Recipes for Health: Quinoa and Cauliflower Kugel — Recipes for Health


Andrew Scrivani for The New York Times NYTCREDIT: Andrew Scrivani for The New York Times







Cauliflower, steamed until tender then finely chopped, combines beautifully here with quinoa and cumin. Millet would also be a good grain choice.




 


2 tablespoons extra virgin olive oil


1/2 medium onion, finely chopped


1/2 cup quinoa


1 1/4 cups water


Salt to taste


1 pound cauliflower (1/2 medium head), broken into florets


1 cup low-fat cottage cheese


2 eggs


1 scant teaspoon cumin seeds, lightly toasted and crushed


Freshly ground pepper


 


1. Heat 1 tablespoon of the olive oil in a medium saucepan and add the onion. Cook, stirring, until just about tender, 3 to 5 minutes, and add the quinoa. Cook, stirring, for another 2 to 3 minutes, until the quinoa begins to smell toasty and the onion is tender. Add the water and salt to taste and bring to a boil. Cover, reduce the heat and simmer 15 to 20 minutes, until the quinoa is tender and the grains display a threadlike spiral. If any water remains in the pot, drain the quinoa through a strainer, then return to the pot. Place a dish towel over the pot, then return the lid and let sit undisturbed for 10 to 15 minutes.


2. Meanwhile, steam the cauliflower over 1 inch of boiling water for 10 minutes, or until tender. Remove from the heat.


3. Preheat the oven to 375 degrees and oil a 2-quart baking dish or gratin.


4. Finely chop the steamed cauliflower, either with a chef’s knife or using a food processor fitted with the steel blade. Place in a large mixing bowl. In a food processor fitted with the steel blade, purée the cottage cheese until smooth. Add the eggs and process until the mixture is smooth. Add salt (I suggest about 1/2 teaspoon), pepper and the cumin seeds and mix together. Scrape into the bowl with the cauliflower. Add the quinoa and stir everything together. Scrape into the oiled baking dish. Drizzle the remaining oil over the top and place in the oven.


5. Bake 35 to 40 minutes, until the top is lightly browned. Remove from the oven and allow to cool for at least 15 minutes before serving. Serve warm or at room temperature, cut into squares or wedges.


Yield: 6 servings.


Advance preparation: The quinoa can be prepared through Step 1 up to 3 days ahead (it also freezes well). The kugel will keep for 3 days in the refrigerator. Reheat in a medium oven.


Nutritional information per serving (6 servings): 166 calories; 8 grams fat; 1 gram saturated fat; 1 gram polyunsaturated fat; 4 grams monounsaturated fat; 64 milligrams cholesterol; 15 grams carbohydrates; 3 grams dietary fiber; 151 milligrams sodium (does not include salt to taste); 10 grams protein


Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”


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Syrian Rebels Claim to Kill Dozens of Soldiers


SANA, via Associated Press


An image released by Syria’s official news agency showed Damascus residents gathering at the scene of a blast on Monday.







BEIRUT, Lebanon — Syria was convulsed by one of the most violent days in months on Monday, with heavy fighting reported around Palestinian neighborhoods in southern Damascus, at least two car-bomb explosions and strikes by government aircraft on numerous rebel targets.




Sharply conflicting accounts emerged from the government and the rebels on the toll from a car bombing near the central city of Hama, with the rebels reporting dozens of soldiers dead and the government saying just two civilians were killed.


The Syrian Observatory for Human Rights, a group based in Britain with a network of contacts inside Syria, said that Jabhet al-Nusra, a jihadist organization, and other rebel groups in the region collaborated in a suicide car bombing of a government checkpoint in a village near Hama, killing at least 50 soldiers.


“They targeted one of the biggest checkpoints in the region. It’s a big building where the regime forces were headquartered,” said Ahmad Raadoun, a member of the Free Syrian Army in the Hama suburbs, who was reached via Skype.


Mr. Raadoun, who said he was about 20 miles from the village of Ziyara, where the attack took place, said the bomb caused extensive casualties and other damage in what he described as a “big operation.”


The official news agency, SANA, said the explosion, outside a government building called the Rural Development Center, was orchestrated by terrorist groups and left 2 civilians dead and 10 wounded. The government has repeatedly labeled opposition groups seeking to topple President Bashar al-Assad as terrorist organizations.


The reasons for such divergent accounts could not be immediately ascertained.


Checkpoints in rural areas often serve as rudimentary bases for the government, with large numbers of men and matériel stationed in them to carry the fight across the province.


