Think Like a Doctor: The Man Who Wobbled

The Challenge: Can you solve the medical mystery of a man who suddenly becomes too dizzy to walk?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a 56-year-old factory worker with dizziness and panic attacks. I have provided records from his two hospital visits that will give you all the information available to the doctor who finally made the diagnosis.

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 stumped a roomful of specialists.

The Patient’s Story:

The middle-aged man clicked his way through the multiple reruns of late-late-night television. He should have been in bed hours ago, but lately he hadn’t been able to get to sleep. Suddenly his legs took on a life of their own. Stretched out halfway to the center of the room, they began to shake and twitch and jump around. The man watched helplessly as his legs disobeyed his mental orders to stop moving. He had no control over them. He felt nauseous, sweaty and out of breath, as if he had been running some kind of race. He called out to his wife. She hurried out of bed, took one look at him and called 911.

The Patient’s History:

By the time the man arrived at Huntsville Hospital, in Alabama, the twitching in his legs had subsided and his breathing had returned to normal. Still, he had been discharged from that same hospital for similar symptoms just two weeks earlier. They hadn’t figured out what was going on then, so they weren’t going to send him home now.

The patient considered himself pretty healthy, but the past year or so had been tough. In 2011, at the age of 54, he had had a mild stroke. He had no medical problems that put him at risk for stroke — no high blood pressure, no high cholesterol, no diabetes. A work-up at that time showed that he had a hole in his heart that allowed a tiny clot from somewhere in his body to travel to the brain and cause the stroke. He was discharged on a couple of blood thinners to keep his blood from making more clots. He hadn’t really felt completely well, though, ever since. His balance seemed a little off, and he was subject to these weird panic attacks, in which his heart would pound and he would feel short of breath whenever he got too stressed. Mostly he could manage them by just walking away and focusing on his breathing. Still, he never felt as if he was the kind of guy to panic.

And he had always been quick on his feet. The first half of his career he had been in the steel business — building huge metal trusses and supports. He and his team put together 60-plus tons of steel structures every day. For the past decade he had been machining car parts. After his stroke, work seemed to get a lot harder.

The Dizziness:

A few weeks ago, he stood up and wham — suddenly the whole world went off-kilter. He felt as if he was constantly about to fall over in a world that no longer lay down flat. His first thought was that he was having another stroke. He went straight to his doctor’s office. The doctor wasn’t sure what was going on and sent him to that same emergency room at Huntsville Hospital. After three days of testing and being evaluated by lots of specialists, his doctors still were not sure what was going on. He hadn’t had a heart attack; he hadn’t had a stroke. There was no sign of infection. All the tests they could think of were normal.

The only abnormal finding was that when he stood up, his blood pressure dropped. Why this happened wasn’t clear, but the doctors in the hospital gave him compression stockings and a pill — both could help keep his blood pressure in the normal range. Then they sent him home. He was also started on an antidepressant to help with the panic attacks he continued to have from time to time.

You can read the report from that hospital admission below.

You can also read the consultation and discharge notes from that hospital visit here.

He had been home for nearly two weeks and still he felt no better. He tried to go back to work after a week or so at home, but after driving for less than five miles, he felt he had to turn around. He wasn’t sure what was wrong; he just knew he didn’t feel right. Then his legs started jumping around, and he ended up back in the hospital.

The Doctor’s Exam:

It was nearly dawn by the time Dr. Jeremy Thompson, the first-year resident on duty that night, saw the patient. Awake but tired, the patient told his story one more time. He had been at home, watching TV, when his legs started jumping on their own and he started feeling short of breath. His wife sat at the bedside. She looked just as worried and exhausted as he did. She told the resident that when he spoke that night at home, his speech was slurred. And when the ambulance came, he could barely walk. He has never missed this much work, she told the young doctor. It’s not like him. Can’t you figure out what’s wrong?

The resident had already reviewed the records from the patient’s previous hospital admissions. He asked a few more questions: the patient had never smoked and rarely drank; his father died at age 80; his mother was still alive and well. The patient exam was normal, as were the studies done in the E.R.

The first E.R. doctor thought that his symptoms were a result of anxiety, culminating in a full-blown panic attack. The resident thought that was probably right. In any case he would discuss the case with the attending in a couple of hours during rounds on the new patients. Till then, he told the worried couple, they should just try to get a little sleep.

An Important Clue:

Dr. Robert Centor was definitely a morning person. His cheerful enthusiasm about teaching and taking care of patients made him a favorite among residents. At 7:30 that morning, he stood outside the patient’s door as Dr. Thompson relayed the somewhat frustrating case of the middle-aged man with worsening dizziness and panic attacks. Then they went into the room to meet the patient. He was a big guy, tall and muscular with the first signs of middle-aged thickening around his middle. His complexion had the look of someone who spent a lot of time outdoors. Dr. Centor introduced himself and pulled up a chair as the rest of the team watched. He asked the patient what brought him to the hospital.

“Every time I get up, I get dizzy,” the man replied. Sure, he had had some balance problems ever since his stroke, he explained, but this felt different – somehow worse. He could hardly walk, he told the doctor. He just felt too unstable.

“Can you get up and show us how you walk?” Dr. Centor asked.

“Don’t let me fall,” the patient responded. He carefully swung his legs over the side of the bed. The resident and intern stood on either side as he slowly rose. He stood with his feet far apart. When asked to close his eyes as he stood there, he wobbled and nearly fell over. When he took a few steps, his heel and toes hit the ground at the same time, making a strange slapping sound.

