Study Raises Questions on Coating of Aspirin

While aspirin may prevent heart attacks and strokes, a commonly used coating to protect the stomach may obscure the benefits, leading doctors to prescribe more expensive prescription drugs, according to a study published Tuesday in the journal Circulation.

The conclusion about coated aspirin was only one finding in the study, whose main goal was to test the hotly disputed idea that aspirin does not help prevent heart attacks or stroke in some people.

For more than a decade, cardiologists and drug researchers have posited that anywhere from 5 to 40 percent of the population is “aspirin resistant,” as the debated condition is known. But some prominent doctors say that the prevalence of the condition has been exaggerated by companies and drug makers with a commercial interest in proving that aspirin — a relatively inexpensive, over-the-counter drug whose heart benefits have been known since the 1950s — does not always work.

The authors of the new study, from the University of Pennsylvania, claim that they did not find a single case of true aspirin resistance in any of the 400 healthy people who were examined. Instead, they claim, the coating on aspirin interfered with the way that the drug entered the body, making it appear in tests that the drug was not working.

The study was partly financed by Bayer, the world’s largest manufacturer of brand-name aspirin, much of which is coated.

Aside from whether coating aspirin conceals its effects in some people, there is little evidence that it protects the stomach better than uncoated aspirin, said Dr. Garret FitzGerald, chairman of pharmacology at the University of Pennsylvania and one of the study’s authors.

“These studies question the value of coated, low-dose aspirin,” he said in a statement accompanying the article. “This product adds cost to treatment, without any clear benefit. Indeed, it may lead to the false diagnosis of aspirin resistance and the failure to provide patients with an effective therapy.”

In a statement, Bayer took issue with some of the study’s conclusions and methods and said previous studies of coated aspirin, also called enteric-coated aspirin, have been shown to stop blood platelets from sticking together — which can help prevent heart attacks and stroke — at levels comparable to uncoated aspirin. Bayer also noted that the price difference between its coated and uncoated aspirin was negligible, although Dr. FitzGerald argued there was no reason patients should use anything other than uncoated generic aspirin, which is cheaper.

“When used as directed,” the company said, “both enteric and nonenteric coated aspirin provides meaningful benefits, is safe and effective and is infrequently associated with clinically significant side effects.”

Although researchers had long observed that, as is true with most drugs, aspirin’s effects varied among patients, the existence of “aspirin resistance” gained currency in the 1990s and early 2000s. One often-cited study, published in 2003, found that about 5 percent of cardiovascular patients were aspirin-resistant and that that group was more than three times as likely as those not aspirin-resistant to suffer a major event like a heart attack.

But some said the popularity of aspirin resistance got a boost in part because of the development of urine and blood tests to measure it and the arrival on the market of drugs like Plavix, a more expensive prescription drug sold by Bristol-Myers Squibb that also thins the blood.

In the most recent study, the patients who initially tested positive for aspirin resistance later tested negative for it and by the end of the study, Dr. FitzGerald said, none of the patients showed true resistance. “Nobody had a stable pattern of resistance that was specific to coated aspirin,” he said. If resistance to aspirin exists, he said, “I think that the incidence is vanishingly small.”

Dr. Eric Topol, one of the authors of the 2003 study, said he strongly disagreed with Dr. FitzGerald’s conclusions, noting that it looked only at healthy volunteers, “which is very different than studying people who actually have heart disease or other chronic illnesses who are taking various medications.” Those conditions or medications could affect the way aspirin works in the body, he said.

But Dr. Topol and Dr. FitzGerald did agree that there was little value in testing for whether someone was aspirin-resistant, in part because there was little evidence that knowing someone is resistant to aspirin will prevent a heart attack or stroke.

Representatives for Accumetrics, which sells a blood test, and Corgenix, which sells a urine test, maintained that there was value in determining how well aspirin worked in individual patients, and said more recent research on the issue has moved away from a stark determination of whether someone is resistant to aspirin. “This whole concept of drug resistance has moved past that term and moved into the level of response that someone has,” said Brian Bartolomeo, market development manager at Accumetrics.

