Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

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Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

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Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

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This post has been revised to reflect the following correction:

Correction: February 12, 2013

An earlier version of this article misstated the location of the Medical College of Wisconsin. It is in Milwaukee, not Madison.

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Media Decoder Blog: Comcast Buys Rest of NBC In Early Sale

8:53 p.m. | Updated Comcast gave NBCUniversal a $16.7 billion vote of confidence on Tuesday, agreeing to pay that sum to acquire General Electric’s remaining 49 percent stake in the entertainment company. The deal accelerated a sales process that was expected to take several more years.

Brian Roberts, chief executive of Comcast, said the acquisition, which will be completed by the end of March, underscored a commitment to NBCUniversal and its highly profitable cable channels, expanding theme parks and the resurgent NBC broadcast network.

“We always thought it was a strong possibility that we’d some day own 100 percent,” Mr. Roberts said in a telephone interview.

He added that the rapidly changing television business and the growing necessity of owning content as well as the delivery systems sped up the decision. “It’s been a very smooth couple of years, and the content continues to get more valuable with new revenue streams,” he said.

Comcast also said that NBCUniversal would buy the NBC studios and offices at 30 Rockefeller Center, as well as the CNBC headquarters in Englewood Cliffs, N.J. Those transactions will cost about $1.4 billion.

Mr. Roberts called the 30 Rockefeller Center offices “iconic” and said it would have been “expensive to replicate” studios elsewhere for the “Today” show, “Saturday Night Live,” “Late Night With Jimmy Fallon” and other programs produced there. “We’re proud to be associated with it,” Mr. Roberts said of the building.

With the office space comes naming rights for the building, according to a General Electric spokeswoman. So it is possible that one of New York’s most famous landmarks, with its giant red G.E. sign, could soon be displaying a Comcast sign instead.

When asked about a possible logo swap on the building, owned by Tishman Speyer, Mr. Roberts told CNBC, that is “not something we’re focused on talking about today.” Nevertheless, the sale was visible in a prominent way Tuesday night: the G.E. letters, which have adorned the top of 30 Rock for several decades, were no longer illuminated.

Comcast, with a conservative, low-profile culture, had clashed with the G.E. approach, according to employees and executives in television. Comcast moved NBCUniversal’s executive offices from the 52nd floor to the 51st floor — less opulent space that features smaller executive offices and a cozy communal coffee room instead of General Electric’s lavish executive dining room.

Comcast took control of NBCUniversal in early 2011 by acquiring 51 percent of the media company from General Electric. The structure of the deal gave Comcast the option of buying out G.E. in a three-and-a-half to seven-year time frame. In part because of the clash in corporate cultures, television executives said, both sides were eager to accelerate the sale.

Price was also a factor. Mr. Roberts said he believed the stake would have cost more had Comcast waited. Also, he pointed to the company’s strong fourth-quarter earnings to be released late Tuesday afternoon, which put it in a strong position to complete the sale.

Comcast reported a near record-breaking year with $20 billion in operating cash flow in the fiscal year 2012. In the three months that ended Dec. 31, Comcast’s cash flow increased 7.3 percent to $5.3 billion. Revenue at NBCUniversal grew 4.8 percent to $6 billion.

“We’ve had two years to make the transition and to make the investments that we believe will continue to take off,” Mr. Roberts said.

The transactions with General Electric will be largely financed with $11.4 billion of cash on hand, $4 billion of subsidiary senior unsecured notes to be issued to G.E. and a $2 billion in borrowings.

Even with the investment in NBCUniversal, Comcast said it would increase its dividend by 20 percent to 78 cents a share and buy back $2 billion in stock in 2013.

When it acquired the 51 percent stake two years ago, Comcast committed to paying about $6.5 billion in cash and contributed all of its cable channels, including E! and some regional sports networks, to the newly established NBCUniversal joint venture. Those channels were valued at $7.25 billion.

The transaction made Comcast, the single biggest cable provider in the United States, one of the biggest owners of cable channels, too. NBCUniversal operates the NBC broadcast network, 10 local NBC stations, USA, Bravo, Syfy, E!, MSNBC, CNBC, the NBC Sports Network, Telemundo, Universal Pictures, Universal Studios, and a long list of other media brands.

Mr. Roberts and Michael J. Angelakis, vice chairman and chief financial officer for the Comcast Corporation, led the negotiations that began last year with Jeffrey R. Immelt, chief executive of General Electric, and Keith Sharon, the company’s chief financial officer. JPMorgan Chase, Goldman Sachs, Centerview Partners and CBRE provided financial and strategic advice.

