Drug Shortages Are Becoming Persistent in U.S.

Paul Davis, the chief of a rural ambulance squad in southern Ohio, was down to his last vial of morphine earlier this fall when a woman with a broken leg needed a ride to the hospital.

The trip was 30 minutes, and the patient was in pain. But because of a nationwide shortage, his morphine supply had dwindled from four doses to just one, presenting Mr. Davis with a stark quandary. Should he treat the woman, who was clearly suffering? Or should he save it for a patient who might need it more?

In the end, he opted not to give her the morphine, a decision that haunts him still. “I just feel like I’m not doing my job,” said Mr. Davis, who is chief of the rescue squad in Vernon, Ohio. He has since refilled his supply. “I shouldn’t have to make those kinds of decisions.”

From rural ambulance squads to prestigious hospitals, health care workers are struggling to keep vital medicines in stock because of a drug shortage crisis that is proving to be stubbornly difficult to fix. Rationing is just one example of the extraordinary lengths being taken to address the shortage, which health care workers say has ceased to be a temporary emergency and is now a fact of life. In desperation, they are resorting to treating patients with less effective alternative medicines and using expired drugs. The Cleveland Clinic has hired a pharmacist whose only job is to track down hard-to-find drugs.

Caused largely by an array of manufacturing problems, the shortage has prompted Congressional hearings, a presidential order and pledges by generic drug makers to communicate better with federal regulators.

The problem peaked in 2011, when a record 251 drugs were declared in short supply. This year, slightly more than 100 were placed on the list, and workers say the battle to keep pharmacy shelves stocked continues unabated. The list of hard-to-find medicines ranges from basic drugs like the heart medicine nitroglycerin to a lidocaine injection, which is used to numb tissue before surgery.

A deadly meningitis outbreak caused by contamination at a large drug producer could worsen the situation, federal officials have warned. The Food and Drug Administration said that shortages of six drugs — medicines used during surgery and to treat conditions like congestive heart failure — could get worse after a big compounding pharmacy closed over concerns about drug safety. The pharmacy, Ameridose, shares some management with the New England Compounding Center, which is at the center of a meningitis outbreak that has claimed 33 lives.

“When you can’t treat basic things — cardiac arrest, pain management, seizures — you’re in trouble,” said Dr. Carol Cunningham, the state medical director for the Ohio Department of Public Safety’s emergency services division. “When you only have five tools in your toolbox and three of them are gone, what do you do?”

Dr. Margaret A. Hamburg, the F.D.A. commissioner, said in an interview this week that she was “guardedly optimistic” that the shortage crisis was abating. “I think there’s been an enormous amount of progress,” she said. “We’re seeing real change in the number of shortages that we’re able to recognize early.” More than 150 new shortages have been prevented this year, according to the agency.

But Erin Fox, who tracks supply levels for a broader range of drugs at the University of Utah, said once a drug became scarce, it tended to stay scarce. The university’s Drug Information Service was actively tracking 282 hard-to-find products by the end of the third quarter of this year, a record.

“The shortages we have aren’t going away — they’re not resolving,” she said. “But the good news is we’re not piling more shortages on top.”

In 2011, prompted by emotional pleas by cancer patients and others who said the drug shortage was threatening lives, President Obama issued an executive order requiring drug makers to notify the F.D.A. when a shortage appeared imminent. The agency also loosened some restrictions on importing drugs, and sped up approvals by other manufacturers to make certain medicines.

A law passed this summer contains several provisions aimed at improving the situation, including expediting approval of new generic medicines and requiring the agency’s enforcement unit to better coordinate with its drug-shortage officials before it takes action against a manufacturer.

Ralph G. Neas, the chief executive of the Generic Pharmaceutical Association, said fixing the drug shortage was complex and would take time, but was a top priority. “One shortage is one shortage too many,” he said. “One patient not getting a critical drug is one patient too many.”

Federal drug officials trace much of the drug shortage crisis to delays at plants that make sterile injectable drugs, which account for about 80 percent of the scarce medicines. Nearly a third of the industry’s manufacturing capacity is not running because of plant closings or shutdowns to fix serious quality issues. Other shortages have been caused by supply disruptions of the raw ingredients used to make the drugs, or by manufacturers exiting the market.

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Shortcuts: The Meaning in a Drawer Full of Old Family Snapshots

Eric Thayer/Reuters

A resident found photos as she sifted the debris of a house destroyed by Hurricane Sandy in Union Beach, N.J.

I WASN’T going to write about Hurricane Sandy. I was going to write about the changing nature of photographs and our relationship to them in this digital age.

Doug Mills/The New York Times

Picture-taking is now mainly digital, making prints of photos uncommon.

But as I began my research, I came across a Facebook page where lost photos from the storm were posted. Called “Union Beach — Photos and Misplaced Items,” the page shows photos of newborns and birthday parties, weddings and family gatherings.

