Queens Doctor Is Charged in 2 Patients’ Deaths

A doctor accused of running a prescription pain medication mill out of a basement office in Queens was charged with manslaughter on Thursday in the deaths of two former patients.

John Marshall Mantel for The New York Times

Dr. Stan Xuhui Li, center, in court Thursday. Dr. Li is charged with manslaughter for prescribing pain medicine for medically unsound reasons to 20 patients. Seven later died from overdoses.

An indictment filed in State Supreme Court in Manhattan accused the doctor, Stan Xuhui Li, of prescribing pain medicine for medically unsound reasons to 20 patients, seven of whom died from overdoses.

Joseph Haeg, 37, and Nicholas Rappold, 21, the two patients whose deaths led to the manslaughter charges, had visited Dr. Li within three days of their deaths, and the pill bottles were found next to their bodies, prosecutors said.

Mr. Haeg had received 15 prescriptions from Dr. Li in the three months before his death in December 2009, and more than 500 pills of controlled substances in his last month, according to court records.

During Mr. Rappold’s last visit with Dr. Li, he received prescriptions for Xanax and oxycodone. He was found dead in his parked car in Queens in September 2010, and the cause of death was acute intoxication by the combined effects of Xanax and oxycodone, according to court records.

Bridget G. Brennan, New York City’s special narcotics prosecutor, said her office was not aware of any other cases in which a physician was charged with homicide under New York State law in the death of a patient. She said her office took the unusual step in part because Dr. Li’s prescriptions could be proved to be the cause of the deaths, and because he ignored obvious signs of his patients’ deteriorating health.

“Dr. Li flouted the fundamental principle in medicine: first do no harm,” Ms. Brennan said. “He jeopardized lives by repeatedly prescribing dangerous controlled substances and narcotic drugs for cash, not medical need.”

Prosecutors also said that Dr. Li, 58, prescribed controlled substances to another man, David Laffer, last year, just one week before Mr. Laffer fatally shot four people while stealing thousands of pain pills from a pharmacy in Medford, N.Y. Dr. Li has not been charged in that episode.

Dr. Li was arrested last year and charged with criminal sale of a prescription for a controlled substance and reckless endangerment in the death of Michael Cornetta, 40, who overdosed in November 2010. Dr. Li’s license to practice medicine was suspended in January.

He was also charged on Thursday with several counts related to making false insurance claims and altering patient records that he supplied to the state’s Office of Professional Medical Conduct, which is responsible for physician discipline.

Dr. Li had been free on bail since shortly after his arrest last year. He was rearrested near his home in Hamilton, N.J., on Nov. 27. He appeared in court wearing a blue plaid shirt and pleaded not guilty to all the charges.

His lawyer, Raymond W. Belair, said Dr. Li would fight the charges and try to keep his medical license. He described Dr. Li as a “careful and caring physician” who should not be held responsible if his patients were taking doses in excess of the prescribed levels or “doctor shopping” to get more prescriptions.

“Everything that has taken place here has taken place in the context of a pain-management situation,” Mr. Belair said in court.

Justice Michael R. Sonberg ordered Dr. Li held in bail of $750,000 in bond or $250,000 in cash.

Dr. Li worked as an anesthesiologist in New Jersey, but on weekends prescribed hundreds of pain pills from a building in Flushing. Patients would line up around the corner, be given numbers as they entered and then be called by number rather than by name, prosecutors said.

Charlotte Fishman, an assistant district attorney, said in court that Dr. Li had collected more than $450,000 in cash from selling prescriptions over the two years before his arrest.

“He literally filled his pockets with money on those weekend days,” Ms. Fishman said.

Dr. Li faces up to 15 years in prison on each of the manslaughter charges.

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McAfee Antivirus Software Pioneer Arrested in Guatemala City

MEXICO CITY — The antivirus software pioneer John McAfee was arrested in Guatemala City on Wednesday after he slipped over the border from his home in Belize where police want to question him in their investigation of the murder of his neighbor.

Jorge Dan Lopez/Reuters

John McAfee spoke during an interview in Guatemala City on Wednesday.

The interior minister, Mauricio Lopez Bonilla, told The Associated Press that Mr. McAfee, 67, had been arrested on charges of entering Guatemala illegally. He said that Mr. McAfee had been arrested at a hotel in the capital and taken to a detention center for migrants who are in the nation illegally.

Mr. McAfee had been on the run for almost a month since his neighbor, Gregory Faull, on the Belizean island of Ambergris Caye was found dead at his home on Nov. 11. Police there cited Mr. McAfee as a “person of interest” in their investigation, but Mr. McAfee disapppeared.

But he did not disappear from the Internet. He kept up a continuous stream of comment on his blog and on Twitter, accusing the Belizean authorities of persecuting him.

On Tuesday, he resurfaced in Guatemala, dressed in a suit, his blond curls dyed dark brown.

Accompanied by his 20-year-old Belizean girlfriend, Samantha Venagas, and his Guatemalan lawyer, Telésforo Guerra, Mr. McAfee said that he would seek political asylum in Guatemala. Mr. Guerra, a former Guatemalan attorney general, told reporters at a chaotic news conference outside the Supreme Court that his client was being persecuted because he refused to pay Belizean authorities off any longer.

Mr. McAfee has not been associated with the software company that bears his name since 1994, when he sold it and began to pursue his other interests. He ran a yoga retreat and then built a complex in New Mexico to indulge his hobby of flying motorized ultralight airplanes.

He moved to Belize about four years ago, buying properties on the mainland and on Ambergris Caye. It was there that he clashed with Mr. Faull, who complained about the unleashed dogs that Mr. McAfee kept on his property.

On Nov. 9, several of the dogs were found dead. They had been poisoned.

During his time in Belize, Mr. McAfee had apparently become interested in developing a designer drug called MDPV. He posted extensively about his experiments on a Web site.

But he attracted the attention of Belizean authorities, who raided one of his properties in April. He spent a night in jail, but law enforcement officials found no evidence that he was producing methamphetamine and dropped the charges.

After that experience, though, Mr. McAfee appeared to become increasingly convinced that he was being persecuted by the Belizean government. Officials deny that they are persecuting him.

Mr. Guerra told Guatemalan reporters late Wednesday that since there was no warrant for Mr. McAfee’s arrest and since his client was not a fugitive, he would seek to have his client released and returned to the hotel where he would remain under guard.

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Antismoking Outlays Drop Despite Tobacco Revenue

Faced with tight budgets, states have spent less on tobacco prevention over the past two years than in any period since the national tobacco settlement in 1998, despite record high revenues from the settlement and tobacco taxes, according to a report to be released on Thursday.

Paul J. Richards/Agence France-Presse — Getty Images

State antismoking spending is the lowest since the 1998 national tobacco settlement.

States are on track to collect a record $25.7 billion in tobacco taxes and settlement money in the current fiscal year, but they are set to spend less than 2 percent of that on prevention, according to the report, by the Campaign for Tobacco-Free Kids, which compiles the revenue data annually. The figures come from state appropriations for the fiscal year ending in June.

The settlement awarded states an estimated $246 billion over its first 25 years. It gave states complete discretion over the money, and many use it for programs unrelated to tobacco or to plug budget holes. Public health experts say it lacks a mechanism for ensuring that some portion of the money is set aside for tobacco prevention and cessation programs.

“There weren’t even gums, let alone teeth,” Timothy McAfee, the director of the Office on Smoking and Health at the Centers for Disease Control and Prevention, said, referring to the allocation of funds for tobacco prevention and cessation in the terms of the settlement.

Spending on tobacco prevention peaked in 2002 at $749 million, 63 percent above the level this year. After six years of declines, spending ticked up again in 2008, only to fall by 36 percent during the recession, the report said.

Tobacco use is the No. 1 cause of preventable death in the United States, killing more than 400,000 Americans every year, according to the C.D.C.

The report did not count federal money for smoking prevention, which Vince Willmore, the vice president for communications at the Campaign for Tobacco-Free Kids, estimated to be about $522 million for the past four fiscal years. The sum — about $130 million a year — was not enough to bring spending back to earlier levels.

The $500 million a year that states spend on tobacco prevention is a tiny fraction of the $8 billion a year that tobacco companies spend to market their products, according to a Federal Trade Commission report in September.

Nationally, 19 percent of adults smoke, down from over 40 percent in 1965. But rates remain high for less-educated Americans. Twenty-seven percent of Americans with only a high school diploma smoke, compared with just 8 percent of those with a college degree or higher, according to C.D.C. data from 2010. The highest rate — 34 percent — was among black men who did not graduate from high school.

