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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IHT Rendezvous: French Communists Abandon Hammer and Sickle

LONDON — The Communist Party of France has sparked a revolution among the comrades by removing the hammer and sickle from their membership cards.

The iconic symbol of the international proletariat has been replaced with the star of the multi-party European Left alliance, much to the horror of traditionalists at the party’s 36th congress that opened near Paris on Thursday.

What was billed by the party leadership as a forward-looking move was denounced by others as revisionist backsliding and part of a conspiracy to abandon the movement to the embrace of social democracy.

Emmanuel Dang Tran, secretary of the party’s Paris section, told France Info radio that members were shocked at the abandoning of “what represents, for the working class of this country, a historic element in resistance against the politics of capitalism.”

An anonymous commenter on the radio’s website suggested wryly: “It’s natural that they’ve abandoned their tools. There’s no work anymore!”

Mr. Tran was among those who believed the symbol change amounted to the party paying allegiance to the European Left, a coalition of left-wing movements formed in 1999 to cooperate within the European Parliament.

He said the leadership was trying to create a social democracy mark-2 alongside “Greens, socialists, Trotskyists and I don’t know who else.”

Pierre Laurent, the party’s national secretary, defended the decision to dump the hammer and sickle, saying it no longer represented present-day realities. “We want to turn towards the future,” he said on Friday.

The internal spat was the latest upset for a communist party that was once powerful on the left in France, with ministers serving in a number of Socialist-led administrations.

It remains the country’s largest left-wing party in terms of membership. But its standing has declined rapidly since the collapse of communism in Eastern Europe.

For the first time last year, it failed to put up its own candidate at a presidential election and opted instead to support Jean-Luc Mélenchon of the Left Front.

Although the Communist Party is the largest grouping in the Left Front, hardliners complain it risks playing second fiddle to other movements in the alliance despite being its “sole historically revolutionary component.”

The 20Minutes news Website asked whether the loss of the hammer and sickle meant the party was becoming a “Communist Party light” and noted that this week’s congress had also adopted Mr. Mélenchon’s “people first” slogan.

“That is something to chew on for the many who fear the party will be dissolved into a Left Front led by Jean-Luc Mélenchon,” it wrote.

L’Humanité, the former official Communist newspaper that retains close links with the party, managed to remain upbeat as the congress opened. It ran a poll that indicated the party’s public image had improved since the creation of the Left Front.

It also interviewed the rank and file at the party congress who said that, among other things, they saw the gathering as an occasion for communists to go on the offensive, continue a citizens’ revolution, or simply spend a “fraternal moment with all the comrades.”

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AP Source: Hernandez on verge of new deal with M's

SEATTLE (AP) — Felix Hernandez and the Seattle Mariners are working on a $175 million, seven-year contract that would make him the highest-paid pitcher in baseball, according to a person with knowledge of the deal's details.

The person spoke to The Associated Press Thursday on condition of anonymity because the agreement has not been completed. USA Today first reported the deal.

Seattle would add $134.5 million of guaranteed money over five years to the contract of the 2010 AL Cy Young Award winner, whose current agreement calls for him to receive $40.5 million over the next two seasons.

Hernandez's total dollars would top CC Sabathia's original $161 million, seven-year contract with the New York Yankees and his $25 million average would surpass Zack Greinke's $24.5 million under his new contract with the Los Angeles Dodgers and tie him for the second-highest in baseball with Josh Hamilton and Ryan Howard behind Alex Rodriguez ($27.5 million). Hernandez's new money would average $26.9 million over five years.

Hernandez agreed to a $78 million, five-year contract in January 2010 and has earned an additional $2.5 million in escalators and $300,000 in bonuses. He is due $20 million this year and $20.5 million in 2014, which would be superseded by the new deal.

Seattle general manager Jack Zduriencik said he could not comment when reached on Thursday, and Hernandez's representatives didn't immediately return messages.

