Health Risks of Limited-Contact Water Recreation

Abstract

Background: Wastewater-impacted waters that do not support swimming are often used for boating, canoeing, fishing, kayaking, and rowing. Little is known about the health risks of these limited-contact water recreation activities.

Objectives: We evaluated the incidence of illness, severity of illness, associations between water exposure and illness, and risk of illness attributable to limited-contact water recreation on waters dominated by wastewater effluent and on waters approved for general use recreation (such as swimming).

Methods: The Chicago Health, Environmental Exposure, and Recreation Study was a prospective cohort study that evaluated five health outcomes among three groups of people: those who engaged in limited-contact water recreation on effluent-dominated waters, those who engaged in limited-contact recreation on general-use waters, and those who engaged in non–water recreation. Data analysis included survival analysis, logistic regression, and estimates of risk for counterfactual exposure scenarios using G-computation.

Results: Telephone follow-up data were available for 11,297 participants. With non–water recreation as the reference group, we found that limited-contact water recreation was associated with the development of acute gastrointestinal illness in the first 3 days after water recreation at both effluent-dominated waters [adjusted odds ratio (AOR) 1.46; 95% confidence interval (CI): 1.08, 1.96] and general-use waters (1.50; 95% CI: 1.09, 2.07). For every 1,000 recreators, 13.7 (95% CI: 3.1, 24.9) and 15.1 (95% CI: 2.6, 25.7) cases of gastrointestinal illness were attributable to limited-contact recreation at effluent-dominated waters and general-use waters, respectively. Eye symptoms were associated with use of effluent-dominated waters only (AOR 1.50; 95% CI: 1.10, 2.06). Among water recreators, our results indicate that illness was associated with the amount of water exposure.

Conclusions: Limited-contact recreation, both on effluent-dominated waters and on waters designated for general use, was associated with an elevated risk of gastrointestinal illness.

Cyberbullying, School Bullying, and Psychological Distress

Gang Homicides -- 5 US Cities, 2003-2008

Combined Oral Contraceptives and Venous Thromboembolism

Use of the Tdap Vaccine in an Emergency Department

New cases of accessory and cavitated uterine masses (ACUM): a significant cause of severe dysmenorrhea and recurrent pelvic pain in young women

1. P. Acién1,2,*,
2. A. Bataller1,
3. F. Fernández1,
4. M.I. Acién1,2,
5. J.M. Rodríguez1 and
6. M.J. Mayol3

+ Author Affiliations

1. ¹Services of Obstetrics and Gynaecology, University Hospital of San Juan, San Juan, Spain
2. ²Department/Area of Obstetrics and Gynaecology, ‘Miguel Hernández’ University, Campus of San Juan, 03550 Alicante, Spain
3. ³Services of Pathology, University Hospital of San Juan, San Juan, Spain

1. ↵*Correspondence address. Tel: +34-965919272; Fax: +34-965919551; E-mail: acien@umh.es

• Received November 1, 2011.
• Revision received December 12, 2011.
• Accepted December 19, 2011.

Abstract

BACKGROUND To raise awareness about the accessory and cavitated uterine masses (ACUM) with functional endometrium as a different entity from adult adenomyosis and to highlight the importance of a correct diagnosis, we studied four new cases of ACUM and 15 cases reported as juvenile cystic adenomyoma (JCA) by reviewing the literature from the last year. This entity is problematic because of a broad differential diagnosis, including rudimentary and cavitated uterine horns; and is generally underdiagnosed, being more frequent than previously thought.

METHODS We report four cases of young women who underwent surgery in our hospital from January to July 2011 after presenting with an ACUM. We also reviewed and tabulated the cases from literature beginning in 2010. Main outcome measures were diagnostic tools, surgical and histopathological findings and improvement of symptoms.

RESULTS The addition of the four cases reported here to the 15 published as JCA raises the total number of cases of ACUMs to 19, which is more than all of the cases reported prior to 2010. In our cases, it is interesting to highlight that one of them also had an adjacent accessory rudimentary tube and another had two ACUMs at the same location. All patients suffered from severe dysmenorrhea and pelvic pain and were young women. Suspicion, transvaginal ultrasound and magnetic resonance image were found to be the best diagnostic tools. Most of the cases were treated by laparoscopic tumorectomy.

CONCLUSIONS ACUMs are generally underdiagnosed and often reported as JCAs but they are not adenomyosis. Early surgical treatment involving the laparoscopic or laparotomic removal of the mass could prevent the usual prolonged suffering of these young women. In our opinion, this entity is a new variety of Müllerian anomaly. 

Source : http://humrep.oxfordjournals.org/content/27/3/683.abstract

Tropism of HSV Type 1 to Nonmelanoma Skin Cancers: Results Authors and Disclosures

Authors and Disclosures

Results

Viability in Organ Culture of Human Nonmelanoma Skin Cancer

We established organ cultures from tissue samples of 47 BCC and 11 SCC patients as described in Materials and methods. Cell death in the tissue slices cultivated in organ culture was examined in histology sections (5 μm) by staining with HE and by immune staining for activated caspase-3 in sequential histological sections. Nodular BCC composites of solid nests of basaloid cells (Fig. 1a, left panel) and SCC with some atypical hyperchromatic nuclei (Fig. 1a, middle panel) were confirmed by HE. Tissue levels of activated caspase-3 in BCC and SCC samples immediately after surgical removal, as well as 24 and 72 h later, were found to be similar (compare Fig. 1a at 0, 24 and 72 h). We noted the presence of some apoptotic cells in the tissues immediately after surgical removal but no significant increase in the first 3 days of culture. In comparison, treatment of the tissues with cisplatin, a well-known apoptosis inducer, resulted in extensive staining with anticaspase-3 antibodies (Fig. 1a, right panel). Additionally, we show stable mitochondrial dehydrogenase (MTT) enzyme specific activity, indicating tissue viability during the first 3 days in organ culture (Fig. 1b). These results indicate that the organ culture system provides adequate conditions for the maintenance of BCC and SCC tissue slices ex vivo for the duration of all subsequent experiments. No difference was observed in the viability of different BCC subtypes (results not shown).

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Figure 1. Viability of nonmelanoma skin cancers in organ culture. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) tissues were prepared for organ culture as described in Materials and methods and incubated for the indicated times. (a) Histological sections (4 μm) were stained with haematoxylin and eosin (HE). Immunohistochemical analyses of activated (cleaved) caspase-3 (Casp-3) were performed on sequential slices. For positive control, BCC slices were treated with cisplatin for 24 h before staining for caspase-3. Negative control slides were treated with phosphate-buffered saline instead of antibody to caspase-3. Bar = 100 μm. (b) Quantitative assessment of tissue viability was performed at different time points postculturing using the MTT assay.33 The absorbance (540 nm) of the formazan product indicates cell viability. The MTT values were normalized for protein content in the extract. Data reflect mean ± SD, n = 4; *P = 0·02.

