Well: Warning Too Late for Some Babies

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

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

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

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Catherine Saint Louis speaks about using SimplyThick in premature infants.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Bucks Blog: Many Relying on Home Equity for Retirement

Even though the housing market has not recovered, nearly half of older working Americans expect to use equity in their homes to help finance their retirement, a new survey finds.

Roughly 47 percent of employed Americans ages 50 to 70 said they were relying on equity in their homes, the Retirement Check-In survey from Ameriprise Financial found. The finding is surprising, an accompanying report notes, because housing values in many parts of the country remain below the level they were before the recession. Also, 37 percent of homeowners say they’re not on track to pay off their mortgage before they retire.

More people said they were relying on home equity now compared with before the recession, the report finds. When participants were asked whether, before the downturn, they had expected to rely on home equity to help pay for their retirement, just 39 percent said yes.

While the reason for that shift isn’t entirely clear, the report says its plausible that the loss in value of other investments during the recession may have been so steep that many older workers feel they have no other alternative, even if their homes are worth less than they used to be.

“My hypothesis is that people didn’t think they were going to need to tap into equity because they thought they would have sufficient assets,” said Suzanna de Baca, vice president of wealth strategies at Ameriprise Financial. “Now, despite the fact they have reduced home equity, the shortfall between what they’ve saved and what they need is greater.”

The finding is typical of a “perplexing disparity” between Americans’ emotional outlook for retirement and the reality they face, the report said.

For instance, nearly three-quarters indicated that their dream retirement included taking “really nice vacations.” Yet, when asked if they would be able to afford the essentials in retirement, fewer than half said they felt “extremely” or “very” confident. And just 38 percent said they were confident they could afford the extras they had been anticipating in retirement, like traveling and hobbies.

The telephone survey included 1,000 employed Americans age 50 to 70, with investable assets of at least $100,000 (including employer-based retirement plans, but not real estate) and who are planning to retire at some point. Koski Research conducted the survey on behalf of Ameriprise Financial from Oct. 31 and Nov. 14, 2012. The margin of sampling error is plus or minus 3 percentage points.

What role does home equity play in your retirement plans?

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High-Level Feud Bares Tensions in Iran

TEHRAN — President Mahmoud Ahmadinejad escalated a bitter political fight this week with Iran’s most influential political family by disclosing secret film recordings of what he purported were fraudulent business deals.

During a Sunday session of Parliament, broadcast on state radio, Mr. Ahmadinejad singled out the head of the Parliament, Ali Larijani, a political rival with strong links to influential Shiite Muslim clerics and one of several brothers who have held top positions in the Iranian government.

His older brother, Sadegh, 52, heads Iran’s judiciary, while another brother, Mohammad Javad, a Berkeley-educated mathematician, is also a judiciary official.

On Monday, Iran’s state newspaper, Kayhan, which is run by an editor appointed by the supreme leader, Ayatollah Ali Khamenei, hinted that Ayatollah Khamenei had been forced to step in to prevent both men from giving potentially damaging news conferences, which were both canceled at the last minute.

This was not the first time Ayatollah Khamenei has been forced to intervene in this feud. In October, he issued an edict aimed at stopping the infighting, saying that those creating divisions in the leadup to the June 14 presidential elections “betray” the country.

Mr. Ahmadinejad, who went to the Parliament in a failed attempt to head off the impeachment of his labor minister, Abdolreza Sheikholeslami, said Mr. Larijani and his fellow lawmakers had obstructed the government, stepped beyond their constitutional boundaries and written letters ordering the annulment of government decisions.

Instructed by Mr. Larijani to stick to the subject of the impeachment, Mr. Ahmadinejad said, “Don’t order me to close my mouth because you say it’s the law.”

With that, Mr. Ahmadinejad, who for years has threatened to reveal the names of corrupt officials, played a video clip of a conversation in which another of Mr. Larijani’s brothers, Fazel, appeared to discuss the purchase of a state company under favorable terms, the semiofficial Tabnak Web site reported. While Fazel Larijani used to head a medical association in Iran, his current position is unclear.

