over the last several years for many chief executives, politicians and economists as an explanation — or perhaps an excuse — for the economy’s slow growth, for the lack of hiring by business and for the volatility in the stock market.

“The claim is that businesses and households are uncertain about future taxes, spending levels, regulations, health care reform and interest rates. In turn, this uncertainty leads them to postpone spending on investment and consumption goods and to slow hiring, impeding the recovery,” a group of professors from Stanford University and the University of Chicago wrote in a study that found “current levels of economic policy uncertainty are at extremely elevated levels compared to recent history.” (The professors have created a Web site, policyuncertainty.com, where you can track the “uncertainty” levels.)

Come Wednesday morning, we should know who our president will be. But the uncertainty hardly ends there.

Almost immediately after the elections, the next big talking point on Wall Street and in Washington is going to be the now infamous “fiscal cliff,” a series of automatic tax increases and spending cuts that was the result of a Congressional compromise reached last summer and is to take effect on Jan. 1, unless Congress finds an alternative. Some economists say the tax increases and spending cuts in the existing agreement could shave as much as 4 percent off G.D.P. if they are not renegotiated. Already, executives say that the uncertainty over the outcome of the fiscal cliff is causing them to hold back from making new investments.

But the greatest likelihood is that the fiscal cliff isn’t going to be resolved soon at all —the betting line of the political cognoscenti is that no matter who wins, Congress will find a way to kick the issue down the road, perhaps as far as the fall of 2013, providing a new cloud of uncertainty over the economy.

For investors, the fiscal cliff includes a tax increase on dividends (making them the equivalent of ordinary income, on which rates could rise to as high as 39.6 percent) and capital gains (up to 20 percent from 15 percent). In a note to clients sent out on Sunday night, Goldman Sachs said that it expected the rate for both dividends and capital gains to be negotiated to 20 percent in either a second Obama term or a Romney presidency. But more important, Goldman noted that when similar tax increases were on the table in 1970 and 1986, “the S.& P. 500 posted negative returns in the December prior to implementation as investors locked in the lower rate.” December, the report said, “has the second-highest average monthly return” since 1928.

Many investors have already begun selling stocks and companies in anticipation of tax increases. Speculation was rampant last week that one of the reasons for the timing of the sale of George Lucas’s company, Lucasfilm, to Disney for $4.1 billion in cash and stock, was the impending changes in tax policy. (Mr. Lucas has said that he plans to donate a majority of his wealth to charity.)

Once we get past the fiscal cliff, if we do at all, there is Europe. Remember Europe? The issues in Greece and Spain have managed to stay off the front pages during the election run-up, but they have not gone away. Some economists have argued that things have gotten worse. Angela Merkel, the chancellor of Germany, who will face election in 2013, said on Monday that the fiscal crisis in Europe was likely to last at least five years. “Whoever thinks this can be fixed in one or two years is wrong,” she said.

And don’t forget the Middle East. That “uncertainty” for the world — and the global economy — isn’t going away anytime soon either. Questions about a possible attack on Iran will persist under either candidate.

And finally, there is Ben Bernanke, chairman of the Federal Reserve, one of the biggest uncertainties of them all. As I reported in this column two weeks ago, the greatest likelihood is that Mr. Bernanke will step down at the end of his term in early 2014 no matter who wins the election.

It’s possible — though unlikely — that his departure could happen even sooner if Mr. Romney wins. Over the next year and a half, Mr. Bernanke’s future as the Fed chairman will feed a sense of uncertainty among investors who have become accustomed to his easy money policies. If President Obama wins, he is likely to appoint a successor to Mr. Bernanke who is dovish on monetary policy, and more likely to keep printing money as Mr. Bernanke has, a strategy that comes with its own risks. If Mr. Romney wins, he may appoint a more hawkish chairman, a move that could create a different sense of uncertainty about how the Federal Reserve will unwind itself from Mr. Bernanke’s policies.

None of these issues are new. President Obama took office facing a fiscal policy dispute that was not and probably could not be settled given the gridlock in Congress. No solution is in sight for Europe’s problems. Tension in the Middle East is escalating as fast as nuclear technology. And the Federal Reserve’s monetary policy is at its most opaque since the Reagan administration.

