Advanced Breast Cancer May Be Rising Among Young Women, Study Finds

The incidence of advanced breast cancer among younger women, ages 25 to 39, may have increased slightly over the last three decades, according to a study released Tuesday.

But more research is needed to verify the finding, which was based on an analysis of statistics, the study’s authors said. They do not know what may have caused the apparent increase.

Some outside experts questioned whether the increase was real, and expressed concerns that the report would frighten women needlessly.

The study, published in The Journal of the American Medical Association, found that advanced cases climbed to 2.9 per 100,000 younger women in 2009, from 1.53 per 100,000 women in 1976 — an increase of 1.37 cases per 100,000 women in 34 years. The totals were about 250 such cases per year in the mid-1970s, and more than 800 per year in 2009.

Though small, the increase was statistically significant, and the researchers said it was worrisome because it involved cancer that had already spread to organs like the liver or lungs by the time it was diagnosed, which greatly diminishes the odds of survival.

For now, the only advice the researchers can offer to young women is to see a doctor quickly if they notice lumps, pain or other changes in the breast, and not to assume that they cannot have breast cancer because they are young and healthy, or have no family history of the disease.

“Breast cancer can and does occur in younger women,” said Dr. Rebecca H. Johnson, the first author of the study and medical director of the adolescent and young adult oncology program at Seattle Children’s Hospital.

But Dr. Johnson noted that there is no evidence that screening helps younger women who have an average risk for the disease and no symptoms. “We’re certainly not advocating that young women get mammography at an earlier age than is generally specified,” she said.

Expert groups differ about when screening should begin; some say at age 40, others 50.

Breast cancer is not common in younger women; only 1.8 percent of all cases are diagnosed in women from 20 to 34, and 10 percent in women from 35 to 44. However, when it does occur, the disease tends to be more deadly in younger women than in older ones. Researchers are not sure why.

The researchers analyzed data from SEER, a program run by the National Cancer Institute to collect cancer statistics on 28 percent of the population of the United States. The study also used data from the past when SEER was smaller.

The study is based on information from 936,497 women who had breast cancer from 1976 to 2009. Of those, 53,502 were 25 to 39 years old, including 3,438 who had advanced breast cancer, also called metastatic or distant disease.

Younger women were the only ones in whom metastatic disease seemed to have increased, the researchers found.

Dr. Archie Bleyer, a clinical research professor in radiation medicine at the Knight Cancer Institute at the Oregon Health and Science University in Portland who helped write the study, said scientists needed to verify the increase in advanced breast cancer in young women in the United States and find out whether it is occurring in other developed Western countries. “This is the first report of this kind,” he said, adding that researchers had already asked colleagues in Canada to analyze data there.

“We need this to be sure ourselves about this potentially concerning, almost alarming trend,” Dr. Bleyer said. “Then and only then are we really worried about what is the cause, because we’ve got to be sure it’s real.”

Dr. Johnson said her own experience led her to look into the statistics on the disease in young women. She had breast cancer when she was 27; she is now 44. Over the years, friends and colleagues often referred young women with the disease to her for advice.

“It just struck me how many of those people there were,” she said.

Dr. Donald A. Berry, an expert on breast cancer data and a professor of biostatistics at the University of Texas’ M. D. Anderson Cancer Center in Houston, said he was dubious about the finding, even though it was statistically significant, because the size of the apparent increase was so small — 1.37 cases per 100,000 women, over the course of 30 years.

More screening and more precise tests to identify the stage of cancer at the time of diagnosis might account for the increase, he said.

“Not many women aged 25 to 39 get screened, but some do, but it only takes a few to account for a notable increase from one in 100,000,” Dr. Berry said.

Dr. Silvia C. Formenti, a breast cancer expert and the chairwoman of radiation oncology at New York University Langone Medical Center, questioned the study in part because although it found an increased incidence of advanced disease, it did not find the accompanying increase in deaths that would be expected.

A spokeswoman for an advocacy group for young women with breast cancer, Young Survival Coalition, said the organization also wondered whether improved diagnostic and staging tests might explain all or part of the increase.

“We’re looking at this data with caution,” said the spokeswoman, Michelle Esser. “We don’t want to invite panic or alarm.”