Seeing that, Dr. Centor knew where the problem lay and ordered a few tests to confirm his diagnosis.

You can see the review report and notes for the patient’s second hospital visit below.

Solving the Mystery:

What tests did Dr. Centor order? Do you know what is making this middle-aged man wobble? Enter your guesses below. I’ll post the answer tomorrow.

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

Friday March 1, 1:21 p.m. | Updated Thanks for all your responses! You can learn the correct diagnosis at “Think Like a Doctor: The Wobble Solved!”

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Detroit Car Sales Climb Again

DETROIT – Sales of new vehicles in the United States rose modestly in February, as consumers continued to buy more fuel-efficient cars and as businesses replaced aging pickup trucks with newer models.

Auto executives said overall industry sales for the month would improve about 2 percent over the strong results reported in the same period a year ago.

The seasonally adjusted annual sales rate – a closely watched indicator for the industry – is expected to total about 15.5 million vehicles for February.

That seasonal rate bodes well for the industry going forward, as automakers ratchet up production to meet demand for their new products.

The Detroit auto companies all posted positive results during the month.

General Motors, the largest American automaker, said it sold 224,000 vehicles in February, a 7 percent increase from the same month in 2012.

All of G.M.'s domestic brands – Chevrolet, Cadillac, GMC and Buick – had higher year-over-year sales. Cadillac led the way with a 20 percent gain, primarily because of healthy sales of the new ATS compact sedan.

G.M. also reported increases in sales of its newest small cars, like the Buick Verano and the Chevrolet Spark. But its most prominent gains were in pickup trucks.

The company said that sales of the Chevrolet Silverado pickup rose 29 percent, and the GMC Sierra increased 25 percent. Executives attributed the performance to a surge in housing starts and the need for construction companies to replace older pickups.

“A significant tailwind for our industry is new home construction, which is creating jobs and fueling the demand for pickups,” said Kurt McNeil, G.M.'s vice president of United States sales operations.

The Ford Motor Company, the second-biggest Detroit auto company, said it sold 195,000 vehicles during the month, a 9 percent gain from a year ago.

Ford said that many of its gains came from sales of sport utilities such as the Escape and Explorer. The company’s redesigned midsize sedan, the Fusion, also had a good month, with a 28 percent improvement over last year.

Like G.M., Ford also benefitted from the surging demand for pickups. Ford said that it sold 54,000 F-series trucks during the month, a 15 percent increase from February of 2012.

Chrysler, the smallest of the Detroit automakers, saw its growth rate slow somewhat after several months of reporting double-digit increases.

The company said that it sold 139,000 vehicles in February, a 4 percent improvement over a year earlier. That is a smaller increase than Chrysler has reported in previous months.

“In spite of a cautious ramp-up of some of our most popular products, which limited inventory last month, we still managed to record our strongest February in five years,” said Reid Bigland, head of United States sales for Chrysler.

Chrysler’s best performers during the month were passenger cars such as the new Dodge Dart. Sales of its Ram pickup increased 3 percent, while sales of its Jeep SUVs dropped 16 percent.

The big Japanese automakers were to report results later Friday. Analysts expected Toyota and Honda to continue their steady comeback from inventory disruptions because of the earthquake and tsunami in Japan two years ago.

Volkswagen, the German automaker that is rapidly expanding its American operations, said it sold 31,000 vehicles in February, a 3 percent increase from a year earlier.

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Jury in Bell corruption trial may be deadlocked

A court spokeswoman said Thursday the jury in the Bell corruption case appears to be deadlocked.

“The jurors may be at an impasse,” said Patricia Kelly, a spokeswoman for L.A. County Superior Court.

Jurors sent a note to the judge Thursday morning, and all the attorneys in the case were called in.

Six former Bell City Council members are accused of stealing public money by paying themselves extraordinary salaries in one of Los Angeles County’s poorest cities.

Luis Artiga, Victor Bello, George Cole, Oscar Hernandez, Teresa Jacobo and George Mirabal are accused of misappropriation of public funds, felony counts that could bring prison terms.

They were arrested in September 2010 and have been free on bail.

The nearly $100,000 salaries drawn by most of the former elected officials are part of a much larger municipal corruption case in the southeast Los Angeles County city in which prosecutors allege that money from the city’s modest general fund flowed freely to top officials.

The three defendants who testified painted a picture of a city as a place led by a controlling, manipulative administrator who handed out enormous salaries, loaned city money and padded future pensions. Robert Rizzo, the former adminstrator, and ex-assistant city manager Angela Spaccia are also awaiting trial.

The four-week trial of the former council members turned on extremes.

Deputy Dist. Atty. Edward Miller said the council members were little more than common thieves who were consumed with fattening their paychecks at the expense of the city’s largely immigrant, working-poor residents.

Miller said the accused represented the “one-percenters" of Bell who had “apparently forgotten who they are and where they live."

Defense attorneys said the former city leaders -- one a pastor, another a mom-and-pop grocery store owner, another a funeral director -- were dedicated public servants who put in long hours and tirelessly responded to the needs of their constituents.

Jacobo testified that Rizzo informed her she could quit her job as a real estate agent and receive a full-time salary as a council member. She said she asked City Attorney Edward Lee if that was possible and he nodded his head.

"I thought I was doing a very good job to be able to earn that, yes," Jacobo said.

Cole said Rizzo was so intimidating that the former councilman voted for a 12% annual pay raise out of fear the city programs he established would be gutted by Rizzo in retaliation if he opposed the pay hikes.

