Extended Use of Breast Cancer Drug Suggested

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Read More..

Extended Use of Breast Cancer Drug Suggested

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Read More..

In Inquiry, Drilling Company Chief Quits

LONDON — The chief executive of Saipem, the largest European drilling and engineering contractor for the oil industry, resigned Wednesday evening after an Italian prosecutor’s office said it was investigating possible corruption.

The executive, Pietro Franco Tali, also served as deputy chairman of the company, in which the big Italian oil company Eni has a controlling stake.

A Saipem spokesman, Andrea Pagano Mariano, said the investigation related to contracts on oil and gas projects in Algeria involving the state oil company Sonatrach. He declined to elaborate.

Although Mr. Tali “is in no manner a subject of the prosecutor’s investigation, he felt that his resignation would better enable the company to respond to the prosector’s inquiry,” Saipem said in a statement. The activities were said to have occurred through 2009.

Eni, which has about 43 percent of Saipem’s shares, held an emergency board meeting Wednesday night, according to a news release. In recent days, it said, the board had urged the drilling company’s chairman, Alberto Meomartini, “to take immediate remedial actions in managing the situation.”

Eni’s chief financial officer, Alessandro Bernini, who held the same position at Saipem until 2008, also resigned Wednesday, although he “considers that his actions were right and proper,” according to an Eni release.

An Eni spokeswoman, Erika Mandraffino, said the accusations about Saipem came to Eni’s attention a few days ago. She declined to indicate what the inquiry involves in Algeria, where Saipem has billions of dollars’ worth of oil and gas operations and drilling contracts, and about 2,600 employees.

Saipem’s board named the chief operating officer of Eni’s gas and power division, Umberto Vergine, to replace Mr. Tali as Saipem’s chief.

The company also suspended Pietro Varone, chief operating officer of Saipem’s engineering and construction unit, following a notice of inquiry from the prosecutor related to the same investigation. Saipem’s board also ordered an internal audit using external consultants.

“Saipem believes that its business activities have been conducted in compliance with applicable, internal procedures” and its code of ethics, the company said, and has offered its full cooperation to the prosecutor’s office.

The investigation is a blow to ENI, which under its chief executive, Paolo Scaroni, is working to establish itself as a premier exploration and production company. Earlier on Wednesday, Eni announced a new natural gas discovery off the coast of Mozambique, where the company has become an early leader in staking a position in that country’s promising gas reserves.

Although Eni stresses that Saipem is independently managed, the two companies are closely intertwined.

In an interview on Nov. 19, Mr. Scaroni said that while the company was divesting other noncore assets, he considered Saipem “a major asset.”

He said that Saipem was “managed at arm’s length” because Eni was only “one of the customers” of the engineering company. He said Saipem was the top candidate to build the portion of the proposed South Stream natural gas pipeline from Russia to Eastern and Western Europe, under the Black Sea.

Eni, along with Gazprom, is a crucial backer of the project.

Read More..

Cheering U.N. Palestine Vote, New York Synagogue Tests Its Members

Congregation B’nai Jeshurun, a synagogue with several thousand members on the Upper West Side of Manhattan, is known for its charismatic rabbis, its energetic and highly musical worship, and its liberal stances on social causes.

But on Friday, when its rabbis and lay leaders sent out an e-mail enthusiastically supporting the vote by the United Nations to upgrade Palestine to a nonmember observer state, the statement was more than even some of its famously liberal congregants could stomach.

“The vote at the U.N. yesterday is a great moment for us as citizens of the world,” said the e-mail, which was sent to all congregants. “This is an opportunity to celebrate the process that allows a nation to come forward and ask for recognition.”

The statement, at a time when the United Nations’ vote was opposed by the governments of the United States and Israel, as well as by the leadership of many American Jewish organizations, reflected a divide among American Jews and a willingness to break a longstanding taboo by publicly disagreeing with Israel.

Clergy at several Jewish congregations have, in various ways, spoken out sympathetically about the United Nations’ vote.

At B’nai Jeshurun, reaction from congregants was swift. Some, like Allan Ripp, said he and his wife were appalled.

