Singapore eases monetary policy, avoids recession

By AFP
14 October 2019

Singapore eases monetary policy, avoids recession
A general view shows the skyline of the financial district in Singapore. Photo: Wallace Woon/EPA

Singapore eased monetary policy for the first time in over three years Monday as the US-China trade war bites, while the export-reliant economy narrowly avoided recession in the third quarter.

The financial hub’s central bank joins others around the world, from Europe to the US, in loosening policy as fears mount of a global economic slowdown.

The city-state has traditionally been the first among Asia’s export-driven economies to be affected during a downturn, making it a closely watched barometer of global demand for goods and services for the rest of the region.

And it has been hard hit in recent months, with growth rates and exports plummeting, dragged down by a weak manufacturing sector.

The Monetary Authority of Singapore (MAS) said it will “reduce slightly” the slope of the band at which its currency is allowed to move, effectively allowing for a weaker dollar, as had been expected.

Instead of using interest rates, Singapore manages monetary policy by letting the local dollar rise or fall against a currency basket of its main trading partners.

“In the last six months, the drag on GDP (gross domestic product) growth exerted by the manufacturing sector has intensified, reflecting the ongoing downturn in the global electronics cycle as well as the pullback in investment spending, caused in part by the uncertainty in US-China relations,” MAS said.

Preliminary GDP data released at the same time showed Singapore’s economy narrowly avoided tipping into a technical recession.

It expanded 0.6 percent in the three months to September on a quarterly basis, bouncing back from a shock 2.7 percent second-quarter contraction. The economy grew 0.1 percent on a yearly basis.

The decline was led by the manufacturing sector, a pillar of the trade-dependent economy. The sector shrank by 3.5 percent, extending a 3.3 percent contraction the previous quarter.

Singapore’s exports have been hammered by dampened demand as the United States and China slapped tit-for-tat tariffs on each other worth billions of dollars in two-way trade, affecting export demand worldwide.

The city-state last slipped into recession in the aftermath of the global financial crisis in 2008.

© AFP

Eliud Kipchoge Breaks Two-Hour Marathon Barrier

VIENNA — On a misty Saturday morning in Vienna, on a course specially chosen for speed, in an athletic spectacle of historic proportions, Eliud Kipchoge of Kenya ran 26.2 miles in a once-inconceivable time of 1 hour 59 minutes 40 seconds.

In becoming the first person to cover the marathon distance in less than two hours, Kipchoge, 34, achieved a sports milestone granted almost mythical status in the running world, breaking through a temporal barrier that many would have deemed untouchable only a few years ago.

Kipchoge, an eight-time major marathon winner and three-time Olympic medalist, pounded his chest twice as he crossed the finish line in Vienna’s leafy Prater Park, where the majority of the run had unfolded on a long straightaway of recently paved road, with roundabouts on either end.

Cheered on by a thick crowd of spectators, he was lifted into the air by members of his team, including the 41 professional runners who had acted as pacesetters during the run.

For Kipchoge, the feat merely burnished his credentials as the world’s greatest marathoner.

“Together, when we run, we can make this world a beautiful world,” Kipchoge said after finishing.

For all its magnitude, the accomplishment will be regarded largely as a symbolic one. The eye-popping time, which was 10 seconds quicker than the 1:59:50 time Kipchoge and his team had set out to achieve, will not be officially recognized as a world record because it was not run under open marathon conditions and because it featured a dense rotation of professional pacesetters.

What the event lacked in officially sanctioned gravitas, though, it seemed determined to make up for with theater and grandiose proclamations.

The run, organized by the petrochemical company INEOS, featured a cycle of hype and commercial buildup more reminiscent of a heavyweight prizefight than a road race.

Organizers billed the two-hour mark as “the last barrier of modern athletics” and tried to get a hashtag, #nohumanislimited, trending on social media.

Kipchoge repeatedly compared a potential sub-two-hour marathon to humanity’s first journey onto the surface of the moon.

“The pressure was very big on my shoulders,” said Kipchoge, who revealed he had received a call from President Uhuru Kenyatta of Kenya the night before the run.

Whatever the scope of the achievement, it required a prodigious amount of planning.

Seeking the most welcoming environment for Kipchoge to attempt such a feat, the event’s organizers had settled on Vienna: It was not too warm, not too cold and not at all hilly. The altitude, 540 feet above sea level, was just right, and it was only one time zone away from Kipchoge’s training camp in Kaptagat, Kenya, where he had worked out for the past four months under the guidance of his longtime coach, Patrick Sang.

He had led a monastic existence there, eating, sleeping and exercising for the sole purpose of running fast. To his normal preparations he added workouts focused on core strength in order to lessen the strain on his hamstrings.

On Saturday, Kipchoge showed the subtlest signs of strain on his face in the first half of the run and fell a couple seconds behind his desired pace in a few portions. He ran the final stretches of the marathon with his lips curled into a gentle smile. Afterward, he walked with a barely perceptible limp.

“There are no guarantees in sports,” Jim Ratcliffe, the billionaire founder of INEOS, said to Kipchoge after the finish. “You could have had a bad day. But you had a really good day.”

Kipchoge had made an attempt at the two-hour barrier once before. In 2017, in a similar event organized by Nike, he ran a 2:00:25 marathon around an auto racetrack in Monza, Italy. It was by far the fastest marathon ever run, but it was not officially recognized as a world record because it was not run under normal race conditions

Since then, and in officially sanctioned major marathons, Kipchoge produced the two fastest times in history at the time they were run, posting a world-record time of 2:01:39 in Berlin in 2018 and 2:02:37 last April in London.

