Well: Ignoring the Science on Mammograms

Last week The New England Journal of Medicine published a study with the potential to change both medical practice and public consciousness about mammograms.

Published on Thanksgiving Day, the research examined more than 30 years of United States health statistics to determine, through observation, if screening mammography has reduced breast cancer deaths. The researchers found that, as expected, the introduction of mammogram screening led to an increase in the number of breast cancers detected at an early stage.

But importantly, the number of cancers diagnosed at the advanced stage was essentially unchanged. If mammograms were really finding deadly cancers sooner (as suggested by the rise in early detection), then cases of advanced cancer should have been reduced in kind. But that didn’t happen. In other words, the researchers concluded, mammograms didn’t work.

This is a bold claim for an observational study. There are countless reasons why conclusions from such studies are commonly fraught with error. What if, for instance, the lion’s share of advanced cancers occurred among women without access to screening mammograms—a fact often not available in health statistics? Or what if mammography successfully prevented a major increase in advanced cancers, leaving the health statistics unchanged?

Hippocrates, the father of medicine, called experience “delusive.” He recognized that uncontrolled observations may lead to faulty conclusions. For centuries the flawed logic of observational data seemed to validate bloodletting, an unhelpful and often harmful therapy. But most who were bled eventually improved—no thanks to the bloodletting—an observation that led medical authorities to believe in the practice.

Fortunately, we have learned something about bad logic. Today we seek studies designed to neutralize illusions. By enrolling people in a study and assigning them randomly to treatments, for instance, groups tend to be evenly balanced in every way except one: the treatment. Controlled studies led to the discovery that bloodletting is harmful rather than helpful, and randomized trials of screening mammography would therefore be a worthy gold standard to answer once and for all the question of whether the test saves lives.

It may be surprising, therefore, to learn that numerous trials of mammography have indeed randomly assigned nearly 600,000 women to undergo either regular mammography screening or no screening. The results of more than a decade of follow-up on such studies, published more than 10 years ago, show that women in the mammogram group were just as likely to die as women in the no-mammogram group. The women having mammograms were, however, more likely to be treated for cancer and have surgeries like a mastectomy. (Some of the studies include trials from Norway, the Netherlands, Sweden, and this major review of the data.)

In other words, mammograms increased diagnoses and surgeries, but didn’t save lives—exactly what the researchers behind last week’s observational study concluded.

It is affirming to see this newest study. But it raises an awkward question: why would a major medical journal publish an observational study about the effects of screening mammography years after randomized trials have answered the question? Perhaps it is because many doctors and patients continue to ignore the science on mammograms.

For years now, doctors like myself have known that screening mammography doesn’t save lives, or else saves so few that the harms far outweigh the benefits. Neither I nor my colleagues have a crystal ball, and we are not smarter than others who have looked at this issue. We simply read the results of the many mammography trials that have been conducted over the years. But the trial results were unpopular and did not fit with a broadly accepted ideology—early detection—which has, ironically, failed (ovarian, prostate cancer) as often as it has succeeded (cervical cancer, perhaps colon cancer).

More bluntly, the trial results threatened a mammogram economy, a marketplace sustained by invasive therapies to vanquish microscopic clumps of questionable threat, and by an endless parade of procedures and pictures to investigate the falsely positive results that more than half of women endure. And inexplicably, since the publication of these trial results challenging the value of screening mammograms, hundreds of millions of public dollars have been dedicated to ensuring mammogram access, and the test has become a war cry for cancer advocacy. Why? Because experience deludes: radiologists diagnose, surgeons cut, pathologists examine, oncologists treat, and women survive.

Medical authorities, physician and patient groups, and ‘experts’ everywhere ignore science, and instead repeat history. Wishful conviction over scientific rigor; delusion over truth; form over substance.

It is normally troubling to see an observational study posing questions asked and answered by higher science. But in this case the research may help society to emerge from a fog that has clouded not just the approach to data on screening mammography, but also the approach to health care in the United States. In a system drowning in costs, and at enormous expense, we have systematically ignored virtually identical data challenging the effectiveness of cardiac stents, robot surgeries, prostate cancer screening, back operations, countless prescription medicines, and more.

When Thomas Jefferson described his vision for the institution that would become the University of Virginia, he said:

This place will be based on the illimitable freedom of the human mind. For here we are not afraid to follow truth, wherever it may lead.

As we begin down the arduous path of health care reform, requisite to economic success, the question for policymakers and health care authorities is this: Are we ready to stop ignoring science? If so, the road may be smoother than we imagined for there is, and has been, much truth to follow.

---

Dr. David Newman is an emergency room physician in New York City and author of the book, “Hippocrates Shadow: Secrets from the House of Medicine.“

Read More..

Well: Ignoring the Science on Mammograms

Last week The New England Journal of Medicine published a study with the potential to change both medical practice and public consciousness about mammograms.

