Extended Use of Breast Cancer Drug Suggested


The widely prescribed drug tamoxifen already plays a major role in reducing the risk of death from breast cancer. But a new study suggests that women should be taking the drug for twice as long as is now customary, a finding that could upend the standard that has been in place for about 15 years.


In the study, patients who continued taking tamoxifen for 10 years were less likely to have the cancer come back or to die from the disease than women who took the drug for only five years, the current standard of care.


“Certainly, the advice to stop in five years should not stand,” said Prof. Richard Peto, a medical statistician at Oxford University and senior author of the study, which was published in The Lancet on Wednesday and presented at the San Antonio Breast Cancer Symposium.


Breast cancer specialists not involved in the study said the results could have the biggest impact on premenopausal women, who account for a fifth to a quarter of new breast cancer cases. Postmenopausal women tend to take different drugs, but some experts said the results suggest that those drugs might be taken for a longer duration as well.


“We’ve been waiting for this result,” said Dr. Robert W. Carlson, a professor of medicine at Stanford University. “I think it is especially practice-changing in premenopausal women because the results do favor a 10-year regimen.”


Dr. Eric P. Winer, chief of women’s cancers at the Dana-Farber Cancer Institute in Boston, said that even women who completed their five years of tamoxifen months or years ago might consider starting on the drug again.


Tamoxifen blocks the effect of the hormone estrogen, which fuels tumor growth in estrogen receptor-positive cancers that account for about 65 percent of cases in premenopausal women. Some small studies in the 1990s suggested that there was no benefit to using tamoxifen longer than five years, so that has been the standard.


About 227,000 cases of breast cancer are diagnosed each year in the United States, and an estimated 30,000 of them are in premenopausal women with estrogen receptor-positive cancer and prime candidates for tamoxifen. But postmenopausal women also take tamoxifen if they cannot tolerate the alternative drugs, known as aromatase inhibitors.


The new study, known as Atlas, included nearly 7,000 women with ER-positive disease who had completed five years of tamoxifen. They came from about three dozen countries. Half were chosen at random to take the drug another five years, while the others were told to stop.


In the group assigned to take tamoxifen for 10 years, 21.4 percent had a recurrence of breast cancer in the ensuing 10 years, meaning the period 5 to 14 years after their diagnoses. The recurrence rate for those who took only five years of tamoxifen was 25.1 percent.


About 12.2 percent of those in the 10-year treatment group died from breast cancer, compared with 15 percent for those in the control group.


There was virtually no difference in death and recurrence between the two groups during the five years of extra tamoxifen. The difference came in later years, suggesting that tamoxifen has a carry-over effect that lasts long after women stop taking it.


Whether these differences are big enough to cause women to take the drug for twice as long remains to be seen.


“The treatment effect is real, but it’s modest,” said Dr. Paul E. Goss, director of breast cancer research at the Massachusetts General Hospital.


Tamoxifen has side effects, including endometrial cancer, blood clots and hot flashes, which cause many women to stop taking the drug. In the Atlas trial, it appears that roughly 40 percent of the patients assigned to take tamoxifen for the additional five years stopped prematurely.


Some 3.1 percent of those taking the extra five years of tamoxifen got endometrial cancer versus 1.6 percent in the control group. However, only 0.6 percent of those in the longer treatment group died from endometrial cancer or pulmonary blood clots, compared with 0.4 percent in the control group.


“Over all, the benefits of extended tamoxifen seemed to outweigh the risks substantially,” Trevor J. Powles of the Cancer Center London, said in a commentary published by The Lancet.


Dr. Judy E. Garber, director of the Center for Cancer Genetics and Prevention at Dana-Farber, said many women have a love-hate relationship with hormone therapies.


“They don’t feel well on them, but it’s their safety net,” said Dr. Garber, who added that the news would be welcomed by many patients who would like to stay on the drug. “I have patients who agonize about this, people who are coming to the end of their tamoxifen.”


Emily Behrend, who is a few months from finishing her five years on tamoxifen, said she would definitely consider another five years. “If it can keep the cancer away, I’m all for it,” said Ms. Behrend, 39, a single mother in Tomball, Tex. She is taking the antidepressant Effexor to help control the night sweats and hot flashes caused by tamoxifen.


Cost is not considered a huge barrier to taking tamoxifen longer because the drug can be obtained for less than $200 a year.


The results, while answering one question, raise many new ones, including whether even more than 10 years of treatment would be better still.


Perhaps the most important question is what the results mean for postmenopausal women. Even many women who are premenopausal at the time of diagnosis will pass through menopause by the time they finish their first five years of tamoxifen, or will have been pushed into menopause by chemotherapy.


Postmenopausal patients tend to take aromatase inhibitors like anastrozole or letrozole, which are more effective than tamoxifen at preventing breast cancer recurrence, though they do not work for premenopausal women.


Mr. Peto said he thought the results of the Atlas study would “apply to endocrine therapy in general,” meaning that 10 years of an aromatase inhibitor would be better than five years. Other doctors were not so sure.


