A delicate new balancing act in senior healthcare









When Claire Gordon arrived at Cedars-Sinai Medical Center, nurses knew she needed extra attention.


She was 96, had heart disease and a history of falls. Now she had pneumonia and the flu. A team of Cedars specialists converged on her case to ensure that a bad situation did not turn worse and that she didn't end up with a lengthy, costly hospital stay.


Frail seniors like Gordon account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.





The U.S. population is aging quickly: People older than 65 are expected to make up nearly 20% of it by 2030. Linda P. Fried, dean of the Columbia University Mailman School of Public Health, said now is the time to train professionals and test efforts to improve care and lower healthcare costs for elderly patients.


"It's incredibly important that we prepare for being in a society where there are a lot of older people," she said. "We have to do this type of experiment right now."


At Cedars-Sinai, where more than half the patients in the medical and surgical wards are 65 or older, one such effort is dubbed the "frailty project." Within 24 hours, nurses assess elderly patients for their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.


The Cedars project stands out nationally because medical professionals are working together to identify high-risk patients at the front end of their hospitalizations to prevent problems at the back end, said Herb Schultz, regional director of the U.S. Department of Health and Human Services.


"For seniors, it is better care, it is high-quality care and it is peace of mind," he said.


The effort and others like it also have the potential to reduce healthcare costs by cutting preventable medical errors and readmissions, Schultz said. The federal law penalizes hospitals for both.


Gordon, an articulate woman with brightly painted fingernails and a sense of humor, arrived at Cedars-Sinai by ambulance on a Monday.


Soon, nurse Jacquelyn Maxton was at her bedside asking a series of questions to check for problems with sleep, diet and confusion. The answers led to Gordon's designation as a frail patient. The next day, the project team huddled down the hall and addressed her risks one by one. Medical staff would treat the flu and pneumonia while at the same time addressing underlying health issues that could extend Gordon's stay and slow her recovery, both in the hospital and after going home.


To reduce the chance of falls, nurses placed a yellow band on her wrist that read "fall risk" and ensured that she didn't get up on her own. To prevent bed sores, they got her up and moving as often as possible. To cut down on confusion, they reminded Gordon frequently where she was and made sure she got uninterrupted sleep. Medical staff also stopped a few unnecessary medications that Gordon had been prescribed before her admission, including a heavy narcotic and a sleeping pill.


"It is really a holistic approach to the patient, not just to the disease that they are in here for," said Glenn D. Braunstein, the hospital's vice president for clinical innovation.


Previously, nurse Ivy Dimalanta said, she and her colleagues provided similar care but on a much more random basis. Under the project, the care has become standardized.


The healthcare system has not been well designed to address the needs of seniors who may have had a lifetime of health problems, said Mary Naylor, gerontology professor at the University of Pennsylvania School of Nursing. As a result, patients sometimes fall through the cracks and return to hospitals again and again.


"That is not good for them and that is not good for society to be using resources in that way," Naylor said.


Using data from related projects, Cedars began a pilot program in 2011 and expanded it last summer. The research is continuing but early results suggest that the interventions are leading to fewer seniors being admitted to the intensive care unit and to shorter hospital stays, said Jeff Borenstein, researcher and lead clinician on the frailty project. "It definitely seems to be going in the right direction," he said.


The hospital is now working with Naylor and the University of Pennsylvania to design a program to help the patients once they go home.


"People who are frail are very vulnerable when they leave the hospital," said Harriet Udin Aronow, a researcher at Cedars. "We want to promote them being safe at home and continuing to recover."


In Gordon's case, she lives alone with the help of her children and a caregiver. The hospital didn't want her experiencing complications that would lengthen the stay, but they also didn't want to discharge her before she was ready. Under the health reform law, hospitals face penalties if patients come back too soon after being released.


Patients and their families often are unaware of the additional attention. Sitting in a chair in front of a vase of pink flowers, Gordon said she knew she would have to do her part to get out of the hospital quickly. "You have to move," she said. "I know you get bed sores if you stay in bed."


Gordon said she was comfortable at the hospital but she wanted to go back to her house as quickly as she could. "There's no place like home," she said.


Two days later, that's where she was.


anna.gorman@latimes.com





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Snoop Dogg blazes one during BMI songwriting panel


LOS ANGELES (AP) — Music fans who turned out to BMI's annual pre-Grammy Awards "How I Wrote That Song" discussion got a little more than they expected thanks to Snoop Dogg — a contact high.


The rapper smoked marijuana during Saturday's panel discussion, lighting up a large, Kush-filled blunt on stage at The Roxy. He briefly passed it off to B.o.B before methodically reducing it to ash over a 15-minute period. The panel also included Busta Rhymes and songwriters Luke Laird and Evan Bogart, all of whom abstained — at least on stage.


Fittingly, the conversation eventually turned to Snoop's groundbreaking work on "The Chronic."


Laird recalled growing up at the end of a dirt road 10 miles outside Conneaut Lake, a small town of 700 in rural Pennsylvania. Yet Snoop's work with Dr. Dre still infiltrated his world and that of all the other country kids around him.


"Let me just say, the album everyone was listening to was 'The Chronic,'" Laird said, noting how surreal it was to be sitting on stage with Snoop.


With acoustic guitar in hand, he played a bit of his Blake Shelton hit "Hillbilly Bone" in its original form: a rap song. The Nashville-based songwriter had everyone bobbing their heads to the beat.


"Now I feel like more than ever you see these influences crossing genres," Laird said.


___


Follow AP Music Writer Chris Talbott at http://twitter.com/Chris_Talbott .


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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen





At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.




The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.


Most of the victims were women and were shot in the back of the head, local reports said.


A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.


Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.


No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.


Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.


Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.


While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.


Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.


Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”


In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.


Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.


“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.


About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.


Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.


Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”


Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”


Aminu Abubakar contributed reported from Kano, Nigeria.



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Entrepreneur Brian Lee is business partner to the stars









The gig: Lawyer-turned-serial-entrepreneur Brian Lee, 41, is pulling double duty as the chief executive of two celebrity-backed e-commerce websites: ShoeDazzle, co-founded with Kim Kardashian, and Honest Co., co-founded with Jessica Alba. The companies are headquartered in Santa Monica and offer customers monthly subscription plans in addition to typical a la carte shopping for shoes and baby products, respectively.


ShoeDazzle has more than 15 million registered users and last year posted $100 million in revenue, up 80% from 2011; it has raised $66 million from investors including venture capital firm Andreessen Horowitz. Honest Co., launched a year ago, has yet to release membership or financial numbers but has raised $27 million.


From Seoul to L.A.: Lee was born in Seoul. When he was 1, his family immigrated to Huntington Beach, where he grew up.





As an 8-year-old, Lee mapped out his trick-or-treating route on Halloween so he could collect as much candy as possible. When he got home, he separated his loot into Ziploc bags, which he sold at school for 25 cents each.


"Cost of goods: zero. Profit margins: 100%, outside of my own little labor," he said. "I probably did that for five years."


