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Monday, May 12, 2008

That Must Be Bob. I Hear His New Hip Squeaking.


Right, Dr. William Walter

Susan O’Toole’s artificial hip developed a squeak, a problem with ceramic parts. Used components show areas of friction.

The first time John L. Johnson’s artificial hip squeaked, he was bending down to pick up a pine cone in his yard in Thomasville, Ga. Mr. Johnson looked up, expecting to find an animal nearby.

Susan O’Toole, a nutritionist at Montefiore Medical Center in the Bronx, who first squeaked going up stairs after getting home from her hip-replacement surgery in 2005, said she thought the banister she was gripping needed repair.

And Edward Heary, an apprentice appraiser in Hatboro, Pa., said clients sometimes look with embarrassment or concern at their floorboards when he walks though their homes.

As all three patients — and hundreds of others — discovered once they pinpointed the source of the noises, they had become guinea pigs in an unfolding medical mystery. Their artificial hips are made of ceramic materials that were promoted as being much more durable than older models. But for reasons not yet fully understood, their hips started to squeak, raising questions about whether the noises herald more serious malfunctions.

“There is something amiss here,” said Dr. Douglas E. Padgett, chief of adult reconstructive and joint replacement service at the Hospital for Special Surgery in New York. More than 250,000 Americans get total hip implants each year, a procedure that generally costs close to $45,000. Hip replacements have a success rate of more than 90 percent, based on patients’ achieving relatively pain-free mobility after recovery periods that range from a few months to a year.

Any artificial hip can occasionally make a variety of noises. But until Stryker, a medical products company, began marketing highly durable ceramic hips in the United States in 2003, squeaking was extremely rare.

Now, tens of thousands of ceramic hips later — from Stryker and other makers that entered the field — many patients say their squeaking hips are interfering with daily life. One study in the Journal of Arthroplasty found that 10 patients of 143 who received ceramic hips from 2003 to 2005, or 7 percent, developed squeaking. Meanwhile, no squeaks occurred among a control group of 48 patients who received hips made of metal and plastic. “It can interrupt sex when my wife starts laughing,” said one man, who discussed the matter on the condition that he not be named.

Beyond annoyance and embarrassment, many patients and their surgeons fear that the squeaky ceramic hips may signal that the joints are wearing out prematurely. That could force patients to undergo the very operation — a second replacement of the same hip joint — they had hoped to avoid by choosing ceramics.

Already, dozens of patients have elected to endure subsequent surgeries to replace the noisy hips. Some have sued Stryker, the pioneer and market leader, which some doctors say has been slow to take their patients’ concerns seriously.

Last fall, the Food and Drug Administration issued a warning to Stryker, saying it had failed to take the steps needed to prevent squeaking and other problems. Clouding things further, Stryker last year recalled ceramic hip parts made at its factory in Cork, Ireland, after determining that some did not meet its sterility specifications.

Stryker says that none of the problems underlying the recall or the warning letter from the F.D.A. reflect problems that cause squeaking, which it contends occurs in less than 1 percent of implants.

Whatever the actual frequency, some investigators who have looked at the problem say the squeaking seems to be associated with extreme flexing of the ceramic implants, but exactly how is unclear. In X-rays, many of the squeaking hips appear to be perfectly aligned. Nor is there a clear relationship between squeaking and hip pain or other conditions some patients say they have encountered, like the sensation that the hip disengages slightly when a patient walks.

Some patients squeak even they are walking normally, like Ms. O’Toole or Michael Mueller, a software executive in Scottsdale, Ariz. Mr. Mueller is so frustrated with squeaks, pain and popping noises for which he blames his ceramic hip that he has displayed his problem on YouTube.

While there have been no reported cases of serious mishaps, some surgeons fear that the ceramic material might shatter at some point, leaving a patient with so many inflammatory shards in the hip that a doctor could never find them all.

“Catastrophic failure has been a concern in the past, with older ceramic components,” said Dr. James M. Bried, a surgeon in Poway, Calif. Ceramic materials have been used since the 1960s. Dr. Bried, who implanted Mr. Mueller’s hip last year, said he was concerned that squeaking might be “a harbinger of something similar.”

Mr. Mueller said Dr. Bried had told him to consider getting the hip replaced “sooner rather than later.”

Stryker says such fears are overblown.

“It is important to keep this in perspective,” said Aaron R. Kwittken, a spokesman for Stryker. “Published research shows squeaking is rare compared with other total-hip-related risks like infection, dislocation and leaving patients with uneven leg length.”

But plaintiffs lawyers, who have already filed scores of lawsuits on behalf of ceramic hip patients, are gearing up to argue that squeaking is not a minor problem for many who experience it.

