The Mirror: Fears of Aging Color the Discussion of Gray Hair

I OFTEN think longingly of buying a wig. My newly bought hair would be the little black dress of wigs. It would be my hair, or rather, someone else’s hair, but it would look the way mine did at its best: raven, not too long, not too short, glossy, curly without frizz and easy to wear.

I still have that kind of hair, somewhere in my mind, and somewhere in the vague recesses of eternal hope, I expect it to return, just as I expect that with enough discipline, I will be able to get into shape such that I can again wear that cotton red strapless dress I only wore twice: to my engagement party and to interview Brian Wilson (though that history alone might justify my keeping it).

The hair that I now see in the mirror is inconvenient impostor hair. It is still dark, but it has a hint of shellac to it; its color is solid where there should be hints of light, and the tone only varies toward the ends, where, thinned and frizzed, a faintly electric red takes over.

I dye my hair, and every time I do, my hair dies a little. What age was already doing slowly to its texture, in addition to its color, the dying process is only exacerbating in some sort of vicious death-spiral, like the relationship between global warming and air-conditioning: the more one suffers from the first, the more one needs the second, which only exacerbates the first.

Here is what burns: Within weeks of the coloring, still there is the creep, the inexorable encroaching of gray at my temples that make me think, with uneasiness, of the word “distinguished.” I see those hints of gray and I think of aging male executives with drooping eyes, I think of Birkenstocks and faded Barnes & Noble canvas bags, and I think I should maybe have my hair colored again.

But wasn’t I just there? Wasn’t I just in there, politely making small talk with Arnulfo, a kind and talented colorist who asks me questions about how my hair has fared with the concerned, exacting tones of a good internist? Wasn’t I just there, opening my wallet to pay in cash so that my husband, who would not really care, does not know exactly how much I spend to stop that creep of distinguished gray? Wasn’t I just there, my heart rate elevating with every passing wasted minute, waiting out the slathering on, the processing period, the shampoo, the rinse?

I never think more about buying a wig than I do in those last 10 minutes at the hair salon, itching out of my skin, not only at my scalp. “I’ll just go out with it wet!” I invariably tell Arnolfo toward the end as he goes for a hair dryer. I try to keep the hysteria out of my voice. I am not sure I have succeeded. Arnulfo generally looks at me with that same medical concern, this time concerned more about my mental health than my roots.

The salon where Arnulfo works, Cristiano Cora, offers a seemingly miraculous hair dye that requires only a 15-minute wait, though Arnolfo told me sadly that it is not as short for people with hair as coarse as mine. And there are the temporary fixes: powder sprays and mascara wands for stray graying strands and the like. I have something that looks like a thick lipstick, only it is so dark brown it is almost black. If I suddenly notice I am looking too distinguished, I sometimes apply this magic wand of product furtively to my roots in the office bathroom. It smells faintly cloying, and makes me think of the powder my grandmother used to wear, a beauty trick I knew she used more out of habit than conviction.

My wand is designed to look like lipstick, but somehow instead of that making it seem less strange, it only reminds me how strange lipstick is, a highly packaged, pigmented formula applied to the face. My ambivalence about one heightens my ambivalence about the other, causing midday existential questions about mortality and identity when I am merely trying to tamp down some self-consciousness about messy-looking roots.

I am, if nothing, a practical person. I buy black dresses in quantity, ideally ones with three-quarter-length sleeves so that they are flexible for every season. I am not going for noticeably stylish; I am going for the easiest thing that will look the most put-together. I am going for clothing that is a form of invisible, and that is what I would like, in many ways, in my hair.

But that is the problem with hair once it starts to turn gray: there is no version of invisible. There is always the tell. To dye one’s hair is to confess to caring, to fighting age: it fools no one, although it reveals the effort to do so. It only tells the viewer that I am someone who is unwilling and unready to give in to the physical symbols of aging, which is its own social signaling. But not to dye one’s hair is to make a whole other statement: I am someone who does not care. And I am not ready for that one, either.

Susan Dominus is a staff writer for The Times Magazine.

Read More..