“Smoking used to be the rich man’s habit,” said Danny McGoldrick, the vice president for research at the Campaign for Tobacco-Free Kids, “and now it’s decidedly a poor person’s behavior.”

Aggressive antismoking programs are the main tools that cities and states have to reach the demographic groups in which smoking rates are the highest, making money to finance them even more critical, Mr. McGoldrick said.

The decline in spending comes amid growing certainty among public health officials that antismoking programs, like help lines and counseling, actually work. California went from having a smoking rate above the national average 20 years ago to having the second-lowest rate in the country after modest but consistent spending on programs that help people quit and prevent children from starting, Dr. McAfee said.

An analysis by Washington State, cited in the report, found that it saved $5 in tobacco-related hospitalization costs for every $1 spent during the first 10 years of its program.

Budget cuts have eviscerated some of the most effective tobacco prevention programs, the report said. This year, state financing for North Carolina’s program has been eliminated. Washington State’s program has been cut by about 90 percent in recent years, and for the third year in a row, Ohio has not allocated any state money for what was once a successful program, the report said.

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Antismoking Outlays Drop Despite Tobacco Revenue

Faced with tight budgets, states have spent less on tobacco prevention over the past two years than in any period since the national tobacco settlement in 1998, despite record high revenues from the settlement and tobacco taxes, according to a report to be released on Thursday.

Paul J. Richards/Agence France-Presse — Getty Images

State antismoking spending is the lowest since the 1998 national tobacco settlement.

States are on track to collect a record $25.7 billion in tobacco taxes and settlement money in the current fiscal year, but they are set to spend less than 2 percent of that on prevention, according to the report, by the Campaign for Tobacco-Free Kids, which compiles the revenue data annually. The figures come from state appropriations for the fiscal year ending in June.

The settlement awarded states an estimated $246 billion over its first 25 years. It gave states complete discretion over the money, and many use it for programs unrelated to tobacco or to plug budget holes. Public health experts say it lacks a mechanism for ensuring that some portion of the money is set aside for tobacco prevention and cessation programs.

“There weren’t even gums, let alone teeth,” Timothy McAfee, the director of the Office on Smoking and Health at the Centers for Disease Control and Prevention, said, referring to the allocation of funds for tobacco prevention and cessation in the terms of the settlement.

Spending on tobacco prevention peaked in 2002 at $749 million, 63 percent above the level this year. After six years of declines, spending ticked up again in 2008, only to fall by 36 percent during the recession, the report said.

Tobacco use is the No. 1 cause of preventable death in the United States, killing more than 400,000 Americans every year, according to the C.D.C.

The report did not count federal money for smoking prevention, which Vince Willmore, the vice president for communications at the Campaign for Tobacco-Free Kids, estimated to be about $522 million for the past four fiscal years. The sum — about $130 million a year — was not enough to bring spending back to earlier levels.

The $500 million a year that states spend on tobacco prevention is a tiny fraction of the $8 billion a year that tobacco companies spend to market their products, according to a Federal Trade Commission report in September.

Nationally, 19 percent of adults smoke, down from over 40 percent in 1965. But rates remain high for less-educated Americans. Twenty-seven percent of Americans with only a high school diploma smoke, compared with just 8 percent of those with a college degree or higher, according to C.D.C. data from 2010. The highest rate — 34 percent — was among black men who did not graduate from high school.

“Smoking used to be the rich man’s habit,” said Danny McGoldrick, the vice president for research at the Campaign for Tobacco-Free Kids, “and now it’s decidedly a poor person’s behavior.”

Aggressive antismoking programs are the main tools that cities and states have to reach the demographic groups in which smoking rates are the highest, making money to finance them even more critical, Mr. McGoldrick said.

The decline in spending comes amid growing certainty among public health officials that antismoking programs, like help lines and counseling, actually work. California went from having a smoking rate above the national average 20 years ago to having the second-lowest rate in the country after modest but consistent spending on programs that help people quit and prevent children from starting, Dr. McAfee said.

An analysis by Washington State, cited in the report, found that it saved $5 in tobacco-related hospitalization costs for every $1 spent during the first 10 years of its program.

Budget cuts have eviscerated some of the most effective tobacco prevention programs, the report said. This year, state financing for North Carolina’s program has been eliminated. Washington State’s program has been cut by about 90 percent in recent years, and for the third year in a row, Ohio has not allocated any state money for what was once a successful program, the report said.

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Apple to Resume U.S. Manufacturing

For the first time in years, Apple will manufacture computers in the United States, the chief executive of Apple, Timothy D. Cook, said in interviews with NBC and Bloomberg Businessweek.

“Next year, we will do one of our existing Mac lines in the United States,” he said in an interview to be broadcast Thursday on “Rock Center With Brian Williams” on NBC.

Apple, the biggest company in the world by market value, moved most of its manufacturing to Asia in the late 1990s. As an icon of American technology success and innovation, the California-based company has been criticized in recent years for outsourcing jobs abroad.

“I don’t think we have a responsibility to create a certain kind of job,” Mr. Cook said in the Businessweek interview. “But I think we do have a responsibility to create jobs.”

The company plans to spend $100 million on the American manufacturing in 2013, according to the interviews, a small fraction of its overall factory investments and an even tinier portion of its available cash.

In the interviews, Mr. Cook suggested the company would work with partners and that the manufacturing would be more than just the final assembly of parts. He noted that parts of the company’s ubiquitous iPhone, including the “engine” and the glass screen, were already made in America. The processor is manufactured by Samsung in Texas, while Corning makes the glass screen in Kentucky.

Over the last few years, sales of the iPhone, iPod and iPad have overwhelmed Apple’s line of Macintosh computers, the basis of the company’s early business. Revenue from the iPhone alone made up 48 percent of the company’s total revenue for its fiscal fourth quarter ended Sept. 30.

But as recently as October, Apple introduced a new, thinner iMac, the product that pioneered the technique of building the computer innards inside the flat screen.

Mr. Cook did not say in the interviews where in the United States the new manufacturing would occur. But he did defend Apple’s track record in American hiring.

“When you back up and look at Apple’s effect on job creation in the United States, we estimate that we’ve created more than 600,000 jobs now,” Mr. Cook told Businessweek. Those jobs include positions at partners and suppliers.

Steve Dowling, a spokesman for Apple, declined on Thursday to provide additional details on Apple’s plans, referring to Mr. Cook’s interviews.

Apple has for years done the final assembly of some Macs in the United States, mainly systems that customers buy with custom configurations, like bigger hard drives and more memory than on standard machines.

Mr. Cook’s statements suggested Apple is planning to build more of the Mac’s ingredients domestically, although with partners. He told Businessweek that the plan “doesn’t mean that Apple will do it ourselves, but we’ll be working with people, and we’ll be investing our money.”

While Apple’s products are typically made in Asian factories owned by other companies, Apple itself often purchases the sophisticated manufacturing equipment required to make its cutting-edge designs, spending billions of dollars a year on such machines.

Foxconn Technology, which manufactures more than 40 percent of the world’s electronics, is one of Apple’s main overseas manufacturing contractors. Based in Taiwan, Foxconn is China’s largest private employer, with 1.2 million workers, and it has come under intense scrutiny over working conditions inside its factories.

In March, Foxconn pledged to sharply curtail the number of working hours and significantly increase wages. The announcement was a response to a far-ranging inspection by the Fair Labor Association, a monitoring group that found widespread problems — including numerous instances where Foxconn violated Chinese law and industry codes of conduct.

Apple, which recently joined the labor association, had asked the group to investigate plants manufacturing iPhones, iPads and other devices. A growing outcry over conditions at overseas factories prompted protests and petitions, and several labor rights organizations started scrutinizing Apple’s suppliers.

Almost all of the 70 million iPhones, 30 million iPads and 59 million other products Apple sold in 2011 were manufactured overseas. Apple employs 43,000 people in the United States and 20,000 overseas. An additional 700,000 people engineer, build and assemble iPads, iPhones and Apple’s other products, mostly abroad.

At a meeting with Silicon Valley executives in 2011, President Obama asked Steven P. Jobs, then the Apple chief executive, what it would take to make iPhones in the United States. Mr. Jobs, who died later that year, told the president, “Those jobs aren’t coming back.”

Nick Wingfield contributed reporting.

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Britons Are Warned of Lingering Austerity

Andrew Winning/Reuters

A closed business in London. A nonpartisan agency monitoring the data said it expected the economy to shrink this year.

LONDON — Britons, many already weary of government austerity budgets that some economists say are impeding the country’s recovery, are going to have to wait even longer for relief.