Tropism of Herpes Simplex Virus Type 1 in Basal Cell Carcinoma and Squamous Cell Carcinoma Tissues

We next explored tropism of viruses to the BCC and SCC tumours. The viral vectors express reporter genes, GFP and β-gal. Results shown in Figure 2 indicate that HSV-1 infects BCC and SCC tissues, targeting areas at the perimeter of the tumour nodules (Fig. 2a, b). Quantitative analyses of β-gal using the β-glo assay indicated that AD infected equally well BCC and SCC tissues, while HSV-1 demonstrated a twofold higher infectivity in SCC tissue as compared with BCC (Fig. 2c). No difference was observed in the tropism of HSV-1 to the different BCC subtypes (results not shown).

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Figure 2. Tropism of herpes simplex virus type 1 (HSV-1) and adenovirus (AD) to basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) tissues. (a) Patterns of infection with HSV-1 vector: BCC slices were infected for 24 h with 2 × 106 infectious units of HSV-1 or mock infected, and stained with X-gal. (b) Histological sections were prepared from HSV-1-infected BCC and SCC tissues and stained with X-gal and with haematoxylin and eosin. Bar = 100 μm. (c) Virus infection was analysed quantitatively for β-gal enzyme specific activity by the β-glo assay, as described in Materials and methods. Data reflect mean ± SD, n = 6 replicates taken from the same patient; *P < 0·05. Results are representative of three independent experiments.

Herpes Simplex Virus Type 1 Induces Apoptosis following Infection of Basal Cell Carcinoma and Squamous Cell Carcinoma Tissues

The ability of HSV-1 to infect BCC and SCC tissues raised the possibility of utilizing the virus to induce apoptosis in these tumours. To examine this possibility we infected SCC and BCC slices in organ cultures with HSV-1 for 1, 5 and 7 days, stained with X-gal to detect the infected cells and prepared the tissues for HE staining and immunohistology analysis with antibodies against activated caspase-3. Figure 3a shows tissue destruction after 7 days as compared with mock-infected tissues (Fig. 1 and data not shown for 7 days). In particular, BCC cells infected by HSV-1 turned into empty shadows (arrows) where the blue staining has already leaked out of the cells, indicating extensive cytolysis induced by the virus. Staining with antibodies to caspase-3 enabled us to examine apoptosis (brown-stained cells) in relation to viral infection (blue cells). Figure 3b shows intense caspase-3 staining, representing apoptotic cells following infection.

(Enlarge Image)

Figure 3. Apoptosis is induced by herpes simplex virus type 1 (HSV-1) in basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). (a) BCC tissues were infected in organ cultures as described in Materials and methods with HSV-1 (106 infectious units) for 1, 5 or 7 days, and stained with X-gal. Histological sections were prepared and stained with haematoxylin and eosin. Arrows point at empty shadows indicating extensive cytolysis. (b) BCC and SCC were infected with HSV-1, or mock infected with the same volume of phosphate-buffered saline, in organ cultures for 24 h and stained with X-gal. Histological sections were prepared and analysed by immunohistochemistry using antibodies to activated (cleaved) caspase-3 as a marker for apoptosis. Viral-infected cells are presented in blue-green; caspase-3-positive cells are stained in brown. Arrows point at apoptotic cells in close vicinity to the infected cells in the tissues. Bar = 100 μm.

Herpes Simplex Virus Type 1 Infects a Specific Subpopulation of Early Progenitor Cells in the Basal Cell Carcinoma and Squamous Cell Carcinoma Tissues

To characterize the infected cells further, we used antibodies to three epidermal differentiation markers: K14, p63 and K15. Immunohistochemistry analysis was performed either with fixed tissue sections (5 μm) or with whole-mount tissues (100-μm sections).

The analysis shows that viral infection (β-gal staining) was mostly restricted to cells that express p63 (Fig. 4, arrows). In contrast, we could not identify coexpression of β-gal reporter gene and K14 or K15 in cells (Fig. 4). The immunohistochemistry methodology did not facilitate an accurate determination of coexpression of the reporter gene and the cellular marker in the same cell. Therefore, we used a whole-mount immunoflorescence technique to identify virus infection by the reporter GFP (green) and fluorescent-labelled antibodies against p63, K15 or K14 (red). In many of the infected cells p63 and virus GFP were colocalized (yellow cells); no colocalization between K14 and K15 was observed (Fig. 5). These results suggest that the virus preferentially infects progenitor keratinocytes, characterized by p63 expression.

(Enlarge Image)

Figure 4. Herpes simplex virus type 1 (HSV-1) colocalizes with p63 (arrows) but not with keratin 15 (K15) or keratin 14 (K14) markers in basal cell carcinoma (BCC) and squamous cell carcimona (SCC) infected cells (histological analysis). Tissues were infected in organ cultures as described in Materials and methods with HSV-1 (106 infectious units) for 24 h and stained with X-gal (blue-green). Histological sections were prepared and analysed by immunohistochemistry using antibodies to p63, K14 and K15 (brown). Bar = 100 μm.

(Enlarge Image)

Figure 5. Herpes simplex virus type 1 (HSV-1) colocalizes with p63 but not with keratin 14 (K14) or keratin 15 (K15) in (a) basal cell carcinoma (BCC) and (b) squamous cell carcinoma (SCC). BCC tissues in organ culture were infected with HSV-1 (106 infectious units mL−1) for 24 h as described in Materials and methods. Whole-mount tissues (100-μm slices) were fixed and stained with Cy5-conjugated antibodies to p63, K14 and K15. Images were collected using a confocal microscope. HSV-1 infection was detected by green fluorescent protein (GFP; green). The GFP signal (green) was merged with Cy5 signal (red) to determine colocalization (yellow; arrows) of the two colours and thus the virus and cell marker. Fluorescence background was determined in the mock-infected control tissue and subtracted from all the infected tissues. Bar = 200 μm.

Basal Cell Carcinoma and Squamous Cell Carcinoma Tissues Express High Levels of ΔNp63 and TAp63 Isoforms

To evaluate further the abundance of p63 expression in BCC and SCC tissues, before and after infection with HSV-1, we performed quantitative real-time RT-PCR analyses using primers specific for the two mRNA isoforms of p63, ΔNp63 and TAp63. Figure 6a and b shows that BCC and SCC tissues taken immediately after surgery, before viral infection, express relatively high levels of both isoforms. As p63+ cells are of low abundance in normal epidermis (Fig. 6a), we chose to correlate the expression of p63 in BCC and SCC tissues to primary culture of normal keratinocytes. After two passages in tissue culture, the population of normal epidermal keratinocytes is enriched with the early/progenitor cells.

