The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Ex-NASA Scientist’s Data Fears Come True

In 2007, Robert M. Nelson, an astronomer, and 27 other scientists at the Jet Propulsion Laboratory sued NASA arguing that the space agency’s background checks of employees of government contractors were unnecessarily invasive and violated their privacy rights.

Privacy advocates chimed in as well, contending that the space agency would not be able to protect the confidential details it was collecting.

The scientists took their case all the way to the Supreme Court only to lose last year.

This month, Dr. Nelson opened a letter from NASA telling him of a significant data breach that could potentially expose him to identity theft.

The very thing he and advocates worried about had occurred. A laptop used by an employee at NASA’s headquarters in Washington had been stolen from a car parked on the street on Halloween, the space agency said.

Although the laptop itself was password protected, unencrypted files on the laptop contained personal information on about 10,000 NASA employees — including details like their names, birth dates, Social Security numbers and in some cases, details related to background checks into employees’ personal lives.

Millions of Americans have received similar data breach notices from employers, government agencies, medical centers, banks and retailers. NASA in particular has been subject to “numerous cyberattacks” and computer thefts in recent years, according to a report from the Government Accountability Office, an agency that conducts research for Congress.

Even so, Dr. Nelson, who recently retired from the Jet Propulsion Laboratory, a research facility operated by the California Institute of Technology under a contract with NASA, stands out as a glaring example of security lapses involving personal data, privacy advocates say.

“To the extent that Robert Nelson looks like millions of other people working for firms employed by the federal government, this would seem to be a real problem,” said Marc Rotenberg, the executive director of the Electronic Privacy Information Center, an advocacy group which filed a friend-of-the-court brief for Dr. Nelson in the Supreme Court case.

In a 2009 report titled “NASA Needs to Remedy Vulnerabilities in Key Networks,” the Government Accountability Office noted that the agency had reported 1,120 security incidents in fiscal 2007 and 2008 alone.

It also singled out an incident in 2009 in which a NASA center reported the theft of a laptop containing about 3,000 unencrypted files about arms traffic regulations and wind tunnel tests for a supersonic jet.

“NASA had not installed full-disk encryption on its laptops at all three centers,” the report said. “As a result, sensitive data transmitted through the unclassified network or stored on laptop computers were at an increased risk of being compromised.” Other federal agencies have had similar problems. In 2006, for example, the Department of Veteran’s Affairs reported the theft of an employee laptop and hard drive that contained personal details on about 26.5 million veterans. Last year, the G.A.O. cited the Internal Revenue Service for weaknesses in data control that could “jeopardize the confidentiality, integrity, and availability of financial and sensitive taxpayer information.”

Also last year, the Securities and Exchange Commission warned its employees that their confidential financial information, like brokerage transactions, might have been compromised because an agency contractor had granted data access to a subcontractor without the S.E.C.’s authorization.

In a phone interview, Dr. Nelson, the astronomer, said he planned to hold a news conference on Wednesday morning in which he would ask members of Congress to investigate NASA’s data collection practices and the recent data breach.

Robert Jacobs, a NASA spokesman, said the agency’s data security policy already adequately protected employees and contractors because it required computers to be encrypted before employees took them off agency premises. “We are talking about a computer that should not have left the building in the first place,” Mr. Jacobs said. “The data would have been secure had the employee followed policy.”

The government argued in the case Dr. Nelson filed that a law called the Privacy Act, which governs data collection by federal agencies, provided the scientists with sufficient protection. The case reached the Supreme Court, which upheld government background checks for employees of contractors. The roots of Dr. Nelson’s case against NASA date back to 2004 when the Department of Homeland Security, under a directive signed by President George Bush, required federal agencies to adopt uniform identification credentials for all civil servants and contract employees. As part of the ID card standardization process, the department recommended agencies institute background checks.

Several years later, when NASA announced it intended to start doing background checks at the Jet Propulsion Laboratory, Dr. Nelson and other scientists there objected.

Those security checks could have included inquiries into medical treatment, counseling for drug use, or any “adverse” information about employees such as sexual activity, or participation in protests, said Dan Stormer, a lawyer representing Dr. Nelson.

