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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BP Executive Testifies That Rig Explosion Was Known Risk

NEW ORLEANS — On the first day of testimony in the BP Gulf of Mexico oil spill trial, BP’s top executive for North American operations at the time of the disaster acknowledged on Tuesday that a well explosion had been identified as a risk before it happened.

“There was a risk identified for a blowout,” said Lamar McKay, the former president of BP America and current chief executive in charge of global upstream operations. “The blowout was an identified risk, and it was a big risk, yes.”

Robert Cunningham, a lawyer for private plaintiffs, tried to pin down Mr. McKay on BP’s responsibility for the 2010 disaster that killed 11 workers and dumped millions of barrels of oil into the gulf. Mr. Cunningham suggested that the British company’s cost-cutting and risk-taking culture were at the heart of the explosion and spill. He pressed Mr. McKay on the fact that a BP report on the accident held contractors responsible, but did not cite management failures.

Mr. McKay repeatedly responded that BP was responsible for designing the well, but that the rig, cement and other contractors shared responsibility for safety on the drilling operations.

“It’s a team effort,” he said. “It’s a shared responsibility to manage the safety and risk.”

Mr. McKay testified for more than an hour at the end of the day and will continue on Wednesday. He told the court that there were risks involved with drilling both in deep waters and in shallow waters, but that a blowout could be more difficult to control, and therefore more damaging, in deep waters. There was little, if anything, in his comments that diverged from what BP executives have said in the past.

After the April 2010 spill, internal BP documents showed that the company had struggled with a loss of “well control” in March, after several weeks of problems on the rig. And for months before that, it had been concerned about the well casing and the blowout preventer, which are considered critical pieces in the chain of events that led to the disaster.

On June 22, 2009, for example, BP engineers expressed concerns that the metal casing the company wanted to use might collapse under high pressure.

“This would certainly be a worst-case scenario,” Mark E. Hafle, a senior drilling engineer at BP, warned in an internal report. “However, I have seen it happen so know it can occur.”

Early in his testimony, Mr. McKay shifted and appeared uncomfortable on the witness stand. He acknowledged that he had never read a textbook on safety system engineering before or after the accident, or a safety report written by a BP consultant who testified earlier in the day.

Mr. McKay was the second witness to appear in a multiphase trial that will determine who was responsible for the accident, whether they were grossly negligent and how much oil was spilled. He followed Robert Bea, a professor emeritus of engineering at the University of California, Berkeley, and former safety systems consultant for BP, who largely blamed the company’s culture for the accident.

“It’s a culture of every dollar counts,” Dr. Bea said. “It’s a classic failure of management and leadership.”

The Federal District Court trial in New Orleans is bundling suits brought by the Justice Department, state governments, private businesses and individual claimants against BP and several of its contractors. Decisions on culpability and damages could be a year or more away, but they are likely to have profound effects on environmental law and on the viability of BP as a major oil company with global ambitions.

Under the Clean Water Act, fines against BP could range from $1,100 for every barrel spilled through simple negligence to as much as $4,300 a barrel if the company were found to have been grossly negligent. The federal government has estimated that about four million barrels of oil were spilled, meaning liabilities of as much as $4.4 billion to $17.2 billion. BP has claimed that the amount spilled was at most 3.1 million barrels.

This article has been revised to reflect the following correction:

Correction: February 26, 2013

An earlier version of this article misstated Lamar McKay’s title when he headed BP America. He was president, not chief executive. Because of an editing error, the article also misstated the federal government’s estimate of the number of barrels spilled. It is about four million barrels, meaning a liability range of $4.4 billion to $17.2 billion, not 4.9 million barrels and a liability range of $5.4 billion to $21 billion.

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Little Clarity in Italian Vote, Aside from Anger

Italians Head to the Polls:
Italians voted Sunday and Monday in a general election that is being closely watched to see whether a clear winner will emerge.

ROME — Italian voters delivered a rousing anti-austerity message and a strong rebuke to the existing political order in national elections on Monday, plunging the country into political paralysis after results failed to produce a clear winner.

Analysts said that the best-case scenario would be shaky coalition government, which would once again expose Italy and the euro zone to turmoil if markets question its commitment to measures that have kept the budget deficit within a tolerable 3 percent of gross domestic product. News of the stalemate sent tremors through the financial world, sending the Dow Jones Industrial Average down more than 200 points.