The Atlas study was paid for by various organizations including the United States Army, the British government and AstraZeneca, which makes the brand-name version of tamoxifen.


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Software Founder John McAfee Is Denied Asylum







GUATEMALA CITY (AP) — Software company founder John McAfee was hospitalized Thursday after being denied political asylum in Guatemala and his lawyers said they were making a last-ditch effort to keep him from being flown back to Belize for questioning about the killing of a fellow American expatriate.




McAfee told The Associated Press that he suffered chest pains overnight but didn't believe he had a heart attack. A government doctor who examined him agreed, saying that McAfee's heart rhythm and blood pressure were normal and that he appeared to be suffering from high stress.


McAfee was moved from an immigration center to a police-run hospital Thursday afternoon after Guatemalan authorities said McAfee's request for asylum had been denied. They did not explain why. Shortly after the decision was announced, McAfee issued a plea on his blog for the public to petition Guatemalan President Otto Perez Molina to let him stay.


"Please email the President of Guatemala and beg him to allow the court system to proceed, to determine my status in Guatemala, and please support the political asylum that I am asking for," the post read.


McAfee's legal team said they were preparing to appeal the denial of asylum to the country's constitutional court, a process that could give McAfee perhaps another day or two in Guatemala. The court would have to issue a decision within 48 hours.


McAfee's complaints of chest pain prompted authorities to move him from the immigration center where he had been held overnight. He had been taken to the center after his arrest for illegally entering the country after a bizarre weekslong journey as a self-styled fugitive with an active blog and constant contact with the press.


During an exclusive interview with the AP Thursday morning from inside his private room at the center, McAfee said he was refusing to travel to a hospital because he had been using Chinese herbal medicine since suffering a heart attack in 1993.


"Last night I had a little bit of pain, but I am fine this morning," he said. "I don't like Western medicine ... if the people around me are kind and compassionate, that's all that matters in life. The people of Guatemala are very kind people, so I have no complaints."


A couple of hours later, an AP reporter returned to McAfee's room and found him changed into a suit but lying on the floor as he was examined by a doctor. Shortly after, he was taken to the police hospital.


Belizean police spokesman Raphael Martinez said officials expected McAfee to be flown back to his country's capital. Police want to question him about the fatal shooting of killing of Gregory Viant Faull, who was shot to death in early November on the Belize island where both men lived.


There is no warrant for McAfee's arrest, so it is possible his self-initiated flight from Belizean authority could end up with him free to roam the Caribbean island where he lived for years, often clashing with neighbors and authorities over allegations he kept aggressive dogs, weapons and drug paraphernalia on his property.


The Faull family has said through a representative that the murder of their loved one on Ambergris Caye has gotten lost in the media frenzy provoked by McAfee's manipulation of the media through phone calls, emails and blog posts detailing his life on the lam.


McAfee updated his blog Thursday after being given a computer by the warden at the immigration center in Guatemala City, a three-story building with mesh-covered windows and barbed-wire on the roof.


McAfee said U.S. Embassy officials had said they couldn't help him with a request to be returned to the United States instead of Belize. McAfee said he had formally requested asylum in Guatemala because he fears for his safety in Belize because he has sensitive information about official corruption and refused to donate to local politicians.


Guerra warned Wednesday night that the 67-yeard-old McAfee's life would be in danger if he is sent back to Belize.


"He will be in danger if he is returned to Belize, where he has denounced authorities," Guerra said. "From the moment he asked for asylum he has to have the protection of the Guatemalan government."


Police in Belize deny they are persecuting McAfee and say there is no warrant for his arrest. The country's prime minister has questioned McAfee's mental state.


McAfee went on the run last month after officials tried to question him about the killing of Faull, who was shot to death in early November.


McAfee acknowledges that his dogs were bothersome and that Faull had complained about them, but denies killing Faull. Faull's home was a couple of houses down from McAfee's compound.


McAfee, the creator of the McAfee antivirus program, has led an eccentric life since he sold his stake in the anti-virus software company that is named after him in the early 1990s and moved to Belize about three years ago to lower his taxes.


He told The New York Times in 2009 that he had lost all but $4 million of his $100 million fortune in the U.S. financial crisis. However, a story on the Gizmodo website quoted him as calling that claim "not very accurate at all." He has dabbled in yoga, ultra-light aircraft and producing herbal medications.


___


Associated Press writers Patrick E. Jones in Belize City and Michael Weissenstein in Mexico City contributed to this report.


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Typhoon Bopha Kills Hundreds in Philippines


Bullit Marquez/Associated Press


A resident hung clothing amid fallen trees and debris on Wednesday, a day after Typhoon Bopha made landfall in the village of Andap, in southern Philippines. More Photos »







MANILA — With many roads and bridges washed away, rescue teams struggled Wednesday to reach isolated villages in the southern Philippines after a powerful out-of-season typhoon tore through the region, leaving more than 270 people dead and hundreds more missing, officials said.




Typhoon Bopha packed winds of up to 100 miles per hour when it struck Tuesday, bringing torrential rains that washed away villages and left thousands homeless.


