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.

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Apple Will Bring Jobs Making PCS Back to the U.S.

Apple plans to join a small but growing number of companies that are bringing some manufacturing jobs back to the United States, drawn by the growing economic and political advantages of producing in their home market.

Kevork Djansezian/Getty Images

Timothy D. Cook, Apple's chief executive, introduced new products in October, including a thinner iMac.

On Thursday, Apple’s chief executive, Timothy D. Cook, who built its efficient Asian manufacturing network, said the company would invest $100 million in producing some of its Mac computers in the United States, beyond the assembly work it already does in the United States. He provided little detail about how the money would be spent or what kinds of workers might benefit.

Apple, which long manufactured parts in the United States but stopped about a decade ago, has been under pressure to create more jobs here given its market power. It sold 237 million iPods, iPads, Macs and other devices in the year ended in September.

“I don’t think we have a responsibility to create a certain kind of job,” Mr. Cook told Bloomberg Businessweek. “But I think we do have a responsibility to create jobs.”

Some analysts are hopeful that the move by a big, innovative company like Apple could inspire a broader renaissance in American manufacturing, but a number of experts remain skeptical.

“I find it hard to see how the supply chains that drive manufacturing are going to move back here,” said Andre Sharon, a professor at Boston University and director of the Fraunhofer Center for Manufacturing Innovation. “So much of the know-how has been lost to Asia, and there’s no compelling reason for it to return. It’s great when a company says they want to create American jobs — but it only really helps the country if those are jobs that belong here, if it starts a chain reaction or is part of a bigger economic shift.”

Over the last few years, companies across various industries, including electronics, automotive and medical devices, have announced that they are “reshoring” jobs after decades of shipping them abroad. Lower energy costs in America, rising wages in developing countries like China and Brazil, quality control issues and the desire to keep the supply chain close to the gigantic American consumer base have all factored into these decisions.

“Companies were going abroad in pursuit of cost reduction, and it turns out there were a lot of unintended costs,” said Diane Swonk, chief economist at Mesirow Financial. “America has been looking a lot more competitive lately.”

Even so, the impact on the American job market has been modest so far. Much of the work brought back has been high-value-added, automated production that requires few actual workers, which is part of the reason America’s higher wages are not scaring off companies.

American manufacturing has been growing in the last two years, but the sector still has two million fewer jobs than it had when the recession began in December 2007. Worldwide manufacturing appears to be growing much faster, even for many of the American-owned companies that are expanding at home. General Electric, for example, has hired American workers to build water heaters, refrigerators, dishwashers and high-efficiency topload washers, but continues to add more jobs overseas as well.

Apple has not announced plans to move the complex, faster-growing portions of its product lines. Macs now represent a relatively small portion of Apple’s business, accounting for less than 20 percent of its nearly $36 billion in revenue in its most recent quarter. The company’s iPad and iPhone products, which amount to nearly 70 percent of its sales, will continue to be made in low-cost centers of manufacturing like China, mostly on contract with outside companies like Foxconn.

Mr. Cook’s statements suggested Apple was planning to build more of the Mac’s components domestically, but with partners. He told Bloomberg Businessweek that the plan “doesn’t mean that Apple will do it ourselves, but we’ll be working with people, and we’ll be investing our money.”

Whether Apple’s newly announced plan might help create other higher-paying jobs along the supply line depends on the nature of the manufacturing.

Other computer manufacturing has been trickling back to the United States after largely shifting overseas in the 1990s.

Charles Duhigg and Quentin Hardy contributed reporting.

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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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Still Jets' starter, Sanchez out to prove himself

FLORHAM PARK, N.J. (AP) — Mark Sanchez spent a few days after his miserable performance wondering what was next.

The New York Jets quarterback had been benched, his coach tired of his mistakes, and there was no guarantee Rex Ryan would give him his job back anytime soon.

"I knew at some point before I died, I'd start at quarterback again," Sanchez said Wednesday. "I'm glad it's this week."

Ryan gathered his three quarterbacks Wednesday morning and told them he made up his mind: He's sticking with Sanchez.

For this week, at least.

Ryan weighed his options after pulling Sanchez for Greg McElroy last Sunday against Arizona, talking to many people within the organization before settling on his quarterback.

"I have to get this decision right," Ryan said, "and I believe I have."

So it will be Sanchez and not McElroy or Tim Tebow on Sunday when the Jets take on the Jaguars in Jacksonville.

"I'm pleased with coach's decision," Sanchez said. "Now it's my job to go make him right."

Sanchez was removed late in the third quarter against Arizona, and McElroy came in and led the Jets to the only touchdown of the game on his first NFL drive, helping New York to a 7-6 victory. Sanchez was 10 of 21 for 97 and three interceptions, while McElroy was 5 of 7 for 29 yards and the score, and appeared to spark the team.