The architect of the austerity program, George Osborne, the chancellor of the Exchequer, told Parliament on Wednesday that the government had missed one of its self-imposed debt-cutting goals and would have to extend the belt-tightening into 2018, a year longer than previously promised.

Although Mr. Osborne maintained that the debt reduction plan was still on track, his presentation drew heckling and laughter from some opposition lawmakers, particularly after he argued that new tax measures would show that “we’re all in this together.”

The next general election in Britain will take place in 2015, well before the end of austerity measures that have included cuts in welfare services and the elimination of tens of thousands of public sector jobs.

On Wednesday, the Office for Budget Responsibility, a nonpartisan body that is monitoring the economy, said it now expected full-year data to show that the economy shrank 0.1 percent this year, instead of growing 0.8 percent, as the office had previously forecast.

It also said the economy would grow 1.2 percent next year as opposed to the 2 percent predicted earlier.

“It’s a hard road but we are getting there,” Mr. Osborne told Parliament. “Britain is on the right track. Turning back now would be a disaster.”

Reducing the budget deficit and truly getting the economy back on track has been the overriding objective binding the uneasy coalition between Prime Minister David Cameron’s Conservative Party and Liberal Democrat lawmakers that has governed Britain since 2010.

Both parties have been betting that imposing the most severe government spending cuts in recent decades will reap economic rewards before the next general election. But the last missed target for cutting debt, combined with a painfully slow recovery, risks undermining the entire political strategy and stoking tensions within the coalition. And it undermines the coalition’s message that it is better equipped to deal with the economy than the Labour Party.

“The government’s strategy is to combine deficit reduction with economic recovery, but at the moment we are not getting much of either,” said Andrew Smith, chief economist at the auditing and advisory firm KPMG.

The government has been defending its austerity measures, which include tax increases and spending cuts, by saying they help to keep Britain’s borrowing costs low and so will contribute to a revival of the British economy. Compared with the Continent, Britain has a relatively better economic outlook, and its borrowing costs are much lower.

Mr. Osborne said the British economy was facing “a multitude of problems” at home and abroad, making the recovery more difficult. He mentioned uncertainty about averting the so-called fiscal cliff crisis in the United States in January, slowing growth in China and the euro zone recession.

“They really need some growth now,” said David Tinsley, an economist at BNP Paribas. “Making the cuts when the economy is stuck is really difficult.”

Ed Balls, economic spokesman for the Labour Party, said Wednesday that Mr. Osborne’s statements illustrated an economic failure of government. “The defining purpose of the government, the cornerstone of the coalition, the one test they set themselves — to balance the books and get the debt falling by 2015 — is now in tatters,” he said.

Labour, which is leading in some recent national polls, has been criticizing Mr. Osborne’s austerity plan as going too far and trying to cut debt too quickly without offering any investments to fuel economic growth. But economists said that with public finances stretched as they were, there was little Mr. Osborne could spend on a revival.

He announced a one percentage point cut in the corporation tax, to 21 percent, and canceled a planned increase in the fuel tax paid by consumers. He also said the government planned to be much stricter on going after tax dodgers.

“I know these tax measures will not be welcomed by all,” Mr. Osborne said. “But we must show we’re all in this together.”

So far, Mr. Osborne has managed to balance the competing demands of Conservatives, who generally favor tax and benefit cuts, and Liberal Democrats who would rather increase the burden on the wealthy if necessary. But blaming the weakness of the British economy for the euro zone crisis may become a less effective political weapon if the single-currency area begins to stabilize.

“The strains are muted because people understand the seriousness of the situation and the absence of any obvious way of getting out of it,” said one senior member of the Liberal Democrats, who was not authorized to speak publicly. “But as it goes on for longer, the strains under which the coalition begins to operate will become greater.”

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Storm Hits Hiring in November; Service Sector Expands

NEW YORK (Reuters) - Private-sector hiring took a hit in November due to the impact of storm Sandy that ravaged consumers and businesses in the northeastern United States, but the huge services sector continued to expand albeit at a modest pace.

The ADP National Employment Report, which is closely watched as it comes two days ahead of the government's monthly employment report, showed that the private sector added 118,000 jobs during the month, below expectations for a gain of 125,000.

The report largely confirmed economists' forecast for a weak reading in the Labor Department payrolls report on Friday. Economists expect the economy added 93,000 jobs in November, down from 171,000 the month before, according to a Reuters poll.

"It's close to what the market was expecting. If Friday's employment report from the U.S. Labor Department comes in similar to this, that would be a good outcome," said Terry Sheehan, economic analyst at Stone and McCarthy Research Associates in Princeton, New Jersey.

A separate report on the U.S. services sector showed a similar dip in hiring during the month. But forward-looking indicators pointed to faster growth as a rise in new orders and business activity helped offset a slowdown in employment and prices.

The Institute for Supply Management said its services index rose to 54.7 last month from 54.2 the month before, with 50 being the divide between growth and contraction. The reading topped economists' forecasts for growth of 53.5, according to a Reuters survey.

"The much larger service side of the U.S. economy remains relatively healthy," said Joseph Trevisani, chief market strategist at Worldwide Markets, Woodcliff Lake, New Jersey.

"It has so far avoided the contraction in manufacturing, but worse is probably coming in the first quarter of next year as the economy continues to slow."

A separate report on Monday showed that the manufacturing sector contracted after two months of growth.

U.S. stocks were little changed after the data but drifted lower by midmorning. The S&P 500 index, a broad measure of U.S. stocks, traded down 0.4 percent at 1,401.74 points.

Also on Wednesday, a report showed new orders received by U.S. factories unexpectedly rose in October as demand for motor vehicles and a range of other goods offset a slump in defense and civilian aircraft orders, a hopeful sign for the manufacturing sector.

That chimed with another report showing U.S. nonfarm productivity increased at a much faster clip than initially thought in the third quarter as businesses held the line on hiring even as output surged, with unit labor costs falling at their fastest pace in almost a year.

Mark Zandi, chief economist of Moody's Analytics, who helps compile the ADP report, said underlying jobs growth was closer to 150,000 in November after discounting the impact of the storm as well as seasonal jobs brought forward at the start of the holiday season.

"Abstracting from the storm, the job market turned in a good performance during the month," he said. "Superstorm Sandy wreaked havoc on the job market in November, slicing an estimated 86,000 jobs from payrolls."

Zandi said he was seeing little indication that budget negotiations in Washington aimed at averting the so-called "fiscal cliff," a series of automatic tax hikes and spending cuts due in 2013, were having a significant impact of hiring.

"I don't sense that businesses have pulled back on their hiring or increased their layoffs as a result of the angst surrounding the fiscal issues," said Zandi.

The current impasse over the fiscal cliff, which could impact the economy to the tune of $600 billion next year, has been blamed for fueling uncertainty and causing corporate managers to delay business decisions.

(Reporting By Edward Krudy; Editing by Clive McKeef and Chizu Nomiyama)

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Well: For Athletes, Risks From Ibuprofen Use

Phys Ed

Gretchen Reynolds on the science of fitness.

Many active people use the painkiller ibuprofen on an almost daily basis. In surveys, up to 70 percent of distance runners and other endurance athletes report that they down the pills before every workout or competition, viewing the drug as a preemptive strike against muscle soreness.

But a valuable new study joins growing evidence that ibuprofen and similar anti-inflammatory painkillers taken before a workout don’t offer any benefit and may be causing disagreeable physical damage instead, particularly to the intestines.

Studies have already shown that strenuous exercise alone commonly results in a small amount of intestinal trauma. A representative experiment published last year found that cyclists who rode hard for an hour immediately developed elevated blood levels of a marker that indicates slight gastrointestinal leakage.

Physiologically, it makes sense that exercise would affect the intestines as it does, since, during prolonged exertion, digestion becomes a luxury, said Dr. Kim van Wijck, currently a surgical resident at Orbis Medical Center in the Netherlands, who led the small study. So the blood that normally would flow to the small intestine is instead diverted to laboring muscles. Starved of blood, some of the cells lining the intestines are traumatized and start to leak.

Thankfully, the damage seems to be short-lived, Dr. van Wijck said. Her research has shown that within an hour after a cyclist finished riding, the stressed intestines returned to normal.

But the most common side-effect of ibuprofen is gastrointestinal damage. And since many athletes take the drug for pain before and after a workout, Dr. van Wijck set out to determine the combined effect of exercise and ibuprofen.

For the new study, published in the December issue of Medicine & Science in Sports & Exercise, researchers at Maastricht University in the Netherlands recruited nine healthy, active men and had them visit the university’s human performance lab four times.

