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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McAfee wants to return to US, ‘normal life’

BACALAR, Mexico (AP) — Software company founder John McAfee said Sunday he wants to return to the United States and “settle down to whatever normal life” he can.

In a live-stream Internet broadcast from the Guatemalan detention center where he is fighting a government order that he be returned to Belize, the 67-year-old said “I simply would like to live comfortably day by day, fish, swim, enjoy my declining years.”

Police in neighboring Belize want to question McAfee in the fatal shooting of a U.S. expatriate who lived near his home on a Belizean island in November.

The creator of the McAfee antivirus program again denied involvement in the killing during the Sunday Internet video hook-up, during which he answered what he said were reporters’ questions.

His comments were sometimes contradictory. McAfee is an acknowledged practical joker who has dabbled in yoga, ultra-light aircraft and the production of herbal medications.

The British-born McAfee first said that returning to the United States “is my only hope now.” But he later added, “I would be happy to go to England, I have dual citizenship.”

He was emphatic that “I cannot ever return to Belize …. there is no hope for my life if I am ever returned to Belize.”

“If I am returned,” he said, “bad things will clearly happen to me.”

He descibed the health problems that had him briefly hospitalized earlier this week after Guatemalan authorities detained him for entering the country illegally. He apparently snuck in across a rural, unguarded spot along the border.

“I did not eat for two days, I drank very little liquids, and for the first time in many years I’ve been smoking almost non-stop,” he said. “I stood up, passed out hit my head on the wall, came to,” though he now said he was feeling better.

McAfee praised the role his 20-year-old Belizean girlfriend, Samantha Vanegas, played in his escape from Belize, where he claims he is being persecuted by corrupt politicians. Authorities in Belize deny that they are persecuting him and have questioned his mental state.

“Sam saved the day many times” during their escape, he said, and suggested he would take her with him to the United States if he is allowed to go there.

He confirmed that journalists from Vice magazine who accompanied him on his escape after weeks of hiding in Belize had unwittingly posted photos with embedded data that revealed his exact location.

“It was an error anyone could make,” he said, noting they were under a lot of pressure at the time.

McAfee has led an eccentric life since he sold his stake in the anti-virus software company named after him in the early 1990s and moved to Belize about three years ago to lower his taxes.

He told The New York Times in 2009 that he had lost all but $ 4 million of his $ 100 million fortune in the U.S. financial crisis. However, a story on the Gizmodo website quoted him as describing that claim as “not very accurate at all.”

McAfee’s Guatemalan attorney, Telesforo Guerra, says that he has filed three separate legal appeals in the hope that his client can stay in Guatemala, where his political asylum request was rejected.

Guerra said he filed an appeal for a judge to make sure McAfee’s physical integrity is protected, an appeal against the asylum denial and a petition with immigration officials to allow his client to stay in this Central American country indefinitely.

The appeals could take several days to resolve, Guerra said. He added that he could still use several other legal resources but wouldn’t give any other details.

Fredy Viana, a spokesman for the Immigration Department, said that before the agency looks into the request to allow McAfee to stay in Guatemala, a judge must first deal with the appeal asking that authorities make sure McAfee’s physical integrity is protected.

“We won’t look into (allowing him to stay) until the other appeal is resolved,” Viana said. “The law gives me 30 days to resolve the issue.”

McAfee went on the run last month after Belizean officials tried to question him about the killing of Gregory Viant Faull, who was shot to death in early November.

McAfee acknowledges that his dogs were bothersome and that Faull had complained about them, but denies killing Faull. Faull’s home was a couple of houses down from McAfee’s compound in Ambergris Caye, off Belize’s Caribbean coast.

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Black women battle obesity with dialogue, action

WASHINGTON (AP) — Nicole Ari Parker was motivated by frustration. For Star Jones, it was a matter of life or death. Toni Carey wanted a fresh start after a bad breakup.

All three have launched individual campaigns that reflect an emerging priority for African-American women: finding creative ways to combat the obesity epidemic that threatens their longevity.

African-American women have the highest obesity rate of any group of Americans. Four out of five black women have a body mass index above 25 percent, the threshold for being overweight or obese, according to the Centers for Disease Control and Prevention. By comparison, nearly two-thirds of Americans overall are in this category, the CDC said.

Many black women seem to not be be bothered that they are generally heavier than other Americans.

