Flu Widespread, Leading a Range of Winter’s Ills

It is not your imagination — more people you know are sick this winter, even people who have had flu shots.

The country is in the grip of three emerging flu or flulike epidemics: an early start to the annual flu season with an unusually aggressive virus, a surge in a new type of norovirus, and the worst whooping cough outbreak in 60 years. And these are all developing amid the normal winter highs for the many viruses that cause symptoms on the “colds and flu” spectrum.

Influenza is widespread, and causing local crises. On Wednesday, Boston’s mayor declared a public health emergency as cases flooded hospital emergency rooms.

Google’s national flu trend maps, which track flu-related searches, are almost solid red (for “intense activity”) and the Centers for Disease Control and Prevention’s weekly FluView maps, which track confirmed cases, are nearly solid brown (for “widespread activity”).

“Yesterday, I saw a construction worker, a big strong guy in his Carhartts who looked like he could fall off a roof without noticing it,” said Dr. Beth Zeeman, an emergency room doctor for MetroWest Medical Center in Framingham, Mass., just outside Boston. “He was in a fetal position with fever and chills, like a wet rag. When I see one of those cases, I just tighten up my mask a little.”

Massachusetts General Hospital in Boston started asking visitors with even mild cold symptoms to wear masks and to avoid maternity wards. The hospital has treated 532 confirmed influenza patients this season and admitted 167, even more than it did by this date during the 2009-10 swine flu pandemic.

At Brigham and Women’s Hospital, 100 patients were crowded into spaces licensed for 53. Beds lined halls and pressed against vending machines. Overflow patients sat on benches in the lobby wearing surgical masks.

“Today was the first time I think I was experiencing my first pandemic,” said Heidi Crim, the nursing director, who saw both the swine flu and SARS outbreaks here. Adding to the problem, she said, many staff members were at home sick and supplies like flu test swabs were running out.

Nationally, deaths and hospitalizations are still below epidemic thresholds. But experts do not expect that to remain true. Pneumonia usually shows up in national statistics only a week or two after emergency rooms report surges in cases, and deaths start rising a week or two after that, said Dr. Gregory A. Poland, a vaccine specialist at the Mayo Clinic in Minnesota. The predominant flu strain circulating is an H3N2, which typically kills more people than the H1N1 strains that usually predominate; the relatively lethal 2003-4 “Fujian flu” season was overwhelmingly H3N2.

No cases have been resistant to Tamiflu, which can ease symptoms if taken within 48 hours, and this year’s flu shot is well-matched to the H3N2 strain, the C.D.C. said. Flu shots are imperfect, especially in the elderly, whose immune systems may not be strong enough to produce enough antibodies.

Simultaneously, the country is seeing a large and early outbreak of norovirus, the “cruise ship flu” or “stomach flu,” said Dr. Aron J. Hall of the C.D.C.’s viral gastroenterology branch. It includes a new strain, which first appeared in Australia and is known as the Sydney 2012 variant.

This week, Maine’s health department said that state was seeing a large spike in cases. Cities across Canada reported norovirus outbreaks so serious that hospitals were shutting down whole wards for disinfection because patients were getting infected after moving into the rooms of those who had just recovered. The classic symptoms of norovirus are “explosive” diarrhea and “projectile” vomiting, which can send infectious particles flying yards away.

“I also saw a woman I’m sure had norovirus,” Dr. Zeeman said. “She said she’d gone to the bathroom 14 times at home and 4 times since she came into the E.R. You can get dehydrated really quickly that way.”

This month, the C.D.C. said the United States was having its biggest outbreak of pertussis in 60 years; there were about 42,000 confirmed cases, the highest total since 1955. The disease is unrelated to flu but causes a hacking, constant cough and breathlessness. While it is unpleasant, adults almost always survive; the greatest danger is to infants, especially premature ones with undeveloped lungs. Of the 18 recorded deaths in 2012, all but three were of infants under age 1.

That outbreak is worst in cold-weather states, including Colorado, Washington, Wisconsin, Minnesota and Vermont.

Although most children are vaccinated several times against pertussis, those shots wear off with age. It is possible, the authorities said, that a new, safer vaccine introduced in the 1990s gives protection that does not last as long, so more teenagers and adults are vulnerable.

And, Dr. Poland said, if many New Yorkers are catching laryngitis, as has been reported, it is probably a rhinovirus. “It’s typically a sore, really scratchy throat, and you sometimes lose your voice,” he said.

Though flu cases in New York City are rising rapidly, the city health department has no plans to declare an emergency, largely because of concern that doing so would drive mildly sick people to emergency rooms, said Dr. Jay K. Varma, deputy director for disease control. The city would prefer people went to private doctors or, if still healthy, to pharmacies for flu shots. Nursing homes have had worrisome outbreaks, he said, and nine elderly patients have died. Homes need to be more alert, vaccinate patients, separate those who fall ill and treat them faster with antivirals, he said.

Dr. Susan I. Gerber of the C.D.C.’s respiratory diseases branch, said her agency has not seen any unusual spike of rhinovirus, parainfluenza, adenovirus, coronavirus or the dozens of other causes of the “common cold,” but the country is having its typical winter surge of some, like respiratory syncytial virus “that can mimic flulike symptoms, especially in young children.”