During two of the visits, the men rested languorously for an hour, although before one of the visits, they swallowed 400 milligrams of ibuprofen the night before and also the morning of their trip to the lab. (Four hundred milligrams is the recommended non-prescription dosage for adults using the drug to treat headaches or other minor pain.)

During the remaining visits, the men briskly rode stationary bicycles for that same hour. Before one of those rides, though, they again took 400 milligrams of ibuprofen the night before and the morning of their workout.

At the end of each rest or ride, researchers drew blood to check whether the men’s small intestines were leaking. Dr. van Wijck found that blood levels of a protein indicating intestinal leakage were, in fact, much higher when the men combined bike riding with ibuprofen than during the other experimental conditions when they rode or took ibuprofen alone. Notably, the protein levels remained elevated several hours after exercise and ibuprofen.

The health implications of this finding are not yet clear, although they are worrying, Dr. van Wijck said. It may be that if someone uses ibuprofen before every exercise session for a year or more, she said, “intestinal integrity might be compromised.” In that case, small amounts of bacteria and digestive enzymes could leak regularly into the bloodstream.

More immediately, if less graphically, the absorption of nutrients could be compromised, especially after exercise, Dr. van Wijck said, which could affect the ability of tired muscles to resupply themselves with fuel and regenerate.

The research looks specifically at prophylactic use of ibuprofen and does not address the risks and benefits of ibuprofen after an injury occurs. Short-term use of Ibuprofen for injury is generally considered appropriate.

Meanwhile, the Dutch study is not the first to find damage from combining exercise and ibuprofen. Earlier work has shown that frequent use of the drug before and during workouts also can lead to colonic seepage. In a famous study from a few years ago, researchers found that runners at the Western States 100-Mile Endurance Run who were regular ibuprofen users had small amounts of colonic bacteria in their bloodstream.

Ironically, this bacterial incursion resulted in “higher levels of systemic inflammation,” said David C. Nieman, a professor of health and exercise science at Appalachian State University who conducted the study and is himself an ultramarathoner. In other words, the ultramarathon racers who frequently used ibuprofen, an anti-inflammatory, wound up with higher overall levels of bodily inflammation. They also reported being just as sore after the race as runners who had not taken ibuprofen.

Animal studies have also shown that ibuprofen hampers the ability of muscles to rebuild themselves after exercise. So why do so many athletes continue enthusiastically to swallow large and frequent doses of ibuprofen and related anti-inflammatory painkillers, including aspirin, before and during exercise?

“The idea is just entrenched in the athletic community that ibuprofen will help you to train better and harder,” Dr. Nieman said. “But that belief is simply not true. There is no scientifically valid reason to use ibuprofen before exercise and many reasons to avoid it.”

Dr. van Wijck agrees. “We do not yet know what the long-term consequences are” of regularly mixing exercise and ibuprofen, she said. But it is clear that “ibuprofen consumption by athletes is not harmless and should be strongly discouraged.”

Read More..

Well: For Athletes, Risks From Ibuprofen Use

Phys Ed

Gretchen Reynolds on the science of fitness.

Many active people use the painkiller ibuprofen on an almost daily basis. In surveys, up to 70 percent of distance runners and other endurance athletes report that they down the pills before every workout or competition, viewing the drug as a preemptive strike against muscle soreness.

But a valuable new study joins growing evidence that ibuprofen and similar anti-inflammatory painkillers taken before a workout don’t offer any benefit and may be causing disagreeable physical damage instead, particularly to the intestines.

Studies have already shown that strenuous exercise alone commonly results in a small amount of intestinal trauma. A representative experiment published last year found that cyclists who rode hard for an hour immediately developed elevated blood levels of a marker that indicates slight gastrointestinal leakage.

Physiologically, it makes sense that exercise would affect the intestines as it does, since, during prolonged exertion, digestion becomes a luxury, said Dr. Kim van Wijck, currently a surgical resident at Orbis Medical Center in the Netherlands, who led the small study. So the blood that normally would flow to the small intestine is instead diverted to laboring muscles. Starved of blood, some of the cells lining the intestines are traumatized and start to leak.

Thankfully, the damage seems to be short-lived, Dr. van Wijck said. Her research has shown that within an hour after a cyclist finished riding, the stressed intestines returned to normal.

But the most common side-effect of ibuprofen is gastrointestinal damage. And since many athletes take the drug for pain before and after a workout, Dr. van Wijck set out to determine the combined effect of exercise and ibuprofen.

For the new study, published in the December issue of Medicine & Science in Sports & Exercise, researchers at Maastricht University in the Netherlands recruited nine healthy, active men and had them visit the university’s human performance lab four times.

During two of the visits, the men rested languorously for an hour, although before one of the visits, they swallowed 400 milligrams of ibuprofen the night before and also the morning of their trip to the lab. (Four hundred milligrams is the recommended non-prescription dosage for adults using the drug to treat headaches or other minor pain.)

During the remaining visits, the men briskly rode stationary bicycles for that same hour. Before one of those rides, though, they again took 400 milligrams of ibuprofen the night before and the morning of their workout.

At the end of each rest or ride, researchers drew blood to check whether the men’s small intestines were leaking. Dr. van Wijck found that blood levels of a protein indicating intestinal leakage were, in fact, much higher when the men combined bike riding with ibuprofen than during the other experimental conditions when they rode or took ibuprofen alone. Notably, the protein levels remained elevated several hours after exercise and ibuprofen.

The health implications of this finding are not yet clear, although they are worrying, Dr. van Wijck said. It may be that if someone uses ibuprofen before every exercise session for a year or more, she said, “intestinal integrity might be compromised.” In that case, small amounts of bacteria and digestive enzymes could leak regularly into the bloodstream.

More immediately, if less graphically, the absorption of nutrients could be compromised, especially after exercise, Dr. van Wijck said, which could affect the ability of tired muscles to resupply themselves with fuel and regenerate.

The research looks specifically at prophylactic use of ibuprofen and does not address the risks and benefits of ibuprofen after an injury occurs. Short-term use of Ibuprofen for injury is generally considered appropriate.

Meanwhile, the Dutch study is not the first to find damage from combining exercise and ibuprofen. Earlier work has shown that frequent use of the drug before and during workouts also can lead to colonic seepage. In a famous study from a few years ago, researchers found that runners at the Western States 100-Mile Endurance Run who were regular ibuprofen users had small amounts of colonic bacteria in their bloodstream.

Ironically, this bacterial incursion resulted in “higher levels of systemic inflammation,” said David C. Nieman, a professor of health and exercise science at Appalachian State University who conducted the study and is himself an ultramarathoner. In other words, the ultramarathon racers who frequently used ibuprofen, an anti-inflammatory, wound up with higher overall levels of bodily inflammation. They also reported being just as sore after the race as runners who had not taken ibuprofen.

Animal studies have also shown that ibuprofen hampers the ability of muscles to rebuild themselves after exercise. So why do so many athletes continue enthusiastically to swallow large and frequent doses of ibuprofen and related anti-inflammatory painkillers, including aspirin, before and during exercise?

“The idea is just entrenched in the athletic community that ibuprofen will help you to train better and harder,” Dr. Nieman said. “But that belief is simply not true. There is no scientifically valid reason to use ibuprofen before exercise and many reasons to avoid it.”

Dr. van Wijck agrees. “We do not yet know what the long-term consequences are” of regularly mixing exercise and ibuprofen, she said. But it is clear that “ibuprofen consumption by athletes is not harmless and should be strongly discouraged.”

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Gadgetwise Blog: No More Need to 'Tap and Swipe'

Part of the appeal of apps like Angry Birds and Cut the Rope is their simplicity. Just tap and swipe. But some of the more advanced app games require more complex finger maneuvers, making you wish you could use a physical controller.

Enter Discovery Bay Games, the maker of the new Duo Gamer game controller for Apple devices.

Duo Gamer connects wirelessly to an iPad or iPhone to play a range of adventure games from the app publisher Gameloft, including titles like Modern Combat 3: Fallen Nation and Asphalt 7: Heat.

Duo Gamer mimics the shape and size of video game controllers and has similar buttons, like a D-pad, triggers and left and right thumb sticks. It’s comfortable to hold, and the buttons are easy to use. It’s not designed for hours of gameplay, but most game apps don’t last that long anyway.

In the hands of a casual game player, the Duo Gamer controls are intuitive, especially if you already have experience using a controller. First-person shooter games like Modern Combat are much easier to play with Duo Gamer than they are using tap and swipe movements because you can focus on the game and forget about where your thumbs are. I had less success with the Asphalt racing game, which is more fun to play using the gyroscope in the iPad 2 to steer the cars.

