Bombings Are Said to Kill Dozens Near Syria’s Capital

The Syrian opposition pushed ahead on military and political fronts on Wednesday, as rebels shot down a government warplane in the north of Syria and a newly formed coalition started talks in Cairo on how to pick a transitional government to replace that of President Bashar al-Assad.

The coalition, whose official name is the National Coalition of Syrian Revolutionary and Opposition Forces, was formed at a meeting in Qatar earlier this month, and has already been anointed with official recognition from Britain, France, Turkey and the members of the Gulf Cooperation Council. But in order to encourage further recognition internationally, it must tackle the broader problem of uniting multiple groups in exile and rebels on the ground in Syria.

That challenge was apparent on the first day of what are expected to be two days of talks in Egypt. Disagreements emerged over the composition of the coalition when the Syrian National Council, one of its members, tried to increase the number of its representatives.

“Nothing will proceed until we work this out,” said one council member at the talks, who spoke to Reuters on condition of anonymity.

The talks took place against the backdrop of a 20-month civil war in which about 40,000 people have been killed so far in clashes between armed rebels and jihadist forces on one side and Mr. Assad’s military on the other. The conflict has flared at various times along Syria’s borders with Lebanon, Israel, Turkey and Jordan and in most of the country’s cities, including deadly car bombings on Wednesday near Damascus, the capital.

In Turkey, once an ally of the Assad government, a team of NATO inspectors visited sites on Wednesday where the alliance might install batteries of Patriot antiaircraft missiles that Turkey, a member, has requested to prevent any incursions by the Syrian air force, which has become the Assad government’s main weapon against the rebels. Patriot missiles have also been discussed as a way of enforcing a no-fly zone over rebel-held areas of Syria near the Turkish border if one is imposed.

Meanwhile, opposition politicians gathered in a Cairo hotel to shape an alternative government. Ahmad Ramadan, a member of the national council, said in an interview with Radio Sawa, an Arabic-language broadcaster sponsored by the United States government, that the talks were more likely to decide on the selection process than to choose actual candidates.

Khaled Khoja, a coalition member attending the talks, said: “I don’t think we’ll be discussing the election of a transitional government during the meeting today. We’re still discussing whether to have a government or to have committees instead.”

State media said on Wednesday that at least 34 people, and possibly many more, died in the two car bombings in Jaramana, a suburb of Damascus that is populated by minorities.

The official SANA news agency said the explosions struck at about 7 a.m. and were the work of “terrorists,” the word used by the authorities to denote rebel forces seeking the overthrow of President Assad.

The agency said the bombings were in the main square of Jaramana, which news reports said is largely populated by members of the Christian and Druse minorities. Residents said the neighborhood was home to many families who have fled other parts of Syria because of the conflict and to some Palestinian families. The blasts caused “huge material damage to the residential buildings and shops,” SANA said.

The death toll was not immediately confirmed. An activist group, the British-based Syrian Observatory for Human Rights, initially said that 29 people had died but revised the figure later to 47, of whom 38 had been identified. Of the 120 injured, the rebel group said, 23 people were in serious condition, meaning that the tally could climb higher.

There were also reports from witnesses in Turkey and antigovernment activists in Syria that for the second successive day insurgents had shot down a government aircraft in the north of the country, offering further evidence that the rebels are seeking a major shift by challenging the government’s dominance of the skies. It was not immediately clear how the aircraft, apparently a plane, had been brought down.

Video posted on the Internet by rebels showed wreckage with fires still burning around it. The aircraft appeared to show a tail assembly clearly visible jutting out of the debris. Such videos are difficult to verify, particularly in light of the restrictions facing reporters in Syria. However, the episode on Wednesday seemed to be confirmed by other witnesses.

“We watched a Syrian plane being shot down as it was flying low to drop bombs,” said Ugur Cuneydioglu, who said he observed the incident from a Turkish border village in southern Hatay Province. “It slowly went down in flames before it hit the ground. It was quite a scene,” Mr. Cuneydioglu said.

Video posted by insurgents on the Internet showed a man in aviator coveralls being carried away. It was not clear if the man was alive but the video said he had been treated in a makeshift hospital. A voice off-camera says, “This is the pilot who was shelling residents’ houses.”

The aircraft was said to have been brought down while it was attacking the town of Daret Azzeh, 20 miles west of Aleppo and close to the Turkish border. The town was the scene of a mass killing last June, when the government and the rebels blamed each other for the deaths and mutilation of 25 people. The video posted online said the plane had been brought down by “the free men of Daret Azzeh soldiers of God brigade.”

On Tuesday, Syrian rebels said they shot down a military helicopter with a surface-to-air missile outside Aleppo and they uploaded video that appeared to confirm that rebels have put their growing stock of heat-seeking missiles to effective use.

In recent months, rebels have used mainly machine guns to shoot down several Syrian Air Force helicopters and fixed-wing attack jets. In Tuesday’s case, the thick smoke trailing the projectile, combined with the elevation of the aircraft, strongly suggested that the helicopter was hit by a missile.

Rebels hailed the event as the culmination of their long pursuit of effective antiaircraft weapons, though it was not clear if the downing on Tuesday was an isolated tactical success or heralded a new phase in the war that would present a meaningful challenge to the Syrian government’s air supremacy.

