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: The Lytro Camera Adds a New Perspective

The Lytro camera made a splash with its ability to refocus photos after they were taken. Now the company is adding a new trick — allowing the camera to shift your viewing angle slightly on your finished photo.

The new feature, called “Perspective Shift,” is a software upgrade that will be released to the public Dec. 4. It will be included with new cameras, and will be a free upgrade for older cameras.

Lytro is able to add Perspective Shift because it doesn’t work like a traditional camera. Instead of capturing light as data, the way digital cameras do, it captures data about the light. It reads the direction of the light, so it knows what light rays are traveling toward your subject and what light rays are bouncing off your subject for you to see.

Using that information, it constructs a image. But it can use that data to construct that image in many different ways, which is how it manages to change focus. It can use the data about the light to construct the photo as it would be if you were focused on the foreground, or  to construct the same photo as if you were focused on the background.

This also gives it the new capability to shift perspective. From the data about the light, it can construct the photo as if you were standing a little bit to one side or the other.

When you use the software that lets you interact with your photos, you can roll your cursor around the picture and see the view shift as you do.

While it’s an interesting novelty, the immediate value isn’t apparent – the perspective shift is fairly subtle. But it may have much greater value down the road, because the shift is enough to build 3-D images from a single photo. It’s a capability that the Lytro says is on the way.

The company has also added “Living Filters,” which are photo effects like those you’re used to seeing on phone camera apps like Instagram. The difference here is you can move the filters around and apply them selectively.

You can see a demonstration of both Perspective Shift and Living Filters on the Lytro Web site gallery.

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Israel Prepares Possible Ground Offensive in Gaza


Rina Castelnuovo for The New York Times


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







JERUSALEM — After a morning of heavy rocket fire from Gaza into Israel, the Israeli military seemed to be edging closer to 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 Israeli military said paratrooper and infantry brigades had completed final preparations for a potential ground operation, which 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 Arab Spring uprisings.


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


An Israeli police spokesman, Micky Rosenfeld, said the rocket that was fired at Tel Aviv probably landed in the sea, and that it was one of about 120 rockets fired into Israel by dusk on Friday. Israeli officials say that the only rockets in Gaza with a range that can reach Tel Aviv are the Iranian-made Fajr-5 projectiles that Israel has been targeting in its hundreds of airstrikes over the last two days.


That these rockets were still being fired seemed to weigh heavily in Israeli military calculations about a ground invasion. After a meeting with President Shimon Peres, Prime Minister Benjamin Netanyahu said the Israeli army was “continuing to hit Hamas hard and is ready to expand the operation into Gaza,” according to a statement from his office.


Mr. Netanyahu said the aim was “to take out the terrorist infrastructure in Gaza while doing everything possible not to harm civilians.”


The rapidly escalating confrontation between Hamas and Israel followed an Israeli 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 Col. Amir Baram, commander of the Israel 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 no doubt that we have to operate. This is why we enlisted, and why we have trained.”


Witnesses on the Gaza-Israel border said Israeli tanks had massed in several places.


Early on Friday, the Israeli military said it had called up 16,000 army reservists after Defense Minister Ehud Barak authorized the call-up of 30,000 reservists, if needed, to move against what Israel considers an unacceptable security threat from smuggled rockets amassed by Hamas, which does not recognize Israel’s right to exist.


It was not initially clear whether the show of Israeli force on the ground was meant as more of an intimidation tactic to further pressure Hamas leaders, who had all been forced into hiding on Wednesday after the group’s military chief, Ahmed al-Jabari, was killed in a pinpoint aerial bombing. But Israel’s preparations seemed to pick up on Friday after the attempts to land rockets in Tel Aviv added new urgency while Hamas itself seemed emboldened by Egypt’s support.


“The time in which the Israeli occupation does whatever it wants in Gaza is gone,” said Ismail Haniya, the Hamas prime minister.


Initially, the Egyptian initiative was portrayed as a potential harbinger of reduced hostilities, and, as Prime Minister Hesham Qandil of Egypt prepared to travel to Gaza, Israel agreed to a temporary conditional cease-fire for the visit. But the truce never took root.