(Enlarge Image)

Figure 6. Quantitative real-time reverse transcription–polymerase chain reaction (PCR) analysis of p63 isoforms. (a) Expression of ΔNp63 mRNA in three basal cell carcinoma (BCC), four squamous cell carcinoma (SCC) tumour tissues and a normal epidermis sample, as compared with the expression in normal human epidermal keratinocytes (NHEK). (b) Expression of TAp63 mRNA in three BCC and four SCC tumour tissues as compared with expression in NHEK. (c) Quantitative TAp63 mRNA expression in five BCC and two SCC samples 24 h after herpes simplex virus type 1 (HSV-1) infection (striped bars) compared with mock-infected samples (grey bars). Significant signals in real-time PCR fluorescent (Ct) for both p63 isoforms were normalized to a PCR fluorescent signal obtained from reference mRNA (GAPDH). Comparative and relative quantifications on gene products normalized to GAPDH were calculated by the 2−ΔΔCt method. Calibrator mRNA level (= 1) is NHEK. Data reflect mean ± SD, n = 3; *P < 0·05.

The mRNA isoform ΔNp63 is expressed to a much higher degree (4–35 times) in NMSC than in normal human primary keratinocytes, while the TAp63 isoform is expressed 2–26 times more in NMSC than in normal keratinocytes. Furthermore, following infection with HSV-1, we detected an increase of TAp63 isoform expression in three of five samples of BCC tested; in two of these tissues a statistical significance was observed. Two SCC tissue samples were tested for p63 expression and both showed an increase in TAp63 expression in the HSV-1-infected tissues; in one of them the increase was significant as compared with the same mock-infected tissues (Fig. 6c). In contrast, no significant changes were detected in ΔNp63 expression following HSV-1 infection of all the BCC and SCC tissues tested. Furthermore, expression of ΔNp63 mRNA in the tumour tissues was significantly higher than in normal keratinocytes (data not shown).

How Small Businesses Are Coping With Health Insurance

By ROBB MANDELBAUM

The Agenda

How small-business issues are shaping politics and policy.

Robert Caplin for The New York TimesAnn Gish: “I’m not stupid.”

Occasionally in the coming weeks and months, The Agenda will introduce you to small-business owners who are wrestling with how to provide health insurance to their employees. Over time, we hope to delve into all aspects of a crucial decision — not just managing the costs but sorting out benefit packages, weighing alternatives, and dealing with insurers and brokers. Along the way, we hope to get a better understanding of how the 2010 health-care legislation will, or won’t, affect small businesses.
Today we meet Ann Gish, who designs high-end bed linens from offices in Manhattan. As we proceed with this series, we’d like to hear from you. What questions would you like us to ask of the business owners we profile? Do you have an interesting health insurance story to tell? Please drop us a line.
THE OWNER Ann Gish, 63.
THE COMPANY Ann Gish Inc. designs and distributes luxury bed and table linens and pillows, which are sold at Bergdorf Goodman, NeimanMarcus.com and boutiques nationwide. In 2011, the company opened its own store in Manhattan. Excluding Ms. Gish and her husband, Ann Gish Inc. employs 10 people in the United States.
WHAT THE COMPANY PAYS The company bears the entire premium cost for its workforce, $472 a month per employee. It provides individual coverage only, but Ms. Gish said that most of her employees are either unmarried or have spouses who get insurance through their jobs. One sales manager, however, has a self-employed husband with a pre-existing condition and a child. Ms. Gish pays the employee’s premiums, and the employee pays the insurance for the rest of her family — an additional $1,300 a month. “She used her agent, we used our agent, and this was the best we could do,” Ms. Gish said. “If she could find a better deal, we’d give her the $500.” Ms. Gish said she is giving serious thought to reducing the share of employee premiums that her company pays: “I want to see what happens business-wise over the next year, and I want to see what happens when the health care reform kicks in.”
THE PLAN Ann Gish offers preferred provider organization coverage, a form of managed care that favors doctors and hospitals that are in-network. One aspect of the plan that galls Ms. Gish is that doctors must seek permission from the insurer before prescribing some treatments. However, Ms. Gish said, the plan is “non-gated,” meaning that employees don’t need permission from their primary doctor to see a specialist.
THE INSURER Currently, it’s Aetna; before that, it was Oxford. “We’ve changed either every year or every two years,” Ms. Gish said, “because they take away the policy that you have, and they give you a new one that’s more money and generally fewer benefits.” In recent years, premiums have bounced around, Ms. Gish said: $422 in 2009, $479 in 2010, back down to $443 last year, and now back up again. Meanwhile, she said, this year employees face slightly higher co-payments and much steeper deductibles.
THE HEADACHE Pounding and relentless. Even simple tasks, she said, like adding or removing employees from the rolls, are complicated: “My husband, who does all of the C.F.O. stuff, has spent hours and hours and hours on this. And I spend a couple days a year on it. And I’m not stupid. I’ve started a successful business.”
WHAT DIFFERENCE THE OVERHAUL HAS MADE SO FAR None. She looked into the health care tax credit available to small businesses under the law but found that the average wages her company pays exceed the law’s $50,000 threshold for the credit.
WHAT SHE WANTS FROM REFORM Simplification. Health insurance, Ms. Gish said, “should be put together in a way that any idiot could understand.” Though Ms. Gish has occasionally read press accounts of how the Affordable Care Act will change insurance, she concedes that she still does not know what to expect. “I figure when 2014  comes, I’ll have to learn it,” she said. “But since I feel pretty powerless about doing anything, and since it could all change before then, what’s the point in trying to sink your teeth into it now?”
Do you have any thoughts on Ms. Gish’s situation? What percentage of employee premiums does your company pay?

State to Close Program on Federal Health Law

By THANH TAN

 

A program created to help insurance-seekers in Texas cut through the complexities of federal health care reforms is shutting down in April, just 15 months after it opened its call center and years before the law goes into full effect.

Officials with the Texas Department of Insurance say they plan to help fill the gap, but it is unclear whether they can handle what some health experts call a beast of a policy change: millions of new patients will be required to acquire health insurance, and those first-time policy holders will need help understanding their rights and benefits.

When President Obama signed the Patient Protection and Affordable Care Act in 2010, a consumer education program was also created. That September, the federal government awarded the Texas Department of Insurance a $2.8 million grant to start the Consumer Health Assistance Program.