Another car bombing was reported in Mazzeh 86, a Damascus neighborhood on the slopes below the presidential palace, home to many members of the security forces. The forces are dominated by members of Mr. Assad’s Alawite minority, which controls the country.


The Free Syrian Army claimed responsibility for that attack, saying in a statement that its fighters had targeted officers as well as members of the armed militias who fight for the government. The statement, posted on Facebook, claimed a large number of casualties but did not give any figures.


The Syrian Observatory said the bomb, which it described as a booby-trapped car that exploded in Bride Square, killed 5 people and wounded more than 30, some of them critically.


Pictures posted on Facebook showed a large column of smoke rising from the area.


Damascus residents reached by telephone said that they were trying to flee the heavy fighting, but that there was so much going on in every direction that they did not quite know where to run.


“There is very, very intense shelling on southern Damascus right now,” said an activist reached by Skype who goes by Abu Qays al-Shami. At least 10 people were killed as government helicopters and tanks blasted the area, he said.


Residents said the fighting had erupted in and around the Yarmouk camp in southern Damascus, the center of Palestinian life in Syria for decades. Many Palestinians have sided with the nearly 20-month-old anti-Assad uprising, but the Popular Front for the Liberation of Palestine-General Command, a splinter Palestinian group long supported by the government, still backs Mr. Assad. The fighting erupted between the organization and government opponents.


Elsewhere in southern Damascus, government helicopters were shelling the restive neighborhood of Hajjar al-Aswad, a target of frequent attacks in recent weeks, according to the Local Coordinating Committees, an anti-Assad activist group that keeps track of casualties. SANA said five people were killed in Yarmouk, including a woman and three children, when a mortar shell hit a public minibus. The agency blamed terrorist organizations.


In its daily roundup of violence around the country, SANA also said that government forces clashed with opposition groups in the eastern city of Deir ez-Zour and in Aleppo, the northern city that has been a battleground since midsummer.


Activist organizations reported a number of airstrikes around the country.


One extremely graphic video posted from the village of Kafrnabel, near Idlib, shows bloodied victims dumped into a truck in the aftermath of what was described as an aerial assault. A shot of the main street shows flames leaping from vehicles and residents running around in panic. At least five men and one woman died, the Syrian Observatory said, but more victims were believed buried under the rubble. Video accounts cannot be independently confirmed.


At the United Nations on Monday, a top relief official said the organization’s aid effort in Syria “is very dangerous and very difficult.” The official, John Ging, director of operations of the Office for the Coordination of Humanitarian Affairs, told reporters at a news conference that the United Nations was supplying 1.5 million people in Syria with food and that nearly half is delivered into areas of conflict, but “there are areas beyond our reach, particularly areas under opposition control for quite a long time.”


Reporting was contributed by Hania Mourtada from Beirut, Hala Droubi from Dubai, United Arab Emirates, and Rick Gladstone from New York.



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Google Casts a Big Shadow on Smaller Web Sites


Annie Tritt for The New York Times


Jeffrey G. Katz, the chief executive of Wize Commerce, seen with employees. He says that about 60 percent of the traffic for the company’s Nextag comparison-shopping site comes from Google.





In a geeky fire drill, engineers and outside consultants at Nextag scrambled to see if the problem was its own fault. Maybe some inadvertent change had prompted Google’s algorithm to demote Nextag when a person typed in shopping-related search terms like “kitchen table” or “lawn mower.”


But no, the engineers determined. And traffic from Google’s search engine continued to decline, by half.


Nextag’s response? It doubled its spending on Google paid search advertising in the last five months.


The move was costly but necessary to retain shoppers, Mr. Katz says, because an estimated 60 percent of Nextag’s traffic comes from Google, both from free search and paid search ads, which are ads that are related to search results and appear next to them. “We had to do it,” says Mr. Katz, chief executive of Wize Commerce, owner of Nextag. “We’re living in Google’s world.”


Regulators in the United States and Europe are conducting sweeping inquiries of Google, the dominant Internet search and advertising company. Google rose by technological innovation and business acumen; in the United States, it has 67 percent of the search market and collects 75 percent of search ad dollars. Being big is no crime, but if a powerful company uses market muscle to stifle competition, that is an antitrust violation.


So the government is focusing on life in Google’s world for the sprawling economic ecosystem of Web sites that depend on their ranking in search results. What is it like to live this way, in a giant’s shadow? The experience of its inhabitants is nuanced and complex, a blend of admiration and fear.