If the deal is finalized, it would leave Detroit's Justin Verlander and the Dodgers' Clayton Kershaw as the most attractive pitchers eligible for free agency after the 2014 season. Tampa Bay's David Price is eligible after the 2015 season.

Hernandez has become the face of Seattle's struggling franchise, transforming from a curly haired 19-year-old who wore his hat crooked to one of the most dominant and exciting pitchers in baseball. Known as "King Felix," he became the first Seattle pitcher to throw a perfect game in a 1-0 win over Tampa Bay last August.

His fiery enthusiasm on the mound and his willingness to first sign a long-term deal in 2010 have endeared him to fans in the Pacific Northwest who have gone more than a decade without seeing postseason baseball.

Hernandez, who will turn 27 on April 8, is 98-76 with a 3.22 ERA in eight seasons with the Mariners. He won a career-high 19 games in 2009 when he finished second in the Cy Young voting then won the award a year later when he went just 13-12 but had a 2.27 ERA and 232 strikeouts.

Hernandez appeared to be making another Cy Young push last year before going 0-4 in his last six starts, which left him at 13-9 with 223 strikeouts.

His career record would be even better if he didn't play with one of baseball's worst offenses. Seattle had the lowest batting average in the major leagues in each of the last three seasons. Hernandez has taken 10 losses during that span when he's given up two earned runs or less.

For his career, Hernandez has allowed two earned runs or less in 141 of 238 starts, but the team is only 99-42 in those games due to the offensive problems.

Locking up Hernandez long-term won't solve all of the problems that have left Seattle looking up at Texas, Oakland and the Los Angeles Angles in the AL West for most of the last 10 years. The Mariners have tried to address some of those issues this offseason by trading for Kendrys Morales and Michael Morse to provide more punch to go along with young prospects Dustin Ackley, Kyle Seager and Jesus Montero, who have all shown flashes early in their careers.

But should the deal be finalized, the Mariners at least have the security of knowing who'll be at the top of their rotation for most of this decade.

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AP Sports Writer Ronald Blum contributed to this report.

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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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Dell’s Largest Investor to Oppose Buyout

(Reuters) - Dell Inc's largest independent shareholder, Southeastern Asset Management, on Friday vowed to fight a $24.4 billion buyout of the No. 3 PC maker led by CEO Michael Dell, cementing opposition to what would be the largest buyout since the start of the financial crisis.

Southeastern's opposition to the deal, which Reuters first reported late on Thursday, sets up a potential battle with billionaire founder Dell and private equity firm Silver Lake, who are pushing a deal to take the company private at $13.65 a share.

Southeastern, run by activist investor Mason Hawkins and owner of 8.5 percent of Dell, including options, argues that the company is worth $24 a share if its financial services division, recent acquisitions and other assets were factored in.

With Southeastern's objection, shareholders representing 11 percent of the Dell shares not held by Michael Dell have now said they will vote against the deal, according to news reports. Billionaire Dell, who created the computer maker out of his college dorm room in 1984, holds a roughly 16 percent stake.

Dell shares reversed course and climbed into positive territory on Friday after the announcement, and closed up 0.74 percent at $13.63.

"We are writing to express our extreme disappointment regarding the proposed go-private transaction, which we believe grossly undervalues the Company," Hawkins and Chief Investment Officer Staley Cates wrote in a letter.

"We retain and intend to avail ourselves of all options at our disposal to oppose the proposed transaction, including but not limited to a proxy fight, litigation claims and any available Delaware statutory appraisal rights."

Representatives of Dell and Silver Lake declined to comment on Southeastern's statement.

Sanford Bernstein analyst Toni Sacconaghi estimates Hawkins' asset management house paid an average of more $20 a share for its stake, meaning a loss of at least $825 million at the current $13.65 offer price.

A LOOMING BATTLE

Under the buyout's terms, a majority of shares not held by Michael Dell must be voted in favor of the deal for it to proceed.

