Study finds mammograms lead to unneeded treatment

Mammograms have done surprisingly little to catch deadly breast cancers before they spread, a big U.S. study finds. At the same time, more than a million women have been treated for cancers that never would have threatened their lives, researchers estimate.

Up to one-third of breast cancers, or 50,000 to 70,000 cases a year, don't need treatment, the study suggests.

It's the most detailed look yet at overtreatment of breast cancer, and it adds fresh evidence that screening is not as helpful as many women believe. Mammograms are still worthwhile, because they do catch some deadly cancers and save lives, doctors stress. And some of them disagree with conclusions the new study reached.

But it spotlights a reality that is tough for many Americans to accept: Some abnormalities that doctors call "cancer" are not a health threat or truly malignant. There is no good way to tell which ones are, so many women wind up getting treatments like surgery and chemotherapy that they don't really need.

Men have heard a similar message about PSA tests to screen for slow-growing prostate cancer, but it's relatively new to the debate over breast cancer screening.

"We're coming to learn that some cancers — many cancers, depending on the organ — weren't destined to cause death," said Dr. Barnett Kramer, a National Cancer Institute screening expert. However, "once a woman is diagnosed, it's hard to say treatment is not necessary."

He had no role in the study, which was led by Dr. H. Gilbert Welch of Dartmouth Medical School and Dr. Archie Bleyer of St. Charles Health System and Oregon Health & Science University. Results are in Thursday's New England Journal of Medicine.

Breast cancer is the leading type of cancer and cause of cancer deaths in women worldwide. Nearly 1.4 million new cases are diagnosed each year. Other countries screen less aggressively than the U.S. does. In Britain, for example, mammograms are usually offered only every three years and a recent review there found similar signs of overtreatment.

The dogma has been that screening finds cancer early, when it's most curable. But screening is only worthwhile if it finds cancers destined to cause death, and if treating them early improves survival versus treating when or if they cause symptoms.

Mammograms also are an imperfect screening tool — they often give false alarms, spurring biopsies and other tests that ultimately show no cancer was present. The new study looks at a different risk: Overdiagnosis, or finding cancer that is present but does not need treatment.

Researchers used federal surveys on mammography and cancer registry statistics from 1976 through 2008 to track how many cancers were found early, while still confined to the breast, versus later, when they had spread to lymph nodes or more widely.

The scientists assumed that the actual amount of disease — how many true cases exist — did not change or grew only a little during those three decades. Yet they found a big difference in the number and stage of cases discovered over time, as mammograms came into wide use.

Mammograms more than doubled the number of early-stage cancers detected — from 112 to 234 cases per 100,000 women. But late-stage cancers dropped just 8 percent, from 102 to 94 cases per 100,000 women.

The imbalance suggests a lot of overdiagnosis from mammograms, which now account for 60 percent of cases that are found, Bleyer said. If screening were working, there should be one less patient diagnosed with late-stage cancer for every additional patient whose cancer was found at an earlier stage, he explained.

"Instead, we're diagnosing a lot of something else — not cancer" in that early stage, Bleyer said. "And the worst cancer is still going on, just like it always was."

Researchers also looked at death rates for breast cancer, which declined 28 percent during that time in women 40 and older — the group targeted for screening. Mortality dropped even more — 41 percent — in women under 40, who presumably were not getting mammograms.

"We are left to conclude, as others have, that the good news in breast cancer — decreasing mortality — must largely be the result of improved treatment, not screening," the authors write.

The study was paid for by the study authors' universities.

"This study is important because what it really highlights is that the biology of the cancer is what we need to understand" in order to know which ones to treat and how, said Dr. Julia A. Smith, director of breast cancer screening at NYU Langone Medical Center in New York. Doctors already are debating whether DCIS, a type of early tumor confined to a milk duct, should even be called cancer, she said.

Another expert, Dr. Linda Vahdat, director of the breast cancer research program at Weill Cornell Medical College in New York, said the study's leaders made many assumptions to reach a conclusion about overdiagnosis that "may or may not be correct."

"I don't think it will change how we view screening mammography," she said.

A government-appointed task force that gives screening advice calls for mammograms every other year starting at age 50 and stopping at 75. The American Cancer Society recommends them every year starting at age 40.

Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer, said the study should not be taken as "a referendum on mammography," and noted that other high-quality studies have affirmed its value. Still, he said overdiagnosis is a problem, and it's not possible to tell an individual woman whether her cancer needs treated.

