Hacking Report Criticizes Murdoch Newspaper and British Press Standards

LONDON — The leader of a major inquiry into the standards of British newspapers triggered by the phone hacking scandal offered an excoriating critique of the press as a whole on Thursday, saying it displayed “significant and reckless disregard for accuracy,” and urged the press to form an independent regulator to be underpinned by law.

Dan Kitwood/Getty Images

Lord Justice Sir Brian Leveson on Thursday with his inquiry on press standards.

Kerim Okten/European Pressphoto Agency

The British actor Hugh Grant arrived Thursday at the Queen Elizabeth II conference center in London, where Lord Justice Sir Brian Leveson was scheduled to release a report on the British press.

The report singled out Rupert Murdoch’s defunct tabloid The News of the World for sharp criticism.

“Too many stories in too many newspapers were the subject of complaints from too many people with too little in the way of titles taking responsibility, or considering the consequences for the individuals involved,” the head of the inquiry, Lord Justice Sir Brian Leveson, said in a 46-page summary of the findings in his long-awaited, 1,987-page report published in four volumes.

“The ball moves back into the politicians’ court,” Sir Brian said, referring to what form new and tighter regulations should take. “They must now decide who guards the guardians.”

Mr. Murdoch closed the 168-year-old News of the World in July 2011 as the phone hacking scandal blossomed into broad public revulsion with reports that the newspaper had ordered the interception of voice mail messages left on the cellphone of Milly Dowler, British schoolgirl who was abducted in 2002 and later found murdered.

Sir Brian said there had been a “failure of management and compliance” at The News of the World, accusing it of a “general lack of respect for individual privacy and dignity.”

“It was said that The News of the World had lost its way in relation to phone hacking,” the summary said. “Its casual attitude to privacy and the lip service it paid to consent demonstrated a far more general loss of direction.”

Speaking after the report was published, Sir Brian said that while the British press held a “privileged and powerful place in our society,” its “responsibilities have simply been ignored.”

“A free press in a democracy holds power to account. But, with a few honorable exceptions, the U.K. press has not performed that vital role in the case of its own power.”

“The press needs to establish a new regulatory body which is truly independent of industry leaders and of government and politicians,” he said. “Guaranteed independence, long-term stability and genuine benefits for the industry cannot be realized without legislation,” he said, adding: “This is not and cannot reasonably or fairly be characterized as statutory regulation of the press.”

In the body of the exhaustive report, reprising at length the testimony of many of the witnesses who spoke at the hearings, the document discusses press culture and ethics; explores the press’s attitude toward the subjects of its stories; and discusses the cozy relationship between the press and the police, and the press and politicians.

The report devotes an entire section to The News of the World. Using a number of case studies that came from the testimony of witnesses, it described a newsroom under immense pressure to bring in stories exclusively and quickly, full of journalists with cavalier and sometimes cruel attitudes toward the privacy and feelings of the people they were covering. Sir Brian said that reporters regularly obtained illegal information about their subjects, harassed and threatened subjects into cooperating, and concealed their identities in pursuit of stories.   

Concluding the section on the ethical  practices and culture of the news media, Sir Brian said he recognized that “most of what the press does is good journalism free from the sort of vices I have had to address at length.” But still,  he says, “it is essential that the need for a fresh start in press regulation is fully embraced and a new regime thereafter implemented.”

In the current system of self-regulation by a body called the Press Complaints Commission, newspapers effectively regulate themselves. The report urged the creation of a new independent regulatory body with powers to fine offending newspapers up to $1.6 million, made up of people who are not serving editors and should not be either lawmakers or figures from the government.

Lark Turner contributed reporting.

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Ex-NASA Scientist’s Data Fears Come True

In 2007, Robert M. Nelson, an astronomer, and 27 other scientists at the Jet Propulsion Laboratory sued NASA arguing that the space agency’s background checks of employees of government contractors were unnecessarily invasive and violated their privacy rights.

Privacy advocates chimed in as well, contending that the space agency would not be able to protect the confidential details it was collecting.