As of January, the department reported, the program had answered 8,900 calls and resolved nearly 5,600 cases statewide. A staff of nine employees had dispersed multilingual public service announcements, given field presentations, begun a Web site and staffed a hot line.

State officials say they were allowed to use unspent money to keep those employees on through April 14. But federal financing was not renewed, and unlike some other states, Texas is not seeking alternative means to maintain its program.

Medical officials who are aware of the unit’s work lament the timing of its closure, as the Affordable Care Act’s rules will not be completely in place until 2018.

In the meantime, health providers are anticipating a nightmare situation. Nearly a quarter of Texas’ population is estimated to be uninsured. Unless the United States Supreme Court dismantles parts or all of the law, those people will be required to sign up for benefits beginning in 2014.

“There will be lots of people who’ve had no experience with insurance before who will need to have a lot of guidance,” said Regina Rogoff, the chief executive of People’s Community Clinic in Austin, a safety net provider. “They’re driving blind.”

Louis J. Goodman, the chief executive of the Texas Medical Association, said doctors were as perplexed as consumers. The federal law is wide in scope, and the association has poured resources into helping practitioners understand the rules and deadlines.

“We’ve worked on the doctors’ side as much as we can,” Mr. Goodman said, but more consumer education is “absolutely necessary.”

In the field, he said, overhead costs at clinics could rise because patients increasingly rely on nonmedical staff in their doctor’s office to explain benefits.

Processing claims can be tedious. The medical association’s Hassle Factor Log, a last resort for doctors trying to resolve claims issues, recovered a record $1.6 million last year for 300 doctors who would have otherwise gone unpaid for their services.

Genevieve Davis, the medical association’s payment advocacy director, said she regularly spoke with doctors who complain of spending less time with patients and more time mired in paperwork. And when insurers or employers refuse to cover a service, patients blame their doctors.

“Trying to get patients to understand that takes away from being able to focus on practicing medicine,” Ms. Davis said.

Health providers say that what separates the assistance program from other insurance resources is that it arms consumers with information on the new health care laws before they walk into a doctor’s office.

But John Greeley, a Texas Department of Insurance spokesman, said the tools developed by the program would carry over to a different section in the agency that covers general consumer concerns. He said the department would maintain resources to help people gain access to insurance.

ttan@texastribune.org

 

Many States Take a Wait-and-See Approach on New Insurance Exchanges

By ROBERT PEAR

WASHINGTON — States are lagging in the creation of health insurance exchanges, the supermarkets where millions of consumers are supposed to buy subsidized private coverage under President Obama’s health care overhaul.

Many states are waiting for a Supreme Court decision or even the November election results, to see whether central elements of the new law might be overturned or repealed. But that will be too late to start work. By Jan. 1, 2013, the Obama administration will decide whether each state is ready to run its own exchange or whether the federal government should do the job instead.

Republican governors and state legislators across the country are split. Some want to set up rudimentary exchanges with limited features — as a defensive tactical maneuver — rather than cede control to Washington. More-conservative Republicans do not want to do anything at all.

After a great deal of bickering and bargaining, the insurance exchanges emerged as a centerpiece of the 2010 health care law, crucial to achieving Mr. Obama’s promise of affordable coverage for all Americans.

The issue was a major topic of discussion over the weekend at the winter meeting of the National Governors Association here, and it is expected to come up Monday when governors meet with Mr. Obama at the White House.

Gov. Dave Heineman of Nebraska, a Republican who is chairman of the governors association, said his state would not “default to the federal government.” But he said “it would be a costly mistake to spend millions of taxpayer dollars” building an exchange before the Supreme Court issues its decision in a challenge to the health care law, which is expected in late June.

“Let’s just wait,” Mr. Heineman said.

A handful of states, including California, Connecticut, Maryland, Oregon, Rhode Island, Vermont and Washington, are moving at a brisk pace to establish exchanges.

In Washington, State Senator Karen L. Keiser, a Democrat who is chairwoman of the Senate health care committee and a leader of the National Conference of State Legislatures’ health committee, said: “Since 2010, many states that were making solid progress, like Iowa and Maine, have gotten stymied. The Tea Party set back health care reform in states where its members were most active.”

State Representative Gregory D. Wren of Alabama, a Republican who is co-chairman of the health reform task force of the conference of state legislatures, said he was distressed to see states postpone action. “The sands in the hourglass are slipping away across the country,” he said.

Mr. Wren has introduced a bill to create an Alabama exchange, but he said that Gov. Robert Bentley, a Republican and a dermatologist, was “taking a wait-and-see approach, to see what the Supreme Court says.”

Research by the nonpartisan Urban Institute found that 14 states had made significant progress in creating exchanges, 16 had made little or no progress and 20 were somewhere in between.

Paradoxically, said one of the researchers, Matthew Buettgens, “states making the least progress could benefit the most,” because they have large numbers of uninsured residents.

In another curious twist, insurance companies, which battled Mr. Obama over health care in 2009 and 2010, are now urging state officials to set up exchanges. They generally prefer state regulation, and they stand to gain because the United States Treasury will send subsidy payments directly to insurers on behalf of low- and moderate-income people who enroll in health plans offered through an exchange.

“Insurance companies are making planning and investment decisions around the Affordable Care Act,” said Representative Joe Courtney, Democrat of Connecticut. “They want to make sure the exchanges work.”

The federal government has given out more than $600 million to help states establish exchanges, but states must figure out how to pay the operating costs.

Kathleen Sebelius, the secretary of health and human services, said: “States continue to go at their own pace as they set up their exchanges. This is a natural result of a process that gives states maximum flexibility.”

Proponents, including Gov. Andrew M. Cuomo of New York, a Democrat, say the exchanges will simplify the purchase of insurance and cut costs by increasing competition. Each exchange will have a Web site where consumers and small businesses can compare insurance prices and benefits.

Information technology will be the backbone of every exchange. The complexity of the computer systems needed to verify eligibility, enroll consumers, calculate subsidies and connect the exchange to state Medicaid agencies has slowed work in some states.

State officials, who are cutting budgets to cope with fiscal problems, are often reluctant to spend state revenues. 

In Pennsylvania, Gov. Tom Corbett, a Republican, has received $34 million in federal money to develop contingency plans for an exchange even as he denounces the federal law as unconstitutional. A state-run exchange would allow Pennsylvania to “control its own destiny,” said the state insurance commissioner, Michael F. Consedine.