Israel Radio said Palestinian militants had 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.


The Palestinian death toll rose to 23 on Friday. The number included a man apparently executed by Hamas for what it said was collaboration with Israel in the deaths of 15 Palestinian leaders. Three Israelis were killed Thursday in a rocket attack in Kiryat Malachi, a small town in southern Israel, when a rocket fired from Gaza struck their apartment building.


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



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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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Hospital Death in Ireland Renews Fight Over Abortion





DUBLIN — The death of a woman who was reportedly denied a potentially lifesaving abortion even while she was having a miscarriage has revived debate over Ireland’s almost total ban on abortions.




The woman, Savita Halappanavar, 31, a dentist who lived near Galway, was 17 weeks pregnant when she sought treatment at University Hospital Galway on Oct. 21, complaining of severe back pain.


Dr. Halappanavar was informed by senior hospital physicians that she was having a miscarriage and that her fetus had no chance of survival. However, despite repeated pleas for an abortion, she was told that it would be illegal while the fetus’s heart was still beating, her husband, Praveen Halappanavar, said.


It was not until Oct. 24 that the heartbeat ceased and the remains of the fetus were surgically removed. But Dr. Halappanavar contracted a bacterial blood disease, septicemia. She was admitted to intensive care but never recovered, dying on Oct. 28.


Mr. Halappanavar, in an interview with The Irish Times from his home in India, said his wife was told after one request, “This is a Catholic country.”


Two investigations into the case have been announced, and politicians have been quick to express their condolences and to call for legal clarity. Kathleen Lynch, a junior health minister, said medical professionals needed guidelines to deal with such circumstances.


In a statement, the hospital said it would cooperate fully with any inquest but that it had not started its own review because it wanted to consult the woman’s family first.


Mr. Halappanavar told the newspaper that he still could not believe his wife was dead. “I was with her those four days in intensive care,” he said. “They kept telling me: ‘She’s young. She’ll get over it.’ But things never changed; they only got worse. She was so full of life. She loved kids.


“It was all in their hands, and they just let her go. How can you let a young woman go to save a baby who will die anyway?”


But Mr. Halappanavar said he saw no use in being angry. “I’ve lost her,” he said. “I am talking about this because it shouldn’t happen to anyone else.”


Medical professionals were less forgiving. During a miscarriage, the cervix is opened, exposing the woman to infection, and the longer the miscarriage persists, the greater the risk, said a prominent medical commentator here, Dr. Muiris Houston. While Dr. Halappanavar’s death was “on the rare end of the spectrum,” and the facts surrounding the case are not all known, Dr. Houston said, she “undoubtedly needed to go to theater,” meaning to surgery.


“If she had gone to theater earlier she might still have died, but perhaps not,” he said. “Medicine is now increasingly driven by guidelines, and the question must be, ‘Did the hospital have protocols in place when a woman presented with such a condition?’ ”


The legal issues are, if anything, more clouded. In 1992, the Irish Supreme Court ruled that abortion was permissible in cases where there was a “real and substantial risk” to the life of a pregnant woman — including the possibility of suicide. But 20 years later, the Irish government has still not passed a law to this effect.


In 2010, the European Court of Human Rights found that Ireland was in violation of the European Convention on Human Rights by failing to provide an accessible and effective procedure to ascertain whether a woman qualified for a legal abortion.


In response, the current coalition government commissioned a report from an expert group on the issue. It was initially expected in July, but was then postponed until September — a deadline also missed. Given the divisiveness of the abortion issue in Ireland, which has prompted two bitterly fought referendums, successive governments have avoided passing any legislation.


The report was eventually delivered Tuesday night, hours before news broke of Dr. Halappanavar’s death. The government warned people not to link the two, but inevitably the death has led to calls for urgent reform.


Read More..

Hospital Death in Ireland Renews Fight Over Abortion





DUBLIN — The death of a woman who was reportedly denied a potentially lifesaving abortion even while she was having a miscarriage has revived debate over Ireland’s almost total ban on abortions.




