The ConsUmer: Questions About a Robotic Surgery

Ever since it was approved by the Food and Drug Administration in 2005, robotic surgery for hysterectomy has been heavily advertised. Surgeons promise that using the da Vinci robotic device will bring better results and an easier recovery, and many hospitals claim that patients will experience less pain and fewer complications, getting back on their feet faster.

The company that makes da Vinci robotic surgery equipment promoted it last May at free health workshops organized by the federal Office on Womens’ Health. On Sunday, the Liberty Science Museum in Jersey City will host its first “Let’s Operate Day,” offering guests “hands-on” practice peering into video monitors and using da Vinci’s robot arms to pick up and manipulate small objects.

The cost of the new technology is rarely mentioned. But last week, a new study that evaluated outcomes in more than a quarter of a million American women raised questions about the manufacturer’s claims. The paper, published in The Journal of the American Medical Association, compared outcomes in 264,758 women who had either laparoscopic or robotically assisted hysterectomy at 441 hospitals between 2007 and 2010. Both methods are minimally invasive and involve smaller incisions than open abdominal surgery.

The researchers found no overall difference in complication rates between the two groups, and no difference in the rates of blood transfusion, even though one of the claims regarding robotic surgery is that it causes less blood loss.

But the researchers did find a big difference in cost. Robotically assisted surgery for hysterectomy costs on average about one-third more than laparoscopic surgery.

“It’s important to separate the marketing from the data,” said Dr. Jason D. Wright, the study’s lead author, an assistant professor of obstetrics and gynecology at Columbia University Medical Center. “For the surgeon, there is a greater degree of movement and control of the instruments and the visualization is better.

“But the ultimate question is, does this change outcomes for patients? This study suggests that there really is not a lot of difference as far as quantifiable outcomes.”

The majority of patients in both groups left the hospital in less than two days, though patients who had robotic surgery were slightly more likely to go home that early: 80 percent went home in less than two days, compared with 75 percent of those who had laparoscopic surgery.

But the cost of robotic surgeries was significantly higher, with a median cost to the hospital of $8,868, compared with $6,679 for laparoscopic hysterectomy. The study did not look at the difference in patients’ bills, but according to Newchoicehealth.com, the average patient price for a laparoscopic hysterectomy ranges from $7,700 in Dallas to $11,600 in Los Angeles.

With laparoscopic surgery — sometimes called keyhole surgery — narrow instruments and a small video camera are inserted through tiny incisions; the surgeon sees the image on a monitor and can cut and sew tissue with the instruments. With robotically assisted surgery, the surgeon sits at a console with a 3-dimensional view of the surgical site, and computer technology translates his or her hand movements into precise, scaled movements of the instruments.

Even without offering clear advantages the proportion of hysterectomies performed robotically has increased rapidly, up to nearly 10 percent of hysterectomies in 2010 from less than 1 percent in 2007, Dr. Wright said. Minimally invasive surgeries for hysterectomies are increasing across the board, he found, even at hospitals not performing robotic surgery.

Dr. Myriam J. Curet, chief medical adviser to Intuitive Surgical, which makes the da Vinci systems, did not dispute the study’s findings, but said the important message was that more women were able to receive minimally invasive surgeries because more options were available.

“That’s good for patients and for the health care system,” Dr. Curet said. Women who are not candidates for laparoscopic surgery might still be candidates for robotically-assisted surgery, she added.

Right now, however, it is not clear how to identify which women would benefit from robotic surgery and which would do well with a less expensive method.

The growing use of robotic surgery in hospitals will continue to drive up health costs, said Joel S. Weissman, of Brigham and Women’s Hospital and a co-author of an editorial published with the study.

“Once you have that robot, the tendency is to use it for all kinds of things, for which it may or may not have great value,” Dr. Weissman said. Studies like this one, he said, demonstrate the waste of health care dollars on “something that costs a lot more and doesn’t offer any added benefit over current treatment options.”

Each year approximately 600,000 American women have hysterectomies, according to the Centers for Disease Control and Prevention. By age 60, one in three American women has had her uterus removed, often along with her ovaries and cervix.

Critics who say far too many hysterectomies are done in the United States worry that all the attention to surgical method distracts from the question of whether patients should be having the surgery at all.

Most hysterectomies are prescribed for conditions that are not life-threatening, and advocates worry that women are not fully informed of the long-term harms, which may include a loss of sexual responsiveness, depression and chronic constipation, and higher risk for osteoporosis and heart disease, said Nora W. Coffey, the founder of the nonprofit Hysterectomy Educational Resources and Services Foundation.

