Hockey Coaches Defy Doctors on Concussions, Study Finds

Despite several years of intensive research, coverage and discussion about the dangers of concussions, the idea of playing through head injuries is so deeply rooted in hockey culture that two university teams kept concussed players on the ice even though they were taking part in a major concussion study.

The study, which was published Friday in a series of articles in the journal Neurosurgical Focus, was conducted during the 2011-12 hockey season by researchers from the University of Western Ontario, the University of Montreal, Harvard and other institutions.

“This culture is entrenched at all levels of hockey, from peewee to university,” said Dr. Paul S. Echlin, a concussion specialist and researcher in Burlington, Ontario, and the lead author of the study. “Concussion is a significant public health issue that requires a generational shift. As with smoking or seat belts, it doesn’t just happen overnight — it takes a massive effort and collective movement.”

The study is believed to be among the most comprehensive analyses of concussions in hockey, which has a rate of head trauma approaching that of football. Researchers followed two Canadian university teams — a men’s team and a women’s team — and scanned every player’s brain before and after the season. Players who sustained head injuries also received scans at three intervals after the injuries, with researchers using advanced magnetic resonance imaging techniques.

The teams were not named in the study, in which an independent specialist physician was present at each game and was empowered to pull any player off the ice for examination if a potential concussion was observed.

The men’s team, with 25 players and an average age of 22, played a 28-game regular season and a 3-game postseason. The women’s team, with 20 players and an average age of 20, played 24 regular-season games and no playoff games. Over the course of the season, there were five observed or self-reported concussions on the men’s team and six on the women’s team.

Researchers noted several instances of coaches, trainers and players avoiding examinations, ignoring medical advice or otherwise obstructing the study, even though the players had signed consent forms to participate and university ethics officials had given institutional consent.

“Unless something is broken, I want them out playing,” one coach said, according to the study.

In one incident, a neurologist observing the men’s team pulled a defenseman during the first period of a game after the player took two hits and was skating slowly. During the intermission the player reported dizziness and was advised to sit out, but the coach suggested he play the second period and “skate it off.” The defenseman stumbled through the rest of the game.

“At the end of the third period, I spoke with the player and the trainer and said that he should not play until he was formally evaluated and underwent the formal return-to-play protocol,” the neurologist said, as reported in the study. “I was dismayed to see that he played the next evening.”

After the team returned from its trip, the neurologist questioned the trainer about overruling his advice and placing the defenseman at risk.

“The trainer responded that he and the player did not understand the decision and that most of the team did not trust the neurologist,” according to the study. “He requested that the physician no longer be used to cover any more games.”

In another episode, a physician observer assessed a minor concussion in a female player and recommended that she miss the next night’s game. Even though the coach’s own playing career had ended because of concussions, she overrode the medical advice and inserted the player the next evening.

According to the report, the coach refused to speak to another physician observer on the second evening. The trainer was reluctant to press the issue with the coach because, the trainer said, the coach did not want the study to interfere with the team.

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Wealth Matters: Defined-Benefit Plans Allow Fast Retirement Saving, but With Risks

Kevin Moloney for The New York Times

John Rogers, a Denver businessman, used a defined-benefit contribution to catch up on his retirement savings late in his career.

WITH the prospect of significant changes in tax rates and deduction limits, taxpayers have been coming up with all sorts of strategies to save on their taxes, some riskier than others.

So I couldn’t help but be skeptical when I was told about a plan aimed at small-business owners in their 50s who have saved little for retirement but can now afford to put aside a lot of money each year. They can then deduct that money as a business expense, resulting in a significant tax savings.

But I checked with the Internal Revenue Service, and the plan is indeed legitimate.

It is a defined-benefit plan, much like the one large employers once regularly offered their workers, that guarantees a set monthly payment in retirement. In this case, though, the plan works best for really small businesses — those that employ just one or two people.

The I.R.S. allows a maximum annual contribution to the plan of about $255,000 for people in their 50s. (For younger workers, the contribution limit is lower, because the calculation is based on the number of years until retirement. In some cases, the limit is so low that other retirement savings options might be better.) Total holdings in the plan are limited to $2.3 million to $2.4 million, enough to cover the maximum allowed payment in retirement of $200,000 a year.