"Our technology has brought us to the place where we can find a lot of cancer. Our science has to bring us to the point where we can define what treatment people really need," he said.

___

Online:

Study: http://www.nejm.org/doi/full/10.1056/NEJMoa1206809

Screening advice: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

___

Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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A lifeline in Hollywood for young homeless people

Give thanks for the nearly new Nikes, left abandoned beneath the 101 Freeway overpass. They were just M.J.'s size. He had needed shoes, but had no money to buy them.

Give thanks for the tote bag, holding the Vienna sausages that Sam hands M.J. on Hollywood Boulevard. Sam is 4 1/2 months pregnant with her fifth child — their third together — and by April, when the baby is due, she and M.J. , both 26, hope to have a roof over their heads.

Give thanks especially for My Friend's Place, provider of the sausages and so much more.

The privately funded center perched above the Hollywood Boulevard exit is a haven where young homeless people can nurture fragile dreams.

It gives them what food it can afford. It gives them clothes, clean underwear and socks, toilet paper, toiletries and hot showers.

If and when they are ready, it gently helps them head toward self-sufficient lives off the street. In the meantime, it is their daily lifeline, which they huddle close by to grab.

It's easy on this still-sad stretch of the boulevard to notice only the garish come-ons: from Atomic Tattoo, No Limit Tobacco & Accessories, Liquor to Go, Original Tommy's burgers and Palms Thai Restaurant (where Thai Elvis sings).

But scan the sidewalk, and Sams and M.J.s are everywhere — skateboarding around the edges of a parking lot, clutching cardboard signs on offramps, buffered from cold winds by bus-stop glass.

On the south side of Hollywood and Bronson, the bus stop serves as an all-day gathering place, where a 22-year-old who calls himself Lone Ranger can rest before heading to an offramp to "fly a sign" that reads "Vision of a Taco." Where Rancid, who chose her nickname for the band, can puff on a joint and swap bracelets with Sam. (Rail thin, in the shortest shorts, she says she's legal now but ran away from her Hollywood Hills home when she was 9.) Where those who "spange" — or ask for spare change — can feel safe enough to count their coins.

Behind the bus stop is a self-storage business whose windowless, temperature-controlled bays would be luxury shelter for Sam and M.J. As the sun readies to set on this chilly night, they do not know where they will sleep.

They lived for a while in a tent under the overpass. Then Caltrans workers carted off the shelter and many of their belongings.

Before election day, they had earned some cash handing out condoms for the Yes on B campaign, and spent a week in a low-rent hotel room.

More recently, they've been spooning under a Harry Potter blanket in the hollow beneath a flight of stairs, at the lowest level of the parking garage at Hollywood & Highland. But on this morning, they were rousted from that spot — which, post-discovery, will no longer be available to them.

Give thanks that the clothes they have gotten at My Friend's Place are warm.

Sam wears brown wool dress pants and three layers on top — a thick, hooded sweater buttoned over the small swell of her belly, on top of a gray tank top and T-shirt. M.J. has on gray suit pants and a thick, royal blue sweat shirt with the letters "CHELSEA FC" stitched on the back. When the sunlight starts to slip away, he takes it off, zips Sam into it, and stands on the curb, crossing his thin arms for warmth.

Sam and M.J. met in Pennsylvania 10 years ago, around the time she ran away from the Pennsylvania Dutch couple who had adopted her. They took off for the California sun in 2008, and lasted here for more than two years — until they were picked up by police and sent home to do time for stealing a relative's car to make their getaway.

In October, they returned to Hollywood, leaving much in their wake.

M.J. has a 5-year-old daughter who lives with her mom in Pennsylvania. Sam's brother has her 7-year-old son. Her 5-year-old daughter lives with that child's father. Sam and M.J.'s 3-year-old son, born when they were last here, went into the system and was adopted. Their 1-year-old daughter is with a Pennsylvania foster family, who send photos of the chubby, smiling baby.

They know they've made many wrong turns — drinking, doing drugs, stealing to survive. They've filched liquor and sold it by the shot on Venice Beach. They've plucked basic necessities off store shelves.

But they want better.

So this week, when My Friend's Place served up a big Thanksgiving meal — with more than enough home-cooked turkey, mashed potatoes and pie to stuff all the young people who came through its doors — Sam and M.J. skipped the feast and headed to Santa Monica. Sam had an interview for a program that, if she gets in, will care for her through her pregnancy and the baby's first months, and then help them find housing.