The woman, Savita Halappanavar, 31, a dentist who lived near Galway, was 17 weeks pregnant when she sought treatment at University Hospital Galway on Oct. 21, complaining of severe back pain.


Dr. Halappanavar was informed by senior hospital physicians that she was having a miscarriage and that her fetus had no chance of survival. However, despite repeated pleas for an abortion, she was told that it would be illegal while the fetus’s heart was still beating, her husband, Praveen Halappanavar, said.


It was not until Oct. 24 that the heartbeat ceased and the remains of the fetus were surgically removed. But Dr. Halappanavar contracted a bacterial blood disease, septicemia. She was admitted to intensive care but never recovered, dying on Oct. 28.


Mr. Halappanavar, in an interview with The Irish Times from his home in India, said his wife was told after one request, “This is a Catholic country.”


Two investigations into the case have been announced, and politicians have been quick to express their condolences and to call for legal clarity. Kathleen Lynch, a junior health minister, said medical professionals needed guidelines to deal with such circumstances.


In a statement, the hospital said it would cooperate fully with any inquest but that it had not started its own review because it wanted to consult the woman’s family first.


Mr. Halappanavar told the newspaper that he still could not believe his wife was dead. “I was with her those four days in intensive care,” he said. “They kept telling me: ‘She’s young. She’ll get over it.’ But things never changed; they only got worse. She was so full of life. She loved kids.


“It was all in their hands, and they just let her go. How can you let a young woman go to save a baby who will die anyway?”


But Mr. Halappanavar said he saw no use in being angry. “I’ve lost her,” he said. “I am talking about this because it shouldn’t happen to anyone else.”


Medical professionals were less forgiving. During a miscarriage, the cervix is opened, exposing the woman to infection, and the longer the miscarriage persists, the greater the risk, said a prominent medical commentator here, Dr. Muiris Houston. While Dr. Halappanavar’s death was “on the rare end of the spectrum,” and the facts surrounding the case are not all known, Dr. Houston said, she “undoubtedly needed to go to theater,” meaning to surgery.


“If she had gone to theater earlier she might still have died, but perhaps not,” he said. “Medicine is now increasingly driven by guidelines, and the question must be, ‘Did the hospital have protocols in place when a woman presented with such a condition?’ ”


The legal issues are, if anything, more clouded. In 1992, the Irish Supreme Court ruled that abortion was permissible in cases where there was a “real and substantial risk” to the life of a pregnant woman — including the possibility of suicide. But 20 years later, the Irish government has still not passed a law to this effect.


In 2010, the European Court of Human Rights found that Ireland was in violation of the European Convention on Human Rights by failing to provide an accessible and effective procedure to ascertain whether a woman qualified for a legal abortion.


In response, the current coalition government commissioned a report from an expert group on the issue. It was initially expected in July, but was then postponed until September — a deadline also missed. Given the divisiveness of the abortion issue in Ireland, which has prompted two bitterly fought referendums, successive governments have avoided passing any legislation.


The report was eventually delivered Tuesday night, hours before news broke of Dr. Halappanavar’s death. The government warned people not to link the two, but inevitably the death has led to calls for urgent reform.


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Critic’s Notebook: Nintendo’s Wii U, With New Touch-Screen Controller





The Wii U is Nintendo’s capitulation to the screen, the tyrant of the digital age. As the follow-up to the original Wii — the nearly 100-million-selling, get-off-your-couch console that upended the video game industry six years ago — the Wii U does not deliver the sensation that its predecessor unleashed, the sense that something new had been wrought upon this earth. It was not always routine for grandparents and grandchildren to gather in front of the television to wield plastic sticks and pretend to bowl.




Instead, the Wii U feels like an accommodation to the new mode of living that Apple’s iPhone and iPad have introduced. That lifestyle was evoked by a New Yorker cover this summer that featured family members posing for a beach vacation snapshot while engrossed in their personal devices.