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U.S. Navy Denies Iranian Claim to Have Captured Drone

TEHRAN — Iran’s Revolutionary Guards Corps naval forces have captured an American drone that it said entered Iranian airspace over the Persian Gulf, state television reported on Tuesday. The claim was quickly denied by the United States Navy.

Iranian state media said the aircraft was a ScanEagle built by Boeing, which, according to the company’s Web site, can be launched and operated from ships.

A spokesman for the United States Navy in Bahrain denied the Iranian claim, saying that no American drones were missing.

“The U.S. Navy has fully accounted for all unmanned air vehicles operating in the Middle East region,” a spokesman for the United States Naval Forces Central Command in Bahrain told Reuters. “Our operations in the gulf are confined to internationally recognized water and airspace. We have no record that we have lost any ScanEagles recently.”

However, the drone could have been one used by the Central Intelligence Agency, or even the National Security Agency, which both have eyes on Iran. Several kingdoms of the Persian Gulf also have ScanEagle drones.

If the seizure is confirmed, it would indicate a spike in tension between the United States and Iran in the skies over the gulf. On Nov. 8, Pentagon officials said Iranian warplanes had fired at a Predator drone flying over the gulf the previous week. It was believed to be the first incident in which Iranian warplanes had fired on an American drone, they said.

State television showed images of what seemed to be an intact ScanEagle being inspected by Rear Adm. Ali Fadavi, the commander of the Revolutionary Guards’ naval forces. The drone was displayed in front of a large map of the Persian Gulf with a text in English and Persian saying, “We shall trample on the U.S..”

Without mentioning the drone claim, President Mahmoud Ahmadinejad on Tuesday warned Iran’s adversaries against aggression. “Our enemies should open their eyes,” he said in a speech. “They may be able to take a few steps forward, but in the end we will make them retreat behind their own border.”

Iran’s foreign minister, Ali Akbar Salehi, told state television on Tuesday that the country planned to use the capture of the drone as evidence against the United States in international organizations.

“We had announced to the Americans that according to international conventions, we would not allow them to invade our territories, but unfortunately they did not comply,” Mr. Salehi said. “We had objected to the Americans before, but they claimed they were not present in our territories. We will use this drone as evidence to pursue a legal case against American invasion in international forums.” Admiral Fadavi said his forces had “hunted down” the ScanEagle over the gulf after it violated Iranian airspace and had forced it to land electronically, the semiofficial Fars news agency reported. A state television commentator said the drone was on a spy mission.

A September report by the Government Accountability Office on unmanned aircraft systems warned that some drones were sensitive to jamming and spoofing. In a spoofing operation, an unencrypted GPS signal can be taken over by enemy forces, the report warns, effectively hijacking the drone.

A former member of Iran’s Foreign Policy and National Security Commission said the seizure of the drone illustrated Iran’s growing military powers and showed that the United States was not really interested in mending relations with Tehran.

“How can we trust President Obama for talks if he sends his drones into our airspace?” the former commission member, Heshmatollah Falahatpisheh, said in an interview. “This move is counterproductive for any détente.”

Iran’s Parliament, which always cheers on any success by the Revolutionary Guards, invited top commanders to present details of the capture to lawmakers.

“The hunting and capturing of this American drone once again showed off the defensive and repelling strengths of the Islamic republic to the world,” Ebrahim Aghamohammadi, a member of Parliament, told Fars. “We are moving forward with dominance.”

In the Nov. 1 attack on the Predator, American officials maintained that the drone had been over international waters, while Iranian commanders insisted that it had violated Iranian airspace. Sea and air borders in the region are strongly contested. Iranian naval forces in small speedboats and United States warships monitor the sea lanes, through which nearly 30 percent of the world’s oil is transported.

Last month, Iran complained to the United Nations over at least eight violations of its airspace by American planes.

Iran’s latest claim came 12 months after Iran said it had brought down an RQ-170 Sentinel operated by the C.I.A. At the time, Iranian state television showed images of the bat-winged drone — apparently fully intact — that Iran had nicknamed “the beast of Kandahar,” a reference to a drone base in Afghanistan.

Iran has maintained that it hacked into the RQ-170’s controls and forced it to land. But American officials said it had crashed in Iranian territory.