Published on Thanksgiving Day, the research examined more than 30 years of United States health statistics to determine, through observation, if screening mammography has reduced breast cancer deaths. The researchers found that, as expected, the introduction of mammogram screening led to an increase in the number of breast cancers detected at an early stage.

But importantly, the number of cancers diagnosed at the advanced stage was essentially unchanged. If mammograms were really finding deadly cancers sooner (as suggested by the rise in early detection), then cases of advanced cancer should have been reduced in kind. But that didn’t happen. In other words, the researchers concluded, mammograms didn’t work.

This is a bold claim for an observational study. There are countless reasons why conclusions from such studies are commonly fraught with error. What if, for instance, the lion’s share of advanced cancers occurred among women without access to screening mammograms—a fact often not available in health statistics? Or what if mammography successfully prevented a major increase in advanced cancers, leaving the health statistics unchanged?

Hippocrates, the father of medicine, called experience “delusive.” He recognized that uncontrolled observations may lead to faulty conclusions. For centuries the flawed logic of observational data seemed to validate bloodletting, an unhelpful and often harmful therapy. But most who were bled eventually improved—no thanks to the bloodletting—an observation that led medical authorities to believe in the practice.

Fortunately, we have learned something about bad logic. Today we seek studies designed to neutralize illusions. By enrolling people in a study and assigning them randomly to treatments, for instance, groups tend to be evenly balanced in every way except one: the treatment. Controlled studies led to the discovery that bloodletting is harmful rather than helpful, and randomized trials of screening mammography would therefore be a worthy gold standard to answer once and for all the question of whether the test saves lives.

It may be surprising, therefore, to learn that numerous trials of mammography have indeed randomly assigned nearly 600,000 women to undergo either regular mammography screening or no screening. The results of more than a decade of follow-up on such studies, published more than 10 years ago, show that women in the mammogram group were just as likely to die as women in the no-mammogram group. The women having mammograms were, however, more likely to be treated for cancer and have surgeries like a mastectomy. (Some of the studies include trials from Norway, the Netherlands, Sweden, and this major review of the data.)

In other words, mammograms increased diagnoses and surgeries, but didn’t save lives—exactly what the researchers behind last week’s observational study concluded.

It is affirming to see this newest study. But it raises an awkward question: why would a major medical journal publish an observational study about the effects of screening mammography years after randomized trials have answered the question? Perhaps it is because many doctors and patients continue to ignore the science on mammograms.

For years now, doctors like myself have known that screening mammography doesn’t save lives, or else saves so few that the harms far outweigh the benefits. Neither I nor my colleagues have a crystal ball, and we are not smarter than others who have looked at this issue. We simply read the results of the many mammography trials that have been conducted over the years. But the trial results were unpopular and did not fit with a broadly accepted ideology—early detection—which has, ironically, failed (ovarian, prostate cancer) as often as it has succeeded (cervical cancer, perhaps colon cancer).

More bluntly, the trial results threatened a mammogram economy, a marketplace sustained by invasive therapies to vanquish microscopic clumps of questionable threat, and by an endless parade of procedures and pictures to investigate the falsely positive results that more than half of women endure. And inexplicably, since the publication of these trial results challenging the value of screening mammograms, hundreds of millions of public dollars have been dedicated to ensuring mammogram access, and the test has become a war cry for cancer advocacy. Why? Because experience deludes: radiologists diagnose, surgeons cut, pathologists examine, oncologists treat, and women survive.

Medical authorities, physician and patient groups, and ‘experts’ everywhere ignore science, and instead repeat history. Wishful conviction over scientific rigor; delusion over truth; form over substance.

It is normally troubling to see an observational study posing questions asked and answered by higher science. But in this case the research may help society to emerge from a fog that has clouded not just the approach to data on screening mammography, but also the approach to health care in the United States. In a system drowning in costs, and at enormous expense, we have systematically ignored virtually identical data challenging the effectiveness of cardiac stents, robot surgeries, prostate cancer screening, back operations, countless prescription medicines, and more.

When Thomas Jefferson described his vision for the institution that would become the University of Virginia, he said:

This place will be based on the illimitable freedom of the human mind. For here we are not afraid to follow truth, wherever it may lead.

As we begin down the arduous path of health care reform, requisite to economic success, the question for policymakers and health care authorities is this: Are we ready to stop ignoring science? If so, the road may be smoother than we imagined for there is, and has been, much truth to follow.

---

Dr. David Newman is an emergency room physician in New York City and author of the book, “Hippocrates Shadow: Secrets from the House of Medicine.“

Read More..

President Obama Asks Congress to Keep Tax Cuts for Middle Class

Doug Mills/The New York Times

President Obama spoke on Wednesday at an event at the White House with people who would see their taxes go up next year if Congress does not extend tax cuts for the middle class.

WASHINGTON — President Obama called again on Congress on Wednesday to extend Bush-era tax cuts for all income under $250,000 and leave a broader restructuring of the tax code to next year, as he pressures Republicans to let tax rates rise for the wealthiest Americans.