But Dr. Nelson and other long-term employees of the lab challenged the legality of those checks, arguing that they violated their privacy rights. NASA, they said, had not established a legitimate need for such extensive investigations about low-risk employees like themselves who did not have security clearances or handle confidential information. Dr. Nelson, for example, specializes in solar system science — concerning, for example, Jupiter’s moon Io and Titan, a moon of Saturn — and publishes his work in scientific journals

“It was an invitation to an open-ended fishing expedition,” Dr. Nelson said of the background checks.

In friend of the court briefs for Dr. Nelson, privacy groups cited many data security problems at federal agencies, arguing that there was a risk that NASA was not equipped to protect the confidential details it was collecting about employees and contractors.

In 2008, the United States Court of Appeals for the Ninth Circuit in San Francisco temporarily halted the background checks, saying that the case had raised important questions about privacy rights. But last year, the Supreme Court upheld the background investigations of employees of government contractors.

Dr. Nelson said he retired from the Jet Propulsion Laboratory last June rather than submit to a background check. He now works as a senior scientist at the Planetary Science Institute of Tucson.

NASA has contracted with ID Experts, a data breach company, to help protect employees whose data was contained on the stolen laptop against identity theft. Mr. Jacobs, the NASA spokesman, said the agency has encrypted almost 80 percent of its laptops and plans to encrypt the rest by Dec. 21. He added that he too received a letter from NASA warning that his personal information might have been compromised by the laptop theft.

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Politics in Play Over Safety Net in Deficit Talks

Carolyn Kaster/Associated Press

President Obama and Speaker John A. Boehner of Ohio at the White House this month.

WASHINGTON — President Obama’s re-election and Democratic gains in Congress were supposed to make it easier for the party to strike a deal with Republicans to resolve the year-end fiscal crisis by providing new leverage. But they could also make it harder as empowered Democrats, including some elected on liberal platforms, resist significant changes in entitlement programs like Social Security and Medicare.

As Congress returned Monday, the debate over those programs, which many Democrats see as the core of the party’s identity, was shaping up as the Democratic version of the higher-profile struggle among Republicans over taxes.

In failed deficit reduction talks last year, Mr. Obama signaled a willingness to consider substantial changes in the social safety net, including a gradual increase in the eligibility age for Medicare and limits in the growth rate of future Social Security benefits. An urgent question hanging over the new round of deficit talks is which of those changes Mr. Obama and Congressional Democrats would accept today.

While a potential change in calculating Social Security increases was part of the talks with Speaker John A. Boehner last year, the White House press secretary, Jay Carney, made clear on Monday that the administration was not considering changes to the retirement program as part of the deficit talks.

“We should address the drivers of the deficit, and Social Security is not currently a driver of the deficit,” Mr. Carney said.

Republicans insist that changes in the major entitlement programs be on the table in exchange for their willingness to accept increases in tax revenue. But Democrats have given no indication that they are willing to consider policy changes or savings of the magnitude demanded by Republicans. The underlying dispute highlights a reason the politics of the deficit are so thorny: even as many voters say they want Washington to reduce the budget deficit, they oppose many of the benefit cuts and tax increases that could help achieve that goal.

As the negotiations enter a crucial phase, influential outside advocacy groups like AARP and the National Committee to Preserve Social Security and Medicare are weighing in, alerting their members to possible changes in the popular programs.

In the current negotiations with Congress over deficits and the debt, Mr. Obama said he would take a serious look at how to “reform our entitlements” because “health care costs continue to be the biggest driver of our deficits.” Unless Mr. Obama and Congress reach some agreement, tax increases and budget reductions will take effect automatically on Jan. 1.

Mr. Obama’s room for maneuvering is limited by several political factors. In the presidential campaign, for example, he attacked cost-cutting proposals by his Republican opponents and won support from millions of voters by promising to defend Medicare.

Moreover, since the Supreme Court upheld the new health care law in June, Mr. Obama has become skittish about cutbacks in Medicaid, the federal-state program for low-income people. The court said the expansion of Medicaid was an option for states but not a requirement. Cutting federal Medicaid payments to states could reduce the federal budget deficit, but could also cripple Mr. Obama’s efforts to persuade governors to expand the program, the foundation of his health care overhaul.

Even if Mr. Obama and Republican leaders in Congress could agree on savings in Medicare and Medicaid, the president would face resistance from some liberal members of his party who oppose cuts in the two giant health care entitlement programs. Medicare and Medicaid insure one-third of all Americans, account for more than one-fifth of the federal budget and are expected to grow much faster than the economy in the coming decade.