He now lives in Marina del Rey with his wife, Mira; their 4-year-old son, Davis; and their 1-year-old daughter, Madison.


Education: Bachelor's degree in business economics from UCLA in 1993, J.D. from UCLA School of Law in 1996.


Bold cold call: After practicing law for a few years, Lee came up with the idea for LegalZoom, which offers self-help legal documents such as divorce and bankruptcy forms, prenuptial agreements and wills. He wanted a high-profile name to represent the start-up, and decided to approach O.J. Simpson defense attorney Robert Shapiro.


Lee got Shapiro's number from 411 and called him at 10 p.m. "He picked up the phone and said, 'Hi, this is Robert Shapiro, how can I help you?' and I said, 'Well, my name is Brian Lee and I have a business opportunity I'd like to run by you.'... I think he heard the desperation in my voice and he said, 'You've got two minutes.'"


LegalZoom, based in Glendale, launched in 2001.


Online shoe shopping: ShoeDazzle was inspired by Lee's wife, who one day returned from a shopping spree on Robertson Boulevard with a pair of pricey designer shoes. When Lee asked her why she didn't just go to Loehmann's or DSW, she said discount chains didn't provide the type of personalized, one-on-one service that small boutiques did. Lee set out to replicate that experience online and met Kardashian through Shapiro, who is a family friend.


ShoeDazzle launched four years ago as an online subscription business, with members viewing a customized showroom of shoes based on a personal fashion quiz and choosing one new pair to receive every month for $39.95 including shipping.


Taking back the reins: In November, Lee became CEO of ShoeDazzle for a second time. He returned after the departure of Bill Strauss, who scrapped the company's subscription-based business model last year, leading to speculation that the company wasn't doing well.


In his first 100 days on the job, Lee laid off about two dozen employees and hired celebrity fashion stylist Rachel Zoe as the company's chief stylist; ShoeDazzle also began introducing one new shoe style every day. This month the company will roll out an optional $9.95-a-month VIP membership program that includes free shipping, early access to sales, discounts and an extended return policy.


Since a site relaunch in January, orders have increased 30% and repeat visits are up 12%, Lee said. The company sells as many as 250,000 pairs of shoes per month.


From shoes to babies: Lee was approached by Alba when the actress wanted to start an eco-friendly baby products line. Honest Co. sells diapers, shampoo, sunscreen and household items online that are nontoxic and made with organic ingredients.


Caffeine junkie: As the CEO of two companies, Lee arrives at Honest Co. offices by 7 a.m. every day and is there until 9:30 a.m. He then heads over to nearby ShoeDazzle, where he stays until 5 p.m. or so. Then it's back to Honest Co. until about 8 or 9 p.m.


"I drink seven Coca-Colas a day," he said. "Regular Coke, which is really bad for me."


Advice to entrepreneurs: "Believe in the idea with 100% certainty," Lee said. "But also don't be scared to change that idea and pivot very quickly. Because as an entrepreneur, nothing ever goes to plan."


For instance, Lee said that in the early days of LegalZoom, the company created do-it-yourself software programs such as Estate Planning in a Box that it hoped to sell at Staples and OfficeMax. When LegalZoom realized that Internet-based downloading was the future, it dropped those plans.


"We spent a lot of resources on it," he said, "but we weren't afraid at all to just cut it."


andrea.chang@latimes.com





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Big Bear locked down amid manhunt









The bustling winter resort of Big Bear took on the appearance of a ghost town Thursday as surveillance aircraft buzzed overhead and police in tactical gear and carrying rifles patrolled mountain roads in convoys of SUVs, while others stood guard along major intersections.


Even before authorities had confirmed that the torched pickup truck discovered on a quiet forest road belonged to suspected gunman Christopher Dorner, 33, officials had ordered an emergency lockdown of local businesses, homes and the town's popular ski resorts. Parents were told to pick up their children from school, as rolling yellow buses might pose a target to an unpredictable fugitive on the run.


By nightfall, many residents had barricaded their doors as they prepared for a long, anxious evening.





PHOTOS: A tense manhunt amid tragic deaths


"We're all just stressed," said Andrea Burtons as she stocked up on provisions at a convenience store. "I have to go pick up my brother and get him home where we're safe."


Police ordered the lockdown about 9:30 a.m. as authorities throughout Southern California launched an immense manhunt for the former lawman, who is accused of killing three people as part of a long-standing grudge against the LAPD. Dorner is believed to have penned a long, angry manifesto on Facebook saying that he was unfairly fired from the force and was now seeking vengeance.


Forest lands surrounding Big Bear Lake are cross-hatched with fire roads and trails leading in all directions, and the snow-capped mountains can provide both cover and extreme challenges to a fugitive on foot. It was unclear whether Dorner was prepared for such rugged terrain.


Footprints were found leading from Dorner's burned pickup truck into the snow off Forest Road 2N10 and Club View Drive in Big Bear Lake.


San Bernardino County Sheriff John McMahon said that although authorities had deployed 125 officers for tracking and door-to-door searches, officers had to be mindful that the suspect may have set a trap.


"Certainly. There's always that concern and we're extremely careful and we're worried about this individual," McMahon said. "We're taking every precaution we can."


PHOTOS: A fugitive's life on Facebook


Big Bear has roughly 400 homes, but authorities guessed that only 40% are occupied year-round.


The search will probably play out with the backdrop of a winter storm that is expected to hit the area after midnight.


Up to 6 inches of snow could blanket local mountains, the National Weather Service said.


FULL COVERAGE: Sweeping manhunt for rampaging ex-cop


Gusts up to 50 mph could hit the region, said National Weather Service meteorologist Mark Moede, creating a wind-chill factor of 15 to 20 degrees.


Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.


"He could be anywhere at this point," McMahon said. When asked if the burned truck was a possible diversion, McMahon replied: "Anything's possible."


Dorner had no known connection to the area, authorities said.


Craig and Christine Winnegar, of Murrieta, found themselves caught up in the lockdown by accident. Craig brought his wife to Big Bear as a surprise to celebrate their 28th wedding anniversary. Their prearranged dinner was canceled when restaurant owners closed their doors out of fear.





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NBC pulls 'Do No Harm' after 2 low-rated episodes


LOS ANGELES (AP) — NBC is pulling the drama series "Do No Harm" after two low-rated episodes.


The show is a take on the story of Dr. Jekyll and Mr. Hyde, and stars Steven Pasquale of "Rescue Me." He plays a respected neurosurgeon who turns into a dangerous alter ego each night. Other cast members include Alana De La Garza and Phylicia Rashad.


"Do No Harm" started with a historically small audience for a major network debut and then dropped further in its second Thursday airing.


NBC will replace "Do No Harm" with reruns of "Law & Order: Special Victims Unit" for the next two weeks.


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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”


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

Correction: The patient’s eyes were brown, not blue.

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Stocks close higher; S&P 500 highest since Nov. `07












The Standard and Poor's 500 edged up to a five-year high Friday, extending a rally that started in January.

