Seeing Through the Fog of ‘Chemo-Brain’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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States anxious over debt talks stalemate

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Peru’s capital highly vulnerable to major quake

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

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

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

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

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

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

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

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

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

A shallow, direct hit is the big danger.

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

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

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

Environmental and human-made perils compound the danger.

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

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

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

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

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

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

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

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

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

But where would the ambulances go?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Associated Press writer Franklin Briceno contributed to this report.

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

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U.S. judge names lead plaintiffs in Facebook litigation

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

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

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

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

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

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

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

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

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

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

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

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

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

(Reporting by Nate Raymond; Editing by Martha Graybow)

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Cablevision to raise Internet prices by $5 a month

(Reuters) – Cablevision Systems Corp, the New York-based cable operator, said on Thursday it would raise its Internet prices by $ 5 in January, representing an average hike of 3.2 percent for customers’ total monthly bills.

The company said in a statement that prices for its video and phone services will not be affected and that prices for promotional packages, which generally last one year, will not rise.

But all customers who have Internet service as part of their video or phone package will see prices rise.

Cablevision said it had not raised Internet prices in a decade. It raised video prices in 2011, which saw customer bills rise by 2.88 percent on average.

The company said it has invested $ 140 million in improving its Internet network, deployed more than 50,000 WiFi “hotspots,” and puts no usage caps on its service, unlike some cable competitors.

Canaccord Genuity analyst Tom Eagan downgraded his Cablevision rating from “buy” to “hold” on November 27 and said that Cablevision would lose customers if it were to decide to raise prices not long after Superstorm Sandy.

“Given the massive service outages among its subscribers (after Sandy), we don’t believe the company can raise rates … without incurring material customer churn,” Eagan said.

The cable provider, which is controlled by the Dolan family, said in early November that costs from Sandy, which knocked out service for as many as half its customers, would be substantially higher than its $ 16 million bill from Hurricane Irene in 2011.

Like bigger operators Comcast and Time Warner Cable, Cablevision has been losing customers to rivals such as satellite television provider DirecTV and telephone operator Verizon Communications.

Cablevision shares closed up 2.6 percent, at $ 14.16, on Thursday.

(Reporting By Liana B. Baker; Editing by Steve Orlofsky and Leslie Adler)

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

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

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

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

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

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

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

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

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

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Syria's civil war spills into Lebanon, 4 dead

BEIRUT (AP) — Syria's civil war spilled over into neighboring Lebanon once again on Sunday, with gun battles in the northern city of Tripoli between supporters and opponents of President Bashar Assad's regime that left four dead.

Nine Syrian judges and prosecutors also defected to the opposition. It was the latest setback for the regime, which appears increasingly embattled with rebels making gains in northern Syria and near Damascus, the capital.

Germany's Federal Intelligence Service chief Gerhard Schindler predicted the Assad regime would not survive.

"Signs are increasing that the regime in Damascus is in its final phase," he was quoted as telling the daily Frankfurter Allgemeine Sonntagszeitung.

In Geneva, the United Nation's Special Representative for Syria and the Arab League, Lakdhar Brahimi, met with Russian Deputy Foreign Minister Mikhail Bogdanov and U.S. Deputy Secretary of State William Burns to discuss the crisis in Syria. They said in a joint statement that the situation in Syria was "bad and getting worse," adding that a political process to end the conflict was "still necessary and still possible."

Russia and the United States have argued bitterly over how to address the conflict, which began with peaceful protests against Assad in March 2011 and escalated into a civil war that has killed an estimated 40,000 people. Activists said another 45 were killed on Sunday.

The U.S. has criticized Russia for shielding the Assad regime, while Moscow has accused Washington of encouraging the rebels and being intent on regime change.

In Moscow, Russian Foreign Minister Sergey Lavrov said that Russia agreed to take part in the Geneva talks on condition there would be no demand for Assad to step down. Washington and its allies, including Turkey, have repeatedly called on the Syrian president to leave power to help stop the bloodshed.

"We are not conducting any negotiations on the fate of Assad," Lavrov said, adding that the Americans were wrong to see Moscow as softening its position on Syria. "All attempts to portray things differently are unscrupulous, even for diplomats of those countries which are known to try to distort the facts in their favor."

Addressing fears that Assad could use chemical weapons in a last-ditch effort to save his regime, Lavrov once again said the Syrian government has given assurances that it has no intention of ever using the weapons of mass destruction. He said the greatest threat is that they would fall into the hands of militants.

Lavrov met last week with Brahimi and U.S. Secretary of State Hillary Rodham Clinton in Dublin. Afterward, Clinton said the United States and Russia were committed to trying again to get both sides in the Syrian conflict to talk about a political transition. Clinton stressed that the U.S. would continue to insist that Assad's departure be a key part of that transition.

Russia's foreign minister said that after he agreed to a U.S. proposal to have his and Clinton's deputies "brainstorm" on Syria, the Americans began to suggest that Russia was softening its position.