Surrounding himself by supporters he presented as typical middle-class taxpayers, Mr. Obama said he hoped to resolve the tax and spending issues now confronting Washington by an end-of-the-year deadline. But he said lawmakers should not wait for such an agreement to pass legislation preserving current tax rates for 98 percent of Americans.

“My hope is to get this done before Christmas,” he said of an agreement to avert deep spending cuts and tax increases scheduled to take place automatically with the new year. “But the place where we already have in theory at least complete agreement right now is on middle-class taxes.”

He said such an approach “would give us more time next year to work together on a comprehensive plan to bring down our deficits” and “streamline our tax system.”

The administration planned to send a high-level delegation to Capitol Hill to talk through the situation. Treasury Secretary Timothy F. Geithner and Rob Nabors, the White House legislative affairs director, will visit, separately, the top leaders of both parties in both houses, an administration official said.

Republicans in Congress have resisted letting the Bush tax cuts expire for anyone, including the wealthy. But Representative Tom Cole, an Oklahoma lawmaker and a highly regarded party political strategist, broke with his party leadership on Tuesday by calling for a quick deal with Mr. Obama on extending the tax cuts just for the middle class.

Mr. Obama seemed to refer to that during his event in the office building adjacent to the White House. “I’m glad to see if you’ve been reading the papers lately that more and more Republicans in Congress seem to be agreeing with this idea that we should have a balanced approach,” he said.

But a prominent figure in the fiscal discussions expressed pessimism that the two sides would be able to reach an agreement to avert what is being called a fiscal cliff.

“I believe the probability is that we are going over the cliff, and I think that we will be horrible,” Erskine B. Bowles, a former White House chief of staff who served as co-chairman of Mr. Obama’s deficit reduction commission, told reporters at a breakfast hosted by The Christian Science Monitor. “It will be devastating to the economy.”

The president’s appearance with taxpayers was part of a week of campaign-style events staged by the White House to rally public support for its side in the fiscal fight. He planned to meet with 14 chief executives of corporations at the White House later in the day and travel to the Philadelphia suburbs to tour a factory on Friday.

Republicans have said Mr. Obama seems more interested in perpetuating his campaign than in sitting down to hash out the difficult issues. They also note that they have expressed a willingness to raise tax revenue by closing loopholes and limiting deductions, but they have complained that Mr. Obama has not focused as much on the spending side of the equation, particularly entitlement programs like Medicare and Medicaid.

“We have not seen any good-faith effort on the part of this administration to talk about the real problem that we’re trying to fix,” Representative Eric Cantor of Virginia, the House Republican majority leader, told reporters on Wednesday. “This has to be a part of this agreement, or else we just continue to dig the hole deeper, asking folks to allow us to kick the can down the road further. And that we don’t want to do.”

Speaker John A. Boehner of Ohio echoed that argument but expressed hope that he could reach an agreement with Mr. Obama. “It’s time for the president and Democrats to get serious about the spending problem that our country has,” he said at a news conference. “But I’m optimistic that we can continue to work together to avert this crisis, and sooner rather than later.”

But some Republicans were beginning to make the argument that extending the Bush tax cuts for 98 percent of Americans would still be a victory for their party and a validation of the former president.

Senator Patty Murray of Washington, the Democratic chairwoman of the Budget Committee, said the talk was encouraging. “This has never been about partisanship or political point-scoring,” she said. “It’s been about protecting the middle class from paying more in taxes and calling on the wealthy to pay their fair share.”

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Tibetan Protesters Injured in Crackdown; Self-Immolations Continue

BEIJING — At least five Tibetans have set fire to themselves in recent days to protest Chinese rule in Tibetan regions, while at least 5 Tibetan students were in critical condition and 15 others were being treated for injuries after security forces cracked down on a large protest in western China on Monday, according to reports by Radio Free Asia and Free Tibet, an advocacy group.

The protest took place in an area of Qinghai Province that the Chinese call Hainan Autonomous Prefecture, and that Tibetans call Tsolho. More than 1,000 Tibetans, mostly students and teachers, took to the streets to demand equal rights for ethnic minorities and the freedom to study and use the Tibetan language. Several reports said the protest began after local officials distributed a booklet that condemned Tibetans who had self-immolated and belittled the Tibetan language.

With the five recent self-immolations, at least 22 Tibetans have set fire to themselves this month alone, and 86 since 2009, according to Radio Free Asia. The first case was a monk from Kirti Monastery, which became the heart of the self-immolations last year and earlier this year, though the acts have since become more widespread and now constitute one of the largest such phenomena anywhere in the world in recent memory. The latest four cases were reported Sunday and Monday in the western China provinces of Gansu, Sichuan and Qinghai, which all have significant Tibetan populations.