Starting the morning after the storm devastated her community of Union Beach, N.J., Jeanette Van Houten and her niece have collected over a thousand photos and some photo albums. She is making it her mission to scan and post to Facebook as many as possible, including those turned into the fire department, police station and borough hall.

In addition, she was handed a drawerful of over a thousand family photos that must have been wrenched from a dresser.

About 60 photos have been claimed so far, and some professionals have offered to restore damaged photos free.

“These photos were passed down through families and they survived Sandy, even if the structures they were in didn’t,” Ms. Van Houten said. “They tell our story.”

With the Facebook page, Ms. Van Houten uses newer technology to help people reconnect with their old-fashioned snapshots. And seeing the photographs of mundane scenes and milestones on Facebook, along with the grateful comments from people who got back a bit of their lives, reminded me of both the fragility and strength of photos and their continuing importance in our lives. Judith Dupré, author of “Monuments: America’s History in Art and Memory” (Random House, 2007), and other books, teaches a class at her local library in Mamaroneck, N.Y., called “Stories from My Life,” for older residents. They use photos and stories to write about their lives.

“They bring in a basketful of photos,” Ms. Dupré said. “Each one of these photos contains a story — they’re like a key that opens the door to a life.”

And a printed photo “is a different species than a digital photo,” she said. “I don’t think anyone’s figured out the place of digital photos in terms of memory keeping.”

When an elderly aunt of hers died and left behind lots of photographs, Ms. Dupré said the family took them to the memorial service.

“We had a table and people could select and take what they wanted,” she said. “It was a very moving part of the memorial.”

Of course, even prints can lose their meaning and poignancy through the generations.

And in some cases, as with Hurricane Sandy, photos may be safer in cyberspace than in an album on a bookshelf — as long as you remember to upload them to a site like Flickr, Shutterfly, Snapfish or countless other photo sites available. (And make sure you know how long a site will keep your photos. Some, for example, require you to show some activity at least once a year.) That way, if you lose your hard drive, you don’t lose your photos.

But Ms. Dupré said she worried that photos that existed only online somewhere might die with the photographer.

“I don’t even know what my parents have in terms of digital photography,” she said. She said she put the password to her photos safely away with her will and other documents, so her children can access them.

Now I’m not trying to say that the old-fashioned way is the only way. Photography has constantly evolved. The Brownie camera, first sold by Kodak for $1 in 1900, radicalized photography by making it available to just about everyone.

But, and I know this largely a generational thing, I can’t help but wonder about the ubiquity of the cellphone photo. As Ms. Dupré said, “The infinite number of digital photos that can be taken has devalued the single image and made one-of-a-kind prints that much more precious.”

E-mail: shortcuts@nytimes.com

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Israel Sticks to Tough Approach in Conflict With Hamas

TEL AVIV — With rockets landing on the outskirts of Tel Aviv and Jerusalem on Friday and the Egyptian prime minister making a solidarity visit to Gaza, the accelerating conflict between Israel and Hamas — reminiscent in many ways of so many previous battles — has the makings of a new kind of Israeli-Palestinian face-off.

The combination of longer-range and far deadlier rockets in the hands of more radicalized Palestinians, the arrival in Gaza and Sinai from North Africa of other militants pressuring Hamas to fight more, and the growing tide of anti-Israel fury in a region where authoritarian rulers have been replaced by Islamists means that Israel is engaging in this conflict with a different set of challenges.

The Middle East of 2012 is not what it was in late 2008, the last time Israel mounted a military invasion to reduce the rocket threat from Gaza. Many analysts and diplomats outside Israel say the country today needs a different approach to Hamas and the Palestinians based more on acknowledging historic grievances and shifting alliances.

“As long as the crime of dispossession and refugeehood that was committed against the Palestinian people in 1947-48 is not redressed through a peaceful and just negotiation that satisfies the legitimate rights of both sides, we will continue to see enhancements in both the determination and the capabilities of Palestinian fighters — as has been the case since the 1930s, in fact,” Rami G. Khouri, a professor at the American University of Beirut, wrote in an online column. “Only stupid or ideologically maniacal Zionists fail to come to terms with this fact.”

But the government in Israel and the vast majority of its people have drawn a very different conclusion. Their dangerous neighborhood is growing still more dangerous, they agree. That means not concessions, but being tougher in pursuit of deterrence, and abandoning illusions that a Jewish state will ever be broadly accepted here.

“There is a theory, which I believe, that Hamas doesn’t want a peaceful solution and only wants to keep the conflict going forever until somehow in their dream they will have all of Israel,” Eitan Ben Eliyahu, a former leader of the Israeli Air Force, said in a telephone briefing. “There is a good chance we will go into Gaza on the ground again.”

What is striking in listening to the Israelis discuss their predicament is how similar the debate sounds to so many previous ones, despite the changed geopolitical circumstances. In most minds here, the changes do not demand a new strategy, simply a redoubled old one.