The C.D.C. and the local health authorities continue to advocate getting flu shots. Although it takes up to two weeks to build immunity, “we don’t know if the season has peaked yet,” said Dr. Joseph Bresee, chief of prevention in the agency’s flu division.

Flu shots and nasal mists contain vaccines against three strains, the H3N2, the H1N1 and a B. Thus far this season, Dr. Bresee said, H1N1 cases have been rare, and the H3N2 component has been a good match against almost all the confirmed H3N2 samples the agency has tested.

About a fifth of all flus this year thus far are from B strains. That part of the vaccine is a good match only 70 percent of the time, because two B’s are circulating.

For that reason, he said, flu shots are being reformulated. Within two years, they said, most will contain vaccines against both B strains.

Joanna Constantine, 28, a stylist at the Guy Thomas Hair Salon on West 56th Street in Manhattan, said she recently was so sick that she was off work and in bed for five days — and silenced by laryngitis for four of them.

She did not have the classic flu symptoms — a high fever, aches and chills — so she knew it was probably something else.

Still, she said, it scared her enough that she will get a flu shot next year. She had not bothered to get one since her last pregnancy, she said. But she has a 7-year-old son and a 5-year-old daughter, “and my little guys get theirs every year.”

Jess Bidgood contributed reporting.

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State of the Art: Mixing and Matching to Create the Near-Perfect Digital Calendar - State of the Art

60 Seconds With Pogue: Calendars:
David Pogue reviews calendar apps and software.

You know what’s kind of wild? We can identify products by their container designs. You’d know a ketchup bottle, even if it was empty and unlabeled, no matter what the brand. You’d know a pickle jar, or a milk jug, or a bottle of salad dressing, or a cereal box just by their container shapes.

Same goes for the big software categories. You’d know a spreadsheet anywhere — formula bar at the top, grid below — no matter what company made it. Or e-mail program, word processor, Web browser. They all work pretty much alike.

But there’s one software category, an incredibly important one, where there’s no standard design or set of features: calendar software. Each one seems to have evolved on its own Galápagos island.

Take the new Calendar app in Windows 8. So much of Windows 8’s touch-screen mode is modern, updated and fresh — color, gestures, typography — that you’d expect an equally modernized calendar app at its heart.

Wow, would you be wrong. Listen, Microsoft: 1990 called. It wants its calendar back.

You can’t drag vertically through the Day-view column to create an appointment. You can’t drag an appointment to reschedule it. You can’t record an auto-repeating appointment like “Monday, Wednesday, Friday” or “first Tuesday of the month.”

And incredibly, you can’t create separate categories, like Home, Work and Social. There’s no way to color-code your appointments or hide certain categories.

That same week, on another computer, I installed a Mac calendar program called BusyCal 2.0. You know what’s so brilliant? When you open it, today’s date is always in the top row, no matter what week of the month this is. You always see the next four or five weeks, even if some are in the following month.

And why not? Almost always, you open your calendar to check coming dates — so why fill the screen with dates that have already gone by? That’s a limitation of paper calendars, where every month shows 1 in the first square.

And that’s when I had my epiphany. Our electronics are capable of fantastic flexibility, features and design; why are we still modeling our digital calendars on paper ones?

Apple’s Calendar app for the Mac goes so far as to display a little leather “binding” at the top, complete with scraps of torn-off “paper” to indicate where previous months’ “pages” have been torn off. Why?

If you spend enough time with the world’s calendar apps, you can see, through the mist, a vision of the ultimate digital calendar program. If you could mix and match the best of all the motley calendar apps, here’s what you might come up with.

¶ Give us an alternative to tabbing from Start Time to End Time and typing numbers into a tiny New Event box. Let us drag to indicate a meeting’s length. Or give us speech — intelligent speech, like Siri on the iPhone. “Make an appointment next Tuesday morning at seven: tennis with Casey,” you can say. Your hands never leave the wheel, the cat or the delicious beverage.

We should also be able to type plain-English phrases like “tomorrow 1pm lunch mtg” or “4/15 730p Dinner with boss,” and marvel as it creates the right appointment on the right calendar square at the right time. (Google, Apple’s Calendar for the Mac, BusyCal and, in particular, the iPhone app Fantastical can all do this.) Here again, you’re not fiddling with a dialogue box to enter a new event.

¶ Microsoft’s greatest calendaring effort remains Outlook, the e-mail program that comes with some versions of Microsoft Office. Outlook has its detractors, but one thing it got right is integration with your e-mail and address book. What are appointments, after all, but interactions with people you know — and how better to set up meetings with them than with e-mail?

This article has been revised to reflect the following correction:

Correction: January 9, 2013

An earlier version of this article stated that Apple and Android phones do not allow users to drag to reschedule appointments on their calendar apps. The standard Android calendar does not allow users to drag to reschedule.

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Chinese Officials Pledge to Loosen Controls Over Embattled Newspaper

GUANGZHOU, China — Propaganda officials in the southern province of Guangdong have agreed to loosen some controls over an embattled newspaper whose struggle against censorship has galvanized free-speech advocates across China, according to journalists at the newspaper. But the paper’s weekly Thursday edition went to press late partly because of internal disputes over content, one senior editor said.