The Mirror: Fears of Aging Color the Discussion of Gray Hair

I OFTEN think longingly of buying a wig. My newly bought hair would be the little black dress of wigs. It would be my hair, or rather, someone else’s hair, but it would look the way mine did at its best: raven, not too long, not too short, glossy, curly without frizz and easy to wear.

I still have that kind of hair, somewhere in my mind, and somewhere in the vague recesses of eternal hope, I expect it to return, just as I expect that with enough discipline, I will be able to get into shape such that I can again wear that cotton red strapless dress I only wore twice: to my engagement party and to interview Brian Wilson (though that history alone might justify my keeping it).

The hair that I now see in the mirror is inconvenient impostor hair. It is still dark, but it has a hint of shellac to it; its color is solid where there should be hints of light, and the tone only varies toward the ends, where, thinned and frizzed, a faintly electric red takes over.

I dye my hair, and every time I do, my hair dies a little. What age was already doing slowly to its texture, in addition to its color, the dying process is only exacerbating in some sort of vicious death-spiral, like the relationship between global warming and air-conditioning: the more one suffers from the first, the more one needs the second, which only exacerbates the first.

Here is what burns: Within weeks of the coloring, still there is the creep, the inexorable encroaching of gray at my temples that make me think, with uneasiness, of the word “distinguished.” I see those hints of gray and I think of aging male executives with drooping eyes, I think of Birkenstocks and faded Barnes & Noble canvas bags, and I think I should maybe have my hair colored again.

But wasn’t I just there? Wasn’t I just in there, politely making small talk with Arnulfo, a kind and talented colorist who asks me questions about how my hair has fared with the concerned, exacting tones of a good internist? Wasn’t I just there, opening my wallet to pay in cash so that my husband, who would not really care, does not know exactly how much I spend to stop that creep of distinguished gray? Wasn’t I just there, my heart rate elevating with every passing wasted minute, waiting out the slathering on, the processing period, the shampoo, the rinse?

I never think more about buying a wig than I do in those last 10 minutes at the hair salon, itching out of my skin, not only at my scalp. “I’ll just go out with it wet!” I invariably tell Arnolfo toward the end as he goes for a hair dryer. I try to keep the hysteria out of my voice. I am not sure I have succeeded. Arnulfo generally looks at me with that same medical concern, this time concerned more about my mental health than my roots.

The salon where Arnulfo works, Cristiano Cora, offers a seemingly miraculous hair dye that requires only a 15-minute wait, though Arnolfo told me sadly that it is not as short for people with hair as coarse as mine. And there are the temporary fixes: powder sprays and mascara wands for stray graying strands and the like. I have something that looks like a thick lipstick, only it is so dark brown it is almost black. If I suddenly notice I am looking too distinguished, I sometimes apply this magic wand of product furtively to my roots in the office bathroom. It smells faintly cloying, and makes me think of the powder my grandmother used to wear, a beauty trick I knew she used more out of habit than conviction.

My wand is designed to look like lipstick, but somehow instead of that making it seem less strange, it only reminds me how strange lipstick is, a highly packaged, pigmented formula applied to the face. My ambivalence about one heightens my ambivalence about the other, causing midday existential questions about mortality and identity when I am merely trying to tamp down some self-consciousness about messy-looking roots.

I am, if nothing, a practical person. I buy black dresses in quantity, ideally ones with three-quarter-length sleeves so that they are flexible for every season. I am not going for noticeably stylish; I am going for the easiest thing that will look the most put-together. I am going for clothing that is a form of invisible, and that is what I would like, in many ways, in my hair.

But that is the problem with hair once it starts to turn gray: there is no version of invisible. There is always the tell. To dye one’s hair is to confess to caring, to fighting age: it fools no one, although it reveals the effort to do so. It only tells the viewer that I am someone who is unwilling and unready to give in to the physical symbols of aging, which is its own social signaling. But not to dye one’s hair is to make a whole other statement: I am someone who does not care. And I am not ready for that one, either.

Susan Dominus is a staff writer for The Times Magazine.

Read More..

Chinese Messaging App Gains Ground Elsewhere

BEIJING — Chinese Internet companies have long struggled to establish their products beyond the country’s borders. In 2007 China’s dominant search engine, Baidu, announced an ambitious plan to break into the Japanese search engine market; as of last year, the company said it had lost more than $108 million trying.

