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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DC Comics Turns the Occupy Movement Into a Superhero Title

Eighteen months after the phrase first entered the collective public consciousness, the plight of the 99 percent is coming to mainstream superhero comics — via a new series from the second biggest publisher in the American comic industry, which just happens to be a subsidiary of a multi-national corporation that makes around $12 billion a year. Irony, anybody?

In May, DC Comics will launch two new series taking place in their mainstream superhero universe that offer different insights into the class struggle in a world filled with superheroes, alien races and inexplicable events. The Green Team, written by Tiny Titans and Superman Family Adventures creators Art Baltazar and Franco, with art by Ig Guara, revives an obscure 1975 concept about teenage rich kids who try to make the world a better place with their outrageous wealth. In an interview promoting the series, Franco promised that it would address questions like “Can money make you happy?” and “If you had unlimited wealth, could you use that to make the lives of people better?”

Obviously, this is one of the more fanciful series DC will be publishing.

But while DC is promoting The Green Team series as the adventures of the “1%,” its companion title, The Movement, is teased as a chance for us to “Meet the 99%… They were the super-powered disenfranchised — now they’re the voice of the people!”

“It’s a book about power,” explained The Movement writer Gail Simone. “Who owns it, who uses it, who suffers from its abuse. As we increasingly move to an age where information is currency, you get these situations where a single viral video can cost a previously unassailable corporation billions, or can upset the power balance of entire governments. And because the sources of that information are so dispersed and nameless, it’s nearly impossible to shut it all down.”

“The thing I find fascinating and a little bit worrisome is, what happens when a hacktivist group whose politics you find completely repulsive has this same kind of power and influence,” she elaborated in an interview at Big Shiny Robot. “What if a racist or homophobic group rises up and organizes in the same manner?”

While the concept is ambitious, the idea that a comic capable of living up to the book’s populist inspiration could come from DC Entertainment still strikes some as unlikely. Matt Pizzolo, the editor of the Occupy Comics anthology, told Wired that “though DC Comics did help launch Alan Moore and David Lloyd’s seminal anarchist epic V For Vendetta over two decades ago, it’s unlikely they would do so today. Between dismantling Vertigo and frankensteining Watchmen, the past year has demonstrated DC isn’t a safe place for bold creators who want to tell the kinds of stories that would inspire things like Occupy, rather than just cash in on them.”

Still, Simone says that the use of the iconography and language of a real-world populist movement is deliberate, promising that the book will reflect today’s decentralized political world and offer ”a slice of rarity that we’re unlikely to see in most superhero books.”

This wouldn’t the first time that DC has attempted to offer pre-packaged populist rebellion, of course; in addition to the aforementioned publication of the anti-establishment V For Vendetta, the company’s Vertigo imprint also published Grant Morrison’s The Invisibles, a series centering around an international organization struggling against forces of authority and repression that included anti-corporate themes.

Only time will tell whether The Movement will live up to the subversive examples of these earlier books, or just end up a well-intentioned piece of topical super heroics that trades on, and commodifies, a real political movement.

The Movement #1 will be available in both print and digital formats on May 1, while The Green Team #1 will be released on May 22.

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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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Business Week in Pictures

Phil Libin, the chief executive of Evernote, during a staff meeting at Evernote’s headquarters in Redwood City, Calif. Evernote is among the privately held Silicon Valley start-ups that are worth more than $1 billion. An unprecedented number of high technology start-ups, easily 25 and possibly exceeding 40, have crossed that threshold. Many employees are quietly growing rich, or at least building a big cushion against a crash, as they sell shares to outside investors. Airbnb, Pinterest, SurveyMonkey and Spotify are among the better-known privately held companies that have reached $1 billion.

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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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Fate of Historic Landsat Mission Hinges on Upcoming Launch

Since 1972 the Landsat mission has been monitoring natural and human-made changes to our planet. But the continuity of that scientifically precious dataset could be lost unless all goes according to plan on Monday, when the Landsat 8 satellite is scheduled to be launched into orbit from Vandenberg Air Force Base in California. Landsat 8 will take over for the hobbled 14-year old Landsat 7 that has been valiantly carrying the mission alone since December when, after 29 years in orbit, Landsat 5 began to be decommissioned after a gyroscope failure.