The operative metaphor is often described as “cutting the grass,” meaning a task that must be performed regularly and has no end. There is no solution to security challenges, officials here say, only delays and deterrence. That is why the idea of one day attacking Iranian nuclear facilities, even though such an attack would set the nuclear program back only two years, is widely discussed as a reasonable option. That is why frequent raids in the West Bank and surveillance flights over Lebanon never stop.

And that is why this week’s operation in Gaza is widely viewed as having been inevitable, another painful but necessary maintenance operation that, officials here say, will doubtless not be the last.

There are also those who believe that the regional upheavals are improving Israel’s ability to carry out deterrence. One retired general who remains close to the military and who spoke on the condition of anonymity said that with Syria torn apart by civil war, Hezbollah in Lebanon discredited because of its support for the Syrian government, and Egypt so weakened economically, Israel should not worry about anything but protecting its civilians.

“Should we let our civilians be bombed because the Arab world is in trouble?” he asked.

So much was happening elsewhere in the region — the Egyptian and Libyan revolutions, the Syrian civil war, dramatic changes in Yemen and elections in Tunisia — that a few rockets a day that sent tens of thousands of Israeli civilians into bomb shelters drew little attention. But in the Israeli view, the necessity of a Gaza operation has been growing steadily throughout the Arab Spring turmoil.

In 2009, after the Israeli invasion pushed Hamas back and killed about 1,400 people in Gaza, 200 rockets hit Israel. The same was true in 2010. But last year the number rose to 600, and before this week the number this year was 700, according to the Israeli military. The problem went beyond rockets to mines planted near the border aimed at Israeli military jeeps and the digging of explosive-filled tunnels.

“In 2008 we managed to minimize rocket fire from Gaza significantly,” said Lt. Col. Avital Leibovich, a military spokeswoman. “We started that year with 100 rockets a week and ended it with two a week. We were able to give people in our south two to three years. But the grass has grown, and other things have as well. Different jihadist ideologies have found their way into Gaza, including quite a few terrorist organizations. More weapons have come in, including the Fajr-5, which is Iranian made and can hit Tel Aviv. That puts nearly our entire population in range. So we reached a point where we cannot act with restraint any longer.”

Gazans see events in a very different light. The problem, they say, comes from Israel: Israeli drones fill the Gazan skies, Israeli gunboats strafe their waters, Palestinian militants are shot at from the air, and the Gaza border areas are declared off limits by Israel with the risk of death from Israeli gunfire.

But there is little dissent in Israel about the Gaza policy. This week leaders of the leftist opposition praised the assassination of Ahmed al-Jabari, the Hamas military commander, on Wednesday. He is viewed here as the equivalent of Osama bin Laden. The operation could go on for many days before there is any real dissent.

The question here, nonetheless, is whether the changed regional circumstances will make it harder to “cut the grass” in Gaza this time and get out. A former top official who was actively involved in the last Gaza war and who spoke on the condition of anonymity said it looked to him as if Hamas would not back down as easily this time.

“They will not stop until enough Israelis are killed or injured to create a sense of equality or balance,” he said. “If a rocket falls in the middle of Tel Aviv, that will be a major success. But this government will go back at them hard. I don’t see this ending in the next day or two.”

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Automated Bidding Systems Test Old Ways of Selling Ads

Publishers and broadcasters have long tried to offer advertisers the right audience for their products. Want to sell pick-ups to people who like sports? Buy ads at halftime during a football game. Selling luggage or airline tickets? Buy ads in the travel section of a newspaper or Web site.

In digital advertising, that formula is being increasingly tested by fast-paced, algorithmic bidding systems that target individual consumers rather than the aggregate audience publishers serve up. In the world of “programmatic buying” technologies, context matters less than tracking those consumers wherever they go. And that kind of buying is the reason that shoe ad follows you whether you’re on Weather.com or on a local news blog.

That shift is punishing traditional online publishers, like newspaper, broadcast and magazine sites, who are receiving a much lower percentage of ad dollars as marketers use programmatic buying across a much broader canvas. Some sites, like CNN.com, refuse to even accept advertising through programmatic buying because they do not want to cede control over what ads will appear.

“It’s allowing advertisers to assign value to media rather than publishers,” said Ben Winkler, the chief digital officer at OMD, an agency in the Omnicom Media Group. Publishers, he said, “can’t control the price, but they can control the quality of the content and the audience on that site.”

About 10 percent of the display ads that consumers see online have been sold through programmatic bidding channels, according to Walter Knapp, the executive vice president of platform revenue and operations at Federated Media, one of the world’s largest digital advertising networks.

Advertisers like Nike, Comcast, Progressive and Procter & Gamble are now using the programmatic buying, and luxury advertisers are starting to follow. According to data from Forrester Research, all ads traded on exchanges, as programmatic ads are, increased more than 17.5 percent to about 629 billion impressions (the number of times an ad appears) in 2012, from 535 billion in 2011.

That growth is affecting publishers of all stripes, but few are willing to discuss their internal numbers. “For a publisher to admit they’ve been hurt is tough for the big guys,” said John Ebbert, the executive editor and publisher of the Web site AdExchanger.