All of which shows that the comedian Jon Stewart is more on target than ever with the cheeky title of his election coverage on “The Daily Show” on Comedy Central. Carrying on a tradition, it is known as “Indecision 2012.”

Update that to 2013, and it’s good for another year.

A version of this article appeared in print on 11/06/2012, on page B1 of the NewYork edition with the headline: The Election Won’t Solve All Puzzles.

Read More..

Coptic Church Chooses Pope Who Rejects Politics

Tara Todras-Whitehill for The New York Times

Coptic clergymen at a ceremony on Sunday for choosing a pope.

CAIRO — A blindfolded 6-year-old reached into a glass bowl on Sunday to pick the first new Coptic pope in more than 40 years, a patriarch who promises a new era of integration for Egypt’s Christian minority as it grapples with a wave of sectarian violence, new Islamist domination of politics, and internal pressures for reform.

Tara Todras-Whitehill for The New York Times

The acting Coptic pope, before a banner of Bishop Tawadros, held up the names of other candidates to show that the selection was fair.

Speaking to the television cameras that surrounded him at his monastery in a desert town, the pope-designate, Bishop Tawadros, indicated that he planned to reverse the explicitly political role of his predecessor, Pope Shenouda III, who died in March. For four decades, Shenouda acted as the Copts’ chief representative in public life, won special favors for his flock by publicly endorsing President Hosni Mubarak, and last year urged in vain that Copts stay away from the protests that ultimately toppled the strongman.

“The most important thing is for the church to go back and live consistently within the spiritual boundaries because this is its main work, spiritual work,” the bishop said, and he promised to begin a process of “rearranging the house from the inside” and “pushing new blood” after his installation later this month as Pope Tawadros II. Interviewed on Coptic television recently, he struck a new tone by including as his priorities “living with our brothers, the Muslims” and “the responsibility of preserving our shared life.”

“Integrating in the society is a fundamental scriptural Christian trait,” Bishop Tawadros said then. “This integration is a must — moderate constructive integration,” he added. “All of us, as Egyptians, have to participate.”

Coptic activists and intellectuals said the turn away from politics signaled a sweeping transformation in the Christian minority’s relationship to the Egyptian state but also addressed a firm demand by the Christian laity to claim a voice in a more democratic Egypt.

“It can’t continue the way it used to be,” said Youssef Sidhom, editor of the Coptic newspaper Watani. “It is not in the interests of the Copts, if they are trying to speak for themselves as full and equal citizens, to have an intermediary speaking for them, and especially if he is a religious authority. I think the church has gotten this message loud and clear.”

In Egypt’s first free elections for Parliament and president, Christians voted overwhelmingly along sectarian lines, seeking to pool their votes around the most secular candidates — only to see their favorites fall under the Islamist tide. After the Muslim Brotherhood’s political party won parliamentary leadership and then the presidency, many Egyptians joked that the group put a candidate up for Coptic pope, too.

In recent interviews, intellectuals and activists, and churchgoers leaving Mass after the selection of the pope, all said they had concluded that Christians would have to build alliances with Muslims who shared their goal of nonsectarian citizenship.

“We are not the Muslim Brotherhood,” said Tarek Samir, a sales manager leaving the cathedral after the selection of Bishop Tawadros. “Politics is a dirty word to us, and we do not think it should be mixed with religion. But there are moderate Muslims who live the same life we do, who go to work with us, who live together with us, and if I am in trouble they will help me.”

Copts, often estimated to make up about 10 percent of Egypt’s 80 million people, trace their roots here to centuries before the birth of the Prophet Muhammad. They consider St. Mark their first pope; Tawadros II will be the 118th. In some ways, they are now at the spearhead of a challenge confronting Christian minorities across the region amid the tumult of the Arab Spring. In Iraq, Lebanon, Syria and elsewhere, Christian minorities had made peace with authoritarian rulers in the hope of protection from the Muslim majorities. But now the old bargains have broken, leaving Christians to fend for themselves.