“We’re in the infancy of this,” said Douglass A. Kreis, a personal injury lawyer in Pensacola, Fla., whose clients include Ms. O’Toole and Mr. Johnson, who has had his ceramic hip replaced.

Most artificial hips, whatever material they are made of, share a basic design: a socket implanted in the pelvis, into which a spherical head is fitted. The head is attached to a spike that is driven into the femur, or thigh bone, to anchor it.

Durability is paramount with artificial hips. Patients worry that they will outlive their artificial hips and require a second, more extensive and even more expensive procedure at an age when their bodies may be less able to cope with the trauma. Ceramic hips were promoted as lasting much longer than the 15 years or so for conventional artificial joints made of steel and plastic.

Now that the squeaking has raised caution flags, researchers are weighing the noted durability of ceramic-on-ceramic hip joints like Stryker’s Trident model against products with other combinations of materials.

Each combination has known or suspected drawbacks. Metal-on-metal devices, for instance, slowly shed tiny ionized particles that some researchers say might promote cancer. And even the newest plastics are still not as durable as other materials, raising the risks of fragments that can lead to bone-destroying inflammations.

For patients who have already received ceramic hips that have started to squeak, many orthopedic surgeons advise nothing more than watchful waiting unless there are also signs that the hip is slipping out of place or that ceramic particles are breaking loose from the head or the socket. Doctors who have removed ceramic hips say they find dark stripes that indicate accelerated wear on the ceramic heads. But durability tests have suggested that even those extracted hips would have outlasted conventional metal-and-plastic replacement joints, according to researchers.

“There is no evidence that the wear associated with squeaking would lead systems to fail,” said Dr. James A. D’Antonio, an orthopedic surgeon outside Pittsburgh, who was a chief investigator on the clinical trials that led to regulatory approval for Stryker’s Trident.

Dr. D’Antonio, whose longstanding role in Stryker’s product development efforts earned him $1.1 million in consulting payments from the company last year, said he had implanted 400 Tridents since the clinical trials began in 1996. He said that only four of his patients had noticed squeaks and that none of them were able to reproduce them in his office.

But Dr. Fabio Orozco, a surgeon at the Rothman Institute, a major orthopedics group in Philadelphia, said that a recently completed review of about 1,500 Rothman patients with ceramic hips had found that the squeaking condition occurred in 49 of them, or about 3 percent.

“I’m very hesitant to use ceramic-on-ceramic now,” Dr. Orozco said, “unless we are talking about somebody very young.”

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Teenagers to take embarrassing ailments to Second Life doctors

Spanish health authorities launched a virtual portal through the Second Life website yesterday designed to help young people too embarrassed to speak to a doctor about sexually transmitted disease or a drug problem.

Real doctors will log on and offer advice to their anonymous patients. What both will see is an image of a consulting room with a doctor and a typical patient.

Dr Rosario Jimènez, of the Adolescent Attention Working Group, is one of the doctors who will spend up to four hours a week answering their virtual patients' questions.

She said: "Teenagers do not often go to see the doctor but this is an efficient and amusing tool to reach them because we can both use the same route. Even though they do not often suffer serious illnesses, they often expose themselves to risks which can develop into problems in the future.

"This is a way to talk about their doubts about taking drugs or sexual relations which they cannot do in a traditional consultation."

The Second Life health portal was set up by the Spanish Society for Family and Community Medicine (FYC) and the Coalition for Citizens with Chronic Illnesses.

Dr Luis Aguillera, FYC president, said: "This idea started as a way to connect health professionals and adolescents and to give internet users a reliable space to get health advice."

The Spanish-language isla de salud (health island) on Second Life will also include detailed information on health matters and a meeting room for website users.

The FYC plans to open other Second Life portals for chronic conditions in six months.

Aguillera said: "Even though a virtual consultation can never substitute for a real face-to-face one, we will be able to deal with problems of dermatology and psychology through a webcam."

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77 New Cases of Hepatitis Are Identified in Las Vegas

Nevada health officials said Thursday that they had identified 77 new cases of hepatitis C among patients treated at a Las Vegas endoscopy practice, in one of the country’s largest outbreaks of the liver disease.

The officials had previously identified seven cases of the disease linked to the gastroenterology practice, one of the largest in southern Nevada, and a single case in one of the practice’s sister clinics. The infections were caused, they said, by the reuse of anesthesia syringes among multiple patients.

The practice had not received a full inspection since 2001, although state policies dictate that ambulatory surgical centers be reviewed every three years. The licensing agency has blamed the delay on insufficient financing for inspectors.

“This is a very large outbreak and a very serious illness,” said Brian Labus, the senior epidemiologist for the Southern Nevada Health District.