“We are just sort of in a state of shock,” he said. “It’s not as if we don’t support a two-state solution, but to say with such a warm embrace — it is like a high-five to the P.L.O., and that has left us numb.”

Other congregants, however, said it was a bold move that they welcomed.

“I thought it was great; I thought it was very courageous of them,” said Gil Kulick, a congregant. “I think as of late there has been a reluctance to speak out on this issue,” he added, “and that’s why I was really delighted that they chose to take a strong unequivocal stand.”

American Jews have long had a vigorous, and sometimes vitriolic, debate about the positions of the Israeli government and the peace process with the Palestinians. But the tendency has been to keep critical views within the fold, particularly when responding to high-profile actions like the vote supporting an upgrade in Palestinian status in the United Nations.

“In most cases, at most times we impose a kind of discipline upon ourselves — nobody imposes it on us — particularly on a matter that the Israeli government has asked for unanimous support from the Jewish community,” said Samuel Norich, the publisher of The Forward, a Jewish affairs weekly based in New York. “When they speak out, that is rare,” Mr. Norich said of mainstream congregations.

Gary Rosenblatt, the editor and publisher of The Jewish Week, the largest circulation Jewish newspaper in the country, said, “I think the sense of a need for a unified front in the American Jewish community is breaking down.”

In White Plains, a group of synagogues from different branches of Judaism — conservative, reform and reconstructionist — sent an e-mail to congregants after the United Nations’ vote expressing cautious optimism about Palestine’s new status, even as statements from the reform and conservative movements expressed disappointment.

“For their own reasons, most of the American Jewish organizations felt it was necessary to fall into line,” said Lester Bronstein, a rabbi at Bet Am Shalom Synagogue in White Plains and one of the signers of the letter. “I think what we said is indicative of what more and more rabbis believe, and more and more, but in trickles, are able to say it.”

 The rabbis at B’nai Jeshurun — J. Rolando Matalon, Marcelo R. Bronstein and Felicia L. Sol — did not respond to repeated requests this week for comment on why they had sent the e-mail, which was also signed by the president of the synagogue’s board of directors and its executive director. While its gist — that the vote could be a step toward a two-state solution and Middle East peace — was not surprising to congregants, its tone and its timing, so soon after the Gaza conflict, made it stand out, some said.

B’nai Jeshurun, which is not affiliated with any of the major branches of Judaism, worships in an elaborate Moorish-style sanctuary on West 88th Street. The congregation has attracted national attention for its success at energizing a once-struggling synagogue. Some services attract overflow crowds; lectures and events are popular not only among members, but also among young single Jews seeking social connections. During services, congregants are encouraged to express themselves and often clap and even dance to the music, which is played by live musicians with not just a keyboard, but also often with congas, mandolin, flute, guitar or cello.

This article has been revised to reflect the following correction:

Correction: December 4, 2012

An earlier version of this article misspelled the name of the congregation at one point.  It is B’nai Jeshurun, not B’nai Jeshrun,

Read More..

Law Students in Austria Challenge Facebook Privacy Policy

BERLIN — An Austrian student group said Tuesday that it planned to challenge Facebook’s privacy policies in Irish court, alleging that the social networking giant had failed, despite repeated requests and formal complaints made by its members, to adapt to the restrictions of European data protection law.

The group, which calls itself Europe vs. Facebook, said it would begin collecting donations to challenge the policy in Ireland, where the company’s European business is incorporated. Max Schrems, an Austrian law student at the University of Vienna who organized the effort, said Facebook had no interest in adapting its service to meet stricter European privacy requirements.

“We have been pursing this for more than a year with Facebook, but the company has done only about 10 percent of what we had asked them to do,” said Mr. Schrems, 25. “Therefore, we are preparing to go to court.”

Facebook, in a statement, said its European privacy policy had been vetted and approved by Irish regulators and was in compliance with European law.

“The way Facebook Ireland handles personal data has been subject to thorough review by the Irish Data Protection Commissioner over the past year,” the company said. “Nonetheless, we have some vocal critics who will never be happy whatever we do and whatever the D.P.C. concludes.”