She said it was important to note that the findings applied only to women who had metastatic disease at the time of diagnosis, and did not imply that women who already had early-stage cancer faced an increased risk of advanced disease.

Dr. J. Leonard Lichtenfeld
, deputy chief medical officer of the American Cancer Society, said he and an epidemiologist for the society thought the increase was real.

“We want to make sure this is not oversold or that people suddenly get very frightened that we have a huge problem,” Dr. Lichtenfeld said. “We don’t. But we are concerned that over time, we might have a more serious problem than we have today.”

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Economic Scene: Medicare Needs Fixing, but Not Right Now

What’s the rush? For all the white-knuckled wrangling over spending cuts set to start on Friday, the fundamental partisan argument over how to fix the government’s finances is not about the immediate future. It is about the much longer term: how will the nation pay for the care of older Americans as the vast baby boom generation retires? Will the government keep Medicare spending in check by asking older Americans to shoulder more costs? Should we raise taxes instead?

It might not be a good idea to try to resolve these questions quite so urgently. Partisan bickering under the threat of automatic budget cuts is unlikely to produce a calm, thoughtful deal.

“We don’t have to solve this tomorrow; not even next year,” said Jonathan Gruber, an economist at the Massachusetts Institute of Technology who worked on the design of President Obama’s health care reform.

More significantly perhaps, some economists point out that the problem may already be on the way toward largely fixing itself. The budget-busting rise in health care costs, it seems, is finally losing speed. While it would be foolhardy to assume that this alone will stabilize government’s finances, the slowdown offers hope that the challenge may not be as daunting as the frenzied declarations from Washington make it seem.

The growth of the nation’s spending slowed sharply over the last four years. This year, it is expected to increase only 3.8 percent, according to the Centers for Medicare and Medicaid Services, the slowest pace in four decades and slower than the rate of nominal economic growth.

Medicare spending is growing faster — stretched by baby boomers stepping out of the work force and into retirement. But its pace has slowed markedly, too. Earlier this month, the Congressional Budget Office said that by 2020 Medicare spending would be $126 billion less than it predicted three years ago. Spending over the coming decade, it added, would be $143 billion less than it forecast just last August.

While economists acknowledge that the recession accounts for part of the decline, depressing incomes and consumption, something else also seems to be going on: insurers, doctors, hospitals and other providers are experimenting with new, cheaper and more efficient ways to deliver care.

Prodded by President Obama’s Affordable Care Act, which offers providers a share of savings reaped by Medicare from any efficiency gains, many doctors are dropping the costly practice of charging a fee for each service regardless of its contribution to patients’ health. Doctors are joining hundreds of so-called Accountable Care Organizations, which are paid to maintain patients in good health and are thus encouraged to seek the most effective treatments at the lowest possible cost.

This has kindled hope among some scholars that Medicare could achieve the needed savings just by cleaning out the health care system’s waste.

Elliott Fisher, who directs Dartmouth’s Atlas of Health Care, which tracks disparities in medical practices and outcomes across the country, pointed out that Medicare spending per person varies widely regardless of quality — from $7,734 a year in Minneapolis to $11,646 in Chicago — even after correcting for the different age, sex and race profiles of their populations.

He noted that if hospital stays by Medicare enrollees across the country fell to the length prevailing in Oregon and Washington, hospital use — one of the biggest drivers of costs — would fall by almost a third.

“Twenty to 30 percent of Medicare spending is pure waste,” Dr. Fisher argues. “The challenge of getting those savings is nontrivial. But those kinds of savings are not out of the question.”

We could be disappointed, of course. Similar breakthroughs before have quickly fizzled. Just think back to that brief spell in the mid-1990s when health maintenance organizations seemed to have beat health care inflation — until patients rebelled against being denied services and doctors dropped out of their networks rather than accept lower fees.

The Centers for Medicare and Medicaid Services already expects spending to rebound in coming years. Without tougher cost control devices, be it vouchers to limit government spending or direct government rationing, counting on savings of the scale needed to overcome the expected increase in Medicare rolls may be hoping for pie in the sky.

“It makes no sense,” said Eugene Steuerle, an economist at the Urban Institute, to expect the government will reap vast Medicare savings without having an impact on the quality of care.