Including, the Jets hope, Sanchez.

"When I looked at everything, the biggest thing I kept coming back to is, who gives us the best opportunity to win?" Ryan said. "When I kept coming back to that, I believe the correct answer was Mark Sanchez."

It was perhaps the biggest call in Ryan's nearly four years as coach, considering the sensitivity of the situation and the possible ramifications. He acknowledged there were differing opinions among those he spoke to, but said he received no pressure from owner Woody Johnson and added that Johnson was "absolutely" OK with the decision.

"From the day Mr. Johnson hired me," Ryan said, "he said it's 100 percent my decision who plays."

Sanchez, whose confidence was shaken with Sunday's performance, gets a chance to bounce back from the first benching of his NFL career and to regain the trust of his teammates. He has struggled recently, with two touchdowns and five interceptions in his last four games.

"It was probably the worst and best experience of my life," Sanchez said. "Hopefully, you learn from it and move on and never look back. It was definitely was the worst, but it could turn around and be one of the best things that's ever happened."

He said he had never been benched, except for maybe on his fifth-grade basketball team.

"I think (Ryan) was, more or less, sending a message and it's well-received," Sanchez said. "I know. I got it."

He'll likely be on a short leash against Jacksonville — with Tebow the No. 2 if healthy, and McElroy also ready to go — but Ryan acknowledged it might not be a quick hook if he struggles. Ryan also referenced the team's color-coded system which determined how much risk Sanchez can take with each pass, saying the quarterback is now back in the "red light" area — meaning he must be extremely cautious.

"If he throws one interception, it doesn't mean he's going to get benched, necessarily," Ryan said.

It's still uncertain if Tebow will be active against his hometown Jaguars while he recovers from two broken ribs. Despite being medically cleared by team doctors to play, Ryan chose to keep him active but not play against New England on Thanksgiving night, and then made him inactive against Arizona.

If Ryan went with McElroy, a seventh-round pick in 2011 out of Alabama, it would have been a clear indication the franchise is moving on from Sanchez.

"I'm just disappointed because I let a lot of people down," Sanchez said. "You let a lot of teammates down when you play like that. That never feels good. It just doesn't, not the way I prepare, not with the skill set I've been blessed to have."

Money might have played a role in the decision, too, with Sanchez owed $8.25 million next year in guarantees. But Ryan adamantly denied that factored into things.

"Absolutely zero," he said without hesitating.

Still, the Jets are likely stuck with Sanchez and his contract, so they need to see if he can rebound after the lowest point of his career.

"I believe in Mark," Ryan said.

It didn't appear Tebow was much of a factor in Ryan's decision. Ryan said all three quarterbacks would be in the mix, but didn't speculate whether he would have pulled Sanchez in favor of Tebow last Sunday if he were active.

"I'm not too worried about it," Tebow said. "Just trying to get better and trying to heal up."

Tebow was expected to have a major role in the offense, but instead has been a spare part averaging about seven offensive snaps per game. He has been listed as the No. 2 quarterback on the depth chart, but if the Jets turned to McElroy, it would have meant the No. 3 guy leapfrogged Tebow to start for the Jets.

McElroy said he has had a "normal" week so far, taking his usual number of snaps along with practicing with the scout team.

"You're not guaranteed anything, not at all," McElroy said. "You do your best to make the most of your opportunity and do your best to help the team."

The fact the next two games are on the road should also help Sanchez. He was booed mercilessly by the MetLife Stadium crowd last Sunday, particularly after each interception, and chants for McElroy were heard throughout the game. McElroy was cheered as he warmed up late in the third quarter, and there was growing sentiment among some fans and media that he earned a start after lifting the team.

"This is my opinion," Ryan said, "and I believe that sometimes you don't need to sit a guy for 'X' amount of games."

Now, Ryan has sent the message to Sanchez: perform or else. And Sanchez gets another shot to save his job this season — and his status as the Jets' franchise quarterback.

"This kind of thing affects people's lives and careers," Sanchez said. "It's not just, 'Oh, man. Bummer.' It's not like that. This is serious."

___

Online: http://pro32.ap.org/poll and http://twitter.com/AP_NFL

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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.

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In Inquiry, Drilling Company Chief Quits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This article has been revised to reflect the following correction:

Correction: December 4, 2012

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

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Bret Bielema leaves Wisconsin for Arkansas

FAYETTEVILLE, Ark. (AP) — Bret Bielema is taking his brand of power football to Arkansas, leaving Wisconsin after seven seasons.

Arkansas released a statement Tuesday night saying Bielema has agreed to a deal to take over the program reeling following the firing of former coach Bobby Petrino.

A person familiar with the situation, who spoke on the condition of anonymity because the information hasn't been released publicly, says the deal is for six years and $3.2 million annually.