Although analysts blamed the large protest vote on Italy’s political morass and troubled electoral system, the results were also seen as a rejection of the rapid deficit-reduction strategy set by the European Commission and European Central Bank — from a country too big to fail and too big to bail out.

“No doubt Italy has an imperfect political culture, but this election I think is the logical consequence of pursuing policies that have dramatically worsened the economic and social picture in Italy,” said Simon Tilford, the chief economist of the Center for European Reform, a London research institute.

“People have been warning that if they adhere to this policy there will be a political cost, there will be backlash,” he added. “It couldn’t have taken place in a more pivotal country.”

In an election marked by voter anger and low turnout, the center-left Democratic Party appeared to be leading in the Lower House with 29.6 percent, with 99 percent of the votes counted, and in the Senate with one-third of the votes counted by midnight local time.

But that outcome did not give the Democrats a clear victory because the center-right People of Liberty Party of former Prime Minister Silvio Berlusconi was leading in several populous regions that carry more Senate seats, potentially giving him veto power and raising the prospect of political gridlock.

 Even before the final result, the election was a clear victory for the Five Star Movement of the former comedian Beppe Grillo, which in its first-ever national elections appeared to win about 25 percent of the vote in the Lower House. Italians from both right and left — and the wealthier north and poorer south — were drawn to Mr. Grillo’s opposition to austerity measures and cries to oust the existing political order.

And it was a stinging defeat for the caretaker prime minister, Mario Monti, a newly minted politician whose lackluster civic movement appeared to win around 10 percent in both houses. “Grillo had a devastating success; the rest of the situation is very unclear,” said Stefano Folli, a political columnist for the daily business newspaper Il Sole 24 Ore.

Either the Democratic Party and the People of Liberty Party “will form a grand coalition committed to reforms and changing the electoral law, which would be very difficult, or Italy will be ungovernable,” Mr. Folli added.

Mr. Monti’s caretaker government remains in place with full powers until a new government is formed. Appearing on television on Monday evening, Mr. Monti said he felt “tremendous regret” that during his tenure the political parties were not able to change Italy’s electoral law so as to guarantee more political stability. “It is a great responsibility of the political forces, and one of the reasons for the disaffection and distance from and the revindication of the political class,” he added.

Under Italy’s complex electoral laws, it is extremely hard for any one party to gain a strong ruling majority needed to manage an economy with rising unemployment and a credit crunch, let alone push through structural changes to the ossified economy. Instead, the parties have resisted change to protect their own power bases. 

The results of this election would appear to represent new depths of gridlock, and few experts expected any party to form a governing coalition strong enough to prevail for long. Nicolas Véron, an economist and a senior fellow at Bruegel, a Brussels-based research institute, said that regardless of who ultimately controls the levers of government, “The key question is whether we can have serious structural reform.”

Italy “was a work in progress before the elections,” Mr. Véron added, “and I think investors understand that it will remain a work in progress for some time.”

Gaia Pianigiani contributed reporting from Rome, and Nicola Clark from Paris.

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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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Little Clarity in Italian Vote, Aside from Anger

Italians Head to the Polls:
Italians voted Sunday and Monday in a general election that is being closely watched to see whether a clear winner will emerge.

ROME — Italian voters delivered a rousing anti-austerity message and a strong rebuke to the existing political order in national elections on Monday, plunging the country into political paralysis after results failed to produce a clear winner.

Analysts said that the best-case scenario would be shaky coalition government, which would once again expose Italy and the euro zone to turmoil if markets question its commitment to measures that have kept the budget deficit within a tolerable 3 percent of gross domestic product. News of the stalemate sent tremors through the financial world, sending the Dow Jones Industrial Average down more than 200 points.

Although analysts blamed the large protest vote on Italy’s political morass and troubled electoral system, the results were also seen as a rejection of the rapid deficit-reduction strategy set by the European Commission and European Central Bank — from a country too big to fail and too big to bail out.

“No doubt Italy has an imperfect political culture, but this election I think is the logical consequence of pursuing policies that have dramatically worsened the economic and social picture in Italy,” said Simon Tilford, the chief economist of the Center for European Reform, a London research institute.

“People have been warning that if they adhere to this policy there will be a political cost, there will be backlash,” he added. “It couldn’t have taken place in a more pivotal country.”

In an election marked by voter anger and low turnout, the center-left Democratic Party appeared to be leading in the Lower House with 29.6 percent, with 99 percent of the votes counted, and in the Senate with one-third of the votes counted by midnight local time.

