Connie Culp (left), before the injury to her face that would lead her to become the first face transplant patient in the U.S., and on Tuesday at the Cleveland Clinic in Cleveland after a series of surgeries.

CLEVELAND – Five years ago, a shotgun blast left a ghastly hole where the middle of her face had been. Five months ago, she received a new face from a dead woman.

Connie Culp stepped forward Tuesday to show off the results of the nation’s first face transplant, and her new look was a far cry from the puckered, noseless sight that made children run away in horror.

Culp’s expressions are still a bit wooden, but she can talk, smile, smell and taste her food again. Her speech is at times a little tough to understand. Her face is bloated and squarish, and her skin droops in big folds that doctors plan to pare away as her circulation improves and her nerves grow, animating her new muscles.

But Culp had nothing but praise for those who made her new face possible.

“I guess I’m the one you came to see today,” the 46-year-old Ohio woman said at a news conference at the Cleveland Clinic, where the groundbreaking operation was performed. But “I think it’s more important that you focus on the donor family that made it so I could have this person’s face.”

Up until Tuesday, Culp’s identity and how she came to be disfigured were a secret.

Culp’s husband, Thomas, shot her in 2004, then turned the gun on himself. He went to prison for seven years. His wife was left clinging to life. The blast shattered her nose, cheeks, the roof of her mouth and an eye. Hundreds of fragments of shotgun pellet and bone splinters were embedded in her face. She needed a tube into her windpipe to breathe. Only her upper eyelids, forehead, lower lip and chin were left.

A plastic surgeon at the Cleveland Clinic, Dr. Risal Djohan, got a look at her injuries two months later. “He told me he didn’t think, he wasn’t sure, if he could fix me, but he’d try,” Culp recalled.

She endured 30 operations to try to fix her face. Doctors took parts of her ribs to make cheekbones and fashioned an upper jaw from one of her leg bones. She had countless skin grafts from her thighs. Still, she was left unable to eat solid food, breathe on her own, or smell.

Then, on Dec. 10, in a 22-hour operation, Dr. Maria Siemionow led a team of doctors who replaced 80 percent of Culp’s face with bone, muscles, nerves, skin and blood vessels from another woman who had just died. It was the fourth face transplant in the world, though the others were not as extensive.

“Here I am, five years later. He did what he said – I got me my nose,” Culp said of Djohan, laughing.

In January, she was able to eat pizza, chicken and hamburgers for the first time in years. She loves to have cookies with a cup of coffee, Siemionow said.

No information has been released about the donor or how she died, but her family members were moved when they saw before-and-after pictures of Culp, Siemionow said.

Culp said she wants to help foster acceptance of those who have suffered burns and other disfiguring injuries.

Recession forces cutbacks that could endanger health

Diabetics are increasingly risking life and limb by cutting back on – or even going without – doctor visits, insulin, medicines and blood-sugar testing as they lose income and health insurance during the recession, an Associated Press analysis has found.

Doctors have seen a drop in regular appointments with diabetic patients, if they come back at all. Patients more often seek tax-subsidized or charity care. And they end up in emergency rooms more often, patients and physicians said in interviews.

Sales of top-selling drugs and other products used to treat and monitor the disease have dropped since the economic crisis accelerated last fall, the AP analysis found. There are even signs that some patients are choosing less-expensive insulin injections over pricier pills to save money.

Meanwhile, the number of people with the disease keeps growing – another 1.6 million Americans were diagnosed in 2007 alone.

People with other health problems also are cutting back on care amid the recession, but diabetics who don’t closely monitor and control the chronic disease risk particularly dire complications: amputations, vision loss, stroke – even death.

Patients’ frugality comes at a tremendous cost to the already-strained health care system. The typical monthly bill to treat diabetes runs $350 to $900 for those without insurance, a price tag that’s risen as newer, more expensive medicines have hit the market. Emergency care and a short hospitalization can easily top $10,000, and long-term complications can cost far more.

M. Eileen Collins, 48, of Indianapolis, tried to scrimp on her medication last fall after her husband lost his job and with it their insurance. Without money for insulin, test supplies and other medicines, she asked for free samples and also got a few drugs through $4-a-month generic programs. But she stopped taking most of her drugs and cut her insulin doses in half to stretch her budget.

“I truly did not think I was putting my life in danger,” Collins said. “I thought if I was just real careful with what I ate . . . I’d be all right.”

By Thanksgiving eve, Collins was vomiting blood and rushed to a hospital. Doctors diagnosed her as malnourished, anemic and in diabetic ketoacidosis, a life-threatening condition caused by lack of insulin and sky-high blood sugar. She spent a week in the hospital.

Her story is hardly unique.

Dr. Steven Edelman, a University of California, San Diego endocrinologist who runs a free clinic staffed by medical students, has seen a 30 percent surge the past six months in patients seeking free diabetes medicines and supplies, which the clinic has to ration. Many had been solidly middle class, but the recession took their jobs, insurance and even some homes.

