U.S. Is Weighing Stronger Action in Syrian Conflict


Francisco Leong/Agence France-Presse — Getty Images


Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.







WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.




While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.


The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”


But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.


Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.


Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”


The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.


In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.


“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.


France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.


American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.


“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”


Jessica Brandt contributed reporting from Cambridge, Mass.



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Facebook Gift Store Urges Users to Shop While They Share





SAN FRANCISCO — Facebook is already privy to its users’ e-mail addresses, wedding pictures and political beliefs. Now the company is nudging them to share a bit more: credit card numbers and offline addresses.







James Best Jr./The New York Times

Facebook Gifts is a service that prompts users to buy things for friends on the social network.






Sharing Even More




What do you think about Facebook’s plan to have users buy gifts for their friends through the site using their credit cards?







A screenshot of Facebook Gifts.






The nudge comes from a new Facebook service called Gifts. It allows Facebook users — only in the United States for now — to buy presents for their friends on the social network. On offer are items as varied as spices from Dean & DeLuca, pajamas from BabyGap and subscriptions to Hulu Plus, the video service. This week Facebook added iTunes gift cards.


The gift service is part of an aggressive moneymaking push aimed at pleasing Facebook’s investors after the company’s dismal stock market debut. Facebook has stepped up mobile advertising and is starting to customize the marketing messages it shows to users based on their Web browsing outside Facebook.


Those efforts seem to have brought some relief to Wall Street. Analysts issued more bullish projections for the company in recent days, and the stock was up 49 percent from its lowest point, closing Tuesday at $26.15, although that is still well below the initial offering price of $38. The share price has been buoyed in part by the fact that a wave of insider lockup periods expired without a flood of shares hitting the market.


To power the Gifts service, Facebook rented a warehouse in South Dakota and created its own software to track inventory and shipping. It will not say how much it earns from each purchase made through Gifts, though merchants that have a similar arrangement with Amazon.com give it a roughly 15 percent cut of sales.


If it catches on, the service would give Facebook a toehold in the more than $200 billion e-commerce market. Much more important, it would let the company accumulate a new stream of valuable personal data and use it to refine targeted advertisements, its bread and butter. The company said it did not now use data collected through Gifts for advertising purposes, but could not rule it out in the future.


“The hard part for Facebook was aggregating a billion users. Now it’s more about how to monetize those users without scaring them away,” said Colin Sebastian, an analyst with Robert W. Baird.


He added: “Gifts should also contribute more to Facebook’s treasure trove of user data, which has the benefit of a virtuous cycle, driving more personalization of the site, leading to better and more targeted ads, which improves overall monetization.”


Facebook already collects credit card information from users who play social games on its site. But they are a limited constituency, and a wider audience may be persuaded to buy a gift when Facebook reminds them that a friend is expecting a baby or a cousin is approaching her 40th birthday.


The Gifts service, which grew out of Facebook’s acquisition of a mobile application called Karma, was introduced in September and expanded earlier this month on the eve of the holiday shopping season.


Magnolia Bakery, based in New York, was among Facebook’s early partners for Gifts. Its vice president for public relations, Sara Gramling, said the company had sold roughly 200 packages of treats since then. She counted it as a marketing success. The bakery, which gained fame thanks to “Sex and the City,” had only recently begun shipping its goods. “It was a great opportunity to expand our network,” she said.


Magnolia Bakery isn’t exactly catering to the masses. A half-dozen cupcakes cost $35, plus about $12 for shipping. Facebook, Ms. Gramling said, takes care of the billing. The bakery is eyeing Facebook’s global reach, too, as it opens outlets internationally, especially in the Middle East.


One of the appeals of Facebook Gifts is the ease of making a purchase. Facebook users are nudged to buy a gift (a gift-box icon pops up) for Facebook friends on their birthdays. They are offered a vast menu to choose from: beer glasses, cake pops, quilts, marshmallows, magazine subscriptions and donations to charity. They are asked to choose a greeting card. Then they are asked for credit card details. Facebook says it stores that credit card information, unless users remove it after making a purchase.