Reusing syringes is “something that shouldn’t happen anywhere,” Mr. Labus said. “It is not acceptable. What we are focused on now is what was going on and how do we stop it.”

The outbreak, which began in February, has attracted the attention of federal health officials and law enforcement authorities, including the Nevada attorney general and the Federal Bureau of Investigation.

It has also embarrassed the state’s governor, Jim Gibbons, who originally derided news of the outbreak as overstated and a creation of news media “buffoonery.” (Mr. Gibbons, a Republican, has since called for the resignation of state health officials, and on Thursday he called the newly revealed cases “heartbreaking and disturbing.”)

Since February, the county health department has notified 40,000 patients who had visited the clinic that they might have been at risk for infection with the hepatitis B and C viruses or H.I.V. and should be tested. About 50,000 test panels of blood from patients have been conducted in laboratories around the region, although multiple tests may have been done on some patients and some of those tested might never have visited the medical practice.

Of those who tested positive for hepatitis C, Mr. Labus said, eight clearly contracted the illness at the two clinics, and the latest 77 were likely to have been exposed at one of them as well, because the patients had no other known risk factors.

Mr. Labus added that officials believed there were an additional 10,000 patients whom they were unable to locate, and that more tests, continuing through the summer, would most likely reveal more cases of the illness. The effort is believed to be the largest patient notification effort in the United States.

Since the first cases were identified, the Endoscopy Center of Southern Nevada has been closed and fined $500,000. Two doctors, including the center’s owner, Depak Desai, have been required to stop practicing. (Dr. Desai served on Mr. Gibbons’s transition team in 2007.)

Hepatitis C is a dangerous liver disease contracted through the blood of an infected person, generally through needles or sex or from an infected mother during birth. Roughly 80 percent of those infected have chronic lifetime infections, and the disease is the leading cause of liver transplants.

The largest outbreak of hepatitis C in North America, affecting 99 patients, was in 2002 in Nebraska, where patients in a cancer clinic were infected when a nurse used the same syringe on more than one patient.

In the Nevada outbreak, one patient who carried hepatitis could have been the root of the other infections, or a variety of patients could have infected others through the tainted vials.

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‘Mad Pride’ Fights a Stigma

IN the YouTube video, Liz Spikol is smiling and animated, the light glinting off her large hoop earrings. Deadpan, she holds up a diaper. It is not, she explains, a hygienic item for a giantess, but rather a prop to illustrate how much control people lose when they undergo electroconvulsive therapy, or ECT, as she did 12 years ago.

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Shea Roggio for The New York Times

WHO AM I? Liz Spikol, who has a bipolar disorder, has a blog with video clips that presents the various shifts in her life.

Shea Roggio for The New York Times

PUBLIC IMAGES Visitors to Liz Spikol’s blog have also seen her joke about her condition.

Michael Temchine for The New York Times

SEEKING TOLERANCE Elyn Saks remained silent about her condition until she received tenure.

In other videos and blog postings, Ms. Spikol, a 39-year-old writer in Philadelphia who has bipolar disorder, describes a period of psychosis so severe she jumped out of her mother’s car and ran away like a scared dog.

In lectures across the country, Elyn Saks, a law professor and associate dean at the University of Southern California, recounts the florid visions she has experienced during her lifelong battle with schizophrenia — dancing ashtrays, houses that spoke to her — and hospitalizations where she was strapped down with leather restraints and force-fed medications.

Like many Americans who have severe forms of mental illness such as schizophrenia and bipolar disorder, Ms. Saks and Ms. Spikol are speaking candidly and publicly about their demons. Their frank talk is part of a conversation about mental illness (or as some prefer to put it, “extreme mental states”) that stretches from college campuses to community health centers, from YouTube to online forums.

“Until now, the acceptance of mental illness has pretty much stopped at depression,” said Charles Barber, a lecturer in psychiatry at the Yale School of Medicine. “But a newer generation, fueled by the Internet and other sophisticated delivery systems, is saying, ‘We deserve to be heard, too.’ ”

About 5.7 million Americans over 18 have bipolar disorder, which is classified as a mood disorder, according to the National Institute of Mental Health. Another 2.4 million have schizophrenia, which is considered a thought disorder. The small slice of this disparate population who have chosen to share their experiences with the public liken their efforts to those of the gay-rights and similar movements of a generation ago.

Just as gay-rights activists reclaimed the word queer as a badge of honor rather than a slur, these advocates proudly call themselves mad; they say their conditions do not preclude them from productive lives.

Mad pride events, organized by loosely connected groups in at least seven countries including Australia, South Africa and the United States, draw thousands of participants, said David W. Oaks, the director of MindFreedom International, a nonprofit group in Eugene, Ore., that tracks the events and says it has 10,000 members.