The Affordable Care Act already contemplates fairly big cuts to Medicare. In its latest long-term projections published last year, the Congressional Budget Office estimated that under current law, growth in spending per beneficiary over the coming decade would be about half a percentage point slower than the rate of economic growth per person.

To understand how ambitious this is, consider that Medicare spending per beneficiary since 1985 has exceeded the growth of gross domestic product per person by about 1.5 percentage points per year. Slowing down that spending would require deep cuts in doctor reimbursements that, though written into law, Congress has never allowed to happen — repeatedly voting to cancel or postpone them.

Under a more realistic situation, the Budget Office projected that the growth of Medicare spending per capita over the next 10 years would be in fact 0.6 percentage points higher than under current law and accelerate further after that.

Yet despite the ambition of these targets, they would not be enough to stabilize future Medicare spending as a share of the economy. A report by three health care policy experts, Michael Chernew and Richard Frank of Harvard Medical School, together with Stephen Parente of the University of Minnesota, concluded that to do that would require limiting the growth of spending per beneficiary at 1.25 percentage points less than the growth of our gross domestic product per person.

“The Affordable Care Act places Medicare spending on a trajectory that is historically low,” Mr. Chernew said, noting his opinion was not an official statement as vice chairman of Medicare’s Payment Advisory Commission, which advises Congress on Medicare. “Could we do better? Of course. Will we? That requires a little more skepticism.”

Yet even if it is unrealistic to expect that newfound efficiencies will stabilize Medicare’s finances, the slowdown in health care spending suggests that politicians in Washington calm down. It offers, at the very least, more breathing room to carefully consider reforms to the system to raise revenue or trim benefits in the least damaging way.

There are many ideas out there — from changing Medicare’s premiums, deductibles and coinsurance to introducing a tax on carbon emissions to raise revenue. Some of them are not as good as others. Until recently, President Obama favored increasing the eligibility age for Medicare. Then research by the Kaiser Family Foundation concluded that raising the age would increase insurance premiums and cost businesses, beneficiaries and states more than the federal government would save. The nation would lose money in the deal.

“As we do this, there are smarter and dumber ways to do it,” Mr. Gruber said. “It would be a problem if we were to do things in a panic mode that set us backward.”

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Skepticism Surrounds Resumption of Nuclear Talks With Iran

ALMATY, Kazakhstan — Talks between Iran and six world powers over its nuclear program resume here on Tuesday after a break of eight months, but there is a general atmosphere of gloom about their prospects for success, even if narrowly defined.

Since talks in Moscow last June, Iran has continued to increase its stockpile of uranium enriched to 20 percent purity, has begun to install a new generation of centrifuges and has not yet completed an agreement on inspection of suspect military sites with the International Atomic Energy Agency, a deal originally advertised as all but done last May.

With presidential elections in Iran scheduled for June, senior Western diplomats involved with these talks expressed skepticism that Tehran’s chief negotiator, Saeed Jalili, would be willing to make compromises that could be portrayed as weakness at home.

Mr. Jalili is the personal representative of Iran’s supreme leader, Ayatollah Ali Khamenei, considered the dominant voice on the nuclear issue. Ayatollah Khamenei has recently expressed continued mistrust of the United States and its intentions, saying that he would not allow the kind of bilateral talks between Washington and Tehran that most analysts think would be crucial to any resolution.

At the same time, Iran has taken some of its stockpile of 20 percent enriched uranium and converted it into reactor fuel, which cannot easily be turned back. The conversion means that Iran now has less of the uranium needed to make a bomb, reducing the sense of urgency among the six powers, and Israel, that its nuclear program needs to be slowed.

But the total Iranian stockpile of 20 percent enriched uranium has nonetheless grown since November to 167 kilograms from 135 kilograms, according to the most recent I.A.E.A. report — closer to, if still significantly below, the 240 kilograms or 250 kilograms many experts consider necessary, once enriched further, to produce a nuclear weapon.

Iran denies that its nuclear program has any military aim. The six world powers, the so-called P5-plus-1 group, which are the five permanent members of the United Nations Security Council — Britain, China, France, Russia and the United States — and Germany, want Iran to obey Security Council resolutions ordering it to suspend enrichment and open itself up fully to I.A.E.A. inspectors, to ensure that there is no effort to build a nuclear weapon.