"We're going to live in Venice Beach and we're going to have a nice little apartment. Like I said, it's going to be little," she said, hugging M.J. "But it will be ours, and we're going to have our son."

Give thanks for the way hope hangs on against the odds, and for all those who work to keep it alive.

nita.lelyveld@latimes.com

Follow City Beat on Twitter @latimescitybeat or at Los Angeles Times City Beat on Facebook.

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U.S. Seeks Truce on Gaza as Enemies Step Up Attacks

JERUSALEM — Efforts to negotiate a cease-fire between Israel and Hamas were set to continue Wednesday but the struggle to achieve even a brief pause in the fighting emphasized the obstacles to finding any lasting solution.

Overnight, as the conflict entered its eighth day, the Israeli military said in Twitter feeds that “more than 100 terror sites were targeted, of which approximately 50 were underground rocket launchers.” The targets included the Ministry of Internal Security in Gaza, described as “one of the Hamas’ main command and control centers.”

The Israel Defense Forces also said they scored a direct hit early Wednesday on militants building rockets in what were termed hiding places.

On Tuesday — the deadliest day of fighting in the conflict — Secretary of State Hillary Rodham Clinton arrived hurriedly in Jerusalem and met with Prime Minister Benjamin Netanyahu of Israel to push for a truce. She was due in Cairo on Wednesday to consult with Egyptian officials in contact with Hamas, placing her and the Obama administration at the center of a fraught process with multiple parties, interests and demands.

Officials on all sides had raised expectations that a cease-fire would begin around midnight, followed by negotiations for a longer-term agreement. But by the end of Tuesday, officials with Hamas, the militant Islamist group that governs Gaza, said any announcement would not come at least until Wednesday.

The Israelis, who have amassed tens of thousands of troops on the Gaza border and have threatened to invade for a second time in four years to end the rocket fire, never publicly backed the idea of a short break in fighting. They said they were open to a diplomatic accord but were looking for something more enduring.

“If there is a possibility of achieving a long-term solution to this problem through diplomatic means, we prefer that,” Mr. Netanyahu said before meeting with Mrs. Clinton at his office. “But if not, I’m sure you understand that Israel will have to take whatever actions necessary to defend its people.”

Mrs. Clinton spoke of the need for “a durable outcome that promotes regional stability and advances the security and legitimate aspirations of Israelis and Palestinians alike.” It was unclear whether she was starting a complex task of shuttle diplomacy or whether she expected to achieve a pause in the hostilities and then head home.

The diplomatic moves came as the antagonists on both sides stepped up their attacks. Israeli aerial and naval forces assaulted several Gaza targets in multiple strikes, including a suspected rocket-launching site near Al Shifa Hospital. On Wednesday, the Israeli military said that “800 rockets fired from Gaza hit Israel in the past week — 162 during the last day alone.”

More than 30 people were killed on Tuesday, bringing the total number of fatalities in Gaza to more than 130 — roughly half of them civilians, the Gaza Health Ministry said.

A delegation visiting from the Arab League canceled a news conference at the hospital because of the Israeli aerial assaults as wailing ambulances brought victims in, some of them decapitated.

The Israeli assaults continued early Wednesday, with multiple blasts punctuating the otherwise darkened Gaza skies.

Militants in Gaza fired a barrage of at least 200 rockets into Israel, killing an Israeli soldier — the first military casualty on the Israeli side since the hostilities broke out. The Israeli military said the soldier, identified as Yosef Fartuk, 18, had died from a rocket strike that hit an area near Gaza. Israeli officials said a civilian military contractor working near the Gaza border had also been killed, bringing the number of fatalities in Israel from the week of rocket mayhem to five.

Other Palestinian rockets hit the southern Israeli cities of Beersheba and Ashdod, and longer-range rockets were fired at Tel Aviv and Jerusalem. Neither main city was struck, and no casualties were reported. One Gaza rocket hit a building in Rishon LeZion, just south of Tel Aviv, wounding one person and wrecking the top three floors.

Senior Egyptian officials in Cairo said Israel and Hamas were “very close” to a cease-fire agreement. “We have not received final approval, but I hope to receive it any moment,” said Essam el-Haddad, President Mohamed Morsi’s top foreign affairs adviser.

Foreign diplomats who were briefed on the outlines of a tentative agreement said it had been structured in stages — first, an announcement of a cease-fire, followed by its implementation for 48 hours. That would allow time for Mrs. Clinton to involve herself in the process here and create a window for negotiators to agree on conditions for a longer-term cessation of hostilities.