The relationship between Google and Web sites, publishers and advertisers often seems lopsided, if not unfair. Yet Google has also provided and nurtured a landscape of opportunity. Its ecosystem generates $80 billion a year in revenue for 1.8 million businesses, Web sites and nonprofit organizations in the United States alone, it estimates.


The government’s scrutiny of Google is the most exhaustive investigation of a major corporation since the pursuit of Microsoft in the late 1990s.


The staff of the Federal Trade Commission has recommended preparing an antitrust suit against Google, according to people briefed on the inquiry, who spoke on the condition they not be identified. But the commissioners must vote to proceed. Even if they do, the government and Google could settle.


Google has drawn the attention of antitrust officials as it has moved aggressively beyond its dominant product — search and search advertising — into fields like online commerce and local reviews. The antitrust issue is whether Google uses its search engine to favor its offerings like Google Shopping and Google Plus Local over rivals.


For policy makers, Google is a tough call.


“What to do with an attractive monopolist, like Google, is a really challenging issue for antitrust,” says Tim Wu, a professor at Columbia Law School and a former senior adviser to the F.T.C. “The goal is to encourage them to stay in power by continuing to innovate instead of excluding competitors.”


SPEAKING at a Google Zeitgeist conference in Arizona last month, Larry Page, the company’s co-founder and chief executive, said he understood the government scrutiny of his company, given Google’s size and reach. “There’s very many decisions we make that really impact a lot of people,” he acknowledged.


The main reason is that Google is continually adjusting its search algorithm — the smart software that determines the relevance, ranking and presentation of search results, typically links to other Web sites.


Google says it makes the changes to improve its service, and has long maintained that its algorithm weeds out low-quality sites and shows the most useful results, whether or not they link to Google products.


“Our first and highest goal has to be to get the user the information they want as quickly and easily as possible,” says Matt Cutts, leader of the Web spam team at Google.


But Google’s algorithm is secret, and changes can leave Web sites scrambling.


Consider Vote-USA.org, a nonprofit group started in 2003. It provides online information for voters to avoid the frustration of arriving at a polling booth and barely recognizing half the names on the ballot. The site posts free sample ballots for federal, state and local elections with candidates’ pictures, biographies and views on issues.


In the 2004 and 2006 elections, users created tens of thousands of sample ballots. By 2008, traffic had fallen sharply, says Ron Kahlow, who runs Vote-USA.org, because “we dropped off the face of the map on Google.”


As founder of a search-engine optimization company and a recipient of grants that Google gives nonprofits to advertise free, Mr. Kahlow knows a thing or two about how to operate in Google’s world. He pored over Google’s guidelines for Web sites, made changes and e-mailed Google. Yet he received no response.


“I lost all donations to support the operation,” he said. “It was very, very painful.”


A breakthrough came through a personal connection. A friend of Mr. Kahlow knew Ed Black, chief executive of the Computer & Communications Industry Association, whose members include Google. Mr. Black made an inquiry on Mr. Kahlow’s behalf, and a Google engineer investigated.


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Fight Growing Over Online Royalties





The debate playing out in Washington has echoes of a presidential race. One side says businesses will suffer unless the government steps in to lower costs. The other accuses jet-set industrialists of a ploy that will cheat the middle class.




These attacks, however, are not between candidates for the White House. They are being made in a battle over the obscure but increasingly vital issue of royalty rates for streaming music online. The issue pits the survival of Pandora Media and other Internet radio services against the diminished paychecks of musicians in the digital age.


This fight has raged on and off for more than a decade, and it was renewed recently with a bill in Congress that would change the way digital royalty rates are set. But with streaming music starting to account for a significant chunk of the music industry’s revenue, and Pandora now a scrutinized public company, the issue has touched a nerve as never before.


“This is not just about our present; it is about our future, our ability to make it in the digital age,” said Cary Sherman, chief executive of the Recording Industry Association of America. “Artists and labels and the entire music community need to earn a fair return on the creative works that are the reason companies like Pandora exist.”


Tim Westergren, the founder and public face of Pandora, has denounced the current system’s “discrimination” and urged the service’s 175 million users to contact their representatives in Washington. Music industry groups and labor unions have also gone public, casting it as a fair-pay issue.


Rates are set by three judges on the federal Copyright Royalty Board, but they apply a different standard to Internet radio services like Pandora than they do to satellite and cable radio outlets like Sirius XM and Music Choice.