But that outcome did not give the Democrats a clear victory because the center-right People of Liberty Party of former Prime Minister Silvio Berlusconi was leading in several populous regions that carry more Senate seats, potentially giving him veto power and raising the prospect of political gridlock.

 Even before the final result, the election was a clear victory for the Five Star Movement of the former comedian Beppe Grillo, which in its first-ever national elections appeared to win about 25 percent of the vote in the Lower House. Italians from both right and left — and the wealthier north and poorer south — were drawn to Mr. Grillo’s opposition to austerity measures and cries to oust the existing political order.

And it was a stinging defeat for the caretaker prime minister, Mario Monti, a newly minted politician whose lackluster civic movement appeared to win around 10 percent in both houses. “Grillo had a devastating success; the rest of the situation is very unclear,” said Stefano Folli, a political columnist for the daily business newspaper Il Sole 24 Ore.

Either the Democratic Party and the People of Liberty Party “will form a grand coalition committed to reforms and changing the electoral law, which would be very difficult, or Italy will be ungovernable,” Mr. Folli added.

Mr. Monti’s caretaker government remains in place with full powers until a new government is formed. Appearing on television on Monday evening, Mr. Monti said he felt “tremendous regret” that during his tenure the political parties were not able to change Italy’s electoral law so as to guarantee more political stability. “It is a great responsibility of the political forces, and one of the reasons for the disaffection and distance from and the revindication of the political class,” he added.

Under Italy’s complex electoral laws, it is extremely hard for any one party to gain a strong ruling majority needed to manage an economy with rising unemployment and a credit crunch, let alone push through structural changes to the ossified economy. Instead, the parties have resisted change to protect their own power bases. 

The results of this election would appear to represent new depths of gridlock, and few experts expected any party to form a governing coalition strong enough to prevail for long. Nicolas Véron, an economist and a senior fellow at Bruegel, a Brussels-based research institute, said that regardless of who ultimately controls the levers of government, “The key question is whether we can have serious structural reform.”

Italy “was a work in progress before the elections,” Mr. Véron added, “and I think investors understand that it will remain a work in progress for some time.”

Gaia Pianigiani contributed reporting from Rome, and Nicola Clark from Paris.

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Afghanistan Order U.S. Troops From Key Province

Bryan Denton for The New York Times

An Afghan soldier and resident of Maidan Wardak Province, which the government has decreed off limits to United States forces.

KABUL, Afghanistan — The Afghan government barred elite American forces from operating in a strategic province adjoining Kabul on Sunday, citing complaints that Afghans working for American Special Operations forces had tortured and killed villagers in the area.

The ban was scheduled to take effect in two weeks in the province, Maidan Wardak, which is seen as a crucial area in defending the capital against the Taliban. If enforced, it would effectively exclude the American military’s main source of offensive firepower from the area, which lies southwest of Kabul and is used by the Taliban as a staging ground for attacks on the city.

By announcing the ban, the government signaled its willingness to take a far harder line against abuses linked to foreign troops than it has in the past. The action also reflected a deep distrust of international forces that is now widespread in Afghanistan, and the view held by many Afghans, President Hamid Karzai among them, that the coalition shares responsibility with the Taliban for the violence that continues to afflict the country.

Coalition officials said they were talking to their Afghan counterparts to clarify the ban and the allegations that prompted it. They declined to comment further.

Afghan officials said the measure was taken as a last resort. They said they had tried for weeks to get the coalition to cooperate with an investigation into claims that innocent civilians had been killed, abducted or tortured by Afghans working for American Special Operations forces in Maidan Wardak. But the coalition was not responsive, the officials said.

The officials said that without information from the coalition, they could provide few specifics about who was accused or which units they were working with.

A statement from the presidential palace suggested that abuses may have been committed by American Special Operations troops, and not just by Afghans working alongside them. But in interviews after the announcement, Afghan officials indicated that the Afghans were the main suspects, and that the Americans were seen as enabling the abuses rather than perpetrating them.

Throughout the war, the United States military and the C.I.A. have organized and trained clandestine militias. A number still operate, and remain beyond the knowledge or control of the Afghan government. Aimal Faizi, the spokesman for Mr. Karzai, said it was time for foreign forces to hand over control of the “parallel structures,” as he called them, to the government.

Much of the work done by American Special Operations forces in Afghanistan or anywhere else is highly classified, and information about it is closely guarded. A senior American military officer, for instance, said he did not know whether such forces were based in Maidan Wardak or were based elsewhere and were flown in periodically for missions.