WeChat, a mobile messaging application created by Tencent Holdings, China’s largest Internet company, is aggressively trying to buck the trend and establish itself in the expanding global market for smartphone apps. Based on some analysts’ predictions, the company may actually have a shot.

WeChat is most often likened to WhatsApp, a smartphone application popular in the United States that allows users to send text, image or audio messages for free to other subscribers. But WhatsApp’s Chinese counterpart is quickly moving beyond simple multimedia instant-messaging. In the last few months, it has announced a steady stream of new features that many say surpass those offered by WhatsApp and Asian competitors like Kakao Talk and LINE.

“I use WeChat for messaging and group chatting, but I’ve also started getting into its social network,” said Kate Wan, a 29-year-old media professional in Beijing, referring to WeChat “Moments,” a feature that allows users to post pictures and update their online status. “It’s become a huge part of my daily life.”

Since the introduction of the application in January 2011, WeChat, known as Weixin in Chinese, has grown at a blistering pace. In September, Pony Ma, Tencent’s chief executive, announced that its user base had doubled to 200 million from 100 million in six months.

Tencent is vying to make WeChat the dominant global mobile messaging application. The app is available in eight languages, including Russian, Indonesian, Portuguese and Thai, and there are plans to expand into other languages.

“The Chinese Internet market is so set apart from other countries that we inside the industry refer to it as the Galápagos Island syndrome,” said Kai Lukoff, the editor of TechRice, a China-focused technology blog based in Beijing. “Domestic Internet products are extremely well adapted to the Chinese market, but they are way out of place for global users.”

But industry experts now argue that app retailers like the Apple iTunes Store and Google Play empower developers anywhere to reach consumers everywhere. The openness of these distribution platforms could provide WeChat with a conduit into the international smartphone market, some analysts say.

Duncan Clark, chairman of BDA China, a consulting firm that specializes in China’s technology and Internet sectors, said WeChat, with its sophisticated but easy-to-navigate interface and features, had the potential to overcome any lingering doubts in the West over the Made-in-China label.

“Many people are afraid of Chinese products, whether milk, cat food or Internet services,” Mr. Clark said. “But with the App Store, it’s hard to even know that WeChat is Chinese — it really levels the playing field.”

According to App Annie, a mobile analytics company based in Beijing, WeChat’s outward push is beginning to bear fruit. Based on download data from the first three quarters of 2012, the app is growing fastest in Southeast Asia, but it is making headway elsewhere, including Eastern Europe and the Middle East.

The most promising markets this year include Vietnam, Turkey, Thailand, India and Indonesia, with Russia and Saudi Arabia following closely behind.

While WeChat remains relatively obscure in the United States, where players like WhatsApp, Skype and Facebook Messenger dominate the mobile messaging market, analysts say WeChat registered nearly 100,000 new users in the United States in September alone.

“All of my Chinese friends use it here in North Carolina, whether to send group messages or to organize events,” said Zhang Xue, a student at Duke University Law School who is from the city of Harbin in China’s northeast. “I downloaded WhatsApp out of curiosity, but it’s not nearly as convenient as WeChat.”

Read More..

Coptic Church Chooses Pope Who Rejects Politics

Tara Todras-Whitehill for The New York Times

Coptic clergymen at a ceremony on Sunday for choosing a pope.

CAIRO — A blindfolded 6-year-old reached into a glass bowl on Sunday to pick the first new Coptic pope in more than 40 years, a patriarch who promises a new era of integration for Egypt’s Christian minority as it grapples with a wave of sectarian violence, new Islamist domination of politics, and internal pressures for reform.

Tara Todras-Whitehill for The New York Times

The acting Coptic pope, before a banner of Bishop Tawadros, held up the names of other candidates to show that the selection was fair.

Speaking to the television cameras that surrounded him at his monastery in a desert town, the pope-designate, Bishop Tawadros, indicated that he planned to reverse the explicitly political role of his predecessor, Pope Shenouda III, who died in March. For four decades, Shenouda acted as the Copts’ chief representative in public life, won special favors for his flock by publicly endorsing President Hosni Mubarak, and last year urged in vain that Copts stay away from the protests that ultimately toppled the strongman.