The sale ends a long relationship between General Electric and NBC that goes back before the founding days of television. In 1926, the Radio Corporation of America created the NBC network. General Electric owned R.C.A. until 1930. It regained control of R.C.A., including NBC, in 1986, in a deal worth $6.4 billion at the time.

In a slide show on the company’s “GE Reports” Web site titled “It’s a Wrap: GE, NBC Part Ways, Together They’ve Changed History,” G.E. said the deal with Comcast “caps a historic, centurylong journey for the two companies that gave birth to modern home entertainment.”

Mr. Immelt has said that NBCUniversal did not mesh with G.E.’s core industrial businesses. That became even more apparent when the company became a minority stakeholder with no control over how the business was run, according to a person briefed on G.E.’s thinking who could not discuss private conversations publicly.

“By adding significant new capital to our balanced capital allocation plan, we can accelerate our share buyback plans while investing in growth in our core businesses,” Mr. Immelt said in a statement. He added: “For nearly 30 years, NBC — and later NBCUniversal — has been a great business for G.E. and our investors.”

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Pentagon expands military benefits for same-sex couples

WASHINGTON — The Pentagon has agreed to expand benefits for gay and lesbian couples serving in the military, but officials continued to withhold equal access to base housing, healthcare and educational services.

Leon E. Panetta, the outgoing secretary of Defense, signed an order Monday that permits same-sex partners and their dependents to use numerous family-oriented facilities and services on U.S. military bases, including recreation areas, counseling programs, school buses, child care and shopping exchanges.

The order grants same-sex couples the right for the first time to request assignment to the same post or duty station if both serve in the military. It also allows partners to receive pay and other benefits if one is taken prisoner or is missing in action.

The move comes less than a month after President Obama used his second inaugural address to embrace equal rights for gay and lesbian Americans. Three days later, Panetta and Gen. Martin Dempsey, chairman of the Joint Chiefs, announced they were lifting the ban on female soldiers and Marines serving in most ground combat units.

The changes stop far short of full equalization of benefits for same-sex couples in the military.

The Defense of Marriage Act, passed by Congress in 1996, effectively barred same-sex couples in the military from the most generous federal benefits, including free or reduced-cost medical services, and tuition assistance. The law defines marriage as the legal union between a man and a woman.

The Supreme Court has scheduled oral arguments next month in a case that challenges the law as unconstitutional.

But Pentagon officials cited additional obstacles to guaranteeing same-sex couples equal access to base housing as other married couples. They said the issue remained under review.

Speaking at a news briefing, Defense officials said they worried that heterosexual couples and their families might be denied housing on some bases if same-sex couples were allowed to apply.

"One of the concerns was, 'I'm married and now I'm going to be bumped by this person who is not married,'" said one official, citing a military housing shortage. The officials spoke to reporters on condition they not be identified.

Panetta's order also does not allow a same-sex partner to request his or her partner's burial at Arlington National Cemetery.

In addition, the spouse of a heterosexual service member being deployed overseas can seek help obtaining a visa, may have access to medical facilities and has legal immunity for some laws in foreign jurisdictions. Those benefits will not be available to same-sex couples.

Under the order, gay and lesbian service members may file a form with the Defense Department that declares they are in a "domestic partnership," defined as a "committed relationship between two adults of the same sex."

It will take several months to update computer software to permit same-sex partners to receive military identification cards, officials said, but the new benefits must be available by Oct. 1.

Officials said the cost of the expanded benefits would be negligible at a time when the Pentagon faces potentially deep budget cuts. They cited estimates that 5,600 same-sex couples are on active duty, 3,400 serve in the National Guard and Reserves, and 8,000 are retirees.

Gay rights groups applauded the latest move, but critics said the administration was circumventing the Defense of Marriage Act.

"Today, the Pentagon took a historic step forward toward righting the wrong of inequality in our armed forces, but there is still more work to be done," said Chad Griffin, president of Human Rights Campaign, a gay rights organization.

"Once again, the president is eroding our military's apolitical stance and forcing conformity onto the rest of society by pushing his liberal social agenda through the Department of Defense," said Sen. James M. Inhofe (R-Okla.), ranking member of the Senate Armed Services Committee.

Panetta, who is expected to leave the Pentagon this month, vowed when he first took the job in 2011 to study additional steps to equalize benefits. Aides said Monday he wanted to fulfill that promise before he stepped down.