In Egypt, the revolution last year coincided with by far the deadliest 12 months of sectarian violence in decades, including the bombing of an Alexandria church weeks before the revolt, the destruction of at least three churches in sectarian feuds, and the killing of about two dozen Coptic demonstrators by Egyptian soldiers squashing a protest — the single bloodiest episode of sectarian violence in at least half a century.

Known as the Maspero massacre after a nearby television building, the slaughter elicited attempts by top generals to blame the Copts and scant sympathy from the main Islamist groups, crystallizing Coptic anxieties.

Mayy El Sheikh and Mai Ayyad contributed reporting.

Read More..

Gadgetwise Blog: Q&A: Declining a Kindle's Special Offers

How do I turn off the ads on my Kindle e-reader?

If you purchased a Kindle labeled “With Special Offers,” you bought a model that was discounted because of the advertisements shown on the reader’s screen saver and along the bottom of the home screen. If you want to remove the ads, you can do so — but Amazon requires you to make up the price difference (usually $15 to $30, depending on the model) between what you paid for a “Special Offers” Kindle and the same model that was more expensive, but ad-free.

To turn off the ads (or as Amazon calls it, “unsubscribe from special offers”), log onto the Manage Your Kindle page with your Amazon user name and password. In the Manage Your Devices area, find your Kindle model and click the plus (+) icon to show additional details. In the Special Offers area, click Edit and follow along to turn off the ads. You should see how much the bill will be for turning off the advertisements.

When you have adjusted your Kindle preferences online, connect the e-reader to your wireless network so it can update itself. Amazon will then send you an e-mail notification to confirm that you have opted out and paid for it.

Read More..

Chelation Therapy Shows Slight Benefit in Heart Disease Clinical Trial

LOS ANGELES — To the surprise of many cardiologists, a controversial alternative therapy proved beneficial to people with heart disease, reducing the rate of death and cardiovascular problems in a clinical trial, researchers said on Sunday.

The benefit of the treatment, known as chelation therapy, barely reached statistical significance, and there were questions about the reliability of the study. Even the investigators in the trial said the results were insufficient by themselves to justify recommending use of the treatment.

Still, the unexpected finding should provide some vindication to the National Institutes of Health for sponsoring the $30 million study, which was plagued by delays and problems.

“There may be a biological effect and that biological effect should be taken seriously,” and “pursued with additional research,” Dr. Gervasio A. Lamas of Mount Sinai Medical Center in Miami, the lead investigator, said at a news conference here at the annual scientific meeting of the American Heart Association.

Dr. Elliott Antman, representing the heart association, applauded the National Institutes of Health for sponsoring the study while also expressing caution. “Intriguing as these results are, they are unexpected and should not be interpreted as an indication to adopt chelation therapy into clinical practice,” said Dr. Antman, a cardiologist at Brigham and Women’s Hospital in Boston.

Chelation therapy involves the infusion of agents that remove metals from the bloodstream.

More than 100,000 Americans with heart disease undergo chelation therapy each year, at a cost of about $5,000 per course of treatment, experts here said. The hypothesis is that chelation can remove the calcium that is a contributor to arterial plaques.

But skeptics said there was not enough evidence backing chelation therapy to even begin a clinical trial. Proponents of the study said that since chelation therapy was already widely used, it should be subject to the same rigorous scientific testing used to study conventional pharmaceuticals.

And some skeptics were not persuaded at all. Dr. Steven Nissen, head of cardiovascular medicine at the Cleveland Clinic, said the study was “fatally flawed,” with many of the doctors involved being on the fringes of medicine and many patients dropping out of the trial. He said if people got the mistaken idea from the study that chelation was beneficial “it would be a public health catastrophe.”

The study, which began enrolling patients in 2003, was plagued by problems from the start. It fell way behind its goal of recruiting nearly 2,400 patients in three years. The trial was also suspended in 2008 for investigations by government agencies, one over conduct at trial sites and the other about whether patients were being adequately informed that chelation can cause death. The study was allowed to resume the next year, after some changes were made.

The trial ended up with 1,708 patients at 134 centers in the United States and Canada. The patients all had had previous heart attacks.