“Berlin was about running a world record,” Kipchoge said this past week. “Vienna is about running and breaking history, like the first man on the moon.”

He arrived in Austria on Tuesday, but the exact start date for the attempt was not finalized until the following day, and the precise start time was not settled until Friday afternoon.

What materialized on Saturday was perhaps the most finely tuned, carefully orchestrated marathon-length run in history.

Kipchoge got out of his hotel bed at 4:50 a.m. and had oatmeal for breakfast.

At 8:15 a.m., after a three-hour wait that he called “the hardest time ever in my life,” he set out from the Reichsbrücke, a picturesque bridge spanning the Danube, and charged across a stretch of downhill road that led him into the park. There, he ran around a 9.6-kilometer flat circuit, more than 90 percent of which unfurled in a straight line. Portions of the road were painted with lines to highlight the fastest possible path.

Kipchoge — who wore a white singlet, white sneakers (Nikes, as of yet unreleased to the public, built around a carbon-fiber plate) and white sleeves on his arms — had immense support. He ran behind an electric timing car driving 4:34 per mile (with a second car on standby) and with his flock of rotating pacesetters (35 on the course, six on reserve) who happened to include some of the best distance runners in the world, including former world and Olympic gold medalists like Bernard Lagat and Matthew Centrowitz.

Those pacemakers, wearing black jerseys and stern expressions, formed a protective, aerodynamic pocket around Kipchoge, five of them running in front in an open-V formation and two more in the back. They knew exactly where to run thanks to a pattern of thick, green laser beams projected onto the street by the timing car. At predetermined times, the seven pacemakers would make way for another group of seven to slide in and take over.

A team member on a bicycle periodically pedaled into the pack to deliver Kipchoge a carbohydrate-heavy cocktail of gels and fluids.

“Looking at the 1:59:40 time, I got so emotional,” said Lagat, a two-time Olympic medalist.

Down the final stretch, as it was clear that the milestone was easily in reach, the pacesetters, timing car and accompanying cyclists all peeled away, leaving Kipchoge alone to soak in the shouts and applause of the crowd.

After crossing the finish line, Kipchoge jumped into the arms of his wife, Grace, and children. Through all his years of competition, all the victories and medals and records in his career, this was the first time his family had watched him run in person.

For Yankees, Extended Game 2 Showed Limits of Their Bullpen

Before Carlos Correa even stepped to the plate in the bottom of the 11th inning to clobber his walk-off homer to end Game 2 of the American League Championship Series, the Houston Astros had already gained an upper hand. By taking advantage of Yankees starter James Paxton’s uneven command and forcing his early exit on Sunday, the Astros triggered a chain of events that eventually led to the decisive J.A. Happ-Correa matchup.

Happ was the ninth Yankees pitcher of the game, setting a new franchise postseason record. The Astros, on the other hand, needed only six pitchers because their standout starter, Justin Verlander, held steady long enough to pitch into the seventh inning with the score tied.

“If you can kind of put some pressure on them and you get some matchups in your favor, they’re going to continue to make those moves,” Astros Manager A.J. Hinch said of the Yankees after his team’s 3-2 win to even the best-of-seven series at one game apiece.

Two games into the A.L.C.S., one theme is already clear: With the Yankees and Astros fielding two of the best offenses in baseball, the margins for error on the mound are extremely thin — and the differences in the two clubs’ pitching staffs only makes the decision-making harder.

The Astros are relying heavily on their rotation aces — Gerrit Cole, who starts Tuesday; Zack Greinke and Verlander. Their ability to pitch not only well but deep into games is a luxury because it minimizes the impact of the weaker links of their pitching staff. The Yankees, on the other hand, are happy to squeeze as much as possible out of their stout bullpen, which is guided by five relievers — Tommy Kahnle, Adam Ottavino, Zack Britton, Aroldis Chapman and Chad Green.

Until Sunday, the Yankees’ bullpen (and their powerful offense) had successfully mitigated the shortcomings of their starting rotation. And Paxton had been their best starter entering Sunday: Since Aug. 2, he had a 2.74 earned run average and had guided his team to 12 wins, including one in the postseason.

Still, he is not on the same level as Verlander or Cole, both of whom logged over 200 innings and 300 strikeouts during the regular season. So even though the Yankees trailed by only one run with one out in the third inning, Manager Aaron Boone emerged from the dugout and signaled for Green to replace Paxton. The Astros were 4-for-10 with two walks against Paxton, and Boone couldn’t play with fire any longer. With no game on Monday and 10 relievers at his disposal, he felt confident he could get 20 more outs from his bullpen. Problem was, the Yankees would ultimately need more on Sunday as the game went to extra innings.

“You’re playing it to win the game,” Boone said. “You’re not playing it to, ‘What if we go 13, you know?’ You’re playing it to, ‘What gives us the best chance to win here?’ And the bottom line is we end up giving up a third run in the 11th inning. I’d say from a run prevention standpoint it went pretty well.”

It was also a more-aggressive strategy than the one Boone employed last October, when he drew some criticism for leaving pitchers in too long. After Green tossed two innings on Sunday, Ottavino entered in the fifth to face the top of the Astros’ lineup. Ottavino’s wicked slider seemed to be a perfect counter for Astros outfielder George Springer, who is one of the best in baseball at slugging fastballs.

But Ottavino threw a slider over the heart of the plate that Springer blasted to left field for a homer that tied the score at 2-2. “I have a lot of confidence in my slider, obviously, but credit to him: He didn’t miss it when I made the mistake,” Ottavino said of Springer.