The Wii U, which is to be released on Sunday, works with the motion-control remotes you probably already own from the original Wii, and it plays most of the original games. What’s new — beyond high-definition graphics and some Internet-enabled features that won’t be turned on until Sunday — is the Wii U GamePad, a roughly 10-by-5-inch touch-screen controller. With a six-inch display surrounded by thumbsticks, buttons and triggers, the GamePad is the offspring of an iPad Mini and a traditional video game controller.


In its marketing buildup to the Wii U introduction, Nintendo emphasized the benefits of two-screen gaming, particularly competitions in which the player with the GamePad sees something different from what the other players watch on the television. In so doing, Nintendo played down a simpler concept, one more easily understood by casual players and Apple fans: the touch screen.


By merging touch-screen gaming with a video game system that is designed to live next to your TV set rather than be carried around in your pocket or purse, Nintendo is not merely acceding to the cultural tide. It is also trying — valiantly, perhaps quixotically — to stem it. After creating a world in which we are no longer bowling alone (because we are all Wii-bowling together), Nintendo is seeking to invent a new way for us to commune with our screens. The company’s hope is that the Wii U will bring families together in their living rooms for touch-screen gaming rather than leave them isolated with their tablets and smartphones.


Touch has always been a part of gaming, of course, because the physical interaction between player and device is central to the medium. But in recent years the growing complexity of the standard controller has become an obstacle for new players who did not grow up adapting to each iteration: the shift from one button to two buttons to four, or from one joystick to a directional pad to two thumbsticks and a directional pad — not to mention triggers and bumpers and start and select buttons. Easy, right?


Simplicity was a large part of the broad appeal of the first Wii, and though playing with the Wii U is not quite as uncomplicated as standing up and waving your arms around, the touch screen is straightforward compared with the controllers used with an Xbox 360 or a PlayStation 3. Selecting songs in Sing Party, a karaoke game published by Nintendo, is done by swiping through tiles on the GamePad’s touch screen and then tapping the song you want. The same goes for Ubisoft’s Just Dance 4, with the added wrinkle that a player can use the touch screen to choose dance moves, midsong, for the other players to perform.


In Balloon Trip Breeze, one of the mini-games bundled on the Nintendo Land anthology that comes with the $350 Wii U deluxe edition, the player uses a stylus to make quick swipes — familiar to anyone who has played Angry Birds or Fruit Ninja — to make a character pop balloons on the television. In Takamaru’s Ninja Castle, another Nintendo Land game, similar swipes hurl martial arts stars at cartoonish cutouts. In Pikmin Adventure, from the same disc, enemies are defeated by tapping on them as they appear on the GamePad screen. In Yoshi’s Fruit Cart players scrawl a path on the touch screen and then watch a character follow it on television.


The touch screen also allows the GamePad to morph swiftly into a TV remote control; you can adjust the volume on your set or quickly check the score of a football game without reaching for a separate device. And if you like what you see on cable, or if you want to allow someone else to watch TV in the same room, you can switch from playing a game of New Super Mario Bros. U on television to watching it unfold on your GamePad.


As that last trick indicates, the GamePad is more than just a touch screen, and Nintendo Land provides a sketch of other possibilities. The camera inside the GamePad is used in the game Octopus Dance to project the player’s genuine, human face onto the television, a merger of the virtual with the corporeal that goes by the name “augmented reality.”


Lightly blowing into the GamePad’s microphone in Donkey Kong’s Crash Course turns a windmill that moves a cart skyward. The GamePad can be used as a viewfinder in Metroid Blast and the Legend of Zelda: Battle Quest  to target enemies for destruction. And in some other Nintendo Land games, characters can be moved by turning or tilting or lifting the GamePad into the air, another technique borrowed from mobile and tablet gaming.


Equally promising, if not more so, are the possibilities the GamePad presents for intensive, single-player gaming. In Ubisoft’s ZombiU, the GamePad transforms, if not eliminates, some of the metaphors gamers are accustomed to: The map is no longer a tiny icon in the lower-right corner of your television, nor a menu that must be reached by punching a sequence of buttons. It is something you hold in your hands and look down at, something that draws your attention away from the world (of zombies) around you.