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Chiefs had given counseling to Belcher, girlfriend

KANSAS CITY, Mo. (AP) — Kansas City Chiefs officials knew that linebacker Jovan Belcher and his girlfriend were having relationship problems, and the team provided the couple with counseling in an effort to help, a police official said.

Belcher fatally shot Kasandra Perkins, 22, at their Kansas City home Saturday before shooting himself in the head in the Arrowhead Stadium parking lot in front of team officials who were trying to stop him, including general manager Scott Pioli and head coach Romeo Crennel.

Police Sgt. Richard Sharp told The Kansas City Star for a Tuesday story (http://bit.ly/SDwg9m ) that the couple had been arguing over relationship and financial issues for months and that the team had been "bending over backward" trying to help them. Sharp didn't specify how long the couple had been undergoing counseling.

When Belcher arrived at Arrowhead on Saturday, he encountered Pioli in the parking lot and told him the assistance the team had offered hadn't fixed the couple's problems and now "it was too late," police told The Star.

Pioli tried to persuade Belcher to put down his gun as Crennel and linebackers coach Gary Gibbs arrived at the scene.

Belcher thanked the men for everything the team had done for him and asked if Pioli and team owner Clark Hunt would take care of his daughter, The Star reported.

After that, Belcher reportedly said, "Guys, I have to do this."

"I was trying to get him to understand that life is not over," Crennel said Monday. "He still has a chance and let's get this worked out."

When Belcher heard police sirens approaching, he knelt behind a vehicle and shot himself in the head.

Investigators believe Belcher killed himself because he was distraught over shooting Perkins, Sharp said.

"He cared about her," Sharp said. "I don't think he could live with himself."

The night before the killings, Perkins had attended a concert downtown with friends and Belcher had been out at the Power and Light District, police said, while Belcher's mother was watching their 3-month-old baby. Detectives don't know exactly what the couple was arguing about but The Star reported that Belcher was upset that Perkins had stayed out so late.

Autopsies with toxicology tests were performed on both bodies but it could be weeks before results are known, police said.

Police spokesman Darin Snapp said Monday that Belcher's mother was given temporary custody of the couple's daughter.

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Sign Language Researchers Broaden Science Lexicon

Science in Sign:
Lydia Callis, a sign language interpreter, translates a shortened version of an article by Douglas Quenqua, explaining how new signs are being developed that may enhance scientific communication.

Imagine trying to learn biology without ever using the word “organism.” Or studying to become a botanist when the only way of referring to photosynthesis is to spell the word out, letter by painstaking letter.

For deaf students, this game of scientific Password has long been the daily classroom and laboratory experience. Words like “organism” and “photosynthesis” — to say nothing of more obscure and harder-to-spell terms — have no single widely accepted equivalent in sign language. This means that deaf students and their teachers and interpreters must improvise, making it that much harder for the students to excel in science and pursue careers in it.

“Often times, it would involve a lot of finger-spelling and a lot of improvisation,” said Matthew Schwerin, a physicist with the Food and Drug Administration who is deaf, of his years in school. “For the majority of scientific terms,” Mr. Schwerin and his interpreter for the day would “try to find a correct sign for the term, and if nothing was pre-existing, we would come up with a sign that was agreeable with both parties.”

Now thanks to the Internet — particularly the boom in online video — resources for deaf students seeking science-related signs are easier to find and share. Crowdsourcing projects in both American Sign Language and British Sign Language are under way at several universities, enabling people who are deaf to coalesce around signs for commonly used terms.

This year, one of those resources, the Scottish Sensory Centre’s British Sign Language Glossary Project, added 116 new signs for physics and engineering terms, including signs for “light-year,”  (hold one hand up and spread the fingers downward for “light,” then bring both hands together in front of your chest and slowly move them apart for “year”), “mass” and “X-ray” (form an X with your index fingers, then, with the index finger on the right hand, point outward). 