“That’s the conversation we should be having,” Ms. Coffey said.

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Nora W. Coffey and other experts emphasize that women considering a hysterectomy should discuss all options with their doctors.

¶Ask what the alternatives are and whether watchful waiting is an option. Remember that it is irreversible, regardless of how the surgery is done.

¶Learn about the nonreproductive functions of the uterus, ovaries and cervix, and the potential long-term consequences associated with their removal, as well as the function of the ovaries and cervix.

¶If you proceed, discuss the advantages and disadvantages of different surgical methods with your doctor. Interview several surgeons and inquire about the cost and how much insurance will cover. Your co-pay may vary depending on the surgical method.

¶Tell your surgeon if you do not want your ovaries and cervix removed.

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British Government Seeks to Limit Disclosure in Litvinenko Case

The British government sought on Tuesday to limit the information it is ready disclose at a planned inquest into the death of Alexander V. Litvinenko, a former officer in the K.G.B. who died of radiation poisoning in London more than six years ago, and the coroner hearing the case said it may now be postponed.

“Due to the complexity of the investigation which necessarily precedes the hearings” Sir Robert Owen, the coroner said, the planned May 1 start date for the hearings could represent “a timetable to which it may not be possible to adhere.”

The inquest would be the first — and likely the only — public forum at which witnesses would testify under oath about the killing, which strained Britain’s relationship with the Kremlin and kindled memories of the cold war.

The prospect of a postponement brought charges from Ben Emmerson, a lawyer representing Mr. Litvinenko’s widow, Marina Litvinenko, that the British government was trying to gag the inquiry in order to protect lucrative trade deals with Russia.

Referring to Prime Minister David Cameron, Mr. Emmerson said on Tuesday that “the British government, like the Russian government, is conspiring to get this inquest closed down in exchange for substantial trade interests which we know Mr. Cameron is pursuing."

He added: "One has to ask what is going on at the highest level of Her Majesty’s Government, particularly when the highest levels are building bridges with the Kremlin."

The British government, he said, had “no right to say to an independent judiciary, ’you may not investigate these issues’. That happens in Russia, for sure.”

“This has all the hallmarks of a situation which is shaping up to be a stain on British justice,” the lawyer said.

Sir Robert, the coroner, said he would rule on Wednesday on the government’s application for a so-called Public Interest Immunity Certificate, usually issued on the grounds of national security, which would prevent the inquest from hearing information on topics without explaining what those issues were.

British analysts say they believe Britain is keen to avoid disclosing any information that might link Mr. Litvinenko to the British security services.

Last December, Mr. Emmerson, the lawyer, told a preparatory hearing that that Mr. Litvinenko was a “registered and paid agent and employee of MI6,” as the British Secret Intelligence Service is known. Mr. Litvinenko also worked for the Spanish intelligence service, Mr. Emmerson said, and both the British and Spanish spy agencies made payments into a joint account with his wife. The lawyer added that the inquest should consider whether MI6 failed in its duty to protect the onetime KGB officer against a “real and immediate risk to life.”

Mr. Litvinenko, who fled Russia in 2000 and styled himself a whistle-blower and foe of the Kremlin, died in November 2006, aged 43, weeks after he secured British citizenship. He had ingested polonium 210 — a rare radioactive isotope — at the Pine Bar of the Millennium Hotel in London’ central Grosvenor Square.

Britain’s Crown Prosecution Service is seeking the extradition from Russia of Andrei K. Lugovoi, another former K.G.B. officer, to face trial on murder charges. Mr. Lugovoi denies the accusation and Russia says its Constitution forbids it from sending its citizens to other countries to face trial.

The coroner has said in previous hearings that he will examine what was known about threats to Mr. Litvinenko and would also seek to determine whether the Russian state bore responsibility. In a deathbed statement, Mr. Litvinenko directly blamed President Vladimir V. Putin, who dismissed the accusation. Mr. Emmerson, the lawyer, complained on Tuesday that the preparations for the inquest were becoming “bogged down” by “the government’s attempt to keep a lid on the truth.”

“It is the government’s secret files that are delaying this inquest.”

British media outlets including the BBC and The Guardian newspaper are opposing the government’s effort to restrict evidence. The Guardian said that “the public and media are faced with a situation where a public inquest into a death may have large amounts of highly relevant evidence excluded from consideration by the inquest. Such a prospect is deeply troubling.”