To press Iran to comply, the Security Council, the United States and the European Union have created an increasingly painful set of economic sanctions on Iran, as part of a dual-track strategy — negotiations and sanctions. Iran has for its part insisted that as a precondition for serious negotiations, the world should lift all the sanctions and recognize Iran’s “right to enrich,” which Iran asserts it has as a signatory to the Nuclear Nonproliferation Treaty.

The negotiations have been tedious, with Iran appearing to be playing for time, diplomats say. The six powers had asked for a resumption of these talks as early as December, but Iran rejected dates and sites before finally suggesting and agreeing upon Almaty. The choice pleased Western diplomats for its symbolic value, since Kazakhstan, when it became independent of the Soviet Union, freely relinquished the nuclear weapons it had inherited from Moscow. American officials are holding up Kazakhstan, one of the world’s largest producers of uranium and a maker of nuclear fuel, as an example to Iran of the benefits of peaceful nuclear energy and compliance with the I.A.E.A.

President Nursultan Nazarbayev of Kazakhstan appealed to Tehran in a New York Times Op-Ed article in March 2012 to abandon what he suggested was its pursuit of nuclear power status. “Kazakhstan’s experience shows that nations can reap huge benefits from turning their backs on nuclear weapons,” he wrote.

While expectations are low, the six hope to leave here with some momentum and signs of Iranian willingness to engage in what all have agreed should be a reciprocal and step-by-step process of lifting sanctions in return for Iranian actions to comply.

“Iran needs to understand that there is an urgent need to make concrete and tangible progress” in these talks, said Michael Mann, the spokesman for Catherine Ashton, the European Union’s foreign policy chief and chairwoman of the P5-plus-1 group.

Mr. Mann said that the six powers have together “prepared a good and updated offer for the talks which we believe is balanced and a fair basis for constructive talks” and that is “also responsive to Iranian ideas.”

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AP source: Tom Brady gets 3-year extension

Tom Brady will be a Patriot until he is 40 years old.

Brady agreed to a three-year contract extension with New England on Monday, a person familiar with the contract told The Associated Press. The extension is worth about $27 million and will free up nearly $15 million in salary cap room for the team, which has several younger players it needs to re-sign or negotiate new deals with.

The person spoke on condition of anonymity because the extension has not been announced.

Sports Illustrated first reported the extension.

The 35-year-old two-time league MVP was signed through 2014, and has said he wants to play at least five more years.

A three-time Super Bowl champion, Brady will make far less in those three seasons than the going rate for star quarterbacks. Brady currently has a four-year, $72 million deal with $48 million guaranteed.

Drew Brees and Peyton Manning are the NFL's highest-paid quarterbacks, at an average of $20 million and $18 million a year, respectively.

Brady has made it clear he wants to finish his career with the Patriots, whom he led to Super Bowl wins for the 2001, 2003 and 2004 seasons, and losses in the big game after the 2007 and 2011 seasons. By taking less money in the extension and redoing his current contract, he's hopeful New England can surround him with the parts to win more titles.

Among the Patriots' free agents are top receiver Wes Welker and his backup, Julian Edelman; right tackle Sebastian Vollmer; cornerback Aqib Talib; and running back Danny Woodhead.

Brady has been the most successful quarterback of his era, of course, as well as one of the NFL's best leaders. His skill at running the no-huddle offense is unsurpassed, and he's easily adapted to the different offensive schemes New England has concentrated on through his 13 pro seasons.

The Patriots have gone from run-oriented in Brady's early days to a deep passing team with Randy Moss to an offense dominated by throws to tight ends, running backs and slot receivers.

Brady holds the NFL record for touchdown passes in a season with 50 in 2007, when the Patriots went 18-0 before losing the Super Bowl to the Giants. He has thrown for at least 28 touchdowns seven times and led the league three times.

Last season, Brady had 34 TD passes and eight interceptions as the Patriots went 12-4, leading the league with 557 points, 76 more than runner-up Denver.

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine

Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.

On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.

Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative, which will provide the vaccine and help pay for the campaign.

Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.

Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.

Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.

The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)

More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.

The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.

In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.

Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.

Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.

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Time Inc. and Meredith Prepare to Join Magazine Businesses

Mary Chind/The Des Moines Register

Meredith, a magazine company, is headquartered in Des Moines.