As the innings progressed, Boone cycled through his other stout relievers. He pushed Kahnle to two and one-third innings, his longest outing since Game 1 of the 2017 A.L.C.S. After Chapman tossed a scoreless ninth inning, Boone turned to C.C. Sabathia, Jonathan Loaisiga and Happ, all of whom struggled during the season.

Sabathia, a longtime starter who had recently dealt with shoulder soreness, got one out in the 10th inning. But Loaisiga walked both batters he faced. Happ escaped that inherited jam, but faltered himself an inning later on the first pitch he threw to Correa.

It was here that the absences of Dellin Betances (Achilles injury) and Domingo German (administrative leave) were felt acutely. The Astros, thanks to Verlander’s long outing, were able to outlast the Yankees.

“We pitched really well,” Britton said. “It came down to making one more mistake than they did.”

The battle of slim margins could be further complicated by weather: Forecasts were calling for rain on Wednesday before and during Game 4, which is set to start at 8 p.m. If postponed, Games 4 and 5 would be pushed back a day.

That might prove most beneficial for the Astros, since the quality of their starting pitching drops off significantly after Verlander, Cole and Greinke. Wade Miley, the Astros’ fourth starter during the regular season, was left off the A.L.C.S. roster after a rough September. Greinke, who started Game 1, could pitch on Thursday on regular rest.

The Yankees’ plan for Game 4 was, in Boone’s words, for their bullpen to be “unleashed.” They were successful during the regular season with similar nontraditional pitching strategies, going 12-7 when employing an opener. Boone said Happ, a starter during the regular season, could be an option to pitch in some fashion in Game 4. But with a rain postponement, the Yankees could avoid that entirely and have Masahiro Tanaka, an October master, return on regular rest on Thursday in a rematch with Greinke, who he faced in Game 1.

In that game, Tanaka and Greinke each spun six innings, but Tanaka’s were spotless and Greinke allowed three runs. The only Yankees to pitch after Tanaka that day: Ottavino, Britton and, once the lead was large, Loaisiga.

Faced With a Drug Shortfall, Doctors Scramble to Treat Children With Cancer

A critical drug that serves as the backbone of treatment for most childhood cancers, including leukemias, lymphomas and brain tumors, has become increasingly scarce, and doctors are warning that they may soon be forced to consider rationing doses.

Persistent shortages of certain drugs and medical supplies have plagued the United States for years, but physicians say the loss of this medication, vincristine, is uniquely problematic, as there is no appropriate substitute.

“This is truly a nightmare situation,” said Dr. Yoram Unguru, a pediatric oncologist at the Herman and Walter Samuelson Children’s Hospital at Sinai in Baltimore. “Vincristine is our water. It’s our bread and butter. I can’t think of a disease in childhood cancer that doesn’t use vincristine.”

Shortages of the chemotherapy drug, which is on back order, will likely affect children throughout the country, he said, obligating physicians to make difficult decisions.

“There is no substitution for vincristine that can be recommended,” Dr. Unguru said. “You either have to skip a dose or give a lower dose — or beg, borrow or plead.”

Vincristine is one of the drugs used to manage acute lymphoblastic leukemia, the most common childhood cancer. Vincristine is also an important agent in the treatment of Wilms tumor, a rare kidney cancer that mostly affects children.

The Children’s Oncology Group, a collaboration of researchers at hospitals and cancer centers, has made recommendations for altering clinical trial treatment protocols involving vincristine, including checking the hospital pharmacy’s supply before trial enrollment; considering using half the dose if the full amount is not available; skipping doses during the maintenance phase of treatment; or in some cases omitting the drug altogether.

“We are all devastated,” said Dr. Michael Link, a pediatric oncologist at the Stanford University School of Medicine and a former president of the American Society of Clinical Oncology.

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Without vincristine, many children with acute lymphoblastic leukemia will still be cured, “but this is a difficult disease to treat in general, and with one hand tied behind your back, it makes it much more difficult,” Dr. Link said.

Until earlier this year, there were two suppliers of vincristine: Pfizer and Teva Pharmaceutical Industries. In July, Teva made a “business decision to discontinue the drug,” according to the Food and Drug Administration.

Since then, Pfizer has been the sole supplier, and the company lately has experienced manufacturing troubles.

“Pfizer has experienced a delay, and we are working closely with them and exploring all options to make sure this critical cancer drug is available for the patients who need it,” the F.D.A. said in a brief statement.

Jessica Smith, a spokeswoman for Pfizer, said the company would expedite additional shipments of the drug over the next few weeks to “support three to four times our typical production output,” in an effort to make up for Teva’s withdrawal from the market.

Teva did not return numerous calls for comment.

The American Society of Health-System Pharmacists tracks more than 200 medications in short supply, among them everyday necessities like antibiotics, dextrose and several vaccines, including the rabies vaccine.

The shortages tend disproportionately to involve older, generic injectable drugs, which are difficult to manufacture but command low prices, a combination that often leads manufacturers to get out of the business of making them.

Those withdrawals may leave just one or two companies continuing to supply the drugs in the United States. Their factories must run at peak production to turn a profit and provide a sufficient supply, but the moment there is a quality problem and production shuts down, shortages follow.

Generic drugs play a vital role in the treatment of cancer. Of the 19,000 American children and adolescents younger than 19 who develop cancer every year, 85 percent are cured. But treatment hinges largely on inexpensive, older drugs like vincristine, which have been off patent for decades.

Shortages cause disruption in treatment. According to a survey published in the New England Journal of Medicine in 2013, 83 percent of oncologists said that they were unable to prescribe the chemotherapy agent they wanted to use because of a shortage, and that they had to substitute a different drug or delay treatment.

Dr. Unguru said the survival rate for acute lymphoblastic leukemia, which accounts for nearly one-quarter of all cancers in children, is nearly 90 percent. But eight of the 10 drugs most commonly used to treat it have been unavailable at times over the past decade.