Advisers said the plans were less effective in companies with more employees, particularly older ones, because the owner would be required to make contributions for all of them, and at a high level, since older employees are typically better paid and closer to retirement. (If the additional employees were young and low-paid, the cost of offering the plan to them might be low enough for it to make sense.)

“It’s not too good to be true,” said Lisa C. Germano, president and general counsel at Actuarial Benefits and Design Company in Midlothian, Va. “But you need to be able to fund the plan and fund it for an indefinite period. It’s a commitment. That’s one of the reasons you get the reward.”

Some advisers like Ms. Germano were worried that, like other generous deductions, this one could be threatened in the current tax and budget negotiations. But regardless of how the talks in Washington turn out, this is still the time of year when many small-business owners need to decide whether to set up a defined-benefit plan or stick with more traditional forms of retirement savings, like SEP I.R.A.’s for the self-employed or a profit-sharing plan.

Here is some of what I learned.

UPSIDE Defined-benefit plans are mainly a way for small-business owners who neglected to save for retirement to catch up. The ideal candidates can put away $100,000 to $150,000 a year for at least 10 years, said Leigh Goldblatt, vice president and chief compliance officer at Glazer Financial Network.

This was the case with John Rogers, a Denver businessman. “I was in my late 50s and I didn’t have a penny saved for retirement,” he said.

He lost his life savings in his 40s, he said, in a recycling company he started with friends. He also raised six children, four of whom he said he put through college.

But by 2006, he was six years into being an independent contractor for Univera, a company that makes nutritional supplements. (The company’s sales model is similar to Amway’s, where people like Mr. Rogers sell to individuals or find other people to sell for them.)

With his business providing steady, predictable income — he and his wife are ranked as top sellers for the company — he wanted to start saving. He said a defined-benefit plan was attractive for both deferring taxes and for saving for retirement.

“Our adviser tells us at the beginning of the year what we have to contribute,” said Mr. Rogers, 63. “We’re very disciplined. We pay our defined-benefit plan first and then our business expenses.”

But even though the I.R.S. assumes the plan will make monthly payments in retirement, which is why it allows people to save so much over a short period of time, owners shut down most of these plans and roll the money in them to a regular retirement account, said Mr. Goldblatt, whose firm advised Mr. Rogers. This reduces expenses and gives the owner control over how to withdraw the money.

DOWNSIDES Such a chance for a retirement savings do-over, as it were, does not come without catches. And skeptics say these plans lure people with the prospect of quick and large retirement savings without discussing the risks.

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General Assembly Grants Palestine Upgraded Status in U.N.

Chang W. Lee/The New York Times

President Mahmoud Abbas of the Palestinian Authority spoke at the United Nations before the General Assembly voted on Palestine's status as a “nonmember observer state” on Thursday.

UNITED NATIONS — More than 130 countries voted on Thursday to grant Palestine the upgraded status of nonmember observer state in the United Nations, a stinging defeat for Israel and the United States and a boost for President Mahmoud Abbas of the Palestinian Authority, who was weakened by the recent eight days of fighting in Gaza.

The new ranking could make it easier for the Palestinians to pursue Israel in international legal forums, but it remained unclear what effect it would have on attaining what both sides say they want — a two-state solution.

Still, the vote offered a showcase for an extraordinary international lineup of support for the Palestinians and constituted a deeply symbolic achievement for their cause, made even weightier by arriving on the 65th anniversary of the General Assembly vote that divided the former British Mandate of Palestine into two states, one Jewish and the other Arab — a vote that Israel considers the international seal of approval for its birth.

In the West Bank city of Ramallah, about 2,000 Palestinians gathered to celebrate in a central square named after the late Palestinian leader Yasser Arafat. Security forces fired into the air and people applauded, danced in the streets and honked car horns when the results were broadcast to the crowd.

“We are witnessing exceptional moments after 65 years of injustice, suffering and pain,” said Jibril Rajoub, the member of Fatah Central Committee. “We are going to witness an Israeli American efforts to keep this resolution ink on paper.”

The tally, in which 138 members voted yes, 9 voted no and 41 abstained, took place after a speech by Mr. Abbas to the General Assembly, in which he called the moment a “last chance” to save the two-state solution amid a narrowing window of opportunity.

