Well: Weight Loss Surgery May Not Combat Diabetes Long-Term

Weight loss surgery, which in recent years has been seen as an increasingly attractive option for treating Type 2 diabetes, may not be as effective against the disease as it was initially thought to be, according to a new report. The study found that many obese Type 2 diabetics who undergo gastric bypass surgery do not experience a remission of their disease, and of those that do, about a third redevelop diabetes within five years of their operation.

The findings contrast with the growing perception that surgery is essentially a cure for Type II diabetes. Earlier this year, two widely publicized studies reported that surgery worked better than drugs, diet and exercise in causing a remission of Type 2 diabetes in overweight people whose blood sugar was out of control, leading some experts to call for greater use of surgery in treating the disease. But the studies were small and relatively short, lasting under two years.

The latest study, published in the journal Obesity Surgery, tracked thousands of diabetics who had gastric bypass surgery for more than a decade. It found that many people whose diabetes at first went away were likely to have it return. While weight regain is a common problem among those who undergo bariatric surgery, regaining lost weight did not appear to be the cause of diabetes relapse. Instead, the study found that people whose diabetes was most severe or in its later stages when they had surgery were more likely to have a relapse, regardless of whether they regained weight.

“Some people are under the impression that you have surgery and you’re cured,” said Dr. Vivian Fonseca, the president for medicine and science for the American Diabetes Association, who was not involved in the study. “There have been a lot of claims about how wonderful surgery is for diabetes, and I think this offers a more realistic picture.”

The findings suggest that weight loss surgery may be most effective for treating diabetes in those whose disease is not very advanced. “What we’re learning is that not all diabetic patients do as well as others,” said Dr. David E. Arterburn, the lead author of the study and an associate investigator at the Group Health Research Institute in Seattle. “Those who are early in diabetes seem to do the best, which makes a case for potentially earlier intervention.”

One of the strengths of the new study was that it involved thousands of patients enrolled in three large health plans in California and Minnesota, allowing detailed tracking over many years. All told, 4,434 adult diabetics were followed between 1995 and 2008. All were obese, and all underwent Roux-en-Y operations, the most popular type of gastric bypass procedure.

After surgery, about 68 percent of patients experienced a complete remission of their diabetes. But within five years, 35 percent of those patients had it return. Taken together, that means that most of the subjects in the study, about 56 percent — a figure that includes those whose disease never remitted — had no long-lasting remission of diabetes after surgery.

The researchers found that three factors were particularly good predictors of who was likely to have a relapse of diabetes. If patients, before surgery, had a relatively long duration of diabetes, had poor control of their blood sugar, or were taking insulin, then they were least likely to benefit from gastric bypass. A patient’s weight, either before or after surgery, was not correlated with their likelihood of remission or relapse.

In Type 2 diabetes, the beta cells that produce insulin in the pancreas tend to wear out as the disease progresses, which may explain why some people benefit less from surgery. “If someone is too far advanced in their diabetes, where their pancreas is frankly toward the latter stages of being able to produce insulin, then even after losing a bunch of weight their body may not be able to produce enough insulin to control their blood sugar,” Dr. Arterburn said.

Nonetheless, he said it might be the case that obese diabetics, even those whose disease is advanced, can still benefit from gastric surgery, at least as far as their quality of life and their risk factors for heart disease and other complications are concerned.

“It’s not a surefire cure for everyone,” he said. “But almost universally, patients lose weight after weight loss surgery, and that in and of itself may have so many health benefits.”

Read More..

Well: Weight Loss Surgery May Not Combat Diabetes Long-Term

Weight loss surgery, which in recent years has been seen as an increasingly attractive option for treating Type 2 diabetes, may not be as effective against the disease as it was initially thought to be, according to a new report. The study found that many obese Type 2 diabetics who undergo gastric bypass surgery do not experience a remission of their disease, and of those that do, about a third redevelop diabetes within five years of their operation.

The findings contrast with the growing perception that surgery is essentially a cure for Type II diabetes. Earlier this year, two widely publicized studies reported that surgery worked better than drugs, diet and exercise in causing a remission of Type 2 diabetes in overweight people whose blood sugar was out of control, leading some experts to call for greater use of surgery in treating the disease. But the studies were small and relatively short, lasting under two years.

The latest study, published in the journal Obesity Surgery, tracked thousands of diabetics who had gastric bypass surgery for more than a decade. It found that many people whose diabetes at first went away were likely to have it return. While weight regain is a common problem among those who undergo bariatric surgery, regaining lost weight did not appear to be the cause of diabetes relapse. Instead, the study found that people whose diabetes was most severe or in its later stages when they had surgery were more likely to have a relapse, regardless of whether they regained weight.