But the Foreign Office said the authorities had made their application in line with their “duty to protect national security” and the coroner would rule according to “the overall public interest.”

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DealBook: Barnes & Noble Chairman Leonard Riggio to Bid for Bookstore's Retail Business

Correction Appended

The chairman of Barnes & Noble plans to bid for the retail business of the bookstore chain he started 40 years ago, as the company struggles with a changing competitive landscape.

On Monday, Leonard Riggio told the company’s board that he would make an offer for Barnes & Noble Booksellers, barnesandnoble.com and other retail assets. The proposal would not include the e-book division, Nook Media.

Like many retailers, the company is confronted by waning profit in its core business, as online retailers and other competitors gain market share. Barnes & Noble recently warned that earnings would be weak in the latest quarter, with losses rising in its Nook Media division.

Conceived as a serious competitor to Amazon.com’s Kindle, the Nook has instead become an also-ran in the race for digital book supremacy. The Kindle remains the top-selling dedicated e-reader, while the iPad consistently leads the competition among tablets. Amazon’s Kindle app has also maintained a huge lead in popularity, limiting Barnes & Noble’s reach across the broader digital bookselling landscape.

It is the boldest move yet by Mr. Riggio, the company’s largest shareholder who owns nearly 30 percent of Barnes & Noble, to try and save the company.

After building a small chain of college bookstores, Mr. Riggio in the 1970s bought the Barnes & Noble name and the flagship location in Manhattan, which had run into trouble. Over the next several decades, he built the company into the nation’s biggest brick-and-mortar bookseller.

In recent years, Mr. Riggio has fended off challenges from the likes of the billionaire Ronald W. Burkle. As part of that effort, Mr. Riggio argued, in large part, that the company was well-positioned in the future by betting on the Nook and digital books.

Others believed in the promise of the e-reader as well.

Microsoft paid $300 million in April for a 17.6 percent stake in the Nook business, valuing it then at $1.7 billion. Microsoft also secured Barnes & Noble’s commitment to produce an e-reader app for its Windows 8 operating system. And in December, the British publisher Pearson agreed to buy a 5 percent stake for $89.5 million.

Mr. Riggio, plans to negotiate the price with the board, according to a regulatory filing. The proposal is expected to be mainly in cash. The retailer’s board had already been weighing whether to spin off its Nook unit.

Barnes & Noble said in a statement that it had formed a special board committee of three directors – David G. Golden, David A. Wilson and Patricia L. Higgins – to consider Mr. Riggio’s proposal. The committee will be advised by Evercore Partners and the law firm Paul, Weiss, Rifkind, Wharton & Garrison.

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Correction: February 25, 2013

An earlier version of this article referred imprecisely to the role of its largest shareholder, Leonard Riggio, in the company’s history. While Mr. Riggio founded the modern company that acquired the name in the 1970s, William Barnes and G. Clifford Noble opened the original Barnes & Noble bookstore, in 1917.

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'Argo' wins best picture on scattered Oscar night

LOS ANGELES (AP) — Just as Oscar host Seth MacFarlane set his sights on a variety of targets with a mixture of hits and misses, the motion picture academy spread the gold around to a varied slate of films. "Argo" won best picture as expected, along with two other prizes. But "Life of Pi" won the most awards with four, including a surprise win for director Ang Lee.

"Les Miserables" also won three Academy Awards, while "Django Unchained" and "Skyfall" each took two.

Among the winners were the front-runners throughout this lengthy awards season: best actor Daniel Day-Lewis for his deeply immersed portrayal of Abraham Lincoln in Steven Spielberg's epic "Lincoln," best actress Jennifer Lawrence as a troubled young widow in "Silver Linings Playbook" and supporting actress Anne Hathaway as the doomed prostitute Fantine in the musical "Les Miserables." Christoph Waltz was a bit of a surprise for supporting actor as a charismatic bounty hunter in Quentin Tarantino's "Django Unchained," an award he'd won just three years ago for Tarantino's "Inglorious Basterds."

The 22-year-old Lawrence, who got to show her lighter side in the oddball romance "Silver Linings Playbook" following serious roles in "Winter's Bone" and "The Hunger Games," gamely laughed at herself as she tripped on the stairs en route to the stage in her poufy, pale pink Dior Haute Couture gown. Backstage in the press room, when a reporter asked what she was thinking, she responded: "A bad word that I can't say that starts with 'F.'" Keeping journalists in hysterics, she explained, "I'm sorry. I did a shot before I ... sorry."