Sirius, for example, pays 8 percent of its revenue to record companies and artists. Pandora pays a fraction of a cent each time a song is streamed, which last year amounted to about 54 percent of its revenue, or $149 million.


“The rate being too high dramatically depresses how much music gets played,” Mr. Westergren said in a recent interview. “It has really suffocated the industry.”


The Internet Radio Fairness Act, introduced in September, would move Internet radio companies from their “willing buyer, willing seller” standard — which critics like Pandora say results in an unrealistically high rate — to the one used for satellite and cable radio. To determine a fair rate, that standard directs the judges to consider factors including whether the prices will have a “disruptive impact” on the industry.


Music industry groups also want one standard, but one that keeps rates high. For years they have also been pushing for laws that would require terrestrial stations to pay royalties to labels and artists. (In the United States — and almost nowhere else in the world — radio stations pay royalties only to music publishers.)


Representative Jason Chaffetz, a Republican of Utah who co-sponsored the bill, said in a phone interview that the bill was meant to encourage growth in the streaming business. But when Mr. Chaffetz, whose campaign committee has received $2,000 from Pandora, was asked to respond to complaints that the changes would hurt musicians, he could not resist taunting a bit.


“The old-school dinosaurs are trying to help, but they’re stuck in the tar,” he said. “They can go talk to the pterodactyls.”


Pandora has been down this road before, and in 2009 reached an agreement for a temporary discount of about 40 percent off the royalty board’s rates; that deal expires in 2015.


This time Pandora is a different beast: a company with a $1.4 billion market capitalization. Each month, 58 million people use it to stream more than 1.1 billion hours of music.


Streaming is now on every horizon in the music industry. SoundExchange, which collects royalties from Internet and satellite radio, recently announced that it had crossed the $1 billion benchmark in payments to labels and artists.


The royalties issue, Mr. Westergren said, has become a question about the wider health of the streaming business, which he believes has been stunted by royalties.


“This is not an argument about going out of business,” he said. “A fix here would be for the whole industry.”


But there is wide anger in the music industry that the bill would enrich technology companies at the expense of musicians. MusicFirst Coalition, which includes the recording industry association, SoundExchange and others, says it believes that if Pandora gets everything it wants, it could cut its royalty bill by up to 85 percent.


For Pandora, the critical question is whether streaming businesses can be successful at all in the current system. Digital music services have proliferated over the years, but just as many have died, and popular arrivals like Spotify have yet to turn a profit.


Clear Channel Communications, the radio giant, has recently moved more aggressively into streaming with its iHeartRadio app. Robert W. Pittman, its chief executive — who has been outspoken on the royalty issue — said in an interview that a change could generate more money for the music industry by allowing streaming businesses to thrive.


“It’s not so much about rates as about how much dollars you spend,” Mr. Pittman said. “The amount of dollars to artists is rate times volume. If the rate suppresses the volume, there’s less money. If it encourages volume, there’s more money.”


Mr. Westergren is revered as a self-made success with real musical bona fides; he is fond of telling stories about his years of scraping by as a touring musician. But the controversy over the Internet Radio Fairness Act threatens to tarnish that image.


The music industry says that if Pandora needs to improve its bottom line, it should sell more ads. When asked to respond, Mr. Westergren makes a gesture of banging his head on a table.


“It’s an easy thing to say,” he said. “But no one has yet explained to us why Internet radio is under a different standard. No one responds to that fundamental premise.”


Advertising sales, which make up almost 90 percent of Pandora’s revenue, doubled in the company’s last fiscal year.


For Mr. Westergren, though, the most difficult aspect of this battle has been the accusation that Pandora wants to take advantage of musicians.


“This adversarial reaction toward Internet radio is counterproductive,” he said. “It’s causing other businesses to sit on the sidelines, and that is hurting musicians. Ultimately, you want to have many boats in the harbor.”


Read More..

Chelation Therapy Shows Slight Benefit in Heart Disease Clinical Trial


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


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


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


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


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


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


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


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


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


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


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


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


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


Doctors said there were reasons for caution.


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


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


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


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


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


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


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


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


Read More..

Chelation Therapy Shows Slight Benefit in Heart Disease Clinical Trial


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


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


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


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


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


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


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


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


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


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


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


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


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


Doctors said there were reasons for caution.


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


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


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


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


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


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


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


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


Read More..