When The New York Times Company announced its earnings last month, the company posted a profit, but said that digital advertising fell 2.2 percent. Jim Follo, the company’s senior vice president and chief financial officer, attributed the dip, in part, on a “shift toward ad exchanges, real-time bidding and other programmatic buying channels that allow advertisers to buy audience at scale.”

Programmatic buying began as a way for advertisers to place lower-cost ads for products like teeth-whitening products and belly fat pills that filled up the back pages of Web sites. But the practice has gained in sophistication and breadth, with major advertisers and many of the world’s largest ad agencies creating private exchanges to automate the buying and selling of ads.

Programmatic buying includes a number of different technologies and strategies, but it essentially allows advertisers to bid, often in real time, on ad space largely based on the value they have assigned to the consumer on the other side of the screen. Say, for example, that Nike wants to sell running gear to a particular consumer who has a high likelihood of buying shoes based on the data it has collected, including the type of Web sites that consumer typically visits. Because the ad-buying is done through computer trading, the price for that space can change rapidly.

“Accessing media is a commodity now,” said Sheldon Gilbert, the founder and chief executive of Proclivity Media, a company that specializes in digital advertising technologies. “Instead of having to commit four months in advance, you can now bid and buy an individual impression in real time.”

In the short run, the growth in programmatic buying has forced overall ad prices to fall. A media buyer who would have once spent $50,000 worth of advertising on a publisher’s site, at, say, an $8 cost-per-thousand, can now buy ad impressions on any Web site on which they happen to find their intended audience and pay less per ad, Mr. Ebbert said.

“There is no scarcity of premium online,” said Dan Salmon, an equity research analyst at BMO Capital Markets. “There’s only one Super Bowl, but there are lots of different places to buy banner ads online.”

While the “halo effect” of buying an ad against premium content has not disappeared entirely — many advertisers still want front-page placement on popular Web sites — the shift is prompting publishers to rethink how they sell their ads.

Clark Fredricksen, the vice president for communications at eMarketer, a data company, said that publishers were “going to have to double down to prove the value of their inventory as they compete with other, cheaper inventory.”

And some publishers are jumping into the game themselves. During the most recent AOL earnings call, Tim Armstrong, the company’s chairman and chief executive, said it was bullish on programmatic buying, despite being a publisher itself with properties that include TechCrunch and The Huffington Post. The company trades its ads through its own ad network, Ad.com, and others like it.

“We will continue to invest in people and technology to capture the programmatic business of advertising,” Mr. Armstrong said.

Like AOL, Weather.com is also aggressively moving into programmatic bidding. “Instead of thinking of us a publisher, think of us as a marketing engine,” said Curt Hecht, the chief global revenue officer for the Weather Company.

Neal Mohan, the vice president for product management at Google, which sells advertising though its DoubleClick network, says that in the long run, publishers could see higher returns from programmatic advertising. In the last year, the number of advertisers and publishers using the DoubleClick platform has doubled, Mr. Mohan said, while the rates for those using the platform have increased 11 percent. But that means publishers will have to play by different rules.

“Context still matters and so does placement,” Mr. Ebbert said. “But it’s only one element.”

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For Alzheimer’s, Detection Advances Outpace Treatment Options

Joshua Lott for The New York Times

Awilda Jimenez got a scan for Alzheimer’s after she started forgetting things. It was positive.

When Awilda Jimenez started forgetting things last year, her husband, Edwin, felt a shiver of dread. Her mother had developed Alzheimer’s in her 50s. Could his wife, 61, have it, too?

He learned there was a new brain scan to diagnose the disease and nervously agreed to get her one, secretly hoping it would lay his fears to rest. In June, his wife became what her doctor says is the first private patient in Arizona to have the test.

“The scan was floridly positive,” said her doctor, Adam S. Fleisher, director of brain imaging at the Banner Alzheimer’s Institute in Phoenix.

The Jimenezes have struggled ever since to deal with this devastating news. They are confronting a problem of the new era of Alzheimer’s research: The ability to detect the disease has leapt far ahead of treatments. There are none that can stop or even significantly slow the inexorable progression to dementia and death.

Families like the Jimenezes, with no good options, can only ask: Should they live their lives differently, get their affairs in order, join a clinical trial of an experimental drug?

“I was hoping the scan would be negative,” Mr. Jimenez said. “When I found out it was positive, my heart sank.”

The new brain scan technology, which went on the market in June, is spreading fast. There are already more than 300 hospitals and imaging centers, located in most major metropolitan areas, that are ready to perform the scans, according to Eli Lilly, which sells the tracer used to mark plaque for the scan.

The scans show plaques in the brain — barnaclelike clumps of protein, beta amyloid — that, together with dementia, are the defining feature of Alzheimer’s disease. Those who have dementia but do not have excessive plaques do not have Alzheimer’s. It is no longer necessary to wait until the person dies and has an autopsy to learn if the brain was studded with plaques.