The defense argued that the prosecution failed to prove criminal negligence -- that their clients knew what they were doing was wrong or that a reasonable person would know it was wrong.

The attorney for Hernandez, the city’s mayor at the time of the arrests, said his client had only a grade-school education, was known more for his heart than his intellect and was, perhaps, not overly “scholarly.”

Prosecutors argued that the council members pushed up their salaries by serving on city boards that rarely met and, in one case, existed only as a means for paying them even more money.

Jurors were also left to deal with the question of whether council members were protected by a City Charter that was approved in a special election that drew fewer than 400 voters.

Defense attorneys say the charter allowed council members to be paid for serving on the authorities.

But the prosecutor argued that the charter -- a quasi-constitution for a city -- set salaries at what councils in similar-sized cities were receiving under state law: $8,076 a year. Because council members automatically serve on boards and commissions, the district attorney said the total compensation for all of each council member's work was included in that figure.

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Good Eggs Aims to Be the Amazon of Local Food

Good Eggs, which launched last summer as the Etsy of local food, is expanding in a bid to become the Amazon of local food.

The San Francisco-based company launched a new web platform Thursday that lets users select items from local vendors and farmers and combine them in a single order ready for delivery or pickup. That’s transforming Good Eggs from a web stand for multiple vendors to a central hub for purchasing and delivering local food.

“We actually had the inventory for an awesome grocery store, but the missing piece was some kind of central distribution, some way for you place an order across all of these vendors and get a single pickup or delivery,” co-founder Rob Spiro told Wired. “We were experimenting with offices and pickup spots…. The model we found working well was very operational. You end up getting into the logistics game to provide a high quality of service.”

Unlike the traditional CSA (community-supported agriculture) deliveries, Good Eggs lets you customize what you want, to include specific amounts of fruits and veggies, fresh fish, prepared food, baked goods and more. You still pick from what’s in season, but if you hate potatoes, you don’t get potatoes.

To support its newfound operation, Good Eggs is moving into a giant warehouse where it can aggregate all of its vendors’ product and put together its made-to-order boxes of food. Spiro says that they’ve been running test routes throughout the San Francisco Bay Area to figure out which are most efficient, and naturally, the former Googler says that all routes are “optimized algorithmically.”

Delivery does, however, cost an extra $4, whereas pickups at various locations (there are seven in San Francisco) are free.

Unlike Farmigo, another online food startup, Good Eggs caters to the individual rather than the community. Farmigo CEO Benzi Ronen told Wired in December that his company opted out of home delivery because of high costs. Good Eggs’ Spiro says that isn’t so much a concern for him.

“We’re taking the challenge head on,” Spiro said. “We have all these producers already running their businesses through Good Eggs…. You place your orders, it goes directly to the producer, then it goes to this one warehouse…. The long-term goal is to build out hubs in hundreds of areas.”

Good Eggs is already in the process of signing vendors up in Brooklyn, New York City, and plans to expand to several other cities.

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Study Finds Genetic Risk Factors Shared by 5 Psychiatric Disorders

Their study, published online Wednesday in the Lancet, was based on an examination of genetic data from more than 60,000 people world-wide. Its authors say it is the largest genetic study yet of psychiatric disorders. The findings strengthen an emerging view of mental illness that aims to make diagnoses based on the genetic aberrations underlying diseases instead of on the disease symptoms.

Two of the aberrations discovered in the new study were in genes used in a major signaling system in the brain, giving clues to processes that might go awry and suggestions of how to treat the diseases.

“What we identified here is probably just the tip of an iceberg,” said Dr. Jordan Smoller, lead author of the paper and a professor of psychiatry at Harvard Medical School and Massachusetts General Hospital. “As these studies grow we expect to find additional genes that might overlap.”

The new study does not mean that the genetics of psychiatric disorders are simple. Researchers say there seem to be hundreds of genes involved and the gene variations discovered in the new study only confer a small risk of psychiatric disease.

Steven McCarroll, director of genetics for the Stanley Center for Psychiatric Research at the Broad Institute of Harvard and M.I.T., said it was significant that the researchers had found common genetic factors that pointed to a specific signaling system.

“It is very important that these were not just random hits on the dartboard of the genome,” said Dr. McCarroll, who was not involved in the new study.

The work began in 2007 when a large group of researchers began investigating genetic data generated by studies in 19 countries and including 33,332 people with psychiatric illnesses and 27,888 people free of the illnesses for comparison. The researchers studied scans of peoples’ DNA, looking for variations in any of several million places along the long stretch of genetic material containing three billion DNA letters. The question: Did people with psychiatric illnesses tend to have a distinctive DNA pattern in any of those locations?

Researchers had already seen some clues of overlapping genetic effects in identical twins. One twin might have schizophrenia while the other had bipolar disorder. About six years ago, around the time the new study began, researchers had examined the genes of a few rare families in which psychiatric disorders seemed especially prevalent. They found a few unusual disruptions of chromosomes that were linked to psychiatric illnesses. But what surprised them was that while one person with the aberration might get one disorder a relative with the same mutation got a different one.

Jonathan Sebat, chief of the Beyster Center for Molecular Genomics of Neuropsychiatric Diseases at the University of California, San Diego, and one of the discoverers of this effect, said that work on these rare genetic aberrations had opened his eyes. “Two different diagnoses can have the same genetic risk factor,” he said.