The S&P 500 rose 8.54 points to 1,517.93, closing 0.3 percent up for the week. The index is at its highest since November 2007 and has advanced for six weeks, the longest streak of gains since August.

The Dow Jones industrial average rose 48.92 points, or 0.4 percent, to 13,992.97. The Nasdaq composite climbed 28.74 points, or 0.9 percent, to finish the week at 3,193.87.

The Dow had its best January in almost two decades, and closed above 14,000 on Feb. 1 for the first time since 2007. The index is up 6.8 percent so far this year; the S&P 500 is up 6.4 percent.

A last-minute budget deal in Washington to avoid the “fiscal cliff” of tax hikes and spending cuts helped powered the rally, as did as optimism about the housing sector and gradual improvements in the jobs market.

The S&P 500 finished the week higher despite logging its biggest daily decline in almost three months Monday following worrying news from Europe.

The index fell 1.2 percent that day as bond yields in Spain and Italy rose on concern that the region's politicians will drag Europe back into crisis. European Central Bank President Mario Draghi's cautious comments about the region's economy also weighed on markets Thursday.

“Everybody seems to be saying this market needs to correct,” said Robert Pavlik, chief market strategist at Banyan Partners. “Nobody wants to be in it, but nobody wants to be out of it.”

Largely positive corporate earnings reports and a report that showed that the U.S. trade deficit narrowed sharply in December provided more fuel for the market's advance Friday.

The trade deficit fell nearly 21 percent in December from November to $38.6 billion, the smallest in nearly three years, as exports rose while oil imports plummeted. The smaller trade gap means the economy likely performed better in the final three months of last year than first reported last week.

“The trade balance was surprisingly very good,” said Phil Orlando, chief market strategist at Federated Investors.

The government estimated that the U.S. economy contracted at an annual rate of 0.1 percent in the last three months of 2012. Orlando estimates that may now be revised to growth of 0.5 percent.

Shares of LinkedIn, the online professional networking service, jumped $26.39, or 21.3 percent, to $150.40 after the company reported fourth-quarter results late Thursday that beat analysts' forecasts. AOL soared $2.31 to $33.72 after the Internet company said its quarterly revenue grew for the first time in eight years, helped by strength in worldwide advertising.

Currently, analysts are expecting earnings for the fourth quarter of 2012 to rise 6.5 percent for S&P 500 companies, according to data from S&P Capital I&Q. That's an increase from the 2.4 percent growth rate recorded for the preceding quarter.

Stocks have benefited as investors poured a net $4.1 billion into stock mutual funds since the start of the year, according to data provided by Lipper.

“I'm very encouraged by the fact, that finally, for the first time in many years, individual investors seem to be participating in this,” said David Kelly, chief global strategist at J.P. Morgan Funds.

The yield on the 10-year note, which moves inversely to its price, fell one basis point to 1.95 percent.

Trading volume was light as Wall Street braced for what is forecast to be the largest winter storm in more than a year. Up to 2 feet of snow forecast along the densely populated Interstate 95 corridor from the New York City area to Boston and beyond.

Among other stocks making big moves;

— Microchip Technology, a semiconductor maker, jumped $2.45, or 7.2 percent, to $36.39 after its earnings beat estimates. The company said it was seeing “exceptionally strong” bookings.

— Moody's slumped $3.62, or 7.7 percent, to $43.37 even after reporting that fourth-quarter net income jumped 66 percent and revenue blew away expectations. Many are expecting the ratings agency will be the next target of the Justice Department, which filed a suit against rival Standard & Poor's for its actions before the housing market collapse.

— Activision Blizzard, which makes “Call of Duty” and other video games, rose $1.35, or 11.2 percent, to $13.41. The company posted sharply higher earnings and revenue in the fourth quarter, surpassing Wall Street's expectations.

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Friend: Ex-cop 'last guy' expected to be murder suspect









Those who knew Christopher Jordan Dorner during college expressed shock at the news that the former college football player is allegedly responsible for shootings that have left three people dead and two wounded.


Dorner attended Southern Utah University from 1997 to 2001 and graduated with a bachelor of science with a major in political science and a minor in psychology, a university spokesman said.


Neil Gardner, an assistant athletic director who works with the student athletes in media relations, interacted with Dorner when he was on the school’s football team during the 1999 and 2000 seasons. Gardner said Dorner was a backup running back who didn’t play a lot, but was “never a disgruntled guy.”





PHOTOS: Manhunt for ex-LAPD officer


“When he was in college he was a great kid,” Gardner said. “He was a kid you hoped would do well. He was polite. I liked him.” 


Jamie Usera, an attorney in Salem, Ore., said he met Dorner in the spring of 1998 at Southern Utah. Usera, who grew up in Alaska, said he and Dorner, an African American from Southern California, bonded over their shared feelings of culture shock that came with being outsiders on the predominantly white, Mormon campus.


Usera and Dorner eventually joined the football team as running backs and became good friends, Usera said. They shared long hours on the practice field, but neither saw much playing time and both decided to quit the team after two years.


PHOTOS: Manhunt for ex-LAPD officer


The friendship endured throughout their remaining years at the school. Usera said he introduced Dorner to the world of hunting and other outdoor sporting. Usera recalled frequent trips into the Utah desert to hunt rabbits with Dorner.


Nothing about Dorner in college raised any red flags that he was mentally unstable or capable of such violence, Usera said.


“He was a typical guy. I liked him an awful lot,” Usera said. “Nothing about him struck me as violent or irrational in any way.  He was opinionated, but always seemed level-headed.”


Usera said he and Dorner frequently had lively discussions. A recurring theme was race relations in the U.S., and the two often had heated but respectful arguments about the extent of racism in the county, Usera said.


A manifesto that police say was published on what they believe was Dorner’s Facebook page  made reference to Usera. A section read:

“James Usera, great friend, attorney, father, husband, and the most cynical/blatant/politically incorrect friend a man can have. Best quality about you in college and now is that you never sugar coated the truth. I will miss our political discussions that always turned argumentative. Thanks for introducing me to outdoor sports like fishing, hunting, mudding, and also respect for the land and resources. Us city boys don’t get out much like you Alaskans. You even introduced me to PBR. A beer, that when you’re a poor college student is completely acceptable to get buzzed off of. I’m sorry I’ll never get to go on that moose and bear hunt with you. I love you bro.”


Usera could not recall Dorner ever discussing a dream or plan to become a police officer. He remembered his friend talking excitedly with a Marine or Navy recruiter on campus when he was either considering enlisting or after he had already made the decision to do so.


The two lost touch quickly after graduating, Dorner said, but later reconnected out of the blue about four years ago with a phone call. Dorner made passing reference to his discipline problems with the LAPD but did not go into detail. Usera said Dorner did not seem troubled during the 10- to 15-minute conversation. A few text messages followed in the days after the call, but Usera said he had not heard from Dorner since.


“Of all the people I hung out with in college, he is the last guy I would have expected to be in this kind of situation.”





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Bieber's mom trying to stay out of abortion debate


NEW YORK (AP) — Justin Bieber's mom wants to set the record straight: She's not interested in the political fray on abortion as she promotes "Crescendo," a new film she hopes will raise $10 million for centers that help pregnant girls.