But it seemed that each side had steep demands of a longer-term deal that the other side would reject.

Khaled Meshal, the Hamas leader, said in Cairo that Israel needed to end its blockade of Gaza. Israel says the blockade keeps arms from entering the coastal strip.

Ethan Bronner reported from Jerusalem, and David D. Kirkpatrick from Cairo. Reporting was contributed by Jodi Rudoren and Fares Akram from Gaza; Isabel Kershner from Jerusalem; Alan Cowell from London; Peter Baker from Phnom Penh, Cambodia; David E. Sanger and Mark Landler from Washington; and Rick Gladstone from New York.

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The Voice: Top Eight Contestants Revealed

TV Watch

By Julia Haskins

11/20/2012 at 10:05 PM EST

From left: Adam Levine, Cee Lo Green, Christina Aguilera, Blake Shelton and host Carson Daly

Mark Seliger/NBC

Following what Blake Shelton called the "best episode of The Voice we've ever had", spirited group performances on Tuesday night's show kept the energy up and distracted viewers just long enough from the business at hand – impending eliminations.

Christina Aguilera brought the heat with her song "Let There Be Love." Rascal Flatts shared their hit "Changed." Later, Adam Levine performed a rendition of Queen's "Crazy Little Thing Called Love," followed by the contestants taking on Pat Benatar's "Hit Me with Your Best Shot."

But once again, the decisions about who would stay and who would go were completely up to the viewers. No input from the coaches could save contestants this time. Keep reading to find out which contestants will sing again next week ...

The first round of results turned out to be good news for Nicholas David and Cassadee, later joined by Dez Duron and Cody Belew in the top eight.

America also gave Terry McDermott, Melanie Martinez, Trevin Hunte and Amanda Brown another shot at superstardom.

That means Bryan Keith and Sylvia Yacoub won't be singing again on Monday night's episode.

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OB/GYNs back over-the-counter birth control pills

WASHINGTON (AP) — No prescription or doctor's exam needed: The nation's largest group of obstetricians and gynecologists says birth control pills should be sold over the counter, like condoms.

Tuesday's surprise opinion from these gatekeepers of contraception could boost longtime efforts by women's advocates to make the pill more accessible.

But no one expects the pill to be sold without a prescription any time soon: A company would have to seek government permission first, and it's not clear if any are considering it. Plus there are big questions about what such a move would mean for many women's wallets if it were no longer covered by insurance.

Still, momentum may be building.

Already, anyone 17 or older doesn't need to see a doctor before buying the morning-after pill — a higher-dose version of regular birth control that can prevent pregnancy if taken shortly after unprotected sex. Earlier this year, the Food and Drug Administration held a meeting to gather ideas about how to sell regular oral contraceptives without a prescription, too.

Now the influential American College of Obstetricians and Gynecologists is declaring it's safe to sell the pill that way.

Wait, why would doctors who make money from women's yearly visits for a birth-control prescription advocate giving that up?

Half of the nation's pregnancies every year are unintended, a rate that hasn't changed in 20 years — and easier access to birth control pills could help, said Dr. Kavita Nanda, an OB/GYN who co-authored the opinion for the doctors group.

"It's unfortunate that in this country where we have all these contraceptive methods available, unintended pregnancy is still a major public health problem," said Nanda, a scientist with the North Carolina nonprofit FHI 360, formerly known as Family Health International.

Many women have trouble affording a doctor's visit, or getting an appointment in time when their pills are running low — which can lead to skipped doses, Nanda added.

If the pill didn't require a prescription, women could "pick it up in the middle of the night if they run out," she said. "It removes those types of barriers."

Tuesday, the FDA said it was willing to meet with any company interested in making the pill nonprescription, to discuss what if any studies would be needed.

Then there's the price question. The Obama administration's new health care law requires FDA-approved contraceptives to be available without copays for women enrolled in most workplace health plans.

If the pill were sold without a prescription, it wouldn't be covered under that provision, just as condoms aren't, said Health and Human Services spokesman Tait Sye.

ACOG's opinion, published in the journal Obstetrics & Gynecology, says any move toward making the pill nonprescription should address that cost issue. Not all women are eligible for the free birth control provision, it noted, citing a recent survey that found young women and the uninsured pay an average of $16 per month's supply.

The doctors group made clear that:

—Birth control pills are very safe. Blood clots, the main serious side effect, happen very rarely, and are a bigger threat during pregnancy and right after giving birth.

—Women can easily tell if they have risk factors, such as smoking or having a previous clot, and should avoid the pill.