The agreement, reached late Tuesday, was part of a compromise in which reporters and editors who had said they would strike continued to work to put out the newspaper, Southern Weekend, also known as Southern Weekly. It is an iconic liberal publication that has regularly challenged Communist Party officials and policies but has come under tighter control in recent years, particularly since the summer.

The publication delay on Thursday was due in part to a disagreement between the newspaper’s leadership and employees over whether to publish an editorial defending the newspaper and letters of support from readers, the senior editor said. The leadership chose not to publish the editorial or the letters in an effort to calm the crisis, he said.

In Beijing, talk of another newsroom in crisis emerged on Wednesday as reporters at Beijing News, a newspaper co-founded by the parent company of Southern Weekend, said propaganda officials forced the newspaper, against the judgment of its publisher and top editors, to run an editorial attacking Southern Weekend. Some journalists broke down in tears in the newsroom, according to various accounts, and the publisher, Dai Zigeng, threatened to resign, but was still in his job Wednesday night.

The deal in Guangzhou, the provincial capital, appeared to bring a tentative peace to a newsroom in turmoil, though journalists said they would have to see whether provincial officials followed through on their promises.

The journalists appeared to back down from their demands that the top provincial propaganda official, Tuo Zhen, leave his post. Newspaper employees have accused Mr. Tuo of putting in place much stricter censorship rules since he began his job in May; in particular, they said, he had a hand in the rewriting of a New Year’s editorial that was supposed to have been a call for enforcement of constitutional rights but that ended up being more of a paean to the current system. It is unclear what role Mr. Tuo played in the changes, which ignited the call last weekend among some journalists to carry out a strike.

Journalists at Southern Weekend said that under rules imposed by Mr. Tuo, propaganda officials regularly reviewed the content of the paper before it went to print and vetted reporting topics proposed by journalists. Those rules are supposed to be abolished under the new agreement.

Zeng Li, a veteran journalist who reviews articles in-house at Southern Weekend to guard against riling the censors, said, “Now things are calming down.”

“To publish a good paper is the hope of both the leaders and the staff,” he added.

Hu Chunhua, the new party chief of Guangdong, China’s most liberal province, helped mediate the settlement, journalists said. The clash over censorship is the first big test for Mr. Hu, 49, who is considered one of the party’s rising stars and a candidate to be the leader of China in a decade.

The battle at Southern Weekend also poses a challenge for the central authorities. Xi Jinping, the new party chief, made a trip to Guangdong late last year to stress the need to open the economy further. Analysts have wondered whether he will also call for greater political freedoms. Mr. Xi has made remarks, though, that underscore the need for China to remain true to its socialist roots.

Central propaganda officials appear to have taken a tough line on the censorship issue by demanding this week that the biggest news Web sites and some important publications print an editorial criticizing Southern Weekend that was originally published by Global Times, a populist newspaper, and widely derided by Chinese journalists. Beijing News ran a truncated version.

One journalist described the scene in the Beijing News office in a blog post: “Some people look sad; some burst into tears; some shout that they are going to quit.”

The post continued: “We don’t want to kneel down, but our knees have been shattered. We are kneeling down this one time while gnashing our teeth.”

Edward Wong reported from Guangzhou, and Jonathan Ansfield from Beijing. Mia Li contributed research from Guangzhou, and Shi Da from Beijing.

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Online Banking Attacks Were Work of Iran, U.S. Officials Say

SAN FRANCISCO — The attackers hit one American bank after the next. As in so many previous attacks, dozens of online banking sites slowed, hiccupped or ground to a halt before recovering several minutes later.

Daniel Rosenbaum for The New York Times

James A. Lewis of the Center for Strategic and International Studies in Washington believes that recent online attacks on American banks have been the work of Iran.

But there was something disturbingly different about the wave of online attacks on American banks in recent weeks. Security researchers say that instead of exploiting individual computers, the attackers engineered networks of computers in data centers, transforming the online equivalent of a few yapping Chihuahuas into a pack of fire-breathing Godzillas.

The skill required to carry out attacks on this scale has convinced United States government officials and security researchers that they are the work of Iran, most likely in retaliation for economic sanctions and online attacks by the United States.

“There is no doubt within the U.S. government that Iran is behind these attacks,” said James A. Lewis, a former official in the State and Commerce Departments and a computer security expert at the Center for Strategic and International Studies in Washington.

Mr. Lewis said the amount of traffic flooding American banking sites was “multiple times” the amount that Russia directed at Estonia in a monthlong online assault in 2007 that nearly crippled the Baltic nation.

American officials have not offered any technical evidence to back up their claims, but computer security experts say the recent attacks showed a level of sophistication far beyond that of amateur hackers. Also, the hackers chose to pursue disruption, not money: another earmark of state-sponsored attacks, the experts said.

“The scale, the scope and the effectiveness of these attacks have been unprecedented,” said Carl Herberger, vice president of security solutions at Radware, a security firm that has been investigating the attacks on behalf of banks and cloud service providers. “There have never been this many financial institutions under this much duress.”