“The General Assembly is called upon today to issue a birth certificate of the reality of the state of Palestine,” he said before the vote.

But in the run-up to the vote, he and Ron Prosor, the Israeli ambassador to the United Nations, blamed the other side for not doing enough to pursue peace.

”We have not heard one word from any Israeli official expressing any sincere concern to save the peace process,” Mr. Abbas said.

“On the contrary, our people have witnessed, and continue to witness, an unprecedented intensification of military assaults, the blockade, settlement activities and ethnic cleansing, particularly in occupied East Jerusalem, and mass arrests, attacks by settlers and other practices by which this Israeli occupation is becoming synonymous with an apartheid system of colonial occupation, which institutionalizes the plague of racism and entrenches hatred and incitement.”

“The moment has arrived for the world to say clearly: enough of aggression, settlements and occupation,” he said.

Mr. Prosor, speaking after Mr. Abbas but before the vote was taken, said the United Nations resolution would do nothing to advance the process.

“Today the Palestinians are turning their back on peace,” he said. “Don’t let history record that today the U.N. helped them along on their march of folly.”

As expected, the vote won backing from a number of European countries, and was a rebuff to intense American and Israeli diplomacy. In an indication of the bitterness of the blow to the Israelis, the office of Prime Minister Benjamin Netanyahu released a statement calling Mr. Abbas’s speech “defamatory and venomous” that was “full of mendacious propaganda against the IDF and the citizens of Israel.”

“Someone who wants peace does not talk in such a manner," the statement continued.

Among the countries that had forecast their yes votes were France, Spain and Switzerland. Germany and the United Kingdom were among the countries that abstained, and a few countries joined Israel and the United States in voting no.

After the vote, Susan E. Rice, the American ambassador to the United Nations, explained the American vote as a reaction to an “unfortunate and counterproductive” resolution that placed “further obstacles in the path to peace.”

Reporting was contributed by Michael R. Gordon and Mark Landler from Washington, Isabel Kershner from Jerusalem, Khaled Abu Aker from Ramallah, and Nicholas Kulish from Berlin.

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Zynga slides after updated agreement with Facebook

NEW YORK (AP) — Zynga shares tumbled nearly 12 percent in after-hours trading Thursday after the online game company and Facebook disclosed that they changed their relationship status to become less attached to each other.

Zynga Inc. said in a regulatory filing Thursday that it will no longer have to display Facebook ads or use Facebook payments on its own properties — such as Zynga.com. In addition Zynga will no longer be required to use Facebook as the exclusive social site for its games, or to grant Facebook exclusive games.

Facebook Inc., which filed a similar disclosure, will also be able to develop its own games after the end of March. Its deal with Zynga previously prohibited that.

The amendments change the companies’ 2010 contract that gave Zynga special status among Facebook game developers. San Francisco-based Zynga relies on Facebook for most of the revenue it generates, but the company has been working to establish its independence — while also maintaining ties with Facebook.

Zynga’s titles range from “FarmVille” to “CityVille” to “Words With Friends,” the Scrabble-like game made popular on mobile devices.

Zynga shares fell 31 cents, or 11.8 percent, to $ 2.31 in after-hours trading. The stock closed up 11 cents, or 4.4 percent, at $ 2.62 in the regular session.

Social Media News Headlines – Yahoo! News

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Steelers QB Roethlisberger testing hurt shoulder

PITTSBURGH (AP) — Ben Roethlisberger can hold his newborn son Ben Jr. in his injured right arm just fine, thanks.

When the Pittsburgh Steelers quarterback will be able to say the same about a football, even he's not sure.

Roethlisberger practiced in a limited role Thursday and appears a long shot to return for Sunday's game in Baltimore.

"There's always a chance," Roethlisberger offered somewhat hopefully.

The lengthy list of issues still plaguing Roethlisberger more than two weeks after he sprained his right shoulder and suffered a dislocated rib in a 16-13 overtime win against Kansas City, however, suggests he's still a week away from giving it a go.

Though the pain isn't quite as intense as it was in the days after Kansas City linebacker Tamba Hali drilled Roethlisberger into the soggy Heinz Field turf, the two-time Super Bowl winner can still only sleep in certain positions at night. And while he's tested the shoulder this week, he's uncertain if he can make all the throws necessary to attack Baltimore's secondary.