RECENT mad pride activities include a Mad Pride Cabaret in Vancouver, British Columbia; a Mad Pride March in Accra, Ghana; and a Bonkersfest in London that drew 3,000 participants. (A follow-up Bonkersfest is planned next month at the site of the original Bedlam asylum.)

Members of the mad pride movement do not always agree on their aims and intentions. For some, the objective is to continue the destigmatization of mental illness. A vocal, controversial wing rejects the need to treat mental afflictions with psychotropic drugs and seeks alternatives to the shifting, often inconsistent care offered by the medical establishment. Many members of the movement say they are publicly discussing their own struggles to help those with similar conditions and to inform the general public.

“It used to be you were labeled with your diagnosis and that was it; you were marginalized,” said Molly Sprengelmeyer, an organizer for the Asheville Radical Mental Health Collective, a mad pride group in North Carolina. “If people found out, it was a death sentence, professionally and socially.”

She added, “We are hoping to change all that by talking."

The confessional mood encouraged by memoirs and blogs, as well as the self-help advocacy movement in mental health, have deepened the understanding of bipolar disorder and schizophrenia. Books such as Kay Redfield Jamison’s autobiography, “An Unquiet Mind: A Memoir of Moods and Madness,” have raised awareness of bipolar disorder, and movies like “Shine” and “A Beautiful Mind” have opened discussion on schizophrenia and related illnesses. In recent years, groups have started antistigma campaigns, and even the federal government embraces the message, with an ad campaign aimed at young adults to encourage them to support friends with mental illness.

Members of MindFreedom International, which Mr. Oaks founded in the 1980s, have protested drug companies and participated in hunger strikes to demand proof that drugs can manage chemical imbalances in the brain. Mr. Oaks, who was found to be schizophrenic and manic-depressive while an undergraduate at Harvard, says he maintains his mental health with exercise, diet, peer counseling and wilderness trips — strategies that are well outside the mainstream thinking of psychiatrists and many patients.

Other support groups include the Mad Tea Party in Chicago and the Freedom Center in Northampton, Mass., which provides education, acupuncture, yoga and peer discussions to about 100 participants.

The Icarus Project, a New York-based online forum and support network, says it attracts 5,000 unique visitors a month to its Web site, and it has inspired autonomous local chapters in Portland, Ore., St. Louis and Richmond, Va. Participants write and distribute publications, stage community talks, trade strategies for staying well and often share duties like cooking or shopping.

The Icarus Project says its participants are “navigating the space between brilliance and madness.” It began six years ago, after one of its founders, Sascha Altman DuBrul, now 33, wrote about his bipolar disorder in The San Francisco Bay Guardian, a weekly newspaper. Mr. DuBrul, who is known as Sascha Scatter, received an overwhelming response from readers who had experienced similar ordeals, but who felt they had no one to discuss them with.

“We wanted to create a new language that resonated with our actual experiences,” Mr. DuBrul said in a telephone interview.

Some Icarus Project members argue that their conditions are not illnesses, but rather, “dangerous gifts" that require attention, care and vigilance to contain. “I take drugs to control my superpowers,” Mr. DuBrul said.

While psychiatrists generally support the mad pride movement’s desire to speak openly, some have cautioned that a “pro choice” attitude toward medicine can have dire consequences.

“Would you be pro-choice with someone who has another brain disease, Alzheimer’s, who wants to walk outside in the snow without their shoes and socks?” said Dr. E. Fuller Torrey, executive director of the Stanley Medical Research Institute in Chevy Chase, Md.

Dr. Torrey, a research psychiatrist who specializes in schizophrenia and manic depression, said he understood the roots of the movement. “I suspect that not an insignificant number of people involved have had very lousy care and are still reacting to having been involuntarily treated,” he said.

Many psychiatrists now recognize that patients’ candid discussions of their experiences can help their recoveries. “Problems are created when people don’t talk to each other,” said Dr. Robert W. Buchanan, the chief of the Outpatient Research Program at the Maryland Psychiatric Research Center. “It’s critical to have an open conversation.”

Ms. Spikol writes about her experiences with bipolar disorder in The Philadelphia Weekly, and posts videos on her blog, the Trouble With Spikol (http://trouble.philadelphiaweekly.com/).

Thousands have watched her joke about her weight gain and loss of libido, and her giggle-punctuated portrayal of ECT. But another video shows her face pale and her eyes red-rimmed as she reflects on the dark period in which she couldn’t care for herself, or even shower. “I knew I was crazy but also sane enough to know that I couldn’t make myself sane,” she says in the video.