In fact, the new paper reports, distinguishing psychiatric diseases by their symptoms has long been difficult. Autism, for example, at was once called childhood schizophrenia. It was not until the 1970s that autism was distinguished as a separate disorder.

But, Dr. Sebat, who did not work on the new study, said that until now it was not clear whether the rare families he and others had studied were an exception or whether they were pointing to a rule about multiple disorders arising from a single genetic glitch.

“No one had systematically looked at the common variations,” in DNA, he said. “We didn’t know if this was particularly true for rare mutations or if it would be true for all genetic risk.” The new study, he said, “shows all genetic risk is of this nature.”

The new study found four DNA regions that conferred a small risk of psychiatric disorders. For two of them, it is not clear what genes are involved or what they do, said Dr. Smoller. The other two, though, involve genes that are part of calcium channels, which are used when nerves send signals in the brain.

“The calcium channel findings suggest that perhaps – and this is a big if – treatments to affect calcium channel functioning might have effects across a range of disorders,” Dr. Smoller said.

There are drugs on the market that block calcium channels – they are used to treat high blood pressure – and researchers had already postulated that they might be useful for bipolar disorder even before the current findings.

One investigator, Dr. Roy Perlis of Massachusetts General Hospital, just completed a small study of a calcium channel blocker in 10 people with bipolar disorder and is about to expand it to a large randomized clinical trial. He also wants to study the drug in people with schizophrenia, in light of the new findings. He cautions, though, that people should not rush out to take a calcium channel blocker on their own.

“We need to be sure it is safe and we need to be sure it works,” Dr. Perlis said.

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DealBook: For S.E.C., a Setback in Bid for More Time in Fraud Cases

The Supreme Court on Wednesday delivered a swift and decisive rejection of the Securities and Exchange Commission’s argument that it should operate under a more forgiving statute of limitations in pursuing penalties in fraud cases.

As a result of the decision, the agency will have to find a long-term solution to give itself more time to investigate cases.

In Gabelli v. Securities and Exchange Commission, Chief Justice John G. Roberts Jr. wrote in the unanimous decision rejecting the S.E.C.’s argument that a federal statute that limits the government’s authority to pursue civil penalties should commence when a fraud is discovered, not when it occurred.

The S.E.C. was hoping that the court would apply what is known as the “discovery rule.” In 2010, the Supreme Court endorsed this rule in a private securities fraud class-action suit, Merck & Co. v. Reynolds, stating “that something different was needed in the case of fraud, where a defendant’s deceptive conduct may prevent a plaintiff from even knowing that he or she has been defrauded.”

The discovery rule is an exception to the protection afforded by a statute of limitations, which puts an endpoint on potential legal liability for conduct. Unlike most cases, when fraud is involved, it may not be apparent to the victims that they were harmed because the primary goal of deceptive conduct is to keep it from being exposed.

In the Gabelli case, the S.E.C. filed fraud charges in 2008 against the mutual fund manager Marc Gabelli and a colleague, Bruce Alpert, saying they had violated the Investment Advisers Act of 1940 for permitting an investor to engage in market timing. Ten years ago, a major scandal erupted when it came to light that some advisers had permitted select investors to buy shares at favorable prices to take advantage of pricing disparities in the securities held by mutual funds.

In its complaint, the S.E.C. sought civil monetary penalties based on market timing that it claimed had taken place from 1999 to 2002, and resulted in the preferred investor purportedly reaping significant profits while ordinary investors suffered large losses. The defendants denied the charges and filed a motion to dismiss the case because it was not brought in time.

A federal statute, 28 U.S.C. § 2462, provides that “an action, suit or proceeding for the enforcement of any civil fine, penalty, or forfeiture, pecuniary or otherwise, shall not be entertained unless commenced within five years from the date when the claim first accrued.” The provision dates to 1839, and applies to any government agency.

A decision by the United States Court of Appeals for the Second Circuit in Manhattan allowed the case to proceed by applying the discovery rule to a governmental action. Coincidentally, that decision was written by Judge Jed S. Rakoff, who despite being an occasional thorn in the S.E.C.’s side, accepted the agency’s argument to avoid a strict application of the five-year statute of limitations.

The Supreme Court, however, saw things differently. This week, it issued its opinion less than two months after it heard oral argument in the case in January, a clear sign the justices found no merit in the S.E.C.’s contention that the agency should be treated the same as private plaintiffs in trying to get around the statute of limitations.

According to the Supreme Court, victims in securities fraud cases should have a longer period to file a claim – from when the fraud was discovered. “Most of us do not live in a state of constant investigation,” the court wrote. “Absent any reason to think we have been injured, we do not typically spend our days looking for evidence that we were lied to or defrauded.”

Chief Justice Roberts explained that “the S.E.C. as enforcer is a far cry from the defrauded victim the discovery rule evolved to protect.” One of the reasons the agency exists is to detect and penalize violations, with tools that the ordinary investor simply does not have, like the authority to compel testimony and the production of documents. The message is simple. When it’s your job to investigate fraud, you cannot argue that your failure to do so is a justification for not meeting a statute of limitations.

The Supreme Court’s decision puts increased pressure on the S.E.C. to pursue its investigations with greater alacrity and not let them gather dust, which can occur as a result of staff turnover or other pressing issues. The market timing case is a good example of how an investigation might get lost in the shuffle as corporate accounting frauds at large companies like Enron and WorldCom, which also came to light in 2002, strained the S.E.C.’s investigative resources.

There are a couple of options to deal with this issue in the long run, apart from a substantial increase in the agency’s budget – an unlikely prospect in the face of the looming federal budget sequestration deadline.