The students who protested Monday were from the Chabcha Sorig Lobling School, according to Free Tibet. They gathered at 5:40 a.m. and marched peacefully into the town of Chabcha. Chinese security forces began a violent crackdown at 9 a.m., the report said. “It’s still unclear what happened next, but many young students were so badly injured they were taken straight to hospital,” Free Tibet said. Security forces locked down the town, the group added. Radio Free Tibet reported that security forces fired tear gas and beat students with rifle butts, arresting four.

The events could not be independently confirmed; Chinese officials have barred foreign journalists from traveling to the sites of protests or self-immolations by Tibetans. Phone calls made on Tuesday to offices of the prefecture government and party committee went unanswered. A woman answering a call on the prefecture emergency hot line said she had not heard of any protests.

Radio Free Asia, which is financed by the United States government, said the school in Chabcha, known as Gonghe in Chinese, trained students in medicine. The offending booklet that inspired the protests was called “Ten Real Views of Tsolho Area,” and the medical students burned all the copies given to them and “called for equality among nationalities and freedom to study the Tibetan language,” according to a person who was quoted anonymously by Radio Free Asia.

Moves by officials in Qinghai to restrict the use of the Tibetan language, particularly in classrooms, have resulted in protests by students before. The northeast Tibetan region that Qinghai encompasses, generally called Amdo, is historically an area known for Tibetan scholarship and the production of cultural works. Even today, poets, writers and singers in Qinghai create works in the Tibetan language that are distributed widely across the Tibetan world.

Mia Li contributed research.

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Bits Blog: Study Finds Rise in Texting Even as Revenue Drops

A new report finds that certain activities that people do on a cellphone, like taking a picture and shooting video, have increased significantly in the last few years. Texting, in particular, has grown considerably — but not texting in the traditional sense.

The Pew Research Center published a study over the weekend that showed that the number of cellphone owners who text on their phones has grown to 80 percent from 58 percent in 2007.

As I reported this month, traditional text messaging — the kind where you pay to send messages over the phone network — recently declined for the first time in the United States, following a trend in countries around the world, like the Philippines and Finland, according to Chetan Sharma, an independent mobile analyst. As a result, the money that carriers earn from text messaging has been dropping, too.

So how could texting be on the rise? Instead of sending traditional text messages, cellphone owners are shifting toward Internet-based messaging services, like Apple’s iMessage, Facebook messaging and WhatsApp, Mr. Sharma says. These services are popular because they don’t charge per text; they are gradually redefining what we think of as text messaging.

The Pew study also found that the number of cellphone owners who use phones to send e-mail has jumped to 50 percent from 19 percent in 2007, and the number of cellphone owners using phones to shoot video has risen to 44 percent from 18 percent five years ago. The number of cellphone owners who use their phones to download apps is 43 percent, up from 22 percent in 2009. All these factors are directly correlated with the rise of the smartphone — more than 50 percent of American cellphone owners own one, according to Nielsen.

“Cell users now treat their gadget as a body appendage,” said Lee Rainie, director of the Pew Research Center, in a statement. “There is striking growth in the number of people who are taking advantage of the growing number of functions that these phones can perform, and there isn’t much evidence yet that the pace of change is slowing down.”

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Amid Hurricane Sandy, a Race to Get a Liver Transplant

It was the best possible news, at the worst possible time.

The phone call from the hospital brought the message that Dolores and Vin Dreeland had long hoped for, ever since their daughter Natalia, 4, had been put on the waiting list for a liver transplant. The time had come.

They bundled her into the car for the 50-mile trip from their home in Long Valley, N.J., to NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan. But it soon seemed that this chance to save Natalia’s life might be just out of reach.

The date was Sunday, Oct. 28, and Hurricane Sandy, the worst storm to hit the East Coast in decades, was bearing down on New York. Airports and bridges would soon close, but the donated organ was in Nevada, five hours away. The time window in which a plane carrying the liver would be able to land in the region was rapidly closing.

In a hospital room, Natalia watched cartoons. Her parents watched the clock, and the weather. “Our anxiety was through the roof,” Mrs. Dreeland said. “It just made your stomach into knots.”

The Dreelands, who are in their 60s, became Natalia’s foster parents in 2008 when she was 7 months old, and adopted her just before she turned 2. They have another adopted daughter, Dorothy Jane, who is 17.

Natalia is a “smart little cookie” who loves school and dressing up Alice, her favorite doll, her mother said. At age 3, Natalia used the word “discombobulated” correctly, Mr. Dreeland said.

Natalia’s health problems date back several years. Her gallbladder was taken out in 2010, and about half her liver was removed in 2011. The underlying problem was a rare disease, Langerhans cell histiocytosis. It causes a tremendous overgrowth of a type of cell in the immune system and can damage organs. Drugs can sometimes keep it in check, but they did not work for Natalia.

In her case, the disease struck the bile ducts, which led to progressive liver damage. “She would have eventually gone into liver failure,” said Dr. Nadia Ovchinsky, a pediatric liver transplant specialist at NewYork-Presbyterian. “And she demonstrated some signs of early liver failure.”

The only hope was a transplant.

