Seeing Through the Fog of ‘Chemo-Brain’

Two weeks ago, Diem Brown, contestant of the Real World/Road Rules Challenge, shared on her PEOPLE.com blog her frustration with her chemo-brain, after having received chemotherapy over the Thanksgiving holiday for recently diagnosed ovarian cancer.

She writes, “Stressed out, overwhelmed and soooo annoyed that your mind isn’t working as it should. This, my friends, is an example of chemo brain!”

Unfortunately, as a surgeon, I have witnessed too many patients get the diagnosis of cancer. If they can transcend the initial shock, there is a desperation to understand what their lives will be like as cancer patients, and what the odds are that they will be cancer survivors.

But for many women, their fear of death is as strong as their fear of chemotherapy, the poison that along with hope, is inseparable from the Hollywood images of the sick, nauseated, thin and bald.

Diem refers to “chemo-brain”, also known as “chemo-fog”, a side effect of chemotherapy that causes problems with memory, information processing, and mood –- effects that can persistent for as many as 20 years after treatment has subsided.

Mental dullness or fatigue and an inability to focus characterized by difficulty organizing thoughts and keeping memories has also been described by patients who suffer from chemotherapy induced cognitive dysfunction.

For years, chemo-brain went largely unrecognized by health care professionals, and those who suffered from it were left without answers to their confusion.

Recently, through the Internet, web chatting and blogging, many women who suffered from chemo-brain realized they were not alone, and over the last few years, several studies have been done giving credit to the condition. But, as they say, you have to see it to believe it.

And now we can see it. In the process of presenting my own research discussing the use of imaging in breast cancer patients at this week’s San Antonio Breast Cancer Symposium, I stumbled across a presentation discussing how scientists are trying to clear the chemo-fog by imaging the brain.

Dr. Bernadine Cimprich from the University of Michigan, along with a group of scientists from the University of Washington and University of Toronto took the stage in San Antonio Friday to shed some light through the fog, and offer a strategy at prevention.

Since chemo-brain doesn’t affect all cancer patients to the same degree, they asked the question, are some patients who receive chemotherapy predisposed to developing the disease?

Chemo-brain has been studied before, but has been difficult to characterize because so many different types of drugs and regimens are used, and for the most part patient’s memory and cognition are not studied prior to starting cancer therapy.

To help shed some light on the subject, these researchers used functional magnetic resonance imaging, or fMRI – a technology that uses magnets to image the brain as it works.

By taking pictures of the brain before and after chemotherapy, they found that patients who suffered from this condition had inherently different function from those who did not before they had even received treatment.

“Brain imaging before treatment showed reduced function in frontal [brain] regions” says Dr. Cimprich, the precise regions that are needed to perform working memory and guide our day-to-day activities, such as remembering the shopping list, our finding our way home.

Identifying patients who may be predisposed to developing chemo-brain can help oncologists alter treatment strategies in efforts to reduce or eliminate the fog.

Who are the patients at highest risk? Dr. Cimprich’s team used surveys to evaluate pre-treatment cognitive function and found that fatigue is a major factor. He suggests that “early interventions targeting fatigue may improve cognitive function and reduce the distress of chemo-brain”.

While the small study involved 98 patients, only 29 of which received chemotherapy, it still lays ground to understand the true nature of chemo-brain, and as Dr. Cimprich emphasizes, identifying the problem early is crucial, because early cognitive problems can become worse over time.

In her blog, Diem suggests making lists as a way to overcome her chemo-brain. And while we all know that stressful times can side track our minds and dull our spirits, until science can give us better answers, research suggests that a deep breath and a little yoga may help do the job of lifting the fog on chemo-brain.

Dr. Christopher Tokin is a surgical resident at the University of California, San Diego School of Medicine and a resident alumnus of the ABC News Medical Unit.

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States anxious over debt talks stalemate

JEFFERSON CITY, Mo. (AP) — A plunge over the federal "fiscal cliff" may sound like a terrifying risk for many state officials anxiously watching as Washington struggles to avert automatic tax hikes and spending cuts set to start with the new year. Yet their greatest angst may stem not from the potential loss of billions of dollars, but the confusion surrounding it all.

The longer the White House and Congress remain at odds, the more difficult it becomes for governors and lawmakers who are trying to piece together their own budgets. Many states depend on federal grants to help finance education, environmental and community programs that are on the chopping block. Their economies are powered by military bases and defense contractors that could get whacked. And their state income tax revenues could rise or fall as a direct result of federal tax hikes.

All that of that is to say that states have a lot riding on the strained negotiations between national Democrats and Republicans over some way of raising revenues and reducing spending that would avoid a more drastic deficit-reduction plan, known as the "fiscal cliff" because it could send the country back into an economic recession.

"From a general economic standpoint, the sooner they could do something the better," said Missouri budget director Linda Luebbering in a bit of understatement.