Many insurers, including Medicare, will not yet pay for the new scans, which cost several thousand dollars. And getting one comes with serious risks. While federal law prevents insurers and employers from discriminating based on genetic tests, it does not apply to scans. People with brain plaques can be denied long-term care insurance.

The Food and Drug Administration, worried about interpretations of the scans, has required something new: Doctors must take a test showing they can read them accurately before they begin doing them. So far, 700 doctors have qualified, according to Eli Lilly. Other kinds of diagnostic scans have no such requirement.

In another unusual feature, the F.D.A. requires that radiologists not be told anything about the patient. They are generally trained to incorporate clinical information into their interpretation of other types of scans, said Dr. R. Dwaine Rieves, director of the drug agency’s Division of Medical Imaging Products.

But in this case, clinical information may lead radiologists to inadvertently shade their reports to coincide with what doctors suspect is the underlying disease. With Alzheimer’s, Dr. Rieves said, “clinical impressions have been misleading.”

“This is a big change in the world of image interpretation,” he said.

Like some other Alzheimer’s experts, Dr. Fleisher used the amyloid scan for several years as part of a research study that led to its F.D.A. approval. Subjects were not told what the scans showed. Now, with the scan on the market, the rules have changed.

Dr. Fleisher’s first patient was Mrs. Jimenez. Her husband, the family breadwinner, had lost his job as a computer consultant when the couple moved from New York to Arizona to take care of Mrs. Jimenez’s mother. Paying several thousand dollars for a scan was out of the question. But Dr. Fleisher found a radiologist, Dr. Mantej Singh Sra of Sun Radiology, who was so eager to get into the business that he agreed to do Mrs. Jimenez’s scan free. His plan was to be the first in Arizona to do a scan, and advertise it.

After Dr. Sra did the scan, the Jimenezes returned to Dr. Fleisher to learn the result.

Dr. Fleisher, sad to see so much plaque in Mrs. Jimenez’s brain, referred her to a psychiatrist to help with anxiety and suggested she enter clinical trials of experimental drugs.

But Mr. Jimenez did not like that idea. He worried about unexpected side effects.

“Tempting as it is, where do you draw the line?” he asks. “At what point do you take a risk with a loved one?”

At Mount Sinai Medical Center in New York, Dr. Samuel E. Gandy found that his patients — mostly affluent — were unfazed by the medical center’s $3,750 price for the scan. He has been ordering at least one a week for people with symptoms ambiguous enough to suggest the possibility of brain plaques.

Most of his patients want their names kept confidential, fearing an inability to get long-term care insurance, or just wanting privacy.

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Gadgetwise Blog: Q&A: Removing Programs on a Mac

Windows computers have the Add/Remove Program option and many programs include uninstaller software, but how do you uninstall a Mac program?

Some Mac programs do come with their own uninstaller programs to remove the software from the computer. If the program you want to delete does not offer that utility, you can get rid of it in other ways.

Just dragging the program’s icon out of the Applications folder to the Mac’s desktop Trash can — and then going to the Finder’s File menu and choosing Empty Trash — gets rid of the program and many of its associated files. Some Mac application icons contain many more files than just the program itself; just right-click on an icon in the Applications folder and choose Show Package Contents from the menu to see what lies beneath.

Some programs leave other files around the Mac’s system, though, and just deleting the application’s icon from the computer may leave some digital detritus on your drive. If you are comfortable with poking around in OS X, tutorials like those from Cult of Mac or Raw Computing show where to look in your clean-up mission. For a more automatic approach, free or inexpensive utility apps like AppDelete, AppZapper and CleanApp can take care of the job for you.

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Israel Girds for Ground Assault in Gaza; Egypt’s Premier Visits

Ronen Zvulun/Reuters

Israeli soldiers near the border with Gaza on Friday. More Photos »

GAZA CITY — After a morning of heavy rocket fire from Gaza into Israel, the Israeli military seemed to be edging closer toward a ground invasion of Gaza on Friday, saying forces were “on standby” and “ready to enter should it be decided that a ground operation is necessary.”

In a statement, the military said paratrooper and infantry brigades had completed final preparations for a potential ground operation that would be the first since the winter of 2008-09, when Israel drew broad international reproach for an invasion that claimed 1,400 Palestinian lives for the loss of 13 Israelis.

The statement came after scores of rockets were fired into Israel, striking major cities of the south, causing widespread panic and damage and shattering plans for a temporary cease-fire during a remarkable visit to Gaza by the Egyptian prime minister that showed the shifting dynamics of Middle East politics since the turmoil of the so-called Arab Spring.

Word of the potential invasion emerged shortly before a rocket from Gaza struck somewhere near Tel Aviv after sirens wailed. It was the second such attempt to strike at the city in two days. Hamas said it fired a single “homemade” projectile toward Tel Aviv.

The rapidly escalating confrontation between Gaza and Israel followed an Israel airstrike on Wednesday that killed the top commander of Hamas, and the tit-for-tat violence is widely seen as a potential catalyst for broader hostilities at a time of spreading turmoil in Syria and elsewhere in the region.