That's the kind of raunchiness MacFarlane himself seemed to be aiming for as host while also balancing the more traditional demands of the job. There was a ton of singing and dancing during the three-and-half-hour broadcast — no surprise from the musically minded creator of the animated series "Family Guy" — including a poignant performance from Barbra Streisand of "The Way We Were," written by the late Marvin Hamlisch, during the memorial montage. But MacFarlane also tried to keep the humor edgy with shots at Mel Gibson, George Clooney, Chris Brown and Rihanna.

An extended bit in which William Shatner came back from the future as his "Star Trek" character, Capt. James T. Kirk, had its moments while a joke about the drama "Flight" being restaged entirely with sock puppets was a scream. A John Wilkes Booth gag in reference to "Lincoln" was a bit of a groaner, perhaps intentionally, while MacFarlane relied on his alter ego, the cuddly teddy bear from his directorial debut "Ted," to make a crack about a post-Oscar orgy at Jack Nicholson's house. (MacFarlane already has indicated he's one-and-done with Academy Awards hosting.)

But it was Day-Lewis who came up with the kind of pop-culture riffing that's MacFarlane's specialty. In accepting his record third best-actor award from presenter Meryl Streep, he deadpanned that before they'd swapped roles, he originally was set to play Margaret Thatcher "and Meryl was Steven's first choice for 'Lincoln,' and I'd like to see that version."

Besides best picture, "Argo" won for Chris Terrio's adapted screenplay and for William Goldenberg's film editing. Affleck famously (and strangely) wasn't included in the best-director category for his thrilling and surprisingly funny depiction of a daring rescue during the 1979 Iranian hostage crisis. But as a producer on the film alongside George Clooney and Grant Heslov, he got to take home the top prize of the night.

"I never thought I'd be back here, and I am because of so many of you in this academy," said Affleck, who shared a screenplay Oscar with pal Matt Damon 15 years earlier for their breakout film "Good Will Hunting."

Among the wisdom he's acquired since then: "You can't hold grudges — it's hard but you can't hold grudges."

Lee, who previously won best director in 2006 for "Brokeback Mountain" (which also didn't win best picture), was typically low-key and self-deprecating in victory. His "Life of Pi" is a fable set in glorious 3-D, but Spielberg looked like the favorite for "Lincoln." The film also won for its cinematography, original score and visual effects.

"Thank you, movie god," the Taiwanese director said on stage. Later, he thanked his agents and said: "I have to do that," with a little shrug and a smile.

"Les Miserables" also won for sound mixing and makeup and hairstyling. The other Oscar for "Django Unchained" came for Tarantino's original screenplay. Asked about his international appeal backstage, Tarantino was enthusiastic as usual in saying: "I'm an American, and a filmmaker, but I make movies for the planet Earth."

Speaking of global hits, the James Bond action thriller "Skyfall" won for its original song by the unstoppable Adele (with Paul Epworth). It also tied for sound editing with "Zero Dark Thirty," the only win of the night for Kathryn Bigelow's detailed saga about the hunt for Osama bin Laden.

Among the other winners, "Searching for Sugar Man," about a forgotten musician's rediscovery, took the prize for best documentary feature. Pixar's fairy tale "Brave" won best animated feature.

One of the biggest moments of the night came at the end, as First Lady Michelle Obama announced the winner of the best picture prize. Backstage, Affleck described how surreal it was when he heard her say the word: "Argo."

"I was sort of hallucinating when that was happening," he explained. "In the course of a hallucination it doesn't seem that odd: 'Oh look, a purple elephant. Oh look, Michelle Obama.'"

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Contact AP Movie Critic Christy Lemire through Twitter: http://twitter.com/christylemire

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Mediterranean Diet Can Cut Heart Disease, Study Finds

About 30 percent of heart attacks, strokes and deaths from heart disease can be prevented in people at high risk if they switch to a Mediterranean diet rich in olive oil, nuts, beans, fish, fruits and vegetables, and even drink wine with meals, a large and rigorous new study found.

The findings, published on the New England Journal of Medicine’s Web site on Monday, were based on the first major clinical trial to measure the diet’s effect on heart risks. The magnitude of the diet’s benefits startled experts. The study ended early, after almost five years, because the results were so clear it was considered unethical to continue.

The diet helped those following it even though they did not lose weight and most of them were already taking statins, or blood pressure or diabetes drugs to lower their heart disease risk.

“Really impressive,” said Rachel Johnson, a professor of nutrition at the University of Vermont and a spokeswoman for the American Heart Association. “And the really important thing — the coolest thing — is that they used very meaningful end points. They did not look at risk factors like cholesterol of hypertension or weight. They looked at heart attacks and strokes and death. At the end of the day, that is what really matters.”

