Well: No Consensus on Plantar Fasciitis

Phys Ed

Gretchen Reynolds on the science of fitness.

There are more charismatic-sounding sports injuries than plantar fasciitis, like tennis elbow, runner’s knee and turf toe. But there aren’t many that are more common. The condition, characterized by stabbing pain in the heel or arch, sidelines up to 10 percent of all runners, as well as countless soccer, baseball, football and basketball players, golfers, walkers and others from both the recreational and professional ranks. The Lakers star Kobe Bryant, the quarterback Eli Manning, the Olympic marathon runner Ryan Hall and the presidential candidate Mitt Romney all have been stricken.

But while plantar fasciitis is democratic in its epidemiology, its underlying cause remains surprisingly enigmatic. In fact, the mysteries of plantar fasciitis underscore how little is understood, medically, about overuse sports injuries in general and why, as a result, they remain so insidiously difficult to treat.

Experts do agree that plantar fasciitis is, essentially, an irritation of the plantar fascia, a long, skinny rope of tissue that runs along the bottom of the foot, attaching the heel bone to the toes and forming your foot’s arch. When that tissue becomes irritated, you develop pain deep within the heel. The pain is usually most pronounced first thing in the morning, since the fascia tightens while you sleep.

But scientific agreement about the condition and its causes ends about there.

For many years, “most of us who treat plantar fasciitis believed that it involved chronic inflammation” of the fascia, said Dr. Terrence M. Philbin, a board-certified orthopedic surgeon at the Orthopedic Foot and Ankle Center in Westerville, Ohio, who specializes in plantar fasciitis.

It was thought that by running or otherwise repetitively pounding their heels against the ground, people strained the plantar fascia, and the body responded with a complex cascade of inflammatory biochemical processes that resulted in extra blood and fluids flowing to the injury site, as well as enhanced pain sensitivity.

But instead of lasting only a few days and then fading, as acute inflammation usually does, the process can become chronic and create its own problems, causing tissue damage and continuing pain.

This progression is also what experts believed was happening when people developed chronic Achilles tendon pain, tennis elbow or other lingering, overuse injuries.

But when scientists actually biopsied fascia tissue from people with chronic plantar fasciitis, “they did not find much if any inflammation,” Dr. Philbin said. There were virtually none of the cellular markers that characterize that condition.

“Plantar fasciitis does not involve inflammatory cells,” said Dr. Karim Khan, a professor of family practice medicine at the University of British Columbia and editor of The British Journal of Sports Medicine, who has written extensively about overuse sports injuries.

Instead, plantar fasciitis more likely is caused by degeneration or weakening of the tissue. This process probably begins with small tears that occur during activity and that, in normal circumstances, the body simply repairs, strengthening the tissue as it does. That is the point of exercise training.

But sometimes, for unknown reasons, this ongoing tissue damage overwhelms the body’s capacity to respond. The small tears don’t heal. They accumulate. The tissue begins subtly to degenerate, even to shred. It hurts.

By and large, most sports medicine experts now believe that this is how we develop other overuse injuries, like tennis elbow or Achilles tendinopathy, which used to be called tendinitis. The suffix “itis” means inflammation. But since the injury isn’t thought to involve chronic inflammation, its name has changed.

This has not yet happened with plantar fasciitis, and may not, given what a mouthful fasciopathy would be.

The evolving medical opinions about plantar fasciitis matter, beyond nomenclature, though, because treatments depend on causes. At the moment, many physicians rely on injections of cortisone, a steroid that is both a pain reliever and anti-inflammatory, to treat plantar fasciitis. And cortisone shots do reduce the soreness. In a study published last year in BMJ, patients who received cortisone injections reported less heel pain after four months than those whose shots had contained a placebo saline solution.

But whether those benefits will last is unknown, especially if plantar fasciitis is, indeed, degenerative. In studies with people suffering from tennis elbow, another injury that is now considered degenerative, cortisone shots actually slowed tissue healing.

We need similar studies in people with plantar fasciitis, Dr. Khan said. “They have not been done.”

Thankfully, most people who develop plantar fasciitis will recover within a few months without injections or other invasive treatments, Dr. Philbin said, if they simply back off their running mileage somewhat or otherwise rest the foot and stretch the affected tissues. Stretching the plantar fascia, as well as the Achilles tendon, which also attaches to the heel bone, and the hamstring muscles seems to result in less strain on the fascia during activity, meaning less ongoing trauma and, eventually, time for the body to catch up with repairs.