“Some people are under the impression that you have surgery and you’re cured,” said Dr. Vivian Fonseca, the president for medicine and science for the American Diabetes Association, who was not involved in the study. “There have been a lot of claims about how wonderful surgery is for diabetes, and I think this offers a more realistic picture.”

The findings suggest that weight loss surgery may be most effective for treating diabetes in those whose disease is not very advanced. “What we’re learning is that not all diabetic patients do as well as others,” said Dr. David E. Arterburn, the lead author of the study and an associate investigator at the Group Health Research Institute in Seattle. “Those who are early in diabetes seem to do the best, which makes a case for potentially earlier intervention.”

One of the strengths of the new study was that it involved thousands of patients enrolled in three large health plans in California and Minnesota, allowing detailed tracking over many years. All told, 4,434 adult diabetics were followed between 1995 and 2008. All were obese, and all underwent Roux-en-Y operations, the most popular type of gastric bypass procedure.

After surgery, about 68 percent of patients experienced a complete remission of their diabetes. But within five years, 35 percent of those patients had it return. Taken together, that means that most of the subjects in the study, about 56 percent — a figure that includes those whose disease never remitted — had no long-lasting remission of diabetes after surgery.

The researchers found that three factors were particularly good predictors of who was likely to have a relapse of diabetes. If patients, before surgery, had a relatively long duration of diabetes, had poor control of their blood sugar, or were taking insulin, then they were least likely to benefit from gastric bypass. A patient’s weight, either before or after surgery, was not correlated with their likelihood of remission or relapse.

In Type 2 diabetes, the beta cells that produce insulin in the pancreas tend to wear out as the disease progresses, which may explain why some people benefit less from surgery. “If someone is too far advanced in their diabetes, where their pancreas is frankly toward the latter stages of being able to produce insulin, then even after losing a bunch of weight their body may not be able to produce enough insulin to control their blood sugar,” Dr. Arterburn said.

Nonetheless, he said it might be the case that obese diabetics, even those whose disease is advanced, can still benefit from gastric surgery, at least as far as their quality of life and their risk factors for heart disease and other complications are concerned.

“It’s not a surefire cure for everyone,” he said. “But almost universally, patients lose weight after weight loss surgery, and that in and of itself may have so many health benefits.”

Read More..

App Smart: Apps for Home Repairs for the Handy and the Less So

With the holiday season approaching, the last thing you need is to worry about home repairs. And as rain and cold try to penetrate your house, it’s inevitable that something will go awry — a pipe will burst or that warped window frame will let in too much of the cold. That’s my problem right now — a window frame in my bathroom just won’t seal against the breeze (a minor problem, certainly, considering the damage from Hurricane Sandy, but a problem that is crying to be fixed). I could try to repair it myself, but I’m not too confident in working with aluminum windows, so I may end up calling a professional.

Multi Measures HD for iPad can become a spirit level, a surface level, a ruler, a protractor, a plumb bob and more.

The Finding Home & Hardware app locates suppliers.

Tips for fixing frozen pipes on wikiHow.

For issues like this, or even just to while away hours doing some D.I.Y. research, there are many apps to help.

If you find yourself struggling to repair something and really need a handyman, a simple way to find a suitable one nearby is Yelp’s app, free on iOS and Android. Yelp, often a go-to for restaurant advice, works for home repair experts, too. Type “handyman” or “plumber” into the app’s “Filter” boxes, along with location, and it will show a list of people and businesses. The advantage of Yelp is the ability to see how previous clients rated the quality of work. Read several reviews, as people’s experiences and expectations can vary.

For a more controlled experience, try RedBeacon (free on iOS and Android), a popular app with many positive reviews. RedBeacon covers only certain metropolitan areas across the United States, however, and may not help everyone. Unlike Yelp’s more open platform, RedBeacon has a list of approved businesses and tries to match the task at hand with the right worker. The app operates through a “request” system: users enter job details, and can provide photos and video. The system also has reviews, and can help schedule a time for the work.

More confident do-it-yourselfers may tackle a problem on their own. If it’s urgent, like a broken water heater or even water damage after a leak, the WikiHow How To and DIY Survival guide (free on Android and iOS) might be useful. Type in a few key words about the problem into the app’s Search page and the guide will return some advice. Its information pages are clear and well laid-out. They begin with an introductory description, then offer a list of steps to follow. The app displays the necessary tools and items, and includes tips and warnings (like shutting off the electricity before trying to fix a water heater). When you’re done with the home repair tasks, this app can teach self-defense tricks or help you fix your car. But it’s not an exhaustive reference on home upkeep or emergency repairs.