The deaths were concentrated in the province of Compostela Valley, a mountainous gold mining area, and the neighboring province of Davao Oriental, on the eastern coast of the southern Philippine island of Mindanao, Lt. Col. Lyndon Paniza, a military spokesman, said in a telephone interview late Wednesday afternoon.


A national disaster official, Benito Ramos, said at a news conference on Wednesday afternoon that 274 people had died, 339 were injured and 279 were missing. Those figures were likely to rise, he suggested, since rescue workers had not yet reached several villages in the hardest-hit areas and the casualties there were not known.


Most of the dead appeared to have drowned or been hit by falling trees or flying debris, officials said.


“There is debris in the road, so our soldiers are moving by foot,” Colonel Paniza said. “They are crossing rivers and landslides. I don’t want to speculate, but we don’t know what they will find when they reach those cut off areas.”


Three soldiers are known to have died, and eight are missing, he said. Some of the soldiers died when a landslide washed out their patrol base, and others disappeared while on search-and-rescue operations.


Local television crews broadcast grisly footage of mud-covered bodies being loaded into trucks in villages that appeared flattened by the storm. In some areas, not a single structure could be seen standing.


In areas where roads were washed out, the government sent seagoing vessels to take relief goods to remote coastal areas from the provincial capital of Davao Oriental, Mati.


“I have thus authorized the local government of Mati, its mayor and the provincial governor to use their calamity funds to hire all available large, local fishing boats for an immediate sea-lift transfer of goods to the affected areas,” Manuel Roxas, the interior secretary, said in a statement.


The eastern coast of Mindanao, which was the area hardest hit by the storm, is a remote, impoverished agricultural area. Mr. Roxas told reporters on Wednesday that during his visit to the area, he had seen tens of thousands of fallen coconut trees and many acres of destroyed banana plantations.


In New Bataan, the town hit hardest by the storm, Virgilia Babaag had been waiting nervously in her home before dawn on Tuesday as hard rain from the approaching typhoon pounded her small village.


“My neighbors started yelling, ‘The water is coming fast! Run! Run!’ ” she said Wednesday by telephone.


Ms. Babaag gathered up her three young nieces staying with her and ran through the night toward high ground. There she stayed with dozens of others as winds ripped through the town.


“When I came back, my roof was gone,” she said from her devastated home. “The houses around my place are destroyed. There are so many who have died here. The soldiers are still finding more.”


The Philippines is hit by as many as 20 powerful tropical storms each year, but this one struck remote communities south of the usual typhoon path.


“This is the first time that the people in this area have experienced a storm like this,” Colonel Paniza said. “They aren’t accustomed to big storms.”


Last December, Tropical Storm Washi — another out-of-season storm that hit south of the usual Philippine typhoon belt — killed more than 1,200 people and left hundreds of thousands homeless.


This year, officials put out strong warnings days in advance and carried out mandatory early evacuations of vulnerable communities.


President Benigno S. Aquino III, stung by criticism last year that the national government had not done enough to prepare for Tropical Storm Washi, went on television the day before the storm hit and pleaded with people to follow the instructions of local government officials.


“I am facing you now because the incoming storm is no laughing matter,” Mr. Aquino said, adding later, “We expect the cooperation of everyone so that nobody gets in harm’s way.”


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Chiefs players head to Belcher memorial service


KANSAS CITY, Mo. (AP) — Several players for the Kansas City Chiefs attended a memorial service for teammate Jovan Belcher, who killed his girlfriend and then fatally shot himself in the head.


Belcher killed 22-year-old Kasandra Perkins on Saturday at the home they shared in Kansas City with their 3-month-old daughter. He then drove to the Chiefs practice facility at Arrowhead Stadium, where he killed himself in front of team officials, who pleaded with him to put down his gun.


Retired Chiefs Hall of Famer Bobby Bell said after the private hour-long service that general manager Scott Pioli, who witnessed Belcher's suicide, spoke during the service. Bell said an uncle of Belcher also spoke.


The service was held at a church that Belcher and Perkins attended.


Several other Chiefs players declined comment after the service.


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Extended Use of Breast Cancer Drug Suggested


The widely prescribed drug tamoxifen already plays a major role in reducing the risk of death from breast cancer. But a new study suggests that women should be taking the drug for twice as long as is now customary, a finding that could upend the standard that has been in place for about 15 years.


In the study, patients who continued taking tamoxifen for 10 years were less likely to have the cancer come back or to die from the disease than women who took the drug for only five years, the current standard of care.


“Certainly, the advice to stop in five years should not stand,” said Prof. Richard Peto, a medical statistician at Oxford University and senior author of the study, which was published in The Lancet on Wednesday and presented at the San Antonio Breast Cancer Symposium.


Breast cancer specialists not involved in the study said the results could have the biggest impact on premenopausal women, who account for a fifth to a quarter of new breast cancer cases. Postmenopausal women tend to take different drugs, but some experts said the results suggest that those drugs as well might be taken for a longer duration.