“The most important thing is for the church to go back and live consistently within the spiritual boundaries because this is its main work, spiritual work,” the bishop said, and he promised to begin a process of “rearranging the house from the inside” and “pushing new blood” after his installation later this month as Pope Tawadros II. Interviewed on Coptic television recently, he struck a new tone by including as his priorities “living with our brothers, the Muslims” and “the responsibility of preserving our shared life.”

“Integrating in the society is a fundamental scriptural Christian trait,” Bishop Tawadros said then. “This integration is a must — moderate constructive integration,” he added. “All of us, as Egyptians, have to participate.”

Coptic activists and intellectuals said the turn away from politics signaled a sweeping transformation in the Christian minority’s relationship to the Egyptian state but also addressed a firm demand by the Christian laity to claim a voice in a more democratic Egypt.

“It can’t continue the way it used to be,” said Youssef Sidhom, editor of the Coptic newspaper Watani. “It is not in the interests of the Copts, if they are trying to speak for themselves as full and equal citizens, to have an intermediary speaking for them, and especially if he is a religious authority. I think the church has gotten this message loud and clear.”

In Egypt’s first free elections for Parliament and president, Christians voted overwhelmingly along sectarian lines, seeking to pool their votes around the most secular candidates — only to see their favorites fall under the Islamist tide. After the Muslim Brotherhood’s political party won parliamentary leadership and then the presidency, many Egyptians joked that the group put a candidate up for Coptic pope, too.

In recent interviews, intellectuals and activists, and churchgoers leaving Mass after the selection of the pope, all said they had concluded that Christians would have to build alliances with Muslims who shared their goal of nonsectarian citizenship.

“We are not the Muslim Brotherhood,” said Tarek Samir, a sales manager leaving the cathedral after the selection of Bishop Tawadros. “Politics is a dirty word to us, and we do not think it should be mixed with religion. But there are moderate Muslims who live the same life we do, who go to work with us, who live together with us, and if I am in trouble they will help me.”

Copts, often estimated to make up about 10 percent of Egypt’s 80 million people, trace their roots here to centuries before the birth of the Prophet Muhammad. They consider St. Mark their first pope; Tawadros II will be the 118th. In some ways, they are now at the spearhead of a challenge confronting Christian minorities across the region amid the tumult of the Arab Spring. In Iraq, Lebanon, Syria and elsewhere, Christian minorities had made peace with authoritarian rulers in the hope of protection from the Muslim majorities. But now the old bargains have broken, leaving Christians to fend for themselves.

In Egypt, the revolution last year coincided with by far the deadliest 12 months of sectarian violence in decades, including the bombing of an Alexandria church weeks before the revolt, the destruction of at least three churches in sectarian feuds, and the killing of about two dozen Coptic demonstrators by Egyptian soldiers squashing a protest — the single bloodiest episode of sectarian violence in at least half a century.

Known as the Maspero massacre after a nearby television building, the slaughter elicited attempts by top generals to blame the Copts and scant sympathy from the main Islamist groups, crystallizing Coptic anxieties.

Mayy El Sheikh and Mai Ayyad contributed reporting.

Read More..

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.

Read More..

Second Illness Infects Meningitis Sufferers

Just when they might have thought they were in the clear, people recovering from meningitis in an outbreak caused by a contaminated steroid drug have been struck by a second illness.

The new problem, called an epidural abscess, is an infection near the spine at the site where the drug — contaminated by a fungus — was injected to treat back or neck pain. The abscesses are a localized infection, different from meningitis, which affects the membranes covering the brain and spinal cord. But in some cases, an untreated abscess can cause meningitis. The abscesses have formed even while patients were taking powerful antifungal medicines, putting them back in the hospital for more treatment, often with surgery.

The problem has just begun to emerge, so far mostly in Michigan, which has had more people sickened by the drug — 112 out of 404 nationwide — than any other state.

“We’re hearing about it in Michigan and other locations as well,” said Dr. Tom M. Chiller, the deputy chief of the mycotic diseases branch of the Centers for Disease Control and Prevention. “We don’t have a good handle on how many people are coming back.”