Some apps can turn a smartphone into an actual work tool. One app for iOS devices is Multi Measures ($1, or $2 for an “HD” iPad version). The app’s interfaces are attractive and easy to read, and it offers a long list of measurement options that use the device’s sensors. It can become a spirit level, a surface level, a ruler, a protractor, a plumb bob and more. It even has a decibel meter to measure volume, and a teslameter, which measures magnetic fields. This last option turns the device into a metal detector, which could be useful if you’re trying to find buried treasure, or just nailheads that show where the studs are in your walls.

The Smart Tools app is roughly equivalent to Multi Measures, on Android, for $2.50. And some free apps for iOS and Android promise similar features (sometimes separately — for example, Smart Protractor for angles, free on Android, or Dual Level, free on iOS). The apps’ quality can vary significantly, but they cost nothing to download and test-drive.

Finally, when it comes to buying supplies, an app like Finding HOME & Hardware ($1 on iOS and Android) is invaluable. It shows nearby hardware stores that meet your needs.

Happy D.I.Y.-ing. (Or, at least, I hope your apps find you an efficient and cheap plumber!)

Quick Calls

For smartphone or tablet users who dislike the map services from Apple and Google, Nokia’s Here app is a new, free alternative. It is available on iOS now and will be on Android devices later. You may prefer its clean, elegant design to the alternatives. ... In time for holiday shopping, Amazon now has an Android tablet-optimized version of its free Amazon Mobile shopping app ready, with one-click purchase options.

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U.S. Is Weighing Stronger Action in Syrian Conflict

Francisco Leong/Agence France-Presse — Getty Images

Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.

WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.

While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.

The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”

But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.

Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.

Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”

The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.

In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.

“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.

France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.

American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.

“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”

Jessica Brandt contributed reporting from Cambridge, Mass.

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Facebook Gifts Urges Users to Shop While They Share

SAN FRANCISCO — Facebook is already privy to its users’ e-mail addresses, wedding pictures and political beliefs. Now the company is nudging them to share a bit more: credit card numbers and offline addresses.

James Best Jr./The New York Times

Facebook Gifts is a service that prompts users to buy things for friends on the social network.

Sharing Even More

What do you think about Facebook’s plan to have users buy gifts for their friends through the site using their credit cards?

A screenshot of Facebook Gifts.

The nudge comes from a new Facebook service called Gifts. It allows Facebook users — only in the United States for now — to buy presents for their friends on the social network. On offer are items as varied as spices from Dean & DeLuca, pajamas from BabyGap and subscriptions to Hulu Plus, the video service. This week Facebook added iTunes gift cards.

The gift service is part of an aggressive moneymaking push aimed at pleasing Facebook’s investors after the company’s dismal stock market debut. Facebook has stepped up mobile advertising and is starting to customize the marketing messages it shows to users based on their Web browsing outside Facebook.

Those efforts seem to have brought some relief to Wall Street. Analysts issued more bullish projections for the company in recent days, and the stock was up 49 percent from its lowest point, closing Tuesday at $26.15, although that is still well below the initial offering price of $38. The share price has been buoyed in part by the fact that a wave of insider lockup periods expired without a flood of shares hitting the market.

To power the Gifts service, Facebook rented a warehouse in South Dakota and created its own software to track inventory and shipping. It will not say how much it earns from each purchase made through Gifts, though merchants that have a similar arrangement with Amazon.com give it a roughly 15 percent cut of sales.

If it catches on, the service would give Facebook a toehold in the more than $200 billion e-commerce market. Much more important, it would let the company accumulate a new stream of valuable personal data and use it to refine targeted advertisements, its bread and butter. The company said it did not now use data collected through Gifts for advertising purposes, but could not rule it out in the future.

“The hard part for Facebook was aggregating a billion users. Now it’s more about how to monetize those users without scaring them away,” said Colin Sebastian, an analyst with Robert W. Baird.

He added: “Gifts should also contribute more to Facebook’s treasure trove of user data, which has the benefit of a virtuous cycle, driving more personalization of the site, leading to better and more targeted ads, which improves overall monetization.”

Facebook already collects credit card information from users who play social games on its site. But they are a limited constituency, and a wider audience may be persuaded to buy a gift when Facebook reminds them that a friend is expecting a baby or a cousin is approaching her 40th birthday.

The Gifts service, which grew out of Facebook’s acquisition of a mobile application called Karma, was introduced in September and expanded earlier this month on the eve of the holiday shopping season.