The signs were developed by a team of researchers at the center, a division of the University of Edinburgh in Scotland that develops learning tools for students with visual and auditory impairments. The researchers spent more than a year soliciting ideas from deaf science workers, circulating lists of potential signs and ultimately gathering for “an intense weekend” of final voting, said Audrey Cameron, science adviser for the project. (Dr. Cameron is also deaf, and like all non-hearing people interviewed for this article, answered questions via e-mail.)

Whether the Scottish Sensory Centre’s signs will take hold among its audience remains to be seen. “Some will be adopted, and some will probably never be accepted,” Dr. Cameron said. “We’ll have to wait and see what happens.”

Ideally, the standardization of signs will make it easier for deaf students to keep pace with their hearing classmates during lectures. “I can only choose to look at one thing at a time,” said Mr. Schwerin of the F.D.A., recalling his science education, “and it often meant choosing between the interpreter, the blackboard/screen/material, or taking notes. It was like, pick one, and lose out on the others.”

The problem doesn’t end at graduation. In fact, it only intensifies as new discoveries add unfamiliar terms to the scientific lexicon. “I’ve had numerous meetings where I couldn’t participate properly because the interpreters were not able to understand the jargon and they did not know any scientific signs,” Dr. Cameron said.

One general complaint about efforts to standardize signs for technical terms is the idea that, much like spoken language, sign language should be allowed to develop organically rather than be dictated from above.

“Signs that are developed naturally — i.e., that are tested and refined in everyday conversation — are more likely to be accepted quickly by the community,” said Derek Braun, director of the molecular genetics laboratory at Gallaudet University in Washington, D.C., which he said was the first biological laboratory designed and administered by deaf scientists.

This article has been revised to reflect the following correction:

Correction: December 4, 2012

An earlier version of this article misstated the origin of the ASL-STEM Forum.  It was developed by researchers at the University of Washington, not Gallaudet University.  Researchers at Gallaudet and the National Technical Institute for the Deaf at Rochester Institute of Technology work with the University of Washington to provide content and help the forum grow.

This article has been revised to reflect the following correction:

Correction: December 4, 2012

An earlier version of a correction with this article misstated the name of an institute that works on the ASL-STEM Forum. It is the National Technical Institute for the Deaf at Rochester Institute of Technology not the National Institute for the Deaf. 

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The Next Crisis for German Banks Isn’t Greece — It’s Shipping

FRANKFURT — For all the talk about Germany’s financial exposure to Greece, it turns out that some German banks have a problem of more titanic proportions — their vulnerability to the global shipping trade.

Germany’s 10 largest banks have €98 billion, or $128 billion, in outstanding credit or other risks related to the global shipping industry, according to Moody’s Investors Service. That is more than double the value of their holdings of government debt from Greece, Ireland, Italy, Portugal and Spain. And it is more than any other country’s financial exposure to the shipping industry, which is in the fifth year of a recession.

Moreover, German banks bear a generous share of the blame for spawning that recession. By helping to finance and market funds used to build and purchase ships, a popular tax shelter, the banks helped create a glut in large container ships that has led to a collapse in cargo hauling prices worldwide.

Germans grumble chronically about having to pay for Greece’s bad debts, and German policy makers style themselves as guardians of fiscal prudence. But the shipping-related crisis, and the threat it poses to the German economy from billions of euros in bad loans and losses at shipping-related companies, is a reminder that German banks and political leaders also have plenty to answer for.

Shipping’s recession has been overshadowed by the euro zone debt crisis, but it has many of the same causes. They include complex financial products that turned sour, market-distorting government incentives and a gigantic underestimation of risk.

“The container ship market is completely overbuilt,” said Thomas Mattheis, a partner at TPW Todt, an accounting firm in Hamburg that advises clients in the industry. He blamed banks that granted easy credit, cargo companies that ordered too many vessels and investors eager for the tax-free profits that were part of the allure, thanks to German law.

“When you look back you can say they all had a share,” Mr. Mattheis said.

HSH Nordbank in Hamburg, the world’s largest provider of maritime finance, is expected to raise its estimate of potential losses from shipping on Wednesday when it reports quarterly earnings. The bank, owned by local governments and savings banks, has already warned that in coming years it will need to avail itself of €1.3 billion in guarantees offered by Hamburg and the state of Schleswig-Holstein, putting a further strain on taxpayers.