To ensure that you are stretching correctly, Dr. Philbin suggests consulting a physical therapist, after, of course, visiting a sports medicine doctor for a diagnosis. Not all heel or arch pain is plantar fasciitis. And comfort yourself if you do have the condition with the knowledge that Kobe Bryant, Eli Manning and Ryan Hall have all returned to competition and Mr. Romney still runs.

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Boeing Engineers Approve Pact, but Tech Workers Say No

SEATTLE (AP) — It's a split decision from the union representing Boeing Co.'s engineers and technical workers.

The engineers voted Tuesday to accept the aerospace company's four-year contract offer while technical workers rejected it and authorized a future strike.

Bill Dugovich of the Society of Professional Engineering Employees in Aerospace says the votes mean the new contract for the 15,550 engineers is in place.

He says negotiators hope to resume contract talks soon on behalf of the 7,400 technical workers.

A strike by the technical workers is not imminent, but Dugovich says the negotiating team is now authorized to call one. Engineers and technical workers work on plans for planes and solve problems that arise on the factory floor.

Boeing did not comment.

SPEEA last went on strike for 40 days in 2000.

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Complaint alleges racial bias in Palmdale elections

Latinos and African Americans make up about two-thirds of the population of Palmdale. But since the city's incorporation in August 1962, not a single black resident and only one Latino has ever served on the City Council.

That's the backdrop of a complaint filed in Los Angeles County Superior Court by Antelope Valley civil rights activists alleging racial bias in city elections in this High Desert locale. The complaint argues that Palmdale's system of at-large council seats dilutes the influence of minority voters.

"Latinos and African Americans are locked out of the political system in the city of Palmdale," said Malibu attorney Kevin Shenkman, who is representing plaintiff Juan Jauregui, a Palmdale resident. Three local black activists and the NAACP have also said they will join the case, scheduled to go to trial in May.

The litigation is the latest in a series of racially themed conflicts in the Antelope Valley as blacks and Latinos have moved into once mostly white areas. Housing programs and police practices have been flash points as activists have challenged policies they perceive as unfairly targeting minority residents.

Plaintiffs say the city's at-large election system violates the state's 2001 Voting Rights Act, which guards against disenfranchisement of minorities. They seek a change to district-by-district voting.

Palmdale is fighting back. In court documents, city attorneys argue that because blacks and Latinos are a majority of registered voters in the city, they are "in a position, numerically" to elect the mayor and City Council members.

The lawyers also insist that district voting would not have helped minority candidates who lost. "They simply had very little support from voters, and no drawing or gerrymandering of districts would have resulted in a district which would have elected them," the attorneys said.

Moreover, in November 2001 Palmdale's residents voted against a measure to introduce district voting. City Atty. Wm. Matthew Ditzhazy said via email that "ultimately it was the community's decision to make."

In a recent deposition, James Ledford, who has been elected the city's mayor 11 times since 1992, said he did not even know the race of his fellow council members and was not aware that all but one had been white.

Asked whether it bothered him "in any way that racial minorities in Palmdale might feel that they are not being represented in the City Council," Ledford said no.

Ledford declined to be interviewed for this article, although in the past he has said he favored district voting.

Traditionally, low voter turnout among blacks and Latinos in Palmdale's municipal elections has shrunk their voting power compared with that of whites, who turn out in greater numbers, statistics show.

The majority of Palmdale Latinos voted yes for district elections in 2001, but the measure was defeated because 66% of whites opposed it, according to data compiled by a city consultant and cited by Shenkman.

Similarly, in 2009, when V. Jesse Smith, president of the Antelope Valley chapter of the NAACP, ran for City Council, he split the Latino vote 49% to 51% with Steve Fox, who is white. But neither won a council seat. The spots went to white candidates Tom Lackey and Laura Bettencourt, who scored heavily among whites, although neither got a single Latino vote, Shenkman said.

Shenkman acknowledged the poor voting record of minority groups, but he blamed the system of at-large voting. Blacks and Latinos didn't vote because they had "grown to understand that their vote doesn't matter," he said.

At least a dozen government entities in California, including cities, school districts and county boards, have been sued under the state's Voting Rights Act, said Shenkman. Some cases are still pending, others have ended in settlements resulting in district elections, he said.

One of those was Compton, which placed the issue on the ballot last June to settle a lawsuit. Voters approved the switch from at-large to district voting. The change may give Latinos — who make up a majority of the city's population but a minority of eligible voters — a greater chance of putting the first Latino on the City Council in April.