—Other over-the-counter drugs are sold despite rare but serious side effects, such as stomach bleeding from aspirin and liver damage from acetaminophen.

—And there's no need for a Pap smear or pelvic exam before using birth control pills. But women should be told to continue getting check-ups as needed, or if they'd like to discuss other forms of birth control such as implantable contraceptives that do require a physician's involvement.

The group didn't address teen use of contraception. Despite protests from reproductive health specialists, current U.S. policy requires girls younger than 17 to produce a prescription for the morning-after pill, meaning pharmacists must check customers' ages. Presumably regular birth control pills would be treated the same way.

Prescription-only oral contraceptives have long been the rule in the U.S., Canada, Western Europe, Australia and a few other places, but many countries don't require a prescription.

Switching isn't a new idea. In Washington state a few years ago, a pilot project concluded that pharmacists successfully supplied women with a variety of hormonal contraceptives, including birth control pills, without a doctor's involvement. The question was how to pay for it.

Some pharmacies in parts of London have a similar project under way, and a recent report from that country's health officials concluded the program is working well enough that it should be expanded.

And in El Paso, Texas, researchers studied 500 women who regularly crossed the border into Mexico to buy birth control pills, where some U.S. brands sell over the counter for a few dollars a pack. Over nine months, the women who bought in Mexico stuck with their contraception better than another 500 women who received the pill from public clinics in El Paso, possibly because the clinic users had to wait for appointments, said Dr. Dan Grossman of the University of California, San Francisco, and the nonprofit research group Ibis Reproductive Health.

"Being able to easily get the pill when you need it makes a difference," he said.

___

Online:

OB/GYN group: http://www.acog.org

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3 found dead in apparent murder-suicide at Torrance senior home

Three people were found shot to death Tuesday in the lobby of a Torrance senior-living facility in an apparent murder-suicide, allegedly at the hand of a resident who had a history of violent outbursts, according to law enforcement and witnesses.

About noon, the man was seen holding a gun near the business offices of Golden West Tower, a high-rise facility in the 3500 block of Maricopa Street.

One witness, Arturo Ramirez, a maintenance worker at the complex, said he spotted the gunman and dashed to the maintenance office, where he locked himself inside and called 911.

He said he could hear one of the women killed — a caregiver who tended to about 20 residents — plead for mercy.

"I heard her say, 'Please, no! Please!' " he said. "Then, I heard two gunshots."

A few minutes later, Ramirez said he heard another gunshot. He remained locked in the office until police found him and escorted him out of the building.

Other employees told The Times that the alleged perpetrator was a male resident of the facility and that the other woman killed was a manager there. One employee said that the alleged shooter was prone to violent outbursts and had expressed anger toward the two who were killed.

Authorities confirmed that one of the victims was an employee of the complex, but said that none of the purported threats had been reported to Torrance police.

Sgt. Robert Watt of the Torrance Police Department said that a handgun had been used and that investigators were still probing possible motives for the killings.

He could not name the victims, pending identification from the Los Angeles County coroner's office.

As investigators examined the crime scene, authorities cleared the building in the neighborhood of modest apartment complexes off Torrance Boulevard. The more than 100 people evacuated were taken back in, floor by floor, after three hours, Watt said. The crime scene, he said, was not visible to residents.

One of the residents, Lucia Alarcon, has lived in Golden West Tower for 15 years. She said she was scared when police knocked on her fifth-floor apartment door, instructing her to leave.

"I was surprised to see so many cops on my floor," she said.

And she was stunned to hear that such violence had taken place in her apartment building, a place she thought to be safe.

"Nothing like this has ever happened," Alarcon said. "… Life is too short sometimes."

ruben.vives@latimes.com

Times staff writers Rick Rojas and Rosanna Xia contributed to this report.

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Clinton to Visit Israel in Effort to Defuse Gaza Conflict

PHNOM PENH, Cambodia – President Obama is sending Secretary of State Hillary Rodham Clinton to the Middle East to try to defuse the conflict in Gaza, the White House announced on Tuesday.

Mrs. Clinton, who has been accompanying Mr. Obama on his three-country Asia trip, will leave directly from Asia, traveling first to Jerusalem to meet with Prime Minister Benjamin Netanyahu of Israel, then to the West Bank to meet with Palestinian leaders and finally to Cairo to meet with Egyptian officials.