Half the patients received the chelation therapy, a synthetic amino acid called disodium ethylene diamine tetra acetic acid, or EDTA, as well as other substances. These were given by infusion every week for 30 weeks, followed by 10 more infusions at intervals of two to eight weeks. The other half received infusions of placebo.

After a follow-up of 55 months, 26 percent of those who received chelation therapy had died, suffered a heart attack or stroke, had a procedure to reopen a coronary artery or had been hospitalized for angina. That was less than the 30 percent for those who received a placebo, a difference that was barely statistically significant.

Doctors said there were reasons for caution.

Virtually all the of difference between the treatment and the placebo groups occurred in the third of patients who had diabetes. The placebo contained some sugar, which conceivably could have harmed the diabetics. Also, at least within the first two years, the chelation therapy did not improve physical functioning or psychological well being, according to surveys of the patients.

Dr. Mark A. Creager, a cardiologist at Brigham and Women’s Hospital who was not involved in the study, said the chelation infusion also contained a high dose of vitamin C and the blood thinner heparin. It could be that one of those ingredients, not the chelation agent, were responsible for any benefit, he said.

Dr. Lamas, the lead investigator, said the chelation treatment was well tolerated. But he said investigators did not yet know why some patients receiving the therapy dropped out of the trial.

Another study presented at the heart meeting on Sunday found coronary bypass surgery superior to the use of stents for patients with diabetes and multiple heart blockages.

The trial involved 1,900 patients followed for five yeas. About 27 percent of those who received stents either died or had a heart attack or stroke, compared with about 19 percent of those undergoing bypass surgery. There was an increase in stroke risk with surgery, but that was outweighed by fewer deaths and heart attacks.

Previous studies had already suggested that surgery was better for diabetic patients with severe coronary disease, and practice guidelines already say it is “reasonable” to choose surgery. But the new study, sponsored by the National Institutes of Health, shows the same result even using modern drug-covered stents.

About 700,000 Americans undergo artery opening procedures for more than one blood vessel each year, and about 25 percent of them have diabetes, according to the investigators.

The study results were also published online by the New England Journal of Medicine. Johnson & Johnson and Boston Scientific provided the stents used in the study.

Read More..

Chelation Therapy Shows Slight Benefit in Heart Disease Clinical Trial

LOS ANGELES — To the surprise of many cardiologists, a controversial alternative therapy proved beneficial to people with heart disease, reducing the rate of death and cardiovascular problems in a clinical trial, researchers said on Sunday.

The benefit of the treatment, known as chelation therapy, barely reached statistical significance, and there were questions about the reliability of the study. Even the investigators in the trial said the results were insufficient by themselves to justify recommending use of the treatment.

Still, the unexpected finding should provide some vindication to the National Institutes of Health for sponsoring the $30 million study, which was plagued by delays and problems.

“There may be a biological effect and that biological effect should be taken seriously,” and “pursued with additional research,” Dr. Gervasio A. Lamas of Mount Sinai Medical Center in Miami, the lead investigator, said at a news conference here at the annual scientific meeting of the American Heart Association.

Dr. Elliott Antman, representing the heart association, applauded the National Institutes of Health for sponsoring the study while also expressing caution. “Intriguing as these results are, they are unexpected and should not be interpreted as an indication to adopt chelation therapy into clinical practice,” said Dr. Antman, a cardiologist at Brigham and Women’s Hospital in Boston.

Chelation therapy involves the infusion of agents that remove metals from the bloodstream.

More than 100,000 Americans with heart disease undergo chelation therapy each year, at a cost of about $5,000 per course of treatment, experts here said. The hypothesis is that chelation can remove the calcium that is a contributor to arterial plaques.

But skeptics said there was not enough evidence backing chelation therapy to even begin a clinical trial. Proponents of the study said that since chelation therapy was already widely used, it should be subject to the same rigorous scientific testing used to study conventional pharmaceuticals.

And some skeptics were not persuaded at all. Dr. Steven Nissen, head of cardiovascular medicine at the Cleveland Clinic, said the study was “fatally flawed,” with many of the doctors involved being on the fringes of medicine and many patients dropping out of the trial. He said if people got the mistaken idea from the study that chelation was beneficial “it would be a public health catastrophe.”