Duo Gamer comes with an iPad stand, but no content of its own. At $80, it should include some free games, but you have to pay separately for the Gameloft apps. It would be great if Discovery Bay had partnerships with other app publishers as well. The more games that are available, the better Duo Gamer becomes.

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Nasrin Sotoudeh, Iranian Rights Advocate, Ends Hunger Strike

TEHRAN — An imprisoned human rights lawyer serving a sentence for “acting against national security” ended a 49-day hunger strike on Tuesday after judicial authorities acceded to her demand to lift a travel ban imposed on her 12-year-old daughter, her husband said.

Mihan News Agency, via European Pressphoto Agency

Nasrin Sotoudeh, a human rights lawyer, at home. She was put in prison in 2010.

The lawyer, Nasrin Sotoudeh, 49, who until her imprisonment in 2010 was one of the last lawyers taking on high-profile human rights and political cases in Iran, decided in October to go on the hunger strike out of fear of increasing limitations imposed on her family. She fell into fragile health during the hunger strike, in which she would drink only water mixed with salts and sugar. Her weight dropped to 95 pounds.

It was the second time that Ms. Sotoudeh felt compelled to quit eating. She declared her first hunger strike in 2010, after her family was forbidden to visit or make phone calls. In that case, the authorities capitulated after four weeks, allowing her husband and two children to visit weekly.

Ms. Sotoudeh has also written several public letters from prison, one of which thanked the head of the judiciary for putting her in jail, saying she was horrified by the thought of being free while her former clients were still in prison.

In recent years, several lawyers representing people suspected of security crimes have been arrested while others, like Shirin Ebadi, who won the Nobel Peace Prize in 2003, have left the country. Tuesday’s ruling, which had not been officially confirmed by the authorities here, seemed to show that Iranian officials are receptive to pressure in human rights cases — something that Ms. Sotoudeh has argued consistently.

Iranian officials deny there are any political prisoners in Iran, saying that all those behind bars have been tried according to the country’s laws. Ms. Sotoudeh is serving a six-year prison term since her conviction last year on the national security charge and over “misusing her profession as a lawyer.”

During a news conference last week, Mohammad Javad Larijani, a member of an influential political family and the head of the judiciary’s self-appointed Human Rights Council, said that from Iran’s official point of view there was nothing out of the ordinary about Ms. Sotoudeh’s imprisonment.

“Her dossier has had its course,” he told reporters, emphasizing what he called the independence of Iran’s judicial system. “Judges and lawyers have exhausted all legal possibilities, and now she is doing her time in jail.” He said that contrary to reports, Ms. Sotoudeh was in good health. “We care about our inmates, whether they are on hunger strike or not,” Mr. Larijani said.

International rights activists and human rights groups have tried to highlight Ms. Sotoudeh’s case, and international lawyers, movie directors and politicians — among them Secretary of State Hillary Rodham Clinton — have called on Iran to set her free. Ten days into her hunger strike, on Oct. 26, Ms. Sotoudeh, together with Jafar Panahi, an Iranian filmmaker who is under house arrest, was awarded the Sakharov Prize for Freedom of Thought by the European Union.

The international attention, widely replayed on Persian-language satellite channels at odds with Iran’s rulers, has helped raise her profile among middle-class Iranians, who generally admire her persistence. The attention has made it increasingly hard for Iranian officials to ignore her case, Ms. Sotoudeh’s husband, Reza Khandan, a computer engineer, said in an interview.

Mr. Khandan said that his wife is a great admirer of Daw Aung San Suu Kyi, the Burmese opposition leader and Nobel laureate, who spent years under house arrest, became an international symbol of resistance and is now a political leader herself.

“But this is her fight, and not our children’s,” Mr. Khandan said, “so Nasrin does everything she can in order to have something of a normal life.”

This article has been revised to reflect the following correction:

Correction: December 4, 2012

An earlier version of this article misstated the length of a hunger strike by Nasrin Sotoudeh. It was 49 days, not 47.

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Advertising: Stalled Budget Talks Cast Long Shadow

TOP advertising and media executives are expressing concern but not alarm — at least, not yet — about the potential effects that a fiscal crisis in the United States could have on their industries in 2013.

The executives spoke on Monday at the start of the 40th annual global media and communications conference, sponsored by UBS, in Midtown Manhattan. They addressed the possibility of a fiscal crisis in January as part of discussions about issues that could significantly curb growth in ad spending, among them the continued economic difficulties in the euro zone.

Widespread gloom about an inability to avert the fiscal crisis is one of four “gray swans” that are roiling markets, and marketers, said Martin Sorrell, chairman of WPP, the largest advertising holding group by revenue. The phrase is a play on the expression black swans, meaning highly improbable like the global financial crisis of 2008.

“I would err on the side of caution at the moment,” said Mr. Sorrell, whose hundreds of agencies include Grey, JWT, MEC, Mindshare, Ogilvy & Mather and Y&R.

“Whichever way it comes out, it creates tremendous uncertainty,” he added. “It’s much tougher sledding.”

For instance, Mr. Sorrell said, “clients used to look at calendar years” in their planning processes, but “now they look at quarters.”

“We had lunch with the C.E.O. of one of our major packaged-goods clients in New York last week,” he said, and the executive talked about “how hard it is to predict the behavior of consumers month to month.”

“This is packaged goods, not capital goods,” he added for emphasis, almost shaking his head in wonderment.

As a result, Mr. Sorrell said, as WPP agencies go through their fourth-quarter planning for the new year, they are “being told to be cautious” and to budget smaller gains in revenue for 2013 than might otherwise be expected.

Another gray swan influencing Mr. Sorrell’s outlook for next year is, of course, the tumult in the euro zone. He seemed more sanguine about that problem, saying, “By and large, we’ll muddle through.”

Mario Draghi, president of the European Central Bank, has “done a brilliant job,” Mr. Sorrell said, quoting approvingly a remark Mr. Draghi made on Friday that European governments had been “living in a fairy world.”

Mr. Sorrell expressed optimism for the year after next, pointing to a “strong ray of hope” that could shine on the ad industry in 2014 as a result of spending related to the Winter Olympics, the World Cup and, he added, laughing, “would you believe, we have another U.S. Congressional election.”

Another speaker, Michael I. Roth, chairman and chief executive of the Interpublic Group of Companies, repeatedly used the word uncertainty in his remarks, but also said he saw opportunity amid the question marks.

“When clients are faced with this economic uncertainty,” said Mr. Roth, whose agencies include Deutsch, Draftfcb, Initiative, Lowe & Partners and McCann Erickson, it is a chance for Interpublic to demonstrate that “we have the resources to move the needle” in selling goods and services for them.

Also, the current environment is not like the fourth quarter of 2008, Mr. Roth said, when the financial crisis led marketers to sharply and quickly cut their ad budgets.

“In this environment, our clients have plenty of cash,” he added. “The tone right now is O.K. and hopefully, we’ll see a good, vibrant December.”

“We don’t see a wholesale cutback in 2013,” Mr. Roth said, “at least so far,” adding that growth in American ad spending in the low single digits compared with this year “is a fair assumption to make.”

The Magna Global unit of Interpublic forecast on Monday that ad spending in the United States next year would increase 0.6 percent from 2012. That prediction assumes “we don’t fall off the fiscal cliff,” said Vincent Letang, executive vice president and director for global forecasting at Magna Global.

Also on Monday, the GroupM unit of WPP predicted a gain of 2.7 percent for American ad spending in 2013 and the ZenithOptimedia division of the Publicis Groupe forecast an increase of 3.5 percent. By comparison, their predictions for worldwide ad spending in 2013 compared with 2012 were somewhat stronger: Magna Global, up 3.1 percent; GroupM, up 4.5 percent; and ZenithOptimedia, up 4.1 percent.

Steve King, worldwide chief executive of ZenithOptimedia, said that in addition to the potential for a fiscal crisis, he was worried about “continued unrest in the Middle East and its impact on oil prices.”

Mr. Roth said that a possible fiscal crisis loomed larger as a “challenge” for Interpublic because Interpublic derived more of its revenue from the United States than did competitors like WPP, the Omnicom Group or Publicis.

To help insulate Interpublic, he said, “we will continue to invest in emerging markets” and “make sure we have powerful offerings” in fields like advertising, media services and digital marketing.