Bielema, Barry Alvarez's hand-picked successor at Wisconsin, was 68-24 with the Badgers, with four double-digit win seasons. He coached Wisconsin to a 17-14 victory over Arkansas in his first season at the Capital One Bowl.

"His tough, aggressive style of play has been successful and will be appealing to student-athletes and Razorback fans," Arkansas athletic director Jeff Long said in a statement. "He not only shares the vision and values for the future of Arkansas football, he embraces them."

Bielema is leaving the Big Ten for the SEC and a Razorbacks program that opened the year with hopes of challenging for a national championship only to get mired in the Petrino scandal before stumbling to a 4-8 finish.

The move was the second stunning hire this year at Arkansas, which brought in John L. Smith as the interim coach after firing Petrino for hiring his mistress to work in the athletic department. Long announced after the season that Smith wouldn't return.

Bielema seems likely to bring a far different approach than what the Razorbacks have become accustomed to. Arkansas continually ranked among the Southeastern Conference's best passing teams under Petrino while Bielema is known for his dominant offensive lines and slew of running backs.

"During my conversation with Jeff (Long), he described the characteristics for the perfect fit to lead this program," Bielema said in a statement. "It was evident we share the same mission, principles and goals."

Wisconsin running back Montee Ball tied Barry Sanders' long-standing single-season record of 39 touchdowns last year, and this year became the FBS career leader in touchdowns. He currently has 82 touchdowns after running for three Saturday night in the Big Ten title game against Nebraska — a 70-31 romp that secured the Badgers third straight trip to the Rose Bowl, where they will play Stanford on Jan. 1.

The 42-year-old Bielema was the defensive coordinator at Wisconsin for two years before being promoted to head coach in 2006. He played for Iowa and started his coaching career there as an assistant under Hayden Fry and later Kirk Ferentz.

"I was very surprised when Bret told me he was taking the offer from Arkansas," said Alvarez, Wisconsin's athletic director and former coach. "He did a great job for us during his seven years as head coach, both on the field and off. I want to thank him for his work and wish him the best at Arkansas."

The Illinois native takes over a program still reeling following the April scandal, one eager for stability and leadership.

"I'm excited about this decision," Arkansas cornerback Tevin Mitchel tweeted.

The Razorbacks improved their win total in four straight seasons under Petrino, including a 21-5 mark in 2010-11, and finished last season ranked No. 5. They had talked openly in the spring about competing for the school's first SEC championship and perhaps a national title.

Then came the April 1 motorcycle accident that led to Petrino's downfall. The married father of four initially lied about being alone during the wreck, later admitting to riding with his mistress — a former Arkansas volleyball player he had hired to work in the athletic department.

Smith, who had been an assistant the last three seasons at Arkansas under Petrino, was chosen by Long to guide a team that returned first-team All-SEC quarterback Tyler Wilson and a host of other key playmakers. The decision was lauded by the Razorbacks, who welcomed the personable Smith back with open arms.

The season hit the skids with a stunning overtime loss to Louisiana-Monroe on Sept. 8, starting a four-game losing streak that dropped Arkansas out of the rankings. The Razorbacks finished with the school's lowest win total since 2005, missing a bowl game for the first time since 2008.

"It's very difficult for me to believe that is not a bowl-eligible team," LSU coach Les Miles said following the Tigers' win over the Razorbacks in the season finale. "Watching the talent there, (it's) very capable."

Arkansas struggled to find its identity in the SEC after leaving the former Southwest Conference in 1992, but it appeared to have finally found just that under Petrino, who was hired after leaving the Atlanta Falcons during the season in 2007.

The Razorbacks turned into an offensive powerhouse under Petrino, leading the league in scoring and total offense last season. After winning 10 games and reaching the school's first BCS bowl game in 2010, losing to Ohio State, Arkansas won 11 games in 2011, capped by a Cotton Bowl win over Kansas State.

Still, Arkansas has yet to win the SEC, losing in the conference championship game three times.

While the country watched closely to see how Arkansas would react following Petrino's dismissal, Smith made headlines of his own throughout the season. The former Michigan State and Louisville coach filed for bankruptcy during the season, revealing $40.7 million in debt he blamed on bad land deals.

He was under far more fire from Arkansas fans for the mounting losses and it will be up to Bielema to turn things around in the loaded SEC West, with Alabama, LSU and now Texas A&M.

Long said during the season that the new coach would be tasked with building on the recent success at the school, which is looking into expanding the 72,000-seat Razorback Stadium and is currently building an 80,000-square-foot football operations center.

"The infrastructure in place at Arkansas shows the commitment from the administration to accomplish our goals together and I am excited to begin to lead this group of student-athletes," Bielema said. "This program will represent the state of Arkansas in a way Razorback fans everywhere will be proud of."

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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.

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

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

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

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

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

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

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

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

Multimedia: Insider Trading

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

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

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

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

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

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