Since September, intruders have caused major disruptions to the online banking sites of Bank of America, Citigroup, Wells Fargo, U.S. Bancorp, PNC, Capital One, Fifth Third Bank, BB&T and HSBC.

They employed DDoS attacks, or distributed denial of service attacks, named because hackers deny customers service by directing large volumes of traffic to a site until it collapses. No bank accounts were breached and no customers’ money was taken.

By using data centers, the attackers are simply keeping up with the times. Companies and consumers are increasingly conducting their business over large-scale “clouds” of hundreds, even thousands, of networked computer servers.

These clouds are run by Amazon and Google, but also by many smaller players who commonly rent them to other companies. It appears the hackers remotely hijacked some of these clouds and used the computing power to take down American banking sites.

“There’s a sense now that attackers are crafting their own private clouds,” either by creating networks of individual machines or by stealing resources wholesale from poorly maintained corporate clouds, said John Kindervag, an analyst at Forrester Research.

How, exactly, attackers are hijacking data centers is still a mystery. Making matters more complex, they have simultaneously introduced another weapon: encrypted DDoS attacks.

Banks encrypt customers’ online transactions for security, but the encryption process consumes system resources. By flooding banking sites with encryption requests, attackers can further slow or cripple sites with fewer requests.

A hacker group calling itself Izz ad-Din al-Qassam Cyber Fighters has claimed in online posts that it was responsible for the attacks.

The group said it attacked the banks in retaliation for an anti-Islam video that mocked the Prophet Muhammad, and pledged to continue its campaign until the video was scrubbed from the Internet. It called the campaign Operation Ababil, a reference to a story in the Koran in which Allah sends swallows to defeat an army of elephants dispatched by the king of Yemen to attack Mecca in A.D. 571.

But American intelligence officials say the group is actually a cover for Iran. They claim Iran is waging the attacks in retaliation for Western economic sanctions and for a series of cyberattacks on its own systems. In the last three years, three sophisticated computer viruses — called Flame, Duqu and Stuxnet — have hit computers in Iran. The New York Times reported last year that the United States, together with Israel, was responsible for Stuxnet, the virus used to destroy centrifuges in an Iranian nuclear facility in 2010.

“It’s a bit of a grudge match,” said Mr. Lewis of the Center for Strategic and International Studies.

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Gaps Seen in Therapy for Suicidal Teenagers

Most adolescents who plan or attempt suicide have already received at least some mental health treatment, raising questions about the effectiveness of current approaches to helping troubled youths, according to the largest in-depth analysis to date of suicidal behaviors in American teenagers.

The study, in the journal JAMA Psychiatry, found that 55 percent of suicidal teenagers had received some therapy before they thought about suicide, planned it or tried to kill themselves, contradicting the widely held belief that suicide is due in part to a lack of access to treatment.

The findings, based on interviews with a nationwide sample of more than 6,000 teenagers and at least one parent of each, linked suicidal behavior to complex combinations of mood disorders like depression and behavior problems like attention-deficit and eating disorders, as well as alcohol and drug abuse.

The study found that about one in eight teenagers had persistent suicidal thoughts at some point, and that about a third of those who had suicidal thoughts had made an attempt, usually within a year of having the idea.

Previous studies have had similar findings, based on smaller, regional samples. But the new study is the first to suggest, in a large nationwide sample, that access to treatment does not make a big difference.

The study suggests that effective treatment for severely suicidal teenagers must address not just mood disorders, but also behavior problems that can lead to impulsive acts, experts said. According to the Centers for Disease Control and Prevention, 1,386 people between the ages of 13 and 18 committed suicide in 2010, the latest year for which numbers are available.

“I think one of the take-aways here is that treatment for depression may be necessary but not sufficient to prevent kids from attempting suicide,” said Dr. David Brent, a professor of psychiatry at the University of Pittsburgh, who was not involved in the study. “We simply do not have empirically validated treatments for recurrent suicidal behavior.”

The report said nothing about whether the therapies given were state of the art or carefully done, said Matt Nock, a professor of psychology at Harvard and the lead author, and it is possible that some of the treatments prevented suicide attempts. “But it’s telling us we’ve got a long way to go to do this right,” Dr. Nock said. His co-authors included Ronald C. Kessler of Harvard and researchers from Boston University and Children’s Hospital Boston.

Margaret McConnell, a consultant in Alexandria, Va., said her daughter Alice, who killed herself in 2006 at the age of 17, was getting treatment at the time. “I think there might have been some carelessness in the way the treatment was done,” Ms. McConnell said, “and I was trusting a 17-year-old to manage her own medication. We found out after we lost her that she wasn’t taking it regularly.”

In the study, researchers surveyed 6,483 adolescents from the ages of 13 to 18 and found that 9 percent of male teenagers and 15 percent of female teenagers experienced some stretch of having persistent suicidal thoughts. Among girls, 5 percent made suicide plans and 6 percent made at least one attempt (some were unplanned).

Among boys, 3 percent made plans and 2 percent carried out attempts, which tended to be more lethal than girls’ attempts.

(Suicidal thinking or behavior was virtually unheard-of before age 10.)

Over all, about one-third of teenagers with persistent suicidal thoughts went on to make an attempt to take their own lives.