If nothing is done, states stand to lose $7.5 billion in federal funding for 161 grant programs subject to automatic spending cuts, according to the Federal Funds Information for States, a Washington-based organization that tracks the effects of policy decisions on states. The biggest of those cuts could come to federal aid for schools that teach large numbers of low-income students. Funding for special education, early childhood programs and food subsidies for women and children also could take sizable cuts.

If nothing is done, state economies could get jolted by an automatic $33.6 billion of spending cuts for defense contracting and military wages — hitting especially hard in places such as Virginia, California and Texas, according to the FFIS report.

And if nothing is done, state budgets also would feel the ramifications of federal tax increases, though not necessarily in a negative way. Because of how their tax codes are linked to federal regulations, more than half the states could see an increase in state income tax collections if cuts are made to federal income tax deductions and credits.

But that potential boost in state revenues could be wiped out if the plunge over the fiscal cliff were to result in another recession, said Ingrid Schroeder, a research director at the Pew Center on the States. Rising unemployment could mean more people qualifying for Medicaid and other government services, costing states additional money.

This past week, bipartisan groups of governors and state lawmakers met with President Barack Obama to urge a solution that doesn't pass the buck to local governments.

"Don't make the states pay the lion's share of whatever this medicine is that we've all got to swallow," said Arkansas Gov. Mike Beebe.

As governors pressed for resolution, state financial directors churned out dire predictions.

New York Comptroller Thomas DiNapoli warned that state and local governments may have to consider additional tax hikes to counter a projected $5 billion reduction in federal funding over nine years. The burden would fall on some residents who "are literally digging out from (Superstorm) Sandy's devastation," he said.

A report prepared for the Texas Senate estimated that nearly 4,000 jobs could be lost as a result of a projected $565 million cut in federal funds for child care, job training, cancer and AIDS screenings and other services affecting nearly 2 million Texas residents.

Oklahoma Gov. May Fallin said the state could lose as many as 8,000 jobs in the aerospace and defense industries, and Minnesota state economist Tom Stinson forecast "ultimate gloom" under a fiscal-cliff induced downturn that he said could cost 115,000 jobs in 2013-2014 and hundreds of millions of dollars of lost state tax revenues.

In California, letters have been sent to 360,000 jobless residents warning that a federally funded extension of their benefits could expire.

Even through the federal spending cuts and tax hikes have yet to kick in, some state officials believe they already are suffering the effects. Massachusetts Gov. Deval Patrick ordered spending cuts this past week to help close a projected $540 million budget hole that he blamed largely on the federal stalemate. Businesses are reluctant to make capital investments without knowing what will happen, he said.

"By all accounts, that uncertainty and the resulting slowdown in economic growth is the direct cause of our budget challenges," Patrick said.

In many states, confusion reigned. Governors often must present a budget to legislators early in 2013. That means their financial experts are working now on estimates of how much tax revenue they'll receive and how much federal funding they can rely upon. The ongoing negotiations in Washington are forcing some to leave question marks in their calculations.

"States have already had to make really tough budget decisions over the last couple of years," said Schroeder, of the Pew Center. "This uncertainty about exactly what their revenue is going to be makes an already difficult process that much more difficult."

___

Associated Press writers Chuck Bartels in Little Rock, Ark; Thomas Beaumont in Des Moines, Iowa; Patrick Condon in St. Paul, Minn.; Michael Gormley in Albany, N.Y.; Carla Johnson in Chicago; Judy Lin in Sacramento, Calif.; Bob Salsberg in Boston; Tim Talley in Oklahoma City; and Will Weissert in Austin, Texas.

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Black women battle obesity with dialogue, action

WASHINGTON (AP) — Nicole Ari Parker was motivated by frustration. For Star Jones, it was a matter of life or death. Toni Carey wanted a fresh start after a bad breakup.

All three have launched individual campaigns that reflect an emerging priority for African-American women: finding creative ways to combat the obesity epidemic that threatens their longevity.

African-American women have the highest obesity rate of any group of Americans. Four out of five black women have a body mass index above 25 percent, the threshold for being overweight or obese, according to the Centers for Disease Control and Prevention. By comparison, nearly two-thirds of Americans overall are in this category, the CDC said.

Many black women seem to not be be bothered that they are generally heavier than other Americans.

Calorie-rich, traditional soul food is a staple in the diets of many African-Americans, and curvy black women are embraced positively through slang praising them as “thick” with a “little meat on their bones,” or through songs like the Commodore’s “Brick House” or “Bootylicious” by Destiny’s Child. A study by the Kaiser Family Foundation and The Washington Post earlier this year found that 66 percent of overweight black women had high self-esteem, while 41 percent of average-sized or thin white women had high self-esteem.

Still, that doesn’t mean black women reject the need to become healthier.