The public naming, rare in Iran, could signal a new phase in an already intense scrum between Mr. Ahmadinejad, who represents a powerful group of young, ambitious politicians, and Mr. Larijani, who is the official representative of the holy city of Qum, the center of Shiite scholarship in Iran.

Mr. Ahmadinejad said his associate, Saeed Mortazavi, 45, was also present at the taped meeting. In January, Mr. Mortazavi was dismissed as the head of Iran’s enormous social welfare organization under pressure from Parliament. Some days later, however, he was rehired by the president in the same position, this time as official caretaker.

During the conversation, read out in part by Mr. Ahmadinejad to astonished lawmakers, Fazel Larijani appears to try to use his family connections to buy a factory from the social welfare organization. He promises leniency for Mr. Mortazavi, who faces several criminal proceedings over assertions that he played a role in the deaths of three protesters in a substandard prison in 2009.

“These are audio and video, and the tape is clear,” Mr. Ahmadinejad is quoted as saying by the Iranian Students’ News Agency. “If the honorable Parliament speaker sees fit, we can turn over the 24 to 25 hours to you,” he said of the recordings. On Monday, Iran’s Islamic Republic News Agency, a mouthpiece for Mr. Ahmadinejad, deepened the split by publishing the audio tape on its Web site.

Ali Larijani, cheered on by the Parliament, which has lost nearly each serious political battle with the president, silenced the room, saying, “Let him tell his words. If there is anything about my family, then let him talk about it.”

Mr. Larijani said it was a “mafia film” and recalled how he had a meeting with Mr. Ahmadinejad’s estranged brother, Davoud. “He said many things against you,” Mr. Larijani told the president, “about economic corruption, about your inner circle and your relations with foreign countries.”

For his part, Fazel Larijani strongly denied any wrongdoing, saying that while he did appear in the clip, the words were not his, but rather had been added in a voiceover. Calling Mr. Ahmadinejad and Mr. Mortazavi “mafialike individuals,” he said he would sue them both for “spreading lies and disturbing public opinion.”

On Monday, several officials criticized Mr. Ahmadinejad and Ali Larijani, accusing them of lacking self-control and bringing shame on the country. “They broke the leader’s heart and gave the friends of the Islamic republic almost a seizure,” said Mojtaba Zolnour, a special consultant to the supreme leader, Ayatollah Khamenei, the semiofficial Iranian Labor News Agency reported. “They provided ammunition for the foreign media on the eve of our election.”

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Kuwait says backs free speech but must protect ruling emir

KUWAIT (Reuters) – Kuwait supports free speech but must act against illegal comments made about the Gulf state’s ruler, the government said on Monday, after a Twitter user was jailed for five years.

A Kuwaiti court sentenced a man to prison on Sunday for insulting the emir on the social networking site, a rights lawyer and news websites said, in the latest prosecution for criticism of authorities via social media.

“Kuwait has a longstanding proud tradition of open debate and free speech,” the Ministry of Information, which regulates the media, said in a statement to Reuters addressing the case.

“We are a country led by the rule of law and our constitution holds our Emir to be inviolable. If our citizens wish to amend the constitution there is a straightforward legal way to do this, but we will not selectively enforce our laws.”

In recent months Kuwait has penalized several Twitter users for criticizing the emir, who is described as “immune and inviolable” in the constitution.

Kuwait allows the most dissent in the Gulf Arab region and boasts a lively press and critical political debate. But the U.S. ally and OPEC member has been clamping down on politically sensitive comments aired on the internet in recent months.

Twitter is extremely popular in the country of 3.7 million inhabitants and well-known figures can have hundreds of thousands of followers.

In January, a court sentenced two men in separate cases to jail time for insulting the emir on Twitter.

In June last year, a man was sentenced to 10 years in prison after he was convicted of endangering state security by insulting the Prophet Mohammad and the Sunni Muslim rulers of Saudi Arabia and Bahrain on social media.

Two months later, authorities detained a member of the ruling family over remarks on Twitter in which he accused authorities of corruption and called for political reform.