Memphis, Tennessee-based Southeastern believes the Dell board had several alternatives that would have produced a far better outcome for public shareholders, including breaking up the company and selling the units separately.

"Selling multiple business units to strategic buyers could easily exceed $13.65 per share," the letter read.

Dell was regarded as a model of innovation as recently as the early 2000s, pioneering online ordering of custom PCs and working closely with Asian suppliers and manufacturers to assure rock-bottom production costs. But it missed the big industry shift to tablet computers, smartphones and high-powered consumer electronics such as music players and gaming consoles.

Michael Dell struck a deal early this week to take Dell private for $24.4 billion in the biggest leveraged buyout since the financial crisis, partnering with Silver Lake and Microsoft Corp. The aim is to facilitate Dell's difficult transition from a commodity maker of computers into a provider of services to enterprises as a private company, away from Wall Street's scrutiny.

But Southeastern, the most prominent of a clutch of investors, including the Alpine Capital Research and Schneider Capital funds, which have voiced opposition to the buyout, on Friday argued that the company had the capability to pay a $12 special dividend to shareholders, realizing much more value while still retaining significant cash-flow.

It also suggested a Dutch auction or some other structure that would involve a public tender of shares.

Dell has now gone into a go-shop process, during which it can solicit better offers. But Hawkins and Cates argue that Michael Dell's involvement may affect that procedure.

"We are concerned that given the participation of Michael Dell in this transaction, that a traditional go shop process is not sufficient to ensure that the Company receives superior offers," they wrote.

Morningstar analyst Carr Lanphie said it is not a surprise that some investors do not like the offer price, but said the stock would fall sharply if the deal does not go through.

"The point being that if this doesn't go through, you are going to swallow a 35-40 percent decline in share price," Lanphie said. "Then, your chairman just had his attempted buyout rejected.

"Given the management they have lost in the last couple of months, will they be able to continue to grow the company? That is something the investors will need to consider," he added.

(Reporting by Poornima Gupta; Editing by Steve Orlofsky, Gary Hill and Dan Grebler)

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IHT Rendezvous: Baron Von Fancy Goes to Paris

PARIS—Baron Von Fancy’s name may belong in an 18th-century German royal court, but he is very much a 20th-century child. He’s a multimedia artist who lives in New York and surfs on the vintage-is-cool wave, using social media as his manager, agent and public relations firm.

His latest exhibition, “A Thing Called Love,” opened on Monday at the Paris Colette shop, a European mecca of all things fashionable, and runs through Feb. 23. It’s his first big break. “I’m honored to be shown in Colette. I couldn’t have asked for more,” said Baron Von Fancy, who is 28, while sipping tea in a cafe across the street from the store.

The exhibition is a collection of handpainted 1950s-looking signs of catchphrases overheard in the subway and in conversation. Some of them are poetic, some are jokes and some clichés. The theme for the show, whose run encompasses Valentine’s Day, is love. “Crazy About You,” “To the Moon and Back,” “Just Kids” (referencing Patti Smith’s book) are a few examples. He added “Bisous,” and “Loin des yeux, loin du coeur,” as a nod to his new French audience. He also redesigned Colette’s Water Bar menu and painted huge murals. The one behind the cash register reads “The Thrill Is Gone.”

Outside, along the wall, he had started painting the words Very Fancy, but the person who was supposed to help him paint was late and he didn’t have time to finish before the opening of the show. Welcome to France, Mr. Fancy.



Baron Von Fancy isn’t – surprise, surprise – his real name. He was born Gordon Stevenson, in New York, in the early 1980s, one of seven siblings and half-siblings. He is not without connections: his father, Charles Stevenson, is an investor; his stepmother is the writer Alex Kuczynski, who contributes to The New York Times. The story behind his strange but catchy moniker is a mix of many anecdotes including a nickname of an ex-girlfriend’s dog and his fancy collection of vintage Versace jeans.

