A delicate new balancing act in senior healthcare

When Claire Gordon arrived at Cedars-Sinai Medical Center, nurses knew she needed extra attention.

She was 96, had heart disease and a history of falls. Now she had pneumonia and the flu. A team of Cedars specialists converged on her case to ensure that a bad situation did not turn worse and that she didn't end up with a lengthy, costly hospital stay.

Frail seniors like Gordon account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.

The U.S. population is aging quickly: People older than 65 are expected to make up nearly 20% of it by 2030. Linda P. Fried, dean of the Columbia University Mailman School of Public Health, said now is the time to train professionals and test efforts to improve care and lower healthcare costs for elderly patients.

"It's incredibly important that we prepare for being in a society where there are a lot of older people," she said. "We have to do this type of experiment right now."

At Cedars-Sinai, where more than half the patients in the medical and surgical wards are 65 or older, one such effort is dubbed the "frailty project." Within 24 hours, nurses assess elderly patients for their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.

The Cedars project stands out nationally because medical professionals are working together to identify high-risk patients at the front end of their hospitalizations to prevent problems at the back end, said Herb Schultz, regional director of the U.S. Department of Health and Human Services.

"For seniors, it is better care, it is high-quality care and it is peace of mind," he said.

The effort and others like it also have the potential to reduce healthcare costs by cutting preventable medical errors and readmissions, Schultz said. The federal law penalizes hospitals for both.

Gordon, an articulate woman with brightly painted fingernails and a sense of humor, arrived at Cedars-Sinai by ambulance on a Monday.

Soon, nurse Jacquelyn Maxton was at her bedside asking a series of questions to check for problems with sleep, diet and confusion. The answers led to Gordon's designation as a frail patient. The next day, the project team huddled down the hall and addressed her risks one by one. Medical staff would treat the flu and pneumonia while at the same time addressing underlying health issues that could extend Gordon's stay and slow her recovery, both in the hospital and after going home.

To reduce the chance of falls, nurses placed a yellow band on her wrist that read "fall risk" and ensured that she didn't get up on her own. To prevent bed sores, they got her up and moving as often as possible. To cut down on confusion, they reminded Gordon frequently where she was and made sure she got uninterrupted sleep. Medical staff also stopped a few unnecessary medications that Gordon had been prescribed before her admission, including a heavy narcotic and a sleeping pill.

"It is really a holistic approach to the patient, not just to the disease that they are in here for," said Glenn D. Braunstein, the hospital's vice president for clinical innovation.

Previously, nurse Ivy Dimalanta said, she and her colleagues provided similar care but on a much more random basis. Under the project, the care has become standardized.

The healthcare system has not been well designed to address the needs of seniors who may have had a lifetime of health problems, said Mary Naylor, gerontology professor at the University of Pennsylvania School of Nursing. As a result, patients sometimes fall through the cracks and return to hospitals again and again.

"That is not good for them and that is not good for society to be using resources in that way," Naylor said.

Using data from related projects, Cedars began a pilot program in 2011 and expanded it last summer. The research is continuing but early results suggest that the interventions are leading to fewer seniors being admitted to the intensive care unit and to shorter hospital stays, said Jeff Borenstein, researcher and lead clinician on the frailty project. "It definitely seems to be going in the right direction," he said.

The hospital is now working with Naylor and the University of Pennsylvania to design a program to help the patients once they go home.

"People who are frail are very vulnerable when they leave the hospital," said Harriet Udin Aronow, a researcher at Cedars. "We want to promote them being safe at home and continuing to recover."

In Gordon's case, she lives alone with the help of her children and a caregiver. The hospital didn't want her experiencing complications that would lengthen the stay, but they also didn't want to discharge her before she was ready. Under the health reform law, hospitals face penalties if patients come back too soon after being released.

Patients and their families often are unaware of the additional attention. Sitting in a chair in front of a vase of pink flowers, Gordon said she knew she would have to do her part to get out of the hospital quickly. "You have to move," she said. "I know you get bed sores if you stay in bed."

Gordon said she was comfortable at the hospital but she wanted to go back to her house as quickly as she could. "There's no place like home," she said.

Two days later, that's where she was.

anna.gorman@latimes.com

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Beyonce, Jay-Z, Rihanna hang at Roc Nation brunch

LOS ANGELES (AP) — Jay-Z and Beyonce sat tightly with Solange. Kelly Rowland embraced Beyonce with a huge hug. And Rihanna spilled some of her drink laughing with Rowland.

Music's top stars attended the annual pre-Grammy Roc Nation and Nokia brunch Saturday at the Soho House.

Grammy nominee Miguel, Timbaland, Jill Scott and Kylie Mingoue also attended the exclusive event.

Jay-Z is one of six acts nominated for six awards at Sunday's Grammys. Rihanna is up for three trophies, and Beyonce is nominated for one award.

The crowd Saturday was full of members of music industry, who mingled with performers like The-Dream, Jordin Sparks, Melanie Fiona, Diane Warren, Christina Milian, MC Lyte and Santigold.

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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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Boeing 787 Dreamliner takes test flight to assess batteries

SEATTLE — Aerospace giant Boeing Co. sent a 787 Dreamliner passenger jet on a test flight Saturday, the first since the new airliner was grounded three weeks ago because of a battery fire.

The aircraft took off from Boeing Field in Seattle and spent more than two hours flying back and forth over the inland Columbia Plateau. It landed at Boeing Field shortly before 3 p.m. Pacific Time. According to flight-tracking website FlightAware, the aircraft flew 1,131 miles, slightly more than the 919 planned.

The Federal Aviation Administration granted permission for test flights Thursday.

The 787 is the first commercial airliner to rely heavily on lithium-ion batteries, the same kind used in cellphones. Each plane has two of the 63-pound blue power bricks, one near the front to provide power to the cockpit if the engines stop and one near the back to start up the auxiliary power unit, which is essentially a backup generator.

On Jan. 7, a battery on a plane that had recently landed in Boston short-circuited and caught fire. Nine days later, a battery on an All Nippon Airways plane started smoking, leading to an emergency landing in Japan.

Boeing said Saturday's flight was to assess the in-flight performance of the batteries. Data would be used to support continuing investigations of the recent incidents.

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Big Bear locked down amid manhunt

The bustling winter resort of Big Bear took on the appearance of a ghost town Thursday as surveillance aircraft buzzed overhead and police in tactical gear and carrying rifles patrolled mountain roads in convoys of SUVs, while others stood guard along major intersections.