He added, “We are just learning about this and trying to assess how best to manage these patients. They’re very complicated.”

In the last few days, about a third of the 53 patients treated for meningitis at St. Joseph Mercy Hospital in Ann Arbor, Mich., have returned with abscesses, said Dr. Lakshmi K. Halasyamani, the chief medical officer.

“This is a significant shift in the presentation of this fungal infection, and quite concerning,” she said. “An epidural abscess is very serious. It’s not something we expected.”

She and other experts said they were especially puzzled that the infections could occur even though patients were taking drugs that, at least in tests, appeared to work against the fungus causing the infection, a type of black mold called Exserohilum.

The main symptom is severe pain near the injection site. But the abscesses are internal, with no visible signs on the skin, so it takes an M.R.I. scan to make the diagnosis. Some patients have more than one abscess. In some cases, the infection can be drained or cleaned out by a neurosurgeon.

But sometimes fungal strands and abnormal tissue are wrapped around nerves and cannot be surgically removed, said Dr. Carol A. Kauffman, an expert on fungal diseases at the University of Michigan. In such cases, all doctors can do is give a combination of antifungal drugs and hope for the best. They have very little experience with this type of infection.

Some patients have had epidural abscesses without meningitis; St. Joseph Mercy Hospital has had 34 such cases.

A spokesman for the health department in Tennessee, which has had 78 meningitis cases, said that a few cases of epidural abscess had also occurred there, and that the state was trying to assess the extent of the problem.

Dr. Chiller said doctors were also reporting that some patients exposed to the tainted drug had arachnoiditis, a nerve inflammation near the spine that can cause intense pain, bladder problems and numbness.

“Unfortunately, we know from the rare cases of fungal meningitis that occur, that you can have complicated courses for this disease, and it requires prolonged therapy and can have some devastating consequences,” he said.

The meningitis outbreak, first recognized in late September, is one of the worst public health disasters ever caused by a contaminated drug. So far, 29 people have died, often from strokes caused by the infection. The case count is continuing to rise. The drug was a steroid, methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass. Three contaminated lots of the drug, more than 17,000 vials, were shipped around the country, and about 14,000 people were injected with the drug, mostly for neck and back pain. But some received injections for arthritic joints and have developed joint infections.

Inspections of the compounding center have revealed extensive contamination. It has been shut down, as has another Massachusetts company, Ameridose, with some of the same owners. Both companies have had their products recalled.

Compounding pharmacies, which mix their own drugs, have had little regulation from either states or the federal government, and several others have been shut down recently after inspections found sanitation problems.

Read More..

Second Illness Infects Meningitis Sufferers

Just when they might have thought they were in the clear, people recovering from meningitis in an outbreak caused by a contaminated steroid drug have been struck by a second illness.

The new problem, called an epidural abscess, is an infection near the spine at the site where the drug — contaminated by a fungus — was injected to treat back or neck pain. The abscesses are a localized infection, different from meningitis, which affects the membranes covering the brain and spinal cord. But in some cases, an untreated abscess can cause meningitis. The abscesses have formed even while patients were taking powerful antifungal medicines, putting them back in the hospital for more treatment, often with surgery.

The problem has just begun to emerge, so far mostly in Michigan, which has had more people sickened by the drug — 112 out of 404 nationwide — than any other state.

“We’re hearing about it in Michigan and other locations as well,” said Dr. Tom M. Chiller, the deputy chief of the mycotic diseases branch of the Centers for Disease Control and Prevention. “We don’t have a good handle on how many people are coming back.”

He added, “We are just learning about this and trying to assess how best to manage these patients. They’re very complicated.”

In the last few days, about a third of the 53 patients treated for meningitis at St. Joseph Mercy Hospital in Ann Arbor, Mich., have returned with abscesses, said Dr. Lakshmi K. Halasyamani, the chief medical officer.

“This is a significant shift in the presentation of this fungal infection, and quite concerning,” she said. “An epidural abscess is very serious. It’s not something we expected.”

She and other experts said they were especially puzzled that the infections could occur even though patients were taking drugs that, at least in tests, appeared to work against the fungus causing the infection, a type of black mold called Exserohilum.