“A third to a half of these people haven’t been taking their meds at all,” said Edelman, who also founded the advocacy group Taking Control of Your Diabetes.

Diabetes occurs when the body doesn’t make enough insulin or doesn’t efficiently use the hormone, which helps turn sugar from food into energy. The disease can be kept under control by monitoring blood sugar as well as by exercising, improving the diet, taking medications, testing and regular checkups.

Uncontrolled diabetes can cause fatigue, blurry vision, excessive urination, gum problems, infections and wounds that don’t heal. Damage to the kidneys, liver, heart and eyes follow. Often, much of that damage isn’t apparent until a stroke or heart attack strikes.

Sales of diabetes testing supplies and drugs indicate how many Americans have moved beyond scrimping and are cutting vital expenses. Several doctors said they began noticing a shift in August or September, when the financial markets melted down and layoffs accelerated.

Sales have dipped for pricey brand-name diabetes pills, blood glucose monitors and even test strips, based on industry sales figures and interviews with the top two makers of testing supplies.

Most diabetics typically can control the disease for a few years with diet, exercise and pills available as cheap generics. But eventually, those pills stop working well, and patients switch to more advanced – and more expensive – medicines.

Sales of the most widely used pill, $4-a-month Metformin, are up 7 percent since June, according to the AP analysis of figures from health data firm IMS Health Inc. Brand-name versions of the same drug, costing 10 times as much, are down 9 percent, on average, since then.

By February, sales for nearly every other category of diabetes pills and insulins were down from a year earlier, most by double digits, IMS figures show. The only exceptions were a heavily promoted new type of diabetes pill, Januvia, and advanced insulins that tightly control blood sugar levels.

The sales declines come even as the number of diabetes cases grows, fueled by the rise in obesity. According to the American Diabetes Association, more than 24 million Americans have diabetes.

Even as sales of expensive pills have fallen, sales of advanced insulin injections are up 9 percent since summer. That could mean some patients would rather face a needle to save money, according to Brian Lasky, a research analyst at IMS Health.

“By December, people were making decisions in terms of, ‘Do I fill this prescription or . . . buy Christmas presents for my kids and grandkids?’ ” Lasky added.

Johnson & Johnson, a maker of top-selling OneTouch blood sugar meters, testing strips and insulin pumps, reported a 2 percent fourth-quarter drop in U.S. sales for the category compared with the same period a year earlier, a large drop considering quarterly sales up to then had been rising at around 10 percent.

“We’re seeing some signs that consumers and patients are becoming more frugal,” J&J Chief Executive Bill Weldon told analysts in January.

Getting patients to stick to their treatment has long been tough. But rising unemployment has made things worse.

At a family clinic in impoverished Newark, N.J., so many patients simply stopped showing up after losing health insurance that doctors posted notices asking clients with financial troubles to speak up so staff can try to help.

“Sometimes you don’t see (diabetes) patients for several months,” said Dr. Cynthia Paige, medical director of the New Jersey Family Practice Center. They “don’t understand what a nightmare uncontrolled diabetes is and how it’s ravaging your body,” she said.

April Bumpus, 31, of Woodstock, Ga., was laid off from her job in medical sales last spring while recovering from surgery, and her health insurance was canceled. By September, she had to switch from two advanced insulins that tightly controlled her blood sugar to cheaper, older ones that cause surges and drops. The advanced insulin would have cost $360 a month, the older insulin only $100.

Emergency rooms increasingly are treating diabetics who haven’t been taking medicines, according to doctors at several hospitals nationwide and the professional group for ER doctors. Many of the patients have blood sugar so high they are hospitalized for days. Free clinics also are getting a surge of diabetes patients desperate for help.

“There’s an increase in just overall consequences of diabetes: losing a foot, losing a kidney, bad eyesight. At least six people come to mind over the last six months . . . most because of the recession,” said Dr. Nicholas Vasquez, who works in one of the country’s biggest ERs, at St. Joseph’s Hospital in Phoenix.

———

COST OF DIABETES

Typical monthly costs for medicines and testing supplies to control diabetes, for two common categories of patients who don’t have other health problems. Prices are the full cost, and would be lower for someone with insurance. At bottom are initial costs for hospitalized patients with common complications from cutting back on care:

Typical patient with Type 1, or insulin-dependent, diabetes:

Humalog fast-acting insulin: $104.11

Lantus long-acting insulin: $77.20

1 syringe/day for Lantus: $10.50

3 pen needles/day for Humalog: $33.64

4 lancets/day (for finger pricking): $14.99

4 test strips/day: $123.59

Accupril (prevents kidney damage): $58.77

Total: $422.80

Typical patient with Type 2 diabetes:

Glucotrol XL (helps body make more insulin): $70.33

Metformin (helps control blood sugar): $4

Actos (reduces insulin resistance): $222.38

1 lancet/day: $3.75

1 test stri\n\nday: $30.90

Total: $331.36

Average hospitalization for Type 2 diabetes patient who develops a life-threatening complication called ketoacidosis:

$11,080

Average hospitalization for Type 2 diabetes patient who develops dangerously high blood sugar:

$6,430

Sources: American Diabetes Association, www.drugstore.com, U.S. Agency for Healthcare Research and Quality

CLEVELAND – The nation’s first near-total face transplant was performed on a woman at the Cleveland Clinic, the hospital announced Tuesday.