Kuwait has avoided the kind of mass unrest that has spread across the Arab region in the past two years but in 2012 tension escalated between authorities and opposition groups ahead of a parliamentary election.

(Reporting by Sylvia Westall; Editing by Mark Heinrich)

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Indiana moves back into No. 1 in AP poll

For the fifth straight week there is a new No. 1 in The Associated Press' college basketball poll. This time it's Indiana.

The Hoosiers, the preseason No. 1 who held the top spot for the first five weeks of the regular season, moved up two spots Monday, following their weekend win over No. 1 Michigan and No. 2 Kansas' loss to Oklahoma State.

Duke started the current streak of new No. 1s and was followed by Louisville, Duke again, Michigan and Indiana. The last time there were five straight new No. 1s was the last five polls of 2008-09 when it was Connecticut, Pittsburgh, Connecticut again, North Carolina and Louisville.

The Hoosiers received 58 first-place votes from the 65-member national media panel while Florida, which jumped two spots to second, got the other seven.

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Well: A Doctor's Struggle With Numbers

My youngest child has been struggling with numbers.

This all started around the time of his 4th birthday, in mid-November. He knew he was getting older and asked a lot of questions about babies, who were “too little to have a number,” being less than 1 year old. Then, on the day of his birthday, he wanted to know when he was turning 4.

I told him that today was his birthday, that he turned 4 today.

“But when do I turn 4?” He had recently learned to emphasize certain words in an effort to assist his dim parents in getting his questions answered.

I told him at 8 in the morning, the time he was born.

“No, no, when do I turn 4?”

I looked at him helplessly, wondering whether he was expecting some pivotal moment when he would suddenly gain five inches in height. He decided that the anointed time occurred later that day, after he received his presents.

A week later, his mother and I went for a car ride with her parents, both in their mid-70s. In a rare quiet moment amid the usual barrage of instructions on how to navigate the rural western Pennsylvania roads, our son spoke up.

“When is Pappy going to die?”

The adults fell over themselves responding, trying to both reassure him and ourselves, as if the faster and louder we answered his question, the more we would negate it: A lot of years. Not for a long, long time. We hope he never does.

This satisfied him for the moment, but much like his father, he broods about these types of important topics. A couple of hours later, back at the house, he asked as if in mid-thought: “But, what is the last number?”

I repeated his question, stalling.

“Yes, what is the last number? What’s my last number?” he asked. His mother and I glanced at each other, in a quick game of chicken to see who would answer first.

“We don’t know, honey,” I finally said. He looked up at my wife, who nodded in agreement.

My son’s words came back to me the following Monday when I saw my first patient, a man in his 70s whose leukemia didn’t get worse on chemotherapy, but unfortunately also didn’t get better. We had run out of options, aside from supportive care.

“How long does he have?”

My patient’s son asked the question that was on everyone’s mind, and when he did, the wave of emotion that washed across the room was almost palpable. My patient’s daughter crossed her legs, and his wife started to cry. So did my patient, though he tried to hide it, glancing up at the fluorescent ceiling lights of the clinic room. Guys in his generation, I’ve found, don’t like to appear weak in front of their family.

I turned to my patient and asked him if he wanted me to talk about this, about his prognosis. My first responsibility in this type of situation is always to my patient and what he wants to hear. Some people want to know specifics, down to the half-month of predicted survival; others want no information at all, as if hearing a number will seal their fate.

“Sure, I guess so,” he answered. He did want to know, but he didn’t want to know.

Oncologists are notoriously bad at predicting survival, and none of us wants to be known as “the doctor who told me I would be dead by now,” the doctor who made a prediction of imminent demise, sending a family into a terrifying tailspin of goodbyes, only to be proven wrong and subsequently mocked for years to come. One of my patients, upon being told by another doctor that she had two months to live, held Christmas in April so she could spend one last holiday with her grandchildren. She survived to see two more Christmases.

At the same time, we need to be truthful and give guidance to people who want time to prepare, time to write wills and pay off debts, to say goodbyes and to leave instructions, to tie up the loose ends of a life now heavy with meaning.