Hala Droubi reported from Dubai, United Arab Emirates. Alan Cowell contributed reporting from Paris; Sebnem Arsu contributed reporting from Istanbul, and Hania Mourtada from Beirut, Lebanon.

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News Analysis: St. Jude Medical Suffers for Redacting a Product Name

Peter Muhly for The New York Times

Dr. Ernest Lau holds a Durata lead from a St. Jude Medical Fortify ICD, an implanted heart defibrillator.

IS covering a product’s name in a public document a sign that a company has something to hide? And how should doctors, patients and investors react if the product at issue is one on which peoples’ lives and a company’s fortunes depend?

Such questions now loom over St. Jude Medical after the disclosure last week that its executives had blacked out the name of a heart device component when they released a critical federal report involving the product. The value of St. Jude has since plummeted more than $1 billion, or 12 percent. But the company’s actions may have a more lasting impact on its reputation and the health of patients, some experts say.

Last week’s incident was the latest development in a controversy involving the component, an electrical wire that connects an implanted defibrillator to a patient’s heart. St. Jude officials say the wire, which is known as the Durata, is safe. But uncertainty about the company’s statements is growing, underscored by its handling of the report, which involved a Food and Drug Administration inspection of a plant that makes the Durata.

St. Jude released that report in October as part of a filing with the Securities and Exchange Commission. The F.D.A. provides device makers with the reports in an unaltered form, and they may contain criticisms of a company’s procedures.

But the version of the report that St. Jude filed with the S.E.C. left some doctors and analysts uncertain about which company product or products were at issue for a simple reason — St. Jude had redacted, or blocked out, all 20 references to the Durata in it.

Company executives said they had done so based on their “good faith” interpretation of how the F.D.A. would act if it publicly released the report under the Freedom of Information Act. But both an F.D.A spokeswoman and a lawyer who specializes in medical devices took exception with that view, saying that names of approved products typically do not qualify as the type of confidential business information that the F.D.A. would redact.

Among other things, F.D.A. inspectors found significant flaws in the company’s testing and oversight of the Durata. It was those revelations and the implications that the problems could lead to further F.D.A. action against St. Jude that led to the sharp fall last week in its stock price.

In 2005, Guidant, a device maker that no longer exists, also found itself under scrutiny. Back then, its executives decided not to tell doctors that one of its defibrillators could short-circuit when a patient needed an electrical jolt to save a life. The expert who brought the Guidant problem to light, Dr. Robert Hauser, a heart specialist in Minnesota, has also raised concerns about the St. Jude wires, adding that he believes that its executives have been less than forthright.

“Patients and physicians would appreciate more information,” Dr. Hauser said.

In an earlier interview, St. Jude’s chief executive, Daniel J. Starks, said the company had hidden nothing about the Durata or another heart wire named the Riata, which it stopped selling in 2010.

“We’ve been more transparent than others,” said Mr. Starks, referring to company competitors like Medtronic.

Still, some Wall Street analysts share Dr. Hauser’s view. And if one St. Jude executive can claim credit for shaping their opinion, it would be Mr. Starks.

Earlier this year, he sought, among other things, to have a medical journal retract an article written by Dr. Hauser that was critical of the Riata. The publication refused.

Now, after St. Jude’s latest misfire, Wall Street analysts, who usually agree more than disagree, are placing wildly differing bets on St. Jude, with some valuing it at $48 a share and others at $30. On Monday, St. Jude closed at $31.86 on the New York Stock Exchange.

One of those bearish analysts, Matthew Dodds of Citigroup, said he thought the Food and Drug Administration might act soon on Durata. “I believe that a lot of their actions have made the situation worse, ” he said of the company’s executives.

A St. Jude spokeswoman, Amy Jo Meyer, reiterated the company’s stance that it had interpreted agency rules in “good faith” when releasing the redacted report about the Durata. An F.D.A. spokeswoman, Mary Long, said the agency did not consider the names of approved products to be confidential. And a lawyer, William Vodra, said that while device makers try to make a confidentiality argument for product data they consider embarrassing, like injury reports, they rarely succeed.

“In my experience, the F.D.A. consistently rejects” such arguments, Mr. Vodra wrote in an e-mail.

For patients, the dilemma may become more excruciating. The company’s earlier heart wire, the Riata, has begun failing prematurely in some of the 128,000 patients worldwide who received it. And those patients and their doctors face a difficult decision: whether to leave it in place or have it surgically removed, a procedure that carries significant risks.

St. Jude executives say that the Durata, which uses a different type of insulation than the Riata, is not prone to such problems.

And with the Durata already implanted in 278,000 people, many heart specialists certainly hope they are right.

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Books: Woe Is Syphilis, and Other Afflictions of Famous Writers

The old Irishman was a swollen, wheezing mess, blood pressure wildly out of control, kidneys failing, heart fibrillating. “What we have here,” said his new Spanish doctor, “is an antique cardiorenal sclerotic of advanced years.”

In fact, what the doctor had there was William Butler Yeats: the poet had a long list of chronic medical problems and experienced one of his regular cardiac crises while wintering in Spain. He still had three poetically productive years ahead of him before he died of heart failure in 1939, at age 73.