For supporters of district voting in Palmdale, the claim represents a new effort to shake up the political status quo in the Antelope Valley. They say it will make city representatives more accountable to voters.

But Richard Loa, an attorney who in 2001 became the only Latino ever to win a council seat in Palmdale, said that although he supported Latinos' push for representation, he opposes resolving the issue through litigation.

"The important thing is to have effective leadership," said Loa, who has said he will run again.

Race isn't everything, agreed Darren Parker, who as chairman of the California Democratic Party's African American caucus helps recruit potential minority candidates to run for local office, but he said High Desert cities need black voices in leadership.

"I don't believe that anyone who doesn't get up in the morning and look like me can really walk in my shoes," Parker said.

Among the lawyers representing the plaintiffs is attorney R. Rex Parris, mayor of neighboring Lancaster, which uses at-large elections but is weighing a change.

Lancaster's population is about 40% Latino and 20% African American, but the City Council has four white men and one Latina. The city has also faced charges of racial bias, but Lancaster has a track record of minority representation on its council, including an African American who twice served as mayor.

Lilia Galindo, who has used her Palmdale-based Café Con Leche radio talk show to encourage Latinos to get out and vote, said High Desert Latinos were eager to find their political voice. District elections would help, she said.

"We've started to realize how important it is to express our rights as citizens," Galindo said.

ann.simmons@latimes.com

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National Briefing | South: Abortion Curbs Clear Senate in Arkansas

The State Senate voted 25 to 7 on Monday to ban most abortions 20 weeks into a pregnancy. The measure goes back to the House to consider an amendment that added exceptions for rape and incest. The legislation is based on the belief that fetuses can feel pain 20 weeks into a pregnancy, and is similar to bans in several other states. Opponents say it would require mothers to deliver babies with fatal conditions. Gov. Mike Beebe has said he has constitutional concerns about the proposal but has not said whether he will veto it.

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Japan Finds Swelling in Second Boeing 787 Battery

TOKYO (Reuters) - Cells in a second lithium-ion battery on a Boeing Co 787 Dreamliner forced to make an emergency landing in Japan last month showed slight swelling, a Japan Transport Safety Board (JTSB) official said on Tuesday.

The jet, flown by All Nippon Airways Co, was forced to make the landing after its main battery failed.

"I do not know the exact discussion taken by the research group on the ground, but I heard that it is a slight swelling (in the auxiliary power unit battery cells). I have so far not heard that there was internal damage," Masahiro Kudo, a senior accident investigator at the JTSB said in a briefing in Tokyo.

Kudo said that two out of eight cells in the second battery unit showed some bumps and the JTSB would continue to investigate to determine whether this was irregular or not.

The plane's auxiliary power unit (APU) powers the aircraft's systems when it is on the ground. National Transportation Safety Board investigators in the United States are probing the APU from a Japan Airlines plane that caught fire at Boston's Logan airport when the plane was parked.

The U.S. Federal Aviation Authority grounded all 50 Boeing Dreamliners in commercial service on January 16 after the incidents with the two Japanese owned 787 jets.

The groundings have cost airlines tens of millions of dollars, with no solution yet in sight.

Boeing rival Airbus said last week it had abandoned plans to use lithium-ion batteries in its next passenger jet, the A350, in favor of traditional nickel-cadmium batteries.

Lighter and more powerful than conventional batteries, lithium-ion power packs have been in consumer products such as phones and laptops for years but are relatively new in industrial applications, including back-up batteries for electrical systems in jets.

(Reporting by Mari Saito; Editing by Richard Pullin)

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Seawater desalination plant might be just a drop in the bucket

CARLSBAD, Calif. — Dreamers have long looked to the Pacific Ocean as the ultimate answer to California's water needs: an inexhaustible, drought-proof reservoir in the state's backyard. In the last decade, proposals for about 20 desalting plants have been discussed up and down the coast.

But even with construction about to begin on the nation's largest seawater desalination facility, 35 miles north of San Diego, experts say it is doubtful that dream will ever be fully realized.

"While this Poseidon adventure may work out, I don't look for a lot of that," said Henry Vaux Jr., a UC Berkeley professor emeritus of resource economics who contributed to a 2008 National Research Council report on desalination.

The reasons boil down to money and energy. It takes a lot of both to turn ocean water into drinking water, driving the average price of desalinated supplies well above most other sources.