“This morning, Secretary Clinton and the president spoke again about the situation in Gaza and the they agreed that it makes sense for the secretary to travel to the region so Secretary Clinton will depart today,” said Benjamin Rhodes, a deputy national security adviser to Mr. Obama. “Her visits will build on the engagement that we’ve undertaken in the last several days.”

Mr. Rhodes said that “any resolution to this has to include an end to that rocket fire” by Hamas militants on Israeli communities but “the best way to solve this is through diplomacy.”

He added: “It’s in nobody’s interest to see an escalation of the military conflict.”

The decision to dispatch Mrs. Clinton dramatically deepens the American involvement in the crisis. Mr. Obama made a number of late-night phone calls to the Middle East on Monday night that convinced him that he had to become more engaged and that Mrs. Clinton might be able to accomplish something.

After an Asian summit dinner in Phnom Penh on Monday night, Mr. Obama called President Mohamed Morsi of Egypt to discuss the situation, then spoke with Mr. Netanyahu and called Mr. Morsi back. He was up until 2:30 a.m. on the phone, the White House said. He has been consulting with Mrs. Clinton repeatedly on the sidelines of the Asian summit meetings on Tuesday.

Mrs. Clinton will not meet with Hamas representatives on her trip, but instead with leaders of the Palestinian leadership in the West Bank, which is at odds with Hamas, which controls the Gaza Strip. “We do not engage directly with Hamas,” Mr. Rhodes said.

Instead, Mr. Obama is focused on leveraging Egypt’s influence with Hamas to press for a halt to the rocket attacks. “We believe Egypt can and should be a partner in achieving that outcome,” Mr. Rhodes said.

Mr. Rhodes reaffirmed that the United States supports Israel’s right to defend itself and said Mr. Obama did not ask Mr. Netanyahu to hold off a ground incursion into Gaza. Thousands of Israeli forces have gathered in possible preparation to move into Gaza, which would significantly escalate the conflict.

With the United Nations Secretary General Ban Ki-moon scheduled to arrive in Israel on Tuesday followed by Mrs. Clinton, Israel has decided to give some more time to diplomacy to end the crisis with Gaza before launching a ground invasion into the Palestinian enclave, a senior Israeli official said.

The official in the Israeli prime minister’s office said that the country’s top nine ministers, who make up the inner security cabinet, held discussions late into the night on the state of the diplomatic efforts and Israel’s military operation in Gaza, which entered its seventh day on Tuesday. The goal of the operation, Israel says, is to bring about an end to years of rocket fire by Gaza militants against southern Israel.

“A decision has been taken to give diplomacy more time, but not unlimited time,” the official said, speaking on condition of anonymity because the deliberations of the inner cabinet are highly confidential.

Egypt has been brokering efforts, with American involvement, for a cease-fire between Israel and Hamas, the Islamic militant group that controls Gaza.

“What is on the table is not there yet. It does not bring about what we need,” the official said, referring to Israel’s demands for an end to the threat of rocket fire in the south.

Tens of thousands of Israeli reserve soldiers have been mobilized and troops and tanks have massed along the border with Gaza, ready to go in the order is given.

So far Israel has carried out its campaign from the air, pounding more than 1,000 targets in Gaza, including long-range rocket launchers and stores. Palestinian health officials have put the death toll at about 107, including 26 children. Gaza militants have fired more than 800 rockets at Israel, killing three civilians there in one attack. Several have reached as far north as Tel Aviv.

Many of the rockets headed for densely populated areas have been intercepted by Israel’s anti-rocket missile system while others have landed in open ground.

On Tuesday morning, Gaza militants fired more barrages of rockets into southern Israel. One struck a bus in the southern city of Beersheba but the passengers had disembarked and escaped unharmed, according to initial reports.

Mrs. Clinton’s trip comes even as she is preparing to step down as secretary of state, presenting her a delicate late test after four years in which Mr. Obama’s administration has failed to achieve the broader peace it once sought in the region.

With the president’s re-election behind him, Mrs. Clinton plans to resign around the time of the second inauguration on Jan. 20. Aides said she would stay until a successor can be confirmed as long as it does not drag too long into the new year.

The abrupt change in plans here underscored the challenges for Mr. Obama as he tries to reorient American foreign policy away from its dominant focus on the Middle East and more toward the Pacific-Asia region that he sees as the long-term future. Even as he chose Southeast Asia as the destination for the first overseas trip after winning a second term, Mr. Obama has found himself drawn every day into the deadly dispute consuming the Middle East.