Pattie Mallette, an unmarried teen herself when she had Bieber, signed on as an executive producer after the film was finished. She said Thursday that she connected personally with the story about a suicide and abortion attempt by Beethoven's mother.


"The press has been saying that I'm producing an anti-abortion film and taking this big stance. You know, I haven't shared my stance with anyone and I'm not here to make a political statement, so there's been a lot of assumptions made."


Mallette, in numerous interviews and her autobiography, "Nowhere but Up," has recounted her own suicide attempt, pressure to have an abortion when she became pregnant at 18 and struggles with drugs and alcohol before becoming a Christian.


The movie does include some producers who have anti-abortion beliefs, she said, but her goal is simple: to support residential programs like the one that helped her after her parents kicked her out of the house in Canada.


"The pregnancy center that I lived in is now closed because of lack of funds, so I thought it was a really important thing that they're doing to raise money," Mallette said.


The movie will be released Feb. 28 worldwide.


Mallette has had her share of mom moments of late with her only child, who at 18 is the youngest singer to have five chart-topping albums and will be both host and musical guest for the Feb. 9 episode of "Saturday Night Live" on NBC.


Like his Instagram photo (since deleted) of his butt crack. What ran through her head?


"I thought, I'm a mom, I don't want to see that," Mallette sighed, shaking her head. "I don't want to see him doing that kind of stuff. But, you know, he's 18. He's making some of his own decisions and he's going to make some mistakes and he's going to make some good choices, too."


What of reports of pot smoking and partying with "sizzurp"-downing hip hop singers — sizzurp being a purplish mixture of cough syrup with codeine and promethazine, a carbonated soft drink and pieces of Jolly Rancher candy.


"It's hard, you know, as a mom of an 18-year-old because that's the time when you just gotta start letting go," she said. "And, you know, I had to make some of my own mistakes. I gotta kind of let go and let him make some of his own mistakes and just hope that I put all the right things in him."


And what of Bieber's relationship with Selena Gomez?


"I have no idea if they're on-again, off-again," she said. "It's a constant thing. Today I'm not sure where they stand. I try to stay out of it. He's 18. He doesn't want me getting involved in his romantic life."


___


Follow Leanne Italie on Twitter at http://twitter.com/litalie


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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.


Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”
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Retail sales pick up in January after lackluster holidays









Retailers got a much-needed boost in January after a lackluster holiday shopping season, using post-holiday clearance deals to lure cagey consumers worried about higher payroll taxes.


H&M's coupon for 30% off this week drew Toluca Lake payroll accountant Katy Genovese to the store at the Americana at Brand shopping center. She walked out with a $20 dress and $30 in shirts.


Genovese, 57, and her shopping partner, Lori Berlanga, 45, said they spent January hitting up malls for bargains that are increasingly plentiful and longer-lasting. Instead of targeted discounts on specific items, retailers are offering more storewide deals with deeper markdowns.





"We celebrated Christmas after Christmas to hit all the sales," said Berlanga, a Studio City film production coordinator. "Stores are being much more competitive with each other."


Quiz: Do you know your premium jeans?


For a cross section of major retailers, that translated into a 5.8% sales upswing last month from January 2012. Analysts had expected a 3.5% boost.


The data from Thomson Reuters feature a roundup of 18 retailers' same-store sales, which account for revenue at retail locations operating for at least a year to strip out the fluctuations of recent openings and closings.


Some experts say the figures represent at most a snapshot of retail health because the report doesn't include behemoths such as Wal-Mart Stores Inc. and Best Buy Co. And more chains, including Macy's Inc. and Target Corp., are planning to ditch their monthly sales reports to focus on quarterly earnings.


The numbers that retailers did disclose surprised analysts with their strength, given the economic strain weighing down shoppers.


A higher payroll tax went into effect last month. Consumer confidence slid to its lowest level since November 2011, according to the Conference Board last week.


"Our guests continue to shop with discipline in the face of a slow economic recovery and new pressures," Target Chief Executive Gregg Steinhafel said.


The discount chain still enjoyed a 3.1% increase in same-store sales, which he attributed to holiday inventory clearance.


"The good news is that consumers are still showing resilience despite the increase in taxes," said Marshal Cohen, an analyst at the research firm NPD Group. "The bad news is that a lot of that business came at a discount as pent-up demand from December rolled over into January."


Department stores were the best-performing retail segment, bumping up 8.1% in January, according to a separate report from Retail Metrics Inc. analyst Ken Perkins.


Macy's was so heartened by its 11.7% advance in January that it raised its earnings forecast for its fiscal fourth quarter, which it will report Feb. 26. The retailer, which also owns the Bloomingdale's brand, predicts fourth-quarter earnings of $1.94 to $1.99 a share, up from its earlier projection of $1.91 to $1.96.


Perkins deemed teen apparel sellers the worst in show, with the sector taking a 2.2% dip. Wet Seal Inc., which is based in Foothill Ranch, suffered a 9.4% same-store sales slump.


Anthropologie and Free People owner Urban Outfitters Inc. said independently that comparable sales from its stores were flat for its fourth quarter, which ended Jan. 31.


Some shoppers spent January in hibernation.


North Hollywood actor Topher Johnson, 22, said he "got carried away" hunting through Black Friday sales in November and spending some $600 on Christmas presents. Now, with his tax refund coming and work starting to pick up after the holiday slump, he said he's slowing ratcheting up his purchases.


"January, though, was only food, gas and random stuff," he said.


The persistent cold weather was a mixed blessing, Perkins said. Sales of outerwear, which had lagged during the warm December, perked up.


But once after-holiday sales waned, the frigid temperatures caused shopper traffic to slow toward the end of the month, he said. Moving into February, the chilly climes could dampen sales of home improvement products and lighter apparel starting to roll out for spring.


"Valentine's Day and Presidents Day are blips on the retail radar screen," Perkins said. "There really aren't any spending catalysts until the weather warms up."


The trade group International Council of Shopping Centers, in yet another same-store sales report, said that chain retailers in the U.S. — including drugstores buoyed by flu shots — posted a 4.5% gain in January. The jump was the largest since September 2011.


This month, however, the group predicts that the growth rate will sink to roughly 3%.


"There's no ebullient retail sales trend showing that things are materially better," said Larry Palmer, managing director of private wealth management for Morgan Stanley. "There's cautious optimism, but there's also cautious skepticism."


tiffany.hsu@latimes.com





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Obama names REI chief to lead the Interior Department

President Obama nominated REI business executive Sally Jewell to lead his second-term Interior Department.









WASHINGTON – President Obama on Wednesday nominated Sally Jewell, a former oil engineer and banker and current chief executive of a national outdoor retailer, to lead the Interior Department, making an unorthodox pick for his first woman nominee to his second-term Cabinet.