The purified water produced by the Poseidon Resources plant will cost the San Diego County Water Authority more than twice what it now pays the Metropolitan Water District of Southern California for supplies from Northern California and the Colorado River. Over the authority's 30-year contract with Poseidon, San Diego County ratepayers will pay between $3 billion and $4 billion for the desalted water, which is expected to provide no more than a tenth of their overall supply.

Seawater desalination is not new to California. There are number of small coastal plants, used mostly for research or industrial purposes, and a few, such as one on Catalina Island, that provide municipal supplies.

For reasons unique to the region, San Diego County will be the first to stick a big straw into the Pacific. It is at the end of the line for imported water, doesn't have much local groundwater and is perennially battling with Metropolitan, Southern California's wholesaler of imported supplies.

"I do believe it is worth it," said Tom Wornham, board chairman of the county water authority. "I would rather be apologizing to people in 10 years for the rate than the fact they would have no water."

Up the coast, other places have taken a pass on the Pacific. Los Angeles and Long Beach recently shelved seawater desalting plans after concluding that other water sources, such as conservation or recycling, are cheaper and easier to pursue.

Poseidon, a small, privately held company based in Stamford, Conn., started talking about developing a desalination plant in Carlsbad in late 1998. The road to construction has been so long and twisting that Global Water Intelligence, which covers the international water industry, last year listed the project among the "Top 10 Desalination Disasters" of all time.

It took years for the company to get the necessary state and local permits. Environmentalists filed multiple legal challenges, the last of which was only recently resolved in Poseidon's favor. A deal with a number of local water agencies in San Diego County fell apart.

In the end, the Poseidon supplies — up to 56,000 acre-feet a year — will sell for roughly $2,000 an acre-foot, more than double the company's 2004 estimate. (One acre-foot is enough to supply two average homes for a year.) The price will rise with inflation; if energy costs go up, so will the price of water.

On the other side of the Pacific, Australia offers a sobering lesson in the perils of diving too deeply into desalination.

When years of withering drought emptied the country's reservoirs, Australia commissioned six big coastal desalting plants, including some of the world's largest. Then the rains returned. Just as some of the operations were coming on line, they were no longer needed.

Four of the six plants are being idled because cheaper water is available. Australian politicians are bemoaning the desalination binge, complaining that it saddled ratepayers with "hyper-expensive" white elephants they have to pay for regardless of whether the plants are used.

"That's certainly the risk — that we build them when they're not necessary or we build them, frankly, too soon," said Heather Cooley of the Pacific Institute, an Oakland think tank.

Santa Barbara had a similar experience in the early 1990s, when it built a desalination plant during a severe statewide drought that ended before the facility was finished. The $34-million plant, with a tenth of the capacity of the Carlsbad facility, was never used beyond the testing phase, though it could still be brought into service in an emergency.

The $954-million Carlsbad project is being financed with $781 million in tax-exempt construction bonds sold by Poseidon and the water authority. The balance is coming from investors who anticipate a return of about 13%. IDE Americas Inc., the subsidiary of an Israeli firm that runs some of the world's largest coastal desalination facilities in the Middle East, has been hired to design and operate the plant, slated for completion in 2016.

The fresh water will be produced through reverse osmosis, an energy-intensive process that separates salts and contaminants from seawater by forcing it through sand filters and tightly coiled, synthetic membranes peppered with billions of tiny holes a fraction of the width of a human hair. The water will then be pumped inland for distribution — the opposite direction that drinking supplies are usually moved — requiring construction of a 10-mile underground pipeline that the water authority will own and operate.

Poseidon chose the Carlsbad location, next to the Encina Power Station, so it could draw from the power plant's cooling water discharge — thus avoiding the environmental harm of operating its own ocean intake.

But new federal and state environmental regulations are pushing coastal power plants to phase out the use of huge volumes of ocean water for cooling, thwarting that strategy. Poseidon expects the Encina station to be replaced within the decade with a new generating facility employing a different cooling system.

That will mean the desalter will have to pump directly from the ocean, sucking 300 million gallons a day. Of that, 100 million gallons will go through the reverse osmosis process, with half converted to fresh water and half to a concentrated brine. The brine, twice as salty as the sea, will be diluted in a mixing pool with the other 200 million gallons of intake and discharged to the ocean.