Mr. Schrems’s group, which he said was made up of about 10 students at the University of Vienna, filed 22 complaints in 2010 with the Office of the Data Protection Commissioner in Ireland, which regulates Facebook’s European business because it is incorporated there.

As a result of those complaints, the regulator conducted a public audit of Facebook’s privacy policies. In September it announced an agreement with the company that required, among other changes, that Facebook shorten the time it retained consumer data and refrain from building a photo archive on individuals without their prior consent.

But Mr. Schrems said in an interview that Facebook was still violating European law in many areas, including a requirement that Facebook provide users who request it with a full copy of all the data the company has collected on them. Mr. Schrems, a Facebook user since 2007, said he requested his own summary file from Facebook in 2010.

The company, whose global headquarters is in Menlo Park, California, responded by creating a self-service tool for users to extract the data, which Mr. Schrems said supplied him only with information going back to 2010. In addition, he alleged that Facebook’s privacy policy, which users are required to agree to before they can use the service, is too broad and violates European law.

“It is basically a collection of American legalese, which is intentionally vague and gives the company adequate leeway to do basically anything they want with your data,” Mr. Schrems said.

Thilo Weichert, the data protection supervisor for the German state of Schleswig-Holstein, which has also brought legal action against Facebook, said he supported the Austrian student group’s efforts.

“Facebook’s policy is much too vague and broad and does not conform with German or European law,” Mr. Weichert said in an interview. “We think that European privacy officials need to take common action on this.”

Mr. Weichert issued an administrative order in August 2011 that barred businesses in the state, which is located along Germany’s northern border with Denmark, from using Facebook’s social plug-ins like the Like button and Fan pages. The rationale for the order: Those applications collect information on users without their consent by inserting cookies, which track individual computers, through a user’s Web browser.

In November of last year, Mr. Weichert sued several local business organizations, including the state’s own Industrie- und Handelskammer, the equivalent of the local chamber of commerce, for creating their own fan pages on Facebook. The chamber and businesses that have not been identified have challenged that suit, which is pending in court in Kiel.

The privacy policies of Facebook, Google and some other U.S.-based Web companies have come under increasing criticism in Europe.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Precision

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

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

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

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

Read More..

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Precision

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

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

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

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

Read More..

DealBook: Former Goldman Director Gupta to Stay Free Pending His Appeal

A former Goldman Sachs director, Rajat K. Gupta, may remain free on bail while he challenges his insider-trading conviction, a federal appeals court ruled on Tuesday.

In a surprise decision, the United States Court of Appeals for the Second Circuit in Manhattan ruled that Mr. Gupta would not have to report to prison until his appeal is heard, which could take a year. He had been set to start serving his two-year sentence on Jan. 8.

Mr. Gupta, 64, was found guilty in June of leaking Goldman’s boardroom secrets to his friend, the former hedge fund managerRaj Rajaratnam.

Tuesday’s ruling suggested that Mr. Gupta had convinced the judges that he had legitimate issues to argue on appeal. The same federal appeals court had denied a request by Mr. Rajaratnam to remain free on bail pending his appeal. Mr. Rajaratnam is serving an 11-year prison term.

Mr. Gupta’s lawyers are expected to make several arguments. The most significant issue on appeal could be the government’s use of the wiretaps in the trial.

Judge Jed S. Rakoff, the trial court judge, allowed the jury to hear incriminating taped conversations involving Mr. Rajaratnam and his traders. Those conversations suggested Mr. Rajaratnam had a source at Goldman.

“I heard yesterday from somebody who’s on the board of Goldman Sachs that they are going to lose $2 per share,” Mr. Rajaratnam told a colleague on a wiretapped call in October 2008.

Multimedia: Insider Trading

Without the wiretaps, prosecutors would have had to rely on circumstantial evidence — telephone bills and trading records — to prove their case.

Mr. Gupta’s lawyers had argued that because the conversations were between Mr. Rajaratnam and his employees, Judge Rakoff should declare them inadmissible hearsay evidence, meaning that they were too unreliable to be used against Mr. Gupta.

Another issue that Mr. Gupta’s lawyers are expected to raise is that Judge Rakoff erred in limiting testimony by Mr. Gupta’s daughter about her father’s deteriorating relationship with Mr. Rajaratnam.