Even before authorities had confirmed that the torched pickup truck discovered on a quiet forest road belonged to suspected gunman Christopher Dorner, 33, officials had ordered an emergency lockdown of local businesses, homes and the town's popular ski resorts. Parents were told to pick up their children from school, as rolling yellow buses might pose a target to an unpredictable fugitive on the run.

By nightfall, many residents had barricaded their doors as they prepared for a long, anxious evening.

PHOTOS: A tense manhunt amid tragic deaths

"We're all just stressed," said Andrea Burtons as she stocked up on provisions at a convenience store. "I have to go pick up my brother and get him home where we're safe."

Police ordered the lockdown about 9:30 a.m. as authorities throughout Southern California launched an immense manhunt for the former lawman, who is accused of killing three people as part of a long-standing grudge against the LAPD. Dorner is believed to have penned a long, angry manifesto on Facebook saying that he was unfairly fired from the force and was now seeking vengeance.

Forest lands surrounding Big Bear Lake are cross-hatched with fire roads and trails leading in all directions, and the snow-capped mountains can provide both cover and extreme challenges to a fugitive on foot. It was unclear whether Dorner was prepared for such rugged terrain.

Footprints were found leading from Dorner's burned pickup truck into the snow off Forest Road 2N10 and Club View Drive in Big Bear Lake.

San Bernardino County Sheriff John McMahon said that although authorities had deployed 125 officers for tracking and door-to-door searches, officers had to be mindful that the suspect may have set a trap.

"Certainly. There's always that concern and we're extremely careful and we're worried about this individual," McMahon said. "We're taking every precaution we can."

PHOTOS: A fugitive's life on Facebook

Big Bear has roughly 400 homes, but authorities guessed that only 40% are occupied year-round.

The search will probably play out with the backdrop of a winter storm that is expected to hit the area after midnight.

Up to 6 inches of snow could blanket local mountains, the National Weather Service said.

FULL COVERAGE: Sweeping manhunt for rampaging ex-cop

Gusts up to 50 mph could hit the region, said National Weather Service meteorologist Mark Moede, creating a wind-chill factor of 15 to 20 degrees.

Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.

"He could be anywhere at this point," McMahon said. When asked if the burned truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Craig and Christine Winnegar, of Murrieta, found themselves caught up in the lockdown by accident. Craig brought his wife to Big Bear as a surprise to celebrate their 28th wedding anniversary. Their prearranged dinner was canceled when restaurant owners closed their doors out of fear.

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NBC pulls 'Do No Harm' after 2 low-rated episodes

LOS ANGELES (AP) — NBC is pulling the drama series "Do No Harm" after two low-rated episodes.

The show is a take on the story of Dr. Jekyll and Mr. Hyde, and stars Steven Pasquale of "Rescue Me." He plays a respected neurosurgeon who turns into a dangerous alter ego each night. Other cast members include Alana De La Garza and Phylicia Rashad.

"Do No Harm" started with a historically small audience for a major network debut and then dropped further in its second Thursday airing.

NBC will replace "Do No Harm" with reruns of "Law & Order: Special Victims Unit" for the next two weeks.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”

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Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Correction: The patient’s eyes were brown, not blue.

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HealthCare Partners seeks license to operate as managed-care plan

HealthCare Partners, the medical-group giant acquired last year by dialysis chain DaVita Inc. for $4.4 billion, is seeking a state license to operate as a managed-care plan after questions were raised about its compliance with California law.

The California Department of Managed Health Care has been looking into the nation's largest operator of physician groups since last fall when a patient sued the Torrance company and accused it of acting like a health plan without the necessary Knox-Keene Act license. A spokeswoman for the managed-care agency said the allegations against HealthCare Partners "are still under review."

The case is part of a wider debate about whether regulatory oversight is keeping pace with consolidation among doctors, hospitals and insurers and changes in medical payment sparked by the federal healthcare law. A state healthcare board is expected to discuss these matters Monday in Sacramento.

HealthCare Partners, which runs large medical groups in Southern California and four other states, had $2.4 billion in revenue in 2011 and serves about 750,000 patients, including more than 190,000 in Medicare Advantage plans. The combined company, called DaVita HealthCare Partners, is based in Denver.

William Chin, executive medical director at HealthCare Partners, said the company is in full compliance with current law and its application for a limited health plan license is unrelated to the recent complaint.

Chin said the state license hasn't been necessary before because the company contracted with licensed health plans to care for their patients, but new initiatives with Medicare require a different arrangement.

"We are in violation of no statute or law," Chin said. The state "has reviewed these relationships and contracts for decades."

State regulators require insurers and other "risk-bearing organizations" to hold adequate reserves to pay medical bills and to comply with patient protections.

California Senate President Pro Tem Darrell Steinberg (D-Sacramento) asked officials to address these concerns about licensing in November, records show.

In December, Brent Barnhart, director of the Department of Managed Health Care, responded in a letter that the agency "has been actively engaged in discussions with HealthCare Partners regarding its business model."

Steinberg also asked whether the state had a conflict of interest because a HealthCare Partners executive and physician, Keith Wilson, serves as chairman of the agency's Financial Standards Solvency Board. The board advises the agency on certain rules for health plans and medical providers.

"Dr. Wilson's hand in advising the regulation of accountable-care organizations could be viewed as a contributing factor to a biased investigation," Steinberg wrote in his Nov. 20 letter.

The board is scheduled to discuss this potential conflict of interest at its meeting Monday. Barnhart told Steinberg that he plans to "reconfigure the makeup of the board to include additional consumer representation" later this year.

A spokesman for Steinberg said the lawmaker is awaiting more information from the healthcare agency before commenting further.

The senator's concerns stemmed from a lawsuit filed in September by Healthcare Partners patient Juan Carlos Jandres in Los Angeles County Superior Court. The suit alleges that the company engaged in unfair and fraudulent business practices. An additional plaintiff and former HealthCare Partners employee, Corey Hambrick, joined the suit last month.

Jandres sought care in 2010 for a growth in his mouth, according to his suit. He contends HealthCare Partners denied him access to appropriate hospital care because it was trying to avoid hospital claims it was responsible for paying. As a result, according to the suit, Jandres lost most of his jaw to cancer. Chin said the allegations of poor patient care are untrue.

chad.terhune@latimes.com

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Ex-cop called 'depraved,' 'cowardly'

Authorities confirmed Thursday that a door-to-door search for an ex-L.A. police officer wanted in connection with a string of shootings was underway in Big Bear after his vehicle was found burning on a forest road.

San Bernardino Sheriff John McMahon said officials matched the VIN number on the burnt truck to that of suspect Christopher Jordan Dorner, 33, the subject of an intensive hours-long manhunt that stretched across Southern California.