IN a telephone interview, she described one medication that made her salivate so profusely she needed towels to mop it up. “Of course it’s heartbreaking if you let it be,” she said. “But it’s also inherently funny. I’d sit there watching TV and drool so much, it would drip on the couch.”

Ms. Spikol said she has a kind doctor who treats her with respect, and she takes her pharmaceutical drugs to stabilize her mood. “I have asthma, and I use medications to maintain it, too,” she said.

Ms. Saks, the U.S.C. professor, who recently published a memoir, “The Center Cannot Hold: My Journey Through Madness,” has come to accept her illness. She manages her symptoms with a regimen that includes psychoanalysis and medication. But stigma, she said, is never far away.

She said she waited until she had tenure at U.S.C. before going public with her experience. When she was hospitalized for cancer some years ago, she was lavished with flowers. During periods of mental illness, though, only good friends have reached out to her.

Ms. Saks said she hopes to help others in her position, find tolerance, especially those with fewer resources. “I have the kind of life that anybody, mentally ill or not, would want: a good place to live, nice friends, loved ones,” she said.

“For an unlucky person,” Ms. Saks said, “I’m very lucky.”

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The Science of Scotch

Get the scientific low-down on that religiously-revered drink


Where the Magic Happens: Kettles at the Ardmore Distillery Photo by Ardmore and Laphroaig

While most scotch whiskey terminology veers towards the religious, the so-called “water of life” has been subjected to more scientific scrutiny than one might expect. But it's still a work in progress. Earlier this week at the New York Academy of Sciences, Simon Brooking, Master Ambassador for Ardmore and Laphroaig distilleries, appeared in his traditional clan tartan to walk a crowd through the chemistry behind the whiskey.

The Spread: Overtones of banana? Photo by Stuart Fox
As Brookings noted between Scottish toasts and more than a few drinks, the distinctive flavors and textures of scotch whiskies result from three chemical reactions. The initial smoking of the grain with peat fires creates the smoky and sea salt taste distinctive of certain scotches by infusing the barley with large carbon rings called phenols. Those are released from the burning peat; then differently shaped copper kettles determine the texture of the whiskey by regulating how much of the whiskey reacts with the copper during distillation. Finally, the aging in oak barrels gives the whiskey a chance to oxidize, creating chemicals like iso-amyl acetate, or banana flavor.

According to Robert Hicks, Master Blender at the Ardmore distillery, scientific analysis of scotch has uncovered over 800 chemical compounds that affect the flavor of the whiskey. While some of those chemicals exist in only small quantities (the iodine flavor chemical makes up only 5 parts per billion in Laphroaig), their impact on the taste can be immense. However, despite all the technology available to distillers, most still test their scotch the old fashioned way. “There’s a lot of analysis that’s done at the lab,” said Brookings, “but for us down in the distillery, we still like to do it by taste.”

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How Do Painkillers Find & Kill Pain?

pain-killers.jpg

First, we need to make a distinction between the two main classes of painkillers, which are used for different situations and function via different mechanisms.

The first class is the narcotic opioid drugs. These are the heavy-duty drugs, like morphine and codeine, used to treat severe pain. They relieve pain in two ways: first by interfering with and blocking the transmission of pain signals to the brain, and then by working in the brain to alter the sensation of pain. These drugs neither find nor kill pain, but reduce and alter the user’s perception of the pain. They’re kind of like having an optimistic friend that says, “Hey man, everything will be cool. Nothing’s wrong. Here, look at this shiny, distracting thing!”

The other class is the aspirin drugs, like paracetamol and ibuprofen. These are the over the counter drugs we reach for whenever we’ve got a headache or a sore back. Throughout history, people all over the world were using botanical remedies for pain. The ancient Egyptians used leaves from the myrtle bush, Europeans chewed on hunks of willow bark and Native Americans did the same with birch bark. In the nineteenth century, scientists isolated the chemical in all these plants that gave them their pain relieving properties: salicin (which is metabolized to salicylic acid when consumed). They also discovered that these chemicals produced the side effect of horrendous digestive problems (which answers that other burning question, “Why is that Native American in that old commercial crying?”).

bayer.jpgEventually, a scientist at Bayer Pharmaceutical synthesized a less harmful derivative chemical, acetylsalicylic acid (ASA). Bayer dubbed it Aspirin and commercialized it. Hoffmann went on to develop a “non-addictive” substitute for morphine. The resulting product, heroin, was less successful than aspirin. [Bayer image courtesy of Wacky Packages.]