In New Hampshire, Gov. John Lynch, a Democrat, was eager to set up an exchange. But state legislators blocked the idea and forced the insurance commissioner to return $666,000 provided by the federal government for a state-run exchange. “If the federal government sets up an exchange here in New Hampshire, we will not be complicit,” said State Representative Neal M. Kurk, a Republican.

In Oklahoma, State Representative Mark E. McCullough, a Republican, wanted to set up an exchange “as a defensive maneuver, so we could maintain as much control as possible.” But the proposal touched off a furious debate. “We are arguing whether to set up a noncompliant exchange or just sit tight and do nothing.” Mr. McCullough said

In Iowa, State Senator Jack Hatch, a Democrat, is leading efforts to create an exchange. But his bill has only “a one-in-four shot of being passed,” he said.

“Consumer groups, insurance brokers, Democratic legislators and moderate Republicans would like to set up an exchange,” Mr. Hatch said. “But they are being held up by radical conservatives, a Tea Party group, who don’t want to do anything.”

Mr. Hatch said that Gov. Terry E. Branstad, a Republican, was “hiding, remaining silent because he’s afraid to go up against the conservative wing of his party.”

Tim J. Albrecht, a spokesman for Mr. Branstad, said: “That’s simply untrue. If Obamacare is forced on the states, we will be ready. But no state legislation is needed this year.”

Wisconsin began planning an exchange last year under an executive order issued by Gov. Scott Walker, a Republican. But he repealed his own order last month and told state officials to stop work on the exchange.

Florida, which is leading the court challenge to the new law by 26 states, has not made any commitment to set up an exchange and is “taking a wait-and-see approach,” said Jack McDermott, a spokesman for the Florida Office of Insurance Regulation.

Texas is also taking a hard line. “Gov. Rick Perry believes that the federal health care law is unconstitutional, misguided and overreaching,” said his spokeswoman, Lucy Nashed. “Because of that, there are no plans to implement an exchange in Texas.”

In Michigan, Gov. Rick Snyder, a Republican, has urged the Legislature to create an exchange. But his request has stalled in the Republican-led House, where Speaker Jase Bolger says he wants to wait for the Supreme Court ruling.

In Ohio, Democrats have introduced legislation to create an exchange. But State Senator Michael J. Skindell, the sponsor of the Senate bill, said that Gov. John R. Kasich, a Republican, and Republicans who control both houses of the Legislature “are not doing anything with regard to development of an exchange.”

Lt. Gov. Mary Taylor, a Republican who is director of the Ohio Insurance Department, said, “The Obama administration has not issued clear guidance on how either a federal or state exchange will work.”

Bills to create exchanges are gaining momentum in New York and New Jersey. Connecticut established an exchange last year.

 

Democrats See Benefits in Battle on Contraception Access

By JENNIFER STEINHAUER and HELENE COOPER
WASHINGTON — With the cameras running and the microphones on, Congressional Democrats express outrage over Republican efforts to limit the types of health care that employers have to offer to their workers, particularly contraception. This is a fight Democrats are perfectly pleased to have. 

As the issue of contraception access comes to the Senate this week, White House officials and Senate Democrats are increasingly hopeful that it will cut in their favor, believing that voters will conclude that Republicans are overreaching under the rubric of religious freedom.

Democratic leaders, who set the Senate floor schedule, plan to hold a vote this week on a measure offered by Senator Roy Blunt, Republican of Missouri, that would in effect reduce insurance coverage of contraception, by allowing religious institutions not to cover it in the health plans they offer employees.

Democrats see the vote as a way to embarrass Republicans — especially those up for re-election in moderate states like Maine and Massachusetts — and believe that the battle may alienate women and moderates from the Republican Party. Republicans need to pick up a number of seats to take back the Senate.

“They’ve gone way overboard in the mind of independents,” said Senator Charles E. Schumer of New York, the No. 3 Democrat in the Senate, in a conference call with reporters, referring to Republicans generally. The fight over contraception, he said, “is going to do lasting damage” to the Republican Party.

But Republicans contend that the issue helps them politically because it highlights what they see as President Obama’s hostility to religious freedom. “Americans fundamentally understand that an attack on religious liberty by the federal government is an attack on our most basic, personal freedoms,” said Kevin Smith, a spokesman for Representative John A. Boehner of Ohio, the House speaker, “and Democrats risk alienating millions of Americans if they continue down this path.”

The Democrats’ confidence is a turnabout from a few weeks ago, when they had become worried that Mr. Obama might be alienating religious voters. Under pressure from Roman Catholic groups, he modified the policy, saying Catholic institutions would not have to pay for the birth control coverage or refer their employees to it. But they still must offer plans that cover contraception, with the insurance companies covering the direct costs.

Some polls show Americans about evenly divided over the issue of religious-based employers and contraception, while others have demonstrated an edge for Mr. Obama. In the latest New York Times/CBS News poll this month, 61 percent of those polled said they supported the Obama administration’s policy.

Mr. Blunt’s measure would allow employers or insurance plans to exclude any provision that runs counter to their religious or ethical beliefs. The measure is in response to the Obama administration’s change to a provision in the health care overhaul passed in 2010 that requires employers to offer preventive care, including free birth control.

But for many Republicans, the compromise did not go far enough, and several have signed on to Mr. Blunt’s measure, saying that the Obama administration was not respecting religious freedom with its rule. House Republicans are weighing their own bill in response to the administration’s rule.

The issue of women’s health care in particular is resonating nationwide. State legislatures, largely those under Republican control, are revisiting their laws concerning insurance coverage, contraception and abortion. In Virginia last week, Republican lawmakers passed a bill that would force a woman to receive an ultrasound before having an abortion, as well as require doctors to ask whether she wanted to hear the fetal heartbeat and obtain a printed image of the fetus. But the governor has wavered on the measure.

Senate Republicans who support Mr. Blunt’s bill say that they are not concerned with contraception per se, but with protecting religious freedom, a position they believe most Americans share. “This is not a women’s rights issue,” said Senator Kelly Ayotte, Republican of New Hampshire, during a recent news conference with Mr. Blunt. “This is a religious liberty issue.”

In an op-ed article in The St. Louis Post Dispatch over the weekend, Mr. Blunt framed his amendment as a correction to the 2009 health care law, which made broader requirements on coverage. “We have a responsibility to project those liberties from government intrusion,” he wrote, “and I will continue to work with my colleagues on both sides of the aisle to ensure that the Obama administration’s unlawful health care mandate is repealed as soon as possible and replaced with the common-sense reforms our health care system needs.”