Your inventory — the items you carry — also becomes less abstract as you peer into your GamePad to see what’s in your backpack and then physically move, say, a pistol into your hand by sliding it with your finger into an open slot. Similarly, digging through lockers, file cabinets and suitcases in the game world becomes closer to a genuine interaction.


Then again, when the first Wii console felt new, as with Microsoft’s Kinect more recently, many decreed that motion controls would be swiftly and widely integrated into long, narrative games. Surely the intuitive interface of Wii Sports would be merged with storytelling ambition. By and large, that didn’t happen. So, spoiler alert: I have no idea what the Wii U augurs, or whether it will permanently alter how we play, alone or together.


But it’s a pretty nice present.


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Attacks Resume After Israeli Assault Kills Hamas Leader





KIRYAT MALACHI, Israel — Israel and Hamas widened their increasingly deadly conflict over Gaza on Thursday, as a militant rocket killed three civilians in an apartment block in this small southern town. The deaths are likely to lead Israel to intensify its military offensive on Gaza, now in its second day of airstrikes.




In Gaza, the Palestinian death toll rose to 11 as Israel struck what the military described as medium- and long-range rocket and infrastructure sites and rocket-launching squads. The military said it had dispersed leaflets over Gaza warning residents to stay away from Hamas operatives and facilities, suggesting that more was to come.


The regional perils of the situation sharpened, meanwhile, as President Mohamed Morsi of Egypt warned on Thursday that his country stood by the Palestinians against what he termed Israeli aggression, echoing similar condemnation on Wednesday.


“The Egyptian people, the Egyptian leadership, the Egyptian government, and all of Egypt is standing with all its resources to stop this assault, to prevent the killing and the bloodshed of Palestinians,” Mr. Morsi said in nationally televised remarks before a crisis meeting of senior ministers. He also said he had contacted President Obama to discuss strategies to “stop these acts and doings and the bloodshed and aggression.”


In language that reflected the upheaval in the political dynamics of the Middle East since the overthrow of Hosni Mubarak last year, Mr. Morsi said: “Israelis must realize that we don’t accept this aggression and it could only lead to instability in the region and has a major negative impact on stability and security in the region.”


The thrust of Mr. Morsi’s words seemed confined to diplomatic maneuvers, including calls to the United Nations secretary general, Ban Ki-moon, the head of the Arab League and President Obama.


In his conversation with Mr. Obama, Mr. Morsi said, he “clarified Egypt’s role and Egypt’s position; our care for the relations with the United States of America and the world; and at the same time our complete rejection of this assault and our rejection of these actions, of the bloodshed, and of the siege on Palestinians and their suffering.”


Mr. Obama had agreed to speak with Israeli leaders, Mr. Morsi said. Thursday’s deaths in Kiryat Malachi were the first casualties on the Israeli side since Israel launched its assault on Gaza, the most ferocious in four years, in response to persistent Palestinian rocket fire.


Southern Israel has been struck by more than 750 rockets fired from Gaza this year that have hit homes and caused injuries. On Thursday, a rocket smashed into the top floor of an apartment building in Kiryat Malachi, about 15 miles north of Gaza. Two women and a man were killed, according to rescue officials and Army Radio. A baby was among the injured and several Israelis were hospitalized with shrapnel wounds after rockets hit other southern cities and towns, they said.


The apartment house was close to a field in a blue-collar neighborhood and the rocket tore open top-floor apartments, leaving twisted metal window frames and bloodstains.


Nava Chayoun, 40, who lives on the second floor, said her husband, Yitzhak, ran up the stairs immediately after the rocket struck and saw the body of a woman on the floor. He rescued two children from the same apartment and afterward, she said, she and her family “read psalms.”


It was the first time that a building in Kiryat Malachi had been struck and the farthest north a projectile had landed in the current violence. With schools closed after Wednesday’s turmoil, residents said, many people had stayed home with their children.


Residents said people living on the lower floors of the apartment house had taken cover in stairwells, as the police urged residents to do when they heard warning sirens, but those on the top floor apparently had not. The police said 180 rockets had been fired at southern Israel since Wednesday.