Peter Baker reported from Phnom Penh, Cambodia, and Isabel Kershner from Jerusalem

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People turn to Twitter for CPR information: study

(Reuters) – Amid snarky comments and links to cat videos, some Twitter users turn to the social network to find and post information on health issues like cardiac arrest and CPR, according to a U.S. study.

Over a month, researchers found 15,234 messages on Twitter that included specific information about resuscitation and cardiac arrest, said the study published in the journal Resuscitation.

“From a science standpoint, we wanted to know if we can reliably find information on a public health topic, or is (Twitter) just a place where people describe what they ate that day,” said Raina Merchant, the study’s lead author and a professor at the Department of Emergency Medicine at the University of Pennsylvania.

According to the researchers, they found people using Twitter to send and receive a wide variety of information on CPR and cardiac arrest, including their personal experiences, questions and current events.

Some researchers and organizations already use Twitter for public health matters, including tracking the 2009 H1N1 “swine flu” pandemic and finding the source of the Haitian cholera outbreak, the researchers said.

For the study, the researchers created a Twitter search for key terms, such as CPR, AED (automatic external defibrillators), resuscitation and sudden death.

Between April and May 2011, their search returned 62,163 tweets, which were whittled down to 15,324 messages that contained specific information about cardiac arrest and resuscitation.

Only 7 percent of the tweets were about specific cardiac arrest events, such as a user saying they just saw a man being resuscitated, or a user asking for prayers for a sick family member.

About 44 percent of the tweets were about performing CPR and using an AED. Those types of tweets included information on rules about keeping AEDs in businesses and questions about how to resuscitate a person.

The rest of the tweets were about education, research and news events, such as links to articles about celebrities going into cardiac arrest.

The vast majority of the Twitter users send fewer than three tweets about cardiac arrest or CPR throughout the month. Users that sent more tweets typically had more followers – people who subscribe to their messages – and often worked in a health-care related field.

About 13 percent of the tweets were re-sent, or retweeted, by other users. The most popular retweeted messages were about celebrity-related cardiac arrest news, such as an AED being used to revive a fan at a Lady Gaga concert.

“I think the pilot (study) illustrated for us that there is an opportunity to potentially provide research and information for people in real time about cardiac arrest and resuscitation,” Marchant said.

“I can imagine in the future we will see systems that would automatically respond to tweets of individual users. Twitter is a really powerful tool, and we’re just beginning to understand its abilities.”

SOURCE: http://bit.ly/T2bj7u

(Reporting from New York by Andrew Seaman at Reuters Health; editing by Elaine)

Internet News Headlines – Yahoo! News

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Dancing with the Stars: Couples Perform Crazy Combinations in Semi-Finals

TV Watch

Dancing With the Stars

By Aaron Parsley

11/19/2012 at 11:05 PM EST

Shawn Johnson and Derek Hough

Craig Sjodin/ABC

It's the semi-finals!

The remaining five couples on Dancing with the Stars faced two rounds of competition on Monday. First, the pairs performed mixed-up routines, blending uncommon styles with unusual themes. Then, they celebrated the 25th anniversary of Michael Jackson's hit album Bad with more traditional ballroom numbers.

Keep reading for all the details and scores ...

Melissa Rycroft & Tony Dovolani
Last week's top scorers kicked off the night with a caveman hustle. "Fred and Wilma have never danced so well," Len Goodman said, while Bruno Tonioli said they lost footing during the turns. They scored a 27.5. But their red-hot Argentine tango to "Dirty Diana" was a perfect 30. "That was beyond anything I could have imagined for you," a thrilled Carrie Ann Inaba said. "I would be really disappointed if you're not here next week," Len added.

Shawn Johnson & Derek Hough
Hough said he would rather put mustard on ice cream than combine their Knight Rider theme with the Bhangra style. But the judges ate up the routine – and awarded the pair a perfect 30. In round two, their Argentine tango sparked disagreement on the panel. Bruno and Len held up 10s but Carrie Ann knocked off a point. "Every line was perfect, but dance is sometimes more than just movement and I thought that you lacked the real passion of the Argentine tango," she said.

Apolo Ohno & Karina Smirnoff
Their big top jazz routine was another sticking point for Carrie Ann and Bruno. She found the mime-themed dance "very disjointed," "out of sync" and "quite sloppy." He found it "edgy, surreal" and a "great mixture of jazz movement." They earned 27 points. But there was no arguing over their rumba to "Man in the Mirror," which earned a perfect 30. "It was like the sea," Len said. "There was wave after wave of effortless motion. There was a subtlety to it, there was a calmness. It captivated. It was fabulous."