We try to provide hope, but not false hope.

So we give ranges, starting with the best estimate of survival, because my patients have told me they shut down after they hear the worst estimate. We talk about setting goals, about maximizing quality of life, because we don’t have much leverage with quantity of life. We emphasize spending as much time as possible with family and friends, and as little time as possible with people wearing white coats. We tell them we’re not going to give up if they don’t give up.

But the truth is, we don’t know.

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Dr. Mikkael Sekeres is director of the leukemia program at the Cleveland Clinic.

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DealBook: U.S. and States Prepare to Sue S.&P. Over Mortgage Ratings

The Justice Department, along with state prosecutors, plans to file civil charges against Standard & Poor’s Ratings Service, accusing the firm of fraudulently rating mortgage bonds that led to the financial crisis, people briefed on the plan said Monday.

Up until last last week, the Justice Department had been in settlement talks with S.&P., these people said. But the negotiations broke down after the Justice Department said it would seek a settlement in excess of “10 figures,” or at least $1 billion, these people said, which would wipe out the profits of S.&P.’s parent, the McGraw-Hill Company, for an entire year.

McGraw-Hill earned $911 million last year.

A suit against S.&P. would be the first the government has brought against the credit ratings agencies related to the financial crisis, despite continued questions about the agencies’ conflicts of interest and role in creating a housing bubble.

By bringing a civil suit, as opposed to a criminal case, the Justice Department’s burden of proof will be less, perhaps lowering the bar for a successful prosecution.

In a statement on Monday, S.&P. said it had received notice from the Justice Department over a pending lawsuit.

The ratings agency argued any such legal action would be baseless, since it downgraded plenty of mortgage-backed investments, including in the two years leading up to the financial crisis. It also contended that other observers of the debt markets, including government officials, believed at the time that any problems within the housing sector could be contained.

“A D.O.J. lawsuit would be entirely without factual or legal merit,” the agency said in its statement. “With 20/20 hindsight, these strong actions proved insufficient – but they demonstrate that the D.O.J. would be wrong in contending that S.&P. ratings were motivated by commercial considerations and not issued in good faith.”

Shares in McGraw-Hill were down 3.8 percent in midafternoon trading on Monday, at $56.07.

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Letter From Washington: A Rocky Road to Reforming Immigration

WASHINGTON — Immigration reform is having a “Kumbaya” moment, with support from the White House, a bipartisan contingent in Congress, business and labor.

The Republicans are petrified after their dismal showing among the fastest-growing slices of the electorate, Hispanics and Asians; President Barack Obama wants to reward the loyalty of those voters. Business and labor, as well as many politicians, want to fix a totally dysfunctional system. There are more than 11 million undocumented immigrants, 5 percent of the work force. Many of these people live in fear of discovery, while jobs go unfilled in some areas.

Hold the Champagne. When it comes to immigration laws, the concept is always easier than the reality. Change failed to happen six years ago, despite the push from the high-powered coalition led by President George W. Bush and Senators John McCain and Edward M. Kennedy. The dynamics are more favorable today. Still, the same obstacles persist; the powerful countervailing considerations include these issues:

A predicament on citizenship There’s a fairly broad consensus for ending the illegal status of the undocumented. The White House, Hispanic groups and most Senate supporters insist that any overhaul must lead to a pathway to citizenship.

That approach, however, faces great resistance. Some lawmakers demand that any move toward citizenship must come second to solving the border-security problem, at a minimum. For some, this is a political cover; under the Obama administration, resources for border security have been increased sharply, including the use of drones. And deportations of undocumented immigrants are at a record high.

A border-security trigger is realistic if it includes quantifiable goals, like the number of new Border Patrol agents, the amount of resources allocated and the new technologies utilized. It isn’t reasonable if it requires meeting an amorphous standard like “operational control” of a border that is always changing.

Hispanic groups assert that the real motive for such demands is to unreasonably stretch out any possibility of granting citizenship.

“There would be a backlash if citizenship is delayed for 15 or 20 years,” warns Gary M. Segura, a Stanford University professor and co-founder of Latino Decisions, the leading research organization on Hispanic public opinion.