The launch is not likely to fail, but if it does, it won’t be the first time the continuity of the 40-year mission was jeopardized. Along the way funding has come under fire, ownership of the satellites has been transferred between government agencies and private companies, sensors have quit working, and one mission tragically failed to reach orbit. If Landsat 8 fails, Landsat 7 would run out of fuel near the end of 2016, before a replacement could be built and put into orbit.

“I’ve devoted the latter part of my career to the formulation and development of this mission,” the project’s lead scientist, James Irons, told Wired. “On Monday I go out there and look at my baby sitting on top of an enormous firecracker and hope everything goes well.”

“Yeah, I’ll be nervous.”

The scientists and engineers behind the Landsat mission will be hugely relieved once the craft is safely in place 700 kilometers above their heads and then begins beaming data back to Earth about a month later.

In addition to saving the mission from a gap in data, Landsat 8 — more officially known as the Landsat Data Continuity Mission – will boost the rate of coverage of the Earth and will also add more sensing capability and deliver better imagery than its predecessors.

Relying on Landsat 7 alone has meant only imaging the full Earth every 16 days. Once there are two eyes open, coverage will return to 8-day intervals, essentially doubling the resolution of landscape change that will be recorded.

“The major goal of the mission is for us to understand land cover and land use change, and determine the human impacts on the global landscape,” Irons said. “These changes are going on at rates unprecedented in human history.”

“Continuity is more important than ever.”

The new satellite will also add more sensing capability and deliver better imagery than its predecessors. Landsat 8 will measure all the spectral bands of its predecessors, but will add two new bands that are tailored for detecting the coastal zone and cirrus clouds.

The new satellite has a more advanced imaging design as well. Previous Landsat satellites used what is known as a whisk broom sensor system, where an oscillating mirror would sweep back and forth over a row of detectors that collect data across a 185-kilometer swath of the Earth. The new push system uses a very long array of more than 7,000 detectors that will view the 185 km swath simultaneously, alternately collecting light and recording data. This allows each detector to dwell on each pixel for a longer time, resulting in more detailed, accurate descriptions of the landscape.

Once Landsat 8 reaches orbit, the engineers will begin testing the spacecraft during the first week. The next few weeks will be dedicated to testing all the instruments. The satellite will then do a cross-over rendezvous with Landsat 7 to calibrate the two systems. Around day 25, the shutters will be opened and Landsat 8 will take its first look at Earth. By the end of May, the data should be flowing. The new satellite has a design life of five years, but it has enough fuel to operate for 10 years.

But first, the new craft has to get safely into orbit.

“I have a lot of assurance from everyone,” Irons said. “They are taking extraordinary care, proceeding very methodically, cautiously and rigorously.”

“Still, you realize all rocket launches have some inherent risk,” he said. “So, it’s just hold your breath and hope everything goes well.”

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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.”

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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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Trade Deficit Narrows, Brightening Outlook

The United States economy most likely expanded slightly in the fourth quarter, instead of contracting, according to trade data released Friday that suggested a surprise drop in gross domestic product reported last week may have been overstated.

The country’s trade deficit narrowed to $38.5 billion in December, its lowest reading in nearly three years, Commerce Department data showed. The decrease was driven by a drop in oil imports and a surge in exports. The overall trade gap was far smaller than analysts polled by Reuters had expected.

“Trade data for December paint a reassuring and encouraging picture of the U.S. economy at the end of last year,” said Chris Williamson, chief economist at Markit.

A separate report from the Commerce Department showed that wholesale inventories unexpectedly declined in December, a factor that could hamper the stronger trade figures’ effect on growth.

Still, the two reports together suggested the government could revise up its reading on fourth-quarter G.D.P., which showed the economy contracting at a 0.1 percent annual rate. That decline was driven by an expected drop in exports, smaller gains in inventories and a plunge in military spending.

Barclays said that even with December’s decline in wholesale inventories, the economy most likely expanded 0.3 percent in the fourth quarter, thanks to the higher export numbers in Friday’s trade report.

American exports increased by $8.6 billion in December over the year-ago month, lifted by sales of industrial supplies, including a $1.2 billion rise from November in nonmonetary gold.

Reflecting the country’s current boom in oil and natural gas, petroleum exports rose by nearly $1 billion during the month to a record high.

A fall in petroleum purchases led overall imports to decline by $4.6 billion in December from the year-ago period.