Until now, evidence that the Mediterranean diet reduced the risk of heart disease was weak, based mostly on studies showing that people from Mediterranean countries seemed to have lower rates of heart disease — a pattern that could have been attributed to factors other than diet.

And some experts had been skeptical that the effect of diet could be detected, if it existed at all, because so many people are already taking powerful drugs to reduce heart disease risk, while other experts hesitated to recommend the diet to people who already had weight problems, since oils and nuts have a lot of calories.

Heart disease experts said the study was a triumph because it showed that a diet is powerful in reducing heart disease risk, and it did so using the most rigorous methods. Scientists randomly assigned 7,447 people in Spain who were overweight, were smokers, had diabetes or other risk factors for heart disease to follow the Mediterranean diet or a low-fat one.

Low-fat diets have not been shown in any rigorous way to be helpful, and they are also very hard for patients to maintain — a reality born out in the new study, said Dr. Steven E. Nissen, chairman of the department of cardiovascular medicine at the Cleveland Clinic Foundation.

“Now along comes this group and does a gigantic study in Spain that says you can eat a nicely balanced diet with fruits and vegetables and olive oil and lower heart disease by 30 percent,” he said. “And you can actually enjoy life.”

The study, by Dr. Ramon Estruch, a professor of medicine at the University of Barcelona, and his colleagues, was long in the planning. The investigators traveled the world, seeking advice on how best to answer the question of whether a diet alone could make a big difference in heart disease risk. They visited the Harvard School of Public Health several times to consult Dr. Frank M. Sacks, a professor of cardiovascular disease prevention there.

In the end, they decided to randomly assign subjects at high risk of heart disease to three groups. One would be given a low-fat diet and counseled on how to follow it. The other two groups would be counseled to follow a Mediterranean diet. At first the Mediterranean dieters got more intense support. They met regularly with dietitians while the low-fat group just got an initial visit to train them in how to adhere to the diet followed by a leaflet each year on the diet. Then the researchers decided to add more intensive counseling for them, too, but they still had difficulty staying with the diet.

One group assigned to a Mediterranean diet was given extra virgin olive oil each week and was instructed to use at least 4 tablespoons a day. The other group got a combination of walnuts, almonds and hazelnuts and was instructed to eat about an ounce of them each day. An ounce of walnuts, for example, is about a quarter cup — a generous handful. The mainstays of the diet consisted of at least 3 servings a day of fruits and at least two servings of vegetables. Participants were to eat fish at least three times a week and legumes, which include beans, peas and lentils, at least three times a week. They were to eat white meat instead of red, and, for those accustomed to drinking, to have at least 7 glasses of wine a week with meals.

They were encouraged to avoid commercially made cookies, cakes and pastries and to limit their consumption of dairy products and processed meats.

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Many Cruise Ship Lack Backup Power Systems, Vexing Regulators

Denis Poroy/Associated Press

The Carnival Splendor cruise ship was towed into San Diego Bay in 2010, after a fire destroyed its electrical systems.

It is becoming a familiar tale: When the cruise ship was towed into port, the endless hours for passengers of sleeping on deck and going without electricity or toilets were finally over.

“It was really hell,” said Bernice Spreckman, who is 77 and lives in Yonkers, N.Y. “I used my life jacket, which was flashing with a little light on it, to find a bathroom it was so dark.”

Ms. Spreckman was not among the 4,200 people aboard the Carnival Triumph who this month endured five days of sewage-soaked carpets and ketchup sandwiches. Her trial at sea came in 2010, on another ship run by Carnival Cruises, called the Splendor, which carried 4,500 passengers.

On both ships, fires broke out below decks, destroying the electrical systems and leaving them helpless. A preliminary Coast Guard inquiry into the Splendor found glaring deficiencies in its firefighting operations, including manuals that called for crew members to “pull” valves that were designed to turn.

But more than two years after the episode, the final report about what happened on the Splendor has yet to appear, a reflection of what critics say is a pattern of international regulatory roulette that governs cruise ship safety.

While the Splendor was based in the United States, the ship was legally registered in Panama, meaning the Panamanian Maritime Authority had the right to lead the investigation. But after the 2010 fire, Panamanian regulators chose to have the Coast Guard take over the inquiry. Then, officials in both countries apparently spent months trading drafts of their reports.