Historically black, all-female Spelman College in Atlanta is disbanding its NCAA teams and devoting those resources to a campus-wide wellness program. In an open letter announcing Spelman’s “wellness revolution,” president Beverly Daniel Tatum cited a campus analysis that found many of Spelman’s 2,100 students already have high blood pressure, Type 2 diabetes or other chronic ailments.

“Spelman has an opportunity to change the health trajectory of our students and, through their influence, the communities from which they come,” Tatum’s letter said.

Jones, who underwent open heart surgery in 2010 at age 47 and now urges awareness about heart disease among black women, was met by an overflow crowd earlier this year when she convened a Congressional Black Caucus Foundation panel on black women and obesity.

“We have to get ourselves out of being conditioned to think that using soft words so we don’t hurt peoples’ feelings is doing them any favor,” Jones said. “Curvy, big-boned, hefty, full-figured, fluffy, chubby. Those are all words designed to make people feel better about themselves. That wasn’t helpful to me.”

Jones once embraced being large and fabulous, at 5 feet 5 inches tall and 300 pounds. But under that exterior, she said, she was morbidly obese, suffering from extreme fatigue, nausea, lightheadedness, heart palpitations and blurred vision. The attorney and TV personality also had gastric bypass surgery in 2003.

Now, she advises women to make simple changes such as reducing salt intake, exercising 30 minutes a day, quitting smoking, controlling portion sizes and making nutritious dietary choices.

Nutritionist and author Rovenia M. Brock, known professionally as Dr. Ro, agrees with Jones. She said getting active is only about 20 percent of the fight against obesity. The rest revolves around how much people eat.

“Our plates are killing us,” she said.

Brock said “food deserts,” or urban areas that lack quality supermarkets, are a real obstacle. She suggested getting around that by carpooling with neighbors to stores in areas with higher-quality grocery options or buying food in bulk. She also suggested growing herbs and vegetables in window-box gardens.

“Stop focusing on what’s not there, or what you think is not there,” Brock said. “We have to get out of this wimpy, ‘woe is me’ mentality.”

While first lady Michelle Obama has encouraged exercise through her “Let’s Move” campaign targeting childhood obesity, the spark for this current interest among black women may have been comments last year by Surgeon General Regina Benjamin, who observed publicly that women must stop allowing concern about their hair to prevent them from exercising.

Some black women visit salons as often as every two weeks, investing several hours and anywhere from $ 50 to hundreds of dollars each visit — activity that, according to the Black Owned Beauty Supply Association, helps fuel a $ 9 billion black hair care and cosmetics industry.

In an interview during a health conference in Washington last week, Benjamin said the damage sweat can inflict on costly hairstyles can affect women’s willingness to work out, and she hopes to change that. She goes to beauty industry conferences to encourage stylists to create exercise-friendly hairdos.

“I wouldn’t say we use it as an excuse, we use it as a barrier,” Benjamin said. “And that’s not one of the barriers anymore. We’re always going to have problems with balancing our lives, but we could take that one out.”

Parker, an actress who starred in “A Streetcar Named Desire” on Broadway earlier this year, understands this dilemma well. Out of personal frustration over maintaining both her workout and her hair, she created “Save Your Do” Gymwrap — a headband that can be wrapped around the hair in a way that minimizes sweat and preserves hairstyles.

“Not just as a black woman, but as a woman, since the beginning of time, beauty has been our responsibility,” Parker said in an interview. Because of that, she said, exercise has become linked with vanity instead of health.

“We’ve turned exercise into a weight-loss regimen,” Parker said. “No. Exercise is about being grateful for the body you have and sustaining the life you have. … Take all the hype out of the exercise and think of it as brushing your teeth.”

With their mutual family histories of diabetes and high blood pressure in mind, Carey, 28, and her sorority sister Ashley Hicks, 29, co-founded the running club Black Girls Run. Carey also considered it a new beginning after a bad breakup and a move across country. Since 2009, Black Girls Run has amassed 52,000 members who serve as a support system for runners.

Black Girls Run has about 60 groups nationwide that coordinate local races in Atlanta, New York, San Francisco, Washington, D.C, Houston and Greensboro, N.C. Most groups run at least five times a week. Next month, the national running club will take its first “Black Girls Run — Preserve the Sexy” tour to cities with high obesity rates. The tour includes health and fitness clinics with information on nutrition, hair maintenance and running gear.

“We found that when you want to get healthy and when you want to be active, it’s intimidating,” Carey said. “You don’t know where to start. There’s a little coaxing that has to go along with that.”

Parker said once African-American women place value on their bodies and longevity, everything else will follow. It costs her nothing, she said, to walk around an outdoor track with her husband, actor Boris Kodjoe, or run up and down stairs at home with her headphones.

“One good step breeds another one,” Parker said. “You’re going to have one less margarita, one less scoop of Thanksgiving macaroni … and yet you’re not doing anything fanatical or dramatic.”