The scientists took their case all the way to the Supreme Court only to lose last year.

This month, Dr. Nelson opened a letter from NASA telling him of a significant data breach that could potentially expose him to identity theft.

The very thing he and advocates worried about had occurred. A laptop used by an employee at NASA’s headquarters in Washington had been stolen from a car parked on the street on Halloween, the space agency said.

Although the laptop itself was password protected, unencrypted files on the laptop contained personal information on about 10,000 NASA employees — including details like their names, birth dates, Social Security numbers and in some cases, details related to background checks into employees’ personal lives.

Millions of Americans have received similar data breach notices from employers, government agencies, medical centers, banks and retailers. NASA in particular has been subject to “numerous cyberattacks” and computer thefts in recent years, according to a report from the Government Accountability Office, an agency that conducts research for Congress.

Even so, Dr. Nelson, who recently retired from the Jet Propulsion Laboratory, a research facility operated by the California Institute of Technology under a contract with NASA, stands out as a glaring example of security lapses involving personal data, privacy advocates say.

“To the extent that Robert Nelson looks like millions of other people working for firms employed by the federal government, this would seem to be a real problem,” said Marc Rotenberg, the executive director of the Electronic Privacy Information Center, an advocacy group which filed a friend-of-the-court brief for Dr. Nelson in the Supreme Court case.

In a 2009 report titled “NASA Needs to Remedy Vulnerabilities in Key Networks,” the Government Accountability Office noted that the agency had reported 1,120 security incidents in fiscal 2007 and 2008 alone.

It also singled out an incident in 2009 in which a NASA center reported the theft of a laptop containing about 3,000 unencrypted files about arms traffic regulations and wind tunnel tests for a supersonic jet.

“NASA had not installed full-disk encryption on its laptops at all three centers,” the report said. “As a result, sensitive data transmitted through the unclassified network or stored on laptop computers were at an increased risk of being compromised.” Other federal agencies have had similar problems. In 2006, for example, the Department of Veteran’s Affairs reported the theft of an employee laptop and hard drive that contained personal details on about 26.5 million veterans. Last year, the G.A.O. cited the Internal Revenue Service for weaknesses in data control that could “jeopardize the confidentiality, integrity, and availability of financial and sensitive taxpayer information.”

Also last year, the Securities and Exchange Commission warned its employees that their confidential financial information, like brokerage transactions, might have been compromised because an agency contractor had granted data access to a subcontractor without the S.E.C.’s authorization.

In a phone interview, Dr. Nelson, the astronomer, said he planned to hold a news conference on Wednesday morning in which he would ask members of Congress to investigate NASA’s data collection practices and the recent data breach.

Robert Jacobs, a NASA spokesman, said the agency’s data security policy already adequately protected employees and contractors because it required computers to be encrypted before employees took them off agency premises. “We are talking about a computer that should not have left the building in the first place,” Mr. Jacobs said. “The data would have been secure had the employee followed policy.”

The government argued in the case Dr. Nelson filed that a law called the Privacy Act, which governs data collection by federal agencies, provided the scientists with sufficient protection. The case reached the Supreme Court, which upheld government background checks for employees of contractors. The roots of Dr. Nelson’s case against NASA date back to 2004 when the Department of Homeland Security, under a directive signed by President George Bush, required federal agencies to adopt uniform identification credentials for all civil servants and contract employees. As part of the ID card standardization process, the department recommended agencies institute background checks.

Several years later, when NASA announced it intended to start doing background checks at the Jet Propulsion Laboratory, Dr. Nelson and other scientists there objected.

Those security checks could have included inquiries into medical treatment, counseling for drug use, or any “adverse” information about employees such as sexual activity, or participation in protests, said Dan Stormer, a lawyer representing Dr. Nelson.

But Dr. Nelson and other long-term employees of the lab challenged the legality of those checks, arguing that they violated their privacy rights. NASA, they said, had not established a legitimate need for such extensive investigations about low-risk employees like themselves who did not have security clearances or handle confidential information. Dr. Nelson, for example, specializes in solar system science — concerning, for example, Jupiter’s moon Io and Titan, a moon of Saturn — and publishes his work in scientific journals

“It was an invitation to an open-ended fishing expedition,” Dr. Nelson said of the background checks.