The future of immigration policy Equally contentious is the question of future flows of immigrants. One proposal would link the number of legal immigrants to economic conditions: More would be let in when times are good, fewer in tougher times. That sounds easier than it is. There will be clashes over how great a priority should be given to those with high-tech skills or to agriculture workers or to family reunification. Small businesses will rebel against any costly verification plan.

Most independent studies show that immigration is a decided economic plus, bringing in revenue and increasing productivity and innovation.

Yet the arguments of the populist right may resonate more as the debate heats up. NumbersUSA, a leading anti-immigration group, is reviving charges that an immigration overhaul would drive down wages for middle- and low- income workers. Kris Kobach, the Kansas secretary of state who authored anti-immigration measures in several states and the Republican Party’s platform position on the issue last summer, charges that taxpayers would be hit with $2.6 trillion in added food stamps, Medicare and Medicaid, which are government health care programs, and in welfare costs. That estimate is refuted by reliable studies; it still cuts.

The House Republican leadership J. Dennis Hastert, a former Republican speaker of the House, decreed that any bill must command majority support among majority party members. Last month, the House speaker, John A. Boehner, waived the rule twice to pass measures, one avoiding the so-called fiscal cliff and another providing aid to victims of Hurricane Sandy.

The speaker, along with most party leaders, understands his party’s serious difficulties with Hispanic voters and fears making matters worse by blocking an overhaul. Two of the most virulent anti-immigration Republicans in the House, Lamar Smith of Texas and Steve King of Iowa, no longer hold important committee chairmanships.

Yet with anti-immigration sentiment still running high among many Republican rank-and-file voters, it’s tough to imagine a majority of the party’s House members backing a comprehensive bill, even if, as is certain, the Senate goes first. Mr. Boehner’s only option might be to let a bill pass primarily with Democratic votes.

To do that, he would need the support of the House majority leader, Eric Cantor, and the whip, Kevin McCarthy; there’s no shrewder politician than Mr. McCarthy, who is always attuned to the party’s base. He’s also from California, where, since Governor Pete Wilson played the anti-immigration card in 1994, the Democrats completely dominate politics.

The lack of a skilled deal maker The successful, if flawed, passage of Mr. Obama’s health care measure probably wouldn’t have been possible without the savvy hand of Rahm Emanuel, who was the White House chief of staff. Congressional Democrats and some outside advocates see no Emanuel counterpart in the current White House; privately, some say they would like the White House to enlist a special envoy — perhaps Henry G. Cisneros, former housing secretary and former mayor of San Antonio, Texas, or Tom Daschle, the former Senate majority leader — to shepherd legislation.

Egos and tensions already are surfacing among supporters of an overhaul; Republicans don’t trust the White House, and some Democrats worry that Marco Rubio, the ambitious young Republican senator from Florida, will look for a reason to peel off as he comes under pressure from his party’s right wing. There is no senator today who possesses Mr. Kennedy’s skill for navigating these shoals.

It’s still a slightly better bet that a big immigration bill will be enacted in this Congress. Getting there will be ugly, and the measure will seem to die more than once as it battles these cross-pressures.

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Kuwaiti gets five years for insulting ruler

KUWAIT (Reuters) – A Kuwaiti court sentenced a man to five years in prison on Sunday for insulting the emir on Twitter, a rights lawyer and news websites said, in the latest prosecution for criticism of authorities via social media in the Gulf Arab state.

The court gave Kuwaiti Mohammad Eid al-Ajmi the maximum sentence for the comments, news websites al-Rai and alaan.cc reported.

In recent months Kuwait has penalized several Twitter users for criticizing the emir, who is described as “immune and inviolable” in the constitution.

“We call on the government to expand freedoms and adhere to the international (human rights) conventions it has signed,” said lawyer Mohammad al-Humaidi, director of the Kuwait Society for Human Rights, commenting on the case.

Courts in Kuwait generally do not comment to the media.

Amnesty International said in November Kuwait had increased restrictions on freedom of expression and assembly.