The president and CEO of Recreational Equipment Inc., Jewell has no government and little public policy experience, and has spent her career far from Washington. But her resume has elements that appealed to both of the two feuding interests that consume much of the debate at the department that controls public lands: the oil and gas extraction industries seeking access to public lands, as well as environmentalists seeking to preserve them.


Jewell, 56, started her career as a petroleum engineer working in the oil fields of Oklahoma and Colorado for Mobil Oil Corp. She then moved to the corporate banking industry, and joined the REI board in 1996,  becoming chief operating officer four years later.








PHOTOS: President Obama’s past


She has been credited with expanding the Washington state-based retailer's Internet operations and contributing the membership cooperative’s resources to environmental stewardship. Jewell, an avid outdoorswoman, serves on the board of the National Parks Conservation Assn. as well as the Board of Regents of the University of Washington.


In announcing his choice, Obama cast her as someone who would seek a balance between protection and economic development of public lands. 


“She knows the link between conservation and good jobs,” Obama said in remarks at the White House. “She knows that there’s no contradiction between being good stewards of the land and our economic progress, that in fact, those two things need to go hand-in-hand. She’s shown that a company with more than $1 billion in sales can do the right thing for our planet.”


In fact, little is known about Jewell’s policy positions. And while environmental groups largely praised her nomination, Republicans and some Democrats withheld judgment.


“The livelihoods of Americans living and working in the West rely on maintaining a real balance between conservation and economic opportunity,” said Sen. Lisa Murkowski (R-Alaska), the ranking member of the Senate committee on energy and national resources.  “I look forward to hearing about the qualifications Ms. Jewell has that make her a suitable candidate to run such an important agency, and how she plans to restore balance to the Interior Department.”


PHOTOS: President Obama’s second inauguration


If confirmed, Jewell will replace Ken Salazar, who served in the post throughout the president’s first term and led a period of expansion of oil and gas drilling on public lands. Salazar plans to return to Colorado. Obama on Wednesday praised the former senator as a close friend and trusted advisor.


Salazar, he said, had “ushered in a new era of conservation of our land, our water and our wildlife.”


“He’s opened more public land and water for safe and responsible energy production – not just gas and oil, but also wind and solar – creating thousands of new jobs and nearly doubling our use of renewable energy in this country,” Obama said. 


Jewell is the first woman to be named to lead a Cabinet-level department in the second term. After naming a few white men to top jobs, Obama said the next round of nominees would include more women and be more racially diverse.


Follow Politics Now on Twitter and Facebook


Kathleen.hennessey@latimes.com


Twitter: @khennessey





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Chris Brown returns to court for probation issues


LOS ANGELES (AP) — With the woman he assaulted throwing him a kiss, Chris Brown walked into court Wednesday to face allegations he failed to complete his community labor sentence for Rihanna's 2009 beating.


A judge asked for more information and scheduled another hearing in two months.


Rihanna, the glamorous singer whose bruised face became a tabloid fixture after she was beaten by her then-boyfriend on the way to the Grammys, has been dating Brown again.


She arrived with the R&B star, his mother and two other women and blew him a kiss as he entered the courtroom. They left together after the short proceeding in which Superior Court Judge James Brandlin set the next hearing for April 5.


Brown's lawyer, Mark Geragos, said he was disturbed about the way the district attorney handled the matter and said he would be filing a motion opposing the prosecution's move to modify Brown's fulfillment of his community labor sentence.


Prosecutors, who said they could find no credible evidence that Brown had completed his community labor in his home state of Virginia, asked that he start all over and put in 180 days in Los Angeles County.


Prosecutors have suggested there was either sloppy record keeping or fraudulent reporting.


The judge noted during the brief court session that a prosecution filing did not request revocation of Brown's probation and he, therefore, would not revoke it.


A motion filed Tuesday also raised for the first time in Brown's felony assault case several incidents that prosecutors said demonstrate Brown has ongoing anger management issues.


The motion cited a Jan. 27 fight between Brown and fellow R&B star Frank Ocean, and a 2011 outburst in which Brown threw a chair through a window after he was asked about the Rihanna attack on "Good Morning America."


The filing represents a dramatic shift in the case against Brown, who was repeatedly praised by the judge overseeing his case for his completion of domestic violence courses and his community service work in his home state of Virginia.


That changed in September, when prosecutors raised concerns about Brown's community service after he logged 701 hours in seven months — an amount that had previously taken him more than two years to achieve.


Los Angeles investigators traveled to Richmond, Va., to investigate Brown's service, which was only described in broad strokes by Richmond Police Chief Bryan Norwood, who was overseeing the singer's community labor.


"This inquiry provided no credible, competent or verifiable evidence that defendant Brown performed his community labor as presented to this court," Deputy District Attorney Mary Murray wrote.


Brown's attorney Geragos blasted the court filing, saying the prosecutor ignored interviews "where sworn peace officers stated unequivocally that Mr. Brown was supervised and did all of the community service."


"I plan on asking for sanctions from the DA's office for filing a frivolous, scurrilous and frankly defamatory motion," he said Tuesday.


Brown's case was transferred to Brandlin after a recent shuffling of judicial assignments.


After pleading guilty to the Rihanna attack, Brown was given permission to serve 180 days of community labor in his home state of Virginia, but only as long as he performed manual labor such as graffiti removal and roadside cleanup.


Given problems with documentation and statements from some witnesses who contradict Brown's claims of work, prosecutors asked Brandlin to order Brown to repeat his service in Los Angeles.


Brown spent one-third of the hours he logged in Virginia working night shifts at a day care center in rural Virginia where his mother once served as director and where the singer spent time as a child.


A detective who checked on Brown's work nine times at the Tappahannock Children's Center found the singer, his mother and a bodyguard at the center on each visit.


The records said Brown waxed floors or performed general cleaning at the center.


A professional floor cleaner contracted to work at the daycare center told investigators he had been cleaning the floors during the months Brown reported working at the facility.


"Claims that the defendant cleaned, stripped and waxed floors at that location have been credibly contradicted," prosecutors said in the filing.


Brown's mother, Joyce Hawkins, no longer had a formal role at the day care center but had her own set of keys and coordinated her son's work at the facility, prosecutors said.


Murray stated in her filing that Norwood's report on Brown's service was "at best sloppy documentation and at worst fraudulent reporting."


Richmond police spokesman Gene Lepley declined to discuss the allegations.


"We believe it would inappropriate to comment on a matter that's before the court," Lepley said.


According to the motion, officials with Virginia's probation office told investigators that Brown's arrangement to be supervised by Norwood was "extremely unusual" and had not been approved by the agency. No one from Virginia's probation department oversaw Brown's hours, prosecutors said.


The motion noted that the only records the department has to indicate Brown was supervised were officers' overtime sheets. Five of 21 days that officers logged overtime for Brown were spent providing security for the singer's concerts.


The allegations are the latest pre-Grammy controversy for Brown, who was arrested shortly after the 2009 ceremony for his attack on Rihanna. He has since returned to the awards show by performing and winning an award in 2011 for his album "F.A.M.E."


Brown and Ocean are competing against one other for the Best Urban Contemporary Album category at Sunday's Grammys.