Reconstructive surgeon Dr. Maria Siemionow replaced nearly all of the woman’s face – 80 percent – with that of a dead female in an operation a couple of weeks ago.

The patient’s name and age were not released. The hospital plans a news conference Wednesday and would not give details until then.

The world’s first partial face transplant occurred in France three years ago on a woman who had been mauled by her dog. Two others have been announced since then: a Chinese farmer attacked by a bear and a European man disfigured by a genetic condition.

The nature of the injuries or disfigurement that prompted the Cleveland case are not known.

Such transplants are controversial, because they are aimed at improving a patient’s quality of life rather than saving it, and require the recipient to take immune-suppressing drugs for the rest of his life.

A medical examiner’s office in Michigan has canceled public school tours after a high school group watched the autopsy of a 14-year-old girl from their district.

The Detroit News reports Monday that Oakland County officials decided to stop the tours in Pontiac after they were contacted by the girl’s parents, who were very upset about the March tour.

Mike Zehnder, the county’s director of public services, says it was “a poor decision” to let the tour go on.

The newspaper reports the teacher who brought in the Waterford Kettering High School group was told the autopsy would be of a Waterford middle school student and discussed that with students.

The outlook for cancer patients, in some ways, has never been better, with breakthroughs leading to earlier diagnoses of certain malignancies, new treatments and improved survival rates.

But that string of successes could be threatened. By the year 2020, the United States could face a shortage of as many as 4,080 cancer doctors, according to a report by the American Society for Clinical Oncology.

“As of 2007, we were in equilibrium,” says Dean Bajorin, an oncologist at Memorial Sloan-Kettering Cancer Center in New York City and co-chairman of the society’s Workforce Implementation Working Group, which developed the report. “It looks like the demand for services appears comparable to provision of services.

“But, we think it won’t get better than that. The shortage will be gradual over time.”

The report cites several factors likely to lead to the shortfall. They include the aging of the U.S. population, with the number of Americans 65 and older expected to double from 2000 to 2030. Cancer is more common among older adults.

Also, many oncologists are expected to be retiring soon, Bajorin says.

A third factor is the growing number of female oncologists, Bajorin says. While the medical profession applauds the fact that there is more gender balance among oncologists, studies have found women cancer specialists tend to see fewer patients than do male oncologists, he says.

Exactly why isn’t known, Bajorin says. “Some may work fewer hours because of family obligations,” he says. “Or it may be more complicated than that. They may spend more time with their patients than do the men.”

One question being asked by oncologists in anticipation of the expected shortage is whether cancer patients need to be cared for continually by cancer specialists.

One remedy to the shortage might be to train other doctors, or nurse practitioners, to take over some aspects of cancer care, Bajorin says. For instance, they might be trained in “survivorship care,” caring for patients once their cancer has gone into remission or has been eliminated.

Or the solution might require an attitude shift on the part of both oncologists and patients, Bajorin says, from a primary cancer doctor providing care to an entire team providing care, with different health care professionals tending to patients at different stages.

———

COMMUNICATION TIPS

Whether the shortage materializes exactly as predicted or not, learning to communicate with your cancer doctor and others on your team is crucial, say experts at CancerCare, a New York-based nonprofit organization providing support services to those affected by cancer. Among its tips for communicating with your doctor and other health-care team members:

• Remember that you are a consumer of health care. And with that in mind, the best way to begin making difficult decisions about health care is to educate yourself.

• When you have an appointment, bring someone with you. Doing so lends support, in addition to providing a “second set of ears,” and another person to think of questions.

• Write out a list of questions before an appointment; this list will help you remember important questions. Be sure to make the questions specific and brief because your doctor has limited time. And ask your most important questions first.

• Write down the answers and instructions the doctor gives you. Even better, bring a tape recorder to the appointment – as long as the doctor says it’s OK.

• When asking questions, use “I” statements. For example, the phrase “I don’t understand…” is much more effective than “You’re being unclear about…”

• If you’re confused by something your doctor says, repeat it back by saying something like, “So you mean I should…?” And if you’re someone who understands better with the use of visuals, ask to see X-rays or slides, or ask your doctor to draw a diagram.

ON THE WEB

The official Web site for CancerCare, offers additional information: www.cancercare.org/reading_room/fact-sheets.php

When Denise Minks was diagnosed with type 2 diabetes in 1993, she knew nothing about the disease and received little advice except to watch what she ate.