Dr. Tomoaki Kato, Natalia’s surgeon, knew that the liver in Nevada was a perfect match for Natalia in the two criteria that matter most: blood type and size. The deceased donor was 2 years old, and though Natalia is nearly 5, she is small for her age. Scar tissue from her previous operations would have made it very difficult to fit a larger organ into her abdomen.

Though Dr. Kato had considered transplanting part of an adult liver into Natalia, a complete organ from a child would be far better for her. But healthy organs from small children do not often become available, Dr. Kato said. This was a rare opportunity, and he was determined to seize it.

But as the day wore on, the odds for Natalia grew slimmer. The operation in Nevada to remove the liver was delayed several times.

At many hospitals, surgery to remove donor organs is done at the end of the day, after all regularly scheduled operations. The Nevada hospital had a busy surgical schedule that day, made worse by a trauma case that took priority.

At the hospital in New York, Tod Brown, an organ procurement coordinator, had alerted a charter air carrier that a flight from Nevada might be needed. That company in turn contacted West Coast carriers to pick up the donated liver and fly it to New York.

Initially, two carriers agreed, but then backed out. Several other charter companies also declined.

Mr. Brown told Dr. Kato that they might have to decline the organ. Dr. Kato, soft-spoken but relentless, said, “Find somebody who can fly.”

Dr. Kato used to work in Miami, where pilots found ways to bypass hurricanes to deliver organs. Even during Hurricane Katrina, his hospital performed transplants.

“I asked the transplant coordinators to just keep pushing,” he said.

Mr. Brown said, “Dr. Kato knew he was going to get that organ, one way or another.”

As the trajectory of the storm became clearer, one of the West Coast charter companies agreed to attempt the flight. The plan was to land at the airport in Teterboro, N.J. The backup was Newark airport, and the second backup was Albany, from where an ambulance would finish the trip.

The timing was critical: organs deteriorate outside the body, and ideally a liver should be transplanted within 12 hours of being removed.

Early Monday, as the storm whirled offshore, the plane landed at Teterboro. Soon a nurse rushed to tell the Dreelands that she had just seen an ambulance with lights and sirens screech up to the hospital. Someone had jumped out carrying a container.

At about 5 a.m., the couple kissed Natalia and saw her wheeled off to the operating room.

Three weeks later, she is back home, on the mend. The complicated regimen of drugs that transplant patients need is tough on a child, but she is getting through it, her father said.

Recently, Mr. Dreeland said, he found himself weeping uncontrollably during a church service for the family of the child who had died. “Their child gave my child life,” he said.

Though only time will tell, because the histiocytosis appeared limited to Natalia’s bile ducts and had not affected other organs, her doctors say there is a good chance that the transplant has cured her.

This article has been revised to reflect the following correction:

Correction: November 27, 2012

An earlier version of a picture caption with this article misspelled the surname of the family whose daughter received a liver transplant. As the article correctly noted elsewhere, it is Dreeland, not Vreeland.

Read More..

Amid Hurricane Sandy, a Race to Get a Liver Transplant

It was the best possible news, at the worst possible time.

The phone call from the hospital brought the message that Dolores and Vin Dreeland had long hoped for, ever since their daughter Natalia, 4, had been put on the waiting list for a liver transplant. The time had come.

They bundled her into the car for the 50-mile trip from their home in Long Valley, N.J., to NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan. But it soon seemed that this chance to save Natalia’s life might be just out of reach.

The date was Sunday, Oct. 28, and Hurricane Sandy, the worst storm to hit the East Coast in decades, was bearing down on New York. Airports and bridges would soon close, but the donated organ was in Nevada, five hours away. The time window in which a plane carrying the liver would be able to land in the region was rapidly closing.

In a hospital room, Natalia watched cartoons. Her parents watched the clock, and the weather. “Our anxiety was through the roof,” Mrs. Dreeland said. “It just made your stomach into knots.”

The Dreelands, who are in their 60s, became Natalia’s foster parents in 2008 when she was 7 months old, and adopted her just before she turned 2. They have another adopted daughter, Dorothy Jane, who is 17.

Natalia is a “smart little cookie” who loves school and dressing up Alice, her favorite doll, her mother said. At age 3, Natalia used the word “discombobulated” correctly, Mr. Dreeland said.

Natalia’s health problems date back several years. Her gallbladder was taken out in 2010, and about half her liver was removed in 2011. The underlying problem was a rare disease, Langerhans cell histiocytosis. It causes a tremendous overgrowth of a type of cell in the immune system and can damage organs. Drugs can sometimes keep it in check, but they did not work for Natalia.

In her case, the disease struck the bile ducts, which led to progressive liver damage. “She would have eventually gone into liver failure,” said Dr. Nadia Ovchinsky, a pediatric liver transplant specialist at NewYork-Presbyterian. “And she demonstrated some signs of early liver failure.”

The only hope was a transplant.