Two staunch liberals, Senators Tom Harkin of Iowa and John D. Rockefeller IV of West Virginia, said in a letter to Mr. Obama that he should “reject changes to Medicare, Medicaid and Social Security that would cut benefits, shift costs to states, alter the structure of these critical programs, or force vulnerable populations to bear the burden of deficit reduction.”

More than 40 House members, led by the Congressional Progressive Caucus, declare in a resolution that any deal on taxes and spending “should not cut Medicare, Medicaid or Social Security benefits.”

Republicans say the revenue to be gained from Mr. Obama’s tax proposals would be dwarfed by the growing costs of the benefit programs.

“You can’t raise taxes enough to solve the problem,” said the Senate Republican leader, Mitch McConnell of Kentucky. “Additional revenue should be tied to the only thing that will save the country in the long run, and that is reforming entitlements.”

Mr. Boehner said the newest entitlement — insurance subsidies for more than 20 million people under the health care law — should be “on the table” in negotiations. White House officials said the law should be given a chance to work before its budget is cut.

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Audra McDonald new 'Live From Lincoln Center' host

LOS ANGELES (AP) — Broadway superstar Audra McDonald is adding a new chapter to her long history with Lincoln Center.

The singer-actress is the new host of "Live From Lincoln Center," PBS said Tuesday.

McDonald will emcee seven broadcasts from December through spring 2013, starting Dec. 13 with "The Richard Tucker Opera Gala" and Dec. 31 with the New York Philharmonic's New Year's Eve gala.

"It's a great honor. I'm thrilled that they came to me and trusted me to do it," said McDonald, 42, whose five Tony Awards include a trophy this year for "The Gershwins' Porgy and Bess."

Her memories of the Lincoln Center performing arts complex in Manhattan run deep.

"I remember watching Beverly Sills broadcasting from the Met (the center's Metropolitan Opera House) on my PBS channel at my home in Fresno," McDonald said, adding that she was amazed at the venue's size and "inspired by the music."

As a high school student, she had the chance to visit the center and recalled thinking, "This is where I want to be some day."

That wish was fulfilled when she moved to New York to attend The Juilliard School, which has its campus there.

Stepping in as host of the PBS series "feels like it's my way of thanking Lincoln Center," she said.

"We can't imagine a more perfect match," said Elizabeth Scott, the center's executive in charge of the TV series. McDonald's passion for the performing arts is "infectious," Scott added.

McDonald, who starred in "Private Practice" as Dr. Naomi Bennett, has performed on the long-running PBS showcase several times, including programs with Elvis Costello, Patti Lupone and the New York Philharmonic.

She will be working especially hard New Year's Eve when she hosts and performs in the holiday program, "One Singular Sensation: Celebrating Marvin Hamlisch" (check local listings for time).

"We'll see if I fall down by the end of the evening, or by the middle," she said, lightly. What she'll sing is a secret for now, but McDonald said it's among Hamlisch's most famous pieces.

The composer, who died in August at age 68, created more than 40 film scores and won a Tony and the Pulitzer for Broadway's "A Chorus Line."

"Live From Lincoln Center" is in its 37th broadcast season. In recent years, artists and actors including Yo-Yo Ma and Alec Baldwin have filled the host's job that previously saw long tenures by famed opera singer Sills and TV personality Hugh Downs.

___

Online:

http://www.pbs.org

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Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

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News Analysis: St. Jude Medical Suffers for Redacting a Product Name

Peter Muhly for The New York Times

Dr. Ernest Lau holds a Durata lead from a St. Jude Medical Fortify ICD, an implanted heart defibrillator.

IS covering a product’s name in a public document a sign that a company has something to hide? And how should doctors, patients and investors react if the product at issue is one on which peoples’ lives and a company’s fortunes depend?

Such questions now loom over St. Jude Medical after the disclosure last week that its executives had blacked out the name of a heart device component when they released a critical federal report involving the product. The value of St. Jude has since plummeted more than $1 billion, or 12 percent. But the company’s actions may have a more lasting impact on its reputation and the health of patients, some experts say.

Last week’s incident was the latest development in a controversy involving the component, an electrical wire that connects an implanted defibrillator to a patient’s heart. St. Jude officials say the wire, which is known as the Durata, is safe. But uncertainty about the company’s statements is growing, underscored by its handling of the report, which involved a Food and Drug Administration inspection of a plant that makes the Durata.