The S.E.C. can obtain an agreement to stop the statute of limitations, known as tolling, from those it is investigating, something it has done in the past. For example, in its insider trading and securities fraud case against Samuel E. Wyly, his now deceased brother, Charles J. Wyly Jr., and two other defendants, the S.E.C. got an agreement that let it pursue claims beyond the normal five-year limitations period.

A permanent solution would be to seek legislation from Congress that would give the S.E.C. a longer window to complete its investigations. The statute of limitations is not a constitutional protection, so Congress can amend it as it sees fit, which it has done in other areas involving fraud.

The limitations period for banking crimes, for example, was extended to 10 years during the savings and loan crisis because of the crush of cases that made it difficult to finish investigations in the five-year window to initiate criminal prosecutions. The Fraud Enforcement and Recovery Act of 2009 added mail and wire fraud affecting a financial institution to the list of crimes that get the benefit of the 10-year limitations period, again because of fear that cases would be lost because of the number of investigations taking place after the financial crisis.

The issue of the statute of limitations may even come up at the confirmation hearings of Mary Jo White, who has been nominated to be chairwoman of the S.E.C. That could be an early indicator of whether she would be willing to push for relief from the effect of the Gabelli opinion to help out the enforcement division.

In the short run, the Supreme Court’s decision will cause defendants in government enforcement actions to examine whether they might be able to take advantage of the five-year limitations period. Given how slowly the government has been known to move on occasion, it may be that some cases will fall by the wayside because of the Gabelli decision.

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Race for L.A. city controller heats up

A previously low-profile race for Los Angeles city controller has begun to heat up as opponents of City Councilman Dennis Zine accuse him of "double dipping" the city's payroll and question why he is considering lucrative tax breaks for a Warner Center developer.

Zine, who for 12 years has represented a district in the southeast San Fernando Valley, is the better known of the major candidates competing to replace outgoing Controller Wendy Greuel.

The others are Cary Brazeman, a marketing executive, and lawyer Ron Galperin. Zine has raised $766,000 for his campaign, more than double that of Galperin, the next-highest fundraiser, and has the backing of several of the city's powerful labor unions.

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He also has been endorsed by Mayor Antonio Villaraigosa and several of his council colleagues. Galperin is backed by the Service Employees International Union, one the city's largest labor groups, and Brazeman is supported by retired Rep. Diane Watson and several neighborhood council representatives.

With the primary ballot less than a week away, Brazeman and Galperin have turned up the heat on Zine, hoping to push the race beyond the March 5 vote. If no one wins more than 50% of the ballots cast, the top two vote-getters will face a runoff in the May general election.

In a recent debate, Zine's opponents criticized him for receiving a $100,000 annual pension for his 33 years with the Los Angeles Police Department and a nearly $180,000 council salary. Brazeman and Galperin called it an example of "double dipping" that should be eliminated.

That brought a forceful response from Zine, who shot back that he gives a big portion of his police pension check to charities.

"I am so tired of hearing 'double dipping,' " he said. "I worked 33 years on the streets of Los Angeles. I have given over $300,000 to nonprofits that need it.... That's what's happened with that pension."

In the same debate, Brazeman accused Zine of cozying up to a Warner Center developer by pushing for tax breaks on a project that already has been approved. The nearly 30-acre Village at Westfield Topanga project would add 1 million square feet of new shops, restaurants, office space and a hotel to a faded commercial district on Topanga Canyon Boulevard.

"The councilman proposed to give developers at Warner Center tens of millions of dollars in tax breaks even though it's a highly successful project," he said. "He wants to give it away."

City records show that less than a month after the development was approved in February 2012, Zine asked the council for a study looking at possible "economic development incentives" that could be given to Westfield in return for speeding up street and landscaping enhancements to the project's exterior.

The motion's language notes that similar tax breaks have been awarded to large projects in the Hollywood and downtown areas, and that "similar public investment in the Valley has been lacking." Westfield is paying for the $200,000 study.

Zine defended his decision before the debate audience, saying if the study finds that the city will not benefit, no tax breaks will be awarded. "If there's nothing there, then they get nothing," Zine said.

The controller serves as a public watchdog over the city's $7.3-billion annual operation, auditing the general fund, 500 special fund accounts and the performance of city departments. Those audits often produce recommendations for reducing waste, fraud and abuse.

But the mayor and the council are not obligated to adopt those recommendations, and as a result the job is part accountant, part scolder in chief. All the candidates say they will use their elective position not only to perform audits but also to turn them into action.

Their challenge during the campaign has been explaining how they will do that.

Zine, 65, says his City Hall experience has taught him how to get things done by working with his colleagues. He won't be afraid to publicly criticize department managers, he said, but thinks collaboration works better than being combative.

"You can rant and rave and people won't work with you," he said. "Or you can sit down and talk it out, and you can accomplish things."

Galperin, 49, considers himself a policy wonk who relishes digging into the details to come up with ways to become more efficient with limited dollars and to find ways to raise revenue using the city's sprawling assets. For instance, the city owns two asphalt plants that could expand production and sell some of its material to raise money to fix potholes, he said.

He's served on two city commissions, including one that found millions of dollars in savings by detailing ways to be more efficient. Zine is positioning himself as a "tough guy for tough times," but the controller should be more than that, Galperin said.

"What we really need is some thoughtfulness and some smarts and some effectiveness," he said. "Just getting up there and saying we need to be tough is not going to accomplish what needs to be done."