The White House press secretary, Jay Carney, on Monday called Mr. Blunt’s legislation “dangerous and wrong,” continuing a campaign to present the president’s stance as measured and reasonable. While many Democrats, including Vice President Joseph R. Biden Jr., viewed Mr. Obama’s initial position on the contraception matter as a political mistake that unnecessarily alienated Catholic moderates, the administration’s compromise has won wide support from the party and liberal Catholics.

Mr. Biden now believes the president “has landed in the right place,” one senior administration official said.

Stephanie Cutter, Mr. Obama’s deputy campaign manager, said, “Red flags must be going up all over the Republican Party right now.” She added: “If they’re not, they should be. Whether it’s the Virginia ultrasound bill, wanting to give bosses control over female employees’ health decisions, or the ongoing debates over ‘personhood,’ which places an outright ban on birth control, they’re driving independent women away.”

But lawmakers are on guard from either side. For instance, according to news reports, Representative Kathy Hochul of upstate New York was heckled at a town hall-style meeting last week over the issue and at least one attendee carried a sign that read, “Kathy, why have you betrayed our Catholic institutions?”

One White House official cautioned that should the debate devolve into shrill arguments, the net result would be the alienation of the independent or moderate voters whom Mr. Obama is trying to woo in his reelection bid. “Look, we don’t want to overplay this either, so we’ll be cautious,” another White House official said.

The Early Word: Opt Out

The Early Word: Opt Out By JADA F. SMITH Today’s Times
President Obama opted not to endorse the recommendations of a deficit commission he created, but later adopted many of the proposals in a modified form, Jackie Calmes reports. Mr. Obama’s handling of the Bowles-Simpson plan illuminates his struggles with the deficit politics that have curbed his ambitions and forced him to confront the limits of his persuasive powers.
While Mitt Romney is now counting more than ever on superior organization and planning to pull him through a state-by-state battle for delegates, such an image can undercut a candidate as much as it benefits him, Ashley Parker writes. He continues to fight the perception that he, like the operation working to elect him, is a triumph of political engineering over passion and authenticity.
Illegal immigration is no longer the all-consuming issue it had been for so long in Arizona, Adam Nagourney reports. The economic problems – unemployment, home foreclosures – have contributed to the shift in attention, along with some Republicans fearing that the issue could alienate Latino voters.
Republican-led Legislatures are lagging in the creation of health insurance exchanges, a centerpiece of the 2010 health care law, until they know if President Obama will be able to enforce the new law or not, Robert Pear reports. While many states are waiting for a Supreme Court decision or even the November election results, they may run out of time for compliance, as the Obama administration will begin deciding on Jan. 1, 2013 whether each state is ready to run its own exchange or whether the federal government should do the job.
Around the Web
Ann Romney says her husband is done with all the debating, at least until primary season is over.
Happenings in Washington
The president and vice president will host a meeting with the National Governors Association in the State Dining Room. Michelle Obama and Dr. Jill Biden will also be on hand to discuss military spouse employment with the country’s governors.
Vice President Joseph R. Biden Jr. and Dr. Biden will later host a reception in honor of Black History Month at the Naval Observatory.
Nikki Giovanni will judge a high school Poetry Slam at Reagan Washington National Airport in honor of Black History Month.

Senate Nears Showdown on Contraception Policy

By ROBERT PEAR

WASHINGTON — The Senate on Tuesday headed toward a showdown over President Obama’s policy requiring health insurance coverage of contraceptives for women, even as Republicans appeared to be divided over the wisdom of pressing for a vote any time soon.

Senate Republican leaders sought an immediate vote on legislation to overturn the president’s policy and allow a broad exemption for certain insurers and employers that have religious or moral objections to such coverage.

But other Republicans said that the party had other priorities and that they wanted more information about how the new requirement would work.

“I don’t know where we are going with this issue,” said Senator Lisa Murkowski, Republican of Alaska.

Ms. Murkowski said she did not want a vote on the issue this week. “We’ve got way too much else to be doing,” Ms. Murkowski said, adding that her constituents were more concerned about energy policy.

The Senate majority leader, Harry Reid, Democrat of Nevada, announced that the Senate would vote on the issue on Thursday.

The proposal, offered by Senator Roy Blunt, Republican of Missouri, as an amendment to a highway bill, says that health insurance plans and employers may refuse to provide or pay for coverage of “specific items or services” if the coverage would be “contrary to the religious beliefs or moral convictions of the sponsor, issuer or other entity offering the plan.”

Mr. Reid denounced the proposal, saying it “would allow any employer anywhere in our country to deny coverage for virtually any health service for virtually any reason.”

The 2010 health care law requires most insurers to cover preventive services without co-payments or deductibles. Under the administration policy, most health plans must cover birth control for women — all contraceptive drugs and devices approved by the Food and Drug Administration — as well as sterilization procedures.

Church-affiliated universities, hospitals and charities would not have to provide or pay for such coverage. Instead, the White House says, coverage for birth control could be offered to women directly by their employers’ insurance companies, “with no role for religious employers who oppose contraception.”

Mr. Blunt said, “The president’s so-called compromise is nothing more than an accounting gimmick.”

Senator Susan Collins, Republican of Maine, said that before voting on Mr. Blunt’s proposal, she wanted the administration to explain how its policy would work for “self-insured faith-based institutions.”

Such institutions, including many Roman Catholic hospitals, “act as both the employer and the insurer,” Ms. Collins said.

More than 20 national organizations weighed in on Tuesday against Mr. Blunt’s proposal. The groups include the March of Dimes, Easter Seals, the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists.

Under Mr. Blunt’s proposal, they said in a letter to lawmakers, “a small employer or health plan could ban maternity care for women due to religious convictions regarding out-of-wedlock pregnancies.” Likewise, they said, a health plan or a small employer that objects to childhood immunizations or screening of newborns for genetic disorders could deny coverage for those services.

More than 200 House members have signed up as co-sponsors of the House version of Mr. Blunt’s proposal. But Representative Judy Biggert, Republican of Illinois, said lawmakers should focus on the economy and job creation, “instead of getting sidetracked by issues that can divide us.”

House Republican leaders plan to emphasize that the requirement for contraceptive coverage is traceable to the health care overhaul championed by Mr. Obama — an initiative that they believe is unpopular with independent voters in battleground states.

Representative Ann Marie Buerkle, Republican of New York, who is a nurse and a health care lawyer, said Democrats portrayed the president’s directive as a question of contraception or women’s health.

But she said she saw it in broader terms, as “a violation of conscience, a fundamental assault on First Amendment rights.”

Senator Barbara Boxer, Democrat of California, said she was dismayed that “we have to have a vote on birth control” to move forward on a transportation bill.

