Investors Trade Lightly Ahead of Jobs Report

Stocks rose on Thursday, a day ahead of the monthly jobs report, as a rebound in shares of Apple helped technology shares.

Traders were reluctant to bet heavily before the release on Friday of the Labor Department’s employment report for November, and trading volume was lighter than normal.

Investors are also keeping watch on the negotiations in Washington to see if lawmakers can reach a deal to avoid a series of spending cuts and tax increases beginning in January.

“The only stabilizing factor is that Apple is higher again, which is lending some support to the broader market,” Donald Selkin, chief market strategist at National Securities in New York, said.

Apple climbed 1.6 percent to $547.24. The stock was coming off its biggest one-day drop in four years on Wednesday, which occurred on concerns about higher capital gains taxes in 2013 and the company’s tablet computer market share.

The S.& P. technology index was the best performing of the S.& P. 500’s 10 major sectors, gaining 0.8 percent.

The Dow Jones industrial average rose 39.55 points, or 0.3 percent, to 13,074.04 at the close. The Standard & Poor’s 500-stock index added 4.66 points, or 0.33 percent, to 1,413.94. The Nasdaq composite index gained 15.57 points, or 0.52 percent, to close at 2,989.27.

Monthly payroll numbers, which will be released by the Labor Department before the market opens on Friday, are expected to show a sharp slowdown in jobs growth, though that is largely a result of Hurricane Sandy. The unemployment rate is expected to hold steady at 7.9 percent.

Broader moves were limited, however, as traders focused on the fiscal debate in Washington. About three weeks remain before higher tax rates are to go into effect, an event that economists worry will curb economic growth. Legislators are trying to come up with a deal to avoid some of the negative effects on the economy while still reducing the budget deficit.

An S.& P. index of consumer discretionary shares gained 0.6 percent, lifted by Starbucks shares’ advance of 5.7 percent to $53.70 after Baird upgraded the stock to outperform.

H&R Block climbed 5.1 percent to $18.26 after the company reported a quarterly loss that was narrower than expected.

Sirius XM Radio shares rose 0.7 percent to $2.79 after the company’s board approved a $2 billion stock repurchase and declared a special dividend that gave a big payout to its largest shareholder, Liberty Media.

Shares of the navigation device maker Garmin jumped 5.7 percent to $41.99 after Standard & Poor’s said it would add the company to the S.& P. 500. Garmin will replace R. R. Donnelley & Sons after the close of trading on Tuesday.

Interest rates were steady. The Treasury’s 10-year note rose 2/32, to 100 12/32, and the yield was unchanged at 1.59 percent.

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Extended Use of Breast Cancer Drug Suggested

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

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

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

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

State of the Art: All-in-One PCs From Vizio, H.P. and Apple - State of the Art

Try this simple test at home: What’s the name of Dell’s best-selling PC? Anybody? Anybody?

Right. Nobody knows.

And nobody cares. Today, it’s all about phones and tablets, baby. Nobody buzzes about the PC anymore. Innovation is dead. Sales are down, right?

Actually, there’s one pocket of surging sales and innovation in PC land: the luxury all-in-one computer, of the type made famous by the iMac.

I took a look at three silver, high-design, screen-on-a-stalk competitors: Apple’s new iMac ($1,300 and up), Hewlett-Packard’s SpectreOne ($1,300 and up), and the Vizio All-in-One Touch PC ($1,000 and up). (Lenovo, Dell, Samsung and Acer also offer, or soon will offer, very similar all-in-ones.)

What characterizes these computers? First, an emphasis on looks. They’re shiny, sleek, futuristic, uncluttered and cordless (they come with Bluetooth wireless keyboard and trackpad or mouse). They’re sculpture. In your kitchen or on your desk, they contribute to the décor even when they’re turned off.

The usual box of innards is missing. In the iMac, the guts are concealed behind the screen. In the Vizio, they’re in the foot of the monitor. In the H.P., they’re inside the stalk that supports the screen.

The second common trait is state-of-the-art components. These computers offer gorgeous, vivid, high-definition screens. And they’re fast; they’re powered by the latest Intel chips and lots of memory.

Third characteristic: no DVD drive.

What? Do these companies really think that the era of the disc is over? That nobody will ever again want to digitize music from a CD? Or burn some files to a disc to hand to a colleague? Or borrow a DVD from the library?

Apple, H.P. and Vizio seem to believe that everything is online now. Well, it’s not. Want to rent an Indiana Jones movie, “Jurassic Park” or “Schindler’s List”? How about “Star Wars,” “A Beautiful Mind,” “Bridget Jones’s Diary,” or “My Big Fat Greek Wedding”? Too bad; they’re not available to rent online.