Brazeman, 46, started his own marketing and public relations firm in West Los Angeles a decade ago and became active in city politics over his discontent with a development project near his home. He has pushed the council to change several initiatives over the last five years, including changes to the financing of the Farmers Field stadium proposal that will save taxpayer dollars, he said.

As controller, he would pick and choose his battles, and, Brazeman said, be "the right combination of constructive, abrasive and assertive."

catherine.saillant@latimes.com

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Private Plan to Send Humans to Mars in 2018 Might Not Be So Crazy

An ambitious private manned mission to Mars aims to launch a two-person crew to fly around the Red Planet and return to Earth in 501 days, starting in January 2018.

This bold undertaking is planned by the Inspiration Mars Foundation, a non-profit company founded by millionaire and space tourist Dennis Tito that was officially unveiled on Feb. 27 after early details leaked. Though the spacecraft would not land humans on Mars or even put them in orbit, it would bring people within a few hundred kilometers of the Martian surface — roughly the same distance between the International Space Station and Earth — and represent a major milestone in human spaceflight. If successful, the mission would go down in history as the first time a private company accomplished something government agencies were unable to do in space.

The mission is extremely ambitious, well beyond anything previously accomplished by the private sector and it faces plenty of obstacles. The company has an aggressive schedule to keep if it wants to hit its 2018 mark and needs to make sure the necessary technology is developed and well-tested. Despite its deep-pocketed backer, the mission has nowhere near the funding it needs to launch and will require raising greater sums than have ever been done for a private space endeavor. Its designers also need to figure out exactly how to keep the crew healthy, both physically and psychologically, for the 501-day duration of the flight as they face dangers from radiation, bone and muscle loss, fatigue, and depression. Mission designers will have to ensure they can get the crew safely to the ground when the capsule returns to Earth at a screaming 30,000 mph.

Yet despite these hurdles, of all the bold announcements from private spaceflight companies in recent years, this one seems the most achievable.

“The reason this entire thing is possible is because it’s actually a very simple mission,” said Jane Poynter, president of the Paragon Space Development Corporation, which makes life-support systems and has partnered with Inspiration Mars. “We’re not trying to land, we’re going to fly by and we’re using extant technologies that NASA and the space industry have been developing for years.”

Inspiration Mars isn’t looking to sell a product in an unknown market, like the asteroid-mining Planetary Resources or the national-moon-ferrying Golden Spike Company, and doesn’t have incredibly aspirational aims, like the planet-colonizing Mars One. It hopes to undertake a straightforward mission that could spur innovation, inspire young scientists and engineers, and move human spaceflight forward.

“You have to have a reasonable degree of skepticism and realism,” said Taber MacCallum, who co-founded Paragon with Poynter (and is also her husband). “We might run into some insurmountable obstacle 18 months in. But with proper engineering, support, and a good mess of luck, we could see this done.”

Now all they have to do is actually fly to Mars.

As currently outlined, the Inspiration Mars mission would be departing on what’s known as a “fast free return trajectory,” which both minimizes the amount of time spent in space and the amount of fuel required. A spacecraft would fire its rockets for a single burn to set off to Mars, make a few course corrections on the way, circumnavigate the Red Planet, and then slingshot back home using Mars’ gravity, negating the need for another burn. Because of the positions of Earth and Mars, opportunities for such quick flybys happen only every 15 years and, if they miss the 2018 deadline, the next chance won’t come until 2031.

Paragon estimates that the mission would need to launch a 10-ton spacecraft with roughly 33 cubic meters of volume, equivalent to the space in the back of a large moving van. About half that volume would be taken up with water tanks, food, and life support, leaving a cramped living space with an area barely bigger than a parking space. That means putting two people in a room for 1.4 years that’s probably smaller than your bathroom.

The crew would process urine and flush water to recycle about 75 percent of it as drinkable water. They would carry the bare minimum of personal provisions, such as clothing and hygiene items. An initial feasibility study co-authored by Poynter, MacCallum, Dennis Tito, and others didn’t make allowances for privacy, separate sleeping quarters, or even showers (just sponge baths) in the habitat, but it remains to be seen how these ideas would evolve for a real mission.

No existing launch vehicle is large enough to get such a mass into space, though SpaceX plans to have its Falcon Heavy rocket ready within a few years. If SpaceX is unable to meet that deadline, the mission could use two smaller existing launch vehicles, one to bring the tank carrying the rocket engines and necessary fuel and another to launch the crew habitat, which complicates the mission and could make it more expensive.

The number one danger during the journey will be radiation. Whether charged particles streaming from the sun or galactic cosmic rays accelerated by distant sources, space is chock full of radiation. Humans on Earth are protected from this fallout by our magnetic field, which also shields astronauts on the ISS. But out in deep space, the crew of a 500-day trip would be exposed to total radiation roughly equal to the dose an astronaut that flew five or six times to the ISS would expect to receive over their career.

Among other things, radiation damages DNA thereby raising the risk of cancer, and lowers blood cell counts. The effect would be like smoking a pack of cigarettes a day during the whole mission, MacCallum said.

The most severe event to watch out for would be a solar flare or mass ejection, where the roiling surface of the sun produces a burst of charged particles and radiation. If exposed to such an occurrence, a crew might experience nausea, vomiting, blistering, and potentially death. Apollo astronauts were spared a potentially fatal flare in 1972 that occurred between Apollo 16 and 17 but the Inspiration Mars mission would be out in space for a long time, raising the odds of getting hit.