"No such thing," Lavrov said. "We have not changed our position."

He urged the international community to come together and "with one voice" to demand a cease-fire, return U.N. observers in bigger numbers and begin a political dialogue. Lavrov repeated that Russia was not wedded to Assad but believed that only the Syrians have the right to choose their leaders.

In Lebanon, fighting between pro-and anti-Assad gunmen flared as bodies of three Lebanese, who were killed after crossing into Syria to fight in the civil war were brought back home for burial, the state-run National News Agency said.

Four people were killed and 12 were wounded in the gunfights, the agency said. Two Lebanese soldiers were also injured, the Lebanese Armed Forces command said.

Syria civil war has often spilled into neighboring countries including Turkey, Lebanon and Israel, raising concerns of a wider war in the volatile region.

Lebanon, which Syria dominated for decades, is particularly vulnerable to getting sucked into the crisis. The two countries share a porous border and a complex web of political and sectarian ties.

Syria's opposition is dominated by members of the Sunni Muslim minority. Assad's regime is predominantly Alawite, an offshoot of Shiite Islam.

Tripoli has been the scene of frequent sectarian clashes between the Alawite and Sunni Muslim communities. Last week, the Lebanese army sent additional troops to Tripoli to try to prevent clashes that broke out over reports that 17 Lebanese men were killed after entering Syria to fight alongside the rebels.

In Syria, fighting between opposition fighters and regime troops was concentrated in northern Idlib province, in the Damascus suburbs and in Aleppo, Syria's largest city, according to the Britain-based opposition activist group Syrian Observatory for Human Rights. At least 45 people were killed in fighting Sunday, said the group, which relies on reports from activists on the ground.

The defecting judges posted a joint statement online urging others to join them and break ranks with Assad's regime. There have been a series of high-level defections over the past year, including Assad's former prime minister. The Observatory said the latest defectors came from the northern city of Idlib.

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Associated Press writers Jamal Halaby in Amman, Jordan, Lynn Berry in Moscow, John Heilprin in Geneva, Switzerland, and Geir Moulson in Berlin contributed to this report.

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Election underscores Ghana’s democratic reputation

ACCRA, Ghana (AP) — Voters in Ghana selected their next president Friday in a ballot expected to mark the sixth transparent election in this West African nation, known as a beacon of democracy in a tumultuous region.

Proud of their democratic heritage, residents of this balmy, seaside capital trudged to the polls more than four hours before the sun was even up, standing inches apart in queues that in some places stretched 1,000-people deep.

By afternoon, some voters were getting agitated, after hitches with the use of a new biometric system caused delays at numerous polling stations.

Each polling station had a single biometric machine, and if it failed to identify the voter’s fingerprint, or if it broke down, there was no backup. At one polling station where the machine had broken down, a local chief said he’d barely moved a few inches: “I’m 58 years old, and I’ve been standing in this queue all day,” Nana Owusu said. “It’s not good.”

Late Friday, when it became clear that large numbers of people had not been able to vote, the election commission announced it would extend voting by a second day. This nation of 25 million is, however, deeply attached to its tradition of democracy, and voters were urging each other to remain calm while they waited their turn to choose from one of eight presidential contenders, including President John Dramani Mahama and his main challenger, Nana Akufo-Addo. The election commission

“Elections remind us how young our democracy is, how fragile it is,” said author Martina Odonkor, 44. “I think elections are a time when we all lose our cockiness about being such a shining light of democracy in Africa, and we start to get a bit nervous that things could go back to how they used to be.”

Ghana was once a troubled nation that suffered five coups and decades of stagnation, before turning a corner in the 1990s. It is now a pacesetter for the continent’s efforts to become democratic. No other country in the region has had so many elections deemed free and fair, a reputation voters hold close to their hearts.

The incumbent Mahama, a former vice president, was catapulted into office in July after the unexpected death of former President John Atta Mills. Before becoming vice president in 2009, the 54-year-old served as a minister and a member of parliament. He’s also written an acclaimed biography, recalling Ghana’s troubled past, called “My First Coup d’Etat.”

Akufo-Addo is a former foreign minister and the son of one of Ghana’s previous presidents. In 2008, Akufo-Addo lost the last presidential election to Mills by less than 1 percent during a runoff vote. Both candidates are trying to make the case that they will use the nation’s oil riches to help the poor.

Besides being one of the few established democracies in the region, Ghana also has the fastest-growing economy. But a deep divide still exists between those benefiting from the country’s oil, cocoa and mineral wealth and those left behind financially.

A group of men who had just voted gathered at a small bar a block away from a polling station in the middle class neighborhood of South Labadi. Danny Odoteye, 36, who runs the bar, said that the country’s economic progress is palpable and that the ruling party, and its candidate, are responsible for ushering in a period of growth.

“I voted for John Mahama,” he said. “Ghana is a prosperous country. Everything is moving smoothly.”