You can, of course, buy an external DVD drive. But aren’t these called “all in ones”? A drive just looks stupid.

Now, on a laptop, eliminating the DVD drive is understandable. You carry laptops. Weight matters. Bulk matters. But why eliminate DVD drives on computers that stay in one place?

All right, end of rant.

The new iMac, clad in its traditional aluminum, is stunning. The stand is still a thin, curved L of metal — but now, the screen appears to be just as thin (0. 2 inches). Where are the guts?

Turns out it’s a trick — an illusion. Behind the screen, you see a substantial bulge; Apple tapered the aluminum as it approaches the screen, so that from front angles it seems that the whole screen is razor thin. Apple has also eliminated much of the glare that has long dogged today’s glossy screens. Viewed side-by-side with its rivals, the iMac is a lot less reflective.

There are two iMac sizes: 21.5 and 27 inches. The $1,300 and $1,800 base models come with a 1-terabyte hard drive, 8 gigabytes of memory and an i5 Intel processor. Each has four USB 3.0 jacks, two Thunderbolt jacks (for video input or output or external hard drives), and camera memory-card slot, awkwardly positioned on the back. Apple has ditched the FireWire jack it spent so many years promoting.

On the 21.5-incher, you can’t upgrade the memory yourself; what you buy is what you’ll have forever, unless you take it into the shop.

On the 27-inch model, you can install as much as 32 gigabytes yourself, through an easily opened door. (That, for the record, is about 262,144 times the memory as the original Macintosh.) Online, you can order your iMac with a 3-terabyte hard drive, 32 gigabytes of memory, a 768-gigabyte flash-memory drive and a $3,700 invoice.

Vizio isn’t a company you expect to be in the PC business; it made its mark selling high-quality, low-price TV sets. And sure enough, by far the best part of the All-in-One Touch PC is its lovely touch screen, available in 24- and 27-inch versions.

A nontouch version is also available, but the Vizio comes with Windows 8, which is far more pleasant to use with a touch screen.

E-mail: pogue@nytimes.com

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For Greece, Oligarchs Are an Obstacle to Recovery

ATHENS — A dynamic entrepreneur, Lavrentis Lavrentiadis seemed to represent a promising new era for Greece. He dazzled the country’s traditionally insular business world by spinning together a multibillion-dollar empire just a few years after inheriting a small family firm at 18. Seeking acceptance in elite circles, he gave lavishly to charities and cultivated ties to the leading political parties.

Icon/Reuters

Lavrentis Lavrentiadis embezzled money from a bank he controlled, prosecutors say.

But as Greece’s economy soured in recent years, his fortunes sagged and he began embezzling money from a bank he controlled, prosecutors say. With charges looming, it looked like his rapid rise would be followed by an equally precipitous fall. Thanks to a law passed quietly by the Greek Parliament, however, he avoided prosecution, at least for a time, simply by paying the money back.

Now 40, Mr. Lavrentiadis is back in the spotlight as one of the names on the so-called Lagarde list of more than 2,000 Greeks said to have accounts in a Geneva branch of the bank HSBC and who are suspected of tax evasion. Given to Greek officials two years ago by Christine Lagarde, then the French finance minister and now head of the International Monetary Fund, the list was expected to cast a damning light on the shady practices of the rich.

Instead, it was swept under the rug, and now two former finance ministers and Greece’s top tax officials are under investigation for having failed to act.

Greece’s economic troubles are often blamed on a public sector packed full of redundant workers, a lavish pension system and uncompetitive industries hampered by overpaid workers with lifetime employment guarantees. Often overlooked, however, is the role played by a handful of wealthy families, politicians and the news media — often owned by the magnates — that make up the Greek power structure.

In a country crushed by years of austerity and 25 percent unemployment, average Greeks are growing increasingly resentful of an oligarchy that, critics say, presides over an opaque, closed economy that is at the root of many of the country’s problems and operates with virtual impunity. Several dozen powerful families control critical sectors, including banking, shipping and construction, and can usually count on the political class to look out for their interests, sometimes by passing legislation tailored to their specific needs.

The result, analysts say, is a lack of competition that undermines the economy by allowing the magnates to run cartels and enrich themselves through crony capitalism. “That makes it rational for them to form a close, incestuous relationship with politicians and the media, which is then highly vulnerable to corruption,” said Kevin Featherstone, a professor of European Politics at the London School of Economics.

This week the anticorruption watchdog Transparency International ranked Greece as the most corrupt nation in Europe, behind former Soviet states like Bulgaria, Romania and Slovakia. Under the pressure of the financial crisis, Greece is being pressed by Germany and its international lenders to make fundamental changes to its economic system in exchange for the money it needs to avoid bankruptcy.