Calorie-rich, traditional soul food is a staple in the diets of many African-Americans, and curvy black women are embraced positively through slang praising them as “thick” with a “little meat on their bones,” or through songs like the Commodore’s “Brick House” or “Bootylicious” by Destiny’s Child. A study by the Kaiser Family Foundation and The Washington Post earlier this year found that 66 percent of overweight black women had high self-esteem, while 41 percent of average-sized or thin white women had high self-esteem.

Still, that doesn’t mean black women reject the need to become healthier.

Historically black, all-female Spelman College in Atlanta is disbanding its NCAA teams and devoting those resources to a campus-wide wellness program. In an open letter announcing Spelman’s “wellness revolution,” president Beverly Daniel Tatum cited a campus analysis that found many of Spelman’s 2,100 students already have high blood pressure, Type 2 diabetes or other chronic ailments.

“Spelman has an opportunity to change the health trajectory of our students and, through their influence, the communities from which they come,” Tatum’s letter said.

Jones, who underwent open heart surgery in 2010 at age 47 and now urges awareness about heart disease among black women, was met by an overflow crowd earlier this year when she convened a Congressional Black Caucus Foundation panel on black women and obesity.

“We have to get ourselves out of being conditioned to think that using soft words so we don’t hurt peoples’ feelings is doing them any favor,” Jones said. “Curvy, big-boned, hefty, full-figured, fluffy, chubby. Those are all words designed to make people feel better about themselves. That wasn’t helpful to me.”

Jones once embraced being large and fabulous, at 5 feet 5 inches tall and 300 pounds. But under that exterior, she said, she was morbidly obese, suffering from extreme fatigue, nausea, lightheadedness, heart palpitations and blurred vision. The attorney and TV personality also had gastric bypass surgery in 2003.

Now, she advises women to make simple changes such as reducing salt intake, exercising 30 minutes a day, quitting smoking, controlling portion sizes and making nutritious dietary choices.

Nutritionist and author Rovenia M. Brock, known professionally as Dr. Ro, agrees with Jones. She said getting active is only about 20 percent of the fight against obesity. The rest revolves around how much people eat.

“Our plates are killing us,” she said.

Brock said “food deserts,” or urban areas that lack quality supermarkets, are a real obstacle. She suggested getting around that by carpooling with neighbors to stores in areas with higher-quality grocery options or buying food in bulk. She also suggested growing herbs and vegetables in window-box gardens.

“Stop focusing on what’s not there, or what you think is not there,” Brock said. “We have to get out of this wimpy, ‘woe is me’ mentality.”

While first lady Michelle Obama has encouraged exercise through her “Let’s Move” campaign targeting childhood obesity, the spark for this current interest among black women may have been comments last year by Surgeon General Regina Benjamin, who observed publicly that women must stop allowing concern about their hair to prevent them from exercising.

Some black women visit salons as often as every two weeks, investing several hours and anywhere from $ 50 to hundreds of dollars each visit — activity that, according to the Black Owned Beauty Supply Association, helps fuel a $ 9 billion black hair care and cosmetics industry.

In an interview during a health conference in Washington last week, Benjamin said the damage sweat can inflict on costly hairstyles can affect women’s willingness to work out, and she hopes to change that. She goes to beauty industry conferences to encourage stylists to create exercise-friendly hairdos.

“I wouldn’t say we use it as an excuse, we use it as a barrier,” Benjamin said. “And that’s not one of the barriers anymore. We’re always going to have problems with balancing our lives, but we could take that one out.”

Parker, an actress who starred in “A Streetcar Named Desire” on Broadway earlier this year, understands this dilemma well. Out of personal frustration over maintaining both her workout and her hair, she created “Save Your Do” Gymwrap — a headband that can be wrapped around the hair in a way that minimizes sweat and preserves hairstyles.

“Not just as a black woman, but as a woman, since the beginning of time, beauty has been our responsibility,” Parker said in an interview. Because of that, she said, exercise has become linked with vanity instead of health.

“We’ve turned exercise into a weight-loss regimen,” Parker said. “No. Exercise is about being grateful for the body you have and sustaining the life you have. … Take all the hype out of the exercise and think of it as brushing your teeth.”

With their mutual family histories of diabetes and high blood pressure in mind, Carey, 28, and her sorority sister Ashley Hicks, 29, co-founded the running club Black Girls Run. Carey also considered it a new beginning after a bad breakup and a move across country. Since 2009, Black Girls Run has amassed 52,000 members who serve as a support system for runners.