Facebook has declined to say how many users have bought gifts, only that among those who have, the average purchase is $25.


David Streitfeld contributed reporting.



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Recipes for Health: Spinach and Turkey Salad — Recipes for Health


Andrew Scrivani for The New York Times







Turkey or chicken transforms this classic spinach salad (minus the bacon) into a light main dish, welcome after Thanksgiving and before the rest of the holiday season feasting begins.




2 cups (12 ounces) shredded cooked turkey, chicken breast or chicken breast tenders


1 6-ounce bag baby spinach


6 white or cremini mushrooms, thinly sliced


1 cup cooked wild rice


2 tablespoons chopped walnuts


1 to 2 hard boiled eggs (to taste), finely chopped (optional)


2 tablespoons chopped chives


1 to 2 tablespoons chopped fresh herbs such as parsley, tarragon or marjoram


For the dressing:


2 tablespoons fresh lemon juice


1 tablespoon red wine vinegar, tarragon vinegar or sherry vinegar


1 teaspoon Dijon mustard


Salt and freshly ground pepper


1 small garlic clove, pureed


1/3 cup extra virgin olive oil


2 tablespoons plain low-fat yogurt


1. Combine all of the salad ingredients in a large salad bowl. Whisk together the lemon juice, vinegar, Dijon mustard, salt, pepper, garlic, olive oil and yogurt. Toss with the salad just before serving.


Yield: Serves 4 as a main dish


Advance preparation: The salad can be assembled and the dressing mixed several hours before serving. Refrigerate and toss together when ready to serve.


Variation: Add 1 ripe but firm persimmon, peeled, cored and sliced, to the mixture.


Nutritional information per serving: 375 calories; 25 grams fat; 4 grams saturated fat; 5 grams polyunsaturated fat; 15 grams monounsaturated fat; 53 milligrams cholesterol; 14 grams carbohydrates; 2 grams dietary fiber; 119 milligrams sodium (does not include salt to taste); 26 grams protein


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


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Recipes for Health: Spinach and Turkey Salad — Recipes for Health


Andrew Scrivani for The New York Times







Turkey or chicken transforms this classic spinach salad (minus the bacon) into a light main dish, welcome after Thanksgiving and before the rest of the holiday season feasting begins.




2 cups (12 ounces) shredded cooked turkey, chicken breast or chicken breast tenders


1 6-ounce bag baby spinach


6 white or cremini mushrooms, thinly sliced


1 cup cooked wild rice


2 tablespoons chopped walnuts


1 to 2 hard boiled eggs (to taste), finely chopped (optional)


2 tablespoons chopped chives


1 to 2 tablespoons chopped fresh herbs such as parsley, tarragon or marjoram


For the dressing:


2 tablespoons fresh lemon juice


1 tablespoon red wine vinegar, tarragon vinegar or sherry vinegar


1 teaspoon Dijon mustard


Salt and freshly ground pepper


1 small garlic clove, pureed


1/3 cup extra virgin olive oil


2 tablespoons plain low-fat yogurt


1. Combine all of the salad ingredients in a large salad bowl. Whisk together the lemon juice, vinegar, Dijon mustard, salt, pepper, garlic, olive oil and yogurt. Toss with the salad just before serving.


Yield: Serves 4 as a main dish


Advance preparation: The salad can be assembled and the dressing mixed several hours before serving. Refrigerate and toss together when ready to serve.


Variation: Add 1 ripe but firm persimmon, peeled, cored and sliced, to the mixture.


Nutritional information per serving: 375 calories; 25 grams fat; 4 grams saturated fat; 5 grams polyunsaturated fat; 15 grams monounsaturated fat; 53 milligrams cholesterol; 14 grams carbohydrates; 2 grams dietary fiber; 119 milligrams sodium (does not include salt to taste); 26 grams protein


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


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General Allen Investigation Narrows Focus





WASHINGTON — Two and a half weeks after Defense Secretary Leon E. Panetta announced an inquiry into e-mail exchanges between Gen. John R. Allen of the Marines and a socialite in Tampa, Fla., some 15 investigators working seven days a week in the Pentagon inspector general’s office have narrowed their focus to 60 to 70 e-mails that “bear a fair amount of scrutiny,” a defense official said.