A drug shortages task force established in 2018 by the former F.D.A. Commissioner Scott Gottlieb is supposed to submit a report with findings and recommendations to Congress by the end of the year.

“This shouldn’t be happening in the United States,” said Dr. Peter Adamson, chair of the Children’s Oncology Group.

“It’s hard enough for any family having a kid with cancer, and having a child with cancer likely to be cured except we can’t give them the drug is beyond the imagination. How can we do that to families?”

England’s European Championship Qualifier Marred by Racist Abuse

SOFIA, Bulgaria — England’s Football Association called on UEFA to take “very stringent” action after the country’s European Championship qualifier against Bulgaria was stopped twice in the first half because of racist chants and Nazi salutes from the home supporters.

England’s 6-0 win was halted in the 28th minute and again in the 43rd, but the English players opted against leaving the field and the game was quickly resumed after both breaks.

Bulgaria supporters in the crowd were seen directing monkey chants at England players, doing Nazi salutes and holding up shirts with the UEFA logo and the text “No Respect” — a reference to the European governing body’s “Respect” campaign aimed at curbing racism in the sport.

During the first break, the public announcer warned that the match could be called off completely unless the racist abuse stopped — the first step in UEFA’s anti-racism protocol for games. During the second break, dozens of Bulgaria fans involved in the chanting, many of them wearing dark hooded sweatshirts, left the stadium.

“I would like to see a very stringent review by UEFA because I know they take racism very seriously,” English F.A. Chairman Greg Clarke said. “We should join a movement to drive racism out of our game and have zero tolerance for it.”

The F.A. also issued a statement saying the England players “were subjected to abhorrent racist chanting,” which seemed to be aimed mainly at black players like Raheem Sterling and Tyrone Mings.

“As we are sadly aware, this is not the first time our players have been subjected to this level of abuse and there is no place for this kind of behavior in society, let alone in football. We will be asking UEFA to investigate as a matter of urgency,” the F.A. said.

Mings initially asked one of the assistant referees if he had heard the chants and England Coach Gareth Southgate then held a discussion with the fourth official before the game was halted for the first time.

“It was quite clear to hear on the pitch, but we showed a great response, we showed a good togetherness and ultimately we let the football do the talking,” Mings told ITV. “We made a decision at halftime to come out and play the game which we thought was the right decision and if anything else had happened we would have taken appropriate action.”

The delays led to six minutes of added time, during which Sterling tapped in England’s fourth goal.

Bulgaria’s captain, Ivelin Popov, appeared to have a heated debate with a section of home fans, asking them to stop the chants, as the rest of the players went to the dressing rooms at halftime.

The second half passed without interruption, with Sterling scoring his second goal with a precise finish in the 69th, and Kane completing the rout in the 85th minute, shortly after he was denied by the post.

The Vasil Levski Stadium in Sofia was already subject to a partial closure for the match after Bulgaria was sanctioned for racist chanting during qualifiers against Kosovo and the Czech Republic.

“We have made two statements by winning the game but also we have raised the awareness of everyone of the situation,” Southgate said. “The game was stopped twice. I know for some people that won’t be enough.”

Rx for Doctors: Stop With the Urine Tests

It’s such a common routine in a doctor’s office or clinic or hospital that patients tend to comply without thinking: Step on the scale, roll up your sleeve for the blood pressure cuff, urinate into a cup.

But that last request should prompt questions, at the least. The urine test is the first step into what’s sometimes called “the culture of culturing.”

In patients who have none of the typical symptoms of a urinary tract infection — no painful or frequent urination, no blood in the urine, no fever or lower abdominal tenderness — lab results detecting bacteria in the urine don’t indicate infection and thus shouldn’t trigger treatment.

Older people, and nursing home residents in particular, often have urinary systems colonized by bacteria; they will have a positive urine test almost every time, but they’re not sick.

Yet such test results, signifying what’s known in doctor-talk as asymptomatic bacteriuria, frequently lead to unnecessary treatment with antibiotics. Public health leaders and researchers have battled for years to persuade providers to stop reaching for their prescription pads every time a urine test comes back positive.

They have been only modestly successful. A recent study in 46 Michigan hospitals, for instance, found that of 2,733 patients with asymptomatic bacteriuria (average age: 77), almost 83 percent received a full course of antibiotics. The odds of this overtreatment rose 10 percent with each decade of age.

“We now recognize that there’s a strong cognitive bias,” said Dr. Christine Soong, head of hospital medicine at Sinai Health System in Toronto and co-author of a recent editorial on the subject in JAMA Internal Medicine. “Once a clinician sees bacteria in the urine, the reflex is, you can’t ignore it. You want to treat it.”

Now, the campaign has changed from trying to prevent needless treatment to trying to curtail the testing that prompts it. If concerned doctors can’t dissuade their colleagues from treating these non-infections, they’re trying to discourage them from ordering urine tests in the first place.

The very reserved headline on Dr. Soong’s editorial was: “De-adoption of Routine Urine Culture Testing — A Call to Action.” It probably should have been: “For Crying Out Loud, Stop With the Pee in the Cup.”

What’s raising this issue once more are the latest guidelines from the United States Preventive Services Task Force, the independent expert panel that reviews medical evidence and advises on prevention and screenings.

The task force concluded last month that for virtually everyone except pregnant women, screening for and treating asymptomatic bacteriuria provides no benefit and has potential harms. This didn’t come as news — the task force reached essentially the same determination in 1996, in 2004 and in 2008.