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U.S. judge names lead plaintiffs in Facebook litigation

NEW YORK (Reuters) – A group of investors including state pension funds in North Carolina and Arkansas will be the lead plaintiffs in securities lawsuits arising out of Facebook Inc’s $ 16 billion initial public offering, a U.S. judge ruled on Thursday.

The investors, in a proposed class-action case, have accused Facebook of misrepresenting its financial condition in the run-up to the May stock offering. They are represented by law firms Bernstein Litowitz Berger & Grossmann and Labaton Sucharow.

The ruling helps set a structure for the Facebook IPO litigation, a headache for the social media company and a nagging reminder of the technical glitches in the highly anticipated stock market debut.

U.S. District Judge Robert Sweet in Manhattan also named lead plaintiffs for lawsuits against NASDAQ OMX Group Inc stemming from the IPO. NASDAQ was sued over allegations that orders to buy and sell Facebook were not properly executed on the first day of trading.

Facebook, which has defended its pre-IPO disclosures, declined to comment on Thursday. A spokesman for NASDAQ declined to comment on the litigation.

Facebook shares made their debut at $ 38 per share, and later fell as much as 50 percent. On Thursday, they closed at $ 26.90, down 2.6 percent.

Sweet consolidated the cases and picked lead plaintiffs to head up most of the 42 lawsuits before him arising out of the IPO.

Under a federal law governing securities lawsuits, courts routinely select a lead plaintiff in class actions. The lead plaintiff typically is the shareholder with the biggest losses, though judges have discretion to pick a different investor.

The plaintiff group picked to lead 31 cases alleging securities violations against Facebook includes the North Carolina Retirement Systems, Arkansas Teacher Retirement System, the Fresno County Employees’ Retirement Association and Banyan Capital Master Fund Ltd.

The group has collectively claimed a combined $ 7.1 million in losses.

“Its members are large, institutional investors with experience representing shareholder classes in similar litigation with the resources to pursue the action,” Sweet said.

In the securities lawsuits against NASDAQ, the judge said First New York Securities LLC, T3 Trading Group LLC, and Avatar Securities LLC would act as co-lead plaintiffs. The group traded a combined $ 316 million in Facebook shares the day of the IPO, the decision said.

The case is In re Facebook, Inc, IPO Securities and Derivative Litigation, U.S. District Court, Southern District of New York, MDL No. 12-2389.

(Reporting by Nate Raymond; Editing by Martha Graybow)

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Health workers march in Spain’s capital against cuts, reforms

MADRID (Reuters) – Thousands of health workers, on strike since last month, marched on Sunday in Madrid to protest against budget cuts and plans from the Spanish capital’s regional government to privatize the management of public hospitals and medical centers.

It was the third time doctors, nurses and health workers have rallied since the local authorities put forward a plan in October to place six hospitals and dozens of medical practices under private management. The plan also calls for patients to be charged a fee of 1 euro for prescriptions.

Workers launched an indefinite strike last month against the plan, which has not been endorsed by the centre-right government of Prime Minister Mariano Rajoy. Health workers in the capital are striking Monday-Thursday each week and seeing patients only on Fridays, while also responding to emergencies.

Spain’s 17 autonomous regions control health and education policies and spending. They have all had to implement steep cuts this year as the country struggles to meet tough European Union-agreed deficit targets.

Dressed in white scrubs, the protesters shouted slogans such as “Health is not for sale” and “Health 100 percent public, no to privatizations”.

“Of course, privatization can be reversed. Actually the question is not if it can be reversed, because privatization should never have a future,” said Luis Alvarez, an unemployed man from Madrid attending the demonstration.

Belen Padilla, a doctor at Madrid’s hospital Gregorio Maranon, said one million citizens had already signed a petition rejecting the plan.

(Reporting by Reuters Television; Writing by Julien Toyer; Editing by Peter Graff)

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As Syria's rebels close in, Assad has three options

The magnificent views across Damascus from the presidential palace on Mount Qassioun are unlikely to provide much comfort these days for Bashar al-Assad, Syria’s beleaguered head of state.

For several weeks, the skyline to the north, east, and south has been stained by black columns of smoke from artillery explosions and air strikes as Syrian government forces struggle to prevent the Free Syrian Army (FSA) rebels from inching ever closer to their goal of unseating Mr. Assad’s regime.

After 20 months of confrontation, Assad’s hold on power is looking increasingly frail, leaving him and his regime with few remaining options.

“There is no doubt that the regime’s capacity is declining and that the FSA continues to become ever stronger and better armed,” says a European diplomat closely following developments in Syria.

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The current status of the regime is uncertain and it is not even clear if Assad is still in charge. The diplomat says that Assad appears to have become a “prisoner of his own system,” no longer playing an active leadership role and confined to his palace. Instead, there are indications that an informal "security council” has emerged consisting of between 50 to 100 top regime and military figures drawn from the minority Alawite community which is handling the daily confrontation against the armed opposition.