It urged Kuwait to ensure protection for users of social media, whether they supported or opposed the government, as long as they did not incite racial hatred or violence.

Kuwait, a U.S. ally and major oil producer, has been taking a firmer line on politically sensitive comments aired on the internet. Twitter is extremely popular in the country of 3.7 million.

In January, a court sentenced two men in separate cases to jail time for insulting the emir on Twitter.

In June 2012, a man was sentenced to 10 years in prison after he was convicted of endangering state security by insulting the Prophet Mohammad and the Sunni Muslim rulers of Saudi Arabia and Bahrain on social media.

Two months later, authorities detained Sheikh Meshaal al-Malik Al-Sabah, a member of the ruling family, over remarks on Twitter in which he accused authorities of corruption and called for political reform.

The recent Twitter cases have been carried out under the state security law and penal code. Last year Kuwait passed new legislation aimed at regulating social media.

Public demonstrations and debates about local issues are common in a state that allows the most dissent in the Gulf, but Kuwait has avoided the kind of mass unrest that unseated four heads of Arab states in 2011.

But tensions intensified between authorities and opposition groups last year ahead of a parliamentary election deemed unfair by opposition politicians and activists.

The opposition movement said new voting rules introduced by Sheikh Sabah by emergency decree in October would skew the December 1 election in favor of pro-government candidates. The emir said the old voting system was flawed and that his changes were constitutional and necessary for Kuwait’s “security and stability”.

(Reporting by Ahmed Hagagy, Writing by Sylvia Westall; editing by Sami Aboudi and Andrew Roche)

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What comes now for NFL after tumultuous season?

NEW ORLEANS (AP) — The Super Bowl closes a tumultuous year for the NFL.

Suicides by former NFL players. Thousands of others filing concussion lawsuits. New studies linking football to brain disease. Still no testing for human growth hormone. The specter of other purported performance-enhancing products — deer-antler spray, anyone? — being peddled to players.

A pay-for-pain bounty scandal. A lockout of officials resolved only after a ludicrous game-ending call. Zero minority hires for 15 coach or general manager openings.

And yet the league is as popular as ever.

Advertisers paid nearly $4 million per 30-second television commercial for the right to reach the 100 million or so Americans expected to tune in to Sunday's Super Bowl between the AFC champion Baltimore Ravens and NFC champion San Francisco 49ers. Eleven of the 12 most-watched TV programs during the last 2½ years were NFL postseason games, according to the league.

Uncertain, though, is what the future holds for an NFL still coming to grips with the dangers of a brutal sport that makes it tremendously wealthy.

"The game has changed and keeps changing. ... It is such a violent game, and such a collision game, that careers are going to be kind of like not long at all. Because you take those licks — you've only got so many in your body, and at some point that's going to wear it out," said Ravens running backs coach Wilbert Montgomery, who played that position for the Philadelphia Eagles and Detroit Lions from 1977-85.

Montgomery said he got six concussions in one season alone, and others along the way, including one that knocked him out cold a few days before playing for the Eagles in the NFC title game at the end of the 1980 season.

"I know one thing: Back then, it didn't make any difference. They gave you smelling salts and then, after that, you went back in," Montgomery said. "I have headaches all the time. That's why I say my wife is always messing with me when I have outbursts, saying, 'You've been hit too many times upside the head.'"

Montgomery laughed for a moment. Then he rubbed his forehead and continued talking, mentioning former teammate and friend Andre Waters and opponent Dave Duerson. Both committed suicide; researchers studied their brain tissue and found signs of chronic traumatic encephalopathy, or CTE, a degenerative disease also found in boxers and often linked with repeated blows to the head. Former star linebacker Junior Seau, who shot himself in May, also was found to have CTE. Baltimore's starting center on Sunday, Matt Birk, has pledged to donate his brain for study when he dies.

"It's a serious thing," Montgomery said. "It's scary."

When the President of the United States refers to fans perhaps having a guilty conscience when watching a game and parents thinking twice before allowing a child to play — as Barack Obama did in a recent interview with The New Republic — it sends a strong signal about what confronts the NFL today.