What makes antique case histories like Yeats’s so compelling to research, so interesting to read? Admittedly, they have educational value — medicine moves forward by looking back — but their major attraction is undoubtedly the operatic vigor of their emotional punch. As we contemplate the poor health of historic notables, we can sigh gustily at the immense suffering our ancestors considered routine, wince at the lunatic treatments they so innocently underwent, and marvel over and over again that the body, the brain and the mind can take such divergent paths.

These pleasures are present in abundance in the newest addition to the genre of medical biography, “Shakespeare’s Tremor and Orwell’s Cough.” Dr. John J. Ross, a Harvard physician, writes that he stumbled into the field by accident while trying to enliven a lecture on syphilis with a few literary references. The discovery that Shakespeare was apparently obsessed with syphilis (and suspiciously familiar with its symptoms) hooked Dr. Ross.

The resulting collection of 10 medico-literary biographical sketches ranges from the tubercular Brontës, whose every moist cough is familiar to their fans, to figures like Nathaniel Hawthorne, whose medical stories are considerably less familiar.

Dr. Ross’s discussion of Shakespeare is unique in the collection for its paucity of relevant data: so few details are known of the playwright’s life, let alone his health, that all commentary is necessarily supposition. Dr. Ross is not the first to note that references to syphilis are “more abundant, intrusive and clinically exact” in Shakespeare’s works than those of his contemporaries. This observation, along with the apparent deterioration of Shakespeare’s handwriting in his last years, leads to the hypothesis that Shakespeare had syphilis repeatedly as a young man, and wound up suffering more from treatment than disease.

The Elizabethans dosed syphilis with a combination of hot baths (treating the disease by raising body temperature endured into the 20th century), cathartics and lavish quantities of mercury. The drooling that accompanies mercury poisoning was considered a sign of excellent therapeutic progress, Dr. Ross writes: “Savvy physicians adjusted the mercury dose to produce three pints of saliva a day for two weeks.”

And so, when Shakespeare signed his will a month before he died with a shaky hand, was his tremor not possibly a sign of residual nerve damage from the mercury doses of his sybaritic youth? No amount of scholarship is likely to confirm this theory, but details of the argument are gripping and instructive nonetheless.

The story of the blind poet John Milton runs for a while along similar lines. Much is known about the long deterioration of Milton’s vision and other particulars of his delicate health, but Dr. Ross observes that many of his problems seem to have cleared up once he actually became blind. Was he vigorously medicating himself with lead-based nostrums in hopes of forestalling what Dr. Ross argues was probably progressive retinal detachment, then recovering from lead poisoning once his vision was irretrievably gone? Another intriguing if unanswerable question.

Just as the competing injuries of disease and treatment battered the luminaries of English and American literature, so did pervasive mental illness.

Jonathan Swift was a classic obsessive-compulsive long before he succumbed to frontotemporal dementia (Pick’s disease). Poor Hawthorne, so forceful on the page, was in person a tortured shrinking violet, the embodiment of social phobia and depression. Emily Brontë’s behavior was strongly suggestive of Asperger syndrome; Herman Melville was clearly bipolar; Ezra Pound was just nuts.

Yet they all wrote on, despite continual psychic and physical torments. Perhaps the thickest medical chart of all belongs to Jack London, who survived several dramatic episodes of scurvy while prospecting in the Klondike (he was treated with raw potatoes, a can of tomatoes and a single lemon), then accumulated a long list of other medical problems before killing himself (inadvertently, Dr. Ross argues) with an overdose of morphine from his personal and very capacious medicine chest.

Dr. Ross has not written a perfect book. The fictionalized scenes he creates between some of his subjects and their medical providers should all have been excised by a kindly editorial hand, which might also have addressed more than a few grammatical errors. Frequent leaps from descriptive to didactic mode as Dr. Ross updates the reader on various medical conditions can be jarring, like PowerPoint slides suddenly deployed in a poetry reading. True literary scholars might dismiss the book as lit crit lite, a hodgepodge of known facts culled from the usual secondary sources.

But all these caveats fade into the background when Dr. Ross hits his narrative stride, as he does in chapter after chapter. Then the stories of the wounded storytellers unfold smoothly on the page, as mesmerizing as any they themselves might have told, those squinting, wheezing, arthritic, infected, demented, defective yet superlative examples of the human condition.

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Books: Woe Is Syphilis, and Other Afflictions of Famous Writers

The old Irishman was a swollen, wheezing mess, blood pressure wildly out of control, kidneys failing, heart fibrillating. “What we have here,” said his new Spanish doctor, “is an antique cardiorenal sclerotic of advanced years.”

In fact, what the doctor had there was William Butler Yeats: the poet had a long list of chronic medical problems and experienced one of his regular cardiac crises while wintering in Spain. He still had three poetically productive years ahead of him before he died of heart failure in 1939, at age 73.

What makes antique case histories like Yeats’s so compelling to research, so interesting to read? Admittedly, they have educational value — medicine moves forward by looking back — but their major attraction is undoubtedly the operatic vigor of their emotional punch. As we contemplate the poor health of historic notables, we can sigh gustily at the immense suffering our ancestors considered routine, wince at the lunatic treatments they so innocently underwent, and marvel over and over again that the body, the brain and the mind can take such divergent paths.