“I have to admit that grave mistakes were made in the years before 2009,” Constantin von Oesterreich, chief executive of HSH, said in an interview published by The Hamburger Abendblatt on Saturday. In October, Mr. von Oesterreich became the bank’s third new chief executive since 2008.

Other German banks that were particularly active in ship finance, including Commerzbank in Frankfurt and NordLB in Hanover, which both rank in the top five globally in that market, have said they have made adequate provisions for losses and will not need any government aid.

Commerzbank, which is partly owned by the German government after a bailout, shut down a unit specializing in ship financing this year and is winding down its holdings. The bank warned in its most recent quarterly report that it would be at least another year before it could sell units that were set up to finance construction of cargo ships with names including “Marseille” and “Palermo.” While larger, relatively new cargo ships sell for tens of millions of dollars, older, smaller ships often fetch only a few million — not much more than the value of the scrap metal.

Exposure to shipping is one reason Moody’s affirmed its negative outlook for German banks last month. In a report, the ratings agency warned that the global shipping industry “faces weakened demand amid sluggish global economic growth and evolving structural overcapacity.” It said money that the 10 largest German banks had lent to the shipping industry equaled 60 percent of their capital, the funds held in reserve for potential losses.

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Royal Baby a ‘Delight,’ Especially to Britain’s Tabloids

LONDON — The speculation began virtually the moment Kate Middleton said “I will” to Prince William in April 2011, saddling an industry full of tabloid newspapers and gossip magazines with a big black hole where the wedding coverage used to be.

Why, they asked, was the former Ms. Middleton, now the duchess of Cambridge, drinking water instead of wine at an official dinner, in what appeared to be a deliberate manner? And those photographs in which her stomach seemed microscopically less flat than normal, what was that all about?

On Monday, everyone who had incorrectly guessed what was going on before could now finally claim to be right. Yes, St. James’s Palace announced, the duchess had become pregnant.

The royal family is not known for its effusions of public emotion, but in statements posted on the royal Web site, the duke and duchess of Cambridge said they were “very pleased,” while the queen and other family members went with “delighted.”

On Twitter, Prime Minister David Cameron declared that he, too, was delighted.

The pregnancy is in its very early stages and has not yet reached the three-month threshold that would normally have prompted the announcement. But the duchess is in the hospital suffering from “acute morning sickness,” the palace said, and hospitalizations are hard to keep secret.

“Her royal highness is expected to stay in hospital for several days and will require a period of rest thereafter,” the palace said.

There are many interesting things about this possible future royal baby. First, it will be third in line to the throne, even if it is a girl; the laws of succession were recently changed for this very reason. Second, its presence would make the chances of the current No. 3, Prince Harry, becoming king ever more remote, barring some bizarre development in which four generations of his family — his grandmother, his father, his brother and his future niece or nephew — all stepped aside.

Also, it gives Britain something to be excited about at a time when life here has not been so exciting, what with austerity and widespread flooding across huge parts of England after a period of nearly biblical rainfall.

“A royal baby is something the whole nation will celebrate,” the Labour leader, Ed Miliband, observed on Twitter. “Fantastic news for Kate, William and the country.”

In addition to being delighted, the prime minister revealed that in his opinion, the duke and duchess of Cambridge would be “wonderful parents.”

But few people could be more excited than the editors of the newspapers and magazines that cover the royal family, who with any luck will have months of things to write about: What will it be, boy or girl? How fat will the duchess look in her pregnancy clothes? What is happening behind closed doors?

Already, The Daily Mail has revealed a gaggle of purportedly insider-ish details about what is really going on, including the news that the duchess began feeling sick over the weekend and was “unable to keep any food or water down.”

It continued, “Sources suggested that the duchess was hooked up to an intravenous drip to increase her fluid and nutrient levels.”

The papers have also made much of a retrospectively significant incident from last Wednesday, when a member of the public handed Prince William a baby outfit decorated with a helicopter and the words “Daddy’s little co-pilot” — and William smiled as he accepted it.