Black Girls Run has about 60 groups nationwide that coordinate local races in Atlanta, New York, San Francisco, Washington, D.C, Houston and Greensboro, N.C. Most groups run at least five times a week. Next month, the national running club will take its first “Black Girls Run — Preserve the Sexy” tour to cities with high obesity rates. The tour includes health and fitness clinics with information on nutrition, hair maintenance and running gear.

“We found that when you want to get healthy and when you want to be active, it’s intimidating,” Carey said. “You don’t know where to start. There’s a little coaxing that has to go along with that.”

Parker said once African-American women place value on their bodies and longevity, everything else will follow. It costs her nothing, she said, to walk around an outdoor track with her husband, actor Boris Kodjoe, or run up and down stairs at home with her headphones.

“One good step breeds another one,” Parker said. “You’re going to have one less margarita, one less scoop of Thanksgiving macaroni … and yet you’re not doing anything fanatical or dramatic.”

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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?”

___

Associated Press writer Franklin Briceno contributed to this report.

___

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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Software guru McAfee did not have heart attack: lawyer

GUATEMALA CITY (Reuters) – Software pioneer John McAfee did not have a heart attack in Guatemala as originally thought, but is suffering from stress and hypertension, his lawyer Telesforo Guerra said on Thursday.

“He never had a heart attack. Nothing like that,” Guerra said in Guatemala City. “I’m not a doctor. I’m just telling you what the doctors told me. He was suffering from stress, hypertension and tachycardia (an abnormally rapid heartbeat).”

After being rushed to a hospital in an ambulance on Thursday, McAfee, 67, was later spirited out of the building out of sight of reporters and into a police patrol car, Guerra said.

McAfee, who is fighting deportation from Guatemala, was detained on Wednesday after crossing illegally into the country from neighboring Belize. Police in Belize want to question McAfee in connection with his neighbor’s murder.

Earlier, Guerra said McAfee had suffered two mild heart attacks in the morning.

(Reporting by Lomi Kriel; Editing by Stacey Joyce)

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As Syria's rebels close in, Assad has three options

The magnificent views across Damascus from the presidential palace on Mount Qassioun are unlikely to provide much comfort these days for Bashar al-Assad, Syria’s beleaguered head of state.

For several weeks, the skyline to the north, east, and south has been stained by black columns of smoke from artillery explosions and air strikes as Syrian government forces struggle to prevent the Free Syrian Army (FSA) rebels from inching ever closer to their goal of unseating Mr. Assad’s regime.

After 20 months of confrontation, Assad’s hold on power is looking increasingly frail, leaving him and his regime with few remaining options.

“There is no doubt that the regime’s capacity is declining and that the FSA continues to become ever stronger and better armed,” says a European diplomat closely following developments in Syria.

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The current status of the regime is uncertain and it is not even clear if Assad is still in charge. The diplomat says that Assad appears to have become a “prisoner of his own system,” no longer playing an active leadership role and confined to his palace. Instead, there are indications that an informal "security council” has emerged consisting of between 50 to 100 top regime and military figures drawn from the minority Alawite community which is handling the daily confrontation against the armed opposition.

THREE OPTIONS

Either way, the regime is steadily losing ground as the rebels attempt to encircle Damascus for an apparent final push into the city center, leaving Assad with three possible choices. The first – although least likely – option is to remain in the presidential palace to the bitter – and probably bloody – end, fulfilling a promise he made last month in an interview with Russian television to “live and die in Syria”.

A second possibility is to escape Damascus with his family and seek asylum in a third country, perhaps Iran or Venezuela, the governments of which openly support the Syrian regime. Faisal Miqdad, Syria’s deputy foreign minister, was reported to have visited Venezuela, Cuba, and Ecuador recently. Ecuador subsequently announced that it was not entertaining the idea of granting asylum to Assad.

The most likely option, however, and one that appears already to be under way, is for the regime and the core of the army and security forces to retreat to the Alawite-populated mountains on the Mediterranean coast. Diplomatic sources say that there are unconfirmed reports that the regime is planning to register all Sunnis who live in the coastal cities of Tartous, Banias, and Latakia which could potentially form part of an Alawite-dominated enclave. The coastal cities are predominantly Sunni-populated while the mountain hinterland is mainly Alawite.