The study, which began enrolling patients in 2003, was plagued by problems from the start. It fell way behind its goal of recruiting nearly 2,400 patients in three years. The trial was also suspended in 2008 for investigations by government agencies, one over conduct at trial sites and the other about whether patients were being adequately informed that chelation can cause death. The study was allowed to resume the next year, after some changes were made.

The trial ended up with 1,708 patients at 134 centers in the United States and Canada. The patients all had had previous heart attacks.

Half the patients received the chelation therapy, a synthetic amino acid called disodium ethylene diamine tetra acetic acid, or EDTA, as well as other substances. These were given by infusion every week for 30 weeks, followed by 10 more infusions at intervals of two to eight weeks. The other half received infusions of placebo.

After a follow-up of 55 months, 26 percent of those who received chelation therapy had died, suffered a heart attack or stroke, had a procedure to reopen a coronary artery or had been hospitalized for angina. That was less than the 30 percent for those who received a placebo, a difference that was barely statistically significant.

Doctors said there were reasons for caution.

Virtually all the of difference between the treatment and the placebo groups occurred in the third of patients who had diabetes. The placebo contained some sugar, which conceivably could have harmed the diabetics. Also, at least within the first two years, the chelation therapy did not improve physical functioning or psychological well being, according to surveys of the patients.

Dr. Mark A. Creager, a cardiologist at Brigham and Women’s Hospital who was not involved in the study, said the chelation infusion also contained a high dose of vitamin C and the blood thinner heparin. It could be that one of those ingredients, not the chelation agent, were responsible for any benefit, he said.

Dr. Lamas, the lead investigator, said the chelation treatment was well tolerated. But he said investigators did not yet know why some patients receiving the therapy dropped out of the trial.

Another study presented at the heart meeting on Sunday found coronary bypass surgery superior to the use of stents for patients with diabetes and multiple heart blockages.

The trial involved 1,900 patients followed for five yeas. About 27 percent of those who received stents either died or had a heart attack or stroke, compared with about 19 percent of those undergoing bypass surgery. There was an increase in stroke risk with surgery, but that was outweighed by fewer deaths and heart attacks.

Previous studies had already suggested that surgery was better for diabetic patients with severe coronary disease, and practice guidelines already say it is “reasonable” to choose surgery. But the new study, sponsored by the National Institutes of Health, shows the same result even using modern drug-covered stents.

About 700,000 Americans undergo artery opening procedures for more than one blood vessel each year, and about 25 percent of them have diabetes, according to the investigators.

The study results were also published online by the New England Journal of Medicine. Johnson & Johnson and Boston Scientific provided the stents used in the study.

Read More..

Benghazi Attack Raises Doubts About U.S. Abilities in Region

Esam Omran Al-Fetori/Reuters

The attack at the American Mission on Sept. 11, seen here, and an annex in Benghazi, Libya, points to a limitation in the capabilities of the American military command responsible for countries swept up in the Arab Spring.

WASHINGTON — About three hours after the American diplomatic mission in Benghazi, Libya, came under attack, the Pentagon issued an urgent call for an array of quick-reaction forces, including an elite Special Forces team that was on a training mission in Croatia.

The team dropped what it was doing and prepared to move to the Sigonella naval air station in Sicily, a short flight from Benghazi and other hot spots in the region. By the time the unit arrived at the base, however, the surviving Americans at the Benghazi mission had been evacuated to Tripoli, and Ambassador J. Christopher Stevens and three other Americans were dead.

The assault, on the anniversary of the Sept. 11, 2001, attacks on the United States, has already exposed shortcomings in the Obama administration’s ability to secure diplomatic missions and act on intelligence warnings. But this previously undisclosed episode, described by several American officials, points to a limitation in the capabilities of the American military command responsible for a large swath of countries swept up in the Arab Spring.

At the heart of the issue is the Africa Command, established in 2007, well before the Arab Spring uprisings and before an affiliate of Al Qaeda became a major regional threat. It did not have on hand what every other regional combatant command has: its own force able to respond rapidly to emergencies — a Commanders’ In-Extremis Force, or C.I.F.