“We’ve been waiting for this result,” said Dr. Robert W. Carlson, a professor of medicine at Stanford University. “I think it is especially practice-changing in premenopausal women because the results do favor a 10-year regimen.”


Dr. Eric P. Winer, chief of women’s cancers at the Dana-Farber Cancer Institute in Boston, said that even women who completed their five years of tamoxifen months or years ago might consider starting on the drug again.


Tamoxifen blocks the effect of the hormone estrogen, which fuels tumor growth in estrogen receptor-positive cancers that account for about 65 percent of cases in premenopausal women. Some small studies in the 1990s suggested that there was no benefit to using tamoxifen longer than five years, so that has been the standard.


About 227,000 cases of breast cancer are diagnosed each year in the United States, and an estimated 30,000 of them would be in premenopausal women with ER-positive cancer and prime candidates for tamoxifen. But postmenopausal women also take tamoxifen if they cannot tolerate the alternative drugs, known as aromatase inhibitors.


The new study, known as Atlas, included nearly 7,000 women with ER-positive disease who had completed five years of tamoxifen. They came from about three dozen countries. Half were chosen at random to take the drug another five years, while the others were told to stop.


In the group assigned to take tamoxifen for 10 years, 21.4 percent had a recurrence of breast cancer in the ensuing ten years, meaning the period 5 to 14 years after their diagnoses. The recurrence rate for those who took only five years of tamoxifen was 25.1 percent.


About 12.2 percent of those in the 10-year treatment group died from breast cancer, compared with 15 percent for those in the control group.


There was virtually no difference in death and recurrence between the two groups during the five years of extra tamoxifen. The difference came in later years, suggesting that tamoxifen has a carry-over effect that lasts long after women stop taking it.


Whether these differences are big enough to cause women to take the drug for twice as long remains to be seen.


“The treatment effect is real, but it’s modest,” said Dr. Paul E. Goss, director of breast cancer research at the Massachusetts General Hospital.


Tamoxifen has side effects, including endometrial cancer, blood clots and hot flashes, which cause many women to stop taking the drug. In the Atlas trial, it appears that roughly 40 percent of the patients assigned to take tamoxifen for the additional five years stopped prematurely.


Some 3.1 percent of those taking the extra five years of tamoxifen got endometrial cancer versus 1.6 percent in the control group. However, only 0.6 percent of those in the longer treatment group died from endometrial cancer or pulmonary blood clots, compared with 0.4 percent in the control group.


“Over all, the benefits of extended tamoxifen seemed to outweigh the risks substantially,” Trevor J. Powles of the Cancer Center London, said in a commentary published by The Lancet.


Dr. Judy E. Garber, director of the Center for Cancer Genetics and Prevention at Dana-Farber, said many women have a love-hate relationship with hormone therapies.


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Obama Tells G.O.P. Not to Tie Debt Ceiling to Fiscal Debate


Doug Mills/The New York Times


President Obama spoke to members of the Business Roundtable in Washington on Wednesday.







WASHINGTON — President Obama warned Republicans on Wednesday not to use the debt ceiling as leverage on spending and tax decisions, saying he refused to engage again in the sort of brinkmanship that brought the country close to default last year and damaged its credit rating.




In a speech to the Business Roundtable, Mr. Obama called that irresponsible. “That is a bad strategy for America, it’s a bad strategy for your businesses and it is not a game that I will play,” he said. “Everybody here is concerned about uncertainty. There’s no uncertainty like the prospect that the United States of America, the largest economy, that holds the world’s reserve currency, potentially defaults on its debts.”


While saying he would not “play that game,” a phrase he repeated, Mr. Obama did not say what he would do in response, but some Democrats have urged him in the past to simply raise the borrowing limit using his own executive authority and let the courts determine if he overstepped his constitutional bounds.


He seemed to embrace a suggestion by John Engler, the Business Roundtable president, to raise the debt ceiling enough to last five years. “John is exactly right when he says that the only thing that the debt ceiling is good for as a weapon is just to destroy your credit rating,” Mr. Obama said.


Mr. Obama was reacting to reports that Republican leadership officials were looking for a fallback in the current debate to avert an end-of-the-year fiscal crisis. Some Republicans foresee accepting Mr. Obama’s call to extend Bush-era tax cuts for the middle class while allowing them to expire for the wealthiest Americans, and then taking up the fight again when the nation’s debt rises to the point that the statutory borrowing limit needs to be raised again, which could be in late January or February.


Republicans view any vote to raise the debt ceiling as a chance to enforce more fiscal discipline on Mr. Obama. Speaker John A. Boehner has said any increase in borrowing capacity should be offset by spending cuts that exceed the increased debt. Mr. Obama has responded by proposing to take away the Congressional power to approve increases in the debt ceiling, but Mr. Boehner said last weekend that “Congress is never going to give up this power.”


Appearing before reporters on Wednesday, Mr. Boehner and other House Republican leaders implored Mr. Obama to sit down with them and begin negotiating in earnest to head off the looming fiscal crisis, but with flattery and aggravation, they made it clear that they were now playing on his turf.