Despite its long history, we didn’t discover how aspirin works until the early 1970s. Unlike narcotics, aspirin drugs are real workhorses that actually go to the source of pain and stop it. When cells are damaged, they produce large quantities of an enzyme called cyclooxygenase-2. This enzyme, in turn, produces chemicals called prostaglandins, which send pain signals to the brain. They also cause the area that has been damaged to release fluid from the blood to create a cushion so the damaged cells don’t take any more of a beating. This cushion is the swelling and inflammation that goes along with our aches and pains. When we take aspirin, it dissolves in our stomachs and travels through the whole body via the bloodstream. Although it’s everywhere, it only works its magic at the site of cell damage by binding to the cylooxygenase-2 enzymes and stopping them from prostaglandins. No more prostaglandins means no more pain signals. The cells at the damage site, of course, are still damaged, but we’re left blissfully unaware.

This prostaglandin-stopping power is also why people take aspirin regularly to reduce the risk of heart attacks, since prostaglandins in the bloodstream can cause clotting. Additionally, aspirin reduces the production of thromboxane, a chemical that makes platelets, a type of blood cell, sticky. With aspirin in our systems, platelets make less thromboxane and are less likely to form a clot and block an artery.

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Busted! What Should I Do Now? - Feature

We ask state troopers what they most want drivers to do during a traffic stop.

Red and blue strobes explode in your mirrors. You pull to the side of the road and madly begin fishing through the glove box for your registration and insurance. Then you tear off the seatbelt so you can jam a hand down your pants to locate your wallet. Just trying to be courteous, right? You know, have all your documents ready when The Man strolls up to your window.

Turns out, most cops don’t want you to do anything except rest your hands on top of the steering wheel until directed otherwise.

Didn’t know that, did you? Neither did we.

We talked to seven state troopers from across the country—Florida, New Jersey, Kentucky, Louisiana, Illinois, Oregon, and New Mexico—and asked, “What are the five best things a motorist can do when pulled over, and what are the five worst?” We wanted to know which procedures would render a traffic stop as painless as possible for both parties. There wasn’t a perfect consensus, but the answers went pretty much like this:

FIVE BEST THINGS TO DO

1. Pull to the right at the first safe opportunity, then turn off your engine.

If it’s not a safe place to stop, Oregon’s Lt. Gregg Hastings wants you to activate your right-turn signal, then drive slowly to a safer place. “A safer place, by the way, isn’t a considerable distance down a dark side road, driveway, or alley,” he says. “Keep in mind that traffic-related officer deaths jumped 16 percent in 2006,” Hastings adds.

2. Stay in your car with your seatbelt fastened. Roll down your window. Turn off the radio. Don’t even think about touching your cell phone.

“When a motorist climbs out of his vehicle,” says New Jersey’s Sgt. Stephen Jones, “it may give the impression he’s aggressive or has something to hide in the vehicle. I remember a man who briskly walked back to my car. I ordered him back, and he kept trying to give me his credentials at the rear of his car. The source of his consternation was two marijuana plants partly under a cloth in his back seat.”

“I pulled over a guy in a Jeep CJ, and he exited his vehicle,” recalls New Mexico’s Lt. Richard Anglada. “That’s when I realized his Jeep was rolling back toward my brand-new police car. Summoning all my strength, I had to hold his Jeep from rolling while I told him to set his brake—another reason we want people to stay in their cars.”

“Roll down your window completely,” adds Sergeant Jones. “Nothing’s more frustrating than trying to speak through a slightly cracked window. If you only give me an inch-wide gap, you hinder my ability to determine your sobriety and are more likely to be invited to continue the conversation outside your car.”

If you don’t leave your seatbelt on, the officer may also assume you were driving unbelted, thus another ticket.

There are exceptions to the stay-in-your-car rule, however. “We always ask the driver to exit the vehicle with his license, registration, and proof of insurance,” says Louisiana Trooper Johnnie Brown. What if you’re not sure whether to stay put or climb out? “Just sit still,” Brown says, “and it won’t be long before we’ll tell you what we want.”

3. Place your hands on top of the steering wheel and sit quietly. Ask passengers to remain silent.

“Whatever dangers we face, they will be channeled through the hands,” says Sergeant Jones. “We’d like to see the hands of every person in the car, frankly.”

Although they don’t insist on it, Lieutenant Hastings, as well as most other troopers, greatly prefer that you tell them where you’re about to reach. “It puts me at ease if you say, ‘I’m going to reach for my wallet now,’ ” he says, “or, ‘I need to open the glove box, okay?’ ”

4. Retrieve license, registration, and proof of insurance only when asked to do so.

Illinois M.Sgt. Luis Gutierrez appreciates it if you turn on your four-way flashers and your interior lights, especially at night. And Lieutenant Hastings strongly advises that you know where your documents are before you’re stopped. “If you start fumbling around, it suggests the car may not be yours, or that you may not have a license, or that you’re hoping the officer won’t see what you’ve hidden in the car,” he says. “And when you find your documents, don’t throw them at me.”