To respond to the Benghazi attack, the Africa Command had to borrow the C.I.F. that belongs to the European Command, because its own force is still in training. It also had no AC-130 gunships or armed drones readily available.

As officials in the White House and Pentagon scrambled to respond to the torrent of reports pouring out from Libya — with Mr. Stevens missing and officials worried that he might have been taken hostage — they took the extraordinary step of sending elite Delta Force commandos, with their own helicopters and ground vehicles, from their base at Fort Bragg, N.C., to Sicily. Those troops also arrived too late.

“The fact of the matter is these forces were not in place until after the attacks were over,” a Pentagon spokesman, George Little, said on Friday, referring to a range of special operations soldiers and other personnel. “We did respond. The secretary ordered forces to move. They simply were not able to arrive in time.”

An examination of these tumultuous events undercuts the criticism leveled by some Republicans that the Obama administration did not try to respond militarily to the crisis. The attack was not a running eight-hour firefight as some critics have contended, questioning how an adequate response could not be mustered in that time, but rather two relatively short, intense assaults separated by a lull of four hours. But the administration’s response also shows that the forces in the region had not been adequately reconfigured.

The Africa Command was spun off from the European Command. At the time it was set up, the Pentagon thought it would be devoted mostly to training African troops and building military ties with African nations. Because of African sensitivities about an overt American military presence in the region, the command’s headquarters was established in Stuttgart, Germany.

While the other regional commands, including the Pacific Command and the Central Command, responsible for the Middle East and South Asia, have their own specialized quick-reaction forces, the Africa Command has had an arrangement to borrow the European Command’s force when needed. The Africa Command has been building its own team from scratch, and its nascent strike force was in the process of being formed in the United States on Sept. 11, a senior military official said.

“The conversation about getting them closer to Africa has new energy,” the military official said.

Some Pentagon officials said that it was unrealistic to think a quick-reaction force could have been sent in time even if the African Command had one ready to act on the base in Sicily when the attack unfolded, and asserted that such a small force might not have even been effective or the best means to protect an embassy. But critics say there has been a gap in the command’s quick-reaction capability, which the force would have helped fill.

A spokesman for the command declined to comment on how its capabilities might be improved.

Read More..

Corner Office | John Duffy: John Duffy of 3C Interactive, on Inspiration and Aspiration

Q. Tell me about your leadership approach.

A. Consistency is important to me. I think my partners and employees appreciate the fact that you get the same John Duffy every day, regardless of the circumstances. You don’t have to think about how to approach me. If one of my employees told me that they had to think about what my mood was on a particular day — “How is he? Can we talk?” — I’d quit. I never want to be that person.

Q. Why is that so important to you?

A. I had a boss who was consistent, pragmatic and disciplined, and he had a big impact on my career. I liked being able to do what I was doing and go back to him for stability and consistency. That helped me be more successful. So I don’t let the things that are bothering me affect how I communicate with people. I try not to, anyway.

Q. What else is important about your approach to leadership?

A. I want to be somebody who not only inspires people, but also helps them learn to aspire. I think there’s a pretty big difference.

Q. Parse that for me.

A. Well, I’m a pretty good salesperson, and I think I’m a fun guy. And if we go out and spend some time and have lunch or a couple of beers, I think you’ll go away being happy that you spent time with me. You’ll feel good, and hopefully inspired by my adventures and stories.

You can also be working with someone regularly and teaching them to aspire for their own development, and helping them understand that there’s a path, a trail of bread crumbs that they can follow that will make a difference in their life. It might be experiences they get, exposure to new things, the questions they ask themselves or the skills associated with planning, problem solving and decision making.

When I work with younger people in our company and talk to them about what they’re doing, why they’re doing it and how it fits into their life plan, hopefully that has a more powerful and longer-term effect than just inspiring them temporarily. I don’t want to be like the guy on the stage who makes you feel great. It’s about taking someone and helping them understand that they can have an impact.