These pleasures are present in abundance in the newest addition to the genre of medical biography, “Shakespeare’s Tremor and Orwell’s Cough.” Dr. John J. Ross, a Harvard physician, writes that he stumbled into the field by accident while trying to enliven a lecture on syphilis with a few literary references. The discovery that Shakespeare was apparently obsessed with syphilis (and suspiciously familiar with its symptoms) hooked Dr. Ross.

The resulting collection of 10 medico-literary biographical sketches ranges from the tubercular Brontës, whose every moist cough is familiar to their fans, to figures like Nathaniel Hawthorne, whose medical stories are considerably less familiar.

Dr. Ross’s discussion of Shakespeare is unique in the collection for its paucity of relevant data: so few details are known of the playwright’s life, let alone his health, that all commentary is necessarily supposition. Dr. Ross is not the first to note that references to syphilis are “more abundant, intrusive and clinically exact” in Shakespeare’s works than those of his contemporaries. This observation, along with the apparent deterioration of Shakespeare’s handwriting in his last years, leads to the hypothesis that Shakespeare had syphilis repeatedly as a young man, and wound up suffering more from treatment than disease.

The Elizabethans dosed syphilis with a combination of hot baths (treating the disease by raising body temperature endured into the 20th century), cathartics and lavish quantities of mercury. The drooling that accompanies mercury poisoning was considered a sign of excellent therapeutic progress, Dr. Ross writes: “Savvy physicians adjusted the mercury dose to produce three pints of saliva a day for two weeks.”

And so, when Shakespeare signed his will a month before he died with a shaky hand, was his tremor not possibly a sign of residual nerve damage from the mercury doses of his sybaritic youth? No amount of scholarship is likely to confirm this theory, but details of the argument are gripping and instructive nonetheless.

The story of the blind poet John Milton runs for a while along similar lines. Much is known about the long deterioration of Milton’s vision and other particulars of his delicate health, but Dr. Ross observes that many of his problems seem to have cleared up once he actually became blind. Was he vigorously medicating himself with lead-based nostrums in hopes of forestalling what Dr. Ross argues was probably progressive retinal detachment, then recovering from lead poisoning once his vision was irretrievably gone? Another intriguing if unanswerable question.

Just as the competing injuries of disease and treatment battered the luminaries of English and American literature, so did pervasive mental illness.

Jonathan Swift was a classic obsessive-compulsive long before he succumbed to frontotemporal dementia (Pick’s disease). Poor Hawthorne, so forceful on the page, was in person a tortured shrinking violet, the embodiment of social phobia and depression. Emily Brontë’s behavior was strongly suggestive of Asperger syndrome; Herman Melville was clearly bipolar; Ezra Pound was just nuts.

Yet they all wrote on, despite continual psychic and physical torments. Perhaps the thickest medical chart of all belongs to Jack London, who survived several dramatic episodes of scurvy while prospecting in the Klondike (he was treated with raw potatoes, a can of tomatoes and a single lemon), then accumulated a long list of other medical problems before killing himself (inadvertently, Dr. Ross argues) with an overdose of morphine from his personal and very capacious medicine chest.

Dr. Ross has not written a perfect book. The fictionalized scenes he creates between some of his subjects and their medical providers should all have been excised by a kindly editorial hand, which might also have addressed more than a few grammatical errors. Frequent leaps from descriptive to didactic mode as Dr. Ross updates the reader on various medical conditions can be jarring, like PowerPoint slides suddenly deployed in a poetry reading. True literary scholars might dismiss the book as lit crit lite, a hodgepodge of known facts culled from the usual secondary sources.

But all these caveats fade into the background when Dr. Ross hits his narrative stride, as he does in chapter after chapter. Then the stories of the wounded storytellers unfold smoothly on the page, as mesmerizing as any they themselves might have told, those squinting, wheezing, arthritic, infected, demented, defective yet superlative examples of the human condition.

Read More..

The Hard Road Back: Prosthetic Arms a Complex Test for Amputees

SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.

The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.

He had been blown up, and was drowning at the bottom of an irrigation ditch.

Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.

Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.

Success.

“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”

It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.

Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.

To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.

“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.

The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.

Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.

For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.

But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.

More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.

In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.

But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.

Corporal Gallegos was not always that person.

His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.

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Protesters Gather Again in Cairo Streets to Denounce Morsi

CAIRO — Thousands of people flowed into the streets of Cairo, the Egyptian capital, Tuesday afternoon for a day of protest against President Mohamed Morsi’s attempt to assert broad new powers for the duration of the country’s political transition, dismissing his efforts just the night before to reaffirm his deference to Egyptian law and courts.

By early Tuesday afternoon in Cairo, a dense crowd of hundreds had gathered outside the headquarters of a trade group for lawyers, and thousands more had filed in around a small tent city in Tahrir Square. In an echo of the chants against Hosni Mubarak, Egyptian’s ousted president, almost two years ago, they shouted, “Leave, leave!” and “Bring down the regime!” They also denounced the spiritual leader of the Muslim Brotherhood, the Islamist group allied with Mr. Morsi.

A few blocks away, in a square near the American Embassy and the Interior Ministry headquarters, groups of young men resumed a running battle that began nine days ago, throwing rocks and tear gas canisters at riot police officers. Although those clashes grew out of anger over the deaths of dozens of protesters in similar clashes one year ago, many of the combatants have happily adopted the banner of protest against Mr. Morsi as well.

