Well: Warning Too Late for Some Babies

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

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

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

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Catherine Saint Louis speaks about using SimplyThick in premature infants.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Nanoparticles in Food Raise Concern by Advocacy Group

Nanomaterials, substances broken down by technology into molecule-size particles, are starting to enter the food chain through well-known food products and their packaging, but there is little acknowledgment by the companies using them, according to a new report from a nonprofit group that works to enhance corporate accountability.

Some companies may not even know whether nanomaterials are present in their products, the corporate accountability group As You Sow said.

Only 26 out of 2,500 companies, including PepsiCo, Whole Foods and the corporate parent of Pizza Hut and Taco Bell, responded to a survey from As You Sow about their use of nanomaterials.

“Only 14 said they don’t use nanomaterials, and of those only two had any policies on the use of nanomaterials,” said Andy Behar, chief executive of As You Sow. Various food companies have said they are interested in nanotechnology, which can help make products creamier without additional fat, intensify and improve flavors and brighten colors.

Their small size allows nanoparticles to go places in the body where larger particles cannot and enter cells. They have been found in the blood stream after ingestion and inhalation, and while research on their health effects is limited, studies have shown them to have deleterious effects on mice and cells.

“We’re not taking a no nano position,” Mr. Behar said. “We’re saying just show it’s safe before you put these things into food or food packaging.”

He noted that the European Union requires labeling of foods containing nanomaterials and that the European Food Safety Authority has published guidance for assessing nanomaterials in food and animal feed.

Last April, the Food and Drug Administration issued an unusually emphatic statement on nanomaterials, saying it did not have enough data to determine the safety of nanomaterials in food.

The Environmental Protection Agency is evaluating various nanoparticles used in consumer products, like sunscreens.

As You Sow tested 10 varieties of powdered doughnuts for the presence of nanoparticles. With the help of an independent lab, it found that Hostess Donettes and Dunkin’ Donuts Powdered Cake Donuts tested positive for the presence of titanium dioxide materials of less than 10 nanometers. Titanium dioxide is used to brighten white substances. The nano variety is under investigation by the E.P.A.

Michelle King, a spokeswoman for Dunkin’ Donuts, said the company was working with its supplier to validate As You Sow’s findings. Hostess Brands went out of business during the test and closed its factories.

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Scientists identify remains as those of King Richard III

LONDON -- More than 500 years after his death in battle, scientists announced Monday that they had definitively identified a skeleton unearthed in central England last summer as that of Richard III, the medieval king portrayed by William Shakespeare as a homicidal tyrant who killed his two young nephews in order to ascend the throne.

DNA from the bones, found beneath the ruins of an old church, matches that of a living descendant of the monarch's sister, researchers said.

"Rarely have the conclusions of academic research been so eagerly awaited," Richard Buckley, the lead archaeologist on the excavation, told a phalanx of reporters Monday morning. "Beyond reasonable doubt, the individual exhumed ... is indeed Richard III, the last Plantagenet king of England."

PHOTOS: Remains of King Richard III

The dramatic announcement capped a brief hunt for Richard's remains, the progress of which has been closely charted by international media and whose success has been barely short of miraculous.

Working from old maps of Leicester, about 100 miles northwest of London, archaeologists from the local university had less than a month to dig in a small municipal parking lot -- one of the few spaces not built over in the crowded city center. The team stumbled on the ruins of the medieval priory where records say Richard was buried, then found the bones a few days later last September.

"It was an extraordinary discovery that stunned all of us," Buckley said.

The nearly intact skeleton bore obvious traces of trauma to the skull and of scoliosis, a curvature of the spine that matched contemporary descriptions of Richard's appearance. The feet were missing, almost certainly the result of later disturbance, and the hands were crossed at the wrist, which suggests that they may have been tied.

Scientists at the University of Leicester, which pioneered the practice of DNA fingerprinting, were able to extract samples from the bones and compare them to a man descended from Richard III's sister Anne. The match through the maternal line was virtually perfect.

"The DNA evidence points to these being the remains of Richard III," said Turi King, the project’s geneticist.

Richard reigned from 1483 to 1485, and occupies a unique place in England's long line of colorful rulers. He was the last English king to be killed in combat, at the Battle of Bosworth Field, by his successor, Henry VII. His death ended the Plantagenet dynasty and ushered in the long era of the Tudors, including Henry VIII and Elizabeth I.