In a research note last week, Brian Wieser, an analyst at the Pivotal Research Group, estimated that an inability to resolve the fiscal crisis could result in American ad spending declining next year by 4 percent, or $9 billion, rather than growing by 1 percent as he has forecast.

“While economists’ consensus and our model speaks of optimism that this won’t happen,” Mr. Wieser wrote, “our brain increasingly thinks it just might.”

The UBS conference continues through Wednesday afternoon.

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Well: New Meaning and Drive in Life After Cancer

When people hear the words “You have cancer,” life is suddenly divided into distinct parts. There was their life before cancer, and then there is life after cancer.

The number of people in that second category continues to grow. In June, the National Cancer Institute reported that an estimated 13.7 million living Americans are cancer survivors, and the number will increase to almost 18 million over the next decade. More than half are younger than 70.

A new book, “Picture Your Life After Cancer,” (American Cancer Society) focuses on the living that goes on after a cancer diagnosis. It’s based on a multimedia project by The New York Times that asked readers to submit photos and their personal stories. So far, nearly 1,500 people have shared their experiences — the good, the bad, the challenging and the inspirational — creating a dramatic photo essay of the varied lives people live in the years after diagnosis.

For Susan Schwalb, a 68-year-old artist from Manhattan, a diagnosis of early-stage breast cancer at the age of 62 led to a lumpectomy, followed by a mastectomy and then failed reconstruction surgery. She discovered that cancer was not only a physical challenge but a mental one as well, and she turned to friends and support groups to cope with the emotional strain. When she saw the “Picture Your Life” project, she submitted a photo of herself wearing a paint-splattered artist’s apron.

“What cancer made me do in my own professional life is to pedal faster,” Ms. Schwalb said in an interview. “I’ve encountered some people who decide to enjoy life, retire, work in a garden. I decided I had to have more of what I wanted in life, and I better move fast because maybe I don’t have the long life I imagined I would have.”

Indeed, a common theme of the “Picture Your Life” project is that cancer spurs people to take long-delayed trips, seek out adventure and spend time with their families. Photos of mountain climbs, a ride on a camel, scuba diving excursions and bicycle trips are now part of the online collage.

Dr. David Posner, associate program director of pulmonary medicine at Lenox Hill Hospital in Manhattan, says a diagnosis of metastatic colon cancer at the age of 47 has helped him relate to his own patients with cancer. The past decade has included nine operations, six recurrences and three rounds of chemotherapy, but Dr. Posner said he never missed more than three weeks of work.

“My salvation has been my family and my work,” he said. “When I was at work I wasn’t thinking about myself, and it was very therapeutic. I see my share of cancer patients, and I motivate them and they motivate me.”

Dr. Posner said he decided to be part of “Picture Your Life” because he wants to get the word out that a cancer diagnosis — even a dire one like his — doesn’t have to define your life.

“I think about someone asking me, ‘So how was your last decade — was it wasted or was it a life filled with a lot of happiness and joy?’ ” he said. “The cancer thing was a pain, but for the most part I’ve had a pretty good time.”

The “Picture Your Life” collage includes photo after photo of survivors with their pets. Sandra Elliott, 59, of Claremont, Calif., submitted a picture of herself with her two golden retrievers, Buddy and Molly. They were just puppies when she received a diagnosis of Stage 2 breast cancer in 2003. During her recovery from surgery and chemotherapy treatments, she took the dogs to romp on the Pomona College campus, near her home, and one day a professional photographer snapped the picture.

“No matter how bad I felt that day, no matter how many chemo treatments or doctors appointments, those two little puppies with these big black eyes would look at me with their tails wagging as if to say, ‘It’s time. It’s time. It’s time to go out!’  ” Ms. Elliott recalled.

“I felt so physically horrible, and I’d look at them and the pure joy on their faces and in their bodies for just being out in nature and being able to smell the air, smell the trees, chase a squirrel — that sheer in-the-moment love of life they showed me really lifted my spirit on a daily basis.”

Ms. Elliott still lives with chronic pain as a result of nerve damage from her cancer treatment, and she can relate to others in the “Picture Your Life” project who worry that their cancer will recur or that they’ll never feel completely normal again. But she says a stronger theme runs through all the pictures and stories.

“We have all been forced to find the joy in the smallest things,” she said. “I’m sitting here looking at a geranium about to bloom. These things are out there — we just have to be reminded to look at them. And cancer is a big reminder.”

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Well: New Meaning and Drive in Life After Cancer

When people hear the words “You have cancer,” life is suddenly divided into distinct parts. There was their life before cancer, and then there is life after cancer.

The number of people in that second category continues to grow. In June, the National Cancer Institute reported that an estimated 13.7 million living Americans are cancer survivors, and the number will increase to almost 18 million over the next decade. More than half are younger than 70.

A new book, “Picture Your Life After Cancer,” (American Cancer Society) focuses on the living that goes on after a cancer diagnosis. It’s based on a multimedia project by The New York Times that asked readers to submit photos and their personal stories. So far, nearly 1,500 people have shared their experiences — the good, the bad, the challenging and the inspirational — creating a dramatic photo essay of the varied lives people live in the years after diagnosis.

For Susan Schwalb, a 68-year-old artist from Manhattan, a diagnosis of early-stage breast cancer at the age of 62 led to a lumpectomy, followed by a mastectomy and then failed reconstruction surgery. She discovered that cancer was not only a physical challenge but a mental one as well, and she turned to friends and support groups to cope with the emotional strain. When she saw the “Picture Your Life” project, she submitted a photo of herself wearing a paint-splattered artist’s apron.

“What cancer made me do in my own professional life is to pedal faster,” Ms. Schwalb said in an interview. “I’ve encountered some people who decide to enjoy life, retire, work in a garden. I decided I had to have more of what I wanted in life, and I better move fast because maybe I don’t have the long life I imagined I would have.”

Indeed, a common theme of the “Picture Your Life” project is that cancer spurs people to take long-delayed trips, seek out adventure and spend time with their families. Photos of mountain climbs, a ride on a camel, scuba diving excursions and bicycle trips are now part of the online collage.

Dr. David Posner, associate program director of pulmonary medicine at Lenox Hill Hospital in Manhattan, says a diagnosis of metastatic colon cancer at the age of 47 has helped him relate to his own patients with cancer. The past decade has included nine operations, six recurrences and three rounds of chemotherapy, but Dr. Posner said he never missed more than three weeks of work.

“My salvation has been my family and my work,” he said. “When I was at work I wasn’t thinking about myself, and it was very therapeutic. I see my share of cancer patients, and I motivate them and they motivate me.”

Dr. Posner said he decided to be part of “Picture Your Life” because he wants to get the word out that a cancer diagnosis — even a dire one like his — doesn’t have to define your life.

“I think about someone asking me, ‘So how was your last decade — was it wasted or was it a life filled with a lot of happiness and joy?’ ” he said. “The cancer thing was a pain, but for the most part I’ve had a pretty good time.”

The “Picture Your Life” collage includes photo after photo of survivors with their pets. Sandra Elliott, 59, of Claremont, Calif., submitted a picture of herself with her two golden retrievers, Buddy and Molly. They were just puppies when she received a diagnosis of Stage 2 breast cancer in 2003. During her recovery from surgery and chemotherapy treatments, she took the dogs to romp on the Pomona College campus, near her home, and one day a professional photographer snapped the picture.

“No matter how bad I felt that day, no matter how many chemo treatments or doctors appointments, those two little puppies with these big black eyes would look at me with their tails wagging as if to say, ‘It’s time. It’s time. It’s time to go out!’  ” Ms. Elliott recalled.

“I felt so physically horrible, and I’d look at them and the pure joy on their faces and in their bodies for just being out in nature and being able to smell the air, smell the trees, chase a squirrel — that sheer in-the-moment love of life they showed me really lifted my spirit on a daily basis.”

Ms. Elliott still lives with chronic pain as a result of nerve damage from her cancer treatment, and she can relate to others in the “Picture Your Life” project who worry that their cancer will recur or that they’ll never feel completely normal again. But she says a stronger theme runs through all the pictures and stories.

“We have all been forced to find the joy in the smallest things,” she said. “I’m sitting here looking at a geranium about to bloom. These things are out there — we just have to be reminded to look at them. And cancer is a big reminder.”

Read More..

Software Programs Help Doctors Diagnose, but Can’t Replace Them

SAN FRANCISCO — The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the moment of truth arrived, and the room was silent with anticipation.

At last he spoke. “Lymphoma with secondary hemophagocytic syndrome,” he said. The crowd erupted in applause.