Afghan officials are, for the most part, told even less, and many in the Karzai administration no longer wish to allow Americans to continue “running roughshod all around our country,” said a person who is close to Mr. Karzai.

As additional evidence of that sentiment, the person close to Mr. Karzai, who asked not to be identified because he was discussing internal deliberations, cited an order issued earlier this month by Mr. Karzai sharply curtailing the circumstances in which Afghan forces could call in coalition airstrikes.

That order, however, simply brought Afghan forces into line with the rules that coalition troops have followed since last year. Neither Afghan nor foreign military commanders believe its impact will be far-reaching.

It will probably be harder to assess the effects of the ban decreed on Sunday, and the competing views on the matter illustrate just how far apart Afghan and coalition officials are when it comes to charting a course for the war.

With the withdrawal of American forces picking up pace, most of the coalition’s conventional forces in eastern Afghanistan, including in Maidan Wardak, have shifted into advisory roles. Among coalition troops, offensive operations are increasingly becoming the sole purview of the Special Operations forces.

United States officials, in fact, are planning to rely heavily on the elite troops to continue hunting members of Al Qaeda and other international militants in Afghanistan after the NATO mission here ends in 2014.

Afghans have expressed far less enthusiasm about foreign forces, either conventional or Special Operations troops, continuing to operate in Afghanistan for years to come. “The international forces, they are also factors in insecurity and instability — it’s not only the insurgency,” said Mr. Faizi, the presidential spokesman.

As for concerns that the new ban could reduce pressure on the Taliban, Mr. Faizi said that the Afghan Army and the police would “certainly be able to handle this work.”

Habib Zahori and Sangar Rahimi contributed reporting.

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Johnson wins 2nd Daytona 500; Patrick finishes 8th

DAYTONA BEACH, Fla. (AP) — A big first for Danica Patrick, but an even bigger second for Jimmie Johnson.

Patrick made history up front at the Daytona 500 Sunday, only to see Johnson make a late push ahead of her and reclaim his spot at the top of his sport.

It was the second Daytona 500 victory for Johnson, a five-time NASCAR champion who first won "The Great American Race" in 2006.

"There is no other way to start the season than to win the Daytona 500. I'm a very lucky man to have won it twice," said Johnson, who won in his 400th career start. "I'm very honored to be on that trophy with all the greats that have ever been in our sport."

It comes a year after Johnson completed only one lap in the race because of a wreck that also collected Patrick, and just three months after Johnson lost his bid for a sixth Sprint Cup title to go two years without a championship after winning five straight.

Although he didn't think he needed to send a message to his competitors — "I don't think we went anywhere; anybody in the garage area, they're wise to all that," Johnson said — the win showed the No. 48 team is tired of coming up short after all those years of dominance.

"Definitely a great start for the team. When we were sitting discussing things before the season started, we felt good about the 500," Johnson said, "but we're really excited for everything after the 500. I think it's going to be a very strong year for us."

Patrick is hoping for her own success after a history-making race.

The first woman to win the pole, Patrick also became the first woman to lead the race. She ran inside the top 10 almost the entire race, kept pace with the field and never panicked on the track.

Her only mistakes were on pit road, where she got beat on the race back to the track, and on the final lap, when she was running third but got snookered by the veterans and faded to eighth. That's going to stick with Patrick for some time.

"I would imagine pretty much anyone would be kicking themselves about what they coulda, shoulda have done to give themselves an opportunity to win," she said. "I think that's what I was feeling today, was uncertainty as to how I was going to accomplish that."

There were several multicar crashes, but no one was hurt and none of them approached the magnitude of the wreck that injured more than two dozen fans in the grandstand at the end of the second-tier Nationwide Series race on the same track a day earlier. Daytona International Speedway workers were up until 2 a.m repairing the fence that was damaged in the accident, and track officials offered Sunday morning to move any fans who felt uneasy sitting too close to the track.

Several drivers said the accident and concern for the fans stuck with them overnight and into Sunday morning, and Johnson was quick to send his thoughts from Victory Lane.

"I just want to give a big shout-out to all the fans, and I also want to send my thoughts and prayers out to everybody that was injured in the grandstands," Johnson said.

Dale Earnhardt Jr., whose father was killed in this race 12 years ago, was involved in Saturday's accident but refocused and finished second to Johnson, his Hendrick Motorsports teammate.