Alex Wong/Getty Images

Gen. John R. Allen testifying before the House Armed Services Committee in March. He is being investigated over e-mails he sent to Jill Kelley, who was also an acquaintance of David H. Petraeus.








Tampa Bay Magazine, via Associated Press

Jill Kelley with her husband, Scott.






The official did not disclose the content of the e-mails, but senior Pentagon officials have described the voluminous correspondence between General Allen, the top NATO commander in Afghanistan, and the socialite, Jill Kelley, as potentially “inappropriate communication.” Law enforcement officials say the e-mails number in the hundreds and cover a period of two and a half years starting in 2010, when General Allen was the deputy commander of Central Command, based in Tampa.


The investigation, which is delaying and could derail General Allen’s appointment to be the NATO supreme allied commander in Europe, is on a fast track but is unlikely to be completed before the end of the year. Investigations of senior officers in the inspector general’s office usually take about seven months on average, although normally there are only two or three investigators assigned to a case.


The defense official, who asked not to be named because of the nature of the inquiry, said investigators were trying to determine whether the e-mails violated Defense Department policy, government regulations or military law. They were discovered in the course of an F.B.I. investigation into anonymous e-mails to Ms. Kelley warning her to stay away from David H. Petraeus, then the C.I.A. director. The F.B.I. found that the e-mails had been sent by Paula Broadwell, Mr. Petraeus’s biographer; he admitted to having had an affair with Ms. Broadwell and resigned on Nov. 9.


Like General Allen, Mr. Petraeus, a retired four-star general, was a social acquaintance of Ms. Kelley when he was stationed at MacDill Air Force Base in Tampa, headquarters of the Central Command.


The e-mails between General Allen and Ms. Kelley were sent to the Pentagon by the F.B.I. on Nov. 11. “They just forwarded the evidence,” the official said, referring to the F.B.I. “People have to go through and decide if they fit one of three potential violations.” Those violations include misconduct, which could range from inappropriate language on a government computer to adultery, prohibited under military law; more than an incidental use of government property for personal matters; and security breaches.


The defense official said there was no evidence so far that there had been security violations. General Allen, who is in Kabul planning the drawdown of American forces from Afghanistan, is cooperating with the investigation and has said through associates that he did not commit adultery. The inquiry does not appear to have progressed to interviews with General Allen, 58, who is married and the father of two, or Ms. Kelley, 37, the wife of a cancer surgeon and the mother of three.


Gen. Joseph F. Dunford Jr., who has been nominated to succeed General Allen as part of a regular military rotation, is expected to be confirmed by the Senate before the end of the year and to be in Kabul by February. General Allen is expected to return to the United States at that time, but it is unclear what he will do.


There have been conflicting accounts of the nature of the e-mails between him and Ms. Kelley. A law enforcement official has described some of them as sexually explicit. Pentagon officials briefed on the matter say they have been told that half a dozen are embarrassing. But General Allen’s associates say they are innocuous and contain little beyond language like “you’re a sweetheart.”


Although Ms. Kelley’s e-mail correspondence with General Allen has not been made public, dozens of her e-mails to Mayor Bob Buckhorn of Tampa have been released under Florida’s public record laws and refer to her friendship with both General Allen and Mr. Petraeus.


A year ago, after inviting the mayor to a birthday party for one of her children, she added a casual P.S.: “I’ll be in DC this weekend with Petraeus, but let’s set up a double date when I return!” Last January, she wrote to a mayoral aide, “I’m up in DC having dinner tonight with Gen. Petraeus and Gen. John Allen.”


Thom Shanker and Eric Schmitt contributed reporting.