For the entire year, the country’s imports of crude oil fell to their lowest levels since 1997 in terms of volume.

Stocks prices on American exchanges rose as investors took note of the strong trade data, which included the United States figures as well as readings showing stronger exports and imports in China during January. The price of the benchmark 10-year Treasury note also rose.

For all of 2012, the United States trade gap shrank by 3.5 percent, to $540.4 billion. Running trade deficits means the country loses dollars, which drags on the economy; rising exports reduce that effect.

Exports last year rose 4.4 percent.

Even the American trade balance with China had a silver lining. While imports from China increased to a record high last year, so did American exports there. The December trade deficit in goods with China, not seasonally adjusted, narrowed by $4.5 billion from the previous month on a drop in imports.

Also in December, United States wholesale inventories unexpectedly fell as auto dealers and agricultural suppliers drew down their stocks.

The Commerce Department said stocks of unsold goods at wholesalers dropped 0.1 percent during the month and grew less than initially estimated in November.

Economists polled by Reuters had expected wholesale inventories to rise 0.4 percent.

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Ex-cop at center of manhunt called 'depraved,' 'cowardly'

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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Investigators Pinpoint a Short Circuit Within a 787 Dreamliner Battery

The National Transportation Safety Board believes an internal short circuit within a single cell inside a lithium-ion battery led to a fire aboard a Boeing 787, shedding new light on the battery problem that has grounded every one of the 50 Dreamliners in service worldwide.

The agency said Wednesday that it has completed disassembling the 32-volt battery that caught fire on a Japan Airlines 787 after passengers had disembarked in Boston on January 7. Investigators found evidence that the fire — called “thermal runaway” — started with a short circuit in cell no 6. There are eight cells in the 63-pound lithium-ion battery, and the NTSB said it found evidence that cell no. 6 sustained multiple short circuits. Investigators have ruled out mechanical damage as a cause of the short, as well as the possibility that the short circuit occurred between the cell and the battery case. Rather, the damage to the case containing the battery was caused by the fire that resulted from the short.

“The short circuit came first, the thermal runaway followed in cell no. 6 and it propagated to the other cells,” NTSB chairman Deborah Hersman told reporters in a press conference this morning. Hersman said they have yet to find the cause of the short circuit but are looking at several possibilities.

“We are looking at the state of charge of the battery cells, we are looking at manufacturing processes and we are looking at the design of the battery,” she said.

The new information came the same day that Boeing flew a 787 from its paint facility in Texas back to its factory north of Seattle. The flight was a one-time-only ferry flight approved by the Federal Aviation Administration, and only the pilots were allowed aboard. They closely monitored the battery during the flight to Paine Field and experienced no problems during the three-and-a-half-hour trip. It was the first flight of a 787 since the entire fleet of Dreamliners was grounded pending an investigation by the FAA.

Late today the FAA announced they will allow limited test flights by Boeing to collect data about the battery and electrical systems during flight. The test flights will be flown over unpopulated areas with just the Boeing crew on board the aircraft. Like today’s flight, pilots will carefully monitor the batteries and will be required to land immediately in the case of a battery malfunction. One of Boeing’s 787 flight-test work horses, ZA005, will be used for the flights.

Boeing, along with investigators in the United States and Japan, have focused on the lithium-ion battery from the start. And today’s announcement that the problem appears to have started with a short circuit within a cell is exactly what battery expert Dr. K.M. Abraham suggested was the problem when we spoke with him last month. The lithium-ion cells within the 787 batteries use a graphite-coated copper anode and a lithium cobalt oxide-coated aluminum cathode. The anode and cathode are separated by a very thin polyethylene film known as the separator.

The separator is roughly the same thickness as cellophane and behaves in a similar way. There doesn’t need to be a tear or a hole to create a short circuit that can cause thermal runaway. The material is very thin – typically around 25 microns, according to Abraham – and small irregularities in the thickness can be enough to lead to problems. A section of the separator that is just 20 microns thick might be enough.

“It could be a stretch, it doesn’t necessarily have to be a big hole, just a weak point where you have low resistance,” Abraham said. “It can be a problem when you have such a very large surface area electrode where there is a lot of inhomogeneity in the current distribution.”