One official in Panama said the authority had completed its review of the Splendor report in October 2012. But a Coast Guard spokeswoman, Lisa Novak, said it still had not “finalized” the report. In the case of the Carnival Triumph, the regulatory scene will shift to the Bahamas, where that ship was registered.

In a recent letter to Coast Guard officials, Senator Jay Rockefeller, Democrat of West Virginia, said that cruise ships seemed to have two separate lives. Only during days near port are they closely monitored.

“Once they are beyond three nautical miles from shore, the world is theirs,” said the letter from Senator Rockefeller, who has headed recent inquiries into cruise ship safety.

Cruise industry officials point out that seaborne vacations are extremely safe and that some 20 million people go on cruises annually, with few problems. The most glaring exception to that record occurred last year when a vessel operated by a subsidiary of Carnival, the Costa Concordia, ran aground off the coast of Italy, resulting in 32 deaths.

In the Triumph’s case, the Coast Guard has said that the ship’s safety equipment failed to contain the blaze. And both the Triumph and the Splendor returned from their aborted voyages without serious injuries to passengers or crew.

But those successes also underscore what most travelers do not realize when they book cruises: nearly all ships lack backup systems to help them return to port should power fail because to install them would have cost operators more money.

The results are repeated episodes involving dead ships, with all the discomforts and potential dangers such situations can bring. In another case, in late 2012, the Costa Allegra cruise ship, a sister ship of the Concordia, lost power after a fire in the generator room and it had to be towed under guard from its location in the Indian Ocean.

In many ways, passengers aboard boats like the Triumph and Splendor were lucky because their ships were disabled in calm weather, when instead they could have been knocked out during storms, or when they were far out at sea or in pirate-infested waters, experts said.

“Anything that knocks a ship dead in the water is serious,” said Mark Gaouette, a safety expert and former Navy officer.

This article has been revised to reflect the following correction:

Correction: February 25, 2013

A caption with an earlier version of this article misstated the number of passengers on the Carnival Splendor when it was disabled at sea. There were 4,500 aboard, not 14,500.

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Palestinians Demand Inquiry Into Detainee’s Death in Israel

JERUSALEM — Palestinian officials on Sunday called for an international investigation into the death of a 30-year-old prisoner in an Israeli jail, saying the man was tortured during interrogation, as thousands of Palestinian prisoners went on a one-day hunger strike in protest.

“Israel is responsible for what happened,” Issa Qaraqa, the Palestinian minister for prisoner affairs, said at a news conference in Ramallah, in the West Bank.

“I accuse the State of Israel of subjecting him to tough physical and psychological pressure,” Mr. Qaraqa said. “He was subjected to a heavy and severe torture.”

Israeli authorities said the prisoner, Arafat Jaradat, died of a heart attack. An autopsy was scheduled for Sunday, with a Palestinian forensic specialist and a relative of Mr. Jaradat scheduled to attend.

Amid intensifying demonstrations in the West Bank that some officials and analysts see as the stirrings of a third intifada, or uprising, Israel on Sunday transferred to the Palestinian Authority $100 million in tax revenue that it had been withholding. Isaac Molho, Prime Minister Benjamin Netanyahu’s special envoy, also sent a message to the Palestinian leadership that Israeli officials described as an “unequivocal demand to restore quiet on the ground.”

Israel has refused Palestinian requests to release four prisoners whe have been on long-term hunger strike or 123 people who have been detained since before the signing of the Oslo Accords in 1993. “Some of these people are accused of very heinous crimes,” a senior Israeli official said, speaking on the condition of anonymity because he was not authorized to discuss the matter with the news media. “They’re saying that every Palestinian hunger striker should have a get-out-of-jail-free card. You can’t have a system like that. It’s not sustainable.”

After days of demonstrations in solidarity with the hunger strikers that have included clashes with Israeli soldiers and settlers, hundreds of Palestinians turned out Sunday in several cities and villages to protest Saturday’s death of Mr. Jaradat, who relatives said worked in a gas station and was the father of a 4-year-old girl and 2-year-old boy. Demonstrators in Gaza waved the flags of Palestinian political factions along with banners reading “Tortured” and “Their freedom is our responsibility.”

“We will resort to all means to liberate the prisoners,” said Sami Abu Zuhri, a spokesman for Hamas, the militant Islamist party that rules the Gaza Strip.

Atallah Abu al-Sabah, Hamas’s minister of prisoner affairs, criticized Palestinian leaders in the West Bank for their handling of the issue, and called for kidnapping Israeli soldiers “instead of pursuing playful negotiations that brought nothing to the Palestinian cause.”