The Israeli military said that Col. Amir Baram, commander of the Israeli Defense Forces’ paratroopers brigade, had addressed his forces during a preparatory briefing in the field, saying: “We are already 48 hours into an operation that we knew would have to happen. We have spoken about it during training, exercises and conferences. There is now doubt that we have to operate. This is why we enlisted, and why we have trained.”

His words followed earlier indications that Israel was sending armored vehicles toward Gaza and had called up reservists for a possible invasion, while Egypt sought to show support for Hamas and to broker an end to hostilities.

As Prime Minister Hesham Kandil of Egypt prepared to travel to Gaza, Israel agreed to a temporary cease-fire for the visit. But the truce never took root.

Israel Radio said Palestinian militants fired 25 rockets into southern Israel, one of them striking a house. There were no immediate reports of casualties.

What sounded like airstrikes by Israeli F-16s were also audible in Gaza City. The Israeli military said no such strikes had taken place, but the Hamas Health Ministry reported that two people, including a child, were killed in the north of Gaza City while the Egyptian delegation was on the ground, pushing the Palestinian death toll in three days of aerial bombardment to 21.

Three Israelis were killed in a rocket attack on Thursday in Kiryat Malachi, a small town in southern Israel, when a rocket fired from Gaza struck their apartment building.

Mr. Kandil’s visit produced dramatic imagery to underpin the Egyptian government’s support for Hamas, which Israel, the United States and much of the West consider to be a terrorist organization.

Mr. Kandil and Ismail Haniya, his Hamas counterpart, visited the Al Shifa hospital amid a huge scrum of bodyguards and journalists, saying they had carried the body of Mohammed Yasser, one of eight children who Palestinian health officials say have been killed in the surge of violence since a top Hamas commander was killed in an Israeli airstrike on Wednesday.

“This is the blood of our children on our clothes,” Mr. Haniya said as he showed spatters on his clothing, “These are the Egyptian and the Palestinian blood united together.”

Like President Mohamed Morsi of Egypt on Thursday, Mr. Kandil walked a delicate line between support for Hamas, condemnation of Israel and a quest for calm in a region increasingly threatened by the spillovers from Syria’s civil war, as well as by the long-festering impasse between the Israelis and Palestinians.

“The aim of this visit is not only to show political support but to support the Palestinian people on the ground,” Mr. Kandil said, noting that he had brought with him a delegation from the Egyptian Health Ministry. He said a cease-fire between Gaza and Israel was “the only way to achieve stability in the region” and also called on the Palestinians to repair the rift between Hamas in Gaza and the Fatah group that dominates the Palestinian Authority in the West Bank. “We call on the Palestinian people to unite because their power and strength is in their unity,” Mr. Kandil said. “That’s the only way to liberate Palestine.”

Jodi Rudoren reported from Gaza City, Isabel Kershner from Jerusalem, and Alan Cowell from Paris. Reporting was contributed by Fares Akram from Gaza, Rick Gladstone from New York, Rina Castelnuovo from Kiryat Malachi, Israel, Mayy El Sheikh and David D. Kirkpatrick from Cairo, Gabby Sobelman from Jerusalem, and Elisabeth Bumiller from Bangkok.

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Greece Looks at Offering Creditors a Buyback to Lower Its Debt

LONDON — As Greece’s creditors bicker over the terms of its bailout, the government is examining a more radical approach that could reduce the country’s escalating debt pile in one fell swoop.

Milos Bicanski/Getty Images

An anti-austerity protest on Wednesday in Athens. The government this month narrowly secured parliamentary approval for yet another round of spending cuts and tax increases.

Fotis Plegas G./European Pressphoto Agency

Charles Dallara of the Institute of International Finance argues that the real issue is Greece’s inability to revive its economy.

Essentially, Greece would propose that its private sector bondholders sell back their sovereign debt holdings for a small profit, but at a price favorable to Greece. The move takes a page from the playbook Greece used earlier this year in which the government pressured banks and other private holders to take a loss on their sovereign bonds so Greece could ease its debt load. This time, they would not be forced to take a haircut, but some would most likely balk at being forced to accept a new deal.

The aim is to further reduce an ever-increasing sovereign debt burden that is fast approaching 200 percent of gross domestic product, far beyond Europe’s ideal of 60 percent or less.

Many different strategies about how to address Greece’s debt load are being discussed by its creditors, with the buyback option being just one of several. The government this month narrowly secured parliamentary approval for yet another round of spending cuts and tax increases, putting Greece on the verge of receiving 31 billion euros, or $39 billion, in desperately needed bailout loans. The euro zone is also weighing measures — like extending loan maturities and paring interest rates — that would further ease the country’s financial burden.

While the most pressing need is securing the 31 billion euros Greece needs to survive, arriving at a long-term solution for its bloated sovereign debt is also seen as crucial, given that the economy continues to shrink. An estimate released Wednesday showed Greece’s economy contracted by 7 percent in the third quarter — which makes the debt relative to economic output all the more onerous.