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Obama Is Taking Himself and #My2K to Twitter This Afternoon

What a day for Twitter! First the Pope, then the Royal Baby, and now President Obama will come online to answer questions about the fiscal cliff. A @WhiteHouse tweet with the distincitive “-bo” signature, announced not long ago that the big guy himself will be taking questions online, starting at 2:00 p.m. ET.

Good to see lots of folks on twitter speaking out on extending middle class tax cuts. I’ll answer some Qs on that at 2ET. Ask w/ #My2k –bo

— The White House (@whitehouse) December 3, 2012

Unfortunately, he’s sticking with the troublesome #My2K hashtag that conservatives have already seized upon in a back-and-forth battle for messaging. Trying to mobilize your supporters through social media is all well and good, but the problem with any genuinely open town hall, is that anyone can invite themselves—even those who disagree with you and might be louder than your friends. (Plus, any reasonably popular hashtag moves much to fast for anyone to follow it or have an actual conversation on Twitter anyway.)

RELATED: Don’t Expect Too Much From Social Media Town Halls

But ask away! Maybe you’ll get luck and get RT’d by the President himself. And then find yourself becoming the next conservative meme as soon as the hashtag-averse pundits start making fun of your question. Should be a fun afternoon.

Social Media News Headlines – Yahoo! News

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A-Rod needs hip surgery, will miss season's start

NASHVILLE, Tenn. (AP) — Alex Rodriguez will have surgery on his left hip and will miss the start of the season and possibly the entire first half.

Rodriguez has a torn labrum, bone impingement and a cyst, the Yankees said Monday. The third baseman will need to follow a pre-surgery program over the next four-to-six weeks, and the team anticipates he will be sidelined four-to-six months after the operation. That timetable projects to a return between the start of May and mid-July.

A-Rod had right hip surgery on March 9, 2009, and returned that May 8. The Yankees said this operation will be "similar but not identical."

Rodriguez, who turns 38 in July, complained of pain in his right hip the night Raul Ibanez pinch hit for him — and hit a tying ninth-inning home run — against Baltimore during the AL division series in October. He went to a hospital and was checked out then.

His left hip injury was detected last month during an exam by Dr. Marc Philippon, who operated on Rodriguez three years ago. A-Rod then got a second opinion from Dr. Bryan Kelly, who will repair the latest injury at the Hospital for Special Surgery in New York.

"Both doctors believe that there is a very strong possibility that Rodriguez's hip condition may have had a negative effect on his performance during the latter stages of the season and the playoffs," the Yankees said.

Rodriguez was benched in three of nine postseason games and pinch hit for in three others. He hit .120 (3 for 25) with no RBIs in the playoffs, including 0 for 18 with 12 strikeouts against right-handed pitchers.

A-Rod broke his left hand when he was hit by a pitch from Seattle's Felix Hernandez on July 24. He returned Sept. 3 and hit .195 with two homers and six RBIs over the final month of the regular season.

This will be Rodriguez's sixth trip to the disabled list in six seasons. He had a strained quadriceps in 2008, the hip surgery in 2009, a strained calf in 2010, knee surgery in 2011 and the broken hand this year.

Signed to a record $275 million, 10-year contract after the 2007 season, Rodriguez is owed $114 million by New York over the next five years.

Fifth on the career list with 647 home runs, he had just 34 the last two seasons.

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Quest to Eliminate Diagnostic Lapses

SAN FRANCISCO — The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the moment of truth arrived, and the room was silent with anticipation.

At last he spoke. “Lymphoma with secondary hemophagocytic syndrome,” he said. The crowd erupted in applause.

Professionals in every field revere their superstars, and in medicine the best diagnosticians are held in particularly high esteem. Dr. Gurpreet Dhaliwal, 39, a self-effacing associate professor clinical medicine at the University of California, San Francisco, is considered one of the most skillful clinical diagnosticians in practice.

The case Dr. Dhaliwal was presented, at a medical  conference last year, began with information that could have described hundreds of diseases: the patient had intermittent fevers, joint pain, and weight and appetite loss.

To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course. He was given new information bit by bit — lab, imaging and biopsy results. Over the course of the session, he drew on an encyclopedic familiarity with thousands of syndromes. He deftly dismissed red herrings while picking up on clues that others might ignore, gradually homing in on the accurate diagnosis.