Magnolia Bakery, based in New York, was among Facebook’s early partners for Gifts. Its vice president for public relations, Sara Gramling, said the company had sold roughly 200 packages of treats since then. She counted it as a marketing success. The bakery, which gained fame thanks to “Sex and the City,” had only recently begun shipping its goods. “It was a great opportunity to expand our network,” she said.

Magnolia Bakery isn’t exactly catering to the masses. A half-dozen cupcakes cost $35, plus about $12 for shipping. Facebook, Ms. Gramling said, takes care of the billing. The bakery is eyeing Facebook’s global reach, too, as it opens outlets internationally, especially in the Middle East.

One of the appeals of Facebook Gifts is the ease of making a purchase. Facebook users are nudged to buy a gift (a gift-box icon pops up) for Facebook friends on their birthdays. They are offered a vast menu to choose from: beer glasses, cake pops, quilts, marshmallows, magazine subscriptions and donations to charity. They are asked to choose a greeting card. Then they are asked for credit card details. Facebook says it stores that credit card information, unless users remove it after making a purchase.

Facebook has declined to say how many users have bought gifts, only that among those who have, the average purchase is $25.

David Streitfeld contributed reporting.

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Amid Hurricane Sandy, a Race to Get a Liver Transplant

It was the best possible news, at the worst possible time.

The phone call from the hospital brought the message that Dolores and Vin Dreeland had long hoped for, ever since their daughter Natalia, 4, had been put on the waiting list for a liver transplant. The time had come.

They bundled her into the car for the 50-mile trip from their home in Long Valley, N.J., to NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan. But it soon seemed that this chance to save Natalia’s life might be just out of reach.

The date was Sunday, Oct. 28, and Hurricane Sandy, the worst storm to hit the East Coast in decades, was bearing down on New York. Airports and bridges would soon close, but the donated organ was in Nevada, five hours away. The time window in which a plane carrying the liver would be able to land in the region was rapidly closing.

In a hospital room, Natalia watched cartoons. Her parents watched the clock, and the weather. “Our anxiety was through the roof,” Mrs. Dreeland said. “It just made your stomach into knots.”

The Dreelands, who are in their 60s, became Natalia’s foster parents in 2008 when she was 7 months old, and adopted her just before she turned 2. They have another adopted daughter, Dorothy Jane, who is 17.

Natalia is a “smart little cookie” who loves school and dressing up Alice, her favorite doll, her mother said. At age 3, Natalia used the word “discombobulated” correctly, Mr. Dreeland said.

Natalia’s health problems date back several years. Her gallbladder was taken out in 2010, and about half her liver was removed in 2011. The underlying problem was a rare disease, Langerhans cell histiocytosis. It causes a tremendous overgrowth of a type of cell in the immune system and can damage organs. Drugs can sometimes keep it in check, but they did not work for Natalia.

In her case, the disease struck the bile ducts, which led to progressive liver damage. “She would have eventually gone into liver failure,” said Dr. Nadia Ovchinsky, a pediatric liver transplant specialist at NewYork-Presbyterian. “And she demonstrated some signs of early liver failure.”

The only hope was a transplant.

Dr. Tomoaki Kato, Natalia’s surgeon, knew that the liver in Nevada was a perfect match for Natalia in the two criteria that matter most: blood type and size. The deceased donor was 2 years old, and though Natalia is nearly 5, she is small for her age. Scar tissue from her previous operations would have made it very difficult to fit a larger organ into her abdomen.

Though Dr. Kato had considered transplanting part of an adult liver into Natalia, a complete organ from a child would be far better for her. But healthy organs from small children do not often become available, Dr. Kato said. This was a rare opportunity, and he was determined to seize it.

But as the day wore on, the odds for Natalia grew slimmer. The operation in Nevada to remove the liver was delayed several times.

At many hospitals, surgery to remove donor organs is done at the end of the day, after all regularly scheduled operations. The Nevada hospital had a busy surgical schedule that day, made worse by a trauma case that took priority.

At the hospital in New York, Tod Brown, an organ procurement coordinator, had alerted a charter air carrier that a flight from Nevada might be needed. That company in turn contacted West Coast carriers to pick up the donated liver and fly it to New York.

Initially, two carriers agreed, but then backed out. Several other charter companies also declined.

Mr. Brown told Dr. Kato that they might have to decline the organ. Dr. Kato, soft-spoken but relentless, said, “Find somebody who can fly.”

Dr. Kato used to work in Miami, where pilots found ways to bypass hurricanes to deliver organs. Even during Hurricane Katrina, his hospital performed transplants.

“I asked the transplant coordinators to just keep pushing,” he said.

Mr. Brown said, “Dr. Kato knew he was going to get that organ, one way or another.”