Jo Appleby, an osteologist at the university, said the skeleton belonged to an adult male in his late 20s to late 30s; Richard III was 32 when he died. The man would have stood 5-foot-8 at full height, but the curved spine would have made him appear shorter.

The skull was riddled with wounds strongly indicative of death in battle, including two blows from bladed weapons, either of which would have been fatal, Appleby said.

Richard III is one of England's most controversial monarchs, reviled by some as a bloodthirsty despot who stopped at nothing to gain power, but revered by others who insist that he has been unfairly maligned. His supporters note that the repugnant portrait of Richard in today's popular imagination is based almost entirely on accounts from the time of the usurping Tudors, especially Shakespeare's indelible characterization of him as a "deform'd, unfinish'd" man without scruples.

Fans say Richard III was an enlightened, capable ruler whose important social reforms included the presumption of innocence for defendants and the granting of bail, which remain pillars of the legal system in Britain and the U.S.

However, what happened to Richard's two nephews, who were his rivals for the throne and who were locked up in the Tower of London as young boys, never to be seen again, remains a mystery.

ALSO:

Race to unearth a royal mystery

Bones found in hunt for King Richard III's remains

Netanyahu officially asked to put together new Israeli government

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Navy's Next-Gen Binoculars Will Recognize Your Face

Take a close look, because the next generation of military binoculars could be doing more than just letting sailors and soldiers see from far away. The Navy now wants binoculars that can scan and recognize your face from 650 feet away.

That’s according to a Jan. 16 contract announcement from the Navy’s Space and Naval Warfare Systems Command, which is seeking a “Wireless 3D Binocular Face Recognition System.” During a testing period of 15 months, the plan is to improve “stand-off identification of uncooperative subjects” during daylight, using binoculars equipped with scanners that can read your mug from “100 to 200 meters” away, or about 328 to 650 feet. After scanning your mug, the binoculars then transmit the data to a database over a wireless network, where the data is then analyzed to determine a person’s identity. The no-bid contract, for an unspecified amount of money, went to California biometrics firm StereoVision Imaging.

“High level, it’s a surveillance and identification system,” Greg Steinthal, StereoVision’s president, tells Danger Room. “It’s using the ubiquitous binocular for real-time identification. The data point here is that this is to be used to add objectivity to an operation that’s highly subjective. So this is not intended for kinetic action to go arrest or detain someone. It’s more a tool to put other eyes on him or her.”

It helps that the technology — at least in a more limited form — already exists. StereoVision has developed a face-recognizing binocular system called 3DMobileID, with a maximum distance of around 328 feet, or 100 meters. “You have an unfair advantage,” the company touts in one promotional video, showing images of a human face being scanned at a distance, before the background is stripped out for a blue screen and then matched up to a database.

Depending on how well the binoculars work — and there’s reason to be cautious — it could give the Navy the ability to take advanced facial recognition into a much more portable and long-distance version than many current systems. Facebook uses the technology to match faces when users upload new photos. Google has its own version as well for its its Picasa photo service, and Apple has been researching face recognition as a way to unlock smartphones. (There are apps for iOS that do this, too.)

But the ranges on most systems also tend to max out at a few feet. For the military, that can be dangerous. Close-range biometric scanners (iris scanners are currently used by soldiers in Afghanistan) can pose a danger to the operator, as a person walking up to have their features scanned from a few inches away could be preparing to detonate an explosive vest. And what if a person happens to be on the move, or is bobbing and weaving through a crowd? That can render the scanners ineffective. Once upon a time, many face scanners also depended on the relatively crude practice of scanning 2-D images of the human face, which are an imprecise method when there are varying lighting conditions.

But the key to solving many of these problems could be a simple upgrade: StereoVision’s system scans in 3-D. When the system first scans you, it creates a 3-D model of your face instead of a 2-D image. That allows the system to isolate your face from a crowd, sharpen the image — which boosts the range — and then compares the image to a database. A filter also adjusts for varying degrees of light by smoothing out light across the face into a uniform pattern.

Now for the flaws in the system. The binoculars are not intended to work at night, and have difficulty scanning faces in twilight. When the binoculars can’t draw an image, it gives off a an audible beep to the operator, which is helpful. Otherwise, the process takes “about five to 10 seconds,” says Steinthal.