Mr. Boehner and his leadership team did not give an inch on their opposition to raising tax rates on the wealthy or their insistence that any deficit-reduction plan emphasize spending cuts. But the speaker sounded exasperated as he insisted that he had moved toward the president’s position by agreeing to $800 billion in higher tax revenue over 10 years.


“The revenues we’re putting on the table will come from guess who? The rich,” he said, his voice rising. “There are ways to limit deductions, close loopholes and have the same people pay more of their money to the federal government without raising tax rates.”


Representative Peter Roskam of Illinois, a member of the Republican leadership, appealed to Mr. Obama’s own view of himself as a politician able to rise above partisanship, a characterization Republicans have rarely, if ever, agreed with.


“I’ve seen an attribute in President Obama when we served together in the Illinois State Senate, where he was able to rise above donkeys and elephants and transform some very controversial issues in a way that was powerful,” Mr. Roskam said, imploring the president to eschew the politics of the victor and seize “an unbelievable opportunity to be a transformational president, that is to bring the country together.”


The dueling public appearances underscored how far apart the two sides were, at least as a matter of principle. Mr. Obama’s plan calls for $1.6 trillion in new taxes over 10 years, mainly through allowing rates to rise on income above $200,000 a year for individuals or $250,000 for families. He has also revived a year-old plan to trim health care and other mandatory spending by $600 billion over 10 years, but he also wants to spend $50 billion in the short term to help the economy.


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Nasrin Sotoudeh, Iranian Rights Advocate, Ends Hunger Strike





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




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


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


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


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


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


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


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


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


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


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


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


This article has been revised to reflect the following correction:

Correction: December 4, 2012

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



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Auburn hires ex-assistant Malzahn as head coach


AUBURN, Ala. (AP) — Auburn has turned to Gus Malzahn to restore a program that made an unprecedented fall two years after winning a national title with Cam Newton operating his high-powered offense to perfection.


The school announced that it will introduce the former Arkansas State coach in a news conference Tuesday night.


Malzahn was the Tigers' offensive coordinator during their 2010 national championship run before heading to Arkansas State for his first college head coaching position.


He led the Red Wolves to a 9-3 record, a Sun Belt Conference title and a berth in the GoDaddy.com Bowl then parlayed that into a job in the powerhouse Southeastern Conference.


"It's an outstanding institution with a storied football program that I had the pleasure of experiencing firsthand for three years," Malzahn said in a statement. He thanked school representatives for their confidence "in my ability to turn this program around and to bring Auburn back to national prominence. This is a homecoming for me and I look forward to being reunited with the Auburn family."


Malzahn, 47, returns with his fast-paced, no-huddle offensive style. He replaces former boss Gene Chizik, who was fired one day after a 49-0 loss to No. 2 Alabama to complete a 3-9 season.


Before his arrival at Auburn in 2009, Malzahn had spent two seasons as Tulsa's offensive coordinator. He was the offensive coordinator at Arkansas for one year after a successful run in the Arkansas high school ranks.


Auburn had the nation's 115th-ranked offense last season, averaging 305 yards a game. The Red Wolves were ranked 19th in total yards under Malzahn.


It's the second straight time Auburn has turned to one of its coordinators from an unbeaten team. Chizik ran the defense for the 13-0 team in 2004 but was hired by the Tigers despite a 5-19 record in two seasons at Iowa State.


"We are tremendously excited that Gus Malzahn will be our next head football coach," athletic director Jay Jacobs said. "Coach Malzahn was the clear unanimous choice of our search committee, and I am pleased that Dr. Gogue has accepted our recommendation. This is a great day for Auburn football and Auburn University."


The search committee was comprised of Jacobs, Auburn Heisman Trophy winners Pat Sullivan and Bo Jackson and former Tigers player Mac Crawford.


Auburn owes more than $11 million in buyouts to Chizik and his coaching staff. Malzahn's contract and salary information was not immediately available.


The Tigers are hoping he can return them to success after a winless SEC season.


"Gus Malzahn is a proven winner," Jacobs said. "He is without question one of the brightest minds in college football and he has won everywhere he has been. Coach Malzahn knows what it takes to build a championship program in the Southeastern Conference. He knows our state and region and he understands what it will take to turn our program around. Coach Malzahn will also be an outstanding ambassador for Auburn University, and that was important to the committee."


The NCAA has been investigating the recruitment of signee Jovon Robinson, who was ruled ineligible after a guidance counselor admitted to creating a fake transcript.


The Tigers badly struggled in a transition to Scot Loeffler's pro-style last season, starting three quarterbacks.


Auburn was ranked in the top seven in rushing, total and scoring offense in 2010 and Newton won the Heisman Trophy in his lone season out of the junior college ranks. It was the Tigers' first national title since 1957.


Without Newton, the Tigers slipped to 100th in total offense in 2011 and then dipped even further.


The hiring reunites Malzahn with the quarterback he recruited out of Arkansas. Kiehl Frazier was benched last season after struggling as the starter. He was USA Today's national offensive player of the year as a high school senior.