Almost all of the suicidal adolescents in the study qualified for some psychiatric diagnosis, whether depression, phobias or generalized anxiety disorder. Those with an added behavior problem — attention-deficit disorder, substance abuse, explosive anger — were more likely to act on thoughts of self-harm, the study found.

Doctors have tested a range of therapies to prevent or reduce recurrent suicidal behaviors, with mixed success. Medications can ease depression, but in some cases they can increase suicidal thinking. Talk therapy can contain some behavior problems, but not all.

One approach, called dialectical behavior therapy, has proved effective in reducing hospitalizations and suicide attempts in, among others, people with borderline personality disorder, who are highly prone to self-harm.

But suicidal teenagers who have a mixture of mood and behavior issues are difficult to reach. In one 2011 study, researchers at George Mason University reduced suicide attempts, hospitalizations, drinking and drug use among suicidal adolescent substance abusers. The study found that a combination of intensive treatments — talk therapy for mood problems, family-based therapy for behavior issues and patient-led reduction in drug use — was more effective than regular therapies.

“But that’s just one study, and it’s small,” said Dr. Brent of the University of Pittsburgh. “We can treat components of the overall problem, but that’s about all.”

Ms. McConnell said that her daughter’s depression had seemed mild and that there was no warning that she would take her life. “I think therapy does help a lot of people, if it’s handled right,” she said.

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Gaps Seen in Therapy for Suicidal Teenagers

Most adolescents who plan or attempt suicide have already received at least some mental health treatment, raising questions about the effectiveness of current approaches to helping troubled youths, according to the largest in-depth analysis to date of suicidal behaviors in American teenagers.

The study, in the journal JAMA Psychiatry, found that 55 percent of suicidal teenagers had received some therapy before they thought about suicide, planned it or tried to kill themselves, contradicting the widely held belief that suicide is due in part to a lack of access to treatment.

The findings, based on interviews with a nationwide sample of more than 6,000 teenagers and at least one parent of each, linked suicidal behavior to complex combinations of mood disorders like depression and behavior problems like attention-deficit and eating disorders, as well as alcohol and drug abuse.

The study found that about one in eight teenagers had persistent suicidal thoughts at some point, and that about a third of those who had suicidal thoughts had made an attempt, usually within a year of having the idea.

Previous studies have had similar findings, based on smaller, regional samples. But the new study is the first to suggest, in a large nationwide sample, that access to treatment does not make a big difference.

The study suggests that effective treatment for severely suicidal teenagers must address not just mood disorders, but also behavior problems that can lead to impulsive acts, experts said. According to the Centers for Disease Control and Prevention, 1,386 people between the ages of 13 and 18 committed suicide in 2010, the latest year for which numbers are available.

“I think one of the take-aways here is that treatment for depression may be necessary but not sufficient to prevent kids from attempting suicide,” said Dr. David Brent, a professor of psychiatry at the University of Pittsburgh, who was not involved in the study. “We simply do not have empirically validated treatments for recurrent suicidal behavior.”

The report said nothing about whether the therapies given were state of the art or carefully done, said Matt Nock, a professor of psychology at Harvard and the lead author, and it is possible that some of the treatments prevented suicide attempts. “But it’s telling us we’ve got a long way to go to do this right,” Dr. Nock said. His co-authors included Ronald C. Kessler of Harvard and researchers from Boston University and Children’s Hospital Boston.

Margaret McConnell, a consultant in Alexandria, Va., said her daughter Alice, who killed herself in 2006 at the age of 17, was getting treatment at the time. “I think there might have been some carelessness in the way the treatment was done,” Ms. McConnell said, “and I was trusting a 17-year-old to manage her own medication. We found out after we lost her that she wasn’t taking it regularly.”

In the study, researchers surveyed 6,483 adolescents from the ages of 13 to 18 and found that 9 percent of male teenagers and 15 percent of female teenagers experienced some stretch of having persistent suicidal thoughts. Among girls, 5 percent made suicide plans and 6 percent made at least one attempt (some were unplanned).

Among boys, 3 percent made plans and 2 percent carried out attempts, which tended to be more lethal than girls’ attempts.

(Suicidal thinking or behavior was virtually unheard-of before age 10.)

Over all, about one-third of teenagers with persistent suicidal thoughts went on to make an attempt to take their own lives.

Almost all of the suicidal adolescents in the study qualified for some psychiatric diagnosis, whether depression, phobias or generalized anxiety disorder. Those with an added behavior problem — attention-deficit disorder, substance abuse, explosive anger — were more likely to act on thoughts of self-harm, the study found.

Doctors have tested a range of therapies to prevent or reduce recurrent suicidal behaviors, with mixed success. Medications can ease depression, but in some cases they can increase suicidal thinking. Talk therapy can contain some behavior problems, but not all.

One approach, called dialectical behavior therapy, has proved effective in reducing hospitalizations and suicide attempts in, among others, people with borderline personality disorder, who are highly prone to self-harm.

But suicidal teenagers who have a mixture of mood and behavior issues are difficult to reach. In one 2011 study, researchers at George Mason University reduced suicide attempts, hospitalizations, drinking and drug use among suicidal adolescent substance abusers. The study found that a combination of intensive treatments — talk therapy for mood problems, family-based therapy for behavior issues and patient-led reduction in drug use — was more effective than regular therapies.