"If I was worried about my health," 49ers quarterback Colin Kaepernick said, "I wouldn't be playing football."

So the league must figure out how to deal with "walking a fine line," as 49ers CEO Jed York described it: The two-sided task of making the game safer, which Commissioner Roger Goodell acknowledges is imperative, while not making it "too safe," thereby diminishing the popularity of an enterprise that is violent by its very nature.

"There's no question that that is a bit of a conundrum. But to me, we've got to place more weight on player safety," New York Giants co-owner John Mara said. "The rules changes that we've implemented over the past five or six years have not made the game any less exciting. If anything, the game is as exciting as ever, and I strongly believe that we can make additional improvements in the rules and we're not going to lose anything in terms of excitement on the field."

Ravens owner Steve Bisciotti is convinced the NFL will strike the proper balance.

"What did they do for boxing when they made them go from 6-ounce, to 8-ounce to 12-ounce gloves or whatever? Did it change boxing? Not really," Bisciotti said. "I believe that with every change, there will be a correction. ... And I believe that we as a league and the (players' union) will agree on things that don't take football out of football."

In a series of moves that began shortly after Goodell was grilled at a congressional hearing, the league has changed concussion return-to-play guidelines, adjusted rules for kickoffs — and floated the idea of eliminating them altogether — stepped up punishment of illegal hits, and stopped arguing against the players' wish for independent neurology specialists on the sidelines during games.

Even if there are some players who in one breath worry about whether their health is imperiled, and in the next say, "We're basically going to be playing two-hand touch in a while" — Baltimore nose tackle Terrence Cody's words this week — the head of their union points out that prudence and popularity do not have to be mutually exclusive.

"The reality of it is, 'football as we know it' has evolved over decades. ... Our job is to have an unqualified commitment to the health and safety of the people who play the game, and then to make those changes where we see necessary," NFL Players Association executive director DeMaurice Smith said.

"I don't think there is this thing of 'football as we know it.' What we have is football that has constantly developed," Smith said. "And even with all of the (recent) rule changes ... my guess is this Super Bowl will be the highest-rated of all time."

Indeed, while the concussion lawsuits mount — a U.S. District Court judge in Philadelphia will hear oral arguments in April on the NFL's effort to dismiss a group of cases — and questions arise about what insurers will charge the league moving forward, the money does keep rolling in. Revenues already topped $9 billion at the time of the last labor deal in 2011, and new TV contracts will only help increase it.

"At $10-to-$12 billion? It ain't going nowhere," said Warren Sapp, a retired defensive tackle elected Saturday to the Pro Football Hall of Fame and who now works for the NFL Network, another piece of the league's marketing machine. "We play a beautiful game. We hit each other. (Players) have to take care of each other better. Then it will be fine."

Meantime, the NFL continues to look for new ways to increase its cash flow.

During his state of the league address two days before the Super Bowl, Goodell did not rule out increasing the regular season from 16 to 18 games, and he reiterated the possibility of expanding the postseason, too. He announced that two 2013 games in London already are sold out, and there could be three in future seasons — down a path that, eventually, could lead to a franchise based in Britain.

"For you to be adding games to the season, are you looking out for player safety? Or are you trying to generate more player revenue?" 49ers receiver Randy Moss said. "If you're trying to look and protect the players, and keep it healthier and better every year, I don't think it's a good idea."

Several players in this year's Super Bowl were incredulous that the league would even consider more games. A handful voiced concern over a disconnect between players and owners.

The president of the NFLPA, former Ravens cornerback Domonique Foxworth, said he wonders how truthful Goodell and other NFL officials are being when they say — as they often do — that players' well-being is a priority.

"The league, their No. 1 focus — at least they say their No. 1 focus — is health and safety. And we say our No. 1 focus is health and safety. How come we have such a hard time moving the ball on some health and safety issues?" Foxworth said. "I believe health and safety is on their list of top five things, but it comes in well behind increasing the bottom line."

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Follow Howard Fendrich on Twitter at http://twitter.com/HowardFendrich

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