 To that end, a small circle of lawyers and bankers are suggesting that Greece offer to buy back its deeply discounted debt at a price of 27 to 33 euro cents, compared to the 25-cent level where it currently trades. If investors hold out for a higher price, the government could invoke collective action clauses (C.A.C.’s) in the bond contracts that, in theory, would prevent a bidding war, thus allowing the country to retire as much as 40 billion euros of its 340 billion euros in debt.

For example, the 62 billion euros’ worth of new bonds that Greece issued as part of its landmark debt restructuring deal reached with private bondholders in March are now valued at about 15 billion euros, or $19 billion. If Greece were to borrow the money to buy back this debt, it could retire 30 billion to 40 billion euros’ worth of its obligations, depending on the ultimate price it pays.

While borrowing such an amount would be a challenge, Germany — the biggest euro zone economy and thus the biggest contributor to the Greek bailout — could take the view that this would be a better way to reduce Greek debt than to ask taxpayers to swallow a loss via a write-down of public sector bailout loans.

Unlike the last time around, when the protracted wrangling between the Greek government and private bondholders centered on banks, hedge funds and other investors’ accepting a reduction in the bonds’ value, they will not have to suffer a large loss on their bond holdings. Depending on the price, however, they may have to forgo some further upside if the bonds continue to rally after the buyback.

If successful, the debt buyback could significantly reduce Greece’s debt and afford the country a realistic chance of meeting the target of a debt ratio of 120 percent of G.D.P. by 2020 that the International Monetary Fund has set as a condition for it to lend more money. European leaders have said that this benchmark is too stringent and needs to be relaxed.

Of course, the idea has infuriated the many hedge funds that in past months have scooped up more than 22 billion euros’ worth of Greek bonds at rock-bottom prices. With many sitting on big profits after the recent market rally, they are in no mood to sell out cheaply, especially if Greece resorts to wielding a legal cudgel to complete the deal.

“It’s really the dumbest thing that Greece can do right now,” said Hans Humes of Greylock Capital, who has been one of the more aggressive investors in terms of accumulating discounted Greek bonds.

Collective action clauses are legal riders in bond contracts that can make it easier for a debtor country to restructure its loans by forcing holdouts to accept the country’s proposal for a bond swap if a certain majority of creditors agree to it. They were used to great effect during the 100 billion euro restructuring of Greece’s private sector debt earlier this year.

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State of the Art: A Review of New Activity-Tracking Bands From Nike and Jawbone

Maybe you’ve heard: Americans are becoming less fit and more fat. There are all kinds of theories about why — bigger meal portions, omnipresent corn syrup and sugar, fewer pickup stickball games after school. But people are starting to think that in many cases, body weight might somehow be linked to diet and exercise.

Now, studies have shown that if there’s some visible, omnipresent monitor of your negative behavior — spending too much money, eating too much food, using too much power in your home — you’re far more likely to correct it.

That’s the idea behind personal activity-tracking bracelets like the Nike FuelBand ($150) and the improved Jawbone Up band ($130). They make you constantly aware of how active you are (or aren’t). They let you compare your data with friends online, establishing a friendly rivalry or at least guilt. And they therefore motivate you to make changes that add up: park farther away, take the stairs, get off one bus stop early.

There are plenty of other fitness trackers, including clip-onto-clothing trackers (like the FitBit and Striiv) and wristwatchlike gadgets (like Motorola’s MotoActiv). But the beauty of the bracelets is that you can leave them on — asleep, in the shower, shirtless or even all three — and so you’re more likely to stick with the program.

Now, those who follow the wearable, accelerometer-based fitness-tracking gadget industry are no doubt scratching their heads right about now. The Up band? Wasn’t that a bracelet that came out about a year ago, and crashed and burned in a humiliatingly public epidemic of hardware failures? Didn’t Jawbone, a company known for Bluetooth speakers and earpieces, pull Up off the market, offering a generous mea culpa (“You can receive a full refund for UP. This is true even if you decide to keep your UP band”)?

Yes.

The company says that after months of testing and millions of dollars in research, it realized that the original band, billed as waterproof, actually wasn’t quite. Water, sweat and shower soap managed to seep inside and short out the components.

The new Up band, the company swears, is bulletproof. Or at least really, truly waterproof. The company says it redesigned 17 parts and made 28 improvements in the manufacturing process. The new band looks identical — it’s still a stiff, rubber, overgrown C in a choice of colors, with ends that overshoot each other — but inside, it’s far better shielded and enclosed. (It’s also $30 more expensive.)

The corresponding iPhone app has had some work done, too. The central conceit is a Facebook-style timeline of your life. Each “post” represents a day’s worth of activity, or a night of sleep, or a meal. (You can enter nonstep-based workouts manually, like biking or weights.) Your friends’ health developments can show up in your stream, too.