Solar particle events like these happen randomly, though in 2018 the sun will be closer to the minimum part of its activity cycle, lessening the chances of a large event. In the case of a major event, sun-observing satellites would provide some warning and the crew could retire to a storm shelter built from vehicle hardware. But a large event or even several smaller ones could weaken astronauts’ immune systems, said radiobiologist Ann Kennedy of the University of Pennsylvania, who works on the effects of radiation for the National Space Biomedical Research Institute.

With the sun at minimum the crew would be exposed to a higher rate of galactic cosmic rays than normal, and the chronic low-dose of ionizing radiation “can not be shielded against with current technology,” said radiation physicist Jeff Chancellor, also of the NSBRI.

Even surrounding the spacecraft with a huge, thick shield, something like five or six times what the ISS has, would not significantly lower galactic cosmic ray exposure, he added. In fact the more shielding you have, the worse, because the charged particles can interact with molecules in the material to produce further harmful radiation.

The crew can help counteract some of the radiation’s effects with drugs for nausea and vomiting and pills or supplements to provide the daily recommended doses of vitamins.

“My gut feeling is there’s a good chance they can do this mission, but there’s a lot left to be seen,” Chancellor said. Space travel is always risky, he added, though there is hope that further research can provide a crew with effective radiation countermeasures before 2018.

Beyond radiation, the main biomedical problem will be muscle and bone deterioration, which occurs to the human body during extended stays in microgravity. To counteract this, Poynter said it would be of the utmost importance for the crew to have an exercise machine that they use daily for several hours.

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Personal Health: Too Many Pills in Pregnancy

The thalidomide disaster of the early 1960s left thousands of babies with deformed limbs because their mothers innocently took a sleeping pill thought to be safe during pregnancy,

In its well-publicized wake, countless pregnant women avoided all medications, fearing that any drug they took could jeopardize their babies’ development.

I was terrified in December 1968 when, during the first weeks of my pregnancy, I developed double pneumonia and was treated with antibiotics and codeine. Before swallowing a single dose, I called my obstetrician, who told me to take what was prescribed, “reassuring” me that if I died of pneumonia I wouldn’t have a baby at all.

In the decades that followed, pregnancy-related hazards were linked to many medicinal substances: prescription and over-the-counter drugs and herbal remedies, as well as abused drugs and even some vitamins.

Now, however, the latest findings about drug use during pregnancy have ignited new concerns among experts who monitor the effects of medications on the developing fetus and pregnancy itself.

During the last 30 years, use of prescription drugs during the first trimester of pregnancy, when fetal organs are forming, has grown by more than 60 percent.

About 90 percent of pregnant women take at least one medication, and 70 percent take at least one prescription drug, according to the Centers for Disease Control and Prevention.

Since the late 1970s, the proportion of pregnant women taking four or more medications has more than doubled.

Nearly one woman in 10 takes an herbal remedy during the first trimester.

A growing number of pregnant women, naïvely assuming safety, self-medicate with over-the-counter drugs that were once sold only by prescription.

While many commonly taken medications are considered safe for unborn babies, the Food and Drug Administration estimates that 10 percent or more of birth defects result from medications taken during pregnancy. “We seem to have forgotten as a society that drugs pose risks,” Dr. Allen A. Mitchell, professor of epidemiology and pediatrics at Boston University Schools of Public Health and Medicine, said in an interview. “Many over-the-counter drugs were grandfathered in with no studies of their possible effects during pregnancy.”

Medical progress has contributed to the rising use of medications during pregnancy, Dr. Mitchell said. Various conditions, like depression, are now recognized as diseases that warrant treatment; drugs have been developed to treat conditions for which no treatment was previously available, and some conditions, like Type 2 diabetes and hypertension, have become more prevalent.

Misled by the Web

Now a new concern has surfaced: Bypassing their doctors, more and more women are using the Internet to determine whether the medication they are taking or are about to take is safe for an unborn baby.

A study, published online last month in Pharmacoepidemiology and Drug Safety, of so-called “safe lists for medications in pregnancy” found at 25 Web sites revealed glaring inconsistencies and sometimes false reassurances or alarms based on “inadequate evidence.”

The report was prepared by Cheryl S. Broussard of the Centers for Disease Control and Prevention with co-authors from Emory, Georgia State University, the University of British Columbia and the Food and Drug Administration.

“Among medications approved for use in the U.S.A. from 2000 to 2010, over 79% had no published human data on which to assess teratogenic risk (potential to cause birth defects), and 98% had insufficient published data to characterize such risk,” the authors wrote.

But that did not stop the 25 Web sites from characterizing 245 medications as “safe” for use by pregnant women, which “might encourage use of medications during pregnancy even when they are not necessary,” the authors suggested.

Furthermore, the information found online was sometimes contradictory. “Twenty-two of the products listed as safe by one or more sites were stated not to be safe by one or more of the other sites,” the study found.

The question of timing was often ignored. A drug that could interfere with fetal organ development might be safe to take later in pregnancy. Or one (for example, ibuprofen) that is safe early in pregnancy could become a hazard later if it raises the risk of excessive bleeding or premature delivery.

Fewer than half the sites advised taking medication only when necessary, and only 13 sites encouraged pregnant women to consult their doctors before stopping or starting a medication.

Doctors, too, are often poorly informed about pregnancy-related hazards of various medications, the authors noted. One woman I know was advised to wean off an antidepressant before she became pregnant, but another was told to continue taking the same drug throughout her pregnancy.