THREE OPTIONS

Either way, the regime is steadily losing ground as the rebels attempt to encircle Damascus for an apparent final push into the city center, leaving Assad with three possible choices. The first – although least likely – option is to remain in the presidential palace to the bitter – and probably bloody – end, fulfilling a promise he made last month in an interview with Russian television to “live and die in Syria”.

A second possibility is to escape Damascus with his family and seek asylum in a third country, perhaps Iran or Venezuela, the governments of which openly support the Syrian regime. Faisal Miqdad, Syria’s deputy foreign minister, was reported to have visited Venezuela, Cuba, and Ecuador recently. Ecuador subsequently announced that it was not entertaining the idea of granting asylum to Assad.

The most likely option, however, and one that appears already to be under way, is for the regime and the core of the army and security forces to retreat to the Alawite-populated mountains on the Mediterranean coast. Diplomatic sources say that there are unconfirmed reports that the regime is planning to register all Sunnis who live in the coastal cities of Tartous, Banias, and Latakia which could potentially form part of an Alawite-dominated enclave. The coastal cities are predominantly Sunni-populated while the mountain hinterland is mainly Alawite.

EXODUS TO THE MOUNTAINS

Furthermore, there appears to be a steady and discreet trickle of families of pro-regime Alawite army officers leaving the upmarket Mezzeh neighborhood of Damascus for the coastal mountains.

“More and more regime supporters and, or their families are moving up the coast, and there are persistent rumors that at least part of the government now sits in Tartous,” the European diplomat says. “All indications are that the regime's fallback position is to retreat to the coastal area of ​​Tartous and Latakia.”

Significantly, units of the rebel Free Syrian Army operating north of Damascus appear to be limiting ambushes to south-bound military traffic heading to the capital along the main highway, the sources say. Vehicles heading north are left unmolested, raising the possibility that the highway, which leads to Tartous, is being offered as an escape route for the regime to prevent a protracted and bloody last stand in Damascus.

INCREMENTAL RETREAT

Still, there might not be a mad dash for the mountains as Damascus falls but more of an incremental retreat.

“I think that the Assad regime will go in stages,” says Andrew Tabler, Syria expert at the Washington Institute for Near East Policy. “You have the north and east go and then after that there will be a real effort to hold on to Damascus as long as possible. But in the end I don't see that as viable.”

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Mr. Tabler says he envisages a staged pullback from Damascus first to the area west of Homs, Syria’s third largest city which lies two-thirds of the way along the Damascus-Tartous highway, and then to the mountains.

“Those areas are viable, I think, in the short- to medium-term,” he says.

A fallback to Homs would explain the fierce fighting that erupted in September and October in a string of villages between Homs and the border with Lebanon, 20 miles to the south. Syrian troops assisted by pro-regime Shabiha militiamen and combatants from Hezbollah, the Lebanese militant Shia group, fought rebel forces to maintain control of the villages which flank the vital Damascus-Tartous highway.

ALAWITE STATELET?

While there appears to be consensus among analysts that the regime will eventually decamp to the coastal region, what remains unclear is the nature of the enclave – if any – that would be established there. The prospect of creating a mini Alawite state along the lines of the French-engineered statelet between 1920 and 1937 appears improbable under current circumstances. It would require the suppression of hostile Sunnis in the coastal cities and would be internationally ostracized and subject to attack by the FSA.

The chief motivation for retreating to the mountains in the first place is self-preservation rather than state-building (Alawites represent about 12 percent of Syria’s 23 million, while Sunnis comprise about 70 percent).

“The Alawite community … is counting on [Assad’s] army to protect them from possible retribution from the rebel militias,” writes Joshua Landis, professor of Middle East history at the University of Oklahoma and author of the influential Syria Comment blog. “Sectarian hatred has been driven to a fever pitch by the brutality of the regime. Syrians have been putting hate into their hearts over the past two years, making the likelihood of some sort of retribution ever more likely and the ethnic cleansing a possibility, even if a small one at the time.”

A rump regime well-entrenched into the mountain villages defended by the Alawite core of the army and security services equipped with armor, artillery, air power and possibly even chemical and biological weapons could buy the Assads some breathing space during a likely period of chaos caused by a sudden leadership vacuum in Damascus. But it is questionable whether it would provide a long-term solution for the Assad clan’s survival.

ALAWITE DIVISIONS

Also working against a more formally established enclave is the fact that not all Alawites support the Assad regime. Some may prefer to cut a deal with the opposition rather than link the fate of the community to that of the Assads. Even Assad’s home town of Qordaha, 15 miles south east of Latakia, has reportedly seen some intra-Alawite unrest between supporters and opponents of the Assad clan.