The Infectious Diseases Society of America, which updated its recommendations this spring, also cautioned against screening and treating, except for pregnant women and patients about to undergo invasive urologic procedures. The Choosing Wisely campaign has similarly weighed in against routine urine testing in older adults.

Why this strenuous effort? All of it is aimed at reducing the persistent overuse of antibiotics.

They’re lifesaving drugs, useful when patients actually have urinary or other bacterial (not viral) infections. But studies have shown that with asymptomatic bacteriuria, withholding antibiotics doesn’t endanger patients. Providing the drugs, however — especially to older people — definitely does pose risks.

“The public thinks it’s good to take an antibiotic,” said Dr. Heidi Wald, a geriatrician and chief quality and safety officer at SCL Health in Denver. “People don’t understand the risks of overuse.”

Antibiotics can cause side effects ranging from nausea and rashes to impaired kidney function and interactions with other commonly used drugs, like cardiac medications and antidepressants.

“The problem I worry about most in the frail elderly is C. difficile,” Dr. Wald said, referring to a virulent, hard-to-eradicate infection that has rampaged through the Medicare population.

Antibiotics affect the human microbiome, wiping out the protective microbes in the gastrointestinal tract and increasing people’s vulnerability to C. difficile, which the Centers for Disease Control and Prevention has called an “urgent threat.”

In the Michigan hospital study, patients treated for asymptomatic bacteriuria fared no better on a variety of measures than those who weren’t treated. “But they stayed in the hospital a day longer,” said Dr. Lindsay Petty, the study’s lead author and an infectious disease specialist at the University of Michigan.

She theorized that their doctors were awaiting urine culture results. The patients, meanwhile, faced additional risks of disrupted sleep, infections, physical deconditioning from time spent in bed and other hazards, while generating needlessly higher hospital bills.

Beyond its effect on individuals, “antibiotic resistance is one of the greatest public health crises of our time,” Dr. Petty said. When bacteria develop resistance to overused drugs, doctors are left with fewer and riskier weapons with which to fight infections.

Because U.T.I.s occur so commonly — 40 percent to 60 percent of women, in whom they’re far more common than in men, will experience at least one in their lifetimes — it’s easy for doctors and patients to engage in so-called scapegoating, blaming a supposed U.T.I. for problems that may have little to do with the urinary tract.

In older patients, particularly, confusion and hospital delirium can lead family members to urge doctors to order urine cultures, especially when dementia makes it difficult for patients to describe their symptoms.

But “the idea of attributing delirium to a U.T.I. is losing ground,” Dr. Wald said. When older patients grow confused, “maybe they’re dehydrated,” she said. “Maybe it’s a new medication.” Hospitalization itself might be to blame.

Doctors understand, after vigorous education efforts, that they need to prescribe fewer antibiotics; virtually every hospital has an antimicrobial stewardship program aimed at that goal. “This isn’t a knowledge gap,” Dr. Soong said.

But since many doctors can’t seem to overlook positive tests, even in asymptomatic patients — fearful, perhaps, of missing an infection — health care systems are working to curb their impulse to treat.

Some organizations have created pop-up alerts in electronic records when health care professionals attempt to order urine tests, reminding them of the proper criteria.

At Dr. Soong’s hospital, withholding the results of urine cultures, unless doctors actually called the microbiology lab to request them, reduced prescriptions for asymptomatic bacteriuria to 12 percent from 48 percent of non-catheterized patients, with no loss of safety.

“The extra step of having the clinician call eliminated a lot of frivolous testing,” Dr. Soong said.

Similarly, another Toronto emergency room reported success using containers with a preservative, allowing urine specimens to be held at room temperature for 48 hours, processed only at a doctor’s request. That two-step approach cut antibiotic prescriptions for emergency room patients in half.

There’s a role here for patients and families, as well. What if we asked why we were being asked to urinate into a cup?

“Asking further questions is always appropriate,” Dr. Petty said. “’Why do you think I need this test? What would you do with the results?’”

(Hint: “It’s just routine” is not a good answer. “The symptoms you’ve described could mean a urinary tract infection” is a better one.)

“Such questions should be welcome,” Dr. Petty said. “It’s a way for patients to protect themselves.”

The New Makers of Plant-Based Meat? Big Meat Companies

Beyond Meat and Impossible Foods, scrappy start-ups that share a penchant for superlatives and a commitment to protecting the environment, have dominated the relatively new market for vegetarian food that looks and tastes like meat.

But with plant-based burgers, sausages and chicken increasingly popular and available in fast-food restaurants and grocery stores across the United States, a new group of companies has started making meatless meat: the food conglomerates and meat producers that Beyond Meat and Impossible Foods originally set out to disrupt.

In recent months, major food companies like Tyson, Smithfield, Perdue, Hormel and Nestlé have rolled out their own meat alternatives, filling supermarket shelves with plant-based burgers, meatballs and chicken nuggets.

Once largely the domain of vegans and vegetarians, plant-based meat is fast becoming a staple of more people’s diets, as consumers look to reduce their meat intake amid concerns about its health effects and contribution to climate change. Over the last five months, Beyond Meat’s stock price has soared and Impossible Foods’ deal to provide plant-based Whoppers at Burger King has prompted a wave of fast-food chains to test similar products. Analysts project that the market for plant-based protein and lab-created meat alternatives could be worth as much as $85 billion by 2030.

Now, at supermarkets across the United States, shoppers can find plant-based beef and chicken sold alongside the packaged meat products that generations of Americans have eaten.

“There is a growing demand out there,” said John Pauley, the chief commercial officer for Smithfield, one of the largest pork producers in the country. “We’d be foolish not to pay attention.”