The main symptom is severe pain near the injection site. But the abscesses are internal, with no visible signs on the skin, so it takes an M.R.I. scan to make the diagnosis. Some patients have more than one abscess. In some cases, the infection can be drained or cleaned out by a neurosurgeon.

But sometimes fungal strands and abnormal tissue are wrapped around nerves and cannot be surgically removed, said Dr. Carol A. Kauffman, an expert on fungal diseases at the University of Michigan. In such cases, all doctors can do is give a combination of antifungal drugs and hope for the best. They have very little experience with this type of infection.

Some patients have had epidural abscesses without meningitis; St. Joseph Mercy Hospital has had 34 such cases.

A spokesman for the health department in Tennessee, which has had 78 meningitis cases, said that a few cases of epidural abscess had also occurred there, and that the state was trying to assess the extent of the problem.

Dr. Chiller said doctors were also reporting that some patients exposed to the tainted drug had arachnoiditis, a nerve inflammation near the spine that can cause intense pain, bladder problems and numbness.

“Unfortunately, we know from the rare cases of fungal meningitis that occur, that you can have complicated courses for this disease, and it requires prolonged therapy and can have some devastating consequences,” he said.

The meningitis outbreak, first recognized in late September, is one of the worst public health disasters ever caused by a contaminated drug. So far, 29 people have died, often from strokes caused by the infection. The case count is continuing to rise. The drug was a steroid, methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass. Three contaminated lots of the drug, more than 17,000 vials, were shipped around the country, and about 14,000 people were injected with the drug, mostly for neck and back pain. But some received injections for arthritic joints and have developed joint infections.

Inspections of the compounding center have revealed extensive contamination. It has been shut down, as has another Massachusetts company, Ameridose, with some of the same owners. Both companies have had their products recalled.

Compounding pharmacies, which mix their own drugs, have had little regulation from either states or the federal government, and several others have been shut down recently after inspections found sanitation problems.

Read More..

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.

Read More..

Gays in Pakistan Move Cautiously to Gain Acceptance

Max Becherer for the International Herald Tribune

HIDING IN PLAIN SIGHT Ali, a gay man who lives in Lahore, is in a support group for lesbian, gay, bisexual and transgender Pakistanis. “The gay scene here is very hush-hush,” he says.

LAHORE, Pakistan — The group meets irregularly in a simple building among a row of shops here that close in the evening. Drapes cover the windows. Sometimes members watch movies or read poetry. Occasionally, they give a party, dance and drink and let off steam.

The group is invitation only, by word of mouth. Members communicate through an e-mail list and are careful not to jeopardize the location of their meetings. One room is reserved for “crisis situations,” when someone may need a place to hide, most often from her own family. This is their safe space — a support group for lesbian, gay, bisexual and transgender Pakistanis.

“The gay scene here is very hush-hush,” said Ali, a member who did not want his full name used. “I wish it was a bit more open, but you make do with what you have.”

That is slowly changing as a relative handful of younger gays and lesbians, many educated in the West, seek to foster more acceptance of their sexuality and to carve out an identity, even in a climate of religious conservatism.

Homosexual acts remain illegal in Pakistan, based on laws constructed by the British during colonial rule. No civil rights legislation exists to protect gays and lesbians from discrimination.

But the reality is far more complex, more akin to “don’t ask, don’t tell” than a state-sponsored witch hunt. For a long time, the state’s willful blindness has provided space enough for gays and lesbians. They socialize, organize, date and even live together as couples, though discreetly.

One journalist, in his early 40s, has been living as a gay man in Pakistan for almost two decades. “It’s very easy being gay here, to be honest,” he said, though he and several others interviewed did not want their names used for fear of the social and legal repercussions. “You can live without being hassled about it,” he said, “as long as you are not wearing a pink tutu and running down the street carrying a rainbow flag.”

The reason is that while the notion of homosexuality may be taboo, homosocial, and even homosexual, behavior is common enough. Pakistani society is sharply segregated on gender lines, with taboos about extramarital sex that make it almost harder to conduct a secret heterosexual romance than a homosexual one. Displays of affection between men in public, like hugging and holding hands, are common. “A guy can be with a guy anytime, anywhere, and no one will raise an eyebrow,” the journalist said.