Since then, Minks, 39, has developed serious wounds on her feet that have kept her bedridden for most of the last year and put her at the brink of losing both of her big toes to amputation. The problem, which is common to diabetics, has opened her eyes to the magnitude of the disease.

Diabetes “is serious and you have to take care of yourself,” says Minks, one of 318,000 Kentucky adults with diabetes. “You have to find out what diabetes is and how it works.”

Though diabetes often is called a silent killer, more people are aware that they have the condition than in the past. The percentage of people with diabetes who don’t know they have it has decreased from 30 percent to 25 percent in recent years, according to federal officials.

But a lack of understanding about the disease persists, hindering people from taking steps to safeguard themselves from complications.

If you’re a diabetic, “you have to get involved. You can’t just be passive,” says Dr. Vasti Broadstone, medical director of the Joslin Diabetes Center at Floyd Memorial Hospital in New Albany, Ind. The disease is “deadly if it’s uncontrolled. It is a big deal, and it’s costly, and it’s a lot cheaper to prevent it.”

You hear about two main kinds of diabetes, which the American Diabetes Association describes as follows:

• In type 1 diabetes, previously known as juvenile diabetes, the body does not produce insulin. Insulin is a hormone that is needed to convert sugar (glucose), starches and other food into energy needed for daily life.

• Type 2 diabetes is the most common form of diabetes. People who have this type don’t produce enough insulin, or the cells ignore the insulin.

Some diabetics have to take insulin to survive. Others are put on medication, such as Glucophage (metformin). They also may be told to make lifestyle adjustments, such as starting an exercise program and losing weight.

But they don’t always follow instructions. For instance, Jennifer Kimberling, director of the Wound Healing Center at Sts. Mary & Elizabeth Hospital in southern Louisville, Ky., sees diabetics who have limb-threatening wounds yet won’t stay off of their feet when told to.

A whopping 57 million people have a precursor to type 2 diabetes called prediabetes, which means their blood sugar is elevated but not quite high enough for them to be diabetic.

Prediabetics are at risk for stroke and other problems, including what Dr. A. O’tayo Lalude, director of the Jewish Hospital Diabetes Center in western Louisville, calls The Three H’s: hyperglycemia (high blood sugar); hyperlipidemia (high blood cholesterol); and hypertension (high blood pressure).

Prediabetics also are at risk for developing type 2 diabetes, but can prevent or delay it by reducing their weight by 5 percent to 10 percent and getting 150 minutes a week of modest physical activity, such as walking, according to the diabetes association.

At one time, a blood sugar of 240 was considered good, Lalude says, and there are some “elder physicians who still think that that’s normal blood sugar.”

However, some experts today are advocating that people with blood sugars around 120 be treated aggressively with a combination of medications, he says.

Instead of waiting for patients to get worse, start them on “medicine that will reverse what is already going on inside their body,” he says.

The diabetes association recommends screening for prediabetes and type 2 diabetes in adults who are overweight and who have additional risk factors, such as having a close relative with diabetes or being part of a high-risk ethnic group, such as blacks, according to guidelines published in January. Otherwise, screening should begin at age 45 in adults, and retesting about every three years if the results are normal, the association says. Children and youths at increased risk for type 2 diabetes also should be tested, state the guidelines.

———

ON THE WEB

American Diabetes Association: www.diabetes.org

Older, frail adults are more susceptible to getting the flu, even if they have been vaccinated, and once getting the flu, they are more susceptible to such complications as pneumonia.

It had been thought that flu vaccine would prevent flu – and pneumonia – across all groups of seniors, but this benefit appears to be largely confined to younger, healthier seniors.

“In seniors, flu vaccine was not linked to a reduced risk of pneumonia,” said lead researcher Michael L. Jackson, a postdoctoral fellow at the Group Health Center for Health Studies in Seattle.

Jackson still recommends that seniors get flu vaccine, however. “There have been good randomized trials that show, at least in healthy seniors, that the vaccine reduces the risk of influenza,” he said. “However, earlier studies have overestimated how well the vaccine works in reducing complications of influenza. So, the vaccine may not reduce the risk of complications as much as previously thought.”

Among young healthy seniors, the vaccine reduces the risk of flu, Jackson said. “When you look at the total population of seniors, which includes people (older than) 75 and people that have chronic health diseases – lung disease, heart disease, diabetes, and things like that – we don’t know if the vaccine is effective in the seniors,” he said. “People with these chronic diseases are more susceptible to getting the flu, and they are more likely to develop pneumonia if they do get influenza.”

The report is published in the Aug. 2 issue of The Lancet.

For the study, Jackson’s team collected data on 1,173 people ages 65 to 94 who developed pneumonia They compared these individuals with 2,346 people who did not get pneumonia. Both groups had similar rates of flu vaccination over the three seasons of studies, the researchers say.