His likely successor, former Nebraska Sen. Chuck Hagel, promised at his confirmation hearing last month to pursue expanded benefits for gay and lesbian service members.

The Senate Armed Services Committee was expected to vote Tuesday to recommend Hagel be confirmed, but several Republican senators planned to delay a vote on his confirmation.

david.cloud@latimes.com

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Health Testing on Mice Is Found Misleading in Some Cases

Evan McGlinn for The New York Times

Dr. H. Shaw Warren is one of the authors of a new study that questions the use of laboratory mice as models for all human diseases.

For decades, mice have been the species of choice in the study of human diseases. But now, researchers report evidence that the mouse model has been totally misleading for at least three major killers — sepsis, burns and trauma. As a result, years and billions of dollars have been wasted following false leads, they say.

The study’s findings do not mean that mice are useless models for all human diseases. But, its authors said, they do raise troubling questions about diseases like the ones in the study that involve the immune system, including cancer and heart disease.

“Our article raises at least the possibility that a parallel situation may be present,” said Dr. H. Shaw Warren, a sepsis researcher at Massachusetts General Hospital and a lead author of the new study.

The paper, published Monday in Proceedings of the National Academy of Sciences, helps explain why every one of nearly 150 drugs tested at a huge expense in patients with sepsis has failed. The drug tests all were based on studies in mice. And mice, it turns out, can have something that looks like sepsis in humans, but is very different from the condition in humans.

Medical experts not associated with the study said that the findings should change the course of research worldwide for a deadly and frustrating condition. Sepsis, a potentially deadly reaction that occurs as the body tries to fight an infection, afflicts 750,000 patients a year in the United States, kills one-fourth to one-half of them, and costs the nation $17 billion a year. It is the leading cause of death in intensive-care units.

“This is a game changer,” said Dr. Mitchell Fink, a sepsis expert at the University of California, Los Angeles, of the new study.

“It’s amazing,” said Dr. Richard Wenzel, a former chairman at the department of internal medicine at Virginia Commonwealth University and a former editor of The New England Journal of Medicine. “They are absolutely right on.”

Potentially deadly immune responses occur when a person’s immune system overreacts to what it perceives as danger signals, including toxic molecules from bacteria, viruses, fungi, or proteins released from cells damaged by trauma or burns, said Dr. Clifford S. Deutschman, who directs sepsis research at the University of Pennsylvania and was not part of the study.

The ramped-up immune system releases its own proteins in such overwhelming amounts that capillaries begin to leak. The leak becomes excessive, and serum seeps out of the tiny blood vessels. Blood pressure falls, and vital organs do not get enough blood. Despite efforts, doctors and nurses in an intensive-care unit or an emergency room may be unable to keep up with the leaks, stop the infection or halt the tissue damage. Vital organs eventually fail.

The new study, which took 10 years and involved 39 researchers from across the country, began by studying white blood cells from hundreds of patients with severe burns, trauma or sepsis to see what genes were being used by white blood cells when responding to these danger signals.

The researchers found some interesting patterns and accumulated a large, rigorously collected data set that should help move the field forward, said Ronald W. Davis, a genomics expert at Stanford University and a lead author of the new paper. Some patterns seemed to predict who would survive and who would end up in intensive care, clinging to life and, often, dying.

The group had tried to publish its findings in several papers. One objection, Dr. Davis said, was that the researchers had not shown the same gene response had happened in mice.

“They were so used to doing mouse studies that they thought that was how you validate things,” he said. “They are so ingrained in trying to cure mice that they forget we are trying to cure humans.”

“That started us thinking,” he continued. “Is it the same in the mouse or not?”

The group decided to look, expecting to find some similarities. But when the data were analyzed, there were none at all.

“We were kind of blown away,” Dr. Davis said.

The drug failures became clear. For example, often in mice, a gene would be used, while in humans, the comparable gene would be suppressed. A drug that worked in mice by disabling that gene could make the response even more deadly in humans.

Even more surprising, Dr. Warren said, was that different conditions in mice — burns, trauma, sepsis — did not fit the same pattern. Each condition used different groups of genes. In humans, though, similar genes were used in all three conditions. That means, Dr. Warren said, that if researchers can find a drug that works for one of those conditions in people, it might work for all three.

This article has been revised to reflect the following correction:

Correction: February 11, 2013

An earlier version of this article misstated the position of Dr. Richard Wenzel. He is a former chairman of the department of internal medicine at Virginia Commonwealth University. He is not currently the chairman.