"Can I put a lot of zip on the ball, throw it really hard before people like Ed Reed and defenders can get to the ball?" Roethlisberger said. "If I can't I'm not putting us in the best situation to win the game."

The Steelers (6-5) have struggled in Roethlisberger's absence, needing overtime to beat the woeful Chiefs before looking listless at times and sloppy at others in losses to Baltimore and Cleveland. A season that looked promising after a 24-20 win over the defending Super Bowl-champion Giants in New Jersey on Nov. 4 is suddenly on very shaky ground.

Still, don't expect Roethlisberger to push too quickly. It's something he's done in the past, with less than desired results. He played on a battered right ankle in San Francisco last year, limping around in a 20-3 loss. He ended up sitting out the next week and wasn't the same when he returned.

"We've had people talk about last year in San Francisco, if I would have rested maybe I would have been better off the next couple games but to me, I live for the here and now," he said. "I'm going to do everything I can to be out there and if it doesn't work then I'll do what I can about the next week."

Offensive coordinator Todd Haley said Roethlisberger threw "a little bit" on Thursday but the team continues to prepare as if Charlie Batch will make his second straight start. Batch completed 20 of 34 passes for 199 yards and three costly interceptions against the Browns, mistakes Haley attributed to rusty timing more than physical ability.

"I don't think there's any limitations to what Chuck can do," Haley said, "or needs to do with the guys we have."

Roethlisberger remains optimistic Batch can muster some of the magic that helped him lead the Steelers to three victories since 2010 while filling in for his good friend.

"I firmly believe that," Roethlisberger said. "They know what he's capable of. He's been doing it a long time. They respect him. I think he's ready to rise to the occasion."

Something the Steelers need to do if they want to build any momentum going into the final quarter of the season. A loss in a place they struggle to play well in — no matter who is behind the center — would leave them with no wiggle room whenever Roethlisberger gets back to work.

The game's importance is not lost on Roethlisberger, who will wear "juiced up" pads to protect his shoulder, though doctors have told him the dislocated rib no longer poses a threat to his aorta.

That's welcome news for a guy in the first days of fatherhood. Roethlisberger called being a dad "pretty cool" and while he's enjoyed the time at home, he's also eager to go back to his job. If he doesn't play on Sunday he'll do what he's done the last two weeks and stand on the sideline — earbuds in place — and provide the kind of insight Batch has imparted on him so many times though the years.

"It's hard for me," Roethlisberger said. "You watched me during these games. I've been on the field more than most of the coaches because I'm just antsy to get out there."

That anxiousness, however, figures to be around for at least another week.

___

NOTES: While Roethlisberger is doubtful, S Troy Polamalu appears ready to play for the first time since Oct. 7. Polamalu practiced for the second straight day and barring a setback should be on the field in Baltimore. Polamalu has been limited to just five quarters all season due to a strained right calf ... Rookie G David DeCastro continued to make progress in his first week on the active roster after recovering from right knee surgery in August. Haley said he expects DeCastro to make an impact on the field before the end of the season.

___

Follow Will Graves at www.twitter.com/WillGravesAP

___

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Clearing the Fog Around Personality Disorders

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

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

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

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

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

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

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

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

Habits of Thought

It wasn’t supposed to be this difficult.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resisting Simplification 

It was easier said than done.

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

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

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

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

This article has been revised to reflect the following correction:

Correction: November 29, 2012

An earlier version of this article misstated the number of traits included in the proposed criteria for narcissistic personality disorder.   The final proposal relies on two personality traits, not four.

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Chamber Competes to Be Heard in Fiscal Debate

WASHINGTON — After months of sparring with President Obama in the heat of the campaign season, Chamber of Commerce executives came to the White House this week with a far more conciliatory tone, offering up suggestions to avert large budget cuts without having to raise taxes.

Jim Young/Reuters

Tom Donahue, the president of the Chamber of Commerce, with President Obama last year. The two have been involved in a showdown on the federal budget deficit.

But Mr. Obama’s top advisers were not budging. There would be no deal on the federal budget deficit, they told chamber executives, without higher taxes, participants said. If there were doubts about the White House’s resolve, Mr. Obama met the chamber’s chief executive afterward for an unscheduled Oval Office chat about the showdown.