"Me personally, I was just really waiting to get the news on how everybody was, how all the fans were overnight, just hoping that things were going to improve," Earnhardt said, adding that he "wasn't really ready to proceed until you had some confirmation that things were looking more positive."

The race itself, the debut for NASCAR's new Gen-6 car, was quite similar to all the other Cup races during Speedweeks in that the cars seemed to line up in a single-file parade along the top groove of the track. It made the 55th running of the Daytona 500 relatively uneventful.

When the race was on the line, Johnson took off.

The driver known as "Five-Time" raced past defending NASCAR champion Brad Keselowski on the final restart and pulled out to a sizable lead that nobody challenged over the final six laps.

Johnson and Keselowski went down to the wire last season in their race for the Sprint Cup title, with Johnson faltering in the final two races as Keselowski won his first Cup championship.

Although it was a bit of an upset that stuck with Johnson into the offseason, it gave him no extra motivation when he found himself racing with Keselowski late Sunday for the Daytona 500.

"As far as racing with Brad out there, you really lose sight of who is in what car," Johnson said. "It's just somebody between you and the trophy. It could have been anybody."

Once Johnson cleared Keselowski on the last restart he had a breakaway lead with Greg Biffle and Patrick behind him. But as the field closed in on the checkered flag, Earnhardt finally made his move, just too late and too far behind to get close enough to the lead.

Earnhardt wound up second for the third time in the last four years. But with all the crashes the Hendrick cars have endured in restrictor-plate races — teammate Kasey Kahne was in the first accident Sunday — team owner Rick Hendrick was just fine with the finish.

"We have a hard time finishing these races. Boy, to run 1-2, man, what a day," Hendrick said. Jeff Gordon, who was a contender early, faded late to 20th.

And Johnson considered himself lucky to be the one holding the trophy at the end.

"Man, it's like playing the lottery; everybody's got a ticket," he said. "I've struck out a lot at these tracks, left with torn-up race cars. Today we had a clean day."

Mark Martin was third in a Michael Waltrip Racing Toyota. Keselowski, who overcame two accidents earlier in the race, wound up fourth in Penske Racing's new Ford. Ryan Newman was fifth in a Chevy for Stewart-Haas Racing and was followed by Roush-Fenway Racing's Greg Biffle, who was second on the last lap but was shuffled back with Patrick to finish sixth.

Regan Smith was seventh for Phoenix Racing, while Patrick, Michael McDowell and JJ Yeley rounded out the top 10.

Patrick was clearly disappointed with her finish. When the race was on the line, she was schooled by Earnhardt, who made his last move and blocked any chance she had.

Still, Patrick became the first woman in history to lead laps in the 500 when she passed Michael Waltrip on a restart on Lap 90. She stayed on the point for two laps, then was shuffled back to third. She ended up leading five laps, another groundbreaking moment for Patrick, who as a rookie in 2005 became the first woman to lead the Indianapolis 500 and now is the 13th driver to lead laps in both the Daytona 500 and the Indy 500.

"Dale did a nice job and showed what happens when you plan it out, you drop back and get that momentum. You are able to go to the front," Patrick said. "I think he taught me something. I'm sure I'll watch the race and there will be other scenarios I see that can teach me, too."

Earnhardt was impressed, nonetheless.

"She's going to make a lot of history all year long. It's going to be a lot of fun to watch her progress," said Earnhardt Jr. "Every time I've seen her in a pretty hectic situation, she always really remained calm. She's got a great level head. She's a racer. She knows what's coming. She's smart about her decisions. She knew what to do today as far as track position and not taking risks. I enjoy racing with her."

Johnson, one of three heavyweight drivers who took their young daughters to meet Patrick — "the girl in the bright green car" — after she won the pole in qualifications, tipped his cap, too.

"I didn't think about it being Danica in the car," Johnson said. "It was just another car on the track that was fast. That's a credit to her and the job she's doing."

The field was weakened by an early nine-car accident that knocked out race favorite Kevin Harvick and sentimental favorite Tony Stewart.

Harvick had won two support races coming into the 500 to cement himself as the driver to beat, but the accident sent him home with a 42nd place finish.

Stewart, meanwhile, dropped to 0-for-15 in one of the few races the three-time NASCAR champion has never won.

"If I didn't tell you I was heartbroken and disappointed, I'd be lying to you," Stewart said.

That accident also took former winner Jamie McMurray, his Chip Ganassi Racing teammate Juan Pablo Montoya, and Kasey Kahne out of contention.