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Media Decoder Blog: Univision and Disney Give Details of Fusion, a Channel for Latinos

A new 24-hour news and entertainment channel has a name, Fusion. It also has powerful backers in Univision and ABC News, a unit of the Walt Disney Company, and distribution deals in at least 20 million homes. What is not known is whether Fusion has an audience.

Fusion will have its premiere late this summer, the companies announced Monday, as the first cable channel aimed to appeal specifically to English-speaking Latinos who can find news and entertainment elsewhere. Its reception will test whether second-generation Latinos want to watch television programming specifically for them.

The 50-50 jointly owned channel underscores the growing influence of a booming population over media companies, marketers and politicians. In 2010, there were 50.5 million Hispanics living in the United States, up from 35.3 million a decade ago, according to the 2010 census. That number is expected to grow by 167 percent by 2050, compared with an estimated 42 percent growth rate for the nation’s total population. Latinos voted in record number in the 2012 presidential election and helped sway the results in Barack Obama’s favor.

“The level of growth of Hispanics in the United States is huge, and that growth is not coming from immigration,” said Isaac Lee, the president of Univision News.

But creating a new 24-hour cable channel for a relatively narrow audience that already has plenty of options in both English and Spanish is a risky proposition. Studies show English-speaking Latinos watch the same types of programs as non-Hispanics.

“This audience identifies as Americans first,” said Larry Lubin, co-founder and president of Lubin Lawrence Inc., a brand consultancy that advised both companies. He also stressed that the venture needed to broaden its appeal. “The brand will be a failure if it only appeals to Latinos.”

Univision has rapidly expanded to meet growing demand, increasing in the last several years to 12 channels from three, including cable channels devoted to sports and telenovela marathons. Fusion represents its first English-language effort.

“This community is exploding from a size and influence perspective, but also from a diversity perspective,” said Cesar Conde, president of Univision Networks. “And we’re going through an explosive period in our evolution.”

Univision and Disney executives first sat down to discuss a joint venture channel aimed at Latinos in March 2011. For Univision, Fusion represents a chance for the largest Spanish-language network to break out of its image as the home of imported Mexican soap operas, soccer and variety shows.

Nearly half of all Latinos in the United States speak more or an equal amount of English at home, a shift Univision has had to adapt to. “They watch English shows,” said Mr. Lubin, adding that they might watch Univision “maybe if they’re at their grandmother’s house.”

For Disney, the cable channel represents a broader corporate effort to appeal to marketers hoping to reach Latino viewers. Nielsen projects the buying power of Hispanics, estimated at $1 trillion in 2010, to grow to $1.5 trillion by 2015. In 2010, advertisers spent $4.3 billion to reach Hispanics, up 14 percent from 2009, according to the Association of Hispanic Advertising Agencies. Unlike NBC with MSNBC, ABC does not have a cable news channel.

Univision spearheaded the channel’s programming and hired employees for its Miami-based headquarters. Disney, which has leverage with cable and satellite providers because of ESPN, handled distributing the channel. So far deals have been struck with Cablevision, Charter, Cox Communications, AT&T U-Verse and Google Fiber. A spokeswoman for ABC News said additional distribution deals were in the works and that the existing ones made Fusion available in states with the largest Hispanic populations, including Texas, California, Florida and Illinois.

Fusion will broadcast unscripted series and specials, all with a Latino slant. Mr. Lee pointed to series like National Geographic’s “Locked Up Abroad” about tourists who end up in foreign prisons, as the type of documentary series he hoped the channel would do. Extensive news coverage in collaboration with ABC News will revolve around the interests of Latinos. Coverage of Pope Benedict XVI’s resignation, for instance, would focus on potential Latin American candidates to succeed him, Mr. Lee said.

The goal at ABC News is that the partnership infuses its editorial choices with a Hispanic perspective. “This will absolutely play a part in our programming choices,” said Ben Sherwood, president of ABC News.

ABC News has provided employees with free Spanish lessons. Univision’s key news anchors, Jorge Ramos and María Elena Salinas, made appearances during ABC News’s election coverage. Univision has installed a liaison in the ABC newsroom in New York to foster collaboration. Sharing news gathering and production resources with Univision could also help ABC News trim costs.