Big Bear Lake Fire Department Asst. Chief Mark Mills told The Times that fresh tracks spotted in the snow were believed to be Dorner's.

McMahon declined to reveal details about what was inside the truck or how it caught fire but said authorities had confirmed Dorner was not inside. He did not discuss which direction Dorner might have traveled.

Authorities were going door-to-door in the mountain community that includes a total of about 400 homes, of which authorities guessed only about 40% were occupied year-round. Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.
"He could be anywhere at this point," McMahon said. When asked if the burnt truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Television footage showed a fatigue-clad SWAT team combing the woods, rifles pointed, and the truck being towed away. Federal authorities later ordered media helicopters away from the area.

McMahon called Thursday a "sad and tragic day for all of us in law enforcement."

Several law enforcement agencies are involved in the manhunt for Dorner and alerts have been issued all across California and in Nevada. The Los Angeles Police Department had dispatched units across the region to protect at least 40 officers and others named in a rambling online manifesto that law enforcement officials attributed to Dorner.

Dorner, who was fired from the LAPD in 2009, is suspected of shooting three police officers, one of whom died, in Riverside County early Thursday.

Dorner also is suspected of killing a couple in Orange County earlier this week who were found shot in a car. One of the victims was the daughter of a former LAPD captain named in the purported manifesto.

Dorner was believed to be carrying multiple weapons, including an assault rifle.

Law enforcement authorities said they were concerned about Dorner's military background and weapons training. The lengthy online message allegedly written by the former Navy Reserve lieutenant threatened "unconventional and asymmetrical warfare" against police.

Dorner received awards for his expertise with a rifle and pistol, according to military records obtained by The Times. He received an Iraq Campaign Medal and was a member of a mobile inshore undersea warfare unit.
Riverside Police Chief Sergio Diaz, calling the attack a "cowardly ambush," said Dorner is suspected of opening fire with a rifle about 1:30 a.m. Thursday as he pulled up to two police officers waiting at a traffic light.

The attack was carried out about 20 minutes after Dorner wounded an LAPD officer in a shooting in nearby Corona, police said.
Early Thursday, two women delivering newspapers in Torrance were shot by Los Angeles police who were guarding an officer named in the manifesto.

The women, shot in the 19500 block of Redbeam Avenue, were taken to area hospitals, Torrance Police Lt. Devin Chase said. One suffered a minor wound, and the other was struck twice and listed in stable condition, LAPD Chief Charlie Beck told reporters.

"Tragically," Beck said, "we believe this is a case of mistaken identity."

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Bieber's mom trying to stay out of abortion debate

NEW YORK (AP) — Justin Bieber's mom wants to set the record straight: She's not interested in the political fray on abortion as she promotes "Crescendo," a new film she hopes will raise $10 million for centers that help pregnant girls.

Pattie Mallette, an unmarried teen herself when she had Bieber, signed on as an executive producer after the film was finished. She said Thursday that she connected personally with the story about a suicide and abortion attempt by Beethoven's mother.

"The press has been saying that I'm producing an anti-abortion film and taking this big stance. You know, I haven't shared my stance with anyone and I'm not here to make a political statement, so there's been a lot of assumptions made."

Mallette, in numerous interviews and her autobiography, "Nowhere but Up," has recounted her own suicide attempt, pressure to have an abortion when she became pregnant at 18 and struggles with drugs and alcohol before becoming a Christian.

The movie does include some producers who have anti-abortion beliefs, she said, but her goal is simple: to support residential programs like the one that helped her after her parents kicked her out of the house in Canada.

"The pregnancy center that I lived in is now closed because of lack of funds, so I thought it was a really important thing that they're doing to raise money," Mallette said.

The movie will be released Feb. 28 worldwide.

Mallette has had her share of mom moments of late with her only child, who at 18 is the youngest singer to have five chart-topping albums and will be both host and musical guest for the Feb. 9 episode of "Saturday Night Live" on NBC.

Like his Instagram photo (since deleted) of his butt crack. What ran through her head?

"I thought, I'm a mom, I don't want to see that," Mallette sighed, shaking her head. "I don't want to see him doing that kind of stuff. But, you know, he's 18. He's making some of his own decisions and he's going to make some mistakes and he's going to make some good choices, too."

What of reports of pot smoking and partying with "sizzurp"-downing hip hop singers — sizzurp being a purplish mixture of cough syrup with codeine and promethazine, a carbonated soft drink and pieces of Jolly Rancher candy.

"It's hard, you know, as a mom of an 18-year-old because that's the time when you just gotta start letting go," she said. "And, you know, I had to make some of my own mistakes. I gotta kind of let go and let him make some of his own mistakes and just hope that I put all the right things in him."

And what of Bieber's relationship with Selena Gomez?

"I have no idea if they're on-again, off-again," she said. "It's a constant thing. Today I'm not sure where they stand. I try to stay out of it. He's 18. He doesn't want me getting involved in his romantic life."

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Follow Leanne Italie on Twitter at http://twitter.com/litalie

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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

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Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

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Hedge fund manager steps up attack on Herbalife

NEW YORK — It might be easy to make a movie about Bill Ackman, the handsome and confident Wall Street tycoon whose actions over the last two months have won him as many friends as they have enemies.

Whether he'd be the hero or the villain depends on whom you ask.

In his own eyes, Ackman is the righteous investor, protecting low-income people from the clutches of health food-and-supplement maker Herbalife Ltd. by betting $1 billion that the Los Angeles company will fail. To Herbalife, he's a nemesis making specious allegations about a company he knows little about, just to make a buck.

Ackman launched a second public-relations assault against Herbalife on Thursday, releasing more than 270 detailed questions and mocking Chief Executive Michael Johnson for comparing the company to the Girl Scouts.

Ackman's 40-page missive also questioned whether Herbalife was complying with a 1986 injunction won by the California attorney general's office that prohibits the company from paying commissions for recruiting. A spokeswoman for Atty. Gen. Kamala Harris declined to say whether her office was investigating the matter.

Wall Street seemed to shrug Thursday; Herbalife's stock rose 13 cents, or about 0.4%, to $35.92. The muted stock movement comes the same day Ackman was to face his own investors at his hedge fund Pershing Square Capital Management's annual dinner in New York.

Either way, Ackman's assault highlights the cutthroat brawls of high finance and thrusts into the spotlight discussions that might otherwise take place behind the closed doors at his marble-and-glass office suite overlooking Central Park. Rather than investing in Herbalife to improve the company, Ackman "shorted," or bet against the stock, and is very publicly trying to help bring the company down.

"I believe it's good for America for this company to disappear," Ackman said in an interview.