Mr. Jaradat was arrested last Monday for throwing stones at Israeli cars near a West Bank settlement during November’s conflict between Israel and the Gaza Strip. Palestinian officials said he admitted the stone-throwing but denied using Molotov cocktails. He also confessed to tossing rocks in a 2006 incident. Officials said his detention was extended 12 days at a hearing on Thursday, during which his lawyer said Mr. Jaradat complained of severe pain in his back and neck that he attributed to his interrogation.

“When he was under interrogation, the interrogator told him, ‘Say goodbye to your kids,’ ” Mr. Jaradat’s uncle, Musa, said at the Ramallah news conference. Musa Jaradat said that his nephew’s father and brothers had all spent time in Israeli jails, and that before his detention, Arafat Jaradat had sought to join the Palestinian security force.

The Palestinian prime minister, Salam Fayyad, issued a statement expressing “deep sorrow and shock” over Mr. Jaradat’s death, saying there was a “need to promptly disclose the true reasons that led to his martyrdom.”

Jodi Rudoren reported from Jerusalem, and Khaled Abu Aker from Ramallah, West Bank. Fares Akram contributed reporting from the Gaza Strip.

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Dozens of stars spend Saturday at Oscar rehearsals

LOS ANGELES (AP) — Some dressed down in jeans and hoodies. Others looked camera-ready in suits or chic dresses and spiky stilettos.

But all of the stars who rehearsed Saturday for the 85th Academy Awards seemed excited about being a part of the big show.

They paraded through the Dolby Theatre in 15-minute increments: Meryl Streep. Ben Affleck. Reese Witherspoon. Richard Gere. Jennifer Aniston. John Travolta. Nicole Kidman. Jack Nicholson. And dozens more.

Each practiced their lines in front of an audience of show workers and awarded prop Oscars to rehearsal actors. They also scanned the theater from the stage, searching for their show-night seats.

"Oh, wow. That's a very dramatic picture of me," best-actress nominee Jessica Chastain said after spotting her seat-saving placard. "I'm looking at everyone's headshots. It's kind of incredible."

Affleck confessed his excitement from the stage as he looked out at all the famous faces expected Sunday.

"This is like the most memorable aspect of the Oscars," the "Argo" director said. "You see all these place cards (at rehearsal), then you come back and they're all here!"

Affleck also chatted backstage with the college students who won a contest to serve as trophy carriers during the ceremony.

"I love that," he said. "It's super cool."

Travolta also took time with the students.

"I was there when that idea was born and I said it was the best idea they could possibly come up with," he told the aspiring filmmakers backstage. "And here you are!"

Travolta plans to bring his 13-year-old daughter, Ella Bleu, to the ceremony.

Kidman made rehearsals a family affair. Husband Keith Urban and their eldest daughter, Sunday, watched from the audience as Kidman ran through her lines.

She looked impeccable in a wine-colored dress and tall, metallic shoes, but other stars were decidedly more casual. Kristen Stewart arrived in jeans, sneakers and a backward ballcap. (She also limped on an injured right foot.) Renee Zellweger also opted for comfort in jeans and running shoes.

The cast of "Chicago," including Gere, Zellweger, Queen Latifah and Catherine Zeta-Jones, injected their rehearsal with silliness. Latifah purposely over-enunciated her lines, and when a pair of rehearsal actors claimed an Oscar onstage and gave an acceptance speech, Zeta-Jones started to play them off with an imaginary violin.

"Get outta here!" Gere said with a smile.

Octavia Spencer, who won the supporting actress Oscar last year for her performance in "The Help," also had a little fun.

"I'm going to do a soft-shoe," she said, shuffling off stage.

Streep and Jane Fonda were each wowed by the set design. Fonda snapped a photo of it with her iPhone, and Streep marveled at how far the walk to the microphone was.

"All the way to here?!" she asked. "Oh my God."

Halle Berry literally stumbled during her first rehearsal, her pointy heel catching on part of the stage. She insisted on trying again.

"Woo hoo," she said. "Made it."

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AP Entertainment Writer Sandy Cohen is on Twitter: www.twitter.com/APSandy .

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Online:

www.oscars.org

Jane Fonda even took a picture of the stage with her iPhone.

The Academy Awards will be presented Sunday and broadcast live on ABC.

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The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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Major Banks Aid in Payday Loans Banned by States

Major banks have quickly become behind-the-scenes allies of Internet-based payday lenders that offer short-term loans with interest rates sometimes exceeding 500 percent.