Destruction of marine life is a major environmental concern of ocean desalination. Raw seawater is full of tiny organisms, including plankton that form a critical part of the food chain and the young stages of fish and invertebrates. When the water they live in is pumped into a plant, they die.

The Coastal Commission is requiring Poseidon to restore 55 acres of marine wetlands in south San Diego Bay to compensate for the plant's projected effects. The State Water Resources Control Board is also developing new seawater desalination regulations that could force Poseidon to change its intake and discharge systems.

"They took a big risk in building this before the rules are finalized," said Joe Geever of the Surfrider Foundation, which tenaciously fought the Carlsbad proposal in court and argues that water agencies should turn to the ocean only as a last resort — after more environmentally benign sources such as recycling and storm-water capture have been aggressively pursued.

Poseidon, which is trying to line up customers for a similar-size desal plant proposed in Huntington Beach, says it is peddling more than water. "What we're selling is ... a reliability premium that's locally controlled, drought-proof," said Carlos Riva, the company's chief executive.

But even Poseidon doesn't predict that the Pacific will become California's dominant water supply. The state has too many other sources.

"We have quite a bit of water to move around," said Peter MacLaggan, the Poseidon executive who is overseeing the Carlsbad project. "I don't think it's ever going to be a majority of supply or anywhere close to that."

bettina.boxall@latimes.com

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<cite>Halo</cite> Creator Unveils Its Next Masterpiece, a Persistent Online World

"Citadel": Concept art from Bungie's Destiny.

BELLEVUE, Washington — Destiny, the new game from the creator of Halo, isn’t just another shooter. It’s a persistent online multiplayer adventure, designed on a galactic scale, that wants to become your new life.

“It isn’t a game,” went the oft-heard tagline at a preview event on Wednesday. “It’s a world where the most important stories are told by the players, not written by the developers.”

This week, Bungie Studios invited the press into its Seattle-area studio to get the first look at Destiny. Although the event was a little short on details — Bungie and Activision didn’t reveal the launch date, handed out concept art instead of screenshots, and dodged most of my questions — it gave an intriguing glimpse at what the creator of Halo believes is the future of shooters.

Bungie was acquired by Microsoft in 2000, and its insanely popular shooter was the killer app that put the original Xbox on the map. Bungie split off from its corporate parent in 2007, and Microsoft produced Halo 4 on its own last year. The development studio partnered up with mega-publisher Activision for its latest project, which was kept mostly secret until now.

Destiny, slated for release on PlayStation 3 and Xbox 360, isn’t exactly an MMO. Activision CEO Eric Hirshberg called it a “shared-world shooter” — multiplayer and online, but something less than massive.

“We’re not doing this just because we have the tech,” Hirshberg said. “We have a great idea, and we’re letting the concept lead the tech.”

Built with new development software created specifically for Destiny, this new game is set in Earth’s solar system and takes place after a mysterious cataclysm wipes out most of humanity. The remaining survivors create a “safe zone” underneath a mysterious alien sphere called “The Traveler.”

The enigmatic sphere imparts players with potent weapons, magic-like powers and defensive technology. Thanks to these gifts, people have begun reclaiming the solar system from alien invaders that moved in while humanity was down.

Bungie fired off a list of design principles that guide Destiny’s creation: Create a world players want to be in. Make it enjoyable by players of all skill levels. Make it enjoyable by people who are “tired, impatient and distracted.” In other words, you don’t have to be loaded for bear and pumped for the firefight of your life every time you log on to Destiny.

After this brief overview, writer/director Joseph Staten used concept art and narration to outline an example of what a typical Destiny player’s experience might be.

Beginning in the “safe zone,” a player would start out from their in-game home and walk into a large common area. From here, the player would be able to explore their surroundings and meet up with friends. Then, they might board their starships and fly to another planet, let’s say Mars, in order to raid territory held by aliens.

During this raid, other real players who traveled to the same zone (like visiting a particular server on an MMO) would be free to come and go as they please. For example, a random participant could simply walk on by. They could stop and observe. Or they could get involved in the fight. In this instance, Staten suggested that a passerby would join the raid and then break off from the group after the spoils were divvied up without any user interface elements to fuss with. Walk away, and it’s done.

Bungie made a point of saying several times over that Destiny will not have any “lobby”-type interfaces, or menus from which to choose from a list of quests. Instead, players will simply immerse themselves in the world and organically choose to participate in whatever activities they stumble upon. Bungie promised solo content, cooperative content, and competitive content, though it provided no further examples of these.