Just how special is Dr. Dhaliwal’s talent? More to the point, what can he do that a computer cannot? Will a computer ever successfully stand in for a skill that is based not simply on a vast fund of knowledge but also on more intangible factors like intuition?

The history of computer-assisted diagnostics is long and rich. In the 1970s, researchers at the University of Pittsburgh developed software to diagnose complex problems in general internal medicine; the project eventually resulted in a commercial program called Quick Medical Reference. Since the 1980s, Massachusetts General Hospital has been developing and refining DXplain, a program that provides a ranked list of clinical diagnoses from a set of symptoms and laboratory data.

And I.B.M., on the heels of its triumph last year with Watson, the Jeopardy-playing computer, is working on Watson for Healthcare.

In some ways, Dr. Dhaliwal’s diagnostic method is similar to that of another I.B.M. project: the Deep Blue chess program, which in 1996 trounced Garry Kasparov, the world’s best player at the time, to claim an unambiguous victory in the computer’s relentless march into the human domain.

Although lacking consciousness and a human’s intuition, Deep Blue had millions of moves memorized and could analyze as many each second. Dr. Dhaliwal does the diagnostic equivalent, though at human speed.

Since medical school, he has been an insatiable reader of case reports in medical journals, and case conferences from other hospitals. At work he occasionally uses a diagnostic checklist program called Isabel, just to make certain he hasn’t forgotten something. But the program has yet to offer a diagnosis that Dr. Dhaliwal missed.

Dr. Dhaliwal regularly receives cases from physicians who are stumped by a set of symptoms. At medical conferences, he is presented with one vexingly difficult case and is given 45 minutes to solve it. It is a medical high-wire act; doctors in the audience squirm as the set of facts gets more obscure and all the diagnoses they were considering are ruled out. After absorbing and processing scores of details, Dr. Dhaliwal must commit to a diagnosis. More often than not, he is right.

When working on a difficult case in front of an audience, Dr. Dhaliwal puts his entire thought process on display, with the goal of “elevating the stature of thinking,” he said. He believes this is becoming more important because physicians are being assessed on whether they gave the right medicine to a patient, or remembered to order a certain test.

Without such emphasis, physicians and training programs might forget the importance of having smart, thoughtful doctors. “Because in medicine,” Dr. Dhaliwal said, “thinking is our most important procedure.”

He added: “Getting better at diagnosis isn’t about figuring out if someone has one rare disease versus another. Getting better at diagnosis is as important to patient quality and safety as reducing medication errors, or eliminating wrong site surgery.”

Clinical Precision

Dr. Dhaliwal does half his clinical work on the wards of the San Francisco V. A. Medical Center, and the other half in its emergency department, where he often puzzles through multiple mysteries at a time.

One recent afternoon in the E.R., he was treating a 66-year-old man who was mentally unstable and uncooperative. He complained of hip pain, but routine lab work revealed that his kidneys weren’t working and his potassium was rising to a dangerous level, putting him in danger of an arrhythmia that could kill him — perhaps within hours. An ultrasound showed that his bladder was blocked.

There was work to be done: drain the bladder, correct the potassium level. It would have been easy to dismiss the hip pain as a distraction; it didn’t easily fit the picture. But Dr. Dhaliwal’s instinct is to hew to the ancient rule that physicians should try to come to a unifying diagnosis. In the end, everything — including the hip pain — was traced to metastatic prostate cancer.

“Things can shift very quickly in the emergency room,” Dr. Dhaliwal said. “One challenge of this, whether you use a computer or your brain, is deciding what’s signal and what’s noise.” Much of the time, it is his intuition that helps figure out which is which.

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Better Economy and Storm Delays Lift U.S. Auto Sales

DETROIT (AP) — Superstorm Sandy gave an extra boost to already strong U.S. auto sales last month, although carmakers warned that uncertainty over the "fiscal cliff" could undo some of those gains.

Most major companies, from Toyota to Chrysler, posted impressive increases from a year earlier. Only General Motors was left struggling to explain its 3-percent sales gain and large inventory of unsold trucks.