The researchers found that vaccinated seniors who got the flu were as likely to develop pneumonia as unvaccinated seniors who got the flu.

Dr. Pascal James Imperato, dean of the master of public health program at the State University of New York Downstate Medical Center in New York City, was not surprised by these results.

“We know that elderly people do not form sufficient antibodies to certain vaccines, the flu vaccine included,” Imperato said. “In addition, people in their 70s and 80s and 90s are more prone to pneumonia with or without influence. A number of these pneumonias may be secondary to other causes aside from influenza.”

Even though many of the elderly will not develop sufficient antibodies to the flu vaccine, getting the shot is still worthwhile, Imperato said. “Having many people vaccinated builds up a herd immunity to disease, and you create barriers to transmission,” he added.

Dr. Marc Siegel, a clinical associate professor of medicine at New York University School of Medicine in New York City, said the results of this study fly in the face of prevailing wisdom.

Siegel noted that 36,000 people in the United States die each year from the flu. “Over 90 percent of them are elderly,” he said. “We give the flu shot primarily to prevent elderly deaths.

The effectiveness of the flu vaccine varies year to year, however, depending on how good a match it is for the circulating strains of influence. “In the best years, the flu vaccine is really only 40 to 60 percent effective,” Siegel added.

In addition, Siegel thinks that the flu vaccine protects against other complications including respiratory diseases, which can also be fatal. “There are plenty of flu-related complications that are life-threatening besides pneumonia,” he said.

“This study is a reminder that flu vaccines are not a panacea, but they are valuable, because they cut down on the incidence of influenza,” Siegel said. “Flu shots definitely cut down on the number of flu-related deaths.”

WASHINGTON – The Senate on Thursday passed and sent to the White House legislation that bans lead from children’s toys and seeks to ensure chemicals posing health problems will not end up on toys and articles that kids chew on and play with.

The Senate, stymied by partisan differences over the energy crisis, put aside those differences momentarily to vote 89-3 for the Consumer Product Safety Improvement Act. The House passed the bill Wednesday 424-1, a reflection of the national outcry over a rash of recalls last year involving toys and children’s products contaminated by lead and other dangerous elements.

“We are going to make a big, big difference in the American marketplace,” said Sen. Mark Pryor, D-Ark., a sponsor of the bill.

The administration has objected to parts of the bill, but White House spokeswoman Dana Perino said Thursday that President Bush would sign it. “We are ensuring that the products that come into America are safe for consumers and that the regulating agencies have what they need to do their job.”

The bill would impose the toughest lead standards in the world, banning lead beyond minute levels in products for children 12 or younger. Lead paint was a major factor in the recall of 45 million toys and children’s items last year, including Cookie Monster toys and Tommy the Tank Engines. Many came from China.

It also bans, either permanently or pending further study, children’s goods containing six types of a chemical called phthalates that are widely used to make plastic products softer and more flexible. The chemical industry insisted that phthalates have been used for decades and there is no evidence they pose health risks to humans.

But consumer advocacy groups pointed out that the European Union has banned the six phthalates and that tests on rats have revealed possible reproductive problems and cancer. “Toxic chemicals like lead and phthalates have no business in our children’s toys,” said Elizabeth Hitchcock, U.S. PIRG public health advocate.

Some major retailers, including Wal-Mart and Toys R Us, have already taken steps to phase out phthalates.

The legislation bolsters the Consumer Product Safety Commission, a 400-staffer agency that took the brunt of criticism last year over the massive recalls and the failure of the government to better test and monitor toy imports before they reach store shelves.

The bill would double the agency’s budget, to $136 million by 2014, and give it new authority to oversee testing procedures and impose civil penalties on violators.

Another key provision requires premarket testing by certified third-party laboratories of children’s products for lead and for compliance with safety standards.

American Academy of Pediatrics President Renee R. Jenkins lauded the “extraordinary effort” of Congress. “Safety testing and certification for such hazards as powerful magnets before products are sold, a ban on lead and phthalates and more, will helpfully put an end to the recalls of children’s products and the horror stories that lead to those recalls.”

The bill also:

• Provides whistle-blower protections to employees who report consumer product hazards. The provision was championed by Sen. Claire McCaskill, D-Mo.

• Requires the CPSC to set up a user-friendly database where consumers, government agencies, child care providers or doctors could report incidents of injury, illness, death or risk related to products.

• Makes more products now covered by voluntary industry standards subject to mandatory standards. With that, more toy hazards, including goods containing small magnets that were included in products recalled last year, would be subject to third-party testing requirements.

• Bans three-wheel all-terrain vehicles and strengthens regulation of other ATVs.

The three senators opposing the bill were Republicans Tom Coburn of Oklahoma, Jim DeMint of South Carolina and Jon Kyl of Arizona. Rep. Ron Paul, R-Texas, was the lone House member voting against the measure.