The developer said that by employing very specialized artificial intelligence working entirely behind the scenes, players will encounter other real players who are best suited for them to interact with, based on their experience levels and other factors.

Staten didn’t say how many players would be able to exist in the world at the same time, but said that characters will be placed in proximity to each other based on very specific criteria, not simply to “fill the world up.”

Bungie showed off three distinct character classes throughout the day’s presentations: Hunter, Titan and Warlock. Although no differences were outlined between them apart from the Warlock being able to use a kind of techno-magic, the developer was keen to emphasize the idea that each character in Destiny would be highly customized and unique, and will grow with the player over an extended period of time.

While many games make the same promise, Destiny’s vision of “an extended period of time” isn’t 100 hours. It’s more like 10 years.

Bungie’s plan is for the Destiny story to unfold gradually over the course of 10 “books,” each with a beginning, middle and end. Through this will run an overarching story intended to span the entire decade’s worth of games, although like many other topics covered during the day, Bungie gave little detail about how this will work.

The developer spent a lot of time emphasizing its claim that no game has been made at this scale before. Bungie says it has a whopping 350 in-house developers working on Destiny.

Senior graphics architect Hao Chen gave examples of the sort of impenetrable mathematics formulas that allow Bungie to craft environments and worlds at a speed that it claims was previously impossible.

Bungie’s malleable team system was also said to increase its output. With the ability to co-locate designers, artists, and engineers at any time, Bungie says it can go through exceptionally rapid on-the-spot iteration and improvement for each facet of the game.

Apart from highly improved technology and the basic concept of humanity taking back the solar system, there’s just not a lot of hard information on Destiny at the moment. One thing that was made quite clear is that the game will not be subscription-based. Every presenter was clear in stating that players will not pay a monthly fee to participate in this persistent world.

While fees may not be required, a constant connection to the Internet will be. Since the core concept of Destiny is exploring a world that exists outside of the player’s console and is populated by real people at all times, it “will need to be connected in order for someone to play,” said Bungie chief operating officer Pete Parsons.

Representatives from both Bungie and Activision gave vague answers when Wired pressed for further details, often stating that they “were not ready” to discuss specifics. Whether that means those things are still being kept from the press, or whether they have not yet been determined by the development team, was unclear.

Questions currently unanswered: How will players communicate? How will players interact with each other outside of combat? What content exists in the non-combat “safe zones”? Subscriptions may be out, but what about in-app purchases? Will player versus player combat be available? Will the game ship on a disc or be download only? Will its persistent world allow Xbox and PlayStation gamers to play together? What content and interactions will be possible via smartphones and tablets (which Bungie alluded to)? Will the fancy new tools be licensed to other developers?

And so on.

For now, Bungie is asking us to take it for granted that it will execute on a bold 10-year plan for a very different sort of shooter. In the history of the always-changing gaming industry, no one’s ever been able to pull off a 10-year plan for anything. Can Bungie do it?

Hey… they made Halo, right?

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Country singer Mindy McCready dead in apparent suicide

LITTLE ROCK, Arkansas (Reuters) – Country music star Mindy McCready, whose albums include “Ten Thousand Angels” and “If I Don’t Stay the Night,” was found dead on Sunday of an apparent self-inflicted gunshot wound, an Arkansas sheriff said. She was 37.

McCready’s body was found on the porch of a house in Heber Springs, Arkansas, on Sunday afternoon. She was pronounced dead at the scene “from what appears to be a single self-inflicted gunshot wound,” the Cleburne County Sheriff’s Office said in a statement.

Deputies had been dispatched to the area following reports of “shots fired,” the sheriff’s office said, adding that McCready’s family had been notified.

Florida-born McCready moved to Nashville, Tennessee, to break into the country music business at the age of 18, according to allmusic.com.

She achieved early success with her 1996 debut album, “Ten Thousands Angels,” which sold a reported 2 million copies. Four other studio albums followed.

While successful in her career, McCready’s personal life had began to unravel in recent years.

In 2004 she was convicted of prescription drug fraud and placed on parole. Three years later she spent time in jail for violating her parole terms.

The sheriff’s office said McCready’s body would be taken to the Arkansas State Crime Lab for an autopsy, adding that “the matter will be fully investigated.”

(Writing by Tim Gaynor in Phoenix; Additional reporting by James B. Kelleher in Chicago; Editing by Eric Beech)

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Well: Health Effects of Smoking for Women

The title of a recent report on smoking and health might well have paraphrased the popular ad campaign for Virginia Slims, introduced in 1968 by Philip Morris and aimed at young professional women: “You’ve come a long way, baby.”