Mr. Gupta, who lives in Westport, Conn., has been free on $10 million bail since his arrest in October 2011. In addition to a team of lawyers from Kramer Levin Naftalis & Frankel that had represented him, Mr. Gupta hired Seth P. Waxman, an experienced appellate lawyer, to help with his appeal.
Mr. Waxman, a partner at WilmerHale, is a former United States solicitor general who has argued more than 50 cases before the United States Supreme Court.

The court is expected to hear Mr. Gupta’s appeal in the spring.

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U.S. Warns Syria Against Using Chemical Weapons

Narciso Contreras/Associated Press

 A kitchen in a home in Aleppo, Syria showed signs of heavy fighting Sunday.

WASHINGTON — President Obama warned Syria on Monday not to use chemical weapons against its own people, vowing to hold accountable anyone who did, even as American intelligence officials picked up signs that such arms might be deployed in the fighting there.

The White House said it had an “increased concern” that the government of President Bashar al-Assad was preparing to use such weapons, effectively confirming earlier reports of activity at chemical weapons sites. The administration said it would take action if they were used, suggesting even the possibility of military force.

“Today I want to make it absolutely clear to Assad and those under his command: The world is watching,” Mr. Obama said in a speech at the National Defense University in Washington. “The use of chemical weapons is and would be totally unacceptable. If you make the tragic mistake of using these weapons, there will be consequences and you will be held accountable.”

Neither the president nor his aides would specify how it would hold Syrians accountable, but the White House confirmed that contingency plans had been drawn for direct action. The president’s statement amplified similar warnings issued by Secretary of State Hillary Rodham Clinton earlier in the day in Prague, the capital of the Czech Republic, which represents the interests of the United States in Damascus now that the American Embassy there has been closed.

“This is a red line for the United States,” Mrs. Clinton said. “I am not going to telegraph in any specifics what we would do in the event of credible evidence that the Assad regime has resorted to using chemical weapons against their own people. But suffice it to say, we are certainly planning to take action if that eventuality were to occur.”

The sharpening language came as NATO was preparing to buttress its member Turkey against a potential attack from Syria. A plan expected to be endorsed by the alliance’s foreign ministers during two-days of meetings that begin Tuesday in Brussels calls for deploying American, German and Dutch Patriot missile-defense batteries under the operational control of the NATO military command, Western officials said Monday.

Such a move would be the most direct action in the Syrian conflict by the alliance, which has remained cautious about intervention there. But for months, Turkey has expressed concerns about the potential of missile attacks from Syria as relations between the two countries have worsened, and last month Ankara asked for Patriot batteries.

As the United States and its allies tried to forestall the conflict from escalating, the Syrian Foreign Ministry said the government “would not use chemical weapons, if it had them, against its own people under any circumstances.” The statement was reported on Syrian state television and on the Lebanese channel LBC.

Mr. Obama has called for Mr. Assad to step down but has shied away from taking direct action sought by Syrian rebels. With the election over, advisers are considering a more robust response, including possibly providing arms to the rebels and recognizing the opposition as the legitimate representative of the Syrian people.

But Mr. Obama avoided any mention of such actions in his speech. “We will work to support the legitimate aspirations of the Syrian people, engaging with the opposition, providing them with the humanitarian aid and working for a transition to a Syria that’s free of the Assad regime,” he said.

Jay Carney, the president’s press secretary, hinted at possible military action in response to any use of chemical weapons but declined to specify options. “We think it is important to prepare for all scenarios,” he said. “Contingency planning is the responsible thing to do.”

Mrs. Clinton flew from Prague to Brussels for the NATO meeting. A senior NATO official said the alliance would declare its support for Turkey’s request for help and welcome the intention of three allied nations to deploy Patriot missile batteries there. It would then be up to the United States, Germany and the Netherlands to decide how many batteries to deploy and for how long.

Surveys are being conducted of 10 potential sites, mainly in southeastern Turkey, but a senior American official traveling with Mrs. Clinton said it would probably take several weeks to deploy the batteries. Once deployed, they would be under the operational control of NATO’s top military commander, Adm. James. G. Stavridis.