Univision’s influence on ABC News’s editorial choices has already been felt. After the Mexican singer Jenni Rivera died in a plane crash in December “we knew to put it on Page 1 because our friends at Univision called me and said, ‘This is going to be the most important event for millions of U.S. Hispanics. Pay attention to this,’ ” Mr. Sherwood said.

Univision’s Spanish-language programming faces competition. In August, News Corporation introduced MundoFOX, a Spanish-language broadcast channel. Under the ownership of Comcast, NBCUniversal has increased investment in Telemundo.

But the biggest competition for Fusion might not come from traditional television. The median age of Hispanics in the United States is 28, and Latinos spent 68 percent more time watching video on the Internet than non-Hispanics, according to figures from Telemundo. Enticing those viewers to watch the old-fashioned way may prove tough.

Last year, the then-unnamed Fusion began news coverage online, in time to cover the presidential election. The channel’s online presence will grow leading up to the TV inauguration. “We will treat digital as the first screen, not the second screen,” Mr. Lee said.

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Gen. Joseph Dunford becomes U.S. commander in Afghanistan

KABUL, Afghanistan — Gen. Joseph F. Dunford Jr. took over Sunday as the newest and probably last U.S. commander in Afghanistan, charged with ending America's longest war even as insurgents continue to challenge the U.S.-backed Afghan government.

Dunford, a four-star Marine officer, arrives as the U.S.-led NATO coalition has closed three-quarters of its 800 bases and as it watches to see whether the Afghan security forces it trained can keep the Taliban insurgency at bay.

A ceremony inside the coalition's heavily guarded compound in Kabul marked the end of the 19-month tenure of Gen. John R. Allen, whose command was marred by a rash of deadly "insider" attacks by Afghan forces against their U.S. and NATO trainers and by strained relations with Afghan President Hamid Karzai.

But in remarks tinged with emotion Sunday, Allen pointed to significant progress, including the growth of the Afghan security forces, an increase in Afghan-led military operations, a sharp reduction in civilian casualties and the withdrawal of about 35,000 U.S. troops.

"This is victory," Allen said. "This is what winning looks like, and we should not shrink from using those words."

Allen was cleared of wrongdoing last month in a Pentagon inquiry into emails he exchanged with a woman who was linked to the sex scandal that forced the resignation of CIA Director David H. Petraeus. Allen has been nominated to lead North Atlantic Treaty Organization forces in Europe.

By replacing Allen with Dunford, the respected but low-key assistant commandant of the Marine Corps, President Obama hopes to repair ties with Karzai so they can cement a long-term security deal that could see several thousand U.S. troops remain in Afghanistan beyond the withdrawal of combat forces next year.

Embracing Allen at the ceremony, Dunford stressed continuity in the mission.

"What's not changed is the will of this coalition," he said. "What's not changed is the growing capability of our Afghan partners."

Obama is expected to spell out plans for the troop withdrawal and a post-2014 U.S. military presence in Afghanistan as early as his State of the Union message Tuesday. Although White House officials have said it's possible that no U.S. troops would remain, Pentagon officials are calling for a residual force that would focus on counter-terrorism and supporting Afghan forces.

Dunford will have a key seat at the table as U.S. officials try to work out the security agreement, which will hinge on earning assurances from Afghan leaders that they won't release prisoners currently in U.S. custody and will guarantee U.S. troops immunity from prosecution in Afghan courts. The failure to reach an immunity guarantee was a main reason no U.S. troops remained in Iraq after the war ended there.

About 65,000 U.S. troops remain in Afghanistan, down from a high of 100,000. Despite flagging U.S. support for the war, military commanders contend that removing the remaining troops precipitously could cause Afghan security forces to collapse.

In his Senate confirmation hearing in November, Dunford offered no prescriptions for troop levels but cautioned against withdrawing too quickly, saying it could destabilize the region.

U.S. officials recently estimated that a residual American force could number from 6,000 to 9,000 troops — fewer than the 15,000 senior military commanders had wanted. Experts say that Dunford will be charged with figuring out how such a force could achieve U.S. strategic aims.

"A major challenge will be identifying a mission that those troops can perform that's useful and doable with that small number," said Stephen Biddle, a defense analyst and professor at George Washington University.

Even as the war winds down, challenges remain. The insider attacks that killed 61 NATO troops in 2012 have dissipated, but only after U.S. troops scaled back joint operations with Afghan forces, hampering training efforts. By next year, Afghan forces are expected to be in the lead of all security operations, but the Taliban, though weakened, retains the ability to attack in Kabul and other strategic areas.