St. Jude released that report in October as part of a filing with the Securities and Exchange Commission. The F.D.A. provides device makers with the reports in an unaltered form, and they may contain criticisms of a company’s procedures.

But the version of the report that St. Jude filed with the S.E.C. left some doctors and analysts uncertain about which company product or products were at issue for a simple reason — St. Jude had redacted, or blocked out, all 20 references to the Durata in it.

Company executives said they had done so based on their “good faith” interpretation of how the F.D.A. would act if it publicly released the report under the Freedom of Information Act. But both an F.D.A spokeswoman and a lawyer who specializes in medical devices took exception with that view, saying that names of approved products typically do not qualify as the type of confidential business information that the F.D.A. would redact.

Among other things, F.D.A. inspectors found significant flaws in the company’s testing and oversight of the Durata. It was those revelations and the implications that the problems could lead to further F.D.A. action against St. Jude that led to the sharp fall last week in its stock price.

In 2005, Guidant, a device maker that no longer exists, also found itself under scrutiny. Back then, its executives decided not to tell doctors that one of its defibrillators could short-circuit when a patient needed an electrical jolt to save a life. The expert who brought the Guidant problem to light, Dr. Robert Hauser, a heart specialist in Minnesota, has also raised concerns about the St. Jude wires, adding that he believes that its executives have been less than forthright.

“Patients and physicians would appreciate more information,” Dr. Hauser said.

In an earlier interview, St. Jude’s chief executive, Daniel J. Starks, said the company had hidden nothing about the Durata or another heart wire named the Riata, which it stopped selling in 2010.

“We’ve been more transparent than others,” said Mr. Starks, referring to company competitors like Medtronic.

Still, some Wall Street analysts share Dr. Hauser’s view. And if one St. Jude executive can claim credit for shaping their opinion, it would be Mr. Starks.

Earlier this year, he sought, among other things, to have a medical journal retract an article written by Dr. Hauser that was critical of the Riata. The publication refused.

Now, after St. Jude’s latest misfire, Wall Street analysts, who usually agree more than disagree, are placing wildly differing bets on St. Jude, with some valuing it at $48 a share and others at $30. On Monday, St. Jude closed at $31.86 on the New York Stock Exchange.

One of those bearish analysts, Matthew Dodds of Citigroup, said he thought the Food and Drug Administration might act soon on Durata. “I believe that a lot of their actions have made the situation worse, ” he said of the company’s executives.

A St. Jude spokeswoman, Amy Jo Meyer, reiterated the company’s stance that it had interpreted agency rules in “good faith” when releasing the redacted report about the Durata. An F.D.A. spokeswoman, Mary Long, said the agency did not consider the names of approved products to be confidential. And a lawyer, William Vodra, said that while device makers try to make a confidentiality argument for product data they consider embarrassing, like injury reports, they rarely succeed.

“In my experience, the F.D.A. consistently rejects” such arguments, Mr. Vodra wrote in an e-mail.

For patients, the dilemma may become more excruciating. The company’s earlier heart wire, the Riata, has begun failing prematurely in some of the 128,000 patients worldwide who received it. And those patients and their doctors face a difficult decision: whether to leave it in place or have it surgically removed, a procedure that carries significant risks.

St. Jude executives say that the Durata, which uses a different type of insulation than the Riata, is not prone to such problems.

And with the Durata already implanted in 278,000 people, many heart specialists certainly hope they are right.

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Time Slipping, U.S. Ponders Afghan Role After 2014

WASHINGTON — American and allied military planners are drawing up the broad outlines of a force that would remain in Afghanistan following the handover to Afghan security after 2014, including a small counterterrorism force with an eye toward Al Qaeda, senior officials say.

Under the emerging plan, the American counterterrorism force might number less than 1,000, one military official said. In a parallel effort, NATO forces would advise Afghan forces at major regional military and police headquarters but most likely have a minimal battlefield role, with the exception of some special operations advisers.

Final decisions on the size of the American and NATO presence after 2014 and its precise configuration have not been made by the United States or its allies. But one option calls for about 10,000 American and several thousand non-American NATO troops.

The planning for a post-2014 mission has emerged as an early test for President Obama in his new term as he tries to flesh out the strategy for transferring the responsibility for security to the Afghans. But it is not the only challenge: After the White House decides what sort of military presence to propose to the Afghan government for after 2014, it must turn to the question of how quickly to reduce its troop force before then.