Americans were already willing to buy a new car or truck last month because they're more confident in the economy. Home values are rising, hiring is up and auto financing is readily available. Also, the average age of a vehicle on U.S. roads is approaching a record 11 years, so many people are looking to replace older cars.

Sandy just boosted that demand. The storm added 20,000 to 30,000 sales industry wide in November, mostly from people who planned to buy cars during the October storm but had to delay their purchases, Ford estimated. People who need to replace storm-damaged vehicles are expected to drive sales for several more months. GM estimates that 50,000 to 100,000 vehicles will eventually need to be replaced.

November sales, when calculated on an annual basis, are likely to be 15 million or more, the highest rate since March of 2008, according to LMC Automotive, a Detroit-area consulting firm. That's higher than the 14.3 million annual rate so far this year, even though November is normally a lackluster month due to cold weather and holiday anticipation. Both GM and Chrysler predicted November sales would run at an annual rate of 15.3 million.

If sales end up at 15 million for the year, it would be a vast improvement over the 10.4 million during the recession in 2009. Sales would still fall short of the recent peak of around 17 million in 2005.

But the ongoing "fiscal cliff" negotiations between Congress and the White House could still derail the industry's recovery. The term refers to sharp government spending cuts and tax increases scheduled to start Jan. 1 unless an agreement is reached to cut the budget deficit. Economists say that those measures, if implemented, could push the U.S. economy back into a recession.

"Exactly how much growth we can expect next year will depend in part on how Congress and the president resolve the fiscal cliff issue," said Kurt McNeil, GM's U.S. sales chief. "Markets and consumers hate uncertainty."

McNeil and other GM executives tried to explain the automaker's disappointing performance. GM's biggest brand, Chevrolet, reported flat sales over last year despite new products like the Spark minicar. Silverado pickup sales fell 10 percent.

GM's sales have been trailing the industry all year. They were up 4 percent through October, compared to the industry-wide increase of 14 percent.

GM said its competitors resorted to higher than usual incentives last month to get rid of 2012 model-year trucks. GM, which had more 2013 trucks on its lots, was only offering an average of $500 per truck, or a third of what others were offering. GM has been trying to hold the line on costly incentives, which can hurt resale value and brand image.

"We want to be known for great products, not great incentives," McNeil said.

But some analysts think GM will be forced to offer more deals in December to clear out higher-than-forecast inventory.

Asian brands also got a boost from some unusually big discounts, said Jesse Toprak, senior analyst for automotive pricing site TrueCar.com. TrueCar estimated that Hyundai and Kia, which were admonished by the U.S. government in late October for overstating gas mileage, increased incentive spending by nearly 30 percent. Nissan spending was up 45 percent to $4,273 per vehicle, by far the highest incentives in the industry.

Toyota said its 17-percent sales increase was partly due to post-Sandy demand. Honda was up 39 percent thanks to strong sales of the new Accord sedan and clearance deals on the outgoing Civic, which was replaced by a new 2013 Civic at the end of the month.

Luxury cars saw their usual yearend surge as holiday commercials started crowding the airwaves. Porsche's sales rose 71 percent to 3,865, a record month for the automaker. Infiniti, Acura, BMW and Lexus all reported big gains.

Edmunds.com analyst Jessica Caldwell said luxury brands have historically targeted their customers at this time of year because of holiday bonuses. That's no longer a driving factor, she said, but it's still a good time of year for people to buy 2012 model-year luxury vehicles because dealers are trying to clear them out.

Other automakers reporting sales Monday:

— Chrysler's sales were up 14 percent. Ram pickups were up 23 percent, while sales of the Fiat 500 minicar more than doubled.

— Hyundai's sales rose 8 percent, led by the Sonata midsize car and the Elantra compact. TrueCar said Hyundai increased incentives by 30 percent it was admonished by the U.S. government in late October for overstating gas mileage.

— Volkswagen's sales rose 29 percent on the strength of the Passat sedan, which was up 75 percent.

— Nissan's sales climbed 13 percent as sales of its new Pathfinder SUV more than tripled over last year.

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