“In many instances the best bet is for mom to stay on her medication,” said Dr. Siobhan M. Dolan, an obstetrician and geneticist at Albert Einstein College of Medicine. She said that if a woman is depressed during pregnancy, her risk of postpartum depression is greater and she may have difficulty bonding with her baby.

Dr. Dolan, who is author, with Alice Lesch Kelly, of the March of Dimes’ newest book, “Healthy Mom Healthy Baby,” emphasized the importance of weighing benefits and risks in deciding whether to take medication during pregnancy and which drugs to take.

“In anticipation of pregnancy, a woman taking more than one drug to treat her condition should try to get down to a single agent,” Dr. Dolan said in an interview. “Of the various medications available to treat a condition, is there a best choice — one least likely to cause a problem for either the baby or the mother?”

She cautioned against sharing medications prescribed for someone else and assuming that a remedy labeled “natural” or “herbal” is safe. Virtually none have been tested for safety in pregnancy.

Among medications a woman should be certain to avoid, in some cases starting three months before becoming pregnant, are isotretinoin (Accutane and others) for acne; valproic acid for seizure disorders; lithium for bipolar disorder; tetracycline for infections, and angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor antagonists for hypertension, Dr. Dolan said.

“Many medications that are not recommended during pregnancy can be replaced with low-risk alternatives,” she wrote.

Dr. Broussard, who did the “safe lists” study, said in an interview, “We’ve heard about women seeing medications on these lists and deciding on their own that it’s O.K. to take them. “Women who are pregnant or even thinking about getting pregnant should talk directly to their doctors before taking anything. They should be sure they’re taking only what’s necessary for their health condition.”

A reliable online resource for both women and their doctors, Dr. Mitchell said, are fact sheets prepared by OTIS, the Organization of Teratology Information Specialists, which are continually updated as new facts become available: http://www.otispregnancy.org.

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State of the Art: A Review of Cookoo, G-Shock and Other Smartwatches

Clockwise from top left: The Cookoo, I'm Watch, Meta Watch, Casio G-Shock GB-6900 and Martian.

Every time you look, our computers have moved closer to us.

In the beginning, they existed only in corporate headquarters. Then came the desktop PC — three feet away. Then the laptop — one foot. Then the smartphone — in our pockets. What’s next — computers on our wrists?

Exactly. As though by silent agreement, the gadget industry seems to have decided that 2013 will be the year of the smartwatch.

The central idea is sound. You already have an iPhone or Android phone. Wouldn’t it be neat if your watch could communicate with it wirelessly?

Imagine: the watch could beep or vibrate whenever you get an incoming call, text message or e-mail. No more, “Sorry I didn’t get your call; my phone was in my backpack.” No more fumbling for your phone when that would be inconvenient or unsafe — like while you’re skiing, skateboarding or driving.

These watches can also make your phone beep loudly when it’s lost in the house. That’s much quicker than using Find My iPhone, which involves logging into a Web site.

They can also serve as a digital “leash”: if you wander away, accidentally leaving your phone on some restaurant table, the watch buzzes to warn you.

I tested the Meta Watch ($180), Cookoo ($130), Casio G-Shock GB-6900 ($180), Martian ($300), and I’m Watch ($400, coming in July). More contenders, like a Kickstarter favorite, Pebble Watch, are on the way. (The Martian, Cookoo and Meta Watch also began life on Kickstarter, the Web site where inventors seek financing from the public.) Even Apple is said to be toying with an iWatch.

The designs are all over the map. Some have touch screens. Some look like regular analog watches; others are basically iPod Nanos with straps. Some require daily charging; others take watch batteries.

They do have some things in common. First, these early smartwatches are thick and chunky — a desirable quality in a stew, maybe, but not for the delicate of wrist.

Second, they communicate with your phone over Bluetooth. You have to “pair” the watch to your phone on the first day — and whenever you exit Airplane Mode. Most models require a companion phone app for this purpose.

Most of these watches use Bluetooth 4.0, which means your phone will lose only a small amount of battery charge each day — maybe 5 or 10 percent — but only recent models, like the iPhone 4S and 5, are compatible.

Finally, the instruction manuals are terrible or nonexistent; it’s as if, in their zeal to make these things work, the companies forgot all about explaining it to you.

Wrists ready? Here we go.

CASIO G-SHOCK GB-6900 ($180). This watch closely resembles Casio’s other G-Shocks: popular, masculine, rugged, waterproof digitals.

But this one can beep or vibrate when calls or e-mail come to your iPhone (Android is in the works) — though not, alas, text messages. There’s no Caller ID; a cramped scrolling display says only “Incoming call.” For e-mail, the sender’s address scrolls slowly. You can dismiss these alerts with a double-tap on the glass — that’s the only thing this watch’s “touch screen” does.

The watch can also set itself as you cross time zones by checking in with your phone.

These limited functions are solid and power-stingy; one watch battery lasts two years. The watch has four buttons — the usual user-hostile digital watch assortment, like Mode, Adjust and Split/Reset — but they get the job done.

COOKOO WATCH ($130). The round face and analog hands offer spartan good looks; only the watch’s alarming thickness (three-quarters of an inch) and four edge buttons let you know that it’s not a Swatch.

There’s no screen. Instead, icons dimly appear on the watch’s black background as notifications of incoming calls, calendar reminders or Facebook posts. (E-mail and text notifications are coming soon, says the company.) If you want to know what they are or who they’re from, you have to get out your phone.

E-mail: pogue@nytimes.com

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