Baron Von Fancy (why call him Gordon when you can call him Baron Von Fancy?) epitomizes Generation Y, also known as Generation Sell. He creates art under both names, but uses Baron Von Fancy as a brand for his more commercial art. As Gordon Stevenson, he paints, dyes waterfalls, and does light installations. When he is Baron, as he says his mother now often calls him, he does lighters, bow ties, socks and his painted signs.

Baron doesn’t whip out a battered Moleskine when he has an idea, he uses Twitter is his notebook. He tweets several times a day, to more than a thousand people, phrases that could end up on a sign in an exhibition.

His Instagram account has more than 4,000 subscribers, and serves as his PR office.

As it happens, Instagram, the photo-sharing application with  90 million users, had a key role in securing his Colette exhibition. 

Several months ago, one of Baron Von Fancy’s friends noticed a picture of a T-shirt on Colette’s Instagram account with what looked like a Baron Von Fancy sign, and notified him. He wrote to Colette’s owner Sarah Andelman and showed her a picture of his art. She agreed the brand they were selling must have copied Baron Von Fancy’s art and invited him to exhibit his work in her store.

“I can’t help but thank Instagram,” says Baron Von Fancy with a laugh. “I realize how crazy that sounds, and people may say I take Instagram too seriously, but it has done so much for me. It has changed my life.”

You can already here a vast group of people shriek and shake their heads at his statement but the fact is that today social media is the way young artists to get themselves known. 

He uses the application to share his vision and show his inspiration, but also to showcase his work.

“All I think of when I wake up in the morning is create,” he says. And although he makes a living writing sentences, he says he’s not a writer, but expresses himself visually. “I’m not very good a keeping a blog, but Instagram is a perfect way to communicate and get visibility.”

Technology has opened many opportunities for him. Through social media, he has started a collaboration with the clothing brand Patagonia (the New York art director followed his Instagram account) and a collaboration with a rapper on socks.

Although Baron Von Fancy is very much an artist of our time, his art is turned toward the past, inspired by old-school classic sign painting. “Today everyone uses computer-generated fonts,” he says, looking out the window at the Parisian store fronts, “but I think that in general there is a real movement of people who are going back to things being made by hand and with care.”

To learn the art of handmade signs, Baron Von Fancy turned toward a old Latvian man called Fred who has a sign store in Queens, New York, and who taught him his art. “I sat there and looked at how he moved his hand,” he explains.

Fred has always worked in Queens, and has no idea what Colette is. He has no idea that this show means his student plays with the big boys now. “He doesn’t even get why I use most of my catchphrases,” says Baron Von Fancy.

But that is exactly what Baron Von Fancy does, and why he’s representative of his generation. He takes something basic and old, and turns into something nostalgically new and cool. Fancy, as it were.

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Armstrong sued for $12 million bonus

AUSTIN, Texas (AP) — A Dallas promotions company sued Lance Armstrong on Thursday, demanding he repay $12 million in bonuses and fees it paid him for winning the Tour de France.

SCA Promotions had tried in a 2005 legal dispute over the bonuses to prove Armstrong cheated to win before it ultimately settled and paid him.

Armstrong recently acknowledged using performance-enhancing drugs after the U.S. Anti-Doping Agency in 2012 detailed a sophisticated doping program by his Armstrong's teams. Armstrong was stripped of his seven Tour de France victories and given a lifetime ban from sports.

Now, the company contends in its lawsuit, Armstrong and agent Bill Stapleton lied and conspired to cheat SCA out of millions. The lawsuit notes that Armstrong repeatedly testified under oath in the 2005 dispute that he did not use steroids, other drugs or blood doping methods to win, all of which he now admits to doing.

"It is time now for Mr. Armstrong to face the consequences of his actions," said the lawsuit, which demands a jury trial. "He admits he doped; he admits he bullied people; he admits he lied."