The bill is H.R. 4040

———

ON THE WEB

Congress: thomas.loc.gov

Suppose you’re a healthy, physically fit, nonsmoking male. Your risk of heart attack is already low. Would having a drink or two of alcohol a day provide any additional protective benefit?

A study by Harvard University researchers suggests the answer is yes. Even among men who are models of health, moderate drinking was associated with a lower risk of heart attack. Those who had one-half to two drinks a day had the lowest heart attack risk – 40 percent to 60 percent lower than healthy men who didn’t drink. And that was true no matter whether they were drinking beer, wine or liquor.

“These results tend to refute the oft-quoted hypothesis that lower coronary heart disease seen among moderate drinkers is due to their associated healthy lifestyle habits, and not to their alcohol consumption,” wrote Dr. R. Curtis Ellison, director of the Institute on Lifestyle and Health at Boston University School of Medicine, and co-author of a critique of the study.

In 2008, an estimated 770,000 people will suffer a heart attack, according to the American Heart Association.

Dozens of studies have linked moderate drinking and lower risk of heart disease. In a nod to that evidence, the AHA advises people who drink to do so in moderation – no more than two drinks a day for men and one drink a day for women.

What’s been less clear is whether people who exercise, abstain from smoking, maintain an optimal weight and adhere to an appropriate diet would see any benefit from drinking.

Using data from more than 50,000 health professionals, study author Dr. Kenneth J. Mukamal, assistant professor of medicine at Harvard Medical School, and his colleagues identified more than 8,800 men who were nonsmokers, ate a healthy diet, exercised at least 30 minutes a day and weren’t overweight. Over a 16-year period, 106 of the men had heart attacks, but those who had two drinks a day had the lowest risk for heart attack, while nondrinkers had the highest risk.

Several other recent studies have added to the evidence suggesting moderate alcohol intake complements a healthy lifestyle.

A recent British study identified moderate alcohol consumption among four healthy behaviors (including not smoking, exercising and eating five servings of fruits and vegetables a day) that added 14 years to life, compared with men and women who did not adopt these behaviors. And Danish researchers reported that both physical activity and moderate drinking have a protective effect on the heart and an additive benefit when combined as part of a healthy lifestyle.

There’s one glaring problem, though. None of the studies were “randomized controlled trials” – the gold standard of scientific research, whereby people are randomly assigned to an intervention, such as exercising or consuming alcohol.

There are lots of observational data to support moderate drinking, said Dr. Robert A. Vogel, professor of medicine and director of clinical vascular biology at the University of Maryland School of Medicine. “However, we do not consider alcohol a validly tested drug because to do that you would have to randomize people for years with alcohol or not – and that’s not a study that can be done,” he said.

Vogel said he enjoys a daily glass of wine as part of a healthy lifestyle and tells patients who do the same that it’s “a reasonable thing to do.” Many doctors, though, tend to shy away from recommending alcohol to their patients. Instead, they have emphasized other lifestyle modifications, including diet and exercise.

“Clinicians are very resistant to taking alcohol out of the ‘alcoholism’ box and asking what its effects might be at more typical levels of intake,” Mukamal said. “Even if clinicians don’t believe there are benefits to alcohol, and I think that’s a reasonable concern since we don’t have randomized trails, they should at least be discussing it, but I don’t think that’s happening.”

Ellison agrees. For middle-aged and older men and postmenopausal women who don’t have ethical, religious or health reasons for avoiding alcohol (such as pregnancy or diseases), “physicians should at least inform them that the scientific data currently available strongly suggest that a small amount of alcohol on a regular basis may lower their risk of heart disease, stroke, diabetes, dementia, and even total mortality,” he said.

———

ON THE WEB

American Heart Association: americanheart.org

Short-term exposure to smog, or ozone, is clearly linked to premature deaths that should be taken into account when measuring the health benefits of reducing air pollution, a National Academy of Sciences report concluded Tuesday.

The findings contradict arguments made by some White House officials that the connection between smog and premature death has not been shown sufficiently, and that the number of saved lives should not be calculated in determining clean air benefits.

The report by a panel of the Academy’s National Research Council says government agencies “should give little or no weight” to such arguments.

“The committee has concluded from its review of health-based evidence that short-term exposure to ambient ozone is likely to contribute to premature deaths,” the 13-member panel said.

It added that “studies have yielded strong evidence that short-term exposure to ozone can exacerbate lung conditions, causing illness and hospitalization and can potentially lead to death.”

The White House Office of Management and Budget, which in its review of air quality regulations has raised questions about the certainty of the pollution and mortality link, did not immediately return a phone call seeking comment.

“The report is a rebuke of the Bush administration which has consistently tried to downplay the connection between smog and premature death,” said Frank O’Donnell, president of Clean Air Watch, a Washington-based advocacy organization.

Vickie Patton, deputy general counsel for the Environmental Defense Fund, said the Academy’s findings “refutes the White House skepticism and denial” of a proven link between acute ozone exposure and premature deaths. Such arguments have been used to diminish the health benefits of reducing air pollution, she said.