Today that slogan should include: “…toward a shorter life.” Ten years shorter, in fact.

The new report is one of two rather shocking analyses of the hazards of smoking and the benefits of quitting published last month in The New England Journal of Medicine. The data show that “women who smoke like men die like men who smoke,” Dr. Steven A. Schroeder, a professor of health and health care at the University of California, San Francisco, wrote in an accompanying editorial.

That was not always the case. Half a century ago, the risk of death from lung cancer among men who smoked was five times higher than that among women smokers. But by the first decade of this century, that risk had equalized: for both men and women who smoked, the risk of death from lung cancer was 25 times greater than for nonsmokers, Dr. Michael J. Thun of the American Cancer Society and his colleagues reported.

Today, women who smoke are even more likely than men who smoke to die of lung cancer. According to a second study in the same journal, women smokers face a 17.8 times greater risk of dying of lung cancer than women who do not smoke; men who smoke are at 14.6 times greater risk to die of lung cancer than men who don’t. Women who smoke now face a risk of death from lung cancer that is 50 percent higher than the estimates reported in the 1980s, according to Dr. Prabhat Jha of the Center for Global Health Research in Toronto and his colleagues.

After controlling for age, body weight, education level and alcohol use, the new analysis found something else: men and women who continue to smoke die on average 10 years sooner than those who never smoked.

Dramatic progress has been made in reducing the prevalence of smoking, which has fallen from 42 percent of adults in 1965 (the year after the first surgeon general’s report on smoking and health) to 19 percent in 2010. Yet smoking still results in nearly 200,000 deaths a year among people 35 to 69 years old in the United States. A quarter of all deaths in this age group would not occur if smokers had the same risk of death as nonsmokers.

The risks are even greater among men 55 to 74 and women 60 to 74. More than two-thirds of all deaths among current smokers in these age groups are related to smoking. Over all, the death rate from all causes combined in these age groups “is now at least three times as high among current smokers as among those who have never smoked,” Dr. Thun’s team found.

While lung cancer is the most infamous hazard linked to smoking, the habit also raises the risk of death from heart disease, stroke, pulmonary disease and other cancers, including breast cancer.

Furthermore, changes in how cigarettes are manufactured may have increased the dangers of smoking. The use of perforated filters, tobacco blends that are less irritating, and paper that is more porous made it easier to inhale smoke and encouraged deeper inhalation to achieve satisfying blood levels of nicotine.

The result of deeper inhalation, Dr. Thun’s report suggests, has been an increased risk of chronic obstructive pulmonary disease, or C.O.P.D., and a shift in the kind of lung cancer linked to smoking. Among nonsmokers, the risk of death from C.O.P.D. has declined by 45 percent in men and has remained stable in women, but the death rate has more than doubled among smokers.

But there is good news, too: it’s never too late to reap the benefits of quitting. The younger you are when you stop smoking, the greater your chances of living a long and healthy life, according to the findings of Dr. Jha’s international team.

The team analyzed smoking and smoking-cessation histories of 113,752 women and 88,496 men 25 and older and linked them to causes of deaths in these groups through 2006.

Those who quit smoking by age 34 lived 10 years longer on average than those who continued to smoke, giving them a life expectancy comparable to people who never smoked. Smokers who quit between ages 35 and 44 lived nine years longer, and those who quit between 45 and 54 lived six years longer. Even quitting smoking between ages 55 and 64 resulted in a four-year gain in life expectancy.

The researchers emphasized, however, that the numbers do not mean it is safe to smoke until age 40 and then stop. Former smokers who quit by 40 still experienced a 20 percent greater risk of death than nonsmokers. About one in six former smokers who died before the age of 80 would not have died if he or she had never smoked, they reported.

Dr. Schroeder believes we can do a lot better to reduce the prevalence of smoking with the tools currently in hand if government agencies, medical insurers and the public cooperate.

Unlike the races, ribbons and fund-raisers for breast cancer, “there’s no public face for lung cancer, even though it kills more women than breast cancer does,” Dr. Schroeder said in an interview. Lung cancer is stigmatized as a disease people bring on themselves, even though many older victims were hooked on nicotine in the 1940s and 1950s, when little was known about the hazards of smoking and doctors appeared in ads assuring the public it was safe to smoke.