___


AP writers Anthony McCartney and Ryan Pearson contributed to this report.


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Personal Health: Effective Addiction Treatment

Countless people addicted to drugs, alcohol or both have managed to get clean and stay clean with the help of organizations like Alcoholics Anonymous or the thousands of residential and outpatient clinics devoted to treating addiction.

But if you have failed one or more times to achieve lasting sobriety after rehab, perhaps after spending tens of thousands of dollars, you’re not alone. And chances are, it’s not your fault.

Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.

According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.

A groundbreaking report published last year by the National Center on Addiction and Substance Abuse at Columbia University concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” The report added, “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”

The Columbia report found that most addiction treatment providers are not medical professionals and are not equipped with the knowledge, skills or credentials needed to provide the full range of evidence-based services, including medication and psychosocial therapy. The authors suggested that such insufficient care could be considered “a form of medical malpractice.”

The failings of many treatment programs — and the comprehensive therapies that have been scientifically validated but remain vastly underused — are described in an eye-opening new book, “Inside Rehab,” by Anne M. Fletcher, a science writer whose previous books include the highly acclaimed “Sober for Good.”

“There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches,” A. Thomas McLellan, co-founder of the Treatment Research Institute in Philadelphia, told Ms. Fletcher.

Ms. Fletcher’s book, replete with the experiences of treated addicts, offers myriad suggestions to help patients find addiction treatments with the highest probability of success.

Often, Ms. Fletcher found, low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan. Indeed, their revolving-door experiences with treatment helped prompt Ms. Fletcher’s exhaustive exploration in the first place.

In an interview, Ms. Fletcher said she wanted to inform consumers “about science-based practices that should form the basis of addiction treatment” and explode some of the myths surrounding it.

One such myth is the belief that most addicts need to go to a rehab center.

“The truth is that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually,” she wrote.

Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”

Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, “You don’t treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it.”

Dr. Willenbring now practices in St. Paul, where he is creating a clinic called Alltyr “to serve as a model to demonstrate what comprehensive 21st century treatment should look like.”

“While some people are helped by one intensive round of treatment, the majority of addicts continue to need services,” Dr. Willenbring said. He cited the case of a 43-year-old woman “who has been in and out of rehab 42 times” because she never got the full range of medical and support services she needed.

Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.

“We have some pretty good drugs to help people with addiction problems, but doctors don’t know how to use them,” he said. “The 12-step community doesn’t want to use relapse-prevention medication because they view it as a crutch.”

Before committing to a treatment program, Ms. Fletcher urges prospective clients or their families to do their homework. The first step, she said, is to get an independent assessment of the need for treatment, as well as the kind of treatment needed, by an expert who is not affiliated with the program you are considering.

Check on the credentials of the program’s personnel, who should have “at least a master’s degree,” Ms. Fletcher said. If the therapist is a physician, he or she should be certified by the American Board of Addiction Medicine.

Does the facility’s approach to treatment fit with your beliefs and values? If a 12-step program like A.A. is not right for you, don’t choose it just because it’s the best known approach.

Meet with the therapist who will treat you and ask what your treatment plan will be. “It should be more than movies, lectures or three-hour classes three times a week,” Ms. Fletcher said. “You should be treated by a licensed addiction counselor who will see you one-on-one. Treatment should be individualized. One size does not fit all.”

Find out if you will receive therapy for any underlying condition, like depression, or a social problem that could sabotage recovery. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”

Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.

Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, “Get Your Loved One Sober,” with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol.

This is the first of two articles on addiction treatment.

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Going good postal








The U.S. Postal Service, in its latest bid to save a few billion bucks, plans to stop delivering mail on Saturdays.


It's not enough.


The ugly truth is that the Postal Service's commitment to universal mail service is no longer financially viable in the age of email, text messages, Facebook and Twitter. As currently configured, it will never again be able to meet its legal obligation to pay its own way.






To survive, the Postal Service will need to reinvent itself for the digital age. I have a few ideas on how to do that, which I'll get back to in a moment.


First, let's look briefly at how we got into this mess.


A big part of the problem is a 2006 law requiring the Postal Service to pay about $5.5 billion a year into a health-benefit fund for retirees. No other government agency faces such a requirement.


Then again, the Postal Service isn't like any other government agency. Many people might not know it, but the Postal Service isn't supported by tax dollars. It has to cover its own nut, yet is unable to do anything without Congress' say-so.


Until now, the agency was able to scrape by because it was allowed by federal law to borrow up to $3 billion a year from the Treasury Department. But its debt couldn't top $15 billion, and the Postal Service maxed out its credit card last year.


That caused it to default for the first time on its payments into the retiree fund and caused the agency to start racking up losses of nearly $36 million a day. The Postal Service's net loss for last year hit a staggering $15.6 billion.


By 2016, if things continue as they're going, the service estimates its annual losses will reach about $21 billion.


Even Pets.com did better than that.


So here we are. On Wednesday, Postmaster General Patrick Donahoe said that Saturday delivery of letters would stop in August, though weekend delivery of packages will continue. This would save about $2 billion a year.


Meanwhile, the Postal Service will continue a massive restructuring that aims to cut its workforce by 193,000, or 28%, and consolidate more than 200 mail processing locations.


"The American public understands the financial challenges of the Postal Service and supports these steps as a responsible and reasonable approach to improving our financial situation," Donahoe said.


"The Postal Service has a responsibility to take the steps necessary to return to long-term financial stability and ensure the continued affordability of the U.S. mail," he said.


I don't care how many packages stream through post offices. It'll never be enough to cover the huge expense of meeting a federal obligation to deliver mail to every home in the country.


Here's the bottom line: The total volume of first-class mail plunged to 73.5 billion pieces of mail in 2011 from about 102 billion in 2002. That's a 28% decrease.


Video killed the radio star. The Internet is killing letters.


Privatizing mail delivery isn't realistic. I've spoken with both FedEx and UPS. They say they're open to dropping off people's letters and catalogs and stuff, but they don't want the responsibility of having to deliver everywhere.


So what's the solution? In an earlier column I floated the idea of forgoing mail delivery to some rural areas, restoring the old-fashioned notion of people coming to the post office for their deliveries.






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L.A. Archdiocese considering $200-million fund-raising campaign









In the midst of renewed public outrage over its handling of the priest molestation cases, the Los Angeles Archdiocese is considering a $200-million fund-raising campaign.


The archdiocese has hired a New York company, Guidance in Giving, to study the feasibility of a capital campaign that would shore up the church’s finances.


The archdiocese is $80 million in debt, according to a recent church financial report. In 2007, the archdiocese agreed to a record $600-million settlement with more than 500 alleged victims of priest abuse.








The consultants conducting the six-month study are interviewing every pastor in the archdiocese, as well as lay leaders.


A spokesman for the church said initial feedback has been “very positive.” The funds used would “be put into various endowments earmarked to support the pastoral priorities of the archdiocese, as well as for the general repair and upkeep of our parish churches and schools,” spokesman Tod Tamberg said in a statement.