As one of his last acts as senior American commander in Afghanistan, Gen. John R. Allen is expected to submit a formal recommendation for how quickly to begin withdrawing the United States’ 66,000 troops. Two American officials who are involved in Afghan issues said that General Allen wants to keep a significant military capability through the fighting season ending in fall 2013, which could translate to a force of more than 60,000 troops until the end of that period.

Afghan forces are to assume the lead role for the war next year, and a military officer said that such a troop level would enable the United States to better support them, maintain the initiative and control critical terrain.

But such an approach may entail a heavier military involvement than the White House, which appears weary of the war, might like.

The White House is expected to ask General Allen to submit a range of options for drawing down forces next year, including some involving substantial reductions in troop levels.

“The White House has not yet asked General Allen for his assessment, nor have we begun considering any specific recommendations for troop numbers in 2013 and 2014,” said George Little, the Pentagon spokesman. “What is true is that in June 2011 the president made clear that our forces would continue to come home at a steady pace as we transition to an Afghan lead for security. That it still the case.”

The issue is already a politically contentious one. Some leading Democratic lawmakers have signaled that they would like to see steady troop reductions next year while Republicans have argued that speedy withdrawals would jeopardize hard-won gains.

There are also questions about General Allen’s future: his e-mails to a woman linked to the F.B.I. inquiry that disclosed David H. Petraeus’s affair are being investigated by the Pentagon inspector general.

But General Allen has resumed his duties in Kabul, and Mr. Obama has said that he thinks highly of his military performance. The Marine general who has been nominated to replace him, Joseph F. Dunford Jr., is not scheduled to take up the post until early February and recently told Congress that he had not been part of the planning process.

The planning for a post-2014 force is the Obama administration’s first order of business on Afghanistan for several reasons. The United States has opened talks with the Afghans on a security agreement that would authorize an American troop presence in Afghanistan after 2014. So American officials need to define what role American and NATO forces might play then.

In addition, NATO’s political arm has authorized the alliance’s military planners to develop a concept for how to carry out the post-2014 mission, which is to be approved by the alliance’s defense ministers early next year.

The planning for after 2014 turns on troubling questions on how to guard against the expansion of terrorist groups and advise an Afghan military that has little airpower, poor logistics and difficulties evacuating and treating its own wounded. But it will also depend heavily on the willingness of allied nations to contribute troops and funds.

Reporting was contributed by Matthew Rosenberg and Alissa J. Rubin from Kabul, Afghanistan, and Eric Schmitt and Wesley S. Morgan from Washington.

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Yes, the Government Can Still Spy on Your Digital Life (for Now)

Ahead of a controversial Senate debate on digital privacy this week, the battle over warrantless cell-phone and Internet searches is beginning to take shape — even as law-enforcement agencies continue to carry out the searches anyway. Judges across the country have thrown out cases that used tracked digital American lives without warrants, but others haven’t, reports The New York Times‘s Somini Sengupta. A DC court, for example, compared text messages to voicemail messages, which because they can be overheard are not protected by state privacy laws, argued one judge. A Louisiana court is deciding if cell-phone records are like business records. Another court ruled that GPS cell phone tracking without a warrant was fine, too. Others, however, argue that cell phones are more than just a paper trail. One judge called cell phones “raw, unvarnished and immediate, revealing the most intimate of thoughts and emotions,” as in something that is subject to higher privacy standards. Meanwhile, we see the same inconsistencies with Internet protections, reports The Wall Street Journal‘s Joe Pallazolo. A federal court recently ruled that people who use their neighbors’ WiFi without permission forfeit privacy, opening up government officials to warrantless searches. The same ruling other courts have made for IP addresses. However, the law isn’t that clear-cut, either, argues George Washington University professor Oren Kerr. 

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Without clear rules, government agencies have continued investigations with warrantless searches. As people have started using cell phones more often and for more than just calling, law enforcement agency requests for cell-phone information have increased, reported The New York Times‘s Eric Lichtblau earlier this year. AT&T gets more than 700 requests a day from various agencies, triple what it got in 2007, he notes. Last year, the total number of requests came in at at least 1.3 million. At the same time, the application for wiretapping warrants declined 14 percent last year to 2,732, according to the Administrative Office of the United States Courts. A curious pattern considering the requests for information have gone up. Though these wireless carriers say they require a search warrant, a court order or a formal subpoena to release information, “in cases that law enforcement officials deem an emergency, a less formal request is often enough,” writes Lichtblau. Or, it’s possible that law enforcement has opted for other forms of tracking that don’t require warrants, at least not according to some judges. 