The variable thickness of the separator material could be a result of manufacturing, but also could occur during charging and discharging of the battery. A very small short might lead to the growth of a lithium crystal within the battery cell.

“Sometimes what happens is you start with a very small dendrite growth due to an internal short,” Abraham says of the small fibers of lithium metal that can grow in the cell, “but it gradually heats up because gas can pass through it and heat up that location.”

And just like cellophane, the separator can shrink when it is heated, Abraham says, “once it starts heating up slowly it will shrink and then a small short will become a massive short.”

Abraham, agreeing with comments made by Tesla Motors CEO Elon Musk, said the relatively large cells in the 787 battery pose a problem. The large surface area of each cell makes the separators particularly susceptible to shorting, Abraham said. The problem of the separator changing thickness due to heating is something addressed in the batteries used in the Chevrolet Volt. The separator is less likely to change thickness due to heating, according to Abraham.

“That was overcome in the Chevrolet Volt separator where they reinforced the separator with ceramic particles to mitigate the shrinking problem,” he said.

According to the NTSB, the separators used in the 787 batteries are not reinforced with ceramic particles.

The NTSB chairwoman told reporters the agency also is looking into the certification of the Dreamliner. Because the 787 is replete with new technology, the FAA had to create nine special conditions for use of the lithium-ion batteries. Much of the testing was performed by Boeing, which performed several rigorous tests including one so grueling as to be called “abusive” to the battery, Hersman said.

Boeing saw no evidence during testing of a problem that would lead to the cell failure propagation the NTSB saw in the battery that caught fire in Boston. Hersman also said Boeing’s tests indicated it was extremely unlikely that a battery problem would generate smoke, much less fire. The difference between the predicted likelihood and the recent events did not sit well with Hersman.

“The design and certification assessment and the assumptions that were made were not born out by what we saw,” she said, speaking about the battery fires in Boston and Japan. “We had two events in two weeks on two separate aircraft. The fleet has less than 100,000 hours and [Boeing] did not expect in their assessment to see a smoke event in but less than 1 in every 10,000,000 hours.”

In a statement released after the NTSB press conference, Boeing said it welcomes the progress being made in the investigation. The company also said it worked within FAA guidelines during certification.

“The 787 was certified following a rigorous Boeing test program and an extensive certification program conducted by the FAA,” the statement read. “We provided testing and analysis in support of the requirements of the FAA special conditions associated with the use of lithium ion batteries.”

Hersman said the NTSB will release an interim report within 30 days. That means the fleet most likely will remain grounded at least another month. Boeing is working on several possible fixes to the issue, including designs that will better protect the electrical bays and aircraft from any potential fire damage.

Meanwhile, several airlines, including All Nippon Airways and United, continue cancelling 787 flights many weeks into the future.

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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.

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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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U.S. Official Faults F.A.A. for Missing 787 Battery Risk

The nation’s top transportation safety official said Thursday that the Federal Aviation Administration accepted test results from Boeing in 2007 that failed to properly assess the risks of smoke or fire leaking from the batteries on Boeing’s new 787 jets.  

Deborah Hersman, the chairwoman of the National Transportation Safety Board, told reporters that the problems seemed to have originated in the battery, when one of the eight cells had a short circuit and the fire spread to the rest of the cells. But she said that Boeing’s tests showed no indication that the new lithium-ion batteries on its 787 planes could erupt in flame and concluded they were likely to emit smoke less than once in every 10 million flight hours.

Once the planes were placed in service, though, the batteries overheated and emitted smoke twice last month, and caused one fire, after about 50,000 hours of commercial flights.

“The assumptions used to certify the batteries must be reconsidered,” Ms. Hersman said.

Late Thursday, the F.A.A. said it would allow Boeing to conduct test flights with its 787 to collect data on the batteries and the plane’s electrical system. The agency said the flights “will be an important part of our efforts to ensure the safety of passengers and return these aircraft to service.” It did not immediately specify the number of test flights or when they would begin.

Ms. Hersman, at her news conference, said that before the F.A.A. certified the batteries, Boeing’s tests found no evidence that a short circuit in one of the eight cells could spread to other cells.

But Ms. Hersman said the fire on a 787 parked at an airport in Boston on Jan. 7 started with a short-circuit in one cell and then spread to the other cells.

She said investigators have still not been able to tell what caused the short-circuit in that cell and led to a “thermal runaway,” overheating up to 500 degrees, that then cascaded to the rest of the cells.