“I find it funny when a driver is reluctant to open his glove box, usually because he doesn’t want me to see what’s in there,” says Lieutenant Anglada. “He’ll open it as slowly as possible to avoid anything falling out. From my vantage, I usually see the contraband before he does.”

Adds Florida Trooper Larry Coggins, “A traffic stop is not the time to clean out your car, sorting through 10 years’ worth of registrations and insurance cards. Also, tell me immediately if you have a gun [legal or otherwise] anywhere on you or in the vehicle.”

“Never reach under your seat,” adds Sergeant Jones, “and never reach into the passenger area.”

“I stopped a motorist for speeding, and he was a security guard,” remembers Trooper Brown. “He exited the vehicle with his service revolver on his side. I made him place his hands on his head, then removed the weapon from his holster, removed the bullets, and placed the revolver separate from the bullets in the passenger compartment. Any weapon—gun, knife, pepper spray, whatever—tell me first.”

5. Answer questions succinctly. Avoid arguing, cursing, or interrupting when the officer speaks to you.

“Don’t assert your disgust about traffic laws,” suggests Trooper Coggins. “There’s nothing we can do about the laws, and the side of the highway is no place to argue your case. Save it for court.”

“Arguing with a trooper about speed,” says Sergeant Jones, “is like spitting into the wind.”

“Be civil,” advises Trooper Brown. “I stopped a pizza-delivery vehicle for 60 mph in a 45 zone. The driver told me to hurry up, that he had a pizza to deliver in 30 minutes or less. I asked for registration and proof of insurance, and he didn’t have either. I informed him I’d have to tow his vehicle for not having the required paperwork. He began to curse at me. After a brief inspection of the vehicle, he received seven tickets.”

FIVE WORST THINGS TO DO

1. Don’t slam on your brakes when you see the flashing lights, and don’t continue driving for an extended distance.

“At times, those actions are perceived as intentional,” says Lieutenant Hastings. “They just place an officer on edge.”

2. Do not jump out of the vehicle, do not make any sudden movements, and do not approach the officer.

“I pulled over a ’60s-model Chevy truck one night,” recalls Lieutenant Anglada, “and the driver gets out and is running toward my car with his hands wrapped in a blanket. I feared he was concealing a weapon. So I drew my side arm and ordered him to show me his hands. Turned out that his old truck didn’t have a heater—he was freezing.”

“Motorists should try to put themselves in my place,” suggests Trooper Coggins. “Just because I stopped a guy for speeding, it still runs through my mind that he might be fleeing a crime scene, might be a wanted fugitive, impaired, a kidnapper with a body in the trunk, a carjacker who hasn’t been called in yet—I just don’t know.”

3. You can complain, you can proffer wild explanations, but not for long.

Lieutenant Anglada claims way too often to have heard the excuse, “I was speeding because I had to go to the bathroom.” He recalls a woman who used that justification, then exited her car. “She asked if I’d hold a blanket around her while she squatted to relieve herself,” Anglada recalls. “I advised her to stroll off into the bushes while I waited. She still got the ticket. Over the years, officers develop an excellent ear for sincerity.”

“We stress to our troopers not to issue ‘attitude tickets,’ ” says Lieutenant Hastings. “But we can take only so much complaining before we’ve heard enough.”

4. Do not lie. If you were speeding, admit it. If you honestly have no clue why you were stopped, wait for the officer to tell you.

“There’s no substitute for frankness, but often we just see freakiness,” says Sergeant Jones. “Don’t respond with, ‘Why’d you stop me? Don’t you have criminals to catch?’ That’s a sure-fire way to receive justice rather than mercy. And think again if you believe you’ve come up with an excuse for speeding that we haven’t heard.”

“If people are honest and admit they’re wrong,” says Lieutenant Anglada, “90 percent of the time I’ll drop their speed or just give them a warning. If the person lies or accuses the officer of being wrong, 99 percent of the time the driver is going to get the ticket with no break.”

5. Do not show your contempt by peeling away after the stop.

Says Lieutenant Hastings, “Squealing your tires, tossing gravel at me, cutting off other motorists as you pull back on the highway—that’ll get you another several minutes with the same officer who just stopped you.”

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Test - Audi R8 test in Las Vegas (Nevada)


This is a video response to Audi TT Mk2 "What can you do in 0,2 seconds?"

Indiana Jones Is Battling the Long Knives of the Internet

David James/Paramount Pictures

Harrison Ford in the coming "Indiana Jones" film.

LOS ANGELES — Now comes the part where Indiana Jones dangles over the snake pit of public opinion.