Dr. Tomoaki Kato, Natalia’s surgeon, knew that the liver in Nevada was a perfect match for Natalia in the two criteria that matter most: blood type and size. The deceased donor was 2 years old, and though Natalia is nearly 5, she is small for her age. Scar tissue from her previous operations would have made it very difficult to fit a larger organ into her abdomen.

Though Dr. Kato had considered transplanting part of an adult liver into Natalia, a complete organ from a child would be far better for her. But healthy organs from small children do not often become available, Dr. Kato said. This was a rare opportunity, and he was determined to seize it.

But as the day wore on, the odds for Natalia grew slimmer. The operation in Nevada to remove the liver was delayed several times.

At many hospitals, surgery to remove donor organs is done at the end of the day, after all regularly scheduled operations. The Nevada hospital had a busy surgical schedule that day, made worse by a trauma case that took priority.

At the hospital in New York, Tod Brown, an organ procurement coordinator, had alerted a charter air carrier that a flight from Nevada might be needed. That company in turn contacted West Coast carriers to pick up the donated liver and fly it to New York.

Initially, two carriers agreed, but then backed out. Several other charter companies also declined.

Mr. Brown told Dr. Kato that they might have to decline the organ. Dr. Kato, soft-spoken but relentless, said, “Find somebody who can fly.”

Dr. Kato used to work in Miami, where pilots found ways to bypass hurricanes to deliver organs. Even during Hurricane Katrina, his hospital performed transplants.

“I asked the transplant coordinators to just keep pushing,” he said.

Mr. Brown said, “Dr. Kato knew he was going to get that organ, one way or another.”

As the trajectory of the storm became clearer, one of the West Coast charter companies agreed to attempt the flight. The plan was to land at the airport in Teterboro, N.J. The backup was Newark airport, and the second backup was Albany, from where an ambulance would finish the trip.

The timing was critical: organs deteriorate outside the body, and ideally a liver should be transplanted within 12 hours of being removed.

Early Monday, as the storm whirled offshore, the plane landed at Teterboro. Soon a nurse rushed to tell the Dreelands that she had just seen an ambulance with lights and sirens screech up to the hospital. Someone had jumped out carrying a container.

At about 5 a.m., the couple kissed Natalia and saw her wheeled off to the operating room.

Three weeks later, she is back home, on the mend. The complicated regimen of drugs that transplant patients need is tough on a child, but she is getting through it, her father said.

Recently, Mr. Dreeland said, he found himself weeping uncontrollably during a church service for the family of the child who had died. “Their child gave my child life,” he said.

Though only time will tell, because the histiocytosis appeared limited to Natalia’s bile ducts and had not affected other organs, her doctors say there is a good chance that the transplant has cured her.

This article has been revised to reflect the following correction:

Correction: November 27, 2012

An earlier version of a picture caption with this article misspelled the surname of the family whose daughter received a liver transplant. As the article correctly noted elsewhere, it is Dreeland, not Vreeland.

Read More..

Dark Warnings About Future of Internet Access

PARIS — Every time an Internet user watches “Gangnam Style” on YouTube, packets of digital data course through the global telecommunications system, converging on an iPhone, a tablet or a laptop.

Having missed out on most of the lucrative revenue that the explosion of digital content has generated for Internet companies, telecommunications providers in Europe, Africa, the Middle East and elsewhere now want to charge them for carrying this traffic.

No way, the content providers say.

This commercial and ideological clash is set for a showdown next week, when representatives of more than 190 governments, along with telecommunications companies and Internet groups, gather in Dubai for a once-in-a-generation meeting.

The ostensible purpose of the World Conference on International Telecommunications is to update a global treaty on technical standards needed to, say, connect a telephone call from Tokyo to Timbuktu. The previous conference took place in 1988, when the Internet was in its infancy and telecommunications remained a highly regulated, mostly analog business.

Critics of the International Telecommunication Union, the United Nations’ agency that is organizing the meeting, see a darker agenda. The blogosphere has been raging over supposed plans led by Russia to snatch away control of the Internet and hand it to the U.N. agency.

That seems unlikely. Any such move would require an international consensus, and opposition is widespread. Terry Kramer, the U.S. ambassador to the conference, has vowed to veto any change in how the Internet is overseen.

Hamadoun Touré, secretary general of the telecommunications union, has repeatedly said that it has no desire to take over the Internet or to stifle its growth. On the contrary, he says, one of the main objectives of the conference is to spread Internet access to more of the four and a half billion people around the world who still do not use it.

And yet, groups as diverse as Google, the Internet Society, the International Trade Union Confederation and Greenpeace warn that the discussions could set a bad precedent, encouraging governments to step up censorship or take other actions that would threaten the integrity of the Internet.

“This is a very important moment in the history of the Internet, because this conference may introduce practices that are inimical to its continued growth and openness,” Vinton G. Cerf, vice president and chief Internet evangelist at Google, said during a conference call.