That doesn’t mean that the app is ready for its close-up. It’s fairly baffling, housing as it does duplicate hidden menus, and it has its share of bugs and quirks. Why, on a screen that’s much taller than it is wide, are your progress graphs inch-tall bars swimming in empty space? And wow — if you did a situp every time you got the “Sorry, there was an error connecting with the UP server” message, you’d have abs of concrete. (An Android app is in the works.)

What’s great, though, is that the Up’s ambitions extend beyond simple activity tracking. If you do a double press on the button at the end of the band when you go to bed, for example, the bracelet does an impressive job of tracking your night of sleep: how long it takes you to drift off, how many times you wake up, how many hours you spend in light and deep sleep.

A related, extremely useful feature: when you need a power nap (a 25-minute quick sleep, whose refreshing qualities have been well documented in studies), the band doesn’t start counting until it sees that you’re actually asleep. So you actually get 25 minutes, after which the band vibrates to rouse you. That’s something the average pedometer doesn’t do.

You can track your food intake in any of three ways: by taking a photo of what you eat, by scanning the bar code on its package (the app instantly and correctly identifies it) or by choosing from a categorized list of common foodstuffs. It’s still fairly manual — no wristband can tell what you’re shoving into your mouth — so most people probably won’t bother.

E-mail: pogue@nytimes.com

Read More..

State of the Art: A Review of New Activity-Tracking Bands From Nike and Jawbone

Maybe you’ve heard: Americans are becoming less fit and more fat. There are all kinds of theories about why — bigger meal portions, omnipresent corn syrup and sugar, fewer pickup stickball games after school. But people are starting to think that in many cases, body weight might somehow be linked to diet and exercise.

Now, studies have shown that if there’s some visible, omnipresent monitor of your negative behavior — spending too much money, eating too much food, using too much power in your home — you’re far more likely to correct it.

That’s the idea behind personal activity-tracking bracelets like the Nike FuelBand ($150) and the improved Jawbone Up band ($130). They make you constantly aware of how active you are (or aren’t). They let you compare your data with friends online, establishing a friendly rivalry or at least guilt. And they therefore motivate you to make changes that add up: park farther away, take the stairs, get off one bus stop early.

There are plenty of other fitness trackers, including clip-onto-clothing trackers (like the FitBit and Striiv) and wristwatchlike gadgets (like Motorola’s MotoActiv). But the beauty of the bracelets is that you can leave them on — asleep, in the shower, shirtless or even all three — and so you’re more likely to stick with the program.

Now, those who follow the wearable, accelerometer-based fitness-tracking gadget industry are no doubt scratching their heads right about now. The Up band? Wasn’t that a bracelet that came out about a year ago, and crashed and burned in a humiliatingly public epidemic of hardware failures? Didn’t Jawbone, a company known for Bluetooth speakers and earpieces, pull Up off the market, offering a generous mea culpa (“You can receive a full refund for UP. This is true even if you decide to keep your UP band”)?

Yes.

The company says that after months of testing and millions of dollars in research, it realized that the original band, billed as waterproof, actually wasn’t quite. Water, sweat and shower soap managed to seep inside and short out the components.

The new Up band, the company swears, is bulletproof. Or at least really, truly waterproof. The company says it redesigned 17 parts and made 28 improvements in the manufacturing process. The new band looks identical — it’s still a stiff, rubber, overgrown C in a choice of colors, with ends that overshoot each other — but inside, it’s far better shielded and enclosed. (It’s also $30 more expensive.)

The corresponding iPhone app has had some work done, too. The central conceit is a Facebook-style timeline of your life. Each “post” represents a day’s worth of activity, or a night of sleep, or a meal. (You can enter nonstep-based workouts manually, like biking or weights.) Your friends’ health developments can show up in your stream, too.

That doesn’t mean that the app is ready for its close-up. It’s fairly baffling, housing as it does duplicate hidden menus, and it has its share of bugs and quirks. Why, on a screen that’s much taller than it is wide, are your progress graphs inch-tall bars swimming in empty space? And wow — if you did a situp every time you got the “Sorry, there was an error connecting with the UP server” message, you’d have abs of concrete. (An Android app is in the works.)

What’s great, though, is that the Up’s ambitions extend beyond simple activity tracking. If you do a double press on the button at the end of the band when you go to bed, for example, the bracelet does an impressive job of tracking your night of sleep: how long it takes you to drift off, how many times you wake up, how many hours you spend in light and deep sleep.

A related, extremely useful feature: when you need a power nap (a 25-minute quick sleep, whose refreshing qualities have been well documented in studies), the band doesn’t start counting until it sees that you’re actually asleep. So you actually get 25 minutes, after which the band vibrates to rouse you. That’s something the average pedometer doesn’t do.

You can track your food intake in any of three ways: by taking a photo of what you eat, by scanning the bar code on its package (the app instantly and correctly identifies it) or by choosing from a categorized list of common foodstuffs. It’s still fairly manual — no wristband can tell what you’re shoving into your mouth — so most people probably won’t bother.

E-mail: pogue@nytimes.com

Read More..