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A Senate debate beginning Thursday to make changes on the Electronic Communications Privacy Act might bring some clarity to these issues. However, it’s unclear if the revised bill will give the government more or less power, and it doesn’t sound like the vote will apply to all cell phone or Internet data. An early draft of the bill reportedly allowed warrantless e-mail searches, reported CNET’s Declan McCullagh. Since, Senator Patrick Leahy, who is spearheading the bill, has denied that the updates to the regulation will do that, however. Instead, the revised bill will require search warrants to get into email no matter how old, says Sengupta. That should presumably apply to some of our smartphone and Internet data, too. But it doesn’t address text messages or location information, other concerns of consumers.

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Rolling Stones storm London; New York next

LONDON (AP) — The verdict is in: The Rolling Stones are back. They may look old, but they still sound young.

That was the consensus Monday as Britain's rock critics responded to the Stones 50th anniversary bash Sunday night, the first of five shows to commemorate their half century of rhythm and blues-tinged rock. It was the band's first London performance in five years, and their own advancing years had led some to be skeptical that they could still perform at the highest level.

They were led by the seemingly ageless Mick Jagger, whose strutting style has not been dimmed, and backed by brilliant guitarists Keith Richards and Ronnie Wood and the energetic drumming of Charlie Watts, who is now past 70 but shows no sign of slowing down. There was a stunning guest appearance by former Stone Mick Taylor, who stole the show during a searing performance of "Midnight Rambler" and a brief visit from former bassist Bill Wyman.

The Daily Mail's Jan Moir said the Stones had somehow beaten the aging process: "You might imagine that they had been worn down by life, by wives, by arthritis, by scandals old and new, by drugs, but no — they seemed indestructible." She said their swampy, gritty sound remains unique after half a century.

Daily Telegraph reviewer Neil McCormick said the band exceeded all expectations. He described the weaving of the guitarists, mixed with Jagger's blues harmonica, as a wonder.

"When looking for the secret of the Stones, it is perhaps that they actually listen to each other while they play, and almost lose themselves in it, while their brilliant frontman keeps it all together," he wrote.

Ebullient fans agreed with this assessment, as did the Guardian newspaper, which gave the performance four out of five stars.

Jagger, in skin-tight black pants, a sparkly tie and a matching checked jacket and hat, took time out from singing to thank the crowd for its loyalty.

"It's amazing that we're still doing this, and it's amazing that you're still buying our records and coming to our shows," he said. "Thank you, thank you, thank you."

Lead guitarist Keith Richards, whose survival has surprised many who thought he would succumb to drugs and drink, was blunter: "We made it," he said. "I'm happy to see you. I'm happy to see anybody."

But the band's fiery music was no joke, fuelled by strong guest appearances by Taylor, and Mary J. Blige, who shook the house in a duet with Jagger on "Gimme Shelter," and Jeff Beck.

The 50th anniversary show, which will be followed by one more in London, then three in the greater New York area, lacked some of the band's customary bravado — the "world's greatest rock 'n' roll band" intro was shelved — and there were some rare nostalgic touches.

The concert began with some early Stones' numbers rarely heard in concert, including the band's cover of the Lennon-McCartney rocker "I Wanna Be Your Man" and a cover of "It's All Over Now," written by Bobby Womack and Shirley Womack.

They didn't shy away from their darker numbers, including "Paint It Black" and "Sympathy for the Devil" — Jagger started that one wearing a slightly silly black, purple-lined faux fur cape that conjured up his late '60s satanic image.

He even cracked a joke about one of the band's low points, telling the audience it was in for a treat: "We're going to play the entire "Their Satanic Majesty's Request" album now," he said, referring to one of the band's least-loved efforts, a psychedelic travesty that has been largely, mercifully, forgotten.

He didn't make good on his threat.

Jagger seemed more mellow than usual, chatting a bit about the good old days and asking if there was anyone in the crowd who had seen them in 1962, when they first took to the stage.

He said 2012 had been a terrific year for Britain and that the Stones nearly missed the boat, playing no role in the celebration of the Queen's Diamond Jubilee, the London Olympics, or the new James Bond film.