In friend of the court briefs for Dr. Nelson, privacy groups cited many data security problems at federal agencies, arguing that there was a risk that NASA was not equipped to protect the confidential details it was collecting about employees and contractors.

In 2008, the United States Court of Appeals for the Ninth Circuit in San Francisco temporarily halted the background checks, saying that the case had raised important questions about privacy rights. But last year, the Supreme Court upheld the background investigations of employees of government contractors.

Dr. Nelson said he retired from the Jet Propulsion Laboratory last June rather than submit to a background check. He now works as a senior scientist at the Planetary Science Institute of Tucson.

NASA has contracted with ID Experts, a data breach company, to help protect employees whose data was contained on the stolen laptop against identity theft. Mr. Jacobs, the NASA spokesman, said the agency has encrypted almost 80 percent of its laptops and plans to encrypt the rest by Dec. 21. He added that he too received a letter from NASA warning that his personal information might have been compromised by the laptop theft.

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Read More..

The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Read More..

Ex-NASA Scientist’s Data Fears Come True

In 2007, Robert M. Nelson, an astronomer, and 27 other scientists at the Jet Propulsion Laboratory sued NASA arguing that the space agency’s background checks of employees of government contractors were unnecessarily invasive and violated their privacy rights.

Privacy advocates chimed in as well, contending that the space agency would not be able to protect the confidential details it was collecting.

The scientists took their case all the way to the Supreme Court only to lose last year.

This month, Dr. Nelson opened a letter from NASA telling him of a significant data breach that could potentially expose him to identity theft.

The very thing he and advocates worried about had occurred. A laptop used by an employee at NASA’s headquarters in Washington had been stolen from a car parked on the street on Halloween, the space agency said.

Although the laptop itself was password protected, unencrypted files on the laptop contained personal information on about 10,000 NASA employees — including details like their names, birth dates, Social Security numbers and in some cases, details related to background checks into employees’ personal lives.

Millions of Americans have received similar data breach notices from employers, government agencies, medical centers, banks and retailers. NASA in particular has been subject to “numerous cyberattacks” and computer thefts in recent years, according to a report from the Government Accountability Office, an agency that conducts research for Congress.

Even so, Dr. Nelson, who recently retired from the Jet Propulsion Laboratory, a research facility operated by the California Institute of Technology under a contract with NASA, stands out as a glaring example of security lapses involving personal data, privacy advocates say.

“To the extent that Robert Nelson looks like millions of other people working for firms employed by the federal government, this would seem to be a real problem,” said Marc Rotenberg, the executive director of the Electronic Privacy Information Center, an advocacy group which filed a friend-of-the-court brief for Dr. Nelson in the Supreme Court case.

In a 2009 report titled “NASA Needs to Remedy Vulnerabilities in Key Networks,” the Government Accountability Office noted that the agency had reported 1,120 security incidents in fiscal 2007 and 2008 alone.

It also singled out an incident in 2009 in which a NASA center reported the theft of a laptop containing about 3,000 unencrypted files about arms traffic regulations and wind tunnel tests for a supersonic jet.

“NASA had not installed full-disk encryption on its laptops at all three centers,” the report said. “As a result, sensitive data transmitted through the unclassified network or stored on laptop computers were at an increased risk of being compromised.” Other federal agencies have had similar problems. In 2006, for example, the Department of Veteran’s Affairs reported the theft of an employee laptop and hard drive that contained personal details on about 26.5 million veterans. Last year, the G.A.O. cited the Internal Revenue Service for weaknesses in data control that could “jeopardize the confidentiality, integrity, and availability of financial and sensitive taxpayer information.”

Also last year, the Securities and Exchange Commission warned its employees that their confidential financial information, like brokerage transactions, might have been compromised because an agency contractor had granted data access to a subcontractor without the S.E.C.’s authorization.