For many in his and previous generations, he said, same-sex attraction was not necessarily an issue because it did not involve questions of identity. Many Pakistani men who have sex with men do not think of themselves as gay. Some do it regularly, when they need a break from their wives, they say, and some for money.

But all the examples of homosexual relations — in Sufi poetry, Urdu literature or discreet sexual conduct — occur within the private sphere, said Hina Jilani, a human rights lawyer and activist for women’s and minority rights. Homoeroticism can be expressed but not named.

“The biggest hurdle,” Ms. Jilani said, “is finding the proper context in which to bring this issue out into the open.”

That is what the gay and lesbian support group in Lahore is slowly seeking to do, even if it still meets in what amounts to near secrecy.

The driving force behind the group comes from two women, ages 30 and 33. They are keenly aware of the oddity that two women, partners no less, have become architects of the modern gay scene in Lahore; if gay and bisexual men barely register in the collective societal consciousness of Pakistan, their female counterparts are even less visible.

“The organizing came from my personal experience of extreme isolation, the sense of being alone and different,” the 30-year-old said.

She decided that she needed to find others like her in Pakistan. Eight people, mostly the couple’s friends, attended the first meeting in January 2009.

Read More..

Think Like a Doctor: A Terrible Leg Wound

The Challenge: Can you solve the case of a middle-aged woman with leg wounds that don’t respond to one of our most powerful antibiotics?

The Diagnosis column of The New York Times Magazine regularly asks Well readers to take on a difficult case and try to solve a diagnostic riddle. This month, you’ll find details about a patient who comes to the hospital with three terrible lesions on her leg that don’t respond to the usual treatment. You will also have access to the notes from the doctors who saw the patient and test results that provide you with the same information that the doctors who originally encountered this medical mystery had.

The first reader to offer the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story” and the satisfaction of solving a case that could have given Gregory House a run for his money. Let’s get started.


The Presenting Problem

A 54-year-old woman comes to the emergency room with sores on her left leg that have been worsening for a month.

The Patient’s Story

The middle-aged woman was inspecting her leg when her roommate walked into the room. “Wow, that looks a lot worse,” he told her. “A whole lot worse.”

The woman looked at the large wounds on the back of her calf and nodded. Over the past week or so they had gotten much larger, and they were terribly painful. Just changing the bandage was excruciating, though she made herself do it every day.

“You need to go to the emergency room,” her roommate persisted. Tomorrow, she told him, definitely tomorrow. “No,” he said firmly, “we need to go now.”

And so, half an hour later the woman found herself in the emergency room of Waterbury Hospital in Connecticut, unwrapping her wounded calf for the young nurse staffing the triage desk. The nurse gasped as the leg was exposed.

The back of the woman’s calf was dominated by a sore larger than a hockey puck and shaped like the continent of Africa. Two smaller lesions flanked it. Their edges were red and angry-looking. The largest wound’s center was invisible behind a layer of purulent fluid that covered the wound and drenched the bandage. “Don’t touch it,” the woman said, sounding almost childlike in her pain and fear.

The nurse excused herself and returned with a doctor. This was an infection that would need intravenous antibiotics, he agreed after a quick look at the leg. The woman needed to be admitted to the hospital. The patient nodded in agreement. This was her first visit to a hospital in over a decade. She hated doctors and feared hospitals. But she knew that she needed to be here.

You can read the emergency department triage report and doctor’s note below.

The Doctor’s Story

Dr. Nadine Stanojevic, an internal medicine resident in her third and last year of training, called out to the medical student on duty after the emergency room doctor had filled her in. They headed down the stairs to the E.R., where they found the patient in the large treatment room on a stretcher, separated from the other patients by long white curtains. The woman was sitting up, hunched over her leg like a mother bird protecting a fledgling. Dr. Stanojevic introduced herself and the medical student, then asked about her leg.

It had all started about a month ago, the patient told them, after a painful red bump appeared on the back of her leg. She’d had other lesions like this over the past year — small, painful abscesses that would appear on her arms or legs, then open and drain and slowly heal. A similar, smaller one had appeared on her arm. But this new leg thing — this was crazy.