In September, Nestlé released the Awesome Burger, its answer to the meatless patties of Beyond Meat and Impossible Foods. (“We do feel like it’s an awesome product,” a Nestlé spokeswoman said.) Smithfield started a line of soy-based burgers, meatballs and sausages, and Hormel began offering plant-based ground meat.

There are also blended options — a kind of faux fake meat that falls somewhere in the existential gray area between the Beyond Burger and a cut of beef. Tyson is introducing a part-meat, part-plant burger. And Perdue is selling blended nuggets, mixing poultry with “vegetable nutrition” in the form of cauliflower and chickpeas.

Many supporters of meatless alternatives have hailed the new products as a sign that plant-based meat has gained widespread acceptance.

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“When companies like Tyson and Smithfield launch plant-based meat products, that transforms the plant-based meat sector from niche to mainstream,” said Bruce Friedrich, who runs the Good Food Institute, an organization that advocates plant-based substitutes. “They have massive distribution channels, they have enthusiastic consumer bases, and they know what meat needs to do to satisfy consumers.”

But the emergence of these meat companies in the plant-based-protein market has also prompted suspicion and unease among some environmental activists, who worry the companies could co-opt the movement by absorbing smaller start-ups, or simply use plant-based burgers to draw attention away from other environmental misdeeds.

“That’s a legitimate concern,” said Glenn Hurowitz, who runs the environmental advocacy organization Mighty Earth. For years, big oil companies bought clean-energy start-ups and essentially shut them down, he noted.

“Making admittedly modest investments in plant-based protein is a legitimately good thing for these businesses to do,” Mr. Hurowitz said, but “it doesn’t entirely balance out all the pollution they’re causing.”

Many of the major food companies began investing in plant-based meat or other vegan alternatives years ago. But the pace has accelerated over the past few months.

“The entire end-to-end process happened in less than a year,” said Justin Whitmore, Tyson’s executive vice president for alternative protein. “We’ll move with the consumer, and we have the capacity that helps us move quickly.”

Veggie burgers have been on store shelves for decades, but companies are only now developing vegetarian products that try to match the experience of eating actual meat, using ingredients such as pea proteins and genetically engineered soy.

Pat Brown, the chief executive of Impossible Foods, has long described the project of creating faux meat as an environmental imperative. “Every aspect of the animal-based food industry is vastly more environmentally disruptive and resource-inefficient than any plant-based system,” he said. Mr. Brown has even set a deadline: Eliminate animal products from the global food supply by 2035.

Not all his new rivals are quite so idealistic. Their goal is not to upend the meat industry in the name of sustainability. It is mainly to make money.

“We’re a meat company, first and foremost,” said Mr. Pauley, the Smithfield official. “We’re not going to apologize for that.”

A spokeswoman for Tyson, the largest meat producer in the United States and the creator of a new line of plant-based chicken nuggets, put it more bluntly. “Right now,” said the spokeswoman, Susan Wassel, “it’s really about the business opportunity.”

Some of the major food companies, including Tyson and Smithfield, have their own sustainability goals. Last month, Nestlé announced a set of environmental initiatives meant to reduce its carbon footprint, including a focus on plant-based products. But as awesome as it may be, the company’s Awesome Burger is not intended to fundamentally change the way we eat.

“We believe in diversity,” said Benjamin Ware, Nestlé’s manager of responsible sourcing. “Products based on animal agents will still have a place in the future, with all the good nutritional aspects.”

That is not necessarily a problem for the future of meatless meat. Any time a plant-based product is added to the grocery aisle is a victory for the movement, many advocates say, regardless of what motivates the company that made it.

“The most important thing to the conventional meat industry is satisfying consumer demand as much as they possibly can,” said Mr. Friedrich, the executive director of the Good Food Institute. “They see that a better technology always replaces an antiquated technology.”

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Still, Mr. Brown said he had no plans to collaborate with the major meat producers, whose marketing power and supply-chain infrastructure could help plant-based start-ups reach more customers. He said it was an “encouraging sign” that such companies were investing in plant-based protein, but he emphasized that the success of the movement depended on products that truly recreated the taste and texture of meat.

“If the products are not that great, if they’re just basically repurposed veggie burgers, the harm it does to us is not competition,” he said. “It’s reinforcing consumers’ belief that a plant-based product can’t deliver what a meat lover wants.”

For now, though, it’s too early to tell how consumers will respond to the wider range of options, said Alexia Howard, an analyst at Bernstein who tracks the plant-based meat industry.

“We’ll inevitably see some chipping away of market share,” Ms. Howard said. “But it’s who has the best product that will ultimately survive.”

Beyond Meat is not worried. Ethan Brown, the chief executive (and no relation to his counterpart at Impossible Foods), said the company’s narrow focus on plant-based products would set it apart from other purveyors of meatless meat.

“If Nestlé or Perdue or Tyson think it’s a good idea to buy our product and reverse-engineer it, they’re chasing a ghost,” he said. “We’ve moved on from those models into new models and new iterations.”

As for burgers that combine meat with vegetables, he added, “I haven’t ever heard a consumer tell me they want a blended product.”

Eric Christianson, the chief marketing officer at Perdue, described the company’s investment in blended products as a simple business decision. Because so many companies are producing meatless meat, he said, Perdue decided to focus on a different category — almost-meatless meat.

“There’s a real opportunity to meet the needs of your mainstream consumers — your mom with kids — by bringing the chicken that they love along with the vegetable nutrition that they need,” Mr. Christianson said.

Beyond Meat and Impossible Foods are not interested in such compromises. But in some ways, the plant-based meat start-ups are beginning to resemble major food companies themselves. Beyond Meat is valued at nearly $9 billion, making it about a third the size of Tyson.