Administrator Victor Nortey, sitting on a plastic chair across from him, disagreed, saying the country’s newfound oil wealth should have resulted in more change.

“I voted for Nana Akufo-Addo,” He said. “Now we have oil. What is Mahama doing with the oil money?” Nortey said. “We can use that money to build schools.”

In an interview on the eve of the vote, Akufo-Addo told The Associated Press that the first thing he will do if elected is begin working on providing free high school education for all. “It’s a matter of great concern to me,” he said, adding that he plans to use the oil wealth to educate the population, industrialize the economy and create better jobs for Ghanaians.

Policy-oriented and intellectual, Akufo-Addo is favored by the young and urbanized voters. He was educated in England and comes from a privileged family. The ruling party has depicted him as elitist.

“The idea that merely because you are born into privilege that automatically means you are against the welfare of the ordinary people, that’s nonsense,” he said.

Ghana had one of the fastest growing economies in the world in 2011. Oil was discovered in 2007 and the country began producing it in December 2010.

Throughout the capital, new condominiums are rising up next to slums and luxury cars creep along narrow alleys lined with open sewers. A mall downtown features a Western-style cinema and is packed on weekends with middle class families. At the same time shantytowns are cropping up, packed with the urban poor.

Polls show that voters are almost evenly split over who can best deliver on the promise of development.

Kojo Mabwa said that he is voting for Akufo-Addo, because he is impressed by his promise of free education. He dismissed critics that say the project is too ambitious. “There is money,” he said. “(The ruling party) has done nothing for us. They are misusing our money.”

Paa Kwesi, a 30-year-old systems analyst, said he doesn’t think Akufo-Addo is making promises he can keep.

“He says he can do free education, but you have to crawl before you can walk. It’s not possible,” he said.

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Associated Press writer Francis Kokutse contributed to this report from Accra, Ghana.

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Rolling Stones hit NY for 50th anniversary gig

NEW YORK (AP) — “Time Waits for No One,” the Rolling Stones sang in 1974, but lately it’s seemed like that grizzled quartet does indeed have some sort of exemption from the ravages of time.

At an average age of 68-plus years, the British rockers are clearly in fighting form, sounding tight, focused and truly ready for the spotlight at a rapturously received pair of London concerts last month.

On Saturday, Mick Jagger, Keith Richards, Ronnie Wood and Charlie Watts hit New York for the first of three U.S. shows on their “50 and Counting” mini-tour, marking a mind-boggling half-century since the band first began playing its unique brand of blues-tinged rock.

And the three shows — Saturday’s at the new Barclays Center in Brooklyn, then two in Newark, N.J., on Dec. 13 and 15 — aren’t the only big dates on the agenda. Next week the Stones join a veritable who’s who of British rock royalty and U.S. superstars at the blockbuster 12-12-12 Sandy benefit concert at Madison Square Garden. Also scheduled to perform: Paul McCartney, the Who, Eric Clapton, Bruce Springsteen & The E Street Band, Alicia Keys, Kanye West, Eddie Vedder, Billy Joel, Roger Waters and Chris Martin.

The Stones‘ three U.S. shows promise to have their own special guests, too. Mary J. Blige will be at the Brooklyn gig, as well as guitarist Gary Clark Jr., the band has announced. (Blige performed a searing “Gimme Shelter” with frontman Jagger in London.) Rumors are swirling of huge names at the Dec. 15 show, which also will be on pay-per-view.

In a flurry of anniversary activity, the band also released a hits compilation last month with two new songs, “Doom and Gloom” and “One More Shot,” and HBO premiered a new documentary on their formative years, “Crossfire Hurricane.”

The Stones formed in London in 1962 to play Chicago blues, led at the time by the late Brian Jones and pianist Ian Stewart, along with Jagger and Richards, who’d met on a train platform a year earlier. Bassist Bill Wyman and drummer Charlie Watts were quick additions.

Wyman, who left the band in 1992, was a guest at the London shows last month, as was Mick Taylor, the celebrated former Stones guitarist who left in 1974 — to be replaced by Wood, the newest Stone and the youngster at 65.

The inevitable questions have been swirling about the next step for the Stones: another huge global tour, on the scale of their last one, “A Bigger Bang,” which earned more than $ 550 million between 2005 and 2007? Something a bit smaller? Or is this mini-tour, in the words of their new song, really “One Last Shot”?

The Stones won’t say. But in an interview last month, they made clear they felt the 50th anniversary was something to be marked.

“I thought it would be kind of churlish not to do something,” Jagger told The Associated Press. “Otherwise, the BBC would have done a rather dull film about the Rolling Stones.”

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Associated Press writer David Bauder contributed to this report.

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Pfizer/Bristol drug cuts recurrence of blood clots – study

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

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

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

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

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

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

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

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

AWAITING U.S. APPROVAL

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

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

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

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

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

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

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

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

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

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

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

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

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