In a phone interview, Dr. Nelson, the astronomer, said he planned to hold a news conference on Wednesday morning in which he would ask members of Congress to investigate NASA’s data collection practices and the recent data breach.

Robert Jacobs, a NASA spokesman, said the agency’s data security policy already adequately protected employees and contractors because it required computers to be encrypted before employees took them off agency premises. “We are talking about a computer that should not have left the building in the first place,” Mr. Jacobs said. “The data would have been secure had the employee followed policy.”

The government argued in the case Dr. Nelson filed that a law called the Privacy Act, which governs data collection by federal agencies, provided the scientists with sufficient protection. The case reached the Supreme Court, which upheld government background checks for employees of contractors. The roots of Dr. Nelson’s case against NASA date back to 2004 when the Department of Homeland Security, under a directive signed by President George Bush, required federal agencies to adopt uniform identification credentials for all civil servants and contract employees. As part of the ID card standardization process, the department recommended agencies institute background checks.

Several years later, when NASA announced it intended to start doing background checks at the Jet Propulsion Laboratory, Dr. Nelson and other scientists there objected.

Those security checks could have included inquiries into medical treatment, counseling for drug use, or any “adverse” information about employees such as sexual activity, or participation in protests, said Dan Stormer, a lawyer representing Dr. Nelson.

But Dr. Nelson and other long-term employees of the lab challenged the legality of those checks, arguing that they violated their privacy rights. NASA, they said, had not established a legitimate need for such extensive investigations about low-risk employees like themselves who did not have security clearances or handle confidential information. Dr. Nelson, for example, specializes in solar system science — concerning, for example, Jupiter’s moon Io and Titan, a moon of Saturn — and publishes his work in scientific journals

“It was an invitation to an open-ended fishing expedition,” Dr. Nelson said of the background checks.

In friend of the court briefs for Dr. Nelson, privacy groups cited many data security problems at federal agencies, arguing that there was a risk that NASA was not equipped to protect the confidential details it was collecting about employees and contractors.

In 2008, the United States Court of Appeals for the Ninth Circuit in San Francisco temporarily halted the background checks, saying that the case had raised important questions about privacy rights. But last year, the Supreme Court upheld the background investigations of employees of government contractors.

Dr. Nelson said he retired from the Jet Propulsion Laboratory last June rather than submit to a background check. He now works as a senior scientist at the Planetary Science Institute of Tucson.

NASA has contracted with ID Experts, a data breach company, to help protect employees whose data was contained on the stolen laptop against identity theft. Mr. Jacobs, the NASA spokesman, said the agency has encrypted almost 80 percent of its laptops and plans to encrypt the rest by Dec. 21. He added that he too received a letter from NASA warning that his personal information might have been compromised by the laptop theft.

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News Analysis: Sunni Leaders Gaining Clout in Mideast

Mohammed Saber/European Pressphoto Agency

A Palestinian woman in Gaza City on Tuesday walked amid the rubble left from eight days of fighting that ended in a cease-fire.

RAMALLAH, West Bank — For years, the United States and its Middle East allies were challenged by the rising might of the so-called Shiite crescent, a political and ideological alliance backed by Iran that linked regional actors deeply hostile to Israel and the West.

But uprising, wars and economics have altered the landscape of the region, paving the way for a new axis to emerge, one led by a Sunni Muslim alliance of Egypt, Qatar and Turkey. That triumvirate played a leading role in helping end the eight-day conflict between Israel and Gaza, in large part by embracing Hamas and luring it further away from the Iran-Syria-Hezbollah fold, offering diplomatic clout and promises of hefty aid.

For the United States and Israel, the shifting dynamics offer a chance to isolate a resurgent Iran, limit its access to the Arab world and make it harder for Tehran to arm its agents on Israel’s border. But the gains are also tempered, because while these Sunni leaders are willing to work with Washington, unlike the mullahs in Tehran, they also promote a radical religious-based ideology that has fueled anti-Western sentiment around the region.