Raising taxes on cigarettes can help. The states with the highest prevalence of smoking have the lowest tax rates on cigarettes, Dr. Schroeder said. Also helpful would be prohibiting smoking in more public places like parks and beaches. Some states have criminalized smoking in cars when children are present.

More “countermarketing” of cigarettes is needed, he said, including antismoking public service ads on television and dramatic health warnings on cigarette packs, as is now done in Australia. But two American courts have ruled that the proposed label warnings infringed on the tobacco industry’s right to free speech.

Health insurers, both private and government, could broaden their coverage of stop-smoking aids and better publicize telephone quit lines, and doctors “should do more to stimulate quit attempts,” Dr. Schroeder said.

As Nicola Roxon, a former Australian health minister, put it, “We are killing people by not acting.”

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Allure of Self-Insurance Draws Concern Over Costs

WASHINGTON — Federal and state officials and consumer advocates have grown worried that companies with relatively young, healthy employees may opt out of the regular health insurance market to avoid the minimum coverage standards in President Obama’s sweeping law, a move that could drive up costs for workers at other companies.

Companies can avoid many standards in the new law by insuring their own employees, rather than signing up with commercial insurers, because Congress did not want to disrupt self-insurance arrangements that were seen as working well for many large employers.

“The new health care law created powerful incentives for smaller employers to self-insure,” said Deborah J. Chollet, a senior fellow at Mathematica Policy Research who has been studying the insurance industry for more than 25 years. “This trend could destabilize small-group insurance markets and erode protections provided by the Affordable Care Act.”

It is not clear how many companies have already self-insured in response to the law or are planning to do so. Federal and state officials do not keep comprehensive statistics on the practice.

Self-insurance was already growing before Mr. Obama signed the law in 2010, making it difficult to know whether the law is responsible for any recent changes. A study by the nonpartisan Employee Benefit Research Institute found that about 59 percent of private sector workers with health coverage were in self-insured plans in 2011, up from 41 percent in 1998.

But experts say the law makes self-insurance more attractive for smaller employers. When companies are self-insured, they assume most of the financial risk of providing health benefits to employees. Instead of paying premiums to insurers, they pay claims filed by employees and health care providers. To avoid huge losses, they often sign up for a special kind of “stop loss” insurance that protects them against very large or unexpected claims, say $50,000 or $100,000 a person.

Such insurance serves as a financial backstop for the employer if, for example, an employee is found to have cancer, needs an organ transplant or has a premature baby requiring intensive care.

In a report to clients last year, SNR Denton, a law firm, wrote, “Faced with mandates to offer richer benefits with less cost-sharing, small and midsize employers in particular are increasingly considering self-insuring.”

Officials from California, Maine, Minnesota, Utah, Washington and other states expressed concern about the potential proliferation of these arrangements at a recent meeting of the National Association of Insurance Commissioners.

Stop-loss insurers can and do limit the coverage they provide to employers for selected employees with medical problems. As a result, companies with less healthy work forces may find self-insuring more difficult.

Christina L. Goe, the top lawyer for the Montana insurance commissioner, said that stop-loss insurance companies were generally “free to reject less healthy employer groups because they are not subject to the same restrictions as health insurers.”

Insurance regulators worry that commercial insurers — and the insurance exchanges being set up in every state to offer a range of plan options to consumers — will be left with disproportionate numbers of older, sicker people who are more expensive to insure.

That, in turn, could drive up premiums for uninsured people seeking coverage in the exchanges. Since the federal government will subsidize that coverage, it, too, could face higher costs, as would some employees and employers in the traditional insurance market.

Large employers with hundreds or thousands of employees have historically been much more likely to insure themselves because they have cash to pay most claims directly.

Now, employee benefit consultants are promoting self-insurance for employers with as few as 10 or 20 employees.

Raeghn L. Torrie, the chief financial officer of Autonomous Solutions, a developer of robotic equipment based in Petersboro, Utah, said her business started a self-insured health plan for its 44 employees on Jan. 1 as a way to cope with the uncertainties created by the new law.

“We have a pretty young, healthy group of employees,” she said.

In Marshfield, Mo., J. Richard Jones, the president of Label Solutions, an industrial label-printing company with 42 employees, said he switched to a self-insurance plan this year “to hold down costs that were going up because of government regulation under Obamacare.”

The Township of Freehold, N.J., made a similar decision in January to gain more control over benefits and costs for its 260 employees.

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