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News Analysis: Sunni Leaders Gaining Clout in Mideast


Mohammed Saber/European Pressphoto Agency


A Palestinian woman in Gaza City on Tuesday walked amid the rubble left from eight days of fighting that ended in a cease-fire.







RAMALLAH, West Bank — For years, the United States and its Middle East allies were challenged by the rising might of the so-called Shiite crescent, a political and ideological alliance backed by Iran that linked regional actors deeply hostile to Israel and the West.




But uprising, wars and economics have altered the landscape of the region, paving the way for a new axis to emerge, one led by a Sunni Muslim alliance of Egypt, Qatar and Turkey. That triumvirate played a leading role in helping end the eight-day conflict between Israel and Gaza, in large part by embracing Hamas and luring it further away from the Iran-Syria-Hezbollah fold, offering diplomatic clout and promises of hefty aid.


For the United States and Israel, the shifting dynamics offer a chance to isolate a resurgent Iran, limit its access to the Arab world and make it harder for Tehran to arm its agents on Israel’s border. But the gains are also tempered, because while these Sunni leaders are willing to work with Washington, unlike the mullahs in Tehran, they also promote a radical religious-based ideology that has fueled anti-Western sentiment around the region.


Hamas — which received missiles from Iran that reached Israel’s northern cities — broke with the Iranian axis last winter, openly backing the rebellion against the Syrian president, Bashar al-Assad. But its affinity with the Egypt-Qatar-Turkey axis came to fruition this fall.


“That camp has more assets that it can share than Iran — politically, diplomatically, materially,” said Robert Malley, the Middle East program director for the International Crisis Group. “The Muslim Brotherhood is their world much more so than Iran.”


The Gaza conflict helps illustrate how Middle Eastern alliances have evolved since the Islamist wave that toppled one government after another beginning in January 2011. Iran had no interest in a cease-fire, while Egypt, Qatar and Turkey did.


But it is the fight for Syria that is the defining struggle in this revived Sunni-Shiite duel. The winner gains a prized strategic crossroads.


For now, it appears that that tide is shifting against Iran, there too, and that it might well lose its main Arab partner, Syria. The Sunni-led opposition appears in recent days to have made significant inroads against the government, threatening the Assad family’s dynastic rule of 40 years and its long alliance with Iran. If Mr. Assad falls, that would render Iran and Hezbollah, which is based in Lebanon, isolated as a Shiite Muslim alliance in an ever more sectarian Middle East, no longer enjoying a special street credibility as what Damascus always tried to sell as “the beating heart of Arab resistance.”


If the shifts seem to leave the United States somewhat dazed, it is because what will emerge from all the ferment remains obscure.


Clearly the old leaders Washington relied on to enforce its will, like President Hosni Mubarak of Egypt, are gone or at least eclipsed. But otherwise confusion reigns in terms of knowing how to deal with this new paradigm, one that could well create societies infused with religious ideology that Americans find difficult to accept. The new reality could be a weaker Iran, but a far more religiously conservative Middle East that is less beholden to the United States.


Already, Islamists have been empowered in Egypt, Libya and Tunisia, while Syria’s opposition is being led by Sunni insurgents, including a growing number identified as jihadists, some identified as sympathizing with Al Qaeda. Qatar, which hosts a major United States military base, also helps finance Islamists all around the region.


In Egypt, President Mohamed Morsi resigned as a member of the Muslim Brotherhood only when he became head of state, but he still remains closely linked with the movement. Turkey, the model for many of them, has kept strong relations with Washington while diminishing the authority of generals who were longstanding American allies.


“The United States is part of a landscape that has shifted so dramatically,” said Mr. Malley of the International Crisis Group. “It is caught between the displacement of the old moderate-radical divide by one that is defined by confessional and sectarian loyalty.”


The emerging Sunni axis has put not only Shiites at a disadvantage, but also the old school leaders who once allied themselves with Washington.


The old guard members in the Palestinian Authority are struggling to remain relevant at a time when their failed 20-year quest to end the Israeli occupation of Palestinian lands makes them seem both anachronistic and obsolete.