The Academy panel examined short-term exposure — up to 24 hours — to high levels of ozone, but said more studies also were needed on long-term chronic exposure where the risk of premature death “may be larger than those observed in acute effects studies alone.”

Ground-level ozone is formed from nitrogen oxide and organic compounds created by burning fossil fuels and is demonstrated often by the yellow haze or smog that lingers in the air. Ozone exposure is a leading cause of respiratory illnesses and especially affects the elderly, those with respiratory problems and children.

While premature death from ozone exposure is greater among individuals with lung and heart disease, the report said such deaths are not restricted to people who are at a high risk of death within a few days.

The scientists said they could not determine, based on a review of health studies, whether there is a threshold below which no fatalities can be assured from ozone exposure. If there is such a point, it is below the ozone levels allowed for public health.

Environmentalists and health advocates have argued that a string of health studies and surveys show that exposure to smoggy air not only aggravates respiratory problems, but causes thousands of deaths a year.

But in a number of instances the EPA and the White House Office of Management and Budget, which reviews regulations, have been at odds over the certainty of a link between smog levels and deaths.

Patton said the OMB in a number of air pollution regulations has sought to minimize the relationship of pollution and premature deaths, resulting in a lower calculation of health benefits from pollution reductions.

“This has been used by industry to try to attack health standards by minimizing the societal benefits,” said Patton.

One such case involves the EPA’s decision last month to toughen the ozone health standard, reducing the allowable concentration in the air.

When the cost-benefit analysis was being prepared in connection with the rulemaking, the OMB argued there is “considerable uncertainty” in the association between ozone levels and deaths.

As a result, the EPA issued a wide cost-benefit range from an annual net societal cost of $20 billion to a savings of $23 billion, depending largely on whether one takes into account lives saved from ozone-related premature deaths.

OMB officials also have objected to the EPA quantifying ozone-related mortality benefits in new emissions standards for lawn mowers and other small engines that release large amounts of ozone-forming pollution.

In response, the EPA removed “all references to quantified ozone benefits” in the proposed rule, according to an e-mail sent by EPA to the OMB. The small engine regulation is awaiting final action.

———

ON THE WEB

The National Academies: www.national-academies.org

Afghanistan, Pakistan get increased emphasis

An Afghan army soldier stands guard during a patrol in Musa Qala, Afghanistan, formerly a Taliban stronghold. The Bush administration is refocusing its terrorism-fighting efforts on Afghanistan and Pakistan.

WASHINGTON – In a shift with profound implications, the Bush administration is attempting to re-energize its terrorism-fighting war efforts in Afghanistan, the original target of a post-Sept. 11 offensive. The U.S. also is refocusing on Pakistan, where a regenerating al-Qaida is posing fresh threats.

There is growing recognition that the United States risks further setbacks, if not deepening conflict or even defeat, in Afghanistan, and that success in that country hinges on stopping Pakistan from descending into disorder.

Privately, some senior U.S. military commanders say Pakistan’s tribal areas are at the center of the fight against Islamic extremism – more so than Iraq, or Afghanistan. These areas border on eastern Afghanistan and provide haven for al-Qaida and Taliban fighters to regroup, rearm and reorganize.

The Pentagon says it has fewer than 100 troops in Pakistan. The U.S. military has used other means, including aerial surveillance by drones, to hunt Osama bin Laden and other senior al-Qaida leaders believed to be hiding near the Afghan border. Ground troops on the Afghan side sometimes fire artillery across the border at known Taliban or al-Qaida targets, and U.S. officials have said special operations forces are poised to strike across the border under certain circumstances.

In recent days, administration officials have said they would send more U.S. forces, including small numbers of combat troops, if the Pakistani government decided it wanted to collaborate more closely.

Pakistan’s president, Pervez Musharraf, said on Friday that his country opposes any foreign forces on its soil.

Two top U.S. intelligence officials made a secret visit to Pakistan in early January to seek Musharraf’s permission for greater involvement of American forces in trying to ferret out al-Qaida and other militant groups active in the tribal regions, a senior U.S. official said Saturday. Musharraf was said to have rebuffed an expansion of an American presence.

The number of U.S. troops in Afghanistan has grown over the past two years from about 20,000 to the current total of 28,000. The total is to jump by 3,200 this spring with a new influx of Marine reinforcements.

“There is strong pressure now from the international community to find some solution to Afghanistan because of the fear that this could quickly go south,” said Ashley J. Tellis, a senior associate at the Carnegie Endowment for International Peace.

———

LATEST DEVELOPMENTS

• Iraqi army reinforcements moved into positions near the northern city of Mosul, ready to strike al-Qaida in Iraq targets, a top officer said.

• The U.S. military reported two soldiers killed over the weekend in separate bombings in Baghdad.