The Assad family, under Bashar’s 12-year rule, has “all but seceded socially and economically” from its roots and has done “precious little” for the Alawites which remains one of the poorest communities in Syria, says Fred Hof, a senior fellow at the Atlantic Council’s Rafik Hariri Center for the Middle East and former special adviser for transition in Syria at the State Department.

“On top of that, they have placed this community in grave jeopardy by recklessly pursuing a sectarian strategy to save their skins and preserve their ability to acquire material wealth,” he says. “In sum, I think it would be inadvisable for the [Assads] and their chief enablers to try and set up shop in Latakia and vicinity. If they have to escape in that direction because of a closed Damascus airport, they’d do well to keep moving. Where to? I don’t know who would have them at this point.”

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Peru’s capital highly vulnerable to major quake

LIMA, Peru (AP) — The earthquake all but flattened colonial Lima, the shaking so violent that people tossed to the ground couldn’t get back up. Minutes later, a 50-foot (15-meter) wall of Pacific Ocean crashed into the adjacent port of Callao, killing all but 200 of its 5,000 inhabitants. Bodies washed ashore for weeks.

Plenty of earthquakes have shaken Peru‘s capital in the 266 years since that fateful night of Oct. 28, 1746, though none with anything near the violence.

The relatively long “seismic silence” means that Lima, set astride one of the most volatile ruptures in the Earth’s crust, is increasingly at risk of being hammered by a one-two, quake-tsunami punch as calamitous as what devastated Japan last year and traumatized Santiago, Chile, and its nearby coast a year earlier, seismologists say.

Yet this city of 9 million people is sorely unprepared. Its acute vulnerability, from densely clustered, unstable housing to a dearth of first-responders, is unmatched regionally. Peru’s National Civil Defense Institute forecasts up to 50,000 dead, 686,000 injured and 200,000 homes destroyed if Lima is hit by a magnitude-8.0 quake.

“In South America, it is the most at risk,” said architect Jose Sato, director of the Center for Disaster Study and Prevention, or PREDES, a non-governmental group financed by the charity Oxfam that is working on reducing Lima’s quake vulnerability.

Lima is home to a third of Peru’s population, 70 percent of its industry, 85 percent of its financial sector, its entire central government and the bulk of international commerce.

“A quake similar to what happened in Santiago would break the country economically,” said Gabriel Prado, Lima’s top official for quake preparedness. That quake had a magnitude of 8.8.

Quakes are frequent in Peru, with about 170 felt by people annually, said Hernando Tavera, director of seismology at the country’s Geophysical Institute. A big one is due, and the chances of it striking increase daily, he said. The same collision of tectonic plates responsible for the most powerful quake ever recorded, a magnitude-9.5 quake that hit Chile in 1960, occurs just off Lima’s coast, where about 3 inches of oceanic crust slides annually beneath the continent.

A 7.5-magnitude quake in 1974 a day’s drive from Lima in the Cordillera Blanca range killed about 70,000 people as landslides buried villages. Seventy-eight people died in the capital. In 2007, a 7.9-magnitude quake struck even closer, killing 596 people in the south-central coastal city of Pisco.

A shallow, direct hit is the big danger.

More than two in five Lima residents live either in rickety structures on unstable, sandy soil and wetlands that amplify a quake’s destructive power or in hillside settlements that sprang up over a generation as people fled conflict and poverty in Peru’s interior. Thousands are built of colonial-era adobe.

Most quake-prone countries have rigorous building codes to resist seismic events. In Chile, if engineers and builders don’t adhere to them they can face prison. Not so in Peru.

“People are building with adobe just as they did in the 17th century,” said Carlos Zavala, director of Lima’s Japanese-Peruvian Center for Seismic Investigation and Disaster Mitigation.

Environmental and human-made perils compound the danger.

Situated in a coastal desert, Lima gets its water from a single river, the Rimac, which a landslide could easily block. That risk is compounded by a containment pond full of toxic heavy metals from an old mine that could rupture and contaminate the Rimac, said Agustin Gonzalez, a PREDES official advising Lima’s government.

Most of Lima’s food supply arrives via a two-lane highway that parallels the river, another potential chokepoint.

Lima’s airport and seaport, the key entry points for international aid, are also vulnerable. Both are in Callao, which seismologists expect to be scoured by a 20-foot (6-meter) tsunami if a big quake is centered offshore, the most likely scenario.

Mayor Susana Villaran’s administration is Lima’s first to organize a quake-response and disaster mitigation plan. A February 2011 law obliged Peru’s municipalities to do so. Yet Lima’s remains incipient.

“How are the injured going to be attended to? What is the ability of hospitals to respond? Of basic services? Water, energy, food reserves? I don’t think this is being addressed with enough responsibility,” said Tavera of the Geophysical Institute.

By necessity, most injured will be treated where they fall, but Peru’s police have no comprehensive first-aid training. Only Lima’s 4,000 firefighters, all volunteers, have such training, as does a 1,000-officer police emergency squadron.