For the United States Chamber of Commerce, long the leading business voice in Washington, this month’s negotiations over the nation’s debt will be a key test of whether it can retain its influence and swagger in the capital even after a string of bruising political losses.

Many business leaders are looking to the chamber as a bulwark against the White House’s push for higher taxes, but it is unclear if the century-old association has the clout it once did. Other business groups seen as more open to tax increases have become players in the negotiations, exposing rifts in the private sector.

The Chamber of Commerce, in the biggest voter mobilization effort in its history, spent tens of millions of dollars in support of pro-business candidates, usually Republicans, in the Nov. 6 elections. But the results were disastrous: out of 48 House and Senate candidates that it spent money to try to either elect or defeat, the outcome went the chamber’s way only seven times, according to data from the Center for Responsive Politics, a Washington research group that tracks political spending.

If the chamber was an 800-pound gorilla before the elections, “now they’re a wounded 500-pound gorilla,” said Cyrus Mehri, a Washington lawyer for U.S. Chamber Watch, a union-backed group that is critical of the chamber’s political practices.

“But they’re still a major force to be reckoned with,” he added.

As the White House looks to work out a deal with Congress to avert hundreds of billions of dollars in automatic budget cuts at the end of the year, Mr. Obama and his top economic advisers have been meeting through the week with business leaders to push their plan for raising taxes on the wealthiest Americans.

Mr. Obama met Wednesday with chief executives from Goldman Sachs, Coca-Cola, Yahoo and other prominent firms, and he met a day earlier with small-business representatives.

The president’s advisers also met with officials from the Campaign to Fix the Debt, a centrist group that has become influential in pushing for a combination of tax increases and spending cuts. It is led by Erskine B. Bowles, a former Clinton administration official, and Alan K. Simpson, a former Republican senator from Wyoming.

When Mr. Obama met two weeks ago with a dozen corporate leaders but did not invite the Chamber of Commerce, it was widely seen as a snub of the group over its political attacks during the presidential campaign. But the chamber got its turn Monday.

Jack Lew, the White House chief of staff, and other senior economic advisers listened as chamber executives, including Thomas J. Donohue, the group’s president, and Bruce Josten, its top lobbyist, laid out their ideas for raising significant revenue without necessarily raising taxes by expanding energy development.

“They wrote it down, but where that goes, I don’t know,” Mr. Josten said in an interview.

But Mr. Josten said that the White House advisers stressed that any debt deal would have to include increased taxes at the highest brackets and that if an agreement could not be reached, they were willing to risk the automatic spending cuts — the so-called fiscal cliff option — at the end of the year.

“They reiterated that they want the higher rates, and they’ll go over the cliff if they need to,” Mr. Josten said.

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As Opposition Meets in Cairo, More Violence Mars Syria

The Syrian opposition pushed ahead on military and political fronts on Wednesday, as rebels shot down a government warplane in the north of Syria and a newly formed coalition started talks in Cairo on how to pick a transitional government to replace that of President Bashar al-Assad.

The coalition, whose official name is the National Coalition of Syrian Revolutionary and Opposition Forces, was formed at a meeting in Qatar earlier this month, and has already been anointed with official recognition from Britain, France, Turkey and the members of the Gulf Cooperation Council. But in order to encourage further recognition internationally, it must tackle the broader problem of uniting multiple groups in exile and rebels on the ground in Syria.

That challenge was apparent on the first day of what are expected to be two days of talks in Egypt. Disagreements emerged over the composition of the coalition when the Syrian National Council, one of its members, tried to increase the number of its representatives.

“Nothing will proceed until we work this out,” said one council member at the talks, who spoke to Reuters on condition of anonymity.

The talks took place against the backdrop of a 20-month civil war in which about 40,000 people have been killed so far in clashes between armed rebels and jihadist forces on one side and Mr. Assad’s military on the other. The conflict has flared at various times along Syria’s borders with Lebanon, Israel, Turkey and Jordan and in most of the country’s cities, including deadly car bombings on Wednesday near Damascus, the capital.