Hamas — which received missiles from Iran that reached Israel’s northern cities — broke with the Iranian axis last winter, openly backing the rebellion against the Syrian president, Bashar al-Assad. But its affinity with the Egypt-Qatar-Turkey axis came to fruition this fall.

“That camp has more assets that it can share than Iran — politically, diplomatically, materially,” said Robert Malley, the Middle East program director for the International Crisis Group. “The Muslim Brotherhood is their world much more so than Iran.”

The Gaza conflict helps illustrate how Middle Eastern alliances have evolved since the Islamist wave that toppled one government after another beginning in January 2011. Iran had no interest in a cease-fire, while Egypt, Qatar and Turkey did.

But it is the fight for Syria that is the defining struggle in this revived Sunni-Shiite duel. The winner gains a prized strategic crossroads.

For now, it appears that that tide is shifting against Iran, there too, and that it might well lose its main Arab partner, Syria. The Sunni-led opposition appears in recent days to have made significant inroads against the government, threatening the Assad family’s dynastic rule of 40 years and its long alliance with Iran. If Mr. Assad falls, that would render Iran and Hezbollah, which is based in Lebanon, isolated as a Shiite Muslim alliance in an ever more sectarian Middle East, no longer enjoying a special street credibility as what Damascus always tried to sell as “the beating heart of Arab resistance.”

If the shifts seem to leave the United States somewhat dazed, it is because what will emerge from all the ferment remains obscure.

Clearly the old leaders Washington relied on to enforce its will, like President Hosni Mubarak of Egypt, are gone or at least eclipsed. But otherwise confusion reigns in terms of knowing how to deal with this new paradigm, one that could well create societies infused with religious ideology that Americans find difficult to accept. The new reality could be a weaker Iran, but a far more religiously conservative Middle East that is less beholden to the United States.

Already, Islamists have been empowered in Egypt, Libya and Tunisia, while Syria’s opposition is being led by Sunni insurgents, including a growing number identified as jihadists, some identified as sympathizing with Al Qaeda. Qatar, which hosts a major United States military base, also helps finance Islamists all around the region.

In Egypt, President Mohamed Morsi resigned as a member of the Muslim Brotherhood only when he became head of state, but he still remains closely linked with the movement. Turkey, the model for many of them, has kept strong relations with Washington while diminishing the authority of generals who were longstanding American allies.

“The United States is part of a landscape that has shifted so dramatically,” said Mr. Malley of the International Crisis Group. “It is caught between the displacement of the old moderate-radical divide by one that is defined by confessional and sectarian loyalty.”

The emerging Sunni axis has put not only Shiites at a disadvantage, but also the old school leaders who once allied themselves with Washington.

The old guard members in the Palestinian Authority are struggling to remain relevant at a time when their failed 20-year quest to end the Israeli occupation of Palestinian lands makes them seem both anachronistic and obsolete.

“Hamas has always argued that it is the future of the changes in the region because of its revolutionary nature, that it is part of the religious political groups who have been winning the revolutions,” said Ghassan Khatib, an official at Birzeit University and former government spokesman.

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News Analysis: St. Jude Medical Suffers for Redacting a Product Name

Peter Muhly for The New York Times

Dr. Ernest Lau holds a Durata lead from a St. Jude Medical Fortify ICD, an implanted heart defibrillator.

IS covering a product’s name in a public document a sign that a company has something to hide? And how should doctors, patients and investors react if the product at issue is one on which peoples’ lives and a company’s fortunes depend?

Such questions now loom over St. Jude Medical after the disclosure last week that its executives had blacked out the name of a heart device component when they released a critical federal report involving the product. The value of St. Jude has since plummeted more than $1 billion, or 12 percent. But the company’s actions may have a more lasting impact on its reputation and the health of patients, some experts say.

Last week’s incident was the latest development in a controversy involving the component, an electrical wire that connects an implanted defibrillator to a patient’s heart. St. Jude officials say the wire, which is known as the Durata, is safe. But uncertainty about the company’s statements is growing, underscored by its handling of the report, which involved a Food and Drug Administration inspection of a plant that makes the Durata.