The next accident — involving nine cars — came 105 laps later and brought a thankful end to Speedweeks for Carl Edwards. He was caught in his fifth accident since testing last month, and this wreck collected six other Ford drivers.

The field suddenly had six Toyota drivers at the front as Joe Gibbs Racing and Michael Waltrip Racing drivers took control of the race. But JGR's day blew up — literally — when the team was running 1-2-3 with Matt Kenseth, Denny Hamlin and Kyle Busch setting the pace.

Kenseth, who led a race-high 86 laps, went to pit road first with an engine problem, and Busch was right behind him with a blown engine. Busch was already in street clothes watching as Hamlin led the field.

"It's a little devastating when you are running 1-2-3 like that," Busch said.

Hamlin's shot disappeared when he found himself in the wrong lane on the final restart. He tried to hook up with Keselowski to get them back to Johnson, but blamed former teammate Joey Logano for ruining the momentum of the bottom lane.

Hamlin offered a backhanded apology to Keselowski on Twitter, posting that he couldn't get close enough because "your genius teammate was too busy messing up the inside line 1 move at a time."

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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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Many Cruise Ship Lack Backup Power Systems, Vexing Regulators

Denis Poroy/Associated Press

The Carnival Splendor cruise ship was towed into San Diego Bay in 2010, after a fire destroyed its electrical systems.

It is becoming a familiar tale: When the cruise ship was towed into port, the endless hours for passengers of sleeping on deck and going without electricity or toilets were finally over.

“It was really hell,” said Bernice Spreckman, who is 77 and lives in Yonkers, N.Y. “I used my life jacket, which was flashing with a little light on it, to find a bathroom it was so dark.”

Ms. Spreckman was not among the 4,200 people aboard the Carnival Triumph who this month endured five days of sewage-soaked carpets and ketchup sandwiches. Her trial at sea came in 2010, on another ship run by Carnival Cruises, called the Splendor, which carried 4,500 passengers.

On both ships, fires broke out below decks, destroying the electrical systems and leaving them helpless. A preliminary Coast Guard inquiry into the Splendor found glaring deficiencies in its firefighting operations, including manuals that called for crew members to “pull” valves that were designed to turn.

But more than two years after the episode, the final report about what happened on the Splendor has yet to appear, a reflection of what critics say is a pattern of international regulatory roulette that governs cruise ship safety.

While the Splendor was based in the United States, the ship was legally registered in Panama, meaning the Panamanian Maritime Authority had the right to lead the investigation. But after the 2010 fire, Panamanian regulators chose to have the Coast Guard take over the inquiry. Then, officials in both countries apparently spent months trading drafts of their reports.

One official in Panama said the authority had completed its review of the Splendor report in October 2012. But a Coast Guard spokeswoman, Lisa Novak, said it still had not “finalized” the report. In the case of the Carnival Triumph, the regulatory scene will shift to the Bahamas, where that ship was registered.

In a recent letter to Coast Guard officials, Senator Jay Rockefeller, Democrat of West Virginia, said that cruise ships seemed to have two separate lives. Only during days near port are they closely monitored.

“Once they are beyond three nautical miles from shore, the world is theirs,” said the letter from Senator Rockefeller, who has headed recent inquiries into cruise ship safety.

Cruise industry officials point out that seaborne vacations are extremely safe and that some 20 million people go on cruises annually, with few problems. The most glaring exception to that record occurred last year when a vessel operated by a subsidiary of Carnival, the Costa Concordia, ran aground off the coast of Italy, resulting in 32 deaths.

In the Triumph’s case, the Coast Guard has said that the ship’s safety equipment failed to contain the blaze. And both the Triumph and the Splendor returned from their aborted voyages without serious injuries to passengers or crew.

But those successes also underscore what most travelers do not realize when they book cruises: nearly all ships lack backup systems to help them return to port should power fail because to install them would have cost operators more money.

The results are repeated episodes involving dead ships, with all the discomforts and potential dangers such situations can bring. In another case, in late 2012, the Costa Allegra cruise ship, a sister ship of the Concordia, lost power after a fire in the generator room and it had to be towed under guard from its location in the Indian Ocean.

In many ways, passengers aboard boats like the Triumph and Splendor were lucky because their ships were disabled in calm weather, when instead they could have been knocked out during storms, or when they were far out at sea or in pirate-infested waters, experts said.

“Anything that knocks a ship dead in the water is serious,” said Mark Gaouette, a safety expert and former Navy officer.

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