“I don’t want to collaborate with them,” Ethan Brown said. “I want to be them.”

Impossible Foods is aiming to expand to other plant-based products, like fishless fish, and make inroads in China. At times, however, the company has struggled to make the transition from start-up to major company. Over the summer, it was unable to meet the rising demand for its patties, leading to shortages at restaurants and forcing staff members to work 12-hour shifts to keep the company’s production facility in Oakland, Calif., running.

Pat Brown, the chief executive, said Impossible Foods had solved that supply-chain problem by collaborating with the OSI Group, a global food processing firm that has worked with big-name brands like McDonald’s and Starbucks. Now, Impossible is poised to quadruple its manufacturing capacity. And the days of marathon factory shifts are over.

“Everybody,” Mr. Brown said, “was happy to see that era come to an end.”

Cardinals’ Hit or Miss Offense Is Missing Again

ST. LOUIS — The baseball schedule is so unforgiving that most teams, by the end, know just who they are. The St. Louis Cardinals are still searching, and they are running out of time.

In the first two games of the National League Championship Series against the Washington Nationals, the Cardinals lost twice and scored just one run. A pinch-hitter, Jose Martinez, was 2 for 2. The rest of the hitters were 2 for 55.

“It’s just pretty obvious,” said Paul Goldschmidt, who singled to break up Max Scherzer’s no-hitter in the seventh inning of Game 2. “You score one run, you’re not going to win many games.”

If you score 10 in the first inning, you have a much better shot. The Cardinals did that in their division series clincher in Atlanta, coasting to a 13-1 victory. But the Nationals have unplugged their offense and hidden the power cord.

“That’s kind of been the story of our season, really,” first baseman Matt Carpenter said. “Our offense, at times, has been hit or miss. We’ve had stretches where we’ve struggled to score and we’ve had stretches where we’ve just poured it on. Hopefully we can get one where we pour it on here in the next couple of days, get some confidence back and get some guys rolling.”

But the Cardinals could not solve the soft-throwing Anibal Sanchez on Friday night, or the hard-throwing Scherzer in the shadows on Saturday afternoon. Now Stephen Strasburg awaits them in Game 3 on Monday at Nationals Park, with Patrick Corbin to follow in Game 4.

Strasburg has 21 strikeouts and one walk in 15 October innings, with a 2.40 earned run average. Corbin, a two-time All-Star, was 8-2 with a 2.40 E.R.A. at home in the regular season.

“I feel like we’re road warriors,” Cardinals second baseman Kolten Wong said. “We’ve found our niche on the road; we know how to play on the road. We know the pitchers we’re up against, the odds we’re up against. But that’s what we’re all about. That’s what we love.”

The Cardinals are an unlikely underdog. They are playing in their 10th N.L.C.S. in the last 20 seasons, and their 11 World Series titles are second only to the Yankees’ 27. But they missed the playoffs the last three seasons as the Chicago Cubs and the Milwaukee Brewers took over the N.L. Central, and needed an all-around effort to return.

“This year, we have a complete team that is doing a lot of different things well that we haven’t been doing the last few years,” starter Adam Wainwright said. “This year we played much better defense, this year we ran the bases much better, this year our starting pitching was a little better, this year our bullpen was certainly much better. We have more thump in the middle of our lineup than we’ve had in years.”

The thumpers — Goldschmidt, Paul DeJong and Marcell Ozuna — combined for 94 homers this season. But the Cardinals had only 210 homers over all and 764 runs scored this season, both figures ranking last among teams with winning records.

That sets these Cardinals apart from their last championship team in 2011. Those Cardinals were a wild-card team, but they led the N.L. in runs scored and beat three Philadelphia Phillies aces — Cliff Lee, Roy Oswalt and Roy Halladay — in a first-round upset. They battered another ace, the Milwaukee Brewers’ Zack Greinke, in the N.L.C.S., and ravaged the Texas Rangers’ bullpen in the World Series.

This time, the Nationals’ aces have dispatched the Cardinals with ease, and relievers Sean Doolittle and Daniel Hudson — who returned to save Game 2 after missing the opener for the birth of his daughter — have been sharp this month.

The Cardinals have hope in Game 3 because of their starter, Jack Flaherty, a 23-year-old right-hander with a 1.13 E.R.A., postseason included, since the All-Star break. The rookie Dakota Hudson, a 16-game winner in the regular season, will start Game 4.

“This series is far from over, and we have a guy going that’s really the best guy in baseball in the second half, undisputed, going for us on Monday,” Manager Mike Shildt said, referring to Flaherty. “I’m very optimistic, still, about this series.”

This is how the Cardinals scripted it, after all, managing their young pitchers’ workloads so they would be available in October. It was a deliberate effort not to repeat the Nationals’ infamous decision to shut down Strasburg before the 2012 playoffs to protect his long-term health. The Cardinals beat Washington in the division series that fall, and it took four more tries for the Nationals to advance to the N.L.C.S.

Now that they have, they seem eager to make it a short stay. They could be just two games away from the World Series, which has not come to Washington since 1933.

“The atmosphere in the playoffs at Nationals Park has been incredible,” Scherzer said. “They come out and they go nuts from the first pitch. So I have a feeling it’s even going to be more crazy given what we have done, and really our first postseason win as an organization. I think it means a lot to everybody in D.C.”

Unless the Cardinals quickly solve Scherzer’s fellow pitchers, the District can start planning the party.