“But that’s just one study, and it’s small,” said Dr. Brent of the University of Pittsburgh. “We can treat components of the overall problem, but that’s about all.”

Ms. McConnell said that her daughter’s depression had seemed mild and that there was no warning that she would take her life. “I think therapy does help a lot of people, if it’s handled right,” she said.

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Baseball Dumping Dugout-to-Bullpen Landlines

The reserve clause is dead. And so are wool uniforms. There are no longer eight teams in each league. And the Houston Astros have departed the National League.

 Major League Baseball is now about to disconnect the landlines that link dugouts to bullpens. Long after the rest of society embraced cellphones, managers and coaches will soon be able to discuss pitching changes on Samsung Galaxy S III phones.

The 21st-century 4G dugout-to-bullpen connection that is being created by T-Mobile USA as part of its wireless sponsorship with Major League Baseball was announced Tuesday at the International Consumer Electronics Show in Las Vegas.

 “This is baseball’s continued push into the digital age,” said Tim Brosnan, Major League Baseball’s executive vice president for business. “It’s also about a very aggressive wireless provider that sought us out to create this unique communications platform.”

Baseball had not thought of a dugout-to-bullpen phone system in its talks with various wireless providers about a national sponsorship over the past decade, Brosnan said.

The wireless system will be tested at the World Baseball Classic in Arizona in March. After assessing how it works and fixing any problems, baseball will roll it out in the major leagues. Whether each stadium will have it in 2013 has not been determined.

T-Mobile’s sponsorship plans also include enhancing network connectivity for fans at all ballparks and helping MLB Advanced Media create content for smartphones and tablets.

To create the dugout-to-bullpen communications system, each ballpark will get the equivalent of a small cellular system with a miniature cell tower.

But while wireless companies like T-Mobile are continuously trying to broaden their national coverage territory, the dugout-to-bullpen system will have limits enforced by a technology called geo-fencing. So, managers and pitching coaches will not be able to chat with the bullpen coach from the pitcher’s mound. And bullpen coaches cannot ask, “Can you hear me now?” once they leave the bullpen’s environs.

“The guidance we’ve been given is that we shouldn’t fundamentally change what makes baseball baseball,” said Mark McDiarmid, T-Mobile’s vice president for engineering. “There is reason to be cautious about how far the coach could move away from the dugout before the umpires might think it’s inappropriate.”

Baseball is not shifting to cellphones because of an incident during the eighth inning of Game 5 of the 2011 World Series when the noise at Rangers Ballpark in Arlington caused Derek Lilliquist, the Cardinals’ bullpen coach, to misunderstand Manager Tony La Russa’s instructions about which relievers should start warming up.

Twice, La Russa asked that Jason Motte get up. Lilliquist apparently did not hear the first request. When La Russa called again to get Motte ready, Lilliquist thought he was asking for Lance Lynn. The miscommunication led to La Russa’s surprise when he summoned a right-hander and Lynn arrived at the mound, not Motte. Lynn stayed in long enough to issue an intentional walk; Motte quickly got ready and replaced him.

Lilliquist might well have heard La Russa’s instructions if they had used the cellphone system, with multiple microphones, noise mitigation and the ability to raise audio levels.

 Given T-Mobile’s investment over the next three years, it is not surprising that each dugout’s branded cellphone docking station — about the size of a personal computer tower — will be about as visible to TV cameras as the Gatorade vessel is.

But, Brosnan said, baseball has not ordained the obvious commercial tie-in: that each call to the bullpen on Fox, ESPN and TBS’s national telecasts be sponsored by T-Mobile.

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News Analysis: Obama Nominees in Step on Light Footprint

Carolyn Kaster/Associated Press

President Obama named John O. Brennan, right, as his choice for C.I.A. director and chose Chuck Hagel, left, to be his next defense secretary.

WASHINGTON — With the selection of a new national security team deeply suspicious of the wisdom of American military interventions around the world, President Obama appears to have ended, at least for the moment, many of the internal administration debates that played out in the Situation Room over the past four years.

He has sided, without quite saying so, with Vice President Joseph R. Biden Jr.’s view — argued, for the most part, in the confines of the White House — that caution, covert action and a modest American military footprint around the world fit the geopolitical moment. The question is whether that approach will fit the coming challenges of stopping Iran’s nuclear program and the potential collapse of Syria.

Gone for the second term are the powerful personalities, and more hawkish voices, that pressed Mr. Obama to pursue the surge in Afghanistan in 2009, a gamble championed by Secretary of State Hillary Rodham Clinton and Robert M. Gates, the former secretary of defense. Gone from the C.I.A. is the man who urged Mr. Obama to keep troops there longer, David H. Petraeus.

The new team will include two Vietnam veterans, Senator John Kerry and Chuck Hagel, who bear the scars of a war that ended when the president was a teenager, and a counterterrorism chief, John O. Brennan, who helped devise the “light footprint” strategy of limiting American interventions, whenever possible, to drones, cyberattacks and Special Operations forces. All are advocates of those low-cost, low-American-casualty tools, and all have sounded dismissive of attempts to send thousands of troops to rewire foreign nations as wasteful and ill-conceived.