In Turkey, once an ally of the Assad government, a team of NATO inspectors visited sites on Wednesday where the alliance might install batteries of Patriot antiaircraft missiles that Turkey, a member, has requested to prevent any incursions by the Syrian air force, which has become the Assad government’s main weapon against the rebels. Patriot missiles have also been discussed as a way of enforcing a no-fly zone over rebel-held areas of Syria near the Turkish border if one is imposed.

Meanwhile, opposition politicians gathered in a Cairo hotel to shape an alternative government. Ahmad Ramadan, a member of the national council, said in an interview with Radio Sawa, an Arabic-language broadcaster sponsored by the United States government, that the talks were more likely to decide on the selection process than to choose actual candidates.

Khaled Khoja, a coalition member attending the talks, said: “I don’t think we’ll be discussing the election of a transitional government during the meeting today. We’re still discussing whether to have a government or to have committees instead.”

State media said on Wednesday that at least 34 people, and possibly many more, died in the two car bombings in Jaramana, a suburb of Damascus that is populated by minorities.

The official SANA news agency said the explosions struck at about 7 a.m. and were the work of “terrorists,” the word used by the authorities to denote rebel forces seeking the overthrow of President Assad.

The agency said the bombings were in the main square of Jaramana, which news reports said is largely populated by members of the Christian and Druse minorities. Residents said the neighborhood was home to many families who have fled other parts of Syria because of the conflict and to some Palestinian families. The blasts caused “huge material damage to the residential buildings and shops,” SANA said.

The death toll was not immediately confirmed. An activist group, the British-based Syrian Observatory for Human Rights, initially said that 29 people had died but revised the figure later to 47, of whom 38 had been identified. Of the 120 injured, the rebel group said, 23 people were in serious condition, meaning that the tally could climb higher.

There were also reports from witnesses in Turkey and antigovernment activists in Syria that for the second successive day insurgents had shot down a government aircraft in the north of the country, offering further evidence that the rebels are seeking a major shift by challenging the government’s dominance of the skies. It was not immediately clear how the aircraft, apparently a plane, had been brought down.

Video posted on the Internet by rebels showed wreckage with fires still burning around it. The aircraft appeared to show a tail assembly clearly visible jutting out of the debris. Such videos are difficult to verify, particularly in light of the restrictions facing reporters in Syria. However, the episode on Wednesday seemed to be confirmed by other witnesses.

“We watched a Syrian plane being shot down as it was flying low to drop bombs,” said Ugur Cuneydioglu, who said he observed the incident from a Turkish border village in southern Hatay Province. “It slowly went down in flames before it hit the ground. It was quite a scene,” Mr. Cuneydioglu said.

Video posted by insurgents on the Internet showed a man in aviator coveralls being carried away. It was not clear if the man was alive but the video said he had been treated in a makeshift hospital. A voice off-camera says, “This is the pilot who was shelling residents’ houses.”

The aircraft was said to have been brought down while it was attacking the town of Daret Azzeh, 20 miles west of Aleppo and close to the Turkish border. The town was the scene of a mass killing last June, when the government and the rebels blamed each other for the deaths and mutilation of 25 people. The video posted online said the plane had been brought down by “the free men of Daret Azzeh soldiers of God brigade.”

On Tuesday, Syrian rebels said they shot down a military helicopter with a surface-to-air missile outside Aleppo and they uploaded video that appeared to confirm that rebels have put their growing stock of heat-seeking missiles to effective use.

In recent months, rebels have used mainly machine guns to shoot down several Syrian Air Force helicopters and fixed-wing attack jets. In Tuesday’s case, the thick smoke trailing the projectile, combined with the elevation of the aircraft, strongly suggested that the helicopter was hit by a missile.

Rebels hailed the event as the culmination of their long pursuit of effective antiaircraft weapons, though it was not clear if the downing on Tuesday was an isolated tactical success or heralded a new phase in the war that would present a meaningful challenge to the Syrian government’s air supremacy.

Hala Droubi reported from Dubai, United Arab Emirates. Alan Cowell contributed reporting from Paris; Sebnem Arsu contributed reporting from Istanbul, and Hania Mourtada from Beirut, Lebanon.