As the trajectory of the storm became clearer, one of the West Coast charter companies agreed to attempt the flight. The plan was to land at the airport in Teterboro, N.J. The backup was Newark airport, and the second backup was Albany, from where an ambulance would finish the trip.

The timing was critical: organs deteriorate outside the body, and ideally a liver should be transplanted within 12 hours of being removed.

Early Monday, as the storm whirled offshore, the plane landed at Teterboro. Soon a nurse rushed to tell the Dreelands that she had just seen an ambulance with lights and sirens screech up to the hospital. Someone had jumped out carrying a container.

At about 5 a.m., the couple kissed Natalia and saw her wheeled off to the operating room.

Three weeks later, she is back home, on the mend. The complicated regimen of drugs that transplant patients need is tough on a child, but she is getting through it, her father said.

Recently, Mr. Dreeland said, he found himself weeping uncontrollably during a church service for the family of the child who had died. “Their child gave my child life,” he said.

Though only time will tell, because the histiocytosis appeared limited to Natalia’s bile ducts and had not affected other organs, her doctors say there is a good chance that the transplant has cured her.

This article has been revised to reflect the following correction:

Correction: November 28, 2012

Because of an editing error, a picture caption with an article on Tuesday about a girl who received a liver transplant during Hurricane Sandy misspelled the surname of the girl’s family. As the article correctly noted, it is Dreeland, not Vreeland.

Read More..

Amid Hurricane Sandy, a Race to Get a Liver Transplant

It was the best possible news, at the worst possible time.

The phone call from the hospital brought the message that Dolores and Vin Dreeland had long hoped for, ever since their daughter Natalia, 4, had been put on the waiting list for a liver transplant. The time had come.

They bundled her into the car for the 50-mile trip from their home in Long Valley, N.J., to NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan. But it soon seemed that this chance to save Natalia’s life might be just out of reach.

The date was Sunday, Oct. 28, and Hurricane Sandy, the worst storm to hit the East Coast in decades, was bearing down on New York. Airports and bridges would soon close, but the donated organ was in Nevada, five hours away. The time window in which a plane carrying the liver would be able to land in the region was rapidly closing.

In a hospital room, Natalia watched cartoons. Her parents watched the clock, and the weather. “Our anxiety was through the roof,” Mrs. Dreeland said. “It just made your stomach into knots.”

The Dreelands, who are in their 60s, became Natalia’s foster parents in 2008 when she was 7 months old, and adopted her just before she turned 2. They have another adopted daughter, Dorothy Jane, who is 17.

Natalia is a “smart little cookie” who loves school and dressing up Alice, her favorite doll, her mother said. At age 3, Natalia used the word “discombobulated” correctly, Mr. Dreeland said.

Natalia’s health problems date back several years. Her gallbladder was taken out in 2010, and about half her liver was removed in 2011. The underlying problem was a rare disease, Langerhans cell histiocytosis. It causes a tremendous overgrowth of a type of cell in the immune system and can damage organs. Drugs can sometimes keep it in check, but they did not work for Natalia.

In her case, the disease struck the bile ducts, which led to progressive liver damage. “She would have eventually gone into liver failure,” said Dr. Nadia Ovchinsky, a pediatric liver transplant specialist at NewYork-Presbyterian. “And she demonstrated some signs of early liver failure.”

The only hope was a transplant.

Dr. Tomoaki Kato, Natalia’s surgeon, knew that the liver in Nevada was a perfect match for Natalia in the two criteria that matter most: blood type and size. The deceased donor was 2 years old, and though Natalia is nearly 5, she is small for her age. Scar tissue from her previous operations would have made it very difficult to fit a larger organ into her abdomen.

Though Dr. Kato had considered transplanting part of an adult liver into Natalia, a complete organ from a child would be far better for her. But healthy organs from small children do not often become available, Dr. Kato said. This was a rare opportunity, and he was determined to seize it.

But as the day wore on, the odds for Natalia grew slimmer. The operation in Nevada to remove the liver was delayed several times.

At many hospitals, surgery to remove donor organs is done at the end of the day, after all regularly scheduled operations. The Nevada hospital had a busy surgical schedule that day, made worse by a trauma case that took priority.

At the hospital in New York, Tod Brown, an organ procurement coordinator, had alerted a charter air carrier that a flight from Nevada might be needed. That company in turn contacted West Coast carriers to pick up the donated liver and fly it to New York.

Initially, two carriers agreed, but then backed out. Several other charter companies also declined.

Mr. Brown told Dr. Kato that they might have to decline the organ. Dr. Kato, soft-spoken but relentless, said, “Find somebody who can fly.”