It’s also less effective when a subject is on the move. “[It] depends on how fast the target is walking,” Steinthal says. “We’re at walking, one-and-half meters per second. Somebody running? We’re not going to be able to do that right now.”

The concept of binoculars that scan and identify is also — perhaps unnervingly — not limited to the military. For one, StereoVision’s binoculars were developed in part with a $409,226 contract from the National Institute of Justice, and face scanners are a popular research topic for the FBI more broadly.

The FBI is spending $1 billion on a program called Next Generation Identification based around developing face scanners and combining the technology with other biometrics like the iris, voice, and fingerprints. A static face recognition system has also been installed at Toucumen International Airport in Panama City that can scan travelers’ faces and match them to criminal databases maintained by the FBI and Interpol. The Los Angeles County Sheriff’s Department and the San Diego Police Department have also tested out the binoculars, according to Steinthal, and are intended there for gang enforcement units and even to track “celebrity stalkers” in the L.A. area. Maybe if the FBI wants its special agents to also have some pretty far-out binoculars too, it should take a peek.

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Ed Koch remembered as quintessential New York City mayor

NEW YORK (Reuters) – Former New York City Mayor Ed Koch was memorialized on Monday as an in-your-face, wisecracking leader who helped transform the city from a symbol of urban decay to the vital, glittering metropolis it is today.

As Koch’s casket was led out of Temple Emanu-El, a soaring Fifth Ave. synagogue opposite Central Park, an organ played Frank Sinatra’s “New York, New York” while mourners including former U.S. President Bill Clinton and a who’s who of New York politics stood and applauded.

Koch died on Friday at the age of 88 in Manhattan — the only place other than heaven he could imagine living, as he was known to say.

“I come today with the love and condolences of 8.4 million New Yorkers who really are grieving with you at this moment,” said the city’s current mayor, Michael Bloomberg.

Speakers joked about the famously attention-loving Koch’s obsession with stage-managing his passing. His grave-stone, complete with an epitaph and a bench bearing Koch’s name, has been ready since 2008, and his friends said he had been planning the funeral for years.

“We started talking about his death in the ’80s,” said his former chief of staff Diane Coffey.

As mayor from 1978 to 1989, Koch, with his trademark phrase “How’m I Doin?”, was a natural showman and tireless promoter of both himself and the city. He helped repair the city’s finances as it teetered on the edge of bankruptcy, and later led a building renaissance that would see 200,000 units of affordable housing erected or rehabilitated in some of the city’s most crime-infested areas.

He could also be a divisive figure. His determination to shut Sydenham, a poorly-performing Harlem hospital that was one of the only city hospitals employing black doctors, angered black New Yorkers. And AIDS activists said he was too slow to react to the epidemic that ravaged the city’s gay population in the 1980s.

Tall, nearly bald and speaking with a high-pitched voice, Koch was an unmistakable presence. He was famously argumentative, and rarely walked away from verbal jousting.

His friend James Gill remembered Koch’s response to someone who had written a letter criticizing the former mayor.

“You are entitled to your opinion of me and I am entitled to my opinion of you,” Koch replied. “My opinion of you is that you are a fool.”

His nephews and grand-nephew and grand-niece remembered Koch, who never married, as devoted “Uncle Eddie” – eager to hear what they thought of his appearances on talk shows but also happy join his 11-year-old grand-niece for a manicure.

Clinton read from a stack of letters Koch had sent him over the years and said Koch had “a big brain, but he had an even bigger heart.”

Koch remained relevant in politics long after 1989, when he lost the Democratic nomination to David Dinkins for what would have been a record fourth term as mayor. But when asked if he would run for office again, he liked to say, “The people threw me out and the people must be punished.”

His endorsement was coveted by candidates decades after he left office. And his unwavering and loud support of Israel made Koch “one of the most influential and important American Zionists,” said former Ambassador Ido Aharoni.

At Monday’s memorial, Bloomberg noted the synagogue Koch had chosen for the funeral stood just a few blocks from the midtown bridge that had been renamed to honor him. Last year, the city released a video of Koch standing at the bridge’s entrance ramp, calling out to approaching cars: “Welcome to my bridge! Welcome to my bridge!”

“No mayor, I think, has ever embodied the spirit of New York City like he did. And I don’t think anyone ever will,” Bloomberg said. “Tough and loud, brash and irreverent, full of humor and chutzpah – he was our city’s quintessential mayor.”