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



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Major Retailers Start Selling Financial Products, Challenging Banks





On a recent shopping trip to Costco, Lilly Neubauer picked up paper towels, lentils, carrots — and a home mortgage.




While Ms. Neubauer, 27, said she was surprised to find the warehouse club selling financial products, she and her husband saved about $200 a month by refinancing there this year. She also bought home insurance from Costco, she said, again because it was cheaper there.


“It opened us up to the fact that Costco is more than toilet paper,” said Ms. Neubauer, who lives in Dallas.


As the nation’s largest banks stay stingy with credit and a growing portion of the population has no bank at all, major retailers are stepping into the void. Customers can now withdraw cash at an A.T.M. with a prepaid card from Walmart, take out a loan at Home Depot for a kitchen renovation or kick-start a new venture with a small-business loan from Sam’s Club. This year, Walmart even started to test selling a life insurance policy.


Consumer advocates are torn about the growth of this shadow banking industry. Financial products are making it into the hands of people who otherwise might not qualify for them, but these products are not always subject to the same regulations as bank products are. And to turn a profit, retailers generally have to charge more to people with poor credit or none at all.


“These products can come with high fees and few real protections,” said Norma P. Garcia, a senior lawyer with Consumers Union.


For the retailers, banking products are not huge profit centers but a business strategy, meant to put money into customers’ hands and get them buying more.


“You’ve got to remember, Walmart is intended to be a one-stop shop,” said Charles M. Holley Jr., the company’s chief financial officer.


Retailers were once interested in actually becoming banks. Sears, in the 1980s, tried a “socks and stocks” strategy that included acquiring the Dean Witter brokerage firm. And Wal-Mart Stores sought a banking charter for almost a decade before finally abandoning the quest in 2007.


While supermarket chains have leased space to bank branches for years, they are now offering their own products or teaming with small financial firms to do an end run around big banks. While the banks are likely to bristle at such competition, supporters of the retailers say the stores are stepping into areas that banks have abandoned.


“The banks kind of dropped the ball, and in my mind, and in the consumers’ mind, they left it open for different approaches,” said Robert L. Phillips, a professor at Columbia Business School.


Part of the lure is the so-called underbanked population — people who use few, if any, bank services. The Federal Deposit Insurance Corporation estimates that roughly 10 million households in the United States do not use a bank, up from nine million three years ago. And the agency says 24 million more households have a bank account but still use nonbank financial services, like prepaid cards.


Mr. Holley said that 20 to 25 percent of Walmart customers were unbanked.


“The more kinds of services we can offer our core customer like that, the better for them,” he said.


Last month, Walmart unveiled a prepaid card with American Express. The card operates much like a debit card except that it is not attached to a bank account. It comes with free customer-service telephone support, and fees are relatively low, but the account is not backed by the F.D.I.C.


Frustrated with the fees charged by her bank, Nancy Fry, a real estate broker in Logan, Utah, bought a prepaid card from Walmart this year. But this was even worse, she said — she was charged $3 every time she loaded money onto the card. “I really don’t have very much money and can’t afford these fees,” she said.


Consumer advocates complain that prepaid cards are loosely regulated and can cannibalize the money put on them. Consumer lawyers have pushed for greater disclosure of fees and more stringent regulation of the card providers. The government is expected to issue new rules this year.  


Walmart began to test selling a one-year MetLife life insurance policy this year, and customers can wire money or pay bills at any Walmart store.


Costco is also courting customers who are fed up with their banks. “A lot of members think their bank fees are too high, or the trust level has gone down over the years, or they’re having issues with debit and credit cards,” said Jay Smith, Costco’s director of business and financial services.


Costco sells auto and homeowners’ insurance, offers credit card processing for small businesses and began making mortgages in late 2010. It does not make money on the mortgages, which are offered by small lenders, Mr. Smith said. The idea is to get people to renew their store memberships, where Costco makes a large chunk of its profit.


Home Depot, whose customers are mainly homeowners, is trying to increase sales by extending credit to people who would otherwise have trouble getting it. Last year, the company began offering loans of up to $40,000, and this year it extended its no-interest credit card payment terms. “We have the ability to get credit to consumers in this tight credit market, and we wanted people to take advantage of that in a market where people don’t have access to home-equity lines of credit like they used to,” said Dwaine Kimmet, Home Depot’s treasurer and vice president for financial services.