When Jack Griffin, the former president of the magazine company Meredith, took the reins at Time Inc., he threw a holiday party for his staff on the 34th floor of the Time & Life Building. For many employees at the famously hierarchal company, their first visit to the rambling executive suites that inspired the sets of “Mad Men” became known as “The Miracle on 34th.”

Mr. Griffin lasted just six months at Time before he was asked to leave by Jeffrey L. Bewkes, the chief executive of its parent company, Time Warner, who publicly rebuked Mr. Griffin, saying that his “leadership style and approach did not mesh with Time Inc. and Time Warner.”

As bankers and media executives hammer out the details of creating a new publicly traded company to house the magazine titles of the Meredith Corporation and the lifestyle titles of Time Inc., employees at both companies have been wondering how executives will take on the harder task of merging two very different corporate cultures.

Meredith’s headquarters in Des Moines have an open floor plan; the executives have their offices on the first floor and favor early-morning meetings. A recent lunch at one of Meredith’s magazines featured kale salad and rosemary-infused cucumber lemonade. Time executives tend toward lunches at Michael’s, where the dry-aged steak is a highlight, and after-work cocktails at the Lamb’s Club.

And then there are the postrecessionary approaches to travel: Meredith’s chief executive turned its corporate jets into shuttles with open seating, while Time still allows staff members to expense hotel rooms at the Four Seasons.

“It’s like the Yankees’ farm team taking over the Yankees,” according to a current Time Inc. executive who, like many who talked about the merger, declined to be identified while criticizing bosses or potential bosses.

The merger news appears to be more troubling to employees at the long revered Time Inc., whose lucrative titles like People and InStyle have been essentially sold off by Time Warner and are likely to be overseen by Meredith’s chief executive, Stephen M. Lacy. Time Inc. employees have made cracks about Des Moines and shared more sobering fears about the merger.

And unanswered questions swirl around the offices: Will Time Inc.’s Cooking Light and its fierce rival at Meredith, Eating Well, be expected to share intelligence? Can celebrity titles like People and InStyle flourish sharing a publisher with Wood magazine? And, most important of all, how many former Time Inc. executives might be moved to Iowa?

Press officers for both Time and Meredith declined to comment about any specific negotiations. But an earlier effort to blend Meredith’s folksy culture with the titans of Time failed quickly.

In August 2010, Mr. Griffin became the first chief executive to join Time Inc. from outside the company. His efforts to restructure some of the company’s entrenched hierarchy and infuse his management experiences from Meredith were largely rebuffed. While he garnered praise for the holiday party, staff members bristled when Mr. Griffin, a marathon runner, introduced 7:30 a.m. breakfast meetings — similar to the daily meetings he attended at Meredith, but a shock to the culture at Time Inc., where late nights on deadline are typical.

But this time, Time and Meredith are blending the titles that magazine industry executives say are more compatible. Time is holding onto the older titles that gave the company its gravitas, like Time, Fortune and Sports Illustrated. The new company will include titles it created or purchased in recent decades, like the cash cows People and InStyle and smaller titles like Southern Living and This Old House.

Both companies also have major workforces beyond their home cities. Only 3,000 of Time Inc.’s nearly 8,000 employees are based in New York City, with offices in London and Birmingham, Ala. Meredith has its 1,000 magazine employees split evenly between its midtown offices on Third Avenue and its headquarters in Des Moines.

“If you take Time, Fortune and Sports Illustrated from the mix, you have much greater similarity to the titles that are left than differences,” said Peter Kreisky, who worked as a senior adviser to Mr. Griffin at Time Inc. and who also has advised Meredith in the past.

This article has been revised to reflect the following correction:

Correction: February 25, 2013

An earlier version of this article misstated the year Nancy Williamson left Time Inc. She retired in 1998, not 1989.

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World Briefing | Middle East: Iran: News Agency Clarifies Drone Report

The Islamic Revolutionary Guards Corps said it had conducted tests aimed at bringing down a “hypothetical” foreign surveillance drone during a military exercise, the official Fars news agency said late Saturday, and did not actually shoot down or capture a foreign drone. The Islamic Republic News Agency, another official news agency, also reported on the exercise, but omitted the word hypothetical, giving the impression that a real drone had been downed. Other official Iranian media outlets later referred to the downing of a “hypothetical” aircraft after the initial erroneous accounts.