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Puerto Rico Races to Rescue Its Pension Fund





Puerto Rico is fighting to stay afloat in a rising sea of debt.




Its economy is sputtering. Its population is shrinking. Its recent election is disputed. Its public pension fund is perilously low on cash. The American territory has just been through a brutal five-year recession, something not experienced in the United States as a whole since the 1930s.


Desperate to raise cash, Puerto Rican officials have been selling off anything they can: two toll roads and the main airport so far.


To bring in tax revenue, they are trying to lure people out of the underground economy. Coffee shops, hairdressers, even outdoor market stalls are being required to issue printed receipts with every sale. The receipts carry a lottery number, with a chance to win cars or cash, as an incentive to get shoppers to pay the island’s 7 percent sales tax.


Though many of Puerto Rico’s problems are reminiscent of Greece’s — tax noncompliance, a stagnant economy, years of issuing long-term debt to cover short-term payments — investors have had a nearly insatiable appetite for its bonds.


But now their support is dwindling. Some big investors are pruning their holdings. That is beginning to widen the cost of borrowing for Puerto Rico relative to other states and municipalities, which are benefiting from a big decline in borrowing costs. The interest rate its 30-year bonds now pay is about 2.5 percentage points higher than other municipal borrowers’, up from a difference of just 1.5 percentage points at the beginning of 2012, according to Municipal Market Data.


The possibility of a credit downgrade also hangs in the air, something that could lead to more selling.


“There is no specific event looming on the horizon,” said Alan Schankel, a managing director at Janney Capital Markets in Philadelphia. “But it’s a problem of immense magnitude, and it’s very challenging to sit here and see how they work their way out of it.”


Puerto Rico needs to be able to issue bonds at attractive rates to cover its short-term financing needs. Perhaps more important, it has to figure out how to salvage its retirement funds. After shortchanging them for years, it now has the weakest major public pension system in America.


The main fund, which serves about 250,000 government workers, past and present, is only 6 percent funded — a small percentage of what is considered the minimum needed for a marginally healthy pension plan — and could run out of money as soon as 2014. Another fund, for about 80,000 teachers, which is 20 percent funded, will last just a few years longer if nothing is done. Police officers and teachers in Puerto Rico have opted out of Social Security and rely entirely on their pensions.


“For now, I’m not totally shaken about the possibility of the fund going broke,” said Jorge Ramón Román, a 78-year-old retired instructor for the island’s Civil Air Patrol. “But I do fear for the future, when I’ll be an even older person, more infirm and with less of a pension.”


Héctor M. Mayol Kauffman, the executive director of the pension system, said it would be impossible to cut the benefits of people who are already retired, citing court precedent.


Puerto Rican officials were racing this fall to put together a rescue plan for the pension fund. Voters, though, pushed out Gov. Luis Fortuño, who had tried austerity measures that included cutting tens of thousands of government workers along with a revamping of the fund.


They elected Alejandro García Padilla, who promised to create 50,000 new jobs in the next 18 months. But the margin was razor-thin and Mr. Fortuño has requested a recount. Mr. García Padilla’s party had dropped out of the retirement overhaul effort, but the governor-elect says he will deal with the looming pension crisis with “diligence and promptness” and has put together a task force of economists and financial advisers.


“We will not leave retired government workers stranded at a bus stop in their older years,” he said.


Since the election, yields on the island’s 30-year bonds have continued to widen.


“I don’t think that there’s a default that’s about to happen, but a default isn’t the only bad thing that can happen when you’ve got bonds,” Mr. Schankel said. Puerto Rico’s bonds are just a notch or two above junk status. If they fall to that level, at least some institutions would be forced to sell, potentially setting off a chain reaction. And individual investors could get a jolt if they saw the value of their holdings fall. Many people own Puerto Rican debt without knowing it, through their mutual funds.


“The concern is that Puerto Rico is a systemic risk to the municipal bond market because it’s so widely held,” said Robert Donahue, a managing director with Municipal Market Advisors.