But it remains an open question whether Greece’s leaders will be able to engineer such a transformation. In the past year, despite numerous promises to increase transparency, the country actually dropped 14 places from the previous corruption survey.

Mr. Lavrentiadis is still facing a host of accusations stemming from hundreds of millions of dollars in loans made by his Proton bank to dormant companies — sometimes, investigators say, ordering an employee to withdraw the money in bags of cash. But with Greece scrambling to complete a critical bank recapitalization and restructuring, his case is emblematic of a larger battle between Greece’s famously weak institutions and fledgling regulatory structures against these entrenched interests.

Many say that the system has to change in order for Greece to emerge from the crisis. “Keeping the status quo will simply prolong the disaster in Greece,” Mr. Featherstone said. While the case of Mr. Lavrentiadis suggests that the status quo is at least under scrutiny, he added, “It’s not under sufficient attack.”

In a nearly two-hour interview, Mr. Lavrentiadis denied accusations of wrongdoing and said that he held “a few accounts” at HSBC in Geneva that totaled only about $65,000, all of it legitimate, taxed income. He also sidestepped questions about his political ties and declined to comment on any details of the continuing investigation into Proton Bank.

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Stocks Close Higher After Remarks by President

Stocks closed higher on Wednesday, their first gain of the week, as bank shares rose and comments by President Obama made investors optimistic that a deal could be made to avoid the federal tax increases and spending cuts expected after the first of the year.

The Dow Jones industrial average rose 82.71 points, to end at 13,034.49. It had been up as much as 137. The Standard & Poor’s 500-stock index closed up 2.23 points, at 1,409.28. The Nasdaq composite index was down 22.99 points, at 2,973.70, held back by a slump in Apple.

Citigroup rose $2.17, or 6.3 percent, to $36.46 after the bank said it planned to eliminate more than 11,000 jobs, or about 4 percent of its work force, to cut expenses and improve efficiency. Travelers, the property insurer, surged $3.47, or 4.9 percent, to $74 after it announced plans to resume stock buybacks. Travelers temporarily suspended repurchases after Hurricane Sandy while it assessed its exposure to damage claims.

In lunchtime remarks to the Business Roundtable in Washington, Mr. Obama said: “We can probably solve this in about a week. It’s not that tough.” The comments, made just before noon, helped push the market higher, said Quincy Crosby, a market strategist at Prudential Financial.

Stocks have been flat for two weeks as investors waited for developments from Washington on crucial budget talks to avoid a series of government spending cuts and tax increases, which is scheduled to start Jan. 1 unless an agreement is reached to cut the budget deficit. Economists say that the measures, if put in place, could push the United States back into recession.

Apple was among the decliners, falling $37.05, or 6.4 percent, to $538.79. A Stifel Financial analyst, Aaron C. Rakers, said the decline was in part a result of comments from AT&T Mobility’s chief executive, Ralph de la Vega, who suggested that smartphone activations this quarter were lagging behind the same period a year ago. The stock has now dropped 23 percent since closing at a record $702.10 in September.

Stocks are still up this year after the Federal Reserve in September extended its bond-buying program, offsetting concern that the European debt crisis was set to spread. The Dow has gained 7 percent and the S.& P. 500 has advanced 12 percent.

“The market will hold on to its gains for the year — given the uncertainty, I don’t see any compelling reasons for an increase,” said Brian Gendreau, a market strategist with the Cetera Financial Group, a Los Angeles-based broker. “But that could change in a blink. If there’s better-than-expected news from these negotiations, the market could pop.”

A Chinese government pledge to maintain policies intended to strengthen its economy, helped raise optimism about global growth. China’s Shanghai Composite Index jumped 2.9 percent to 2,031.91. Hong Kong’s Hang Seng ended 2.2 percent higher, at 22,270.91.

A private survey showed on Wednesday that businesses in the United States added fewer workers in November, in part because the hurricane shut down factories, retail stores and other companies. The payroll processor ADP said employers added 118,000 jobs last month, falling below October’s total of 157,000, which was revised lower. Investors will also look to the monthly jobs report from the Labor Department on Friday for more economic information.

Orders to the nation’s factories rose modestly in October, helped by a big gain in demand for equipment. Factory orders edged up 0.8 percent in October, the Commerce Department said on Wednesday. That followed a 4.5 percent increase in September.

Interest rates were flat. The Treasury’s benchmark 10-year note rose 4/32, to 100 10/32, and the yield fell to 1.59 percent from 1.60 percent late Tuesday.