Malzahn had been earning $1.3 million a year for the Tigers after interviewing with Vanderbilt after the national championship season. He took a substantial pay cut to join the head coaching ranks with the Sun Belt Conference team. Malzahn replaced Hugh Freeze, who also left after one season at Arkansas State to take over at Mississippi.


Chizik's tenure was marred by off-the-field problems, including the arrest of four players from the championship team for armed robbery.


Malzahn also made a couple of decisions with players that didn't pan out. Tailback Mike Dyer transferred from Auburn — where he was suspended — to Arkansas State. He was then dismissed by Arkansas State in July after a state trooper found marijuana and a gun in a car the national title game MVP was driving.


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





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




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


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


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


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


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


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


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


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


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


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


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


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


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


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


Clinical Precision


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


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


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


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


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Michigan Movie Studio Gets Tax Breaks, but Results in Few Jobs





PONTIAC, Mich. — Even the great and powerful Oz could not save the film studio that was supposed to save this town.




The studio, a state-of-the-art facility fit for Hollywood blockbusters, had risen from the ruins of a General Motors complex here. It was the brainchild of a small group of investors with big plans: the studio would attract prestigious filmmakers, and the movie productions would create jobs and pump money into the local economy. A glamorous sheen would rub off on this down-on-its-luck town.


But in Pontiac, happy endings do not usually come Hollywood-style. The tale behind the studio, though, was cinematic in its own right, filled with colorful characters, calls from the White House and a starring role for Michigan’s taxpayers. Rounding out the cast was a big-budget Disney movie, “Oz: The Great and Powerful.”


It all started back in August 2007, when Gov. Jennifer M. Granholm met with Mike Binder, a Michigan-born actor and director who was lamenting the state’s lackluster program to award financial aid — otherwise known as film credits — to the movie industry. Ms. Granholm, an aspiring actress when she was in her early 20s, became determined to make Michigan competitive, she recalled.


Eight months later, the capital of the flailing auto industry became the capital of film tax credits. For every dollar spent locally, filmmakers would receive almost half back from Michigan. That sort of money turns heads at even the richest film studios, and word spreads fast. Janet Lockwood, the director of the state’s film office, said that a week after the enhanced credits were announced, she was besieged at a movie conference in Santa Monica, Calif., by “the baby studios to the big guys.”


Hollywood may make movies about the evils of capitalism, but it rarely works without incentives, which are paid for by taxpayers. Nationwide, about $1.5 billion in tax breaks is awarded to the film industry each year, according to a state-by-state survey by The New York Times.


Within two months, 24 movies had signed up to film in Michigan — up from two the entire year before. The productions estimated that they would spend $195 million filming there, and in return they would be refunded about $70 million in cash.


Before long, residents were rushing out on their lunch breaks to catch a glimpse of celebrities like Drew Barrymore, who was filming her movie “Whip It” in Ann Arbor, and Clint Eastwood, who was shooting “Gran Torino” in the Detroit area. Even Michael Moore, who was filming a movie about corporate welfare called “Capitalism: A Love Story,” sought and received incentives.


A ‘No-Brainer’ for Michigan


It was a time when most financial news was bad. Housing prices plunged, and thousands of automobiles went unsold. Michigan was facing growing budget shortfalls, and some lawmakers who voted for the film credits soon began questioning whether the state could actually afford them.


In Pontiac, tax revenue plummeted as General Motors pulled out and workers left. Half of downtown was boarded up, and landlords accepted rent checks through slits in doors locked for safety. For some, Hollywood provided distraction and hope.


By 2008, a plan was being hatched for what would become the movie studio in Pontiac. The man behind it, Linden Nelson, was a well-connected local entrepreneur with a charismatic personality. He had made a name for himself by creating the removable key chain for valet parkers in the 1980s. His company later manufactured promotional trinkets for brands like AT&T and Harley-Davidson. In the late 1990s, Mr. Nelson found himself in the headlines when a fire broke out at his office in Beverly Hills, Mich. It was ruled accidental.


Mr. Nelson got the idea for the studio, he said, from his college-age son, who had heard that the Michigan tax credits were the talk of the Cannes Film Festival in France that year. Mr. Nelson soon met an old friend, Ari Emanuel, over coffee in Aspen, Colo., to discuss the idea. Mr. Emanuel was the force behind what would become William Morris Endeavor Entertainment, and his fast-talking, take-no-prisoners style had been immortalized in HBO’s “Entourage.” His brother Rahm would soon be named the chief of staff to President Obama.


Intrigued, Mr. Emanuel did not take long to sign on. “I’m, like, blown away by it,” he told a gathering of the Detroit Regional Chamber of Commerce. “Not to use an L.A. phrase — I think this is a no-brainer for the state of Michigan.”


Motown Motion Pictures LLC was incorporated in May 2008, and two more partners came on board. One, John Rakolta Jr., had building expertise as the head of a commercial construction company. The other, A. Alfred Taubman, was a longtime friend of Mr. Nelson and a prominent investor who made billions building shopping malls nationwide.