Google set up a Web site last week, “Take Action,” encouraging visitors to sign a petition for a “free and open Internet.” The campaign is modeled on the successful drive last winter to defeat legislative proposals to crack down on Internet piracy in the United States.

Analysts say the outcry over censorship and Internet governance is a red herring; the real business of the conference is business.

“The far bigger issue — largely obscured by this discussion — are proposals that are more likely to succeed that envision changing the way we pay for Internet services,” Michael Geist, an Internet law professor at the University of Ottawa, said by e-mail.

In one submission to the conference, the European Telecommunications Network Operators’ Association, a lobbying group based in Brussels that represents companies like France Télécom, Deutsche Telekom and Telecom Italia, proposed that network operators be permitted to assess charges for content providers like Internet video companies that use a lot of bandwidth.

Analysts say the proposal is an acknowledgment by telecommunications companies that they cannot compete in the provision of digital content.

“The telecoms realize that they have lost the battle,” said Paul Budde, an independent telecommunications analyst in Australia. “They are saying, ‘We can’t beat the Googles and the Facebooks, so let’s try to charge them.”’

The European lobbying group says that without the new fees, there will be no money to invest in the network upgrades needed to deal with a surge in traffic. Regulators have required European telecommunications operators to open their networks to rivals, and the market for broadband is fiercely competitive, with rock-bottom prices.

In the United States, by contrast, most telecommunications companies have been permitted to maintain local monopolies — or duopolies, with cable companies — in broadband, keeping prices higher. And U.S. regulators have ordered broadband providers to give equal priority to all Internet traffic. Such “network neutrality” is incompatible with charging content providers for carriage.

Analysts say this may explain why U.S. telecommunications companies have not joined the European call for a new business model.

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Egypt’s President Said to Limit Scope of Judicial Decree

CAIRO — President Mohamed Morsi agreed Monday to scale back a sweeping decree he had issued last week that raised his edicts above any judicial review, according to a report by a television network allied with his party. The agreement, reached with top judicial authorities, would leave most of Mr. Morsi’s actions subject to review by the courts, but preserve a crucial power: protecting the constitutional council from being dissolved by the courts before it finishes its work.

Ahmed Jadallah/Reuters

Protesters ran for cover during clashes with riot police at Tahrir square in Cairo on Monday.

Tara Todras-Whitehill for The New York Times

Egyptians mourned Mohammed Gaber Salah, an activist who died Sunday from injuries sustained during protests, before his funeral on Monday in Cairo.

The Muslim Brotherhood, the Islamist group that sponsored Mr. Morsi and his party, announced that it was canceling a major demonstration in support of the president that had been planned for Tuesday.

Cracks appeared in Mr. Morsi’s government on Sunday over the decree after the justice minister, Ahmed Mekki, began arguing publicly for a retreat, and at least three other senior advisers resigned over the measure. The move had also prompted widening street protests and cries from opponents that Mr. Morsi, who already governs without a legislature, was moving toward a new autocracy in Egypt, less than two years after the ouster of the strongman Hosni Mubarak.

With a threatened strike by the nation’s judges, a plunge in the country’s stock market and more street protests looming, Mr. Morsi’s administration initially sent mixed messages on Sunday over whether it was willing to consider a compromise: a spokesman for the president’s party insisted that there would be no change in his edict, but a statement from the party indicated for the first time a willingness to give political opponents “guarantees against monopolizing the fateful decisions of the homeland in the absence of the Parliament.”

Mr. Mekki, the influential leader of a judicial independent movement under Mr. Mubarak and one of Mr. Morsi’s closest aides, actively tried to broker a deal with top jurists to resolve the crisis.

The reaction to the decree had presented the most acute test to date of the ability and willingness of Mr. Morsi, Egypt’s first freely elected president and a former leader of the Muslim Brotherhood, to engage in the kind of give and take that democratic government requires. But he also must contend with real doubts about the willingness of his anti-Islamist opponents to join him in compromise. Each side is mired in deep suspicion of the other, a legacy of the decades when the Brotherhood survived here only as an insular secret society, demonized as dangerous radicals by most of the Egyptian elite.

“There is a deep mistrust,” said Emad Shahin, a political scientist at the American University in Cairo who studies the Brotherhood. “It is an ugly round of partisan politics,” he said, “a bone-crushing phase.”

The scale of the backlash against the decree appeared to catch Mr. Morsi’s government by surprise. “In his head, the president thought that this would push us forward, but then it was met with all this inflammation,” Mr. Mekki said. He faulted the president for failing to consult with his opponents before issuing it, but he also faulted the opponents for their own unwillingness to come to the table: “I blame all of Egypt, because they do not know how to talk to each other.”

Government and party officials maintained that Mr. Morsi was forced to claim the expansive new powers to protect the process of writing the country’s new constitution, and that the decree would be in effect only until the charter was in place. A court of judges appointed under the Mubarak government was widely rumored to be about to dissolve the elected constitutional assembly, dominated by Mr. Morsi’s Islamist allies — just as the same court had previously cast out the newly elected Islamist-led Parliament — and the decree issued by Mr. Morsi on Thursday gave him the power to stop it.