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Bonds, Clemens, Sosa on Hall ballot for first time

NEW YORK (AP) — The most polarizing Hall of Fame debate since Pete Rose will now be decided by the baseball shrine's voters: Do Barry Bonds, Roger Clemens and Sammy Sosa belong in Cooperstown despite drug allegations that tainted their huge numbers?

In a monthlong election sure to become a referendum on the Steroids Era, the Hall ballot was released Wednesday, and Bonds, Clemens and Sosa are on it for the first time.

Bonds is the all-time home run champion with 762 and won a record seven MVP awards. Clemens took home a record seven Cy Young trophies and is ninth with 354 victories. Sosa ranks eighth on the homer chart with 609.

Yet for all their HRs, RBIs and Ws, the shadow of PEDs looms large.

"You could see for years that this particular ballot was going to be controversial and divisive to an unprecedented extent," Larry Stone of The Seattle Times wrote in an email. "My hope is that some clarity begins to emerge over the Hall of Fame status of those linked to performance-enhancing drugs. But I doubt it."

More than 600 longtime members of the Baseball Writers' Association of America will vote on the 37-player ballot. Candidates require 75 percent for induction, and the results will be announced Jan. 9.

Craig Biggio, Mike Piazza and Curt Schilling also are among the 24 first-time eligibles. Jack Morris, Jeff Bagwell and Tim Raines are the top holdover candidates.

If recent history is any indication, the odds are solidly stacked against Bonds, Clemens and Sosa. Mark McGwire and Rafael Palmeiro both posted Cooperstown-caliber stats, too, but drug clouds doomed them in Hall voting.

Some who favor Bonds and Clemens claim the bulk of their accomplishments came before baseball got wrapped up in drug scandals. They add that PED use was so prevalent in the 1980s, 1990s and early 2000s that it's unfair to exclude anyone because so many who-did-and-who-didn't questions remain.

Many fans on the other side say drug cheats — suspected or otherwise — should never be afforded the game's highest individual honor.

Either way, this election is baseball's newest hot button, generating the most fervent Hall arguments since Rose. The discussion about Rose was moot, however — the game's career hits leader agreed to a lifetime ban in 1989 after an investigation concluded he bet on games while managing the Cincinnati Reds, and that barred him from the BBWAA ballot.

The BBWAA election rules allow voters to pick up to 10 candidates. As for criteria, this is the only instruction: "Voting shall be based upon the player's record, playing ability, integrity, sportsmanship, character, and contributions to the team(s) on which the player played."

That leaves a lot of room for interpretation.

Bonds, Clemens and Sosa won't get a vote from Mike Klis of The Denver Post.

"Nay on all three. I think in all three cases, their performances were artificially enhanced. Especially in the cases of Bonds and Clemens, their production went up abnormally late in their careers," he wrote in an email.

They'll do better with Bob Dutton of The Kansas City Star.

"I plan to vote for all three. I understand the steroid/PED questions surrounding each one, and I've wrestled with the implications," he wrote in an email.

"My view is these guys played and posted Hall of Fame-type numbers against the competition of their time. That will be my sole yardstick. If Major League Baseball took no action against a player during his career for alleged or suspected steroid/PED use, I'm not going to do so in assessing their career for the Hall of Fame," he said.

San Jose Mercury News columnist Mark Purdy will reserve judgment.

"At the beginning of all this, I made up my mind I had to adopt a consistent policy on the steroid social club. So, my policy has been, with the brilliance in the way they set up the Hall of Fame vote where these guys have a 15-year window, I'm not going to vote for any of those guys until I get the best picture possible of what was happening then," he wrote in an email.

"We learn a little bit more each year. We learned a lot during the Bonds trial. We learned a lot during the Clemens trial. I don't want to say I'm never going to vote for any of them. I want to wait until the end of their eligibility window and have my best idea of what was really going on," he said.

Clemens was acquitted this summer in federal court on six counts that he lied and obstructed Congress when he denied using performance-enhancing drugs.

Bonds was found guilty in 2011 by a federal court jury on one count of obstruction of justice, ruling he gave an evasive answer in 2003 to a grand jury looking into the distribution of illegal steroids. Bonds is appealing the verdict.

McGwire is 10th on the career home run list with 583, but has never received even 24 percent in his six Hall tries. Big Mac has admitted to using steroids and human growth hormone.