Rafael Matos contributed reporting from San Juan, P.R.



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The New Old Age Blog: New Efforts to Close Hospitals' Revolving Doors

In the past, the only thing a patient was sure to get after a hospital stay was a bill. But as Medicare cracks down on high readmission rates, hospitals are dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing.

Robert Wood Johnson University Hospital in New Brunswick, N.J., has nurses visit high-risk patients at their home within two days of leaving the hosital. Teresa De Peralta, a nurse practitioner who runs the program, said they frequently find that patients don’t realize a drug they were prescribed in the hospital does the same thing as one they have already been taking.

“When medications are changed, they don’t want to throw things out, they think it’s a waste,” Ms. De Peralta said. “We actually go through the cupboards and painstakingly write out in big letters what they should be taking during the day.”

Many hospital officials say their efforts to keep patients healthy after discharge have been spurred by new financial penalties Medicare started imposing in October on places with too many readmissions. Increasingly, hospitals are no longer leaving to patients the responsibility for setting up follow-up appointments or filling new prescriptions.

And hospitals are not assuming that personnel in nursing homes and other facilities know how to properly care for their patients and follow the hospital discharge instructions.

Patients taking the wrong dose or mixing medicines that react badly often end up back in the hospital. A survey of 377 elderly patients at Yale-New Haven Hospital, published this year in The Journal of General Internal Medicine, discovered that 81 percent of the patients either didn’t understand what all their prescriptions were for; were prescribed the wrong drug or the wrong dose; were taken off a drug they needed, or never picked up a new prescription.

Dr. Leora Horwitz, the study’s leader, said patients who were called a week after their discharge and were asked what changes to their medication they were supposed to make “overwhelmingly” couldn’t tell them.

A big part of reducing readmissions is making sure that patients understand early warning signs that their health is deteriorating. Sun Health Care Transitions, a foundation-supported program in Sun City, Ariz., gives scales to some patients with congestive heart failure because small weight gains indicate they are retaining water, a sign that their heart isn’t pumping adequately.

“We have them keep a log,” said Jennifer Drago, a Sun Health vice president. “We want them to be looking for a two-pound daily weight gain, or five pounds over the week.”

Patients whose weight creeps up are quickly sent back to their doctor. Debra Richards, director of case management at Banner Del E. Webb Medical Center, one of the hospitals Sun Health is assisting, said, “That program has helped us quite a bit.”

Shady Grove Adventist Hospital in Rockville, Md., has started taking patients’ cultural backgrounds into consideration when doling out advice about maintaining their health. For example, the hospital encourages Salvadoran patients to substitute olive oils for the palm oils their cuisine traditionally calls for, to roast or bake meat instead of frying it and to use sugar substitutes when making horchata, a popular Central American drink.

When Hackensack University Medical Center sent staff members to teach caregivers how to take care of their patients, one place “didn’t even know what a low-salt diet was,” even though that’s a critical part of keeping heart failure patients from retaining fluids, said Dr. Charles Riccobono, chief quality and safety officer at the New Jersey hospital.

Aurora Health Care, a Milwaukee-based health system, now places its own nurse practitioners in several nursing homes to watch over Aurora’s discharged patients. Aurora says readmission rates of those patients have decreased, in some months by as much as half.

Dr. Eric Coleman, a Denver geriatrician whose ideas on reducing readmissions have been adopted by a number of hospitals and Medicare, said that while some hospital changes are “exciting and new,” others are “relabeling old wine in new bottles.”

“Yesterday we had ‘discharge planning’ and today we have a ‘rapid response transition team,’ and content-wise they’re doing the same thing,” Dr. Coleman said. “But it’s a nice thing to report out to the board of trustees.”

Jordan Rau is a reporter for Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Read More..

The New Old Age Blog: New Efforts to Close Hospitals' Revolving Doors

In the past, the only thing a patient was sure to get after a hospital stay was a bill. But as Medicare cracks down on high readmission rates, hospitals are dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing.