The campaign would be the archdiocese’s first in 60 years. During the Truman administration, the church raised $3.5 million for new schools in just three weeks. At the time of that 1949 drive, there were about 650,000 Catholics in the archdiocese. Now there are more than 5 million, according to church figures.


The church has not announced the possibility of a campaign to the faithful, but Tamberg acknowledged it in response to questions from The Times on Tuesday.
Last week, Archbishop Jose Gomez publicly rebuked his predecessor, Cardinal Roger M. Mahony, and a high-ranking bishop, Thomas J. Curry, for their handling of molestation claims in the 1980 and 1990s. Files made public last month showed Mahony and Curry working to conceal priests’ sex abuse of children from the police.


At the same time he condemned their actions, the church posted 12,000 pages of priest personnel files on its website that revealed many more instances where officials covered up for abusers. Gomez, who got his undergraduate degree in accounting, assembled a special committee last year to evaluate the possibility of a large-scale campaign, according to the church financial report.


The archdiocese is still paying back a $175-million loan it received to pay victims in the civil settlement. “The archbishop considers stewardship of the church’s financial resources and sound fiscal planning to be a vital dimension of the new evangelization,” church auditors wrote in a recent report.





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Disney working on stand-alone 'Star Wars' films


LOS ANGELES (AP) — Disney is mining The Force for even more new films.


Walt Disney Co. CEO Bob Iger said Tuesday that screenwriters Larry Kasdan and Simon Kinberg are working on stand-alone "Star Wars" movies that aren't part of the new trilogy that's in the works.


"There has been speculation about some standalone films that have been in development, and I can confirm to you today that in fact we are working on a few stand-alone films," Iger told CNBC.


Iger said the movies would be based on "great 'Star Wars' characters that are not part of the overall saga." The films would be released during the six-year period of the new trilogy, which starts in 2015 with "Star Wars: Episode VII."


Disney confirmed last month that "Star Trek" director J.J. Abrams will direct the seventh installment of the "Star Wars" saga.


Disney bought "Star Wars" maker Lucasfilm last year for more than $4 billion.


The last "Star Wars" trilogy, a prequel to the original films, was released from 1999 to 2005.


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Well: Warning Too Late for Some Babies

Six weeks after Jack Mahoney was born prematurely on Feb. 3, 2011, the neonatal staff at WakeMed Hospital in Raleigh, N.C., noticed that his heart rate slowed slightly when he ate. They figured he was having difficulty feeding, and they added a thickener to help.

When Jack was discharged, his parents were given the thickener, SimplyThick, to mix into his formula. Two weeks later, Jack was back in the hospital, with a swollen belly and in inconsolable pain. By then, most of his small intestine had stopped working. He died soon after, at 66 days old.

A month later, the Food and Drug Administration issued a caution that SimplyThick should not be fed to premature infants because it may cause necrotizing enterocolitis, or NEC, a life-threatening condition that damages intestinal tissue.


Catherine Saint Louis speaks about using SimplyThick in premature infants.



Experts do not know how the product may be linked to the condition, but Jack is not the only child to die after receiving SimplyThick. An F.D.A. investigation of 84 cases, published in The Journal of Pediatrics in 2012, found a “distinct illness pattern” in 22 instances that suggested a possible link between SimplyThick and NEC. Seven deaths were cited; 14 infants required surgery.

Last September, after more adverse events were reported, the F.D.A. warned that the thickener should not be given to any infants. But the fact that SimplyThick was widely used at all in neonatal intensive care units has spawned a spate of lawsuits and raised questions about regulatory oversight of food additives for infants.

SimplyThick is made from xanthan gum, a widely-used food additive on the F.D.A.’s list of substances “generally recognized as safe.” SimplyThick is classified as a food and the F.D.A. did not assess it for safety.

John Holahan, president of SimplyThick, which is based in St. Louis, acknowledged that the company marketed the product to speech language pathologists who in turn recommended it to infants. The patent touted its effectiveness in breast milk.

However, Mr. Holahan said, “There was no need to conduct studies, as the use of thickeners overall was already well established. In addition, the safety of xanthan gum was already well established.”

Since 2001, SimplyThick has been widely used by adults with swallowing difficulties. A liquid thickened to about the consistency of honey allows the drinker more time to close his airway and prevent aspiration.

Doctors in newborn intensive care units often ask non-physician colleagues like speech pathologists to determine whether an infant has a swallowing problem. And those auxiliary feeding specialists often recommended SimplyThick for neonates with swallowing troubles or acid reflux.

The thickener became popular because it was easy to mix, could be used with breast milk, and maintained its consistency, unlike alternatives like rice cereal.

“It was word of mouth, then neonatologists got used to using it. It became adopted,” said Dr. Steven Abrams, a neonatologist at Texas Children’s Hospital in Houston. “At any given time, several babies in our nursery — and in any neonatal unit — would be on it.”

But in early 2011, Dr. Benson Silverman, the director of the F.D.A.’s infant formula section, was alerted to an online forum where doctors had reported 15 cases of NEC among infants given SimplyThick. The agency issued its first warning about its use in babies that May. “We can only do something with the information we are provided with,” he said. “If information is not provided, how would we know?”

Most infants who took SimplyThick did not fall ill, and NEC is not uncommon in premature infants. But most who develop NEC do so while still in the hospital. Some premature infants given SimplyThick developed NEC later than usual, a few after they went home, a pattern the F.D.A. found unusually worrisome.

Even now it is not known how the thickener might have contributed to the infant deaths. One possibility is that xanthan gum itself is not suitable for the fragile digestive systems of newborns. The intestines of premature babies are “much more likely to have bacterial overgrowth” than adults’, said Dr. Jeffrey Pietz, the chief of newborn medicine at Children’s Hospital Central California in Madera.

“You try not to put anything in a baby’s intestine that’s not natural.” If you do, he added, “you’ve got to have a good reason.”

A second possibility is that batches of the thickener were contaminated with harmful bacteria. In late May 2011, the F.D.A. inspected the plants that make SimplyThick and found violations at one in Stone Mountain, Ga., including a failure to “thermally process” the product to destroy bacteria of a “public health significance.”

The company, Thermo Pac, voluntarily withdrew certain batches. But it appears some children may have ingested potentially contaminated batches.

The parents of Jaden Santos, a preemie who died of NEC while on SimplyThick, still have unused packets of recalled lots, according to their lawyer, Joe Taraska.

The authors of the F.D.A. report theorized that the infants’ intestinal membranes could have been damaged by bacteria breaking down the xanthan gum into too many toxic byproducts.

Dr. Qing Yang, a neonatologist at Wake Forest University, is a co-author of a case series in the Journal of Perinatology about three premature infants who took SimplyThick, developed NEC and were treated. The paper speculates that NEC was “most likely caused by the stimulation of the immature gut by xanthan gum.”

Dr. Yang said she only belatedly realized “there’s a lack of data” on xanthan gum’s use in preemies. “The lesson I learned is not to be totally dependent on the speech pathologist.”