Dr. Kato used to work in Miami, where pilots found ways to bypass hurricanes to deliver organs. Even during Hurricane Katrina, his hospital performed transplants.

“I asked the transplant coordinators to just keep pushing,” he said.

Mr. Brown said, “Dr. Kato knew he was going to get that organ, one way or another.”

As the trajectory of the storm became clearer, one of the West Coast charter companies agreed to attempt the flight. The plan was to land at the airport in Teterboro, N.J. The backup was Newark airport, and the second backup was Albany, from where an ambulance would finish the trip.

The timing was critical: organs deteriorate outside the body, and ideally a liver should be transplanted within 12 hours of being removed.

Early Monday, as the storm whirled offshore, the plane landed at Teterboro. Soon a nurse rushed to tell the Dreelands that she had just seen an ambulance with lights and sirens screech up to the hospital. Someone had jumped out carrying a container.

At about 5 a.m., the couple kissed Natalia and saw her wheeled off to the operating room.

Three weeks later, she is back home, on the mend. The complicated regimen of drugs that transplant patients need is tough on a child, but she is getting through it, her father said.

Recently, Mr. Dreeland said, he found himself weeping uncontrollably during a church service for the family of the child who had died. “Their child gave my child life,” he said.

Though only time will tell, because the histiocytosis appeared limited to Natalia’s bile ducts and had not affected other organs, her doctors say there is a good chance that the transplant has cured her.

This article has been revised to reflect the following correction:

Correction: November 28, 2012

Because of an editing error, a picture caption with an article on Tuesday about a girl who received a liver transplant during Hurricane Sandy misspelled the surname of the girl’s family. As the article correctly noted, it is Dreeland, not Vreeland.

Read More..

Op-Ed Contributor: Break Up the Telecom Cartels

SINCE 1974, when the Justice Department sued to break up the Ma Bell phone monopoly, Americans have been told that competition in telecommunications would produce innovation, better service and lower prices.

What we’ve witnessed instead is low-quality service and prices that are higher than a truly competitive market would bring.

After a brief fling with competition, ownership has reconcentrated into a stodgy duopoly of Bell Twins — AT&T and Verizon. Now, thanks to new government rules, each in effect has become the leader of its own cartel.

The AT&T-DirectTV and Verizon-Bright House-Cox-Comcast-TimeWarner behemoths market what are known as “quad plays”: the phone companies sell mobile services jointly with the “triple play” of Internet, telephone and television connections, which are often provided by supposedly competing cable and satellite companies. And because AT&T’s and Verizon’s own land-based services operate mostly in discrete geographic markets, each cartel rules its domain as a near monopoly.

The result of having such sweeping control of the communications terrain, naturally, is that there is little incentive for either player to lower prices, make improvements to service or significantly invest in new technologies and infrastructure. And that, in turn, leaves American consumers with a major disadvantage compared with their counterparts in the rest of the world.

On average, for instance, a triple-play package that bundles Internet, telephone and television sells for $160 a month with taxes. In France the equivalent costs just $38. For that low price the French also get long distance to 70 foreign countries, not merely one; worldwide television, not just domestic; and an Internet that’s 20 times faster uploading data and 10 times faster downloading it.

America’s Internet started out as No. 1 in speed. It now ranks 26th, far behind the networks in Bulgaria, Ukraine and Lithuania. Americans pay the sixth highest median price in the modern world for Internet data — 16 times the rates paid by South Koreans, according to the Organization for Economic Cooperation and Development.

Just as serious is the problem of coverage: in France, South Korea and other modern countries a superfast Internet is or will soon be available everywhere. In America, AT&T’s fiber optic lines stop short of homes and small businesses, while Verizon plans to end its fiber-optic installation work once it reaches 18 million residences.

As of now huge parts of the United States will never get on the information superhighway but will rather slog along on the digital equivalent of a country road. This presents a genuine economic threat to America: the future industries and jobs that require a universal ultra-high-speed network, after all, will most likely be developed somewhere else.

But the problem is more immediate for consumers. That’s because both of these cartels are telling lawmakers that they need less regulation, not more. A lighter government hand, they say, will mean more competition and yield a better deal for consumers.

In practice, though, deregulation has meant new regulations — written by corporations and for corporations — that have often thwarted competition and run roughshod over the customer.

Few know, for example, that since 1913, Americans have had a legal right to telephone service at any address — or did until recently. Asserting that we now live in a world of competitive telecommunications, the Bell Twins have already managed to repeal this right in at least six states (Alabama, California, Florida, North Carolina, Texas and Wisconsin). And the cartels are apparently working vigorously to extend this repeal. Doubters have only to count the lobbyists hovering around state legislatures: in Kentucky, AT&T employs 36 of them.