He's part of a new breed of activist investors who make public their doubts about a company and put money on the idea that such attention will help topple the company. It's an aggressive tactic, but in the world after the financial crisis, many investors argue that a little skepticism about business is a good thing.

"This idea of people publicly raising issues at companies and short-selling them is really something that we've seen come into the public only really since the financial crisis," said Ron Orol, author of "Extreme Value Hedging: How Activist Hedge Fund Managers Are Taking On the World." "The financial crisis exposed a lot of problems at companies, and so some activists build on that information and publicly try to explain their case."

Because they profit on companies' declining fortunes, short sellers do not always have the rosiest of reputations. But Ackman sees greater need for short sellers on Wall Street.

"If you knew [Bernard] Madoff was a fraud, and you had done 18 months' worth of work and you knew it for a certainty, and you just kept your mouth shut … I think you have a moral obligation," he said. "A whistle-blower-slash-short-seller is a healthy thing for the market and a good thing for the world."

Other money managers disclosed positions on either side of Ackman's bet. Among them are Dan Loeb, founder of the hedge fund Third Point, who sided with Icahn, and Whitney Tilson, co-founder of T2 Partners, who also reportedly shorted Herbalife.

Ackman's crusade against Herbalife seems uniquely passionate and has inspired an equally personal response. Corporate raider Carl Icahn recently slammed Ackman on live TV in what money manager John Hempton went so far as to call "hedge fund porn."

At a recent dinner of 15 or so hedge fund investors, discussion turned to the odd nature of the battle between Icahn and Ackman, said Wilbur Ross, the billionaire best known for buying out steel and coal companies.

"I'm a bit surprised that this is happening," Ross said. "Carl has a good track record. Loeb has a good track record. Ackman has a good track record. At the end of the day, Wall Street people will be interested in who got what and how."

Ackman casts his campaign as a matter of conviction, saying he has plenty of other investment opportunities.

"Why do I feel a moral obligation here?" he said in the interview. "The answer is: Because this company is harming millions of people, and it's done it for 32 years, and the list of heart-[wrenching], disastrous life stories of the people that this company has wrecked is incredible."

Herbalife has angrily fought back against Ackman's claims.

In a statement Thursday, the company said: "Herbalife is a financially strong and successful global nutrition company, having created meaningful value for shareholders, significant opportunities for distributors and positively impacted the lives and health of consumers since our founding in 1980. Pershing Square's latest tome is motivated by a reckless $1-billion short bet."

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Obama names REI chief to lead the Interior Department

President Obama nominated REI business executive Sally Jewell to lead his second-term Interior Department.

WASHINGTON – President Obama on Wednesday nominated Sally Jewell, a former oil engineer and banker and current chief executive of a national outdoor retailer, to lead the Interior Department, making an unorthodox pick for his first woman nominee to his second-term Cabinet.

The president and CEO of Recreational Equipment Inc., Jewell has no government and little public policy experience, and has spent her career far from Washington. But her resume has elements that appealed to both of the two feuding interests that consume much of the debate at the department that controls public lands: the oil and gas extraction industries seeking access to public lands, as well as environmentalists seeking to preserve them.

Jewell, 56, started her career as a petroleum engineer working in the oil fields of Oklahoma and Colorado for Mobil Oil Corp. She then moved to the corporate banking industry, and joined the REI board in 1996,  becoming chief operating officer four years later.

PHOTOS: President Obama’s past

She has been credited with expanding the Washington state-based retailer's Internet operations and contributing the membership cooperative’s resources to environmental stewardship. Jewell, an avid outdoorswoman, serves on the board of the National Parks Conservation Assn. as well as the Board of Regents of the University of Washington.

In announcing his choice, Obama cast her as someone who would seek a balance between protection and economic development of public lands. 

“She knows the link between conservation and good jobs,” Obama said in remarks at the White House. “She knows that there’s no contradiction between being good stewards of the land and our economic progress, that in fact, those two things need to go hand-in-hand. She’s shown that a company with more than $1 billion in sales can do the right thing for our planet.”

In fact, little is known about Jewell’s policy positions. And while environmental groups largely praised her nomination, Republicans and some Democrats withheld judgment.

“The livelihoods of Americans living and working in the West rely on maintaining a real balance between conservation and economic opportunity,” said Sen. Lisa Murkowski (R-Alaska), the ranking member of the Senate committee on energy and national resources.  “I look forward to hearing about the qualifications Ms. Jewell has that make her a suitable candidate to run such an important agency, and how she plans to restore balance to the Interior Department.”

PHOTOS: President Obama’s second inauguration

If confirmed, Jewell will replace Ken Salazar, who served in the post throughout the president’s first term and led a period of expansion of oil and gas drilling on public lands. Salazar plans to return to Colorado. Obama on Wednesday praised the former senator as a close friend and trusted advisor.

Salazar, he said, had “ushered in a new era of conservation of our land, our water and our wildlife.”

“He’s opened more public land and water for safe and responsible energy production – not just gas and oil, but also wind and solar – creating thousands of new jobs and nearly doubling our use of renewable energy in this country,” Obama said. 

Jewell is the first woman to be named to lead a Cabinet-level department in the second term. After naming a few white men to top jobs, Obama said the next round of nominees would include more women and be more racially diverse.

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Kathleen.hennessey@latimes.com

Twitter: @khennessey

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Chris Brown returns to court for probation issues

LOS ANGELES (AP) — With the woman he assaulted throwing him a kiss, Chris Brown walked into court Wednesday to face allegations he failed to complete his community labor sentence for Rihanna's 2009 beating.

A judge asked for more information and scheduled another hearing in two months.

Rihanna, the glamorous singer whose bruised face became a tabloid fixture after she was beaten by her then-boyfriend on the way to the Grammys, has been dating Brown again.

She arrived with the R&B star, his mother and two other women and blew him a kiss as he entered the courtroom. They left together after the short proceeding in which Superior Court Judge James Brandlin set the next hearing for April 5.

Brown's lawyer, Mark Geragos, said he was disturbed about the way the district attorney handled the matter and said he would be filing a motion opposing the prosecution's move to modify Brown's fulfillment of his community labor sentence.

He offered details of Brown's various community labor stints cleaning stables,

Prosecutors, who said they could find no credible evidence that Brown had completed his community labor in his home state of Virginia, asked that he start all over and put in 180 days in Los Angeles County.

Prosecutors have suggested there was either sloppy record keeping or fraudulent reporting.

Later in the day, Geragos filed an angry response, alleging that prosecutors submitted material to the court that was "DEAD WRONG" and asking they be sanctioned.

He offered details of Brown's various community labor stints clearing brush at stables, shredding documents, painting walls and picking up trash.