Egyptian television had captured the growing polarization of the country on Monday in split-screen coverage of two simultaneous funerals, each for a teenage boy killed in clashes set off by disputes over the new president’s powers. Thousands of supporters of Mr. Morsi and his allies in the Muslim Brotherhood marched through the streets of the Nile Delta city of Damanhour to bury a 15-year-old killed outside a Brotherhood office during an attack by protesters. And in Tahrir Square here in Cairo, thousands gathered to bury a 16-year-old killed in clashes with riot police officers and to chant slogans blaming Mr. Morsi for his death. “Morsi killed him,” the boy’s father said in a video statement circulated over the Internet.

“Now blood has been spilled by political factions, so this is not going to go away,” said Rabab el-Mahdi, a professor at the American University in Cairo and a left-leaning activist, adding that these were the first deaths rival factions had blamed on each other and not on the security forces of the Mubarak government since the uprising began last year. Still larger crowds were expected in the evening, as marchers from around the city headed for the square. Many schools and other businesses had closed in anticipation of bedlam, and on Monday, the Brotherhood called off a rival demonstration in support of the president, saying it wanted to avoid violence.

Egypt’s Supreme Judicial Council met again on Tuesday to consider its response to the president, and the leader of Al Azhar, a center of Sunni Muslim learning that is regarded as the pre-eminent moral authority here, met with groups of political leaders in an effort to resolve the battle over the president’s decree and the deadlock in the constitutional assembly, which is trying to draw up a new constitution.

But even as Mr. Morsi met with top judges Monday night in an effort to resolve the crisis, a coalition of opposition leaders held a news conference to declare that preserving the role of the courts was only the first step in a broader campaign against what Abdel Haleem Qandeil, a liberal intellectual, called “the miserable failure of the rule of the Muslim Brothers.” Mr. Morsi “unilaterally broke the contract with the people,” he declared. “We have to be ready to stand up to this group, protest to protest, square to square, and to confront the bullying.”

Mr. Morsi’s effort to remove the last check on his power over the political transition had brought the country’s fractious opposition groups together for the first time in a united front against the Brotherhood. But the show of unity papered over deep divisions between groups and even within them, said Ms. Mahdi of the American University.

“This is not a united front, and I am inside it,” she said. “Every single political group in the country is now divided over this — is this decree revolutionary justice or building a new dictatorship? Should we align ourselves with folool” — the colloquial term for the remnants of the old political elite — “or should we be revolutionary purists? Is it a conflict between the Muslim Brotherhood and the pro-Mubarak judiciary, or is this the beginning of a fascist regime in the making?”

Mayy El Sheikh contributed reporting.

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Euro Finance Ministers Struggle to Reach Accord on Greece

BRUSSELS — Finance ministers from the euro area met on Monday for the third time in three weeks, seeking to bridge differences over bailouts for Greece that have bitterly divided creditor countries like Germany and the International Monetary Fund.

The haggling continues against the background of a financial catastrophe unfolding in Greece, where the economy has shrunk by about one-fifth in three years and unemployment is hovering at around 25 percent. The unrelenting gloom means suffering for the Greek public and also makes it increasingly improbable that the country can pay back its debts in full.

Ministers said ahead of the meeting that they had made strides in a teleconference on Saturday toward reaching a joint position. “All the parameters of the solution are on the table,” the French finance minister, Pierre Moscovici, said on arriving at the meeting.

But diplomats in Brussels said they expected the meeting to be long and stormy and run late into the night — as did a similar gathering last week — as the parties try to find alternative ways of giving Greece relief in light of opposition by major creditors like Germany and the Netherlands to forgiving some Greek debt.

To reach a deal, the I.M.F. may also have to compromise, loosening its budgetary expectations for Greece and accepting that the country will not be able to hit a target of reducing debt to 120 percent of gross domestic product by the end of the decade.

The seemingly endless round of meetings over Greece is a sign that after nearly three years of crises, the politicians are still trying to contain contagion in the euro zone, which began with a huge hole in Greek accounts, even as that country’s debt prospects continue to worsen.

For Greece, the immediate goal is unlocking a loan installment worth €31.5 billion, or $40.8 billion, from an international bailout program.

If ministers reach a deal, Greece is likely to get a larger amount of about €44 billion because two additional installments are due by the end of the year under the program.

In June, creditors froze aid from the current program, worth €130 billion, after determining that Greece was failing to meet the conditions of that bailout, its second.

“Greece has fully delivered its part of the agreement, so we expect our partners to deliver their part too,” Yannis Stournaras, the Greek finance minister, said Monday ahead of the meeting.

The complication that has led to further delays and acrimony among lenders — as well as to the flurry of meetings — are conflicting views about how quickly Greece can grow its economy, lure investors, pay down its towering debt and return to the markets to borrow money once aid programs expire later this decade.

Since June, the Greek economy has worsened and social problems in the country have become more acute as employment has climbed. Those factors have already led Greece’s lenders to agree that the government in Athens will need two years longer than previously agreed, or until 2016, to meet its budget targets.