The new regulations have the potential to leave some customers with only mobile telephone service, which does not work in many areas. Moreover, some proposed new rules, if adopted, may actually put people at risk: AT&T, for instance, has suggested shutting down its old copper wire system — the only telecommunications platform that worked in some areas after Hurricane Sandy because it relies on a separate, minimal supply of electricity.

The remedy for these anti-consumer practices is straightforward: bring back real competition to the telecom industry. The Federal Communications Commission, the Justice Department and lawmakers have long said this is their goal. But absent new rules that promote vigorous competition among telecom companies, it simply won’t happen.

Just as canals and railroads let America grow in the 19th century, and highways and airports did so in the 20th century, the information superhighway is vital for the nation’s economic growth in the 21st. The nation can’t afford to leave its future in the hands of the cartels.

David Cay Johnston, a visiting lecturer at Syracuse University’s College of Law, is author of “The Fine Print: How Big Companies Use ‘Plain English’ to Rob You Blind.”

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News Analysis: Sunni Leaders Gaining Clout in Mideast

Mohammed Saber/European Pressphoto Agency

A Palestinian woman in Gaza City on Tuesday walked amid the rubble left from eight days of fighting that ended in a cease-fire.

RAMALLAH, West Bank — For years, the United States and its Middle East allies were challenged by the rising might of the so-called Shiite crescent, a political and ideological alliance backed by Iran that linked regional actors deeply hostile to Israel and the West.

But uprising, wars and economics have altered the landscape of the region, paving the way for a new axis to emerge, one led by a Sunni Muslim alliance of Egypt, Qatar and Turkey. That triumvirate played a leading role in helping end the eight-day conflict between Israel and Gaza, in large part by embracing Hamas and luring it further away from the Iran-Syria-Hezbollah fold, offering diplomatic clout and promises of hefty aid.

For the United States and Israel, the shifting dynamics offer a chance to isolate a resurgent Iran, limit its access to the Arab world and make it harder for Tehran to arm its agents on Israel’s border. But the gains are also tempered, because while these Sunni leaders are willing to work with Washington, unlike the mullahs in Tehran, they also promote a radical religious-based ideology that has fueled anti-Western sentiment around the region.

Hamas — which received missiles from Iran that reached Israel’s northern cities — broke with the Iranian axis last winter, openly backing the rebellion against the Syrian president, Bashar al-Assad. But its affinity with the Egypt-Qatar-Turkey axis came to fruition this fall.

“That camp has more assets that it can share than Iran — politically, diplomatically, materially,” said Robert Malley, the Middle East program director for the International Crisis Group. “The Muslim Brotherhood is their world much more so than Iran.”

The Gaza conflict helps illustrate how Middle Eastern alliances have evolved since the Islamist wave that toppled one government after another beginning in January 2011. Iran had no interest in a cease-fire, while Egypt, Qatar and Turkey did.

But it is the fight for Syria that is the defining struggle in this revived Sunni-Shiite duel. The winner gains a prized strategic crossroads.

For now, it appears that that tide is shifting against Iran, there too, and that it might well lose its main Arab partner, Syria. The Sunni-led opposition appears in recent days to have made significant inroads against the government, threatening the Assad family’s dynastic rule of 40 years and its long alliance with Iran. If Mr. Assad falls, that would render Iran and Hezbollah, which is based in Lebanon, isolated as a Shiite Muslim alliance in an ever more sectarian Middle East, no longer enjoying a special street credibility as what Damascus always tried to sell as “the beating heart of Arab resistance.”

If the shifts seem to leave the United States somewhat dazed, it is because what will emerge from all the ferment remains obscure.

Clearly the old leaders Washington relied on to enforce its will, like President Hosni Mubarak of Egypt, are gone or at least eclipsed. But otherwise confusion reigns in terms of knowing how to deal with this new paradigm, one that could well create societies infused with religious ideology that Americans find difficult to accept. The new reality could be a weaker Iran, but a far more religiously conservative Middle East that is less beholden to the United States.

Already, Islamists have been empowered in Egypt, Libya and Tunisia, while Syria’s opposition is being led by Sunni insurgents, including a growing number identified as jihadists, some identified as sympathizing with Al Qaeda. Qatar, which hosts a major United States military base, also helps finance Islamists all around the region.

In Egypt, President Mohamed Morsi resigned as a member of the Muslim Brotherhood only when he became head of state, but he still remains closely linked with the movement. Turkey, the model for many of them, has kept strong relations with Washington while diminishing the authority of generals who were longstanding American allies.