Julie Mueller’s daughter Addison was born full-term and given SimplyThick after a swallow test showed she was at risk of choking. It was recommended by a speech pathologist at the hospital.

Less than a month later, Addison was dead with multiple holes in her small intestine. “It was a nightmare,” said Ms. Mueller, who has filed a lawsuit against SimplyThick. “I was astounded how a hospital and manufacturer was gearing this toward newborns when they never had to prove it would be safe for them. Basically we just did a research trial for the manufacturer.”

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Nasdaq reportedly in settlement talks over flubbed Facebook IPO













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Facebook founder Mark Zuckerberg, center, rings the Nasdaq opening bell May 18 from Facebook headquarters in Menlo Park, Calif.
(Zef Nikolla / Associated Press / February 5, 2013)










































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Report: FBI was watching bunker hostage-taker the whole time









Federal Bureau of Investigation negotiators were watching Jimmy Lee Dykes, 65, "the whole time" as they prepared to enter the bunker where Dykes was holding a 5-year-old boy hostage, CBS News reported in its Monday evening broadcast.


Officials rescued the boy, named Ethan, early Monday evening in a surprise raid that left Dykes dead, ending a nearly weeklong standoff that began after Dykes boarded a bus and killed a bus driver before taking the boy to his underground bunker.


Citing unnamed federal sources, CBS News reported that the FBI rescue team created two diversions to distract Dykes before they entered the bunker from the top.





Officials said at a news conference that negotiations had deteriorated over the past 24 hours and that they had seen Dykes with a gun inside the bunker.


“At this point, FBI agents, fearing the child was in imminent danger, entered the bunker and rescued the child," Stephen E. Richardson, the special agent in charge of the FBI’s office in Mobile, Ala., said at a nationally televised news conference.


Officials did not go into further detail at the news conference, promising more information soon.


CBS News reported that officials had lowered a camera into the Dykes' bunker and "had eyes on him the whole time."


Dykes attacked the school bus a day before he was to appear in local court to answer charges of menacing a neighbor. According to residents of Midland City, Dykes was a fierce presence, firing shots at people and beating to death a dog that trespassed on his property.


Authorities maintained contact with Dykes through a 4-inch PVC pipe through which medicine was sent into the underground shelter, built by Dykes. Ethan was said to have a form of autism.


Michael Muskal contributed to this report.


ALSO:


Alabama standoff ends with child released, captor dead


Texas judge faces 'court of inquiry' into wrongful conviction


Ed Koch remembered as 'Uncle Eddie' and a savior of New York





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Live action: Twitter grabs Super Bowl spotlight






NEW YORK (AP) — Beyonce’s splashy show, a freak power outage, and —oh, yeah— a captivating game of football combined to generate a record 24.1 million posts on Twitter during Sunday night’s Super Bowl.


That’s up from 13.7 million last year — and that doesn’t even include chatter surrounding the ads.






Twitter said in a late Sunday blog post that about half of the more than 50 national TV spots that aired during the game included a “hashtag,” a word or phrase preceded by a number sign that’s used to organize subjects on the short messaging site. During last year’s game, only one in five ads included one. Brands ranging from Oreo to Tide and Budweiser, meanwhile, captured online buzz by linking the blackout to their brands in humorous tweets.


Super Bowl XLVII, like the London Summer Olympics and the U.S. presidential election, was yet another moment in which Twitter became the platform for millions of people to share quick reactions and participate in a massive, public conversation. Though it’s not as popular as Facebook Inc. or its buttoned-up cousin LinkedIn Corp., Twitter’s surging popularity during big events is a testament to its reach and utility. The question is whether these moments can translate into revenue for the 7-year-old company.


The company makes money by charging advertisers to promote individual tweets, accounts or trends designed to spark a conversation. Research firm eMarketer estimates that Twitter will book advertising revenue of $ 545.2 million this year, up 89 percent from 2012. Next year, worldwide ad revenue is expected to hit $ 807.5 million, a 48 percent increase from 2013.


Tweetable events such as the 34-minute Super Bowl power outage are ripe with marketing potential, provided that brands act quickly.


“It’s really clear right now that Twitter has a lock on real-time conversation on the Internet,” says eMarketer analyst Debra Aho Williamson.


To capitalize on this, Twitter has to show advertisers that it pays to promote their tweets — even though fans are likely to spread the catchiest slogans on their own, free of charge.


That’s what happened with a certain cream-filled cookie on Sunday.


It took Oreo’s marketers roughly 10 minutes after the power went out to tweet a picture of an Oreo cookie in the half-dark with the words: “You can still dunk in the dark.” As of Monday afternoon, the image had been shared on Twitter more than 15,000 times. Tide followed suit with the slogan “we can’t get your blackout. But we can get your stains out” with more limited success. The message was re-tweeted about 1,300 times. Calvin Klein, meanwhile, tweeted a video of a shirtless, chiseled male model doing crunches “since the lights are still out…”


Such “real-time marketing” is still in its infancy, but Williamson expects this to change, as more companies develop the ability to respond to events immediately.”


“To do what Oreo did actually takes a lot of pre-planning,” she says.


Laurie Guzzinati, spokeswoman for Oreo owner Mondelez says the power outage was a natural moment to engage consumers. The cookie’s TV ad had a planned social media component asking people to follow Oreo on Twitter and post photos on Instagram. The company had set up a “social media command center” that included people from Oreo’s brand team, the ad agency 360i and other partners whose job was to follow the Super Bowl and interact with fans on Facebook, Twitter and elsewhere.


Mondelez likely spent the going rate of as much as $ 4 million on its Super Bowl television spot. But Guzzinati says the company didn’t pay Twitter anything for the “dunk in the dark” picture. Still, Twitter says advertisers moved quickly following the outage.


Matt McGee, editor-in-chief of the blog Marketing Land, counted 26 Twitter mentions in the 52 national spots that aired during the game. Facebook, meanwhile, got only four shout-outs, while Google Plus walked away with zero (though Google Inc.’s YouTube scored one mention from Hyundai).


“When it comes to second-screen advertising, it’s Twitter’s world now and there’s no close second place,” McGee wrote in a blog post late Sunday night. “Last year, brands split their focus on Twitter and Facebook with eight mentions each. This year, brands recognize that Twitter is where they need to try to attract the online conversation around one of the world’s biggest events.”


David Berkowitz, vice president of emerging media at 360i, which worked on the Oreo campaign, says Twitter has done a good job tying itself into major television events.


“If you look at (Twitter’s) trending topics any day especially during prime time or major events, they’re heavily fueled by television,” he says. “So TV is responsible for Twitter’s growth in general.”


He thinks Twitter has done a better job than other social media sites like Tumblr and Pinterest in proving it’s the place to be when it comes to talking about big events online.


“A large part of it right now is just showing this is where the conversation is happening and building their brand around that,” he says. “Even with other very successful social media sites, no one is better at conversation than Twitter.”


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AP Retail Writer Mae Anderson contributed to this story.


Social Media News Headlines – Yahoo! News





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