But that concession will cost more money because of a range of factors including revenues from privatizations that will not be as large as expected. The cost could come to nearly €33 billion on top of existing bailouts to help Greece reach a primary budget surplus, which excludes debt repayments.

The prospect of paying more to Greece has perturbed a number of lenders, particularly Germany, where transferring more wealth to the poorer-performing economies of Southern Europe is politically toxic, particularly as Chancellor Angela Merkel gears up for a re-election fight next year.

Rather than being willing to write down their countries’ Greek holdings, ministers on Monday were instead discussing other options of making Greece’s debt more manageable — like lowering interest rates, lengthening the deadlines for debt repayments, allowing the country to buy back its bonds at a steep discount and asking national governments to return profits made on bonds held by the European Central Bank.

Many analysts regard those measures as necessary but insufficient to remedy Greece’s problems. They say that Germany and other reluctant creditors will have to take politically unpalatable losses, or haircuts, on their holdings of Greek debt to keep the country in the euro area, even if they are able to agree on other measures to reduce the size of the country’s deficit and reform the economy.

The result is a standoff, with Germany trying to keep the bill for Greece as low as possible at least until after the German elections in 2013.

Those concerns were on display over the weekend. Jörg Asmussen, a member of the E.C.B.’s Executive Board, told the German newspaper Bild that a write-down of Greek debt should not be part of the deal, echoing repeated statements from the German finance minister, Wolfgang Schäuble, who said it would be illegal.

Maria Fekter, the Austrian finance minister, seemed to agree, saying Monday, “That’s not on the agenda at the moment.”

“A debt cut for the public bodies, and in fact the taxpayers, was not wanted by any country,” she said.

On the other side is the I.M.F., which insists that fresh money, or even a write-down, will be needed to put Greece on a pathway to manageable debt by the end of the decade. By its own rules, the I.M.F. can lend money only if the debt is “sustainable” or can be paid back by a recipient country, like Greece.

On Monday, the Fund was pressing ministers to agree that Greece’s debt should immediately be cut by 20 percent of G.D.P. through methods like lowering interest rates and extending maturities on loans, and to pledge further reductions in future, with the aim of reaching sustainable levels.

Christine Lagarde, the managing director of the I.M.F., has insisted that Greece pare its debt to 120 percent of gross domestic product by 2020. But that target has steadily become considered unfeasible.

Greek debt is now estimated at 175 percent of G.D.P., and its economy could shrink again, pushing that figure to 190 percent next year, and even up to 200 percent by 2014, according to some E.U. officials.

That means the I.M.F. will almost certainly have to make concessions to help keep Greece afloat by loosening its debt target, perhaps to around 124 percent by the end of the decade.

Arriving at the meeting in Brussels on Monday, Ms. Lagarde pledged “to work towards a solution that is credible for Greece,” and added, “We are going to work very intensely on that.”

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Wealth Matters: Dealing With Doctors Who Accept Only Cash

James Edward Bates for The New York Times

Dr. Stanford Owen no longer accepts insurance. He charges patients like Monica Knight $38 a month.

A FEW weeks ago, my wife and I were at our wits’ end: our 4-month-old daughter wouldn’t sleep for more than an hour at a time at night. We had consulted books and seen our pediatrician, but nothing was working. So my wife called a pediatrician who specializes in babies who struggle with sleep problems.

The next day, he drove an hour from Brooklyn to our house. He then spent an hour and a half talking to us and examining our daughter in her nursery. He prescribed some medicine for her and suggested some changes to my wife’s diet. Within two days, our baby was sleeping through the night and we were all feeling better.

The only catch was this pediatrician did not accept insurance. He had taken our credit card information before his visit and given us a form to submit to our insurance company as he left, saying insurance usually paid a portion of his fee, which was $650.

A couple of weeks later, our insurance company said it wouldn’t pay anything. Here’s how the company figured it: First, it said a fair price for our doctor’s fee was $285, about 60 percent less, because that was the going rate for our town. Then, it said the lower fee was not enough to meet our out-of-network deductible.

While we were none too happy with the insurance company, we remained impressed by the doctor: he had made our baby better and was compensated for it, all the while avoiding the hassle of dealing with insurance.

Last year, I wrote about doctors who catered only to the richest of the rich and charged accordingly. But after my experience, I became interested in doctors for the average person who take only cash. What pushes a doctor to go this route, often called concierge medicine? And how hard is it to make a living?

As to why doctors decide to switch to a concierge practice, the answer is almost always frustration.

“About four years ago, one insurance company was driving me crazy saying I had to fax documents to show I had done a visit,” said Stanford Owen, an internal medical doctor in Gulfport, Miss. “At 2 a.m., I woke up and said, ‘This is it.’ ”

Dr. Owen stopped accepting all insurance and now charges his 1,000 patients $38 a month.

“When I decided to abandon insurance, I didn’t want to lose my patient base and make it unaffordable,” he said. “I have everything from waitresses and shrimpers to international businessmen. It’s a concierge model, but it’s also the personal doctor model.”

Dr. Owen, who once had three nurses and 10 examining rooms, said it was now just him and a receptionist. He has become obsessed with keeping overhead low, but he said that, for the first time since the 1990s, his income was going up.