In a news conference Geragos said, "I've never had a client, and I've represented a wide breadth and thousands of clients, never ever had a client who has been tortured by a DA's office on probation like Chris Brown has."

He said Rihanna was present in support because, "She thinks it's utterly ridiculous what they're doing to him, as do I."

He said prosecutions launched a "vicious and unwarranted attack on Mr. Brown" and officials in Richmond, Va., who oversaw his community labor program.

He submitted a letter from a Richmond Police Department official disputing the prosecution's claims of shoddy record keeping and inadequate supervision in Brown's home state where he was allowed to fulfill the requirements.

The judge noted during the brief court session that a prosecution filing did not request revocation of Brown's probation and he, therefore, would not revoke it.

The prosecution motion filed Tuesday also raised for the first time in Brown's felony assault case several incidents that prosecutors said demonstrate Brown has ongoing anger management issues.

The motion cited a Jan. 27 fight between Brown and fellow R&B star Frank Ocean, and a 2011 outburst in which Brown threw a chair through a window after he was asked about the Rihanna attack on "Good Morning America."

The filing represents a dramatic shift in the case against Brown, who was repeatedly praised by another judge overseeing his case for his completion of domestic violence courses and his community service work in his home state of Virginia.

That changed in September, when prosecutors raised concerns about Brown's community service after he logged 701 hours in seven months — an amount that had previously taken him more than two years to achieve.

Los Angeles investigators traveled to Richmond, Va., to investigate Brown's service.

"This inquiry provided no credible, competent or verifiable evidence that defendant Brown performed his community labor as presented to this court," Deputy District Attorney Mary Murray wrote.

Brown's attorney Geragos blasted the court filing, saying the prosecutor ignored interviews "where sworn peace officers stated unequivocally that Mr. Brown was supervised and did all of the community service."

Brown's case was transferred to Brandlin after a recent shuffling of judicial assignments.

After pleading guilty to the Rihanna attack, Brown was given permission to serve 180 days of community labor in Virginia, but only as long as he performed manual labor such as graffiti removal and roadside cleanup.

Given problems with documentation and statements from some witnesses who contradict Brown's claims of work, prosecutors asked Brandlin to order Brown to repeat his service in Los Angeles.

Brown spent one-third of the hours he logged in Virginia working night shifts at a day care center in rural Virginia where his mother once served as director and where the singer spent time as a child.

A detective who checked on Brown's work nine times at the Tappahannock Children's Center found the singer, his mother and a bodyguard at the center on each visit.

The records said Brown waxed floors or performed general cleaning at the center.

A professional floor cleaner contracted to work at the daycare center told investigators he had been cleaning the floors during the months Brown reported working at the facility.

"Claims that the defendant cleaned, stripped and waxed floors at that location have been credibly contradicted," prosecutors said in the filing.

Brown's mother, Joyce Hawkins, no longer had a formal role at the day care center but had her own set of keys and coordinated her son's work at the facility, prosecutors said.

Murray stated in her filing that the police report on Brown's service was "at best sloppy documentation and at worst fraudulent reporting."

No one from Virginia's probation department oversaw Brown's hours, prosecutors said.

The motion noted that the only records the department has to indicate Brown was supervised were officers' overtime sheets. Five of 21 days that officers logged overtime for Brown were spent providing security for the singer's concerts.

The allegations are the latest pre-Grammy controversy for Brown, who was arrested shortly after the 2009 ceremony for his attack on Rihanna. He has since returned to the awards show by performing and winning an award in 2011 for his album "F.A.M.E."

Brown and Ocean are competing against one other for the Best Urban Contemporary Album category at Sunday's Grammys.

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AP writers Anthony McCartney and Ryan Pearson contributed to this report.

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Personal Health: Effective Addiction Treatment

Countless people addicted to drugs, alcohol or both have managed to get clean and stay clean with the help of organizations like Alcoholics Anonymous or the thousands of residential and outpatient clinics devoted to treating addiction.

But if you have failed one or more times to achieve lasting sobriety after rehab, perhaps after spending tens of thousands of dollars, you’re not alone. And chances are, it’s not your fault.

Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.

According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.

A groundbreaking report published last year by the National Center on Addiction and Substance Abuse at Columbia University concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” The report added, “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”

The Columbia report found that most addiction treatment providers are not medical professionals and are not equipped with the knowledge, skills or credentials needed to provide the full range of evidence-based services, including medication and psychosocial therapy. The authors suggested that such insufficient care could be considered “a form of medical malpractice.”

The failings of many treatment programs — and the comprehensive therapies that have been scientifically validated but remain vastly underused — are described in an eye-opening new book, “Inside Rehab,” by Anne M. Fletcher, a science writer whose previous books include the highly acclaimed “Sober for Good.”

“There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches,” A. Thomas McLellan, co-founder of the Treatment Research Institute in Philadelphia, told Ms. Fletcher.

Ms. Fletcher’s book, replete with the experiences of treated addicts, offers myriad suggestions to help patients find addiction treatments with the highest probability of success.

Often, Ms. Fletcher found, low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan. Indeed, their revolving-door experiences with treatment helped prompt Ms. Fletcher’s exhaustive exploration in the first place.

In an interview, Ms. Fletcher said she wanted to inform consumers “about science-based practices that should form the basis of addiction treatment” and explode some of the myths surrounding it.

One such myth is the belief that most addicts need to go to a rehab center.

“The truth is that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually,” she wrote.

Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”

Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, “You don’t treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it.”

Dr. Willenbring now practices in St. Paul, where he is creating a clinic called Alltyr “to serve as a model to demonstrate what comprehensive 21st century treatment should look like.”

“While some people are helped by one intensive round of treatment, the majority of addicts continue to need services,” Dr. Willenbring said. He cited the case of a 43-year-old woman “who has been in and out of rehab 42 times” because she never got the full range of medical and support services she needed.

Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.

“We have some pretty good drugs to help people with addiction problems, but doctors don’t know how to use them,” he said. “The 12-step community doesn’t want to use relapse-prevention medication because they view it as a crutch.”

Before committing to a treatment program, Ms. Fletcher urges prospective clients or their families to do their homework. The first step, she said, is to get an independent assessment of the need for treatment, as well as the kind of treatment needed, by an expert who is not affiliated with the program you are considering.

Check on the credentials of the program’s personnel, who should have “at least a master’s degree,” Ms. Fletcher said. If the therapist is a physician, he or she should be certified by the American Board of Addiction Medicine.

Does the facility’s approach to treatment fit with your beliefs and values? If a 12-step program like A.A. is not right for you, don’t choose it just because it’s the best known approach.