Mr. Taubman is among the most generous donors to universities and institutions in Michigan and elsewhere. He went to prison for nearly 10 months in 2002 over price-fixing accusations related to Sotheby’s auction house, which his company owned. He has maintained that he was innocent.


When Mr. Taubman first visited the vacated General Motors site in Pontiac, he was brought to tears. “What happened to all the people?” he said, according to Mr. Nelson, who was at his side. “Where are the cars? What happened to their families?”


In early 2009, the four investors bought the property from G.M. for “virtually nothing,” said Mr. Rakolta. General Motors, which had just received a hefty federal bailout, “spent more on the carpet than we spent on this building,” he said.


The investors agreed that they would put in a total of $10 million to $12 million of their own money, according to the studio’s chief financial officer. They would pay for the rest — $70 million or so — using borrowed money and state and federal incentives. “Michigan’s current tax incentive program appears to be the largest competitive advantage for the company,” one studio document said.


Ms. Lockwood, the film commissioner at the time, said she visited Mr. Taubman’s office in early 2009. Over lunch served by a butler, Mr. Taubman filled her in on the plan. “He believed that there was money to be made,” she recalled.


A Town on the Ropes


In public, the investors extolled the studio as an altruistic effort on behalf of Pontiac. “I go into things to make money, but on this, I don’t really care,” Mr. Taubman told The Detroit Free Press. “I just want to help create jobs, and this can create 3,600 jobs.”


Pontiac desperately needed them. In March of that year, roughly one of every two residents was without work, according to federal data. Food pantries had record requests. Pontiac was consistently listed among the top 10 most dangerous cities by the F.B.I. The city had made national news when a group of teenagers approached homeless people on the street and beat them to death.


Ms. Granholm declared the city in a financial crisis in February 2009 and appointed an emergency manager, Fred Leeb. The city’s budget was $54 million a year, but it was overspending by an estimated $7 million to $12 million. Pontiac was also still weighted down by old incentives it had given to businesses like G.M.


The movie studio was an added challenge, since it was seeking financial incentives from the city — not to mention from other branches of the government. It won redevelopment tax credits from the federal government and separate aid from the state that included incentives for technology companies that hire residents.


Job creation became a point of contention with beleaguered Pontiac, which was being asked to waive virtually all property taxes for the studio. The investors claimed that thousands of people would be employed, but Mr. Leeb said that when he asked for job numbers to be written into the contract, the investors refused. “We started seeing some backpedaling,” said Mr. Leeb, who added that the negotiations featured “knock-down, drag-out fights.”


Mr. Nelson said he did not recall that request, but added that his company could not have guaranteed jobs anyway, since they were mainly supposed to be created by filmmakers renting out the studio.


Under pressure from the governor’s office, Mr. Leeb said he had little choice but to approve the investors’ requests.


Ms. Granholm announced the project in her 2009 State of the State address, saying she thought the industry would create a flood of new jobs. “It was very exciting,” recalled Ms. Granholm, a Democrat. “A classic transformation, the phoenix rising from the ashes. This plant in Pontiac — it was a really great moment for a community that really wanted and needed hope.”


That summer, as the studio moved forward, Mr. Nelson was in local headlines for a second fire, this one at his 23,000-square-foot lakefront home in Bloomfield Hills. The fire extensively damaged the home, and its cause was not determined. Mr. Nelson declined to discuss it.


Not long after, he and the other studio investors hit a major hurdle. They would be borrowing around $18 million in municipal bonds, but they needed someone to back them.


Over the objections of some local officials, the state agreed to use the state workers’ pension funds to guarantee the bonds. If the investors failed to pay, the retirees would be on the hook.


At the time of the deal, the governor was speaking regularly with Mr. Obama, who was negotiating the General Motors bailout. Edward B. Montgomery, who was leading the White House’s efforts on communities and workers affected by the automaker’s bankruptcy, was engaged on the studio plans.


Mr. Montgomery said in an interview that he had expressed support for the studio and other projects that he believed would help diversify Michigan’s economy. He said the studio’s investors received assistance from the Treasury Department to qualify for a federal tax credit program. Mr. Montgomery said he was unaware of the bond guarantee involving the state pension fund.


On July 27, 2010, the governor and other officials gathered for the studio’s groundbreaking. Also on hand were Hollywood players like Mr. Binder, a creator of HBO’s “The Mind of the Married Man,” who had been instrumental in persuading the governor to expand the film subsidies.


Mr. Nelson, the studio’s main impresario, talked up the job numbers on local radio that day and said the incentives were necessary. “It’s a very competitive landscape out there,” he said. “There are very, very competitive rebates going on with other states. People don’t realize this, but 40 states have some kind of rebate or another in this industry. It’s an industry that’s fought after.”


Even as Michigan celebrated the studio, the Motion Picture Association of America was facing criticism of the use of film credits in a report by a Washington tax research group. The film association estimated that the industry employs just over two million people and supports 115,000 businesses. The report, conducted by the nonprofit Tax Foundation, which opposes film incentives, said that states justified them using “fanciful estimates of economic activity.”