At the other end of the spectrum is David Edelson, who runs a practice called HealthBridge in Great Neck, N.Y. In addition to five doctors, the practice has a full fitness center and provides the services of a personal trainer, nutritionist, acupuncturist, sleep expert and stress-management consultant.

“The current model for primary care is broken,” Dr. Edelson told me. “Either I can go down with the ship, sell my practice to a hospital or take my practice in the wrong direction. Or I can develop a better mousetrap, which is more time dealing with patients and their care.”

Dr. Edelson has reduced his own practice to 300 patients, from more than 3,000. Of those, 250 pay $1,800 a year for concierge services and 50 others receive scholarships. He estimated that from the combination of the membership fee for the extra services and what gets billed to insurance for typical care, he will make $600,000, and more of that will end up in his pocket.

“We’re bringing in the same fees but we’re reducing our overhead,” he said. Fewer patients means fewer medical assistants, receptionists and staff members to deal with insurance.

But of the five doctors in the practice, he is the only one to go fully concierge. Another, William Klein, is testing the model, with 15 percent of his patients in the concierge program. Dr. Klein said he was hedging his bets because he was not sure what the new federal health care law would mean for primary care physicians.

Weren’t some patients getting shortchanged by this hybrid model? He said he saw no difference in care.

“It’s like paying for first class and not coach,” Dr. Klein said. “Everyone is getting to the same destination, but some people have a better seat.”

This approach to medicine is not without risks for the doctors and downsides for patients.

This article has been revised to reflect the following correction:

Correction: November 23, 2012

An earlier version of this column gave an incorrect middle initial for Mr. Harris. It is M., not V.

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Wealth Matters: Dealing With Doctors Who Accept Only Cash

James Edward Bates for The New York Times

Dr. Stanford Owen no longer accepts insurance. He charges patients like Monica Knight $38 a month.

A FEW weeks ago, my wife and I were at our wits’ end: our 4-month-old daughter wouldn’t sleep for more than an hour at a time at night. We had consulted books and seen our pediatrician, but nothing was working. So my wife called a pediatrician who specializes in babies who struggle with sleep problems.

The next day, he drove an hour from Brooklyn to our house. He then spent an hour and a half talking to us and examining our daughter in her nursery. He prescribed some medicine for her and suggested some changes to my wife’s diet. Within two days, our baby was sleeping through the night and we were all feeling better.

The only catch was this pediatrician did not accept insurance. He had taken our credit card information before his visit and given us a form to submit to our insurance company as he left, saying insurance usually paid a portion of his fee, which was $650.

A couple of weeks later, our insurance company said it wouldn’t pay anything. Here’s how the company figured it: First, it said a fair price for our doctor’s fee was $285, about 60 percent less, because that was the going rate for our town. Then, it said the lower fee was not enough to meet our out-of-network deductible.

While we were none too happy with the insurance company, we remained impressed by the doctor: he had made our baby better and was compensated for it, all the while avoiding the hassle of dealing with insurance.

Last year, I wrote about doctors who catered only to the richest of the rich and charged accordingly. But after my experience, I became interested in doctors for the average person who take only cash. What pushes a doctor to go this route, often called concierge medicine? And how hard is it to make a living?

As to why doctors decide to switch to a concierge practice, the answer is almost always frustration.

“About four years ago, one insurance company was driving me crazy saying I had to fax documents to show I had done a visit,” said Stanford Owen, an internal medical doctor in Gulfport, Miss. “At 2 a.m., I woke up and said, ‘This is it.’ ”

Dr. Owen stopped accepting all insurance and now charges his 1,000 patients $38 a month.

“When I decided to abandon insurance, I didn’t want to lose my patient base and make it unaffordable,” he said. “I have everything from waitresses and shrimpers to international businessmen. It’s a concierge model, but it’s also the personal doctor model.”

Dr. Owen, who once had three nurses and 10 examining rooms, said it was now just him and a receptionist. He has become obsessed with keeping overhead low, but he said that, for the first time since the 1990s, his income was going up.

At the other end of the spectrum is David Edelson, who runs a practice called HealthBridge in Great Neck, N.Y. In addition to five doctors, the practice has a full fitness center and provides the services of a personal trainer, nutritionist, acupuncturist, sleep expert and stress-management consultant.

“The current model for primary care is broken,” Dr. Edelson told me. “Either I can go down with the ship, sell my practice to a hospital or take my practice in the wrong direction. Or I can develop a better mousetrap, which is more time dealing with patients and their care.”

Dr. Edelson has reduced his own practice to 300 patients, from more than 3,000. Of those, 250 pay $1,800 a year for concierge services and 50 others receive scholarships. He estimated that from the combination of the membership fee for the extra services and what gets billed to insurance for typical care, he will make $600,000, and more of that will end up in his pocket.

“We’re bringing in the same fees but we’re reducing our overhead,” he said. Fewer patients means fewer medical assistants, receptionists and staff members to deal with insurance.

But of the five doctors in the practice, he is the only one to go fully concierge. Another, William Klein, is testing the model, with 15 percent of his patients in the concierge program. Dr. Klein said he was hedging his bets because he was not sure what the new federal health care law would mean for primary care physicians.

Weren’t some patients getting shortchanged by this hybrid model? He said he saw no difference in care.

“It’s like paying for first class and not coach,” Dr. Klein said. “Everyone is getting to the same destination, but some people have a better seat.”