Meet with the therapist who will treat you and ask what your treatment plan will be. “It should be more than movies, lectures or three-hour classes three times a week,” Ms. Fletcher said. “You should be treated by a licensed addiction counselor who will see you one-on-one. Treatment should be individualized. One size does not fit all.”

Find out if you will receive therapy for any underlying condition, like depression, or a social problem that could sabotage recovery. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”

Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.

Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, “Get Your Loved One Sober,” with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol.

This is the first of two articles on addiction treatment.

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Saturday mail delivery set to end in August

WASHINGTON — The U.S. Postal Service announced plans to end Saturday mail delivery starting in August while maintaining six-day delivery of packages, a move that faces an unclear future in Congress.

Postal officials said the action was crucial to keeping the agency solvent. It would be the biggest change in mail delivery since the post office ended twice-daily service in the 1950s.

Although the Postal Service no longer receives taxpayer funds, it remains subject to oversight by Congress, which since 1983 has repeatedly passed measures requiring six-day delivery. Postmaster General Patrick Donahoe's announcement appeared to be an effort to force action in Congress after comprehensive postal reform legislation stalled last year.

Postal officials say that as email has reduced the need for standard mail delivery and businesses have shifted to online billing and payment systems, they have been left with more workers and post offices than the volume of mail can support.

"Our financial condition is urgent," Donahoe said at a news conference, adding that ending letter deliveries on Saturdays would save $2 billion. "We need to operate with greater flexibility, so we can adapt quickly to the changing marketplace."

Americans "value the mail they receive, [but] they like to pay their bills online," Donahoe said.

Package delivery is not being curbed because the continued growth of online commerce has increased the agency's shipping business by 14% since 2010. That makes Saturday package delivery a potential moneymaker.

The postal service needs to find $20 billion in cost reductions and revenue increases to continue to operate, Donahoe said. Already, it has cut its workforce — one of the largest in the country — by 193,000 through attrition. It also has reduced costs by $15 billion by consolidating mail processing facilities, eliminating about 21,000 delivery routes and reducing hours at 9,000 postal facilities across the country.

"Even with these significant cost reductions, we still have a large budget gap to fill," Donahoe said.

The proposal announced Wednesday, which would take effect Aug. 5, aims to reduce the postal workforce by at least 20,000 more employees through reassignment and attrition. It would also significantly reduce overtime payments.

The announcement came with little advance notice to lawmakers, who were preparing to renew an effort to pass postal legislation this year.

Though many members of Congress insist they would have to approve the cutback, Donahoe told reporters that the agency believes it can move forward unilaterally. The current mandate for six-day delivery is part of a government funding measure that expires in late March.

"There's plenty of time in there so if there is some disagreement" with lawmakers, "we can get that resolved," he said.

The divide among lawmakers on the issue does not break cleanly along partisan lines. Lawmakers who represent rural areas, who tend to be Republicans, generally have opposed service cutbacks. So have those with strong backing from postal labor unions, mostly Democrats.

Last year, the Senate approved a bill that would have allowed the postal service to end Saturday delivery after a two-year period to evaluate the potential effects. Similar legislation in the House never came up for a vote.

The Obama administration had included a proposal for five-day mail delivery in its 2013 budget plan. White House officials, however, had said they supported that change only in concert with other reforms. White House spokesman Jay Carney said Wednesday that officials hadn't yet studied the latest plan.

Sen. Thomas R. Carper (D-Del.), the new chairman of the Senate Homeland Security and Governmental Affairs Committee, expressed concern that the Postal Service's unilateral announcement could complicate his plans for overall reform.

But, he added, "It's hard to condemn the postmaster general for moving aggressively to do what he believes he can and must do to keep the lights on."

Republican Sen. Susan Collins of Maine, a coauthor of the 2012 Senate bill, was more critical. She said that cutting service should "be the last resort, not the Postal Service's first choice," and said the announcement was "inconsistent with current law and threatens to further jeopardize its customer base."

Carper's counterpart in the House, Rep. Darrell Issa (R-Vista), applauded the postal service announcement as a "common-sense reform" that should draw bipartisan support.

Rep. Adrian Smith (R-Neb.), co-chairman of the House Rural Caucus, called on Congress to find a solution that would "not disproportionately impact rural communities."

The American Postal Workers Union also condemned the move.

"USPS executives cannot save the Postal Service by tearing it apart," said union President Cliff Guffey. "These across-the-board cutbacks will weaken the nation's mail system and put it on a path to privatization."

michael.memoli@latimes.com

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Child porn suspect indicted by federal grand jury

A North Hills woman whom authorities allege plied a young girl with crack cocaine and photographed her having sex with an older man was indicted Tuesday on federal charges of producing child pornography and sex trafficking.

Letha Montemayor Tucker was named Tuesday in a four-count indictment returned by a federal grand jury. If convicted of all the charges, Tucker would face a mandatory minimum federal sentence of 10 years and could get up to life in prison, authorities said.

The charges come a month after authorities sought the public's help in the investigation by releasing photographs of a man and woman depicted in a set of widely circulated child pornography photos.

Tips started pouring in immediately after the photos were released, investigators said.

Tucker, who goes by the name Butterfly, was located about 10 hours after the release of the photos and taken into custody, said Claude Arnold, special agent in charge for Homeland Security Investigations in Los Angeles, a division of U.S. Immigration and Customs Enforcement.

The alleged victim, who was about 12 when the photos were taken, was found within a week of the case going public, Arnold said. She is an adult now and is cooperating with authorities, he said.

In addition to photographing the girl having sex with the man, authorities said, Tucker also committed sex acts with the alleged victim.

The photos were part of a child pornography collection known as the "Jen Series."

The 40-plus photos were first discovered by investigators in the Chicago area in 2007. Investigators said images in the series have been reported about 300 times and have been found on computers across the country.

The victim "didn't even know these images were out there," Arnold said.

"The horror of child pornography is it's for life, the victimization," Arnold said. "Once the photos are there in cyberspace, they're there forever."

The girl, identified in court records only by the initials J.M.M., lived in the same Los Angeles County residential hotel as Tucker, who worked as a prostitute, authorities said.

Around 2000 or 2001, the girl stopped attending school regularly and spent more and more time in Tucker's room, smoking crack cocaine Tucker provided, according to the indictment.

The girl was present when Tucker engaged in prostitution with clients and was usually high when this happened, authorities allege. Tucker instructed the child to take off her clothes in front of the clients, prosecutors alleged in court papers.

The faces of Tucker and the girl are "clearly visible" in the photos, according to the indictment. Tucker had an eyebrow piercing and a tattoo of a sleeping cat behind her shoulder, which made her easier to identify, authorities said.