For ‘Erin Brockovich’ Fans, a David vs. Goliath Tale With a Twist

EXPOSUREPoisoned Water, Corporate Greed, and One Lawyer’s Twenty-Year Battle Against DuPontBy Robert Bilott with Tom Shroder

Robert Bilott never set out to be anyone’s hero. He made his living defending chemical companies at an old-line corporate law firm based in Cincinnati when, just a few months shy of making partner, he received a call from a West Virginia farmer who was convinced that the runoff from a nearby DuPont plant was killing his cows. The man had heard Bilott was an environmental lawyer, apparently not understanding that he wasn’t the kind of attorney who brought cases on behalf of aggrieved individuals; instead, Bilott defended companies against such complaints. The caller, however, dropped a magic name: that of Bilott’s grandmother, a beloved figure in his life. The farmer’s case, filed in 1999, and a second, larger class action suit that grew out of it, would dominate the next 20 years of Bilott’s life.

Bilott skillfully tells the story of his epic battle with DuPont and its lawyers in “Exposure,” which lands in bookstores just ahead of a new movie, “Dark Waters,” starring Mark Ruffalo as Bilott and Anne Hathaway as his put-upon wife. The screenplay is based on a 2016 article in The New York Times Magazine (“The Lawyer Who Became DuPont’s Worst Nightmare”), not Bilott’s manuscript. But as you read “Exposure,” it’s easy to imagine scenes in the film version of Bilott’s life. You see the time he was unable to reach his office phone because of the small skyscrapers of boxes and documents that blocked his way, and the time he was rushed to the hospital because of the physical toll the case was taking on his life. In a made-for-Hollywood twist, DuPont bests Bilott by exploiting his pre-existing relationship with a DuPont lawyer and then he bests DuPont’s attorneys through clever legal maneuvers of his own.

If Bilott makes for an unlikely warrior in the battle for safe drinking water, DuPont plays to type as the faceless behemoth that seems to care more about its bottom line than the health of its employees or the tens of thousands of people who lived near the giant plant it operates outside of Parkersburg, W.Va. Because, of course, it wasn’t just the cows that were suffering. Scientists inside the company were concerned enough about a particularly noxious chemical called PFOA — used to manufacture Teflon, among other products — that they began testing DuPont’s workers for exposure. But when the results suggested potential health problems, corporate’s answer was to stop the testing. The ever-thorough Bilott discovers old laboratory animal studies that DuPont and 3M, which manufactured PFOA, had conducted decades earlier. The results showed dogs and monkeys dying from exposure to PFOA, cancer in rats along with birth defects in its unborn. Yet Bilott found no follow-up investigations. At least within the pages of “Exposure,” plausible denial seems to be DuPont’s corporate motto. Ultimately, Bilott discovers dangerously high concentrations of PFOA leaching into the surrounding community’s drinking water.

Bilott is an engaging narrator who breaks our hearts with tales of clients suffering excruciating ailments and amazes us with endless 14-hour days scouring technical reports in search of that one clue that might help him make his case. The naïve corporate defense attorney we meet at the book’s start is gone by the end, and he seems no longer surprised when he realizes that regulators, including the Environmental Protection Agency, are in DuPont’s pocket. By the time he learns PFOA and its chemical cousins are in the blood of virtually all of us, he knows it’s fallen to him to do the E.P.A.’s job. The book ends with him filing a federal class action suit against eight chemical companies on behalf of every American. His education is complete.

Theme park on a cruise ship with longest rollercoaster at sea is coming in 2021

A CRUISE company is planning to launch a brand new ship featuring the world's longest rollercoaster at sea.

The vessel, known as Global Dream, is currently being built in Germany and is set to debut in 2021.

 Global Dream is set to debut in 2021

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Global Dream is set to debut in 2021Credit: Dream Cruises

According to Dream Cruises, the company behind the new cruise liner, the ride will be part of a new theme park known as Dream Park at the Pier – the first of its kind at sea.

The 300m (984ft) rollercoaster will be called Space Cruiser and will be built by Maurer Rides.

The Germany ride designers have also created attractions including G Force at Drayton Manor and Spinball Whizzer at Alton Towers.

There are just three carts on the ride, each sitting up to two people.

Each of the carts is equipped with an integrated throttle that allows passengers to control the speed.

Marco Hartwig, project manager at Maurer Rides, said that the rollercoaster will be able to travel up to speeds of 37mph and "guarantees a spectacular and breathtaking ride".

 The ship is set to have the worlds longest rollercoaster at sea

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The ship is set to have the worlds longest rollercoaster at seaCredit: Dream Cruises

 The ride will be in the new theme park, Dream Park at the Pier

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The ride will be in the new theme park, Dream Park at the PierCredit: Dream Cruises

In fact, because the ride circles the top deck of the ship, it will made the passengers feel like they're flying over the sea.

While the Space Cruise coaster is the top attraction for guests, there are lots of other things to keep kids of all ages entertained.

Some of the smaller rides include Kranky Kraken where kids can ride a friendly octopus and Little Dreamers Ride where they can drive mini karts.

At the Bounce Activity Park, guests can explore a massive bouncy obstacle course that's spread out over an area that's the size of a basketball court.

There's also Jump, a trampoline park, as well as Shark Bay where guests can try a bungee trampoline.

And on Wipe Out, passengers can try their hands at surfing.

 The rollercoaster will wrap around the top deck of the ship

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The rollercoaster will wrap around the top deck of the ship

 There are lots of rides for smaller kids as well

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There are lots of rides for smaller kids as well

Also on board are cinemas, spas, shops and scores of restaurants.

The huge new ship will have 2,500 cabins that accommodate up to 5,000 passengers.

And for those who can afford it, there are also 151 suites in an area known as The Palace – the liner's ship within a ship.

But all the rooms will feature Bluetooth locks and a smart system that lets passenger control things like lighting and temperature using their phones.