Armstrong won the Tour de France every year from 1999-2005. The SCA lawsuit seeks to recover $9.5 million in bonus money for winning the race from 2002-2004 and another $2.5 million paid to Armstrong for other costs and fees.

The lawsuit names Armstrong, Stapleton and Tailwind Sports, Inc., the team's management entity, as defendants.

Tim Herman, an attorney for Armstrong and Stapleton, did not immediately return telephone messages. Herman has previously noted that SCA previously settled its case with Armstrong and said it should not be allowed to reopen the matter.

An Armstrong spokesman referred to the original settlement signed in February 2006 by SCA President Robert Hamman and Stapleton, both for himself and Armstrong, that states "No party may challenge, appeal or attempt to set aside" the agreement, which is "fully and forever binding."

SCA counters that the case can be reopened because Armstrong's repeated lies under oath prevented it from proving he doped.

"Had SCA — or the Arbitration Panel — known the truth, the arbitration award and settlement never would have occurred," the lawsuit said.

According to the lawsuit, Stapleton and Herman both said in the original dispute that if Armstrong was to be stripped of his titles by official action, SCA would have no obligation to pay or could come after its money.

The 35-page filing also goes after Armstrong's televised interview with Oprah Winfrey last month in which he tearfully recounted having to tell his 13-year-old son the doping allegations were true.

In 2006, Armstrong told the arbitration panel that he didn't dope because he wouldn't want his son to someday follow him into a dirty sport.

"So how could I put my son into this completely dark, dirty underworld of deceit and deception would make no sense to me. I would never do that," Armstrong said, according to the lawsuit.

Separately, USADA chief executive Travis Tygart said Wednesday the agency has been in contact with him Armstrong and is giving him more time to decide if he wants to cooperate with its investigators and tell more about what he knows of doping in cycling.

USADA extended its original Wednesday deadline to Feb. 20 to work out an interview with investigators under oath.

Just two weeks ago, Herman had strongly suggested Armstrong would not be interested in talking with USADA investigators. Tygart said it was Armstrong who asked for more time.

"We understand that he does want to be part of the solution and assist in the effort to clean up the sport of cycling," Tygart said in a statement. "We have agreed to his request for an additional two weeks to work on details to hopefully allow for this to happen."

The agency has said cooperating in its cleanup effort is the only path open to Armstrong if his lifetime ban from sports is to be reduced.

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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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DealBook: K.K.R.'s Earnings Rise 22% on Investment Gains

Improving markets lifted the fortunes of Kohlberg Kravis Roberts in the fourth quarter, as the investment firm reported a 22 percent rise in profit.

K.K.R. said on Thursday that it earned $347.7 million for the quarter, as all of its businesses showed strong gains. For the year, the firm reported earning $2.1 billion.

The fourth-quarter profit, reported as economic net income and which includes unrealized gains from investments, comes out to 48 cents a share. That is more than double the 20-cents-a-share average of analyst estimates compiled by Capital IQ.

Private equity firms have benefited from an improvement in the markets, which have bolstered the value of their own holdings. Last week, the Blackstone Group reported a 43 percent increase in fourth-quarter earnings.

K.K.R. said the value of its investments rose 4 percent for the quarter and 24 percent for the year.

The strongest performers among the firm’s investments included Alliance Boots, a British pharmacy chain; HCA, the giant hospital operator that went public last year; and the Nielsen Company, the media measurement company.

The improved market conditions also make selling portfolio companies a more attractive prospect, letting the firms harvest tangible returns from their investments. That was reflected in K.K.R.’s results, as it reported a nearly fourfold increase in distributable earnings for the quarter, to $546.3 million. That metric tracks how much a firm actually pays to its limited partners.

And K.K.R.’s assets under management rose 13.9 percent from the third quarter, to $75.5 billion.

The firm’s co-founders and co-chairmen, Henry R. Kravis and George R. Roberts, said in a statement that the growth of their private equity portfolio outpaced the Standard & Poor’s 500-stock index by about 7 percent last year.

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