“I see with all of you, clearly, that the court verdict is announced two or three weeks before the court session,” Mr. Morsi told his supporters on Friday, referring to the pervasive rumors about the court’s impending action in a fiery speech defending his decree. “We will dissolve the entire homeland, as it seems! How is that? How? Those waywards must be held accountable."

He said that corrupt Mubarak loyalists were “hiding under the cover of the judiciary” and declared, “I will uncover them!”

But instead of rallying the public to his side and speeding the country’s political transition, as Mr. Morsi evidently hoped, his decree has unleashed new instability across the country. On Sunday, the first day of business here since the decree was issued, the Egyptian stock market fell by about 9.5 percent, erasing more than $4 billion of value.

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G.E. Looks to Industry for the Next Digital Disruption

SAN RAMON, Calif. — When Sharoda Paul finished a postdoctoral fellowship last year at the Palo Alto Research Center, she did what most of her peers do — considered a job at a big Silicon Valley company, in her case, Google. But instead, Ms. Paul, a 31-year-old expert in social computing, went to work for General Electric.

Ms. Paul is one of more than 250 engineers recruited in the last year and a half to G.E.’s new software center here, in the East Bay of San Francisco. The company plans to increase that work force of computer scientists and software developers to 400, and to invest $1 billion in the center by 2015. The buildup is part of G.E’s big bet on what it calls the “industrial Internet,” bringing digital intelligence to the physical world of industry as never before.

The concept of Internet-connected machines that collect data and communicate, often called the “Internet of Things,” has been around for years. Information technology companies, too, are pursuing this emerging field. I.B.M. has its “Smarter Planet” projects, while Cisco champions the “Internet of Everything.”

But G.E.’s effort, analysts say, shows that Internet-era technology is ready to sweep through the industrial economy much as the consumer Internet has transformed media, communications and advertising over the last decade.

In recent months, Ms. Paul has donned a hard hat and safety boots to study power plants. She has ridden on a rail locomotive and toured hospital wards. “Here, you get to work with things that touch people in so many ways,” she said. “That was a big draw.”

G.E. is the nation’s largest industrial company, a producer of aircraft engines, power plant turbines, rail locomotives and medical imaging equipment. It makes the heavy-duty machinery that transports people, heats homes and powers factories, and lets doctors diagnose life-threatening diseases.

G.E. resides in a different world from the consumer Internet. But the major technologies that animate Google and Facebook are also vital ingredients in the industrial Internet — tools from artificial intelligence, like machine-learning software, and vast streams of new data. In industry, the data flood comes mainly from smaller, more powerful and cheaper sensors on the equipment.

Smarter machines, for example, can alert their human handlers when they will need maintenance, before a breakdown. It is the equivalent of preventive and personalized care for equipment, with less downtime and more output.

“These technologies are really there now, in a way that is practical and economic,” said Mark M. Little, G.E.’s senior vice president for global research.

G.E.’s embrace of the industrial Internet is a long-term strategy. But if its optimism proves justified, the impact could be felt across the economy.

The outlook for technology-led economic growth is a subject of considerable debate. In a recent research paper, Robert J. Gordon, a prominent economist at Northwestern University, argues that the gains from computing and the Internet have petered out in the last eight years.

Since 2000, Mr. Gordon asserts, invention has focused mainly on consumer and communications technologies, including smartphones and tablet computers. Such devices, he writes, are “smaller, smarter and more capable, but do not fundamentally change labor productivity or the standard of living” in the way that electric lighting or the automobile did.

But others say such pessimism misses the next wave of technology. “The reason I think Bob Gordon is wrong is precisely because of the kind of thing G.E. is doing,” said Andrew McAfee, principal research scientist at M.I.T.’s Center for Digital Business.

Today, G.E. is putting sensors on everything, be it a gas turbine or a hospital bed. The mission of the engineers in San Ramon is to design the software for gathering data, and the clever algorithms for sifting through it for cost savings and productivity gains. Across the industries it covers, G.E. estimates such efficiency opportunities at as much as $150 billion.

Some industrial Internet projects are already under way. First Wind, an owner and operator of 16 wind farms in America, is a G.E. customer for wind turbines. It has been experimenting with upgrades that add more sensors, controls and optimization software.

The new sensors measure temperature, wind speeds, location and pitch of the blades. They collect three to five times as much data as the sensors on turbines of a few years ago, said Paul Gaynor, chief executive of First Wind. The data is collected and analyzed by G.E. software, and the operation of each turbine can be tweaked for efficiency. For example, in very high winds, turbines across an entire farm are routinely shut down to prevent damage from rotating too fast. But more refined measurement of wind speeds might mean only a portion of the turbines need to be shut down. In wintry conditions, turbines can detect when they are icing up, and speed up or change pitch to knock off the ice.

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