• British diplomat Paddy Ashdown said he had withdrawn from consideration for a U.N. post as a so-called “super envoy” to Afghanistan after Afghan officials said he was not their preferred candidate.

• Afghan police tightened security in Kandahar as officials searched for an American aid worker, her Afghan driver and their kidnappers.

The Associated Press

Garner

Composer-musician Jan Hammer is 58.

Actress Olivia Hussey is 55.

Actor Sean Bean (“Lord of the Rings”) is 47.

Singer Maynard James Keenan of Tool is 42.

Actress Lela Rochon is 42.

Actress Kimberly Elise is 39.

Singer Liz Phair is 39.

Actress Jennifer Garner (“Alias”) is 34.

Singer Victoria Beckham of the Spice Girls is 32.

Actress Lindsay Korman (“Passions”) is 28.

Actress Dee Dee Davis (“The Bernie Mac Show”) is 10.

Linda McCartney

Things that happened long ago this week

1998: Paul McCartney’s wife, Linda, died of breast cancer. She was 56.

‘Apocalypto’ delayed until December

LOS ANGELES – Movie fans will have to wait a bit longer to see Mel Gibson’s Mayan epic “Apocalypto.”

A spokesman for Disney, which is releasing “Apocalypto,” said yesterday the production had fallen behind because of heavy rains in Mexico, where Gibson is shooting the film.

The action adventure has been bumped from an Aug. 4 release to Dec. 8.

Like Gibson’s religious blockbuster “The Passion of the Christ,” which was shot in Aramaic and Latin, “Apocalypto” is being done in an ancient tongue, Yucatec Maya.

“Apocalypto” follows the journey of a Mayan hero on the run through the rain forests of pre-Columbian Mexico.

Ashanti cancels concert after cousin killed

JOHANNESBURG, South Africa – Ashanti pulled out of a concert over the weekend after her cousin was killed by a 17-year-old drunken driver, authorities said.

Quinshae Snead, 20, was on her way to Ashanti’s hotel to fetch something for the Grammy award-winning singer ahead of the concert Saturday when the car she was riding in was rear-ended, police said.

Snead was flung from the car as it rolled over and thrown into the path of another car in the opposite lane.

The teenager was arrested for drunken driving and hospitalized. The driver of the car Snead was riding in also was injured and taken to hospital.

U2′s ‘One’ voted U.K.’s favorite lyric in TV poll

LONDON – The Irish band U2 has given Britain its favorite song lyric, according to a survey released today.

The line “One life, with each other, sisters, brothers” from the 1992 song “One” topped a poll conducted by music channel VH1.

The top 10 ranged from Robbie Williams’ uplifting “Angels” to Radiohead’s sour “Creep.” More than 13,000 people participated in the poll on the station’s Web site.

Brad Pitt and Angelina Jolie are staying at a secluded Namibian beach resort, surrounded by tight security and speculation that their baby will be born in Africa.

CAPE TOWN, South Africa – A local governor in Namibia said Angelina Jolie and Brad Pitt told him they will have their baby in his country and are considering giving the child a Namibian name, a newspaper reported yesterday.

Samuel Sheefeni Nuuyoma, the governor of the Namibian province where the couple are staying at a heavily guarded lodge, said he had breakfast Friday with the two stars, according to The Sunday Times of South Africa.

He said Jolie had made those choices because “she loves Namibia.”

Namibian immigration officials confirmed earlier this month that the couple and five other people, including two children, arrived in Walvis Bay on a chartered jet from Paris, prompting speculation their baby will be born in Africa.

The couple have been shielded from reporters by heavy security at a secluded beach resort near Walvis Bay, in an area where Naimbia’s desert sand dunes descend spectacularly to the sea.

But the Sunday Times carried what it billed as “exclusive” pictures of Jolie hugging year-old Zahara and Pitt carrying sleeping Maddox, 4, to a sports utility vehicle. Pitt and Maddox sported matching haircuts.

The newspaper also said Pitt had managed to evade paparazzi and go riding on an all-terrain vehicle in the Namibian desert, and the couple and the two children have visited game reserves and wildlife foundations.

Nuuyoma said he wanted his guests to feel “at home and free.”

“Namibia is a country where everyone has the right to freedom of movement, and they must not feel inhibited when they visit this beautiful country of ours,” he was quoted as saying by the Sunday Times.

Nuuyoma could not immediately be reached for more comment.

The Namibian government, anxious to keep its high-spending visitors, has warned journalists entering the country without a valid work permit that they risk arrest.

Pitt’s publicist, Cindy Guagenti, said on Jan. 11 that Jolie, 30, is pregnant with the actor’s child. It was unclear when the baby will be born.

Pitt, 42, and Jolie, who co-starred in the 2005 film “Mr. & Mrs. Smith,” have rented all 14 rooms and suites at the Burning Shores resort, a luxury boutique hotel on Long Beach north of Walvis Bay.