EXODUS TO THE MOUNTAINS

Furthermore, there appears to be a steady and discreet trickle of families of pro-regime Alawite army officers leaving the upmarket Mezzeh neighborhood of Damascus for the coastal mountains.

“More and more regime supporters and, or their families are moving up the coast, and there are persistent rumors that at least part of the government now sits in Tartous,” the European diplomat says. “All indications are that the regime's fallback position is to retreat to the coastal area of ​​Tartous and Latakia.”

Significantly, units of the rebel Free Syrian Army operating north of Damascus appear to be limiting ambushes to south-bound military traffic heading to the capital along the main highway, the sources say. Vehicles heading north are left unmolested, raising the possibility that the highway, which leads to Tartous, is being offered as an escape route for the regime to prevent a protracted and bloody last stand in Damascus.

INCREMENTAL RETREAT

Still, there might not be a mad dash for the mountains as Damascus falls but more of an incremental retreat.

“I think that the Assad regime will go in stages,” says Andrew Tabler, Syria expert at the Washington Institute for Near East Policy. “You have the north and east go and then after that there will be a real effort to hold on to Damascus as long as possible. But in the end I don't see that as viable.”

Sunni and Shiite Islam: Do you know the difference? Take our quiz.

Mr. Tabler says he envisages a staged pullback from Damascus first to the area west of Homs, Syria’s third largest city which lies two-thirds of the way along the Damascus-Tartous highway, and then to the mountains.

“Those areas are viable, I think, in the short- to medium-term,” he says.

A fallback to Homs would explain the fierce fighting that erupted in September and October in a string of villages between Homs and the border with Lebanon, 20 miles to the south. Syrian troops assisted by pro-regime Shabiha militiamen and combatants from Hezbollah, the Lebanese militant Shia group, fought rebel forces to maintain control of the villages which flank the vital Damascus-Tartous highway.

ALAWITE STATELET?

While there appears to be consensus among analysts that the regime will eventually decamp to the coastal region, what remains unclear is the nature of the enclave – if any – that would be established there. The prospect of creating a mini Alawite state along the lines of the French-engineered statelet between 1920 and 1937 appears improbable under current circumstances. It would require the suppression of hostile Sunnis in the coastal cities and would be internationally ostracized and subject to attack by the FSA.

The chief motivation for retreating to the mountains in the first place is self-preservation rather than state-building (Alawites represent about 12 percent of Syria’s 23 million, while Sunnis comprise about 70 percent).

“The Alawite community … is counting on [Assad’s] army to protect them from possible retribution from the rebel militias,” writes Joshua Landis, professor of Middle East history at the University of Oklahoma and author of the influential Syria Comment blog. “Sectarian hatred has been driven to a fever pitch by the brutality of the regime. Syrians have been putting hate into their hearts over the past two years, making the likelihood of some sort of retribution ever more likely and the ethnic cleansing a possibility, even if a small one at the time.”

A rump regime well-entrenched into the mountain villages defended by the Alawite core of the army and security services equipped with armor, artillery, air power and possibly even chemical and biological weapons could buy the Assads some breathing space during a likely period of chaos caused by a sudden leadership vacuum in Damascus. But it is questionable whether it would provide a long-term solution for the Assad clan’s survival.

ALAWITE DIVISIONS

Also working against a more formally established enclave is the fact that not all Alawites support the Assad regime. Some may prefer to cut a deal with the opposition rather than link the fate of the community to that of the Assads. Even Assad’s home town of Qordaha, 15 miles south east of Latakia, has reportedly seen some intra-Alawite unrest between supporters and opponents of the Assad clan.

The Assad family, under Bashar’s 12-year rule, has “all but seceded socially and economically” from its roots and has done “precious little” for the Alawites which remains one of the poorest communities in Syria, says Fred Hof, a senior fellow at the Atlantic Council’s Rafik Hariri Center for the Middle East and former special adviser for transition in Syria at the State Department.

“On top of that, they have placed this community in grave jeopardy by recklessly pursuing a sectarian strategy to save their skins and preserve their ability to acquire material wealth,” he says. “In sum, I think it would be inadvisable for the [Assads] and their chief enablers to try and set up shop in Latakia and vicinity. If they have to escape in that direction because of a closed Damascus airport, they’d do well to keep moving. Where to? I don’t know who would have them at this point.”

Sunni and Shiite Islam: Do you know the difference? Take our quiz.

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