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The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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Major Banks Aid in Payday Loans Banned by States

Major banks have quickly become behind-the-scenes allies of Internet-based payday lenders that offer short-term loans with interest rates sometimes exceeding 500 percent.

With 15 states banning payday loans, a growing number of the lenders have set up online operations in more hospitable states or far-flung locales like Belize, Malta and the West Indies to more easily evade statewide caps on interest rates.

While the banks, which include giants like JPMorgan Chase, Bank of America and Wells Fargo, do not make the loans, they are a critical link for the lenders, enabling the lenders to withdraw payments automatically from borrowers’ bank accounts, even in states where the loans are banned entirely. In some cases, the banks allow lenders to tap checking accounts even after the customers have begged them to stop the withdrawals.

“Without the assistance of the banks in processing and sending electronic funds, these lenders simply couldn’t operate,” said Josh Zinner, co-director of the Neighborhood Economic Development Advocacy Project, which works with community groups in New York.

The banking industry says it is simply serving customers who have authorized the lenders to withdraw money from their accounts. “The industry is not in a position to monitor customer accounts to see where their payments are going,” said Virginia O’Neill, senior counsel with the American Bankers Association.

But state and federal officials are taking aim at the banks’ role at a time when authorities are increasing their efforts to clamp down on payday lending and its practice of providing quick money to borrowers who need cash.

The Federal Deposit Insurance Corporation and the Consumer Financial Protection Bureau are examining banks’ roles in the online loans, according to several people with direct knowledge of the matter. Benjamin M. Lawsky, who heads New York State’s Department of Financial Services, is investigating how banks enable the online lenders to skirt New York law and make loans to residents of the state, where interest rates are capped at 25 percent.

For the banks, it can be a lucrative partnership. At first blush, processing automatic withdrawals hardly seems like a source of profit. But many customers are already on shaky financial footing. The withdrawals often set off a cascade of fees from problems like overdrafts. Roughly 27 percent of payday loan borrowers say that the loans caused them to overdraw their accounts, according to a report released this month by the Pew Charitable Trusts. That fee income is coveted, given that financial regulations limiting fees on debit and credit cards have cost banks billions of dollars.

Some state and federal authorities say the banks’ role in enabling the lenders has frustrated government efforts to shield people from predatory loans — an issue that gained urgency after reckless mortgage lending helped precipitate the 2008 financial crisis.

Lawmakers, led by Senator Jeff Merkley, Democrat of Oregon, introduced a bill in July aimed at reining in the lenders, in part, by forcing them to abide by the laws of the state where the borrower lives, rather than where the lender is. The legislation, pending in Congress, would also allow borrowers to cancel automatic withdrawals more easily. “Technology has taken a lot of these scams online, and it’s time to crack down,” Mr. Merkley said in a statement when the bill was introduced.

While the loans are simple to obtain — some online lenders promise approval in minutes with no credit check — they are tough to get rid of. Customers who want to repay their loan in full typically must contact the online lender at least three days before the next withdrawal. Otherwise, the lender automatically renews the loans at least monthly and withdraws only the interest owed. Under federal law, customers are allowed to stop authorized withdrawals from their account. Still, some borrowers say their banks do not heed requests to stop the loans.

Ivy Brodsky, 37, thought she had figured out a way to stop six payday lenders from taking money from her account when she visited her Chase branch in Brighton Beach in Brooklyn in March to close it. But Chase kept the account open and between April and May, the six Internet lenders tried to withdraw money from Ms. Brodsky’s account 55 times, according to bank records reviewed by The New York Times. Chase charged her $1,523 in fees — a combination of 44 insufficient fund fees, extended overdraft fees and service fees.

For Subrina Baptiste, 33, an educational assistant in Brooklyn, the overdraft fees levied by Chase cannibalized her child support income. She said she applied for a $400 loan from Loanshoponline.com and a $700 loan from Advancemetoday.com in 2011. The loans, with annual interest rates of 730 percent and 584 percent respectively, skirt New York law.

Ms. Baptiste said she asked Chase to revoke the automatic withdrawals in October 2011, but was told that she had to ask the lenders instead. In one month, her bank records show, the lenders tried to take money from her account at least six times. Chase charged her $812 in fees and deducted over $600 from her child-support payments to cover them.