But because the firefighters are volunteers, a quake’s timing could influence rescue efforts.

“If you go to a fire station at 10 in the morning there’s hardly anyone there,” said Gonzalez, who advocates a full-time professional force.

In the next two months, Lima will spend nearly $ 2 million on the three fire companies that cover downtown Lima, its first direct investment in firefighters in 25 years, Prado said. The national government is spending $ 18 million citywide for 50 new fire trucks and ambulances.

But where would the ambulances go?

A 1997 study by the Pan American Health Organization found that three of Lima’s principal public hospitals would likely collapse in a major quake, but nothing has been done to reinforce them.

And there are no free beds. One public hospital, Maria Auxiliadora, serves more than 1.2 million people in Lima’s south but has just 400 beds, and they are always full.

Contingency plans call for setting up mobile hospitals in tents in city parks. But Gonzalez said only about 10,000 injured could be treated.

Water is also a worry. The fire threat to Lima is severe — from refineries to densely-backed neighborhoods honeycombed with colonial-era wood and adobe. Lima’s firefighters often can’t get enough water pressure to douse a blaze.

“We should have places where we can store water not just to put out fires but also to distribute water to the population,” said Sato, former head of the disaster mitigation department at Peru’s National Engineering University.

The city’s lone water-and-sewer utility can barely provide water to one-tenth of Lima in the best of times.

Another big concern: Lima has no emergency operations center and the radio networks of the police, firefighters and the Health Ministry, which runs city hospitals, use different frequencies, hindering effective communication.

Nearly half of the city’s schools require a detailed evaluation to determine how to reinforce them against collapse, Sato said.

A recent media blitz, along with three nationwide quake-tsunami drills this year, helped raise consciousness. The city has spent more than $ 77 million for retention walls and concrete stairs to aid evacuation in hillside neighborhoods, Prado said, but much more is needed.

At the biggest risk, apart from tsunami-vulnerable Callao, are places like Nueva Rinconada.

A treeless moonscape in the southern hills, it is a haven for economic refugees who arrive daily from Peru’s countryside and cobble together precarious homes on lots they scored into steep hillsides with pickaxes.

Engineers who have surveyed Nueva Rinconada call its upper reaches a death trap. Most residents understand this but say they have nowhere else to go.

Water arrives in tanker trucks at $ 1 per 200 liters (52 gallons) but is unsafe to drink unless boiled. There is no sanitation; people dig their own latrines. There are no streetlamps, and visibility is erased at night as Lima’s bone-chilling fog settles into the hills.

Homes of wood, adobe and straw matting rest on piled-rock foundations that engineers say will crumble and rain down on people below in a major quake.

A recently built concrete retaining wall at the valley’s head lies a block beneath the thin-walled wood home of Hilarion Lopez, a 55-year-old janitor and community leader. It might keep his house from sliding downhill, but boulders resting on uphill slopes could shake loose and crush him and his neighbors.

“We’ve made holes and poured concrete around some of the more unstable boulders,” he says, squinting uphill in a strong late morning sun.

He’s not so worried if a quake strikes during daylight.

“But if I get caught at night? How do I see a rock?”

___

Associated Press writer Franklin Briceno contributed to this report.

___

Frank Bajak on Twitter: http://twitter.com/fbajak

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Kevin Smith: “Clerks III” will be my last writing/directing effort

LOS ANGELES (TheWrap.com) – “Clerks III” will be Kevin Smith‘s last writing/directing effort, the filmmaker tweeted on Friday morning:

“So with the ‘HIT SOMEBODY‘ shift, the minute Jeff Anderson signs on, my last cinematic effort as a writer/director will be ‘CLERKS III’”

Referring to the ice-hockey comedy he’s writing that takes place over the course of 30 years, the “shift” means now it will be not a theatrical release but a television mini-series.

“Since ‘HIT SOMEBODY’ is now gonna be a mini-series,” the 42-year-old wrote. “Yes – that leaves room for a new final flick before I retire from directing feature films.”

So pending the participation of Anderson, the actor who played Randal Graves in the first two “Clerks” films, Smith’s fans will get the ultimate goodbye gift – a complete trilogy for the convenient store comedy franchise.

The first installment was the director’s mirco-budgeted breakthrough independent film, which launched characters Jay and Silent Bob into pop culture and led to four more spinoffs.

Minimum-wage earners Randal and Dante (Brian O’Halloran) were featured in a series of “Clerks” comics in the late ’90s before becoming the focus of a short-lived animated television series in 2000 (and eventually making it back to the big screen for a quick cameo in 2001′s “Jay and Silent Bob Strike Back”). Smith finally finished their story in 2006′s “Clerks II.”

Or so we thought. Apparently, he wants to end his film-directing career with the characters and actors that helped it begin. However, the tweet heard around the world of cinema suggests it may be somewhat of a challenge to persuade at least one half of the “Clerks” duo to come aboard.