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


Esam Omran Al-Fetori/Reuters


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







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




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


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


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


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


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


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


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


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


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


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


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


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


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Massive Open Online Courses Are Multiplying at a Rapid Pace


Clockwise, from top left: an online course in circuits and electronics with an M.I.T. professor (edX); statistics, Stanford (Udacity); machine learning, Stanford (Coursera); organic chemistry, University of Illinois, Urbana (Coursera).







IN late September, as workers applied joint compound to new office walls, hoodie-clad colleagues who had just met were working together on deadline. Film editors, code-writing interns and “edX fellows” — grad students and postdocs versed in online education — were translating videotaped lectures into MOOCs, or massive open online courses. As if anyone needed reminding, a row of aqua Post-its gave the dates the courses would “go live.”




The paint is barely dry, yet edX, the nonprofit start-up from Harvard and the Massachusetts Institute of Technology, has 370,000 students this fall in its first official courses. That’s nothing. Coursera, founded just last January, has reached more than 1.7 million — growing “faster than Facebook,” boasts Andrew Ng, on leave from Stanford to run his for-profit MOOC provider.


“This has caught all of us by surprise,” says David Stavens, who formed a company called Udacity with Sebastian Thrun and Mike Sokolosky after more than 150,000 signed up for Dr. Thrun’s “Introduction to Artificial Intelligence” last fall, starting the revolution that has higher education gasping. A year ago, he marvels, “we were three guys in Sebastian’s living room and now we have 40 employees full time.”


“I like to call this the year of disruption,” says Anant Agarwal, president of edX, “and the year is not over yet.”


MOOCs have been around for a few years as collaborative techie learning events, but this is the year everyone wants in. Elite universities are partnering with Coursera at a furious pace. It now offers courses from 33 of the biggest names in postsecondary education, including Princeton, Brown, Columbia and Duke. In September, Google unleashed a MOOC-building online tool, and Stanford unveiled Class2Go with two courses.


Nick McKeown is teaching one of them, on computer networking, with Philip Levis (the one with a shock of magenta hair in the introductory video). Dr. McKeown sums up the energy of this grand experiment when he gushes, “We’re both very excited.” Casually draped over auditorium seats, the professors also acknowledge that they are not exactly sure how this MOOC stuff works.


“We are just going to see how this goes over the next few weeks,” says Dr. McKeown.


WHAT IS A MOOC ANYWAY?


Traditional online courses charge tuition, carry credit and limit enrollment to a few dozen to ensure interaction with instructors. The MOOC, on the other hand, is usually free, credit-less and, well, massive.


Because anyone with an Internet connection can enroll, faculty can’t possibly respond to students individually. So the course design — how material is presented and the interactivity — counts for a lot. As do fellow students. Classmates may lean on one another in study groups organized in their towns, in online forums or, the prickly part, for grading work.


The evolving form knits together education, entertainment (think gaming) and social networking. Unlike its antecedent, open courseware — usually written materials or videotapes of lectures that make you feel as if you’re spying on a class from the back of the room — the MOOC is a full course made with you in mind.


The medium is still the lecture. Thanks to Khan Academy’s free archive of snappy instructional videos, MOOC makers have gotten the memo on the benefit of brevity: 8 to 12 minutes is typical. Then — this is key — videos pause perhaps twice for a quiz to make sure you understand the material or, in computer programming, to let you write code. Feedback is electronic. Teaching assistants may monitor discussion boards. There may be homework and a final exam.


The MOOC certainly presents challenges. Can learning be scaled up this much? Grading is imperfect, especially for nontechnical subjects. Cheating is a reality. “We found groups of 20 people in a course submitting identical homework,” says David Patterson, a professor at the University of California, Berkeley, who teaches software engineering, in a tone of disbelief at such blatant copying; Udacity and edX now offer proctored exams.


Some students are also ill prepared for the university-level work. And few stick with it. “Signing up for a class is a lightweight process,” says Dr. Ng. It might take just five minutes, assuming you spend two devising a stylish user name. Only 46,000 attempted the first assignment in Dr. Ng’s course on machine learning last fall. In the end, he says, 13,000 completed the class and earned a certificate — from him, not Stanford.


Laura Pappano is author of “Inside School Turnarounds” and writer in residence at the Wellesley Centers for Women.



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Google Casts a Big Shadow on Smaller Web Sites


Annie Tritt for The New York Times


Jeffrey G. Katz, the chief executive of Wize Commerce, seen with employees. He says that about 60 percent of the traffic for the company’s Nextag comparison-shopping site comes from Google.