“I don’t understand why my own bank just wouldn’t listen to me,” Ms. Baptiste said, adding that Chase ultimately closed her account last January, three months after she asked.

A spokeswoman for Bank of America said the bank always honored requests to stop automatic withdrawals. Wells Fargo declined to comment. Kristin Lemkau, a spokeswoman for Chase, said: “We are working with the customers to resolve these cases.” Online lenders say they work to abide by state laws.

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Papal Conclave Accompanied by Reports of Scandals and Intrigue

Osservatore Romano/Reuters

Pope Benedict XVI, right, spoke to cardinals at the Vatican on Saturday.

VATICAN CITY — As cardinals from around the world begin arriving in Rome for a conclave to elect a successor to Pope Benedict XVI, new shadows have fallen over the delicate transition, which the Vatican fears might influence the vote and with it the direction of the Roman Catholic Church.

In recent days, often speculative reports in the Italian news media — some even alleging gay sex scandals in the Vatican, others focusing on particular cardinals stung by the child sex abuse crisis — have dominated headlines, suggesting fierce internal struggles as prelates scramble to consolidate power and attack enemies in the dying days of a troubled papacy.

The reports, which the Vatican has vehemently denied, touch on some of the most vexing issues of Benedict’s reign, including the child sex abuse crisis and international criticisms of the Vatican Bank’s opaque record-keeping. The recent explosion of bad press — which some Vatican experts say is fed by carefully orchestrated leaks meant to weaken some papal contenders — also speak to Benedict’s own difficulties governing, which analysts say he is trying to address, albeit belatedly, with several high-profile personnel changes.

The drumbeat of scandal has reached such a fever pitch that on Saturday, the Vatican Secretariat of State issued a rare pointed rebuke, calling it “deplorable” that ahead of the conclave there was “a widespread distribution of often unverified, unverifiable or completely false news stories, that cause serious damage to persons and institutions.”

The Vatican compared the news reports to past attempts by foreign states to exert pressure on the papal election, saying the latest efforts to skew the choice of the next pope by trying to shape public opinion were “based on judgments that do not typically capture the spiritual aspect of the moment that the Church is living.”

Benedict had hoped to address at least one scandal with the Feb. 15 appointment of a new head of the Vatican Bank. It is less clear why he reassigned a powerful Vatican diplomatic official to a posting outside Rome, though experts say it diminishes the official’s role in helping steer Vatican policy.

On Feb. 11, Benedict made history by announcing that he would step down by month’s end. He said he was worn down by age and was resigning “in full liberty and for the good of the Church.” The volley of news reports since appeared to underscore the backbiting in the Vatican that Benedict was unable to control, and provided a hint of why he might have decided that someone younger and stronger should lead the church.

At the conclusion of the Vatican’s Lenten spiritual retreat, Cardinal Gianfranco Ravasi, the director of the Pontifical Council for Culture and a papal contender, spoke darkly of the “divisions, dissent, careerism, jealousies” that he said plagued the Vatican hierarchy.

The recent spate of news reports were linked to an earlier scandal in which the pope’s butler stole confidential documents that was considered one of the gravest security breaches in the modern history of the church.

Last week, largely unsourced articles in the center-left daily La Repubblica and the center-right weekly Panorama reported that three cardinals whom Benedict had asked last summer to investigate the leaking of the documents, known as the “VatiLeaks” scandal, had found evidence of Vatican officials who had been put in compromising positions.

The newspapers reported that, after interviewing dozens of people inside and outside the Vatican, the cardinals produced a hefty dossier. “The report is explicit. Some high prelates are subject to ‘external influence’ — we would call it blackmail — by nonchurch men to whom they are bound by ‘worldly’ ties,” La Repubblica wrote.

Vatican experts speculated that prelates eager to undermine opponents during the conclave were behind the leaks to the news media over the last week.

“The conclave is a mechanism that serves to create a dynasty in a monarchy without children, so it’s a complicated operation,” said Alberto Melloni, the director of the John XXIII Center in Bologna and the author of a book on conclaves.

This article has been revised to reflect the following correction:

Correction: February 23, 2013

An earlier version of this article misspelled the last name of a cardinal. His name is Roger M. Mahony, not Roger M. Mahoney.

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