Beyond “Hit Somebody” and “Clerks III,” Smith will keep himself busy with “SModcast,” a weekly podcast, and AMC’s “Comic Book Men,” which has been renewed for a second season.

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Google launches Snapseed photo editor on Android, makes iOS version free

After acquiring the makers of Snapseed in September, Google (GOOG) on Thursday released the popular photo application for Android smartphones and tablets. Google also updated the iOS version of the app to add Google+ integration and some new filters, and it cut the price of the original app from $ 4.99 to free. Snapseed is a simple yet powerful photo editor from Nik Software that allows users to enhance images with various tweaks and gesture-based touch ups, along Instagram-like filters. Snapseed is available now for the iPhone, iPad and Android smartphones and tablets.

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Pfizer/Bristol drug cuts recurrence of blood clots – study

(Reuters) – A new blood clot preventer from Pfizer Inc and Bristol-Myers Squibb Co reduced the risk of recurrence of clots in veins and lungs and death by 80 percent with no increase in major bleeding in a study testing extended use of the drug.

In the year-long trial of 2,486 patients who had been previously treated for the condition known as venous thromboembolism (VTE) the drug, apixaban, met the combined primary goal by significantly reducing the recurrence of blood clots and death from any cause compared with a placebo, according to data presented at the American Society of Hematology (ASH) meeting in Atlanta, Georgia.

The rate of recurrence or death was 11.6 percent in the placebo group compared with 3.8 percent for those who got 2.5 milligrams of apixaban and 4.2 percent for the 5 mg dose of the drug. The results were also published in the New England Journal of Medicine.

The incidence of major bleeding, always a concern with blood thinners, was extremely low in all three arms of the trial, researchers said – 0.5 percent for placebo, 0.2 percent for the low dose of apixaban and 0.1 percent for the higher dose.

“Usually when you have an effective antithrombotic you have to pay a price in terms of bleeding. This was not the case in this study,” Dr. Giancarlo Agnelli, the study’s principal investigator, said in a telephone interview.

“There was no evidence at all of increased major bleeding and this is extremely important because you are comparing an active drug with placebo,” he said.

There was a slightly higher rate of clinically relevant nonmajor bleeding, such as nose bleeds that required medical attention, observed in patients taking the higher dose of apixaban at 4.2 percent compared with the low dose and placebo, researchers said.

Apixaban belongs to a new class of blood thinners that aim to replace decades old and difficult to use warfarin. The drug, which will be sold under the brand name Eliquis, is widely considered to be one of the most important new medicines for Pfizer and Bristol-Myers, both of which saw their top selling products lose patent protection in the past year.

AWAITING U.S. APPROVAL

It is approved in Europe and awaiting a U.S. approval decision for preventing blood clots and strokes in patients with atrial fibrillation – a type of irregular heart beat – and is also being tested against warfarin as a primary treatment for VTE with data expected next year.

A rival drug from Bayer and Johnson & Johnson called Xarelto is already approved for both conditions, but based on clinical data analysts have said they believe Eliquis is the best class.

An approval for extended use in VTE patients, during which they would take the drug for at least a year after initial treatment, could significantly boost future sales.

“The evidence is for one year. The next step would be to see whether this clinical benefit is extended after one year,” Agnelli said.

VTE consists of deep vein thrombosis, typically blood clots in the legs, and pulmonary embolism, which are dangerous clots in the lungs. Clots that begin in the extremities can travel to the heart and lungs and can be fatal. VTE is typically treated with warfarin for three to six months.

After that, “there is quite a remarkable level of uncertainty about whether to extend or not,” explained Agnelli, professor of internal medicine at the University of Perugia in Italy, who presented the data at the ASH meeting.

“Extended treatment might be clinically relevant because the recurrence rate after stopping treatment can be 10 percent in the first year,” Agnelli said. “Reducing the recurrence of VTE means reduced hospitalization costs and in some cases fewer fatal events.”

Physicians have been looking for alternatives to warfarin, which must be closely monitored to keep levels therapeutic but not toxic. The new drugs do not require monitoring or the dietary and lifestyle changes necessary with warfarin. But they still face an uphill battle as warfarin is far less expensive, and doctors have a comfort level using a drug that has been around for more than half a century despite the challenges.

Patients in the study had received treatment with warfarin for six to 12 months before starting the one-year extension trial that aimed to show further treatment could reduce recurrence rates and to see if the lower dose of apixaban was a viable option.

“It is quite clear that the lower dose is as effective as the higher. For the first time we showed that by reducing the dose of an antithrombotic agent in this clinical setting we can have the same efficacy with no major bleeding,” Agnelli said.

“This is actually something that could change clinical practice,” he added.

(Reporting by Bill Berkrot; Editing by Jilian Mincer, Berard Orr)

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