Emmitt Smith & Cheryl Burke
The goal of their espionage lindy hop was to be cartoonish. Though that was tough for the former Dallas Cowboy, the judges were pleased and awarded the pair 27 points. "It was like a Looney Tunes version of James Bond," Bruno said. "It was the most fun performance I've seen you do." Their tango to "Leave Me Alone" was more of a challenge, but Len still gave Smith credit: "You've coped marvelously well with two dances that didn't really suit you," he said.

Kelly Monaco & Val Chmerkovskiy
Their surfer flamenco was super sexy – Val ended up in nothing but Speedo! – but the judges had issues with their technique, and handed out only 25.5 points. "It had a lot of aggression and a lot of fire. But the flamenco has very, very exact placement and it wasn't there," Bruno said. Carrie Ann called it "robotic." But they added 28.5 points with a romantic rumba to "I Just Can't Stop Loving You." "That was smoldering, driven by desire, consumed by lust," Bruno said. "The chemistry between you two is literally singeing."

Two couples are heading home Tuesday night, leaving just three to compete in next week's finale. Who deserves a chance at the mirror-ball trophy? Discuss in the comments below.

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New push for most in US to get at least 1 HIV test

WASHINGTON (AP) — There's a new push to make testing for the AIDS virus as common as cholesterol checks.

Americans ages 15 to 64 should get an HIV test at least once — not just people considered at high risk for the virus, an independent panel that sets screening guidelines proposed Monday.

The draft guidelines from the U.S. Preventive Services Task Force are the latest recommendations that aim to make HIV screening simply a routine part of a check-up, something a doctor can order with as little fuss as a cholesterol test or a mammogram. Since 2006, the Centers for Disease Control and Prevention also has pushed for widespread, routine HIV screening.

Yet not nearly enough people have heeded that call: Of the more than 1.1 million Americans living with HIV, nearly 1 in 5 — almost 240,000 people — don't know it. Not only is their own health at risk without treatment, they could unwittingly be spreading the virus to others.

The updated guidelines will bring this long-simmering issue before doctors and their patients again — emphasizing that public health experts agree on how important it is to test even people who don't think they're at risk, because they could be.

"It allows you to say, 'This is a recommended test that we believe everybody should have. We're not singling you out in any way,'" said task force member Dr. Douglas Owens of Stanford University and the Veterans Affairs Palo Alto Health Care System.

And if finalized, the task force guidelines could extend the number of people eligible for an HIV screening without a copay in their doctor's office, as part of free preventive care under the Obama administration's health care law. Under the task force's previous guidelines, only people at increased risk for HIV — which includes gay and bisexual men and injecting drug users — were eligible for that no-copay screening.

There are a number of ways to get tested. If you're having blood drawn for other exams, the doctor can merely add HIV to the list, no extra pokes or swabs needed. Today's rapid tests can cost less than $20 and require just rubbing a swab over the gums, with results ready in as little as 20 minutes. Last summer, the government approved a do-it-yourself at-home version that's selling for about $40.

Free testing is available through various community programs around the country, including a CDC pilot program in drugstores in 24 cities and rural sites.

Monday's proposal also recommends:

—Testing people older and younger than 15-64 if they are at increased risk of HIV infection,

—People at very high risk for HIV infection should be tested at least annually.

—It's not clear how often to retest people at somewhat increased risk, but perhaps every three to five years.

—Women should be tested during each pregnancy, something the task force has long recommended.

The draft guidelines are open for public comment through Dec. 17.

Most of the 50,000 new HIV infections in the U.S. every year are among gay and bisexual men, followed by heterosexual black women.

"We are not doing as well in America with HIV testing as we would like," Dr. Jonathan Mermin, CDC's HIV prevention chief, said Monday.

The CDC recommends at least one routine test for everyone ages 13 to 64, starting two years younger than the task force recommended. That small difference aside, CDC data suggests fewer than half of adults under 65 have been tested.

"It can sometimes be awkward to ask your doctor for an HIV test," Mermin said — the reason that making it routine during any health care encounter could help.

But even though nearly three-fourths of gay and bisexual men with undiagnosed HIV had visited some sort of health provider in the previous year, 48 percent weren't tested for HIV, a recent CDC survey found. Emergency rooms are considered a good spot to catch the undiagnosed, after their illnesses and injuries have been treated, but Mermin said only about 2 percent of ER patients known to be at increased risk were tested while there.

Mermin calls that "a tragedy. It's a missed opportunity."

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