Professionals in every field revere their superstars, and in medicine the best diagnosticians are held in particularly high esteem. Dr. Gurpreet Dhaliwal, 39, a self-effacing associate professor of clinical medicine at the University of California, San Francisco, is considered one of the most skillful clinical diagnosticians in practice today.

The case Dr. Dhaliwal was presented, at a medical  conference last year, began with information that could have described hundreds of diseases: the patient had intermittent fevers, joint pain, and weight and appetite loss.

To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course. He was given new information bit by bit — lab, imaging and biopsy results. Over the course of the session, he drew on an encyclopedic familiarity with thousands of syndromes. He deftly dismissed red herrings while picking up on clues that others might ignore, gradually homing in on the accurate diagnosis.

Just how special is Dr. Dhaliwal’s talent? More to the point, what can he do that a computer cannot? Will a computer ever successfully stand in for a skill that is based not simply on a vast fund of knowledge but also on more intangible factors like intuition?

The history of computer-assisted diagnostics is long and rich. In the 1970s, researchers at the University of Pittsburgh developed software to diagnose complex problems in general internal medicine; the project eventually resulted in a commercial program called Quick Medical Reference. Since the 1980s, Massachusetts General Hospital has been developing and refining DXplain, a program that provides a ranked list of clinical diagnoses from a set of symptoms and laboratory data.

And I.B.M., on the heels of its triumph last year with Watson, the Jeopardy-playing computer, is working on Watson for Healthcare.

In some ways, Dr. Dhaliwal’s diagnostic method is similar to that of another I.B.M. project: the Deep Blue chess program, which in 1996 trounced Garry Kasparov, the world’s best player at the time, to claim an unambiguous victory in the computer’s relentless march into the human domain.

Although lacking consciousness and a human’s intuition, Deep Blue had millions of moves memorized and could analyze as many each second. Dr. Dhaliwal does the diagnostic equivalent, though at human speed.

Since medical school, he has been an insatiable reader of case reports in medical journals, and case conferences from other hospitals. At work he occasionally uses a diagnostic checklist program called Isabel, just to make certain he hasn’t forgotten something. But the program has yet to offer a diagnosis that Dr. Dhaliwal missed.

Dr. Dhaliwal regularly receives cases from physicians who are stumped by a set of symptoms. At medical conferences, he is presented with one vexingly difficult case and is given 45 minutes to solve it. It is a medical high-wire act; doctors in the audience squirm as the set of facts gets more obscure and all the diagnoses they were considering are ruled out. After absorbing and processing scores of details, Dr. Dhaliwal must commit to a diagnosis. More often than not, he is right.

When working on a difficult case in front of an audience, Dr. Dhaliwal puts his entire thought process on display, with the goal of “elevating the stature of thinking,” he said. He believes this is becoming more important because physicians are being assessed on whether they gave the right medicine to a patient, or remembered to order a certain test.

Without such emphasis, physicians and training programs might forget the importance of having smart, thoughtful doctors. “Because in medicine,” Dr. Dhaliwal said, “thinking is our most important procedure.”

He added: “Getting better at diagnosis isn’t about figuring out if someone has one rare disease versus another. Getting better at diagnosis is as important to patient quality and safety as reducing medication errors, or eliminating wrong site surgery.”

Clinical Precision

Dr. Dhaliwal does half his clinical work on the wards of the San Francisco V. A. Medical Center, and the other half in its emergency department, where he often puzzles through multiple mysteries at a time.

One recent afternoon in the E.R., he was treating a 66-year-old man who was mentally unstable and uncooperative. He complained of hip pain, but routine lab work revealed that his kidneys weren’t working and his potassium was rising to a dangerous level, putting him in danger of an arrhythmia that could kill him — perhaps within hours. An ultrasound showed that his bladder was blocked.

There was work to be done: drain the bladder, correct the potassium level. It would have been easy to dismiss the hip pain as a distraction; it didn’t easily fit the picture. But Dr. Dhaliwal’s instinct is to hew to the ancient rule that physicians should try to come to a unifying diagnosis. In the end, everything — including the hip pain — was traced to metastatic prostate cancer.

“Things can shift very quickly in the emergency room,” Dr. Dhaliwal said. “One challenge of this, whether you use a computer or your brain, is deciding what’s signal and what’s noise.” Much of the time, it is his intuition that helps figure out which is which.

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Letter from China: A Merry Band of Rights Pranksters

BEIJING — They call themselves the Volunteers — a growing band of young Chinese who stage playful, but pointed, public protests for greater rights for women.

They dance and sing on the street wearing oversize “underpants” to assail invasive gynecological examinations for female civil servants, stroll through shopping precincts in bridal gowns spattered with red paint to combat domestic violence and shave off their hair in protest at higher university admissions standards for women.

And while their style is somewhat more subtle than that of Pussy Riot, Russia’s feminist punk collective, it hits home in a country where politics is conducted behind closed doors by men in look-alike dark suits. Against the secrecy and uniformity, the Volunteers’ “happenings” are a flash of color.

“We choose this wild and happy style because if we dance and sing, people pay attention,” said one Volunteer who asked that she be identified by the name she uses widely online, Zhu Xixi, because the group’s actions are risky in a country where the authorities are quick to crack down on public protests.

“We want to be spirited and positive. And it works,” said Ms. Zhu, who plans to take up postgraduate studies. “We want to show we are not victims. If we were too serious, we would scare people off.”

The women, and a few men, are mostly well educated, in their early or mid-20s. While Ms. Zhu wasn’t sure how many Volunteers there were, she said they were in every major city.

“And I think people are watching in every area of the country,” she said. “I think the movement will grow.”

There are certainly scores — perhaps hundreds. Many are students, often specializing in law or sociology, Ms. Zhu said. They are not highly organized, instead relying on social media and word of mouth to stage an event.

They are goaded on by entrenched gender discrimination, long visible in politics and elsewhere, several said in interviews over the last few months.

That discrimination just got worse. When the 18th National Congress of the ruling Communist Party appointed the country’s new leaders last month, the number of women in top positions not only failed to grow, but actually shrank.

The number of women on the party’s new, 205-person Central Committee fell to 10 from 13, according to Xinhua, the state-run news agency. Women now make up just 4.9 percent of members.

On the new Politburo, the 25-member body above the Central Committee, there are two women — one more than before. But the only woman with any chance of moving onto the most powerful body, the Politburo’s seven-member Standing Committee, Liu Yandong, failed to make the final selection.

She remains on the Politburo, joined by Sun Chunlan, the only female party leader for any of China’s 33 provinces and administrative districts, who has been appointed party secretary of Tianjin.

Ms. Liu, despite her solid credentials, was never going to make it into the inner circle of power, said a researcher at a central government institute with professional and personal ties to her. He requested that his name not be used for fear of the impact on his career.

“The Politburo is as high as a woman gets,” he said.

The Volunteers say they were struck by the contrast between the situation of women here and the gains women made in elections last month in the United States, where there will be more women than before in Congress — 20 of 100 in the Senate, and 78 of 435 in the House of Representatives.

So expect more protests in 2013, probably involving costumes, singing and synchronized dancing.

Days after a protest in which Ms. Zhu took part in the city of Wuhan, against requirements that women applying for civil service jobs undergo rigorous gynecological examinations and answer detailed questions about their menstrual cycles, another set of protests were staged in five other cities.

On Dec. 2, in Dongguan, Guangzhou, Xian, Hangzhou and Shanghai, women reprised the “Injured Brides” protest of Beijing last February, donning bridal gowns spattered with “blood” and holding up placards saying: “Love is not an excuse for violence,” part of a campaign for a law against domestic violence that has been debated for years but is not making visible progress.

Earlier this year, too, Volunteers attracted widespread media attention with their protests at public toilets in Guangzhou and other cities, saying women needed more facilities.

In August, Volunteers danced to a song they wrote, “Violence Is Intolerable,” in front of a Beijing courtroom where Kim Lee, a U.S. citizen, was seeking to divorce her Chinese husband, who had admitted physically abusing her. They carried a letter with 1,000 signatures calling for justice for Ms. Lee. The lyrics weren’t Pussy Riot punk, but in China their appeal to Confucian-style moral rectitude resonated:

Crazy violence reverberates through the country. Public apology has no sincerity at all. Repeated violence forces Kim to leave. Domestic violence should be severely punished.

Dad, why are you beating Mom? Is it really all right to hurt her? Mom gets hurt, and we are so scared. We just want a happy and lovely home.

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A Mets Owner and Claims of Consumer Fraud

This article is by Steve Eder, Richard Sandomir and Alison Leigh Cowan.