“The United States is part of a landscape that has shifted so dramatically,” said Mr. Malley of the International Crisis Group. “It is caught between the displacement of the old moderate-radical divide by one that is defined by confessional and sectarian loyalty.”

The emerging Sunni axis has put not only Shiites at a disadvantage, but also the old school leaders who once allied themselves with Washington.

The old guard members in the Palestinian Authority are struggling to remain relevant at a time when their failed 20-year quest to end the Israeli occupation of Palestinian lands makes them seem both anachronistic and obsolete.

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Puerto Rico Races to Rescue Its Pension Fund

Puerto Rico is fighting to stay afloat in a rising sea of debt.

Its economy is sputtering. Its population is shrinking. Its recent election is disputed. Its public pension fund is perilously low on cash. The American territory has just been through a brutal five-year recession, something not experienced in the United States as a whole since the 1930s.

Desperate to raise cash, Puerto Rican officials have been selling off anything they can: two toll roads and the main airport so far.

To bring in tax revenue, they are trying to lure people out of the underground economy. Coffee shops, hairdressers, even outdoor market stalls are being required to issue printed receipts with every sale. The receipts carry a lottery number, with a chance to win cars or cash, as an incentive to get shoppers to pay the island’s 7 percent sales tax.

Though many of Puerto Rico’s problems are reminiscent of Greece’s — tax noncompliance, a stagnant economy, years of issuing long-term debt to cover short-term payments — investors have had a nearly insatiable appetite for its bonds.

But now their support is dwindling. Some big investors are pruning their holdings. That is beginning to widen the cost of borrowing for Puerto Rico relative to other states and municipalities, which are benefiting from a big decline in borrowing costs. The interest rate its 30-year bonds now pay is about 2.5 percentage points higher than other municipal borrowers’, up from a difference of just 1.5 percentage points at the beginning of 2012, according to Municipal Market Data.

The possibility of a credit downgrade also hangs in the air, something that could lead to more selling.

“There is no specific event looming on the horizon,” said Alan Schankel, a managing director at Janney Capital Markets in Philadelphia. “But it’s a problem of immense magnitude, and it’s very challenging to sit here and see how they work their way out of it.”

Puerto Rico needs to be able to issue bonds at attractive rates to cover its short-term financing needs. Perhaps more important, it has to figure out how to salvage its retirement funds. After shortchanging them for years, it now has the weakest major public pension system in America.

The main fund, which serves about 250,000 government workers, past and present, is only 6 percent funded — a small percentage of what is considered the minimum needed for a marginally healthy pension plan — and could run out of money as soon as 2014. Another fund, for about 80,000 teachers, which is 20 percent funded, will last just a few years longer if nothing is done. Police officers and teachers in Puerto Rico have opted out of Social Security and rely entirely on their pensions.

“For now, I’m not totally shaken about the possibility of the fund going broke,” said Jorge Ramón Román, a 78-year-old retired instructor for the island’s Civil Air Patrol. “But I do fear for the future, when I’ll be an even older person, more infirm and with less of a pension.”

Héctor M. Mayol Kauffman, the executive director of the pension system, said it would be impossible to cut the benefits of people who are already retired, citing court precedent.

Puerto Rican officials were racing this fall to put together a rescue plan for the pension fund. Voters, though, pushed out Gov. Luis Fortuño, who had tried austerity measures that included cutting tens of thousands of government workers along with a revamping of the fund.

They elected Alejandro García Padilla, who promised to create 50,000 new jobs in the next 18 months. But the margin was razor-thin and Mr. Fortuño has requested a recount. Mr. García Padilla’s party had dropped out of the retirement overhaul effort, but the governor-elect says he will deal with the looming pension crisis with “diligence and promptness” and has put together a task force of economists and financial advisers.

“We will not leave retired government workers stranded at a bus stop in their older years,” he said.

Since the election, yields on the island’s 30-year bonds have continued to widen.

“I don’t think that there’s a default that’s about to happen, but a default isn’t the only bad thing that can happen when you’ve got bonds,” Mr. Schankel said. Puerto Rico’s bonds are just a notch or two above junk status. If they fall to that level, at least some institutions would be forced to sell, potentially setting off a chain reaction. And individual investors could get a jolt if they saw the value of their holdings fall. Many people own Puerto Rican debt without knowing it, through their mutual funds.

“The concern is that Puerto Rico is a systemic risk to the municipal bond market because it’s so widely held,” said Robert Donahue, a managing director with Municipal Market Advisors.

Rafael Matos contributed reporting from San Juan, P.R.

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