Q. What are some other important leadership lessons you’ve learned?

A. One thing that is critical for me, and critical for the people in our business to be successful, is being coachable. I had a lot of experience with coaches in environments where I was the least successful person in the group. I was on a great wrestling team in college. I was not that great of a wrestler. I didn’t necessarily win a lot of matches, but I had an impact on the team. That has to do with having the attitude that I’m there because I want to get better. I could have gone to a team where I could have been the best player. That has zero appeal for me. I want to be the dumbest, poorest, least successful guy in the room so I can learn what I have to do. I’ve always felt that way.

Q. What are some things that are important to you in terms of culture?

A. We have absolutely clear discussions with everyone about how respect is the thing that cannot be messed with in our culture. We will not allow a cancer. When we have problems with somebody gossiping, or someone being disrespectful to a superior or a subordinate, or a peer, it is swarmed on and dealt with. We don’t always throw that person out, though there are times when you have to do that. But we make everyone understand that the reason the culture works is that we have that respect. And there is a comfort level and a feeling of safety inside our business.

We recently did an employee survey that was really intense. It wasn’t just, “Are you happy?” It was 11 questions about your happiness, answered on a scale of one to seven. The question that kept me up for a week was, “Do you trust John Duffy?” Not the company, not the mission. I was asking them about me. How do you feel about me? I got more than 90 percent extraordinarily positive responses. So that’s where it starts. I have to set the example for treating all of our employees properly, respectfully and appropriately.

When they’re awesome, I tell them they’re awesome. When they mess it up, they hear about it. But do it the right way. Do it consistently. Do it with respect. No yelling and screaming, but here’s our expectation, and here’s where you missed. What do you think you need to do to get better so this doesn’t happen again? That’s what creates the positive culture. That’s what attracts amazingly talented people.

Q. How do you hire?

A. If we’re going to bring someone into the company, especially in a leadership capacity, they have to be additive to the culture, so the process is going to take a while to make sure we’re going to enjoy working with them. And we have to make sure that what they’re going to do in our business helps them meet their long-term objectives. Before we hire people, we also ask them to write a plan. How are you going to be successful here in your first 100 days? Everyone has to do that.

Q. How many words do you typically want or expect?

A. That’s actually the best part. There’s no guidance. I’m asking you, what will you do? And there’s no wrong answer.

By the time a prospect is writing a plan to make a presentation on how they’ll be successful at our company, we’ve decided we want them. The plan is as much about understanding what they will do once they get here. What is their perspective of us? Where do they think they’ll add value? How will they get started? It’s as much about us learning what their expectations are, and where they think we’re at, so we can make that integration happen a little more seamlessly. It’s a very telling process. We lose some candidates when we ask for a plan. Somebody once said, “Are you going to pay me for that?”

Q. Really? They asked that?

A. That was my favorite: “Well, if you hire me as a consultant, I’ll write a plan.”

This interview has been edited and condensed.

Read More..

Opinion: Seeing Things? Hearing Things? Many of Us Do

HALLUCINATIONS are very startling and frightening: you suddenly see, or hear or smell something — something that is not there. Your immediate, bewildered feeling is, what is going on? Where is this coming from? The hallucination is convincingly real, produced by the same neural pathways as actual perception, and yet no one else seems to see it. And then you are forced to the conclusion that something — something unprecedented — is happening in your own brain or mind. Are you going insane, getting dementia, having a stroke?

In other cultures, hallucinations have been regarded as gifts from the gods or the Muses, but in modern times they seem to carry an ominous significance in the public (and also the medical) mind, as portents of severe mental or neurological disorders. Having hallucinations is a fearful secret for many people — millions of people — never to be mentioned, hardly to be acknowledged to oneself, and yet far from uncommon. The vast majority are benign — and, indeed, in many circumstances, perfectly normal. Most of us have experienced them from time to time, during a fever or with the sensory monotony of a desert or empty road, or sometimes, seemingly, out of the blue.

Many of us, as we lie in bed with closed eyes, awaiting sleep, have so-called hypnagogic hallucinations — geometric patterns, or faces, sometimes landscapes. Such patterns or scenes may be almost too faint to notice, or they may be very elaborate, brilliantly colored and rapidly changing — people used to compare them to slide shows.

At the other end of sleep are hypnopompic hallucinations, seen with open eyes, upon first waking. These may be ordinary (an intensification of color perhaps, or someone calling your name) or terrifying (especially if combined with sleep paralysis) — a vast spider, a pterodactyl above the bed, poised to strike.