Freeport-McMoRan Copper and Gold fell $6.12, or 16 percent, to $32.16 after saying it had agreed to buy two oil companies, Plains Exploration and Production and McMoRan Exploration, for about $9 billion.

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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.

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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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Dispute Flares Over Energy Exploration in South China Sea

BEIJING — China and two of its neighbors, Vietnam and India, were locked in a new dispute on Tuesday over energy exploration in the South China Sea, a signal that Beijing plans to continue its hard line in the increasingly contentious waterway.

Vietnam accused a Chinese fishing boat of cutting a seismic cable attached to one of its vessels exploring for oil and gas near the Gulf of Tonkin, an act apparently intended to inhibit Vietnam from pursuing energy deposits.

Vietnam said Tuesday that in retaliation, it would send out new patrols, which would include the marine police, to guard against increasing encroachment by Chinese fishing boats in the South China Sea. India, which operates several joint ventures with Vietnam’s national energy company, Petro Vietnam, said it would consider sending navy vessels to protect its interests in the South China Sea.

The latest episode followed an announcement by Hainan Province in southern China last week that Chinese vessels would board and search ships in contested areas of the waterway, which includes vital shipping lanes through which more than a third of global trade moves.

The new tensions among China, Vietnam and India illustrate in stark terms the competition in the South China Sea for what are believed to be sizable deposits of oil and gas.

Some energy experts in China see the sea as an important new energy frontier close to home that could make China less dependent on its huge oil imports from the Middle East.

On Monday, China’s National Energy Administration named the South China Sea as the main offshore site for natural gas production. Within two years, China aims to produce 150 billion cubic meters of natural gas from fields in the sea, a significant increase from the 20 billion cubic meters produced so far, the agency said.

Earlier this year, China’s third-largest energy company, the state-owned China National Offshore Oil Corporation, began drilling with a rig in deep water in nondisputed waters off the southern coast of China.

The escalation in the South China Sea comes less than a month after Xi Jinping took office as China’s leader. Mr. Xi appears to have taken a particular interest in the South China Sea and the serious dispute between China and Japan over the islands known as Diaoyu in China and as Senkaku in Japan. Whether any of China’s most recent actions in the South China Sea were associated with Mr. Xi was not clear.

But Mr. Xi does lead a small group of policy makers clustered in the Maritime Rights Office, which serves to coordinate agencies within China, according to Zhu Feng, a professor of international relations at Peking University, and other Chinese experts. The unit is part of the office of the Foreign Affairs Leading Small Group, Mr. Zhu said. The leading small group, now headed by Mr. Xi, is widely believed to be China’s central policy-making group.

China’s Foreign Ministry reiterated on Tuesday that China opposed oil and gas development by other countries in disputed waters of the sea. China maintains that it has “undisputed” sovereignty over the South China Sea, and that only China is allowed to develop the energy resources.

“We hope that concerned countries respect China’s position and rights,” said the Foreign Ministry spokesman, Hong Lei.

Vietnam, which has long been wary of China but enjoys a relationship through its governing Communist Party, summoned the Chinese ambassador on Monday to protest the cutting of the seismic cable, the Vietnamese news media reported.

A Web site run by Petro Vietnam, the oil company, reported that the company’s exploration vessel Binh Minh 02 had its seismic cable severed by a Chinese fishing vessel on Friday. In May 2011, the Vietnamese authorities said a similar cable of the Binh Minh 02 was cut by three Chinese surveillance ships, resulting in weeks of anti-China protests in Hanoi.

In its decree on the new patrols, Vietnam said that civilian ships, supported by the marine police and a border force, would be deployed starting next month to stop foreign vessels that violate fishing laws in waters claimed by Vietnam.

A senior official of Petro Vietnam, Pham Viet Dung, was quoted in the Vietnamese news media as saying that large numbers of Chinese fishing boats, many of them substantial vessels, had recently entered waters claimed by Vietnam. The fishing vessels interfered with the operations of the oil company, he said.

India, whose state-run oil company, the Oil and Natural Gas Corporation, has a 45 percent interest in exploration with Petro Vietnam, also reacted strongly.

The head of the Indian Navy, Adm. D. K. Joshi, said that India was prepared to send navy vessels to protect its interests in the sea. “Now, are we preparing for it? Are we having exercises of that nature? The short answer is ‘yes,’ ” Admiral Joshi told reporters in India.

The most recent moves by China in the South China Sea have not won total support at home. Mr. Zhu, the professor, said he did not believe that China had become more assertive in the South China Sea.

But, he said, “the cable cutting is really unfriendly.”

Bree Feng contributed reporting.

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