The Pontiac studio was complete by the summer of 2011. Its first big production moved in after being awarded about $40 million from the state — the largest single movie payout yet. The Disney “Oz” film was being directed by Sam Raimi, a Michigan native who made the recent “Spider-Man” movies.


Over the coming months, the studio’s seven stages were filled with a yellow brick road and a haunted forest. The designers planted live grass and built a huge waterfall and pond where James Franco, the star of the film, could land in a hot-air balloon. Perhaps the most elaborate set was the courtyard around the good witch Glinda’s castle, which took 75,000 hours of work to build and used $9 million worth of wood, according to Mr. Nelson.


Sahir Rashid, a 35-year-old production assistant and Detroit resident, said that walking into the studio had been overwhelming. It was his first time on a soundstage, and he was thankful that the state’s movie boom allowed him to give up construction work. “For me, the films saved my life,” he said. “It’s not a dead-end job. It’s actually a career.”


As for the crew and actors, “the majority of them I think were from L.A.,” said London Moore, a local actress. Ms. Moore was the body double for Michelle Williams, who was playing Glinda. “I went into this thinking these people were probably going to be stuck up, but they welcomed me with open arms. They are like a family to me.”


Film Jobs Prove Scarce


The studio had created only 200 positions by the summer of 2011, according to correspondence between the company and local officials. And when temporary construction workers were excluded from the tally, Pontiac’s records show, the studio reported only two employees in 2010 and 12 the next year. The studio’s chief financial officer said it had not been able to cash in on $110 million in tax credits that were contingent on creating jobs. But the studio did cash in on other credits, including $14 million for a “Film and Digital Media Infrastructure Investment Tax Credit,” he said.


As the “Oz” shoot was under way, Pontiac moved on to its third emergency manager, Louis Schimmel, and he was not a fan of incentives. A former municipal bond analyst, Mr. Schimmel spent decades warning Michigan towns against trading tax revenues for jobs. “I’m just about the biggest critic of these programs, because giving away the taxes of the city is so detrimental,” he said. “The money is needed for police, fire and trash pickup.”


Mr. Schimmel said Disney had offered to prepay its workers’ personal income tax to the city, but Pontiac declined. The city later had problems collecting some of the taxes because Disney operated through a separate business entity that was difficult to track down, he said.


“This is a glamorous industry if you want to talk about Hollywood, but it’s not very glamorous for the municipality that wants to collect something,” Mr. Schimmel said. Pontiac, he said, was outgunned.


Disney declined to comment. Mr. Nelson said the studio and Disney were responsive to the city.


Mr. Schimmel was not alone in his opposition to incentives. Michigan elected a new governor in 2010, Rick Snyder, a Republican who believed that it made better sense to lower taxes for all businesses. The governor’s budget director, John Nixon, said in an interview, “States harm themselves by competing on tax credits.” The governor quickly began reining in the program.


Almost immediately, filmmakers pulled out of Michigan. The change hit hard at “Hollywood-land in Pontiac,” as Mr. Nelson sometimes refers to his studio, now called Michigan Motion Picture Studios. He said the makers of “Iron Man 3” had been considering filming there but opted for North Carolina after Mr. Snyder slashed incentives.


When the bill for the studio’s bond interest came due in February this year, it paid only a portion, $210,000. The state pension fund had to pick up the remaining $420,000. Mr. Nelson said he and his partners would have made the payment if the state had not changed the tax credit program. “No one would have missed a bond payment,” he said. “No one would have missed anything.”


The situation is galling to even longtime government officials, who over the years have seen plenty of economic development deals fail. “Taubman could write the whole check for that himself,” said Doug Smith, an official at the state’s economic development agency. The state pension fund may “end up owning these studios,” he said.


One of the development agency’s board members is Mr. Rakolta, the construction executive who invested in the Pontiac studio. He and Mr. Nelson said in separate interviews that they had never considered personally paying for the bond interest. A deal is a deal, they said, and the state agreed to cover the bond. The studio’s chief financial officer said the investors already stood to lose twice as much as they originally intended to invest.


A spokesman for Mr. Emanuel said he was not willing to discuss the situation on the record. A spokesman for Mr. Taubman said he was unavailable.


In August, the studio defaulted on the entire $630,000 payment on the bond, despite a decision by Mr. Snyder to temporarily allocate some film incentives.


The investors are lobbying state lawmakers to put more money into the tax credits and have formed a political action committee. Donating to the PAC are the four investors; Mr. Emanuel’s agency, William Morris Endeavor; and the Teamsters union. To rally public support, the studio offers public tours. “Please don’t hesitate to contact your state representative,” Mr. Nelson tells visitors. “Tell them you’ve been here, you believe in it, so please appropriate enough money so it will work.”


Mr. Nelson said that if the state did not improve the incentives, the Pontiac studio would probably shut down. For now, the soundstages are empty. Filming wrapped up last month on a Warner Brothers movie called “Black Sky.” It is about a town ravaged by deadly tornadoes.

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