The face of the man, however, is blacked out in the photographs. Authorities are still trying to identify the man, Arnold said.

"Obviously, we want him also to answer for his crimes," Arnold said.

Arnold said the alleged victim is "going to be dealing with this for a long time."

Now that she has been identified, she will receive a victim notification every time one of the images turns up in an investigation, he said.

Tucker is being held without bond and is scheduled to be arraigned in federal court on Feb. 13. Her attorney could not be reached for comment.

hailey.branson@latimes.com

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Fox cuts ties to commentator Dick Morris

NEW YORK (AP) — Political commentator Dick Morris' prediction of a huge landslide for Mitt Romney didn't pan out. And now he's lost his job at Fox News Channel.

Network spokeswoman Dana Klinghoffer said Tuesday that Fox wasn't renewing its contract with Morris, who was steadfast throughout the campaign in his prediction of a big Romney win over President Barack Obama. He has made few appearances on Fox since the election.

Morris had also been criticized for accepting paid advertisements on his website from candidates that he discussed on the air at Fox.

On his website, Morris said he'll be appearing on CNN's Piers Morgan show Wednesday to talk politics.

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Well: Warning Too Late for Some Babies

Six weeks after Jack Mahoney was born prematurely on Feb. 3, 2011, the neonatal staff at WakeMed Hospital in Raleigh, N.C., noticed that his heart rate slowed slightly when he ate. They figured he was having difficulty feeding, and they added a thickener to help.

When Jack was discharged, his parents were given the thickener, SimplyThick, to mix into his formula. Two weeks later, Jack was back in the hospital, with a swollen belly and in inconsolable pain. By then, most of his small intestine had stopped working. He died soon after, at 66 days old.

A month later, the Food and Drug Administration issued a caution that SimplyThick should not be fed to premature infants because it may cause necrotizing enterocolitis, or NEC, a life-threatening condition that damages intestinal tissue.

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Catherine Saint Louis speaks about using SimplyThick in premature infants.

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Experts do not know how the product may be linked to the condition, but Jack is not the only child to die after receiving SimplyThick. An F.D.A. investigation of 84 cases, published in The Journal of Pediatrics in 2012, found a “distinct illness pattern” in 22 instances that suggested a possible link between SimplyThick and NEC. Seven deaths were cited; 14 infants required surgery.

Last September, after more adverse events were reported, the F.D.A. warned that the thickener should not be given to any infants. But the fact that SimplyThick was widely used at all in neonatal intensive care units has spawned a spate of lawsuits and raised questions about regulatory oversight of food additives for infants.

SimplyThick is made from xanthan gum, a widely-used food additive on the F.D.A.’s list of substances “generally recognized as safe.” SimplyThick is classified as a food and the F.D.A. did not assess it for safety.

John Holahan, president of SimplyThick, which is based in St. Louis, acknowledged that the company marketed the product to speech language pathologists who in turn recommended it to infants. The patent touted its effectiveness in breast milk.

However, Mr. Holahan said, “There was no need to conduct studies, as the use of thickeners overall was already well established. In addition, the safety of xanthan gum was already well established.”

Since 2001, SimplyThick has been widely used by adults with swallowing difficulties. A liquid thickened to about the consistency of honey allows the drinker more time to close his airway and prevent aspiration.

Doctors in newborn intensive care units often ask non-physician colleagues like speech pathologists to determine whether an infant has a swallowing problem. And those auxiliary feeding specialists often recommended SimplyThick for neonates with swallowing troubles or acid reflux.

The thickener became popular because it was easy to mix, could be used with breast milk, and maintained its consistency, unlike alternatives like rice cereal.

“It was word of mouth, then neonatologists got used to using it. It became adopted,” said Dr. Steven Abrams, a neonatologist at Texas Children’s Hospital in Houston. “At any given time, several babies in our nursery — and in any neonatal unit — would be on it.”

But in early 2011, Dr. Benson Silverman, the director of the F.D.A.’s infant formula section, was alerted to an online forum where doctors had reported 15 cases of NEC among infants given SimplyThick. The agency issued its first warning about its use in babies that May. “We can only do something with the information we are provided with,” he said. “If information is not provided, how would we know?”

Most infants who took SimplyThick did not fall ill, and NEC is not uncommon in premature infants. But most who develop NEC do so while still in the hospital. Some premature infants given SimplyThick developed NEC later than usual, a few after they went home, a pattern the F.D.A. found unusually worrisome.

Even now it is not known how the thickener might have contributed to the infant deaths. One possibility is that xanthan gum itself is not suitable for the fragile digestive systems of newborns. The intestines of premature babies are “much more likely to have bacterial overgrowth” than adults’, said Dr. Jeffrey Pietz, the chief of newborn medicine at Children’s Hospital Central California in Madera.

“You try not to put anything in a baby’s intestine that’s not natural.” If you do, he added, “you’ve got to have a good reason.”

A second possibility is that batches of the thickener were contaminated with harmful bacteria. In late May 2011, the F.D.A. inspected the plants that make SimplyThick and found violations at one in Stone Mountain, Ga., including a failure to “thermally process” the product to destroy bacteria of a “public health significance.”

The company, Thermo Pac, voluntarily withdrew certain batches. But it appears some children may have ingested potentially contaminated batches.

The parents of Jaden Santos, a preemie who died of NEC while on SimplyThick, still have unused packets of recalled lots, according to their lawyer, Joe Taraska.

The authors of the F.D.A. report theorized that the infants’ intestinal membranes could have been damaged by bacteria breaking down the xanthan gum into too many toxic byproducts.

Dr. Qing Yang, a neonatologist at Wake Forest University, is a co-author of a case series in the Journal of Perinatology about three premature infants who took SimplyThick, developed NEC and were treated. The paper speculates that NEC was “most likely caused by the stimulation of the immature gut by xanthan gum.”

Dr. Yang said she only belatedly realized “there’s a lack of data” on xanthan gum’s use in preemies. “The lesson I learned is not to be totally dependent on the speech pathologist.”

Julie Mueller’s daughter Addison was born full-term and given SimplyThick after a swallow test showed she was at risk of choking. It was recommended by a speech pathologist at the hospital.

Less than a month later, Addison was dead with multiple holes in her small intestine. “It was a nightmare,” said Ms. Mueller, who has filed a lawsuit against SimplyThick. “I was astounded how a hospital and manufacturer was gearing this toward newborns when they never had to prove it would be safe for them. Basically we just did a research trial for the manufacturer.”