Hallucinations (of sight, sound, smell or other sensations) can be associated with migraine or seizures, with fever or delirium. In chronic disease hospitals, nursing homes, and I.C.U.’s, hallucinations are often a result of too many medications and interactions between them, compounded by illness, anxiety and unfamiliar surroundings.

But hallucinations can have a positive and comforting role, too — this is especially true with bereavement hallucinations, seeing the face or hearing the voice of one’s deceased spouse, siblings, parents or child — and may play an important part in the mourning process. Such bereavement hallucinations frequently occur in the first year or two of bereavement, when they are most “needed.”

Working in old-age homes for many years, I have been struck by how many elderly people with impaired hearing are prone to auditory and, even more commonly, musical hallucinations — involuntary music in their minds that seems so real that at first they may think it is a neighbor’s stereo.

People with impaired sight, similarly, may start to have strange, visual hallucinations, sometimes just of patterns but often more elaborate visions of complex scenes or ranks of people in exotic dress. Perhaps 20 percent of those losing their vision or hearing may have such hallucinations.

I was called in to see one patient, Rosalie, a blind lady in her 90s, when she started to have visual hallucinations; the staff psychiatrist was also summoned. Rosalie was concerned that she might be having a stroke or getting Alzheimer’s or reacting to some medication. But I was able to reassure her that nothing was amiss neurologically. I explained to her that if the visual parts of the brain are deprived of actual input, they are hungry for stimulation and may concoct images of their own. Rosalie was greatly relieved by this, and delighted to know that there was even a name for her condition: Charles Bonnet syndrome. “Tell the nurses,” she said, drawing herself up in her chair, “that I have Charles Bonnet syndrome!”

Rosalie asked me how many people had C.B.S., and I told her hundreds of thousands, perhaps, in the United States alone. I told her that many people were afraid to mention their hallucinations. I described a recent study of elderly blind patients in the Netherlands which found that only a quarter of people with C.B.S. mentioned it to their doctors — the others were too afraid or too ashamed. It is only when physicians gently inquire (often avoiding the word “hallucination”) that people feel free to admit seeing things that are not there — despite their blindness.

Rosalie was indignant at this, and said, “You must write about it — tell my story!” I do tell her story, at length, in my book on hallucinations, along with the stories of many others. Most of these people have been reluctant to admit to their hallucinations. Often, when they do, they are misdiagnosed or undiagnosed — told that it’s nothing, or that their condition has no explanation.

Misdiagnosis is especially common if people admit to “hearing voices.” In a famous 1973 study by the Stanford psychologist David Rosenhan, eight “pseudopatients” presented themselves at various hospitals across the country, saying that they “heard voices.” All behaved normally otherwise, but were nonetheless determined to be (and treated as) schizophrenic (apart from one, who was given the diagnosis of “manic-depressive psychosis”). In this and follow-up studies, Professor Rosenhan demonstrated convincingly that auditory hallucinations and schizophrenia were synonymous in the medical mind.

WHILE many people with schizophrenia do hear voices at certain times in their lives, the inverse is not true: most people who hear voices (as much as 10 percent of the population) are not mentally ill. For them, hearing voices is a normal mode of experience.

My patients tell me about their hallucinations because I am open to hearing about them, because they know me and trust that I can usually run down the cause of their hallucinations. For the most part, these experiences are unthreatening and, once accommodated, even mildly diverting.

David Stewart, a Charles Bonnet syndrome patient with whom I corresponded, writes of his hallucinations as being “altogether friendly,” and imagines his eyes saying: “Sorry to have let you down. We recognize that blindness is no fun, so we’ve organized this small syndrome, a sort of coda to your sighted life. It’s not much, but it’s the best we can manage.”

Mr. Stewart has been able to take his hallucinations in good humor, since he knows they are not a sign of mental decline or madness. For too many patients, though, the shame, the secrecy, the stigma, persists.

Oliver Sacks is a professor of neurology at the N.Y.U. School of Medicine and the author, most recently, of the forthcoming book “Hallucinations.”

Read More..