St. Jude released that report in October as part of a filing with the Securities and Exchange Commission. The F.D.A. provides device makers with the reports in an unaltered form, and they may contain criticisms of a company’s procedures.

But the version of the report that St. Jude filed with the S.E.C. left some doctors and analysts uncertain about which company product or products were at issue for a simple reason — St. Jude had redacted, or blocked out, all 20 references to the Durata in it.

Company executives said they had done so based on their “good faith” interpretation of how the F.D.A. would act if it publicly released the report under the Freedom of Information Act. But both an F.D.A spokeswoman and a lawyer who specializes in medical devices took exception with that view, saying that names of approved products typically do not qualify as the type of confidential business information that the F.D.A. would redact.

Among other things, F.D.A. inspectors found significant flaws in the company’s testing and oversight of the Durata. It was those revelations and the implications that the problems could lead to further F.D.A. action against St. Jude that led to the sharp fall last week in its stock price.

In 2005, Guidant, a device maker that no longer exists, also found itself under scrutiny. Back then, its executives decided not to tell doctors that one of its defibrillators could short-circuit when a patient needed an electrical jolt to save a life. The expert who brought the Guidant problem to light, Dr. Robert Hauser, a heart specialist in Minnesota, has also raised concerns about the St. Jude wires, adding that he believes that its executives have been less than forthright.

“Patients and physicians would appreciate more information,” Dr. Hauser said.

In an earlier interview, St. Jude’s chief executive, Daniel J. Starks, said the company had hidden nothing about the Durata or another heart wire named the Riata, which it stopped selling in 2010.

“We’ve been more transparent than others,” said Mr. Starks, referring to company competitors like Medtronic.

Still, some Wall Street analysts share Dr. Hauser’s view. And if one St. Jude executive can claim credit for shaping their opinion, it would be Mr. Starks.

Earlier this year, he sought, among other things, to have a medical journal retract an article written by Dr. Hauser that was critical of the Riata. The publication refused.

Now, after St. Jude’s latest misfire, Wall Street analysts, who usually agree more than disagree, are placing wildly differing bets on St. Jude, with some valuing it at $48 a share and others at $30. On Monday, St. Jude closed at $31.86 on the New York Stock Exchange.

One of those bearish analysts, Matthew Dodds of Citigroup, said he thought the Food and Drug Administration might act soon on Durata. “I believe that a lot of their actions have made the situation worse, ” he said of the company’s executives.

A St. Jude spokeswoman, Amy Jo Meyer, reiterated the company’s stance that it had interpreted agency rules in “good faith” when releasing the redacted report about the Durata. An F.D.A. spokeswoman, Mary Long, said the agency did not consider the names of approved products to be confidential. And a lawyer, William Vodra, said that while device makers try to make a confidentiality argument for product data they consider embarrassing, like injury reports, they rarely succeed.

“In my experience, the F.D.A. consistently rejects” such arguments, Mr. Vodra wrote in an e-mail.

For patients, the dilemma may become more excruciating. The company’s earlier heart wire, the Riata, has begun failing prematurely in some of the 128,000 patients worldwide who received it. And those patients and their doctors face a difficult decision: whether to leave it in place or have it surgically removed, a procedure that carries significant risks.

St. Jude executives say that the Durata, which uses a different type of insulation than the Riata, is not prone to such problems.

And with the Durata already implanted in 278,000 people, many heart specialists certainly hope they are right.

Read More..

Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

Read More..

Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

Read More..

The Hard Road Back: Prosthetic Arms a Complex Test for Amputees

A Future Reset:
After losing his arm in an I.E.D. explosion in Afghanistan, Cpl. Sebastian Gallegos has adjusted to his prosthetic limb.

SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.

The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.

He had been blown up, and was drowning at the bottom of an irrigation ditch.

Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.

Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.

Success.

“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”

It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.

Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.

To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.

“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.

The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.

Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.

For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.

But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.

More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.

In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.

But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.

Corporal Gallegos was not always that person.

His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.

Read More..