In March 2012, a group of online retailers was sued in federal court, accused of having participated in a cynical and longstanding scheme to cheat customers out of millions of dollars. One of the named defendants is 1-800-Flowers.com Inc., which says it is the world’s leading florist and gift shop.

The plaintiffs said the system worked this way: a customer, perhaps racing to buy flowers online for Mother’s Day, would enter a credit card number, click “Purchase,” and then be offered a cash-back rebate. If the customer clicked on the rebate option and failed to read the fine print, however, he or she wound up registering for a near-worthless club membership that would charge the credit card for months, sometimes years, before the expenses on the credit card statements were detected. Outfits like 1-800-Flowers.com received a cut of the operation, what regulators and others have called “bounties.”

A recent legal filing by lawyers in the case asserted that “1-800-Flowers was well aware that its customers were getting defrauded.”

Shortly after the lawsuit was filed in Connecticut last spring, the founder and chief executive of 1-800-Flowers.com officially became a minority owner of the Mets. The company executive, James F. McCann, had been selected by the team’s owners as one of a handful of investors whose infusion of cash was needed to help rescue the Mets from a financial crisis.

The team’s owners, Fred Wilpon and Saul Katz, have never told the public, or fans, the identity of the emergency investors — and new part owners. But McCann, whose company has long been an official sponsor of the Mets, and whose advertisements are prominently displayed at Citi Field, has acknowledged that he now owns a small chunk of the team.

It is unclear if Wilpon and Katz knew that McCann’s company had been accused of defrauding customers.

But a review of 1-800-Flowers.com’s legal problems makes clear that the 2012 lawsuit is hardly the first time someone has accused McCann’s business of knowingly participating in defrauding customers — with some of its victims quite possibly Mets fans, given the company’s aggressive marketing to the team’s loyal supporters.

Two years ago, a lawsuit was filed in federal court in Long Island claiming consumer fraud and racketeering violations against 1-800-Flowers.com and other companies, alleging they had worked together to “levy unauthorized charges on the unsuspecting consumers’ credit or debit card accounts” by inducing customers to pay for memberships to discount clubs without their knowledge.

That lawsuit, now in the process of being consolidated with the Connecticut case, came after the New York attorney general at the time, Andrew M. Cuomo, launched an investigation into the “discount club” industry, finding that 1-800-Flowers.com and other companies had “tricked” consumers into signing up for these memberships that charged them hidden fees.

There were also Senate investigative reports, issued in November 2009 and May 2010, that prominently cited 1-800-Flowers.com for its aggressive online sales tactics, saying the Long Island-based flower firm had been paid more than $10 million for allowing others to engage in what the report described as “post-transaction marketing.”

A spokesman for McCann and 1-800-Flowers.com would not comment for this article but said in an e-mail that the matters raised “are more than two years old, have been largely resolved and have been previously disclosed in our company’s public filings.” Last month, 1-800-Flowers.com Inc. said in a regulatory filing that it intended to defend itself vigorously in each of the outstanding lawsuits.

But in a 2010 settlement with the New York attorney general, the company paid $325,000 and promised to end practices Cuomo’s office had called “fraudulent,” at least as they related to the company’s New York customers. The company neither admitted nor disputed claims of wrongdoing as part of the settlement.

The settlement noted that 1-800-Flowers.com had since removed the solicitation and membership club enrollment link from its order confirmation page.

A spokesman for Wilpon and Katz and the Mets declined to comment on McCann’s legal entanglements.

In 2008, when Bernard L. Madoff was arrested and his multibillion-dollar Ponzi scheme collapsed, Wilpon and Katz, as longtime Madoff clients with investments of hundreds of millions of dollars, had their financial empire upended. Things got worse when, late in 2010, the court-appointed trustee representing Madoff’s victims sued Wilpon and Katz for $1 billion, saying they had enriched themselves for years while ignoring warnings that Madoff was up to no good.

Wilpon and Katz, as a consequence, went in search of cash. The men needed to repay some of their debt and deal with operating losses that rose to $70 million in 2011. The men ultimately decided to raise $200 million by selling 10 to 12 shares in the club, each representing a 4 percent ownership stake. Eventually, 12 were sold, but only a small number went to true outsiders.

One of those outsiders is Steven A. Cohen, the head of SAC Capital Advisors, a $14 billion hedge fund at the focus of an intensifying government investigation into insider trading. Cohen has not been accused of wrongdoing and may never be, but last month federal prosecutors charged a former portfolio manager with a $276 million insider trading scheme that for the first time connected Cohen to some questionable trades. Prosecutors have called the most recent case against an associate of Cohen’s the most lucrative insider trading case in history.

McCann, while technically an outside investor, is an old friend of Wilpon’s. McCann has long been part of a group that every season visits spring training at Port St. Lucie, Fla.

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Study Bolsters Link Between Routine Hits to Head and Long-Term Brain Disease

The growing evidence of a link between head trauma and long-term, degenerative brain disease was amplified in an extensive study of athletes, military veterans and others who absorbed repeated hits to the head, according to new findings published in the scientific journal Brain.

The study, which included brain samples taken posthumously from 85 people who had histories of repeated mild traumatic brain injury, added to the mounting body of research revealing the possible consequences of routine hits to the head in sports like football and hockey. The possibility that such mild head trauma could result in long-term cognitive impairment has come to vex sports officials, team doctors, athletes and parents in recent years.

Of the group of 85 people, 80 percent (68 men) — nearly all of whom played sports — showed evidence of chronic traumatic encephalopathy, or C.T.E., a degenerative and incurable disease whose symptoms can include memory loss, depression and dementia.

Among the group found to have C.T.E., 50 were football players, including 33 who played in the N.F.L. Among them were stars like Dave Duerson, Cookie Gilchrist and John Mackey. Many of the players were linemen and running backs, positions that tend to have more contact with opponents.

Six high school football players, nine college football players, seven pro boxers and four N.H.L. players, including Derek Boogaard, the former hockey enforcer who died from an accidental overdose of alcohol and painkillers, also showed signs of C.T.E. The study also included 21 veterans, most of whom were also athletes, who showed signs of C.T.E.

The study was conducted by investigators at the Boston University Center for the Study of Traumatic Encephalopathy and the Veterans Affairs Boston Healthcare System, in collaboration with the Sports Legacy Institute. It took four years to complete, included subjects 17 to 98 years old, and more than doubled the number of documented cases of C.T.E. The investigators also created a four-tiered system to classify degrees of C.T.E., hoping it would help doctors treat patients.

The volume of cases in the study “allows us to see the disease at all stages of severity and how it starts and spreads in the brain, which gives us an idea of the mechanism of the injury,” said Ann McKee, the main author of the study, who is a professor of neurology and pathology at Boston University School of Medicine and works at the V.A. Boston.

Those categorized as having Stage 1 of the disease had headaches and loss of attention and concentration, while those with Stage 2 also had depression, explosive behavior and short-term memory loss. Those with Stage 3 of C.T.E., including Duerson, a former All-Pro defensive back for the Chicago Bears who killed himself last year, had cognitive impairment and trouble with executive functions like planning and organizing. Those with Stage 4 had dementia, difficulty finding words and aggression.

Despite the breadth of the findings, the study, like others before it, did not prove definitively that head injuries sustained on the field caused C.T.E. To do that, doctors would need to identify the disease in living patients by using imaging equipment, blood tests or other techniques. Researchers have not been able to determine why some athletes who performed in the same conditions did not develop C.T.E.

The study also did not demonstrate what percentage of professional football players were likely to develop C.T.E. To do that, investigators would need to study the brains of players who do not develop C.T.E., and those are difficult to acquire because families of former players who do not exhibit symptoms are less likely to donate their brains to science.

“It’s a gambler’s game to try to predict what percentage of the population has this,” said Chris Nowinski, a co-author of the study and a co-director of the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine. “Many of the families donated the brains of their loved ones because they were symptomatic. Still, this is probably more widespread than we think.”

Researchers expected the details in the study to dispel doubts about the likelihood that many years of head trauma can lead to C.T.E. The growing connections between head trauma and contact sports, though, have led some nervous parents and coaches to assume that any concussion could lead to long-term impairment. Some doctors say that oversimplifies matters. Rather, the total amount of head trauma, including smaller subconcussive hits, as well as how they were treated, must be considered when evaluating whether an athlete is more at risk of developing a disease like C.T.E.

“All concussions are not created equal,” said Robert Cantu, a co-author of the study and a co-director of the encephalopathy center. “Parents have become paranoid about concussions and connecting the dots with C.T.E., and that’s wrong. The dots are really about total head trauma.”

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