Most important to Mr. Obama and his national security adviser, Tom Donilon, all three are likely to accommodate themselves, in ways their predecessors often did not, to a White House that has insisted on running national security policy from the West Wing.

“One of the characteristics of this administration has been that decision-making has been centered in the White House,” said Dennis B. Ross, a Mideast expert who left the Obama administration a year ago but never wandered far from some of its key debates. “And most second-term administrations don’t change their sociology.”

But if they grab hold of the national security levers after what many predict will be, for Mr. Hagel and Mr. Brennan, bruising confirmation hearings, they will confront problems that may test whether the light footprint carries enough weight.

“Issues 1 and 2 will be cutting the defense budget and confronting Iran,” said Michael Mandelbaum, a political scientist whose 2010 book, “The Frugal Superpower,” dealt with the challenge of trying to manage the world on the cheap. “And then you will have issues like Syria, which test the question of whether you can manage to control a dangerous situation with no boots on the ground — and unless something dramatic changes, there will be no boots.”

Mr. Hagel, who was both a senator and a cellphone entrepreneur, has long been a critic of Pentagon bloat. But others with business experience, like Donald Rumsfeld, have believed they could bring market discipline to one of the country’s most sprawling enterprises, only to discover that killing off unneeded weapons systems has almost nothing to do with business decisions and everything to do with the politics of Congressional districts and campaign funds.

Mr. Obama’s bet was that by appointing a Republican, he will better his chances of overcoming those obstacles. What he discovered even before announcing Mr. Hagel’s appointment is that the former senator burned many bridges with his Republican colleagues, in part with his outspoken opposition to the Iraq war, despite voting in 2002 to authorize military action, and to the 2008 surge when President George W. Bush was still in office.

“If the president thinks Chuck Hagel can get him the Republican votes to downsize the Pentagon,” said one former senior aide to Mr. Bush, who declined to speak on the record, “I think he is in for a very rude surprise.”

Then there is Iran, which will be a test for all three men, for different reasons. Mr. Hagel has been particularly vocal about the dangers of a military confrontation with Tehran. While both Mr. Gates and his successor, Leon E. Panetta, expressed similar concerns at various points in the first term, Mr. Hagel’s view is considerably to the left of Mr. Obama’s. The president has, gradually, endorsed “coercive diplomacy,” telling the American Israel Public Affairs Committee in March, “As I’ve made clear time and again during the course of my presidency, I will not hesitate to use force when it is necessary to defend the United States and its interests.”

But Mr. Hagel has opposed unilateral sanctions and suggested that threatening Iran just closes down opportunities for dialogue.

“The key to coercive diplomacy is that the side you are trying to influence is convinced you are willing to follow through on the threat,” said Mr. Ross, who drafted some of those threats. “The president has been clear, but from others there have been mixed messages.”

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Japan’s Cleanup After a Nuclear Accident Is Denounced

Ko Sasaki for The New York Times

Bags of contaminated soil outside the Naraha-Minami school near the Fukushima Daiichi nuclear power plant.

NARAHA, Japan — The decontamination crews at a deserted elementary school here are at the forefront of what Japan says is the most ambitious radiological cleanup the world has seen, one that promised to draw on cutting-edge technology from across the globe.

Ko Sasaki for The New York Times

Workers reflected in the glass of the Naraha-Minami Elementary School

But much of the work at the Naraha-Minami Elementary School, about 12 miles away from the ravaged Fukushima Daiichi nuclear power plant, tells another story. For eight hours a day, construction workers blast buildings with water, cut grass and shovel dirt and foliage into big black plastic bags — which, with nowhere to go, dot Naraha’s landscape like funeral mounds.

More than a year and a half since the nuclear crisis, much of Japan’s post-Fukushima cleanup remains primitive, slapdash and bereft of the cleanup methods lauded by government scientists as effective in removing harmful radioactive cesium from the environment.

Local businesses that responded to a government call to research and develop decontamination methods have found themselves largely left out. American and other foreign companies with proven expertise in environmental remediation, invited to Japan in June to show off their technologies, have similarly found little scope to participate.

Recent reports in the local media of cleanup crews dumping contaminated soil and leaves into rivers has focused attention on the sloppiness of the cleanup.

“What’s happening on the ground is a disgrace,” said Masafumi Shiga, president of Shiga Toso, a refurbishing company based in Iwaki, Fukushima. The company developed a more effective and safer way to remove cesium from concrete without using water, which could repollute the environment. “We’ve been ready to help for ages, but they say they’ve got their own way of cleaning up,” he said.

Shiga Toso’s technology was tested and identified by government scientists as “fit to deploy immediately,” but it has been used only at two small locations, including a concrete drain at the Naraha-Minami school.

Instead, both the central and local governments have handed over much of the 1 trillion yen decontamination effort to Japan’s largest construction companies. The politically connected companies have little radiological cleanup expertise and critics say they have cut corners to employ primitive — even potentially hazardous — techniques.