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Facebook founder Mark Zuckerberg, center, rings the Nasdaq opening bell May 18 from Facebook headquarters in Menlo Park, Calif. (Zef Nikolla / Associated Press / February 5, 2013)

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Scientists identify remains as those of King Richard III

LONDON -- More than 500 years after his death in battle, scientists announced Monday that they had definitively identified a skeleton unearthed in central England last summer as that of Richard III, the medieval king portrayed by William Shakespeare as a homicidal tyrant who killed his two young nephews in order to ascend the throne.

DNA from the bones, found beneath the ruins of an old church, matches that of a living descendant of the monarch's sister, researchers said.

"Rarely have the conclusions of academic research been so eagerly awaited," Richard Buckley, the lead archaeologist on the excavation, told a phalanx of reporters Monday morning. "Beyond reasonable doubt, the individual exhumed ... is indeed Richard III, the last Plantagenet king of England."

PHOTOS: Remains of King Richard III

The dramatic announcement capped a brief hunt for Richard's remains, the progress of which has been closely charted by international media and whose success has been barely short of miraculous.

Working from old maps of Leicester, about 100 miles northwest of London, archaeologists from the local university had less than a month to dig in a small municipal parking lot -- one of the few spaces not built over in the crowded city center. The team stumbled on the ruins of the medieval priory where records say Richard was buried, then found the bones a few days later last September.

"It was an extraordinary discovery that stunned all of us," Buckley said.

The nearly intact skeleton bore obvious traces of trauma to the skull and of scoliosis, a curvature of the spine that matched contemporary descriptions of Richard's appearance. The feet were missing, almost certainly the result of later disturbance, and the hands were crossed at the wrist, which suggests that they may have been tied.

Scientists at the University of Leicester, which pioneered the practice of DNA fingerprinting, were able to extract samples from the bones and compare them to a man descended from Richard III's sister Anne. The match through the maternal line was virtually perfect.

"The DNA evidence points to these being the remains of Richard III," said Turi King, the project’s geneticist.

Richard reigned from 1483 to 1485, and occupies a unique place in England's long line of colorful rulers. He was the last English king to be killed in combat, at the Battle of Bosworth Field, by his successor, Henry VII. His death ended the Plantagenet dynasty and ushered in the long era of the Tudors, including Henry VIII and Elizabeth I.

Jo Appleby, an osteologist at the university, said the skeleton belonged to an adult male in his late 20s to late 30s; Richard III was 32 when he died. The man would have stood 5-foot-8 at full height, but the curved spine would have made him appear shorter.

The skull was riddled with wounds strongly indicative of death in battle, including two blows from bladed weapons, either of which would have been fatal, Appleby said.

Richard III is one of England's most controversial monarchs, reviled by some as a bloodthirsty despot who stopped at nothing to gain power, but revered by others who insist that he has been unfairly maligned. His supporters note that the repugnant portrait of Richard in today's popular imagination is based almost entirely on accounts from the time of the usurping Tudors, especially Shakespeare's indelible characterization of him as a "deform'd, unfinish'd" man without scruples.

Fans say Richard III was an enlightened, capable ruler whose important social reforms included the presumption of innocence for defendants and the granting of bail, which remain pillars of the legal system in Britain and the U.S.

However, what happened to Richard's two nephews, who were his rivals for the throne and who were locked up in the Tower of London as young boys, never to be seen again, remains a mystery.

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Facebook After Death: Who Owns Your Pages When You Die?

Most people can’t live without Facebook — but what happens to your Facebook page when you are no longer living? New Hampshire and other states are trying to figure that out.

State Rep. Peter Sullivan has introduced legislation to allow the executor of an estate control over the social networking pages of the dead. Last week, the New Hampshire House of Representatives voted 222-128 to give Sullivan more time to write an amendment that begins a study of the issue.

The bill proposed by Sullivan, a Democrat from Manchester, would allow control of someone’s Facebook, Twitter, and other accounts such as Gmail to be passed to the executor of their estate after death.

According to Sullivan, passage of his bill would bridge a gap in policies of social media sites regarding posthumous users. He said his bill would protect residents who have suffered loss.

“This would give the families a sense of closure, a sense of peace. It would help prevent this form of bullying that continues even after someone dies and nobody is really harmed by it.”

In an interview with WMUR, Sullivan tells the story of a young Canadian girl who committed suicide because of bullying. After she died the taunting continued on her Facebook page.

Read More About Teens Bullied On Facebook

“The family wasn’t able to do anything; they didn’t have access to her account.” Sullivan said. “They couldn’t go in and delete those comments, and they couldn’t take the page down completely.”

Five other states, including Oklahoma, Idaho, Rhode Island, Indiana and Connecticut, have established legislation regulating one’s digital presence after death. Rhode Island and Connecticut were first, but their bills were limited in scope to email accounts, excluding social networking sites.

According to opponents of Sullivan’s bill, contracts and provisions between the social media user and the site already lay out what happens to the page once the user passes. Opponents say Sullivan’s bill is unenforceable and incomplete. Some also say the issue would be better suited for federal law.

Ryan Kiesel, then a state legislator from Oklahoma, sponsored a similar bill in 2010 called the Digital Property Management After Death law. Though he supports states’ efforts to bring light to this issue, saying that it is a good way to get the conversation started, he also believes that this is a case that should eventually taken up by the federal government.

“Facebook and other online providers have changed their privacy policies to keep up with the times, but we still see a lot of flux within different sites like Facebook , Flickr, or Google, for example.” Keisel told ABC News. “The federal government should pass uniform laws to govern all digital assets because it is quite difficult for an estate to have to navigate endless numbers of digital policies postmortem.”

Kiesel, who now works as a civil rights activist, compared one’s digital legacy to the distribution of someone’s tangible assets after death.

Get more pure politics at ABCNews.com/Politics

“In Oklahoma, if you are administrator of the estate of a deceased person’s house and you find a box under their bed, you are well within your right to see what’s inside that box and if property is worth distributing, you should distribute it accordingly.” Kiesel told ABC News that the same idea goes for digital legacy.

Today marks the ninth Anniversary of the launch of Facebook, which currently has over 1 billion active users. That number, which has grown from just a million users in 2004, suggests there must be an enormous number of Facebook pages that must currently be occupied by deceased people.

Facebook has not completely ignored the growing number of deceased users. The site has created a function allowing Facebook pages to become memorials after they have died.

“Please use this form to request the memorialization of a deceased person’s account,” the site reads. “We extend our condolences and appreciate your patience and understanding throughout this process.”

Memorialization of a Facebook page, however, can only be done via online request. And the terms of service for Facebook’s say that it will not issue login and password information to family members of the deceased. The requestor must contact Facebook and request that the profile is taken down or memorialized.

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