In a geeky fire drill, engineers and outside consultants at Nextag scrambled to see if the problem was its own fault. Maybe some inadvertent change had prompted Google’s algorithm to demote Nextag when a person typed in shopping-related search terms like “kitchen table” or “lawn mower.”


But no, the engineers determined. And traffic from Google’s search engine continued to decline, by half.


Nextag’s response? It doubled its spending on Google paid search advertising in the last five months.


The move was costly but necessary to retain shoppers, Mr. Katz says, because an estimated 60 percent of Nextag’s traffic comes from Google, both from free search and paid search ads, which are ads that are related to search results and appear next to them. “We had to do it,” says Mr. Katz, chief executive of Wize Commerce, owner of Nextag. “We’re living in Google’s world.”


Regulators in the United States and Europe are conducting sweeping inquiries of Google, the dominant Internet search and advertising company. Google rose by technological innovation and business acumen; in the United States, it has 67 percent of the search market and collects 75 percent of search ad dollars. Being big is no crime, but if a powerful company uses market muscle to stifle competition, that is an antitrust violation.


So the government is focusing on life in Google’s world for the sprawling economic ecosystem of Web sites that depend on their ranking in search results. What is it like to live this way, in a giant’s shadow? The experience of its inhabitants is nuanced and complex, a blend of admiration and fear.


The relationship between Google and Web sites, publishers and advertisers often seems lopsided, if not unfair. Yet Google has also provided and nurtured a landscape of opportunity. Its ecosystem generates $80 billion a year in revenue for 1.8 million businesses, Web sites and nonprofit organizations in the United States alone, it estimates.


The government’s scrutiny of Google is the most exhaustive investigation of a major corporation since the pursuit of Microsoft in the late 1990s.


The staff of the Federal Trade Commission has recommended preparing an antitrust suit against Google, according to people briefed on the inquiry, who spoke on the condition they not be identified. But the commissioners must vote to proceed. Even if they do, the government and Google could settle.


Google has drawn the attention of antitrust officials as it has moved aggressively beyond its dominant product — search and search advertising — into fields like online commerce and local reviews. The antitrust issue is whether Google uses its search engine to favor its offerings like Google Shopping and Google Plus Local over rivals.


For policy makers, Google is a tough call.


“What to do with an attractive monopolist, like Google, is a really challenging issue for antitrust,” says Tim Wu, a professor at Columbia Law School and a former senior adviser to the F.T.C. “The goal is to encourage them to stay in power by continuing to innovate instead of excluding competitors.”


SPEAKING at a Google Zeitgeist conference in Arizona last month, Larry Page, the company’s co-founder and chief executive, said he understood the government scrutiny of his company, given Google’s size and reach. “There’s very many decisions we make that really impact a lot of people,” he acknowledged.


The main reason is that Google is continually adjusting its search algorithm — the smart software that determines the relevance, ranking and presentation of search results, typically links to other Web sites.


Google says it makes the changes to improve its service, and has long maintained that its algorithm weeds out low-quality sites and shows the most useful results, whether or not they link to Google products.


“Our first and highest goal has to be to get the user the information they want as quickly and easily as possible,” says Matt Cutts, leader of the Web spam team at Google.


But Google’s algorithm is secret, and changes can leave Web sites scrambling.


Consider Vote-USA.org, a nonprofit group started in 2003. It provides online information for voters to avoid the frustration of arriving at a polling booth and barely recognizing half the names on the ballot. The site posts free sample ballots for federal, state and local elections with candidates’ pictures, biographies and views on issues.


In the 2004 and 2006 elections, users created tens of thousands of sample ballots. By 2008, traffic had fallen sharply, says Ron Kahlow, who runs Vote-USA.org, because “we dropped off the face of the map on Google.”


As founder of a search-engine optimization company and a recipient of grants that Google gives nonprofits to advertise free, Mr. Kahlow knows a thing or two about how to operate in Google’s world. He pored over Google’s guidelines for Web sites, made changes and e-mailed Google. Yet he received no response.


“I lost all donations to support the operation,” he said. “It was very, very painful.”


A breakthrough came through a personal connection. A friend of Mr. Kahlow knew Ed Black, chief executive of the Computer & Communications Industry Association, whose members include Google. Mr. Black made an inquiry on Mr. Kahlow’s behalf, and a Google engineer investigated.


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





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




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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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



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