"We just got in under the wire," he said. "We feel pretty good."

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Agency Investigates Deaths and Injuries Associated With Bed Rails

Thomas Patterson for The New York Times

Gloria Black’s mother died in her bed at a care facility.

In November 2006, when Clara Marshall began suffering from the effects of dementia, her family moved her into the Waterford at Fairway Village, an assisted living home in Vancouver, Wash. The facility offered round-the-clock care for Ms. Marshall, who had wandered away from home several times. Her husband Dan, 80 years old at the time, felt he could no longer care for her alone.

Thomas Patterson for The New York Times

Gloria Black, visiting her mother’s grave in Portland, Ore. She has documented hundreds of deaths associated with bed rails and said families should be informed of their possible risks.

But just five months into her stay, Ms. Marshall, 81, was found dead in her room apparently strangled after getting her neck caught in side rails used to prevent her from rolling out of bed.

After Ms. Marshall’s death, her daughter Gloria Black, who lives in Portland, Ore., began writing to the Consumer Product Safety Commission and the Food and Drug Administration. What she discovered was that both agencies had known for more than a decade about deaths from bed rails but had done little to crack down on the companies that make them. Ms. Black conducted her own research and exchanged letters with local and state officials. Finally, a letter she wrote in 2010 to the federal consumer safety commission helped prompt a review of bed rail deaths.

Ms. Black applauds the decision to study the issue. “But I wish it was done years ago,” she said. “Maybe my mother would still be alive.” Now the government is studying a problem it has known about for years.

Data compiled by the consumer agency from death certificates and hospital emergency room visits from 2003 through May 2012 shows that 150 mostly older adults died after they became trapped in bed rails. Over nearly the same time period, 36,000 mostly older adults — about 4,000 a year — were treated in emergency rooms with bed rail injuries. Officials at the F.D.A. and the commission said the data probably understated the problem since bed rails are not always listed as a cause of death by nursing homes and coroners, or as a cause of injury by emergency room doctors.

Experts who have studied the deaths say they are avoidable. While the F.D.A. issued safety warnings about the devices in 1995, it shied away from requiring manufacturers to put safety labels on them because of industry resistance and because the mood in Congress then was for less regulation. Instead only “voluntary guidelines” were adopted in 2006.

More warnings are needed, experts say, but there is a technical question over which regulator is responsible for some bed rails. Are they medical devices under the purview of the F.D.A., or are they consumer products regulated by the commission?

“This is an entirely preventable problem,” said Dr. Steven Miles, a professor at the Center for Bioethics at the University of Minnesota, who first alerted federal regulators to deaths involving bed rails in 1995. The government at the time declined to recall any bed rails and opted instead for a safety alert to nursing homes and home health care agencies.

Forcing the industry to improve designs and replace older models could have potentially cost bed rail makers and health care facilities hundreds of million of dollars, said Larry Kessler, a former F.D.A. official who headed its medical device office. “Quite frankly, none of the bed rails in use at that time would have passed the suggested design standards in the guidelines if we had made them mandatory,” he said. No analysis has been done to determine how much it would cost the manufacturers to reduce the hazards.

Bed rails are metal bars used on hospital beds and in home care to assist patients in pulling themselves up or helping them out of bed. They can also prevent people from rolling out of bed. But sometimes patients — particularly those suffering from Alzheimer’s — can get confused and trapped between a bed rail and a mattress, which can lead to serious injury or even death.

While the use of the devices by hospitals and nursing homes has declined as professional caregivers have grown aware of the dangers, experts say dozens of older adults continue to die each year as more rails are used in home care and many health care facilities continue to use older rail models.

Since those first warnings in 1995, about 550 bed rail-related deaths have occurred, a review by The New York Times of F.D.A. data, lawsuits, state nursing home inspection reports and interviews, found. Last year alone, the F.D.A. data shows, 27 people died.

As deaths continued after the F.D.A. warning, a working group put together in 1999 and made up of medical device makers, researchers, patient advocates and F.D.A. officials considered requiring bed rail makers to add warning labels.

But the F.D.A. decided against it after manufacturers resisted, citing legal issues. The agency said added cost to small manufacturers and difficulties of getting regulations through layers of government approval, were factors against tougher standards, according to a meeting log of the group in 2000 and interviews.

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