Still, she said, “This investigation has demonstrated that a short-circuit in a single cell can propagate to adjacent cells and result in a fire.”

Battery experts said that the finding pinpointed one step Boeing could take to make the batteries safer: It could expand the size of the battery to create more physical separation between the cells. Ralph J. Brodd, a battery industry consultant in Henderson, Nev., said Boeing and its Japanese battery subcontractor, GS Yuasa, could make the design and manufacturing changes needed to do that fairly quickly.

But unless investigators can determine what caused the first cell to short-circuit, federal officials said, Boeing will also be required to make other changes to prevent any of the possible causes and to better contain or vent any overheated materials. And given the safety board’s findings about how poorly Boeing gauged the original safety risks, the F.A.A. is likely to take its time in assessing the validity of any new tests.

The 787 is the first commercial airplane to use large lithium-ion batteries for major flight functions. All 50 of Boeing’s 787s that were delivered to airlines have been grounded since mid-January, when a 787 made an emergency landing in Japan after the pilots smelled smoke in the cockpit. That incident occurred nine days after the Boston fire.

In searching for the cause of the fire on the plane in Boston, Ms. Hersman said the safety board was still looking at the battery’s charging mechanism and potential manufacturing defects or contamination, and whether the cells were not as isolated as they should have been.

Investigators have so far ruled out two possible reasons for the short-circuit — a mechanical or electrical shock from outside the battery.

“We have not yet identified what the cause of the short-circuit is,” she said. “We are looking at the design of the battery, at the manufacturing, and we are also looking at the cell charging. There are a lot of things we are still looking at.”

Boeing said in a statement Thursday that it viewed the safety board’s findings as narrowing the likely source of the problem to within the battery itself, as opposed to other components of the plane’s extensive new electric system. But company officials said they also recognized that it would take a combination of changes to restore confidence in the battery system.

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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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Microsoft Teases Future Surface Pro Accessories With Extra Battery Power

Days before Surface Pro’s release date, Microsoft is already teasing the types of accessories we’ll see for the device.

In a Reddit AMA hosted on Wednesday, members of the Surface Team responded to user questions, and suggested that a Surface Pro cover that would double as an extra battery pack is in the works. Good thing, too, since we found that the Surface Pro could barely get around four hours of normal usage.

Naturally, that’s a major concern for people considering buying the computer — Reddit members brought it up on multiple occasions. Asked about the new connectors at the bottom of the Surface Pro on either side of the cover port, a Microsoft rep said, “At launch we talked about the ‘accessory spine’ and hinted at future peripherals that can click in and do more. Those connectors look like can carry more current than the pogo pins, don’t they?”

The cryptic answer was fleshed out in another response. A redditor specifically asked if Microsoft plans to make a thicker keyboard with an extra battery pack.

“That would require extending the design of the accessory spine to include some way to transfer higher current between the peripheral and the main battery. Which we did,” a Surface Team member replied.

Considering that Microsoft already has released two covers for Surface Pro and Surface RT, along with a Surface-branded Wedge Touch Mouse, it’s not hard to imagine the company expanding its Surface accessory lineup. It’s a natural next step as the company continues to focus on its hardware division, which has traditionally offered accessories like mice and keyboards.

The Reddit AMA also covered issues like Surface Pro’s lack of storage space and whether the company plans to release a 3G or 4G Surface. The latter answer was a roundabout “no.” As for storage space, the Surface Team’s Marc DesCamp said, once again, that you can extend storage through the USB 3.0 port and microSDX card slot. He also mentioned that initial reports of available storage space (23GB for the 64GB model, and 83GB for the 128GB model) are conservative; you actually get around 6 to 7GB more than that.

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Kiefer Sutherland named Hasty Pudding Man of the Year

LOS ANGELES (TheWrap.com) – Kiefer Sutherland has gained his share of accolades throughout his acting career, but none quite like this.

The “24″ star has been named 2013′s Man of the Year by Harvard University‘s Hasty Pudding Theatricals student society, succeeding “The Muppets” actor Jason Segel, who received the honors last year.

Sutherland will be feted with a roast on Friday at Harvard’s Farkas Hall, where he will receive his ceremonial Pudding Pot. If Hasty Pudding tradition is any indication, Sutherland will also dress at least partially in women’s clothes at some point during the event. Which is presumably a rare event for the actor.