With 15 states banning payday loans, a growing number of the lenders have set up online operations in more hospitable states or far-flung locales like Belize, Malta and the West Indies to more easily evade statewide caps on interest rates.

While the banks, which include giants like JPMorgan Chase, Bank of America and Wells Fargo, do not make the loans, they are a critical link for the lenders, enabling the lenders to withdraw payments automatically from borrowers’ bank accounts, even in states where the loans are banned entirely. In some cases, the banks allow lenders to tap checking accounts even after the customers have begged them to stop the withdrawals.

“Without the assistance of the banks in processing and sending electronic funds, these lenders simply couldn’t operate,” said Josh Zinner, co-director of the Neighborhood Economic Development Advocacy Project, which works with community groups in New York.

The banking industry says it is simply serving customers who have authorized the lenders to withdraw money from their accounts. “The industry is not in a position to monitor customer accounts to see where their payments are going,” said Virginia O’Neill, senior counsel with the American Bankers Association.

But state and federal officials are taking aim at the banks’ role at a time when authorities are increasing their efforts to clamp down on payday lending and its practice of providing quick money to borrowers who need cash.

The Federal Deposit Insurance Corporation and the Consumer Financial Protection Bureau are examining banks’ roles in the online loans, according to several people with direct knowledge of the matter. Benjamin M. Lawsky, who heads New York State’s Department of Financial Services, is investigating how banks enable the online lenders to skirt New York law and make loans to residents of the state, where interest rates are capped at 25 percent.

For the banks, it can be a lucrative partnership. At first blush, processing automatic withdrawals hardly seems like a source of profit. But many customers are already on shaky financial footing. The withdrawals often set off a cascade of fees from problems like overdrafts. Roughly 27 percent of payday loan borrowers say that the loans caused them to overdraw their accounts, according to a report released this month by the Pew Charitable Trusts. That fee income is coveted, given that financial regulations limiting fees on debit and credit cards have cost banks billions of dollars.

Some state and federal authorities say the banks’ role in enabling the lenders has frustrated government efforts to shield people from predatory loans — an issue that gained urgency after reckless mortgage lending helped precipitate the 2008 financial crisis.

Lawmakers, led by Senator Jeff Merkley, Democrat of Oregon, introduced a bill in July aimed at reining in the lenders, in part, by forcing them to abide by the laws of the state where the borrower lives, rather than where the lender is. The legislation, pending in Congress, would also allow borrowers to cancel automatic withdrawals more easily. “Technology has taken a lot of these scams online, and it’s time to crack down,” Mr. Merkley said in a statement when the bill was introduced.

While the loans are simple to obtain — some online lenders promise approval in minutes with no credit check — they are tough to get rid of. Customers who want to repay their loan in full typically must contact the online lender at least three days before the next withdrawal. Otherwise, the lender automatically renews the loans at least monthly and withdraws only the interest owed. Under federal law, customers are allowed to stop authorized withdrawals from their account. Still, some borrowers say their banks do not heed requests to stop the loans.

Ivy Brodsky, 37, thought she had figured out a way to stop six payday lenders from taking money from her account when she visited her Chase branch in Brighton Beach in Brooklyn in March to close it. But Chase kept the account open and between April and May, the six Internet lenders tried to withdraw money from Ms. Brodsky’s account 55 times, according to bank records reviewed by The New York Times. Chase charged her $1,523 in fees — a combination of 44 insufficient fund fees, extended overdraft fees and service fees.

For Subrina Baptiste, 33, an educational assistant in Brooklyn, the overdraft fees levied by Chase cannibalized her child support income. She said she applied for a $400 loan from Loanshoponline.com and a $700 loan from Advancemetoday.com in 2011. The loans, with annual interest rates of 730 percent and 584 percent respectively, skirt New York law.

Ms. Baptiste said she asked Chase to revoke the automatic withdrawals in October 2011, but was told that she had to ask the lenders instead. In one month, her bank records show, the lenders tried to take money from her account at least six times. Chase charged her $812 in fees and deducted over $600 from her child-support payments to cover them.

“I don’t understand why my own bank just wouldn’t listen to me,” Ms. Baptiste said, adding that Chase ultimately closed her account last January, three months after she asked.

A spokeswoman for Bank of America said the bank always honored requests to stop automatic withdrawals. Wells Fargo declined to comment. Kristin Lemkau, a spokeswoman for Chase, said: “We are working with the customers to resolve these cases.” Online lenders say they work to abide by state laws.

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