Palmeiro is among only four players with 500 homers and 3,000 hits, yet has gotten a high of just 12.6 percent in his two years on the ballot. He drew a 10-day suspension in 2005 after a positive test for PEDs, and said the result was due to a vitamin vial given to him by teammate Miguel Tejada.

Biggio topped the 3,000-hit mark — which always has been considered an automatic credential for Cooperstown — and spent his entire career with the Houston Astros.

"Hopefully, the writers feel strongly that they liked what they saw, and we'll see what happens," Biggio said last week.

Schilling was 216-146 and won three World Series championships, including his "bloody sock" performance for the Boston Red Sox in 2004.

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AP Baseball Writer Janie McCauley and AP Sports Writers Arnie Stapleton and Dave Skretta contributed to this report.

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Well: Weight Loss Surgery May Not Combat Diabetes Long-Term

Weight loss surgery, which in recent years has been seen as an increasingly attractive option for treating Type 2 diabetes, may not be as effective against the disease as it was initially thought to be, according to a new report. The study found that many obese Type 2 diabetics who undergo gastric bypass surgery do not experience a remission of their disease, and of those that do, about a third redevelop diabetes within five years of their operation.

The findings contrast with the growing perception that surgery is essentially a cure for Type II diabetes. Earlier this year, two widely publicized studies reported that surgery worked better than drugs, diet and exercise in causing a remission of Type 2 diabetes in overweight people whose blood sugar was out of control, leading some experts to call for greater use of surgery in treating the disease. But the studies were small and relatively short, lasting under two years.

The latest study, published in the journal Obesity Surgery, tracked thousands of diabetics who had gastric bypass surgery for more than a decade. It found that many people whose diabetes at first went away were likely to have it return. While weight regain is a common problem among those who undergo bariatric surgery, regaining lost weight did not appear to be the cause of diabetes relapse. Instead, the study found that people whose diabetes was most severe or in its later stages when they had surgery were more likely to have a relapse, regardless of whether they regained weight.

“Some people are under the impression that you have surgery and you’re cured,” said Dr. Vivian Fonseca, the president for medicine and science for the American Diabetes Association, who was not involved in the study. “There have been a lot of claims about how wonderful surgery is for diabetes, and I think this offers a more realistic picture.”

The findings suggest that weight loss surgery may be most effective for treating diabetes in those whose disease is not very advanced. “What we’re learning is that not all diabetic patients do as well as others,” said Dr. David E. Arterburn, the lead author of the study and an associate investigator at the Group Health Research Institute in Seattle. “Those who are early in diabetes seem to do the best, which makes a case for potentially earlier intervention.”

One of the strengths of the new study was that it involved thousands of patients enrolled in three large health plans in California and Minnesota, allowing detailed tracking over many years. All told, 4,434 adult diabetics were followed between 1995 and 2008. All were obese, and all underwent Roux-en-Y operations, the most popular type of gastric bypass procedure.

After surgery, about 68 percent of patients experienced a complete remission of their diabetes. But within five years, 35 percent of those patients had it return. Taken together, that means that most of the subjects in the study, about 56 percent — a figure that includes those whose disease never remitted — had no long-lasting remission of diabetes after surgery.

The researchers found that three factors were particularly good predictors of who was likely to have a relapse of diabetes. If patients, before surgery, had a relatively long duration of diabetes, had poor control of their blood sugar, or were taking insulin, then they were least likely to benefit from gastric bypass. A patient’s weight, either before or after surgery, was not correlated with their likelihood of remission or relapse.

In Type 2 diabetes, the beta cells that produce insulin in the pancreas tend to wear out as the disease progresses, which may explain why some people benefit less from surgery. “If someone is too far advanced in their diabetes, where their pancreas is frankly toward the latter stages of being able to produce insulin, then even after losing a bunch of weight their body may not be able to produce enough insulin to control their blood sugar,” Dr. Arterburn said.

Nonetheless, he said it might be the case that obese diabetics, even those whose disease is advanced, can still benefit from gastric surgery, at least as far as their quality of life and their risk factors for heart disease and other complications are concerned.

“It’s not a surefire cure for everyone,” he said. “But almost universally, patients lose weight after weight loss surgery, and that in and of itself may have so many health benefits.”

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