“Inception” actress Marion Cotillard, who was named 2013′s Woman of the Year by the theatrical society, was honored at a January 13 ceremony, during which she led a parade through the streets of Cambridge, Mass.

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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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Media Decoder Blog: Cable TV Revenue Help Spur Time Warner Profit

2:14 p.m. | Updated The cable television business helped propel Time Warner to a 51-percent increase in net income and offset weakness in magazine publishing and movies in the three months that ended Dec. 31.

The media company said Wednesday that an increase in advertising revenue and subscription fees paid by cable and satellite companies to carry channels like TNT and TBS helped lift net income in the fourth quarter to $1.17 billion, or $1.21 a share, up from $773 million, or 76 cents a share, in the same three-month period last year. Revenues remained flat at $8.2 billion.

The results underscore the widening gap between the fast-growing cable television business and the more challenged magazine publishing industry and, to a lesser degree, the movie businesses.

Time Warner also said on Wednesday that its board had approved $4 billion in stock buybacks and that it would raise its quarterly dividend by 11 percent to 28.75 cents per share.

Jeffrey L. Bewkes, Time Warner’s chairman and chief executive, called the cable television business the “core of the company.” He praised the premium cable channel HBO, pointing to the interest fueled by returning series like “Game of Thrones” and “True Blood” and new original series like “Girls.” HBO added domestic subscribers in the quarter, the company reported.

At the same time, Time Inc., the nation’s largest magazine publisher, readied for layoffs of 6 percent of its global work force, cutbacks that it announced last week. Time Warner estimated the reductions would cost an estimated $60 million in restructuring charges, which will be reported in the first quarter of 2013.

Revenue at the company’s television networks, which include TNT, TBS, and CNN, rose 5 percent to $3.67 billion in the quarter. Subscription and advertising revenues at Time Warner’s suite of cable channels grew 7 percent and 3 percent, respectively, in the quarter, compared with last year. An increase in the number of National Basketball Association games on Turner channels, as well as coverage of the presidential election on CNN, led to higher ratings.

Mr. Bewkes said that, even with the boon from election coverage, CNN’s ratings disappointed. He praised the recent choice of Jeff Zucker, a former chief executive of NBC Universal, to lead CNN. “I’m optimistic that with the new leadership we’ve announced, CNN will once again fulfill the promise of its iconic brand,” he said on a conference call with analysts.

Revenue at the Warner Brothers studio fell 4 percent in the quarter to $3.7 billion, due largely to a tough comparison with 2011, which included the home entertainment release of the popular “Harry Potter and the Deathly Hallows: Part 2.” The performance of “Argo” and “The Hobbit: An Unexpected Journey” lifted Warner Brothers’ performance in the quarter and contributed to a 29 percent increase in operating income to $522 million.

Last week, Time Warner announced that Kevin Tsujihara, currently the head of the studio’s home entertainment division, would succeed Barry M. Meyer as chief executive of Warner Brothers. “I chose him because he’s got the greatest breadth of experience across Warner’s businesses,” Mr. Bewkes said on Wednesday.

Time Inc., the publisher of People, Sports Illustrated and InStyle, represents a small part of Time Warner’s overall business, but nevertheless continued to weigh on the company’s overall results. Revenues at Time Inc. declined 7 percent to $967 million, while advertising revenues fell 4 percent, or $24 million. Subscription revenues remained flat.

For the full fiscal year, which also ended Dec. 31, Time Warner reported net income of $3 billion, or $3.09 per share, compared with $2.9 billion, or $2.71 per share in 2011. In the full fiscal year, revenues decreased 1 percent to $28.7 billion.

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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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Finally, a Mophie Juice Pack for Your iPhone 5

The iPhone 5 finally has its own Mophie juice pack battery case to call its own, the Juice Pack Helium. The 1,500 mAh battery-toting case boosts your iPhone 5′s battery life by 80 percent, and is 13 percent thinner than Mophie’s previous iPhone juice packs.