This approach to medicine is not without risks for the doctors and downsides for patients.

This article has been revised to reflect the following correction:

Correction: November 23, 2012

An earlier version of this column gave an incorrect middle initial for Mr. Harris. It is M., not V.

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Prototype: Customized Skis, Tailored by Science

CAN a computer algorithm create the perfect pair of skis?

Pete Wagner, a 37-year-old Ohio native, likes to think so. Since 2006, he has been applying his background in mechanical engineering and computer coding to make skis — and a few snowboards, too — that are individually designed to fit each owner.

How does he do it?

“Our computers crunch the numbers,” said Mr. Wagner, a self-professed “nerdy engineer” whose shop-factory, Wagner Custom Skis, is in Placerville, Colo., not far from the alpine paradise of Telluride. “We’ve created a scientific method of fitting people,” based on collecting data about other skis they have used, as well as personal information like height and weight, he said.

Mr. Wagner’s goal goes beyond creating an innovative product. He wants to retool the way people think about ski shopping. Rather than choosing a pair in a store or online, only to find that after a couple of runs down a mountain that they feel leaden, or don’t perform well in powder, he says, people can save time and money by having their skis designed much as they would a custom-made suit or a couture gown. And, yes, as with those luxury items, there is a cost: his skis start at $1,750.

Still, the idea seems to be catching on. Last year, Mr. Wagner sold more than 1,000 pairs of his skis, which are available on the Internet and in a dozen boutique ski shops around the country. He also made a few customized snowboards requested by “friends of friends.”

“It’s a little bit like getting custom clothing,” said Larry Houchon, the owner of Larry’s Bootfitting, a ski boot shop in Boulder, Colo., that has a kiosk where customers can order Mr. Wagner’s skis. “If you’re used to going to Nordstrom’s and buying clothing off the rack, but then you suddenly become more interested in your appearance, you’re going to go talk to a tailor.

“It’s the same with skiing. If you’re more committed to skiing better, and with less effort, the skis just make sense.”

Not everyone can justify the cost, however. Glenn Muxworthy, a ski buyer for the Ski Company in Rochester, said that there wasn’t “a big calling" for custom-made skis because "in this day and age, price is a determining factor." He said that for less than half the price of a pair of Wagner Custom skis, a shopper could buy a pair of Blizzard Cochise skis, a much-buzzed-about product this season.

In Mr. Wagner’s system, the process begins by filling out a “Skier DNA” questionnaire. Among other things, the form asks customers to list their sex and weight, the types of terrain where they like to ski — groomed runs, tree runs, backcountry powder, etc. — and the model of skis they’ve used in the past.

“Skiers can tell us, ‘You know, I’ve got a pair of skis that are five years old,’ so they might be a Völkl Mantra from 2007,” Mr. Wagner said. “Our design software will understand, O.K., that person’s ski has these certain stiffness characteristics, this certain geometry, and is made from these types of materials. Based on that information, and their physical information, where they’re skiing, our algorithms will figure out what kind of design is going to be great for them.”

After a follow-up consultation with Mr. Wagner — by phone, e-mail, Skype or in person — the design recipe goes to the factory, where computer numerical code machines mill the components of the skis, which are then assembled by hand.

“It’s a combination of 21st-century, computer-controlled milling and manufacturing equipment and old-world craftsmanship and attention to detail,” he said of the process.

Unlike other boutique ski makers, he added, he does not rely on precast molds. “We always go through the same steps when we create a ski, but every ski is different.”

Mr. Wagner’s eureka moment came not long after he moved to Telluride in 1998 and bought a new pair of skis that had received high marks in ski magazines.

“I bought them and I started using them and I didn’t really question them,” he said. “And I skied on them for about 80 days and just adapted to them. But after 80 days of skiing, I tried another set of skis, and that’s when I realized I had been crippling myself with the equipment I was on.”

When Mr. Wagner wasn’t skiing, he was writing software for Penley Research and Development, a company that makes custom-designed golf shafts based on a person’s golf swing and size. His experience with his bum skis led him to wonder: what if he adapted the software to create personalized skis?

In 2003, when he enrolled in business school at the University of Colorado, the idea for a customized ski company was still knocking around his head. For his final project, he put together a business plan for his prospective business — but received little encouragement from professors and ski experts.

“There were definitely a lot of industry veterans who were telling me that doing manufacturing in the United States wouldn’t work, and that starting a manufacturing business in a remote ski town made no sense,” Mr. Wagner said.

Mr. Houchon, who saw Mr. Wagner’s business plan, was one of the initial skeptics.

“I was unsure as to whether it would work,” he said. “I didn’t realize the extent to which Pete could streamline the manufacturing process and how good he was working with computers.

“I thought it would be a lot more tedious and difficult.”

In Mr. Wagner’s first year in business, he sold 200 pairs of skis. But through word of mouth, and because he could reach so many people through the Internet — which accounts for 90 percent of his sales — his business began to take off.

Even with his bigger workload, can he still find time to ski?

“Oh, absolutely,” he said. “We have a powder-day clause at our shop. If the Telluride Ski Resort reports five inches or more, then we come in to work at 1 o’clock.”

E-mail: proto@nytimes.com.

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