“We’re supposed to be on the highway bill, which will protect 1.8 million jobs and create an additional million jobs,” Mrs. Boxer said. “So 2.8 million jobs are hanging in the balance.”

Health Care Reform News 2012

After decades of failed attempts by a string of Democratic presidents and a year of bitter partisan combat, President Obama signed legislation on March 23, 2010 to overhaul the nation’s health care system and guarantee access to medical insurance for tens of millions of Americans.

The health care law seeks to extend insurance to more than 30 million people, primarily by expanding Medicaid and providing federal subsidies to help lower- and middle-income Americans buy private coverage. It will create insurance exchanges for those buying individual policies and prohibit insurers from denying coverage on the basis of pre-existing conditions. To reduce the soaring cost of Medicare, it creates a panel of experts to limit government reimbursement to only those treatments shown to be effective, and creates incentives for providers to “bundle’' services rather than charge by individual procedure.

The law will cost the government about $938 billion over 10 years, according to the nonpartisan Congressional Budget Office, which has also estimated that it will reduce the federal deficit by $138 billion over a decade.

It was the largest single legislative achievement of Mr. Obama’s first two years in office, and the most controversial. Not a single Republican voted for the final version, and Republicans across the country campaigned on a promise to repeal the bill. In January 2011, shortly after they took control of the House, Republicans voted 245 to 189 in favor of repeal, in what both sides agreed was largely a symbolic act, given Democratic control of the Senate and White House.

The Birth Control Battle Heats Up

In early February 2012, facing vocal opposition from religious leaders and an escalating political fight, the White House sought to ease mounting objections to a new administration rule that would require health insurance plans — including those offered by Catholic universities and charities — to offer birth control to women free of charge.

As the Republican presidential candidates and conservative leaders sought to frame the rule as showing President Obama’s insensitivity to religious beliefs, Mr. Obama’s aides promised to explore ways to make it more palatable to religious-affiliated institutions, perhaps by allowing some employers to make side insurance plans available that are not directly paid for by the institutions.

But White House officials insisted the president would not back down from his decision in January 2012 that employees at institutions affiliated with religious organizations receive access to contraceptives.

Speaker John A. Boehner stepped into the battle, saying that House Republicans would push legislation to challenge the policy. Mr. Boehner, a practicing Catholic who has been an outspoken critic of policies that he believes infringe on religious beliefs and freedoms, took the House floor to outline his views on the health rule.

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Nutrition: Dessert at Breakfast May Help Dieters

By NICHOLAS BAKALAR As improbable as it sounds, researchers have found that a low-calorie meal plan that includes dessert with breakfast may help dieters.

Scientists randomized 144 obese people, ages 20 to 65, to two low-carbohydrate diets providing 1,400 daily calories for women and 1,600 for men. The diets were identical except that one included a high-carbohydrate, protein-enriched breakfast with a choice of cookies, chocolate, cake or ice cream for dessert.

Throughout the study, which appears in the March 10 issue of the journal Steroids, participants were tested periodically for blood levels of insulin, glucose, lipid and ghrelin, a hormone that stimulates appetite.

During an initial 16-week period, the average weight loss in each group was identical — about 32 pounds. But over a 16-week follow-up, people on the dessert-with-breakfast diet lost an additional 13 pounds on average, while the others gained back all but 3.5 of the pounds they had lost.

Those on the dessert regimen maintained lower levels of ghrelin and reported significantly higher levels of fullness. “Most people simply regain weight, no matter what diet they are on,” said the lead author, Dr. Daniela Jakubowicz of Tel Aviv University. “But if you eat what you like, you decrease cravings. The cake — a small piece — is important.”

 

A Charm Offensive Against AIDS

By DONALD G. McNEIL Jr.

SOWETO, South Africa — Shortly after Michel Sidibé became executive director of the United Nations’ AIDS prevention agency, a court in Senegal sentenced nine gay men, all AIDS educators, to eight years in prison for “unnatural acts.”

This week: A new diplomacy in the fight against AIDS, and should you eat on the run?

 The Science Times Podcast

Gianluigi Guercia/Agence France-Presse

On A MISSION Michel Sidibé, above center, with Archbishop Desmond Tutu and others at a meeting in Cape Town last year on H.I.V./AIDS prevention.

In one of his first moves as the new chief of U.N.AIDS, Mr. Sidibe flew to Senegal to ask its aging president, Abdoulaye Wade, to pardon the men.

Mr. Sidibé, the son of a Muslim politician from Mali and a white French Catholic, asked the president — who is married to a white Frenchwoman — if he had ever suffered discrimination.

“Oh, Sidibé, you have no idea,” came the reply. “And for not marrying a Muslim.”

“Then, Uncle,” Mr. Sidibé said, using the African way to politely address an older man, “why do you accept that men here are put in jail for eight years just for being gay?”

Mr. Wade thought about it and promised to call his justice minister. Shortly afterward, the charges were dropped.

Asked if his predecessor — Dr. Peter Piot, a Belgian and one of the discoverers of the Ebola virus — could have gotten the same results, Mr. Sidibé said, “Without doubt, it would have been more difficult. It would be very automatically perceived as ‘the white people moralizing to us again.’ Since I’m African, I can raise it in a way that is less confrontational.”

Asked about that, Dr. Piot laughed and agreed, saying he sometimes thought his African missions, like those of the U2 singer Bono, “felt like a junior Tanzanian economist and Hugh Masekela coming to Washington to scold Congress for its budget deficit” — with Congress having to grin and bear it because it needed Tanzania’s cash.

Mr. Sidibé, 59, is a former relief worker, rather than a physician, and, along with English and French, he speaks West African Mandingo, the Tamashek of the Tuaregs and other languages.

With a combination of bonhomie and persistence, he has delivered difficult messages to African presidents very persuasively in his three years in office: Convince your men to get circumcised. Tell your teenage girls not to sleep with older men for money. Shelve your squeamishness and talk about condoms. Help prostitutes instead of jailing them. Ask your preachers to stop railing against homosexuals and order your police forces to stop beating them. Let Western scientists test new drugs and vaccines, despite the inevitable rumors that Africans are being used as guinea pigs.

“You can’t say ‘no’ to Michel,” said Dr. Piot, who hired him away from Unicef. “I was at a conference in Ethiopia in December, and for the first time, I felt I was hearing ‘ownership’ of AIDS by African countries. They weren’t talking so much about the donors, but about it as their own problem. I think he had a lot to do with that.”

Thanks, in part, to Mr. Sidibé’s intensive lobbying, South Africa and China are rapidly revising their approaches to the epidemic, and he hopes Russia and India soon will too. And the notoriously conservative African Union has created a committee to help populations it previously ignored: homosexuals, prostitutes and drug abusers.