We’ve been waiting for this since the iPhone came out. Mophie’s juice pack iPhone cases are lifesaver at conferences or all-day events where you’re constantly checking, reading, tapping and typing on your phone. They also excel at protecting your handset while supplying additional battery power to extend your phone’s life. We love Mophie cases because they’re tougher than an organic chemistry final and sleeker than a lot of cases out there. The juice pack charges via micro USB, and when your encased iPhone is plugged in, both are charged. A standby switch keeps the juice pack off until you decide you need the extra power.

The Mophie Juice Pack Helium for iPhone 5 is $80. Available in two hues, “dark metallic” begins shipping Feb. 14, and “silver metallic” ships early March.

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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.

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Catherine Saint Louis speaks about using SimplyThick in premature infants.

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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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Bits Blog: Most Facebook Users Have Taken a Break From the Site, Study Finds

Facebook is the most popular social network in America — roughly two-thirds of adults in the country use it on a regular basis.

But that doesn’t mean they don’t get sick of it.

A new study released on Tuesday by the Pew Research Center‘s Internet and American Life Project found that 61 percent of current Facebook users admitted that they had voluntarily taken breaks from the site, for as many as several weeks at a time.

The main reason for their social media sabbaticals?

Not having enough time to dedicate to pruning their profiles, an overall decrease in their interest in the site as well as the general sentiment that Facebook was a major waste of time. About 4 percent cited privacy and security concerns as contributing to their departure. Although those users eventually resumed their regular activity, another 20 percent of Facebook users admitted to deleting their accounts.

Of course, even as some Facebook users pull back on their daily consumption of the service, the vast majority — 92 percent — of all social network users still maintain a profile on the site. But while more than half said that the site was just as important to them as it was a year ago, only 12 percent said the site’s significance increased over the last year — indicating the makings of a much larger social media burnout across the site.

The study teases out other interesting insights, including the finding that young users are spending less time overall on the site. The report found that 42 percent of Facebook users from the ages of 18 to 29 said that the average time they spent on the site in a typical day had decreased in the last year. A much smaller portion, 23 percent, of older Facebook users, those over 50, reported a drop in Facebook usage over the same period.

Facebook’s biggest challenge revolves around figuring out how to continue to profit from its rich reservoir of one billion users — and a large part of that involves keeping them entertained and returning to the site on a regular basis. Most recently, the company introduced a tool called Graph Search, a research tool that promises to help its users find answers on everything from travel recommendations to potential jobs and even love connections.

Lee Rainie, the director of the Pew Research Center’s Internet & American Life Project, which conducted the survey, described the results as a kind of “social reckoning.”

“These data show that people are trying to make new calibrations in their life to accommodate new social tools,” said Mr. Rainie, in an e-mail. Facebook users are beginning to ask themselves, ” ‘What are my friends doing and thinking and how much does that matter to me?,’ ” he said. “They are adding up the pluses and minuses on a kind of networking balance sheet and they are trying to figure out how much they get out of connectivity vs. how much they put into it.”

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Manson follower parole decision in Gov. Jerry Brown's hands

Bruce Davis, a former member of the Manson Family, moments before the start of his parole hearing in October. (Joe Johnston, The Tribune)

By Paige St. John

February 4, 2013, 2:58 p.m.

It is up to Gov. Jerry Brown whether to release a now-70 follower of murderer Charles Manson.

For at least the second time, the California Board of Parole Hearings has recommended the release of Bruce Davis, imprisoned since 1972 for his role in the murder of two men, a musician and a stuntman. Brown has 30 days to decide whether to allow Davis' release, refer it for a full parole board hearing or follow then-Gov. Arnold Schwarzenegger's example and deny parole.

Manson and his followers killed nine people in July and August 1969, including actress Sharon Tate, and attempted to blame the slaying on black militants. Manson was already standing trial in 1970 for the Tate murders when Davis turned himself in at the Los Angeles County courthouse. He was convicted in two slayings and sentenced to life in prison.

California corrections officials previously rejected Davis' bid for parole 25 times before recommending in 2010 and again in October that parole be granted.

On Friday, the Board of Parole Hearings determined that the recommendation contained no legal errors and forwarded it to Brown.

"I am sorry for who I was and what I did," Davis wrote in a letter submitted to the earlier parole board. "I am now focused on compensating for the lives I destroyed by promoting life-enriching and violence-preventing lifestyles at every opportunity."

L.A. County Dist. Atty. Jackie Lacey wrote a letter to the Board of Parole Hearings objecting to Davis' release.

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