Mr. Kimmet said the loans were especially useful for people who needed emergency items, like a water heater, though shoppers use them for other home décor projects as well.


They are also helpful for Home Depot, whose sales growth has been squeezed by the housing crisis.


Mr. Kimmet said the store loans, unlike home-equity lines of credit, did not require collateral, meaning Home Depot could not seize someone’s house for a failure to pay.


The interest rate on Home Depot’s credit card is higher than that on a typical credit card — 18 percent to 27 percent, depending on credit score, compared with an average of 14.59 percent, according to Bankrate. But Mr. Kimmet said the retailer offered cards to people with credit scores as low as 600, below what many lenders accept.


Other retailers are also trying to make it easier for people to qualify for financial products. Office Depot and Sam’s Club offer loans backed by the government’s Small Business Administration, and both involve quick, one-page initial applications. More than 1,000 Sam’s Club members have used the program since its introduction two years ago, the company said.  


When Kent Prater was about to open a restaurant in Lumberton, N.C., he searched online for loans backed by the Small Business Administration and found that Sam’s Club sold them. He applied online for a $25,000 loan and was approved for a $10,000 loan, with an interest rate of about 10 percent. With a bank, “I think it would probably be a little bit more difficult, because of the environment — the economy and the regulatory environment,” said Mr. Prater, who opened Thai Chili last month.


Paco Underhill, who researches shopper behavior as founder and chief executive of Envirosell, said retailers offering financial products was only the beginning.


“The banks are going to scream bloody murder when retailers try to obtain banking charters,” he said. “But it’s not hard for a retail organization to look across the landscape and say, ‘Who are my customers, and what else could I be selling them?’ ”


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Lance Armstrong Cuts Officials Ties With His Livestrong Charity


In the wake of being stripped of his seven Tour de France titles for doping, Lance Armstrong last week cut all official ties with Livestrong, the charity he founded 15 years ago while he was treated for testicular cancer.


On Nov. 4, he resigned from the organization’s board of directors; he had previously stepped down as the chairman of the board Oct. 17. He has distanced himself from the charity to try to protect it from any damage caused by his doping controversy, the new board chairman, Jeff Garvey, said in a statement.


“Lance Armstrong was instrumental in changing the way the world views people affected by cancer,” Garvey said. “His devotion to serving survivors is unparalleled, and for 15 years, he committed himself to that cause with all his heart.”


Garvey said that the Armstrong family had donated nearly $7 million to the foundation and that the organization under Armstrong had raised close to $500 million to serve cancer survivors.


Last month, the United States Anti-Doping Agency made public its evidence in its doping case against Armstrong, saying he had doped and encouraged his teammates to dope so they could help him win races. He was subsequently barred from Olympic sports for life and was stripped of all the cycling titles he won from August 1998 on.


Since then, Armstrong has spent several weeks in Hawaii, out of the public eye. On Saturday, though, he posted a photograph on Twitter showing him at home in Austin, Tex. He is lounging on a couch with his seven yellow Tour jerseys framed on the wall in the background.


In the post, he said, “Back in Austin and just layin’ around.” The photograph had more than 400,000 page views as of Monday evening, with many people posting negative comments on the page.


“Lance, you have no moral conscious and it’s obvious many of your followers don’t either,” said one person who went by the Twitter handle “irobot,” who also posted that Armstrong needed “professional help.”


A person posting under the name “Aumann” said: “An art thief enjoying all his da Vincis.”


Other people posted words of support, including many who said they still thought Armstrong was the top cyclist in history.


“TomShelton” said of Armstrong’s seven Tour titles, “You earned all 7 of them no matter what is being said about you!”


This article has been revised to reflect the following correction:

Correction: November 13, 2012

An earlier version of this article misstated Jeff Garvey’s estimate of the sum the Livestrong charity had raised to serve cancer survivors. It was close to $500 million, not close to $300 million.



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