Actually, a handful of Web reviewers have already struck at the film “Indiana Jones and the Kingdom of the Crystal Skull,” despite an intense effort by the director Steven Spielberg, the executive producer George Lucas and Paramount Pictures to keep this highly anticipated sequel out of sight until Sunday, May 18.

On that day, this fourth Indiana Jones movie is scheduled to make its debut at the Cannes Film Festival with an afternoon press screening, and another one at night.

At about the same time, the picture, which opens in theaters on the following Thursday, is expected to be screened for the news media and industry insiders at multiple showings in Manhattan and Los Angeles, while other screenings are scheduled around the world.

Mr. Spielberg is unusually fastidious when it comes to protecting his films from advance word that can diminish excitement or muddy a message planted by months of carefully orchestrated publicity and expensive promotions (including, in this case, a February cover article in Vanity Fair, complete with Annie Leibovitz photos of the cast, and leather bullwhips delivered weeks ago to newsrooms).

Mr. Spielberg customarily avoids leaky test screenings. Even Marvin Levy, his publicist of more than 30 years, said he had not yet seen the new movie.

Still, there it was, at 6:42 a.m. on Thursday: a harshly critical review on aintitcoolnews.com, from a poster who identified himself as “ShogunMaster.” Rife with details from the film, the review said, “This is the Indiana Movie that you were dreading.”

By that afternoon two other less critical, but less than sparkling, reviews also appeared on the Web site.

The man who posted as ShogunMaster, reached via the Web site, said he is a theater executive who saw the film at an exhibitors’ screening this week. He spoke on condition of anonymity to avoid reprisal from the studio.

Paramount had shown the film to a handful of theater company executives at its Los Angeles lot and elsewhere.

Movie studios increasingly tend to protect their biggest bets from advance showings. Two years ago, for instance, Sony Pictures screened “The Da Vinci Code” for critics at the Cannes Film Festival only two days before its opening in the United States. But exhibitors’ screenings can open a window for determined reviewers.

Such screenings are required in about two dozen states that have laws against blind-bidding, a practice in which theater owners were once asked to bid on films they had not seen.

As a practical matter, there is little or no actual bidding in the contemporary theater business, which relies instead on negotiations between distributors and theater owners. But distributors continue to hold screenings for theater company executives in the weeks before a film’s release, whether as a courtesy or as a way to avoid conflict with a patchwork of state laws.

Theater executives may have an incentive to play down a movie’s prospects after such a screening, to get better terms. In any case, many fans will most likely flock to “Indiana Jones and the Kingdom of the Crystal Skull,” if only to make their own judgments about Mr. Spielberg’s decision to revisit the franchise fully 19 years after its last installment. Still, bad notices could keep the more ambivalent moviegoers from attending and thwart a truly huge box office haul.

According to Mr. Levy, who spoke by telephone on Thursday, Mr. Spielberg has kept a watchful eye on virtually every aspect of the film’s marketing campaign. “He gets involved with everything,” Mr. Levy said. “Every TV spot, every line in every ad, every advertising concept.” (Among the marketing tie-ins were Indiana Jones fedoras, available at Blockbuster stores.)

The current campaign has been engineered to create excitement around the opening date, May 22 — some billboards feature the date, in flame-colored letters, and little else — without telling too much about the film. Last year the movie’s producers went so far as to file a lawsuit against a bit player who had publicly discussed the film’s plot, which involves the exploits of an aging archaeological adventurer, still played by Harrison Ford, now 65.

The campaign has been effective so far. Fandango, which sells film tickets online, said this week that it was “seeing brisk advance ticket sales” to “Indiana Jones and the Kingdom of the Crystal Skull,” identified as the summer’s most anticipated film in a poll Fandango conducted of moviegoers.

But a better gauge of success is likely to be the extent of online sales in the few days after the film screens at Cannes — and after many reviewers have weighed in.

Tim Ryan, a senior editor at Rottentomatoes.com, which compiles film reviews, said he expected those of “Indiana Jones and the Kingdom of the Crystal Skull” to surface “maybe an hour or two” after the Sunday afternoon press screening in France. His company will have someone on hand to post them immediately, Mr. Ryan said.

As rated by Rottentomatoes, the earlier “Indiana Jones” films enjoyed strong reviews. The worst-reviewed of the three — the second, “Indiana Jones and the Temple of Doom,” released in 1984 — was still the third-most-popular movie of the year.

Mr. Spielberg, Mr. Levy said, may not be the first to know if the aging Indy manages to wriggle past any negative early notices to score another hit. “When a movie opens, he usually disappears,” Mr. Levy said. “He usually doesn’t want to know all the details about how it’s doing.”

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