Robert Wood Johnson University Hospital in New Brunswick, N.J., has nurses visit high-risk patients at their home within two days of leaving the hosital. Teresa De Peralta, a nurse practitioner who runs the program, said they frequently find that patients don’t realize a drug they were prescribed in the hospital does the same thing as one they have already been taking.

“When medications are changed, they don’t want to throw things out, they think it’s a waste,” Ms. De Peralta said. “We actually go through the cupboards and painstakingly write out in big letters what they should be taking during the day.”

Many hospital officials say their efforts to keep patients healthy after discharge have been spurred by new financial penalties Medicare started imposing in October on places with too many readmissions. Increasingly, hospitals are no longer leaving to patients the responsibility for setting up follow-up appointments or filling new prescriptions.

And hospitals are not assuming that personnel in nursing homes and other facilities know how to properly care for their patients and follow the hospital discharge instructions.

Patients taking the wrong dose or mixing medicines that react badly often end up back in the hospital. A survey of 377 elderly patients at Yale-New Haven Hospital, published this year in The Journal of General Internal Medicine, discovered that 81 percent of the patients either didn’t understand what all their prescriptions were for; were prescribed the wrong drug or the wrong dose; were taken off a drug they needed, or never picked up a new prescription.

Dr. Leora Horwitz, the study’s leader, said patients who were called a week after their discharge and were asked what changes to their medication they were supposed to make “overwhelmingly” couldn’t tell them.

A big part of reducing readmissions is making sure that patients understand early warning signs that their health is deteriorating. Sun Health Care Transitions, a foundation-supported program in Sun City, Ariz., gives scales to some patients with congestive heart failure because small weight gains indicate they are retaining water, a sign that their heart isn’t pumping adequately.

“We have them keep a log,” said Jennifer Drago, a Sun Health vice president. “We want them to be looking for a two-pound daily weight gain, or five pounds over the week.”

Patients whose weight creeps up are quickly sent back to their doctor. Debra Richards, director of case management at Banner Del E. Webb Medical Center, one of the hospitals Sun Health is assisting, said, “That program has helped us quite a bit.”

Shady Grove Adventist Hospital in Rockville, Md., has started taking patients’ cultural backgrounds into consideration when doling out advice about maintaining their health. For example, the hospital encourages Salvadoran patients to substitute olive oils for the palm oils their cuisine traditionally calls for, to roast or bake meat instead of frying it and to use sugar substitutes when making horchata, a popular Central American drink.

When Hackensack University Medical Center sent staff members to teach caregivers how to take care of their patients, one place “didn’t even know what a low-salt diet was,” even though that’s a critical part of keeping heart failure patients from retaining fluids, said Dr. Charles Riccobono, chief quality and safety officer at the New Jersey hospital.

Aurora Health Care, a Milwaukee-based health system, now places its own nurse practitioners in several nursing homes to watch over Aurora’s discharged patients. Aurora says readmission rates of those patients have decreased, in some months by as much as half.

Dr. Eric Coleman, a Denver geriatrician whose ideas on reducing readmissions have been adopted by a number of hospitals and Medicare, said that while some hospital changes are “exciting and new,” others are “relabeling old wine in new bottles.”

“Yesterday we had ‘discharge planning’ and today we have a ‘rapid response transition team,’ and content-wise they’re doing the same thing,” Dr. Coleman said. “But it’s a nice thing to report out to the board of trustees.”

Jordan Rau is a reporter for Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Read More..

The Hard Road Back: Prosthetic Arms a Complex Test for Amputees




A Future Reset:
After losing his arm in an I.E.D. explosion in Afghanistan, Cpl. Sebastian Gallegos has adjusted to his prosthetic limb.







SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.




The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.


He had been blown up, and was drowning at the bottom of an irrigation ditch.


Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.


Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.


Success.


“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”


It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.


Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.


To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.


“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.


The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.


Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.


For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.


But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.


More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.


In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.


But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.


Corporal Gallegos was not always that person.


His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.


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