Mr. Sidibé is from so deep in Africa that his professional career actually began in Timbuktu, helping Tuareg nomads. (His grandfather, he said, was a Fulani nomad in the same desert.)

He has the African shtick down. He calls anyone younger than him “my brother” or “my sister.” He seems to remember, and hug, everyone he has met before, from drivers to senators to journalists. He regales guests at cocktail parties with long parables about chameleons that he learned as a teenager in circumcision school (a bonding ritual that many African men remember with a mix of fondness and terror — a cross between boot camp and a bar mitzvah, but ending with a collective bris, sometimes done with a spear blade.)

And he is a relentless joker.

In South Africa, he passed through a maternity clinic in Soweto and greeted the women, whose bellies were bulging out of their robes. Ten minutes later, passing by again, he stopped. “Ladies, you are still waiting?” he teased. “What is happening here? You must complain.”

Minutes later, in the circumcision ward, he was introduced to a stunning young surgeon, Dr. Josephine Otchere-Darko.

 

Aging of Eyes Is Blamed for Range of Health Woes

By LAURIE TARKAN

THE HYPOTHESIS

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NYTCREDIT: Ellen Weinstein

The aging eye filters out blue light, affecting circadian rhythm and health in older adults.

THE INVESTIGATORS

Dr. Martin Mainster and Dr. Patricia Turner, University of Kansas School of Medicine.

For decades, scientists have looked for explanations as to why certain conditions occur with age, among them memory loss, slower reaction time, insomnia and even depression. They have scrupulously investigated such suspects as high cholesterol, obesity, heart disease and an inactive lifestyle.

Now a fascinating body of research supports a largely unrecognized culprit: the aging of the eye.

The gradual yellowing of the lens and the narrowing of the pupil that occur with age disturb the body’s circadian rhythm, contributing to a range of health problems, these studies suggest. As the eyes age, less and less sunlight gets through the lens to reach key cells in the retina that regulate the body’s circadian rhythm, its internal clock.

“We believe the effect is huge and that it’s just beginning to be recognized as a problem,” said Dr. Patricia Turner, an ophthalmologist in Leawood, Kan., who with her husband, Dr. Martin Mainster, a professor of ophthalmology at the University of Kansas Medical School, has written extensively about the effects of the aging eye on health.

Circadian rhythms are the cyclical hormonal and physiological processes that rally the body in the morning to tackle the day’s demands and slow it down at night, allowing the body to rest and repair. This internal clock relies on light to function properly, and studies have found that people whose circadian rhythms are out of sync, like shift workers, are at greater risk for a number of ailments, including insomnia, heart disease and cancer.

“Evolution has built this beautiful timekeeping mechanism, but the clock is not absolutely perfect and needs to be nudged every day,” said Dr. David Berson, whose lab at Brown University studies how the eye communicates with the brain.

So-called photoreceptive cells in the retina absorb sunlight and transmit messages to a part of the brain called the suprachiasmatic nucleus (S.C.N.), which governs the internal clock. The S.C.N. adjusts the body to the environment by initiating the release of the hormone melatonin in the evening and cortisol in the morning.

Melatonin is thought to have many health-promoting functions, and studies have shown that people with low melatonin secretion, a marker for a dysfunctional S.C.N., have a higher incidence of many illnesses, including cancer, diabetes and heart disease.

It was not until 2002 that the eye’s role in synchronizing the circadian rhythm became clear. It was always believed that the well-known rods and cones, which provide conscious vision, were the eye’s only photoreceptors. But Dr. Berson’s team discovered that cells in the inner retina, called retinal ganglion cells, also had photoreceptors and that these cells communicated more directly with the brain.

These vital cells, it turns out, are especially responsive to the blue part of the light spectrum. Among other implications, that discovery has raised questions about our exposure to energy-efficient light bulbs and electronic gadgets, which largely emit blue light.

But blue light also is the part of the spectrum filtered by the eye’s aging lens. In a study published in The British Journal of Ophthalmology, Dr. Mainster and Dr. Turner estimated that by age 45, the photoreceptors of the average adult receive just 50 percent of the light needed to fully stimulate the circadian system. By age 55, it dips to 37 percent, and by age 75, to a mere 17 percent.

“Anything that affects the intensity of light or the wavelength can have important consequences for the synchronization of the circadian rhythm, and that can have effects on all types of physiological processes,” Dr. Berson said.

Several studies, most in European countries, have shown that the effects are not just theoretical. One study, published in the journal Experimental Gerontology, compared how quickly exposure to bright light suppresses melatonin in women in their 20s versus in women in their 50s. The amount of blue light that significantly suppressed melatonin in the younger women had absolutely no effect on melatonin in the older women. “What that shows us is that the same amount of light that makes a young person sit up in the morning, feel awake, have better memory retention and be in a better mood has no effect on older people,” Dr. Turner said.

Another study, published in The Journal of Biological Rhythms, found that after exposure to blue light, younger subjects had increased alertness, decreased sleepiness and improved mood, whereas older subjects felt none of these effects.

Researchers in Sweden studied patients who had cataract surgery to remove their clouded lenses and implant clear intraocular lenses. They found that the incidence of insomnia and daytime sleepiness was significantly reduced. Another study found improved reaction time after cataract surgery.

“We believe that it will eventually be shown that cataract surgery results in higher levels of melatonin, and those people will be less likely to have health problems like cancer and heart disease,” Dr. Turner said.

That is why Dr. Mainster and Dr. Turner question a practice common in cataract surgery. About one-third of the intraocular lenses implanted worldwide are blue-blocking lenses, intended to reduce the risk of macular degeneration by limiting exposure to potentially damaging light.

But there is no good evidence showing that people who have cataract surgery are at greater risk of macular degeneration. And evidence of the body’s need for blue light is increasing, some experts say.

“You can always wear sunglasses if you’re in a brilliant environment that’s uncomfortable. You can remove those sunglasses for optimal circadian function, but you can’t take out the filters if they’re permanently implanted in your eyes,” Dr. Mainster said.

Because of these light-filtering changes, Dr. Mainster and Dr. Turner believe that with age, people should make an effort to expose themselves to bright sunlight or bright indoor lighting when they cannot get outdoors. Older adults are at particular risk, because they spend more time indoors.

“In modern society, most of the time we live in a controlled environment under artificial lights, which are 1,000 to 10,000 times dimmer than sunlight and the wrong part of the spectrum,” Dr. Turner said.

In their own offices, Dr. Mainster and Dr. Turner have installed skylights and extra fluorescent lights to help offset the aging of their own eyes.