The pending move has prompted speculation that it might be an indirect way of extending protection to forces opposing Mr. Assad in northern Syria by targeting Syrian warplanes operating there. But NATO and American officials were adamant that was not the purpose.

“There is no safe haven,” the American official with Mrs. Clinton said. “There is no de facto cross-border aspect to this.”

Instead, officials said the idea was to discourage Syria from threatening Turkey for supporting Syrian insurgents — and to discourage Turkey from feeling pressured to intervene to head off attacks against it. The Turkish military issued a statement Monday calling the deployment “a measure entirely aimed at defense.”

Peter Baker reported from Washington, and Michael R. Gordon from Brussels.

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Court Cases Challenge Border Searches of Laptops and Phones

The government has historically had broad power to search travelers and their property at the border. But that prerogative is being challenged as more people travel with extensive personal and business information on devices that would typically require a warrant to examine.

Several court cases seek to limit the ability of border agents to search, copy and even seize travelers’ laptops, cameras and phones without suspicion of illegal activity.

“What we are asking is for a court to rule that the government must have a good reason to believe that someone has engaged in wrongdoing before it is allowed to go through their electronic devices,” said Catherine Crump, a lawyer for the American Civil Liberties Union who is representing plaintiffs in two lawsuits challenging digital border searches.

A decision in one of those suits, Abidor v. Napolitano, is expected soon, according to the case manager for Judge Edward R. Korman, who is writing the opinion for the Federal District Court for the Eastern District of New York.

In that case, Pascal Abidor, who is studying for his doctorate in Islamic studies, sued the government after he was handcuffed and detained at the border during an Amtrak trip from Montreal to New York. He was questioned and placed in a cell for several hours. His laptop was searched and kept for 11 days.

According to government data, these types of searches are rare: about 36,000 people are referred to secondary screening by United States Customs and Border Protection daily, and roughly a dozen of those travelers are subject to a search of their electronic devices.

Courts have long held that Fourth Amendment protections against unreasonable searches do not apply at the border, based on the government’s interest in combating crime and terrorism. But Mr. Pascal’s lawsuit and similar cases question whether confiscating a laptop for days or weeks and analyzing its data at another site goes beyond the typical border searches. They also depart from the justification used in other digital searches, possession of child pornography.

“We’re getting more into whether this is targeting political speech,” Ms. Crump said.

In another case the A.C.L.U. is arguing, House v. Napolitano, border officials at Chicago O’Hare Airport confiscated a laptop, camera and USB drive belonging to David House, a computer programmer, and kept his devices for seven weeks.

The lawsuit charges that Mr. House was singled out because of his association with the Bradley Manning Support Network. Pfc. Bradley Manning is a former military intelligence analyst accused of leaking thousands of military and diplomatic documents to the antisecrecy group WikiLeaks.

In March, Judge Denise J. Casper of Federal District Court in Massachusetts denied the government’s motion to dismiss the suit, saying that although the government did not need reasonable suspicion to search someone’s laptop at the border, that power did not strip Mr. House of his First Amendment rights. Legal scholars say this ruling could set the stage for the courts to place some limits on how the government conducts digital searches.

“The District Court basically said you don’t need individualized suspicion to search an electronic device at the border,” said Patrick E. Corbett, a professor of criminal law and procedure at Thomas M. Cooley Law School in Lansing, Mich. “What they were troubled with was the fact that the government held these devices for 49 days.”

Customs and Border Protection, part of the Department of Homeland Security, declined to discuss the policy in an interview, but a spokeswoman for the agency said in an e-mail: “Keeping Americans safe and enforcing our nation’s laws in an increasingly digital world depends on our ability to lawfully screen all materials — electronic or otherwise — entering the United States. We are committed to ensuring the rights and privacies of all people while making certain that D.H.S. can take the lawful actions necessary to secure our borders.”

The statement also referred to the agency’s policy on border searches of electronic devices, which says that officers can keep these devices for a “reasonable period of time,” including at an off-site location, and seek help from other government agencies to decrypt, translate or interpret the information they contain. If travelers choose not to share a password for a device, the government may hold it to find a way to gain access to the data.

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