The construction companies have the great advantage of available manpower. Here in Naraha, about 1,500 cleanup workers are deployed every day to power-spray buildings, scrape soil off fields, and remove fallen leaves and undergrowth from forests and mountains, according to an official at the Maeda Corporation, which is in charge of the cleanup.

That number, the official said, will soon rise to 2,000, a large deployment rarely seen on even large-sale projects like dams and bridges.

The construction companies suggest new technologies may work, but are not necessarily cost-effective.

“In such a big undertaking, cost-effectiveness becomes very important,” said Takeshi Nishikawa, an executive based in Fukushima for the Kashima Corporation, Japan’s largest construction company. The company is in charge of the cleanup in the city of Tamura, a part of which lies within the 12-mile exclusion zone. “We bring skills and expertise to the project,” Mr. Nishikawa said.

Kashima also built the reactor buildings for all six reactors at the Fukushima Daiichi plant, leading some critics to question why control of the cleanup effort has been left to companies with deep ties to the nuclear industry.

Also worrying, industry experts say, are cleanup methods used by the construction companies that create loose contamination that can become airborne or enter the water.

At many sites, contaminated runoff from cleanup projects is not fully recovered and is being released into the environment, multiple people involved in the decontamination work said.

Makiko Inoue contributed reporting from Tokyo.

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Questions for Mississippi Doctor After Thousands of Autopsies

JACKSON, Miss. — For a long time, if a body turned up in Mississippi it had a four-in-five chance of ending up in front of Dr. Steven T. Hayne.

Between the late 1980s and the late 2000s, Dr. Hayne had the field of forensic pathology in Mississippi almost to himself, performing thousands of autopsies and delivering his findings around the state as an expert witness in civil and criminal cases. For most of that time, Dr. Hayne performed about 1,700 autopsies annually, more than four for every day of the year and nearly seven times the maximum caseload recommended by the National Association of Medical Examiners.

During the past several months, in courthouses around Mississippi, four new petitions have been quietly submitted on behalf of people in prison arguing that they were wrongfully convicted on the basis of Dr. Hayne’s testimony. Around 10 more are expected in the coming weeks, including three by inmates on death row.

The filings, based on new information obtained as part of a lawsuit settled last spring, charge that Dr. Hayne made “numerous misrepresentations” about his qualifications as a forensic pathologist. They say that he proposed theories in his testimony that lie far outside standard forensic science. And they suggest that Mississippi officials ignored these problems, instead supporting Dr. Hayne’s prolific business.

For many around the state, the Hayne era is considered to be over and any problems fixed. In 2008, amid growing controversy, the state severed ties with Dr. Hayne, who to this day insists that he was treated unfairly. Mississippi officials have since shown almost no inclination to review his past cases.

The recent lawsuits suggest that in only a limited number of cases did a verdict most likely hinge on Dr. Hayne’s testimony. But without any systematic review, it remains a question as to what that number may be.

“There are hundreds of cases that have to be reconsidered,” said Dr. James Lauridson, a former state medical examiner in Alabama, who provided an affidavit in one of the recently filed cases. Dr. Lauridson said Dr. Hayne was an extreme example of a familiar problem: a forensic analyst with inadequate training who was given far too much deference in the courts.

“After you do that long enough, your initially shaky opinions become way out of the mainstream,” Dr. Lauridson said. “That is what happened to him.”

Dr. Hayne was sidelined by state officials after his analyses — and those of one of his close collaborators — led to several murder convictions that were later overturned or thrown out. But he insists that his work has been intentionally distorted by critics.

“I don’t think I was treated fairly,” he said last month at his house in a gated community overlooking the Ross Barnett Reservoir. “Is that the way you treat people after 20 years of working like a dog?”

A physician and pathologist, Dr. Hayne, now 71, began performing autopsies in Mississippi in the late 1980s. He served briefly as interim state medical examiner though he was not, as state law required, board certified in forensic pathology. From 1989, when he left the interim post, to 2010, the office of medical examiner was unfilled for all but five years. Dr. Hayne, working as a private contractor, almost single-handedly picked up the slack.

By his own count, he performed as many as 1,700 autopsies some years, in addition to having his own pathology practice. Dr. David Fowler, the chief medical examiner in Maryland and a former chairman of the standards committee for the National Association of Medical Examiners, called the number “beyond defensible.”

Dr. Hayne said that state-appointed medical examiners simply did not have his motivation as a fee-based contractor, nor his work ethic. “How many autopsies could they do?” he said. “They could do one or 500, they get paid the same amount. Is there any incentive to do a heavy load?”

That incentive is at the heart of the challenges filed on behalf of prisoners in recent weeks, most of them by the Mississippi Innocence Project. The cases in those filings are not clear cut, and in all of them there is circumstantial evidence suggesting guilt and innocence. But Dr. Hayne’s testimony was key.

In one case, Dr. Hayne performed an autopsy of a young boy and concluded he had been suffocated. Some weeks after the boy was buried, his 3-year-old brother told the police that he had been killed by his mother’s boyfriend. Officials exhumed the body, and Dr. Hayne had a cast made of the boy’s face. By comparing his initial notes of face wounds with the cast, Dr. Hayne testified, he found it probable that the boy had been suffocated by a large male hand. The boyfriend was convicted.

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