Initially there was just one lesion. It opened and drained, but instead of resolving as these lesions usually did, it had gotten larger and larger. The two other lesions started just a few days later. She washed the wounds every day and put antibiotic cream and sterile bandages on them, but it didn’t seem to help. She changed creams. Still, they just continued to get bigger.

And the wounds themselves were exquisitely tender. The back of her calf felt like it was on fire. She hadn’t been able to leave the house to go to her office for the past couple of weeks because of the pain. Now, even standing was excruciating.

Dr. Stanojevic could see the toll the lesions had taken on the woman. She’d clearly lost a lot of weight — the skin on her face seemed to be a couple of sizes too large, making her dark eyes look huge. Her graying hair fell in messy curls around her bony face. Neglected remnants of colorful polish streaked across her nails.

As the young doctor watched the woman slowly peel a now saturated gauze pad from around her leg, a smell suggestive of unwashed feet — the scent of pus — seeped into the room. The wound itself was horrific.

More of the Patient’s Story

Although the patient hadn’t been to see a doctor in years, she had several medical problems. She was a recovering heroin addict, participating in a methadone program to stay sober. She had high blood pressure that was well controlled with a single medication (prescribed at the methadone clinic) and arthritis in her hands, knees and feet that required daily doses of ibuprofen. An H.I.V. test done at the clinic six months earlier had come back negative. And though she’d never been tested for hepatitis C, she figured that — like almost everyone she knew — she probably had it.

On exam, the patient didn’t have a fever, and her blood pressure was normal. Her fingers were red and so swollen that the creases in the knuckles were almost invisible. (You can see pictures of her hands here.) On her left shoulder was a small abscess that was hot to the touch and tender.

The E.R. doctor had ordered a slew of labs. (You can see the laboratory results here.)

The patient was mildly anemic, though her white blood count was normal. Hepatitis serologies and an H.I.V. test had been sent, but the results were pending. Blood and wound cultures were sent.

The E.R. doctor had already started her on vancomycin, a powerful antibiotic, for a presumed infection with methicillin-resistant Staphylococcus aureus, or MRSA, a virulent bacterium that can cause abscesses and is resistant to most antibiotics. Dr. Stanojevic and the medical student discussed adding a second antibiotic but, like the E.R. doctor, decided MRSA was the most likely cause of this kind of terrible skin infection.

Dr. Stanojevic asked the surgeons to see the patient, in case the wound needed to be surgically cleaned. And she ordered an X-ray and an M.R.I. to see if the wound had infected the bone beneath. Then her beeper went off, and she and the student left the patient to see their next admission.

You can read Dr. Stanojevic’s admission note here.

A Stalled Recovery

The next day, Dr. Stanojevic thought the wounds looked a little better. The surgeons had cleaned off the yellow discharge, and the bottom of the shallow ulcer could be seen. It was red and angry-looking. The two smaller lesions were partly covered with dark scabs. (You can see what the lesions looked like — be warned: they are hard to look at — here and here.)

The young doctor was relieved to see that there was no evidence that the underlying muscle or bone was involved. But the next day, the patient’s third day in the hospital, the young doctor began to worry.

The wound looked no better, even though the patient had been on antibiotics for 48 hours. Maybe it wasn’t the right antibiotic. Normally, cultures grown from a sample of the wound would reveal the bacterial culprit and identify the antibiotic that would work best. But strangely, neither the blood culture nor the wound culture had grown out anything. Dr. Stanojevic expected to see Staph aureus because normally, Staph grows rapidly in the nutrient-filled culture dishes, but not this time. Why not? If it wasn’t MRSA, what could be eating away this woman’s leg like this?

You can review the M.R.I. and X-ray reports here.

You can review the follow-up laboratory results here.

Solving the Mystery

Now it’s your turn. Can you solve this mystery? Dr. Stanojevic did. I’ll post the answer on Friday.

Nov. 2 | Updated: Thanks for all your responses. To see the correct diagnosis, visit “Think Like a Doctor: A Terrible Leg Wound Solved.”

Rules and Regulations: Post your questions and diagnosis in the Comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Read More..