Experts say that Dunford, who earned the nickname "Fighting Joe" when he led a charge from Kuwait into Baghdad during the 2003 invasion of Iraq, could clash with a second-term Obama Cabinet, whose members — including Secretary of State John F. Kerry and, if he's confirmed, Chuck Hagel as Defense secretary — have not been strong supporters of a large long-term U.S. presence in Afghanistan.

"It's going to be extremely difficult for a commanding general who's not going to have many partners in the administration," said Thomas Donnelly, a military expert at the American Enterprise Institute, a conservative Washington think tank.

"It's a bit of a thankless task, for sure."

shashank.bengali@latimes.com

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For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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The Media Equation: The Inconvenient but Vital Drone Debate

Last week, the debate over drone strikes broke out into plain view during the confirmation hearings for John O. Brennan, President Obama’s choice to head the Central Intelligence Agency. Given that the program has been operating largely under the public radar, a question has been raised whether the news media have done their job in keeping the American public informed about this radically different approach to warfare.

Some think not. In a report released last week by the Joan Shorenstein Center on the Press, Politics and Public Policy, Tara McKelvey, who has done her share of significant reporting on the issue, suggested that during Mr. Obama’s first term, “the media fell short in its coverage” of the drone program.

She applauded the increased attention to the issue, saying in a survey that coverage in five major media outlets had almost doubled since the start of that term, rising to 625 stories in 2012 from 326 in 2009.

Maybe we are asking the wrong question. Journalists at The Los Angeles Times, The Wall Street Journal, Reuters, The New York Times and The New Yorker have done a remarkable job on pulling back the blankets on a covert program overseen by an administration that is very aggressive in protecting secrets.

If the Congress — and perhaps the public — doesn’t know about the drone program, it isn’t for lack of coverage. Perhaps the reason so many people are in the dark is because they want it that way. After all, if the bad guys are on the run without risking legions of boots on the ground, what’s not to like?

For many people, of course, there is plenty not to like. Michael Isikoff of NBC News obtained a 16-page white paper outlining when the government contends that it is legal to kill Americans who join Al Qaeda. His reporting helped make the drone issue part of the confirmation hearings, leading to this statement on Thursday to the Senate Intelligence Committee from Mr. Brennan, which sounded like a parody of Washington doublespeak: “What we need to do is optimize transparency on these issues, but at the same time, optimize secrecy and the protection of our national security.”

Congress, in spite of the pointed questions aimed at Mr. Brennan last week, has been remarkably incurious since the program began.

“Some 3,500 people have died in 420 strikes, and Congress has yet to hold a single public hearing on this issue,” said Micah Zenko, a fellow at the Council on Foreign Relations. “It has happened in the dark because we have allowed it to, and the press has far and away been the lead actor in surfacing this issue.”

Back in 2009, Jane Mayer did a deep dive into the issue. “It’s important,” Ms. Mayer said in a telephone interview. “After scientists working for America split the atom, there was an awesome new technology, and they had to come up with a legal framework to contain it. Drones represent a very big change as well, and there should be a lot of open discussion about defining the rules of its use.”

Most of that discussion has occurred in the press, not in the halls of government. An article by Jo Becker and Scott Shane in The New York Times last May revealed that the administration had a “kill list” of people who were targeted for elimination, often by drones.

Last week, an article in The Times by Robert F. Worth, Mark Mazzetti and Scott Shane pointed out that drones, which are held by the government to be instruments of precision, are often a blunt technology that sometimes takes out the very people the United States needs in places like Yemen.

If some of the news coming out of the hearings last week was a big surprise, it might be because people chose not to pay close attention.

“I think what you saw on Thursday,” Mr. Shane, referring to the Brennan hearings, said in a telephone interview, “is that people are beginning to realize that they have introduced this whole new way of killing people without public debate or pushback and the disaffection with the lack of oversight boiled over.”

The specifics of the drone program have been carefully shielded at every turn. In January a federal judge ruled against The New York Times in its effort to compel the Justice Department to disclose the memo that provided the legal justification for the targeted killing of Anwar al-Awlaki, a United States citizen who died in a drone strike in Yemen in 2011, without any due process of law. (The death of an American at the other end of a drone seemed to prompt a new level of interest and scrutiny by the news media.)

Even though the judge, Colleen McMahon, ruled in the government’s favor, she did not sound very happy about it.

E-mail: carr@nytimes.com; twitter.com/carr2n

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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 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.

Entertainment News Headlines – Yahoo! News

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