(Reporting By Edith Honan; Editing by Paul Thomasch and Alden Bentley)

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Well: Expressing the Inexpressible

When Kyle Potvin learned she had breast cancer at the age of 41, she tracked the details of her illness and treatment in a journal. But when it came to grappling with issues of mortality, fear and hope, she found that her best outlet was poetry.

How I feared chemo, afraid
It would change me.
It did.
Something dissolved inside me.
Tears began a slow drip;
I cried at the news story
Of a lost boy found in the woods …
At the surprising beauty
Of a bright leaf falling
Like the last strand of hair from my head

Ms. Potvin, now 47 and living in Derry, N.H., recently published “Sound Travels on Water” (Finishing Line Press), a collection of poems about her experience with cancer. And she has organized the Prickly Pear Poetry Project, a series of workshops for cancer patients.

“The creative process can be really healing,” Ms. Potvin said in an interview. “Loss, mortality and even hopefulness were on my mind, and I found that through writing poetry I was able to express some of those concepts in a way that helped me process what I was thinking.”

In April, the National Association for Poetry Therapy, whose members include both medical doctors and therapists, is to hold a conference in Chicago with sessions on using poetry to manage pain and to help adolescents cope with bullying. And this spring, Tasora Books will publish “The Cancer Poetry Project 2,” an anthology of poems written by patients and their loved ones.

Dr. Rafael Campo, an associate professor of medicine at Harvard, says he uses poetry in his practice, offering therapy groups and including poems with the medical forms and educational materials he gives his patients.

“It’s always striking to me how they want to talk about the poems the next time we meet and not the other stuff I give them,” he said. “It’s such a visceral mode of expression. When our bodies betray us in such a profound way, it can be all the more powerful for patients to really use the rhythms of poetry to make sense of what is happening in their bodies.”

On return visits, Dr. Campo’s patients often begin by discussing a poem he gave them — for example, “At the Cancer Clinic,” by Ted Kooser, from his collection “Delights & Shadows” (Copper Canyon Press, 2004), about a nurse holding the door for a slow-moving patient.

How patient she is in the crisp white sails
of her clothes. The sick woman
peers from under her funny knit cap
to watch each foot swing scuffing forward
and take its turn under her weight.
There is no restlessness or impatience
or anger anywhere in sight. Grace
fills the clean mold of this moment
and all the shuffling magazines grow still.

In Ms. Potvin’s case, poems related to her illness were often spurred by mundane moments, like seeing a neighbor out for a nightly walk. Here is “Tumor”:

My neighbor walks
For miles each night.
A mantra drives her, I imagine
As my boys’ chant did
The summer of my own illness:
“Push, Mommy, push.”
Urging me to wind my sore feet
Winch-like on a rented bike
To inch us home.
I couldn’t stop;
Couldn’t leave us
Miles from the end.

Karin Miller, 48, of Minneapolis, turned to poetry 15 years ago when her husband developed testicular cancer at the same time she was pregnant with their first child.

Her husband has since recovered, and Ms. Miller has reviewed thousands of poems by cancer patients and their loved ones to create the “Cancer Poetry Project” anthologies. One poem is “Hymn to a Lost Breast,” by Bonnie Maurer.

Oh let it fly
let it fling
let it flip like a pancake in the air
let it sing: what is the song
of one breast flapping?

Another is “Barn Wish” by Kim Knedler Hewett.

I sit where you can’t see me
Listening to the rustle of papers and pills in the other room,
Wondering if you can hear them.
Let’s go back to the barn, I whisper.
Let’s turn on the TV and watch the Bengals lose.
Let’s eat Bill’s Doughnuts and drink Pepsi.
Anything but this.

Ms. Miller has asked many of her poets to explain why they find poetry healing. “They say it’s the thing that lets them get to the core of how they are feeling,” she said. “It’s the simplicity of poetry, the bare bones of it, that helps them deal with their fears.”

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Have you written a poem about cancer? Please share them with us in the comments section below.

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DealBook: Dell Nears a Buyout Deal of More Than $23 Billion

Dell Inc. neared an agreement on Monday to sell itself to a group led by its founder and the investment firm Silver Lake for more than $23 billion, people briefed on the matter said, in what would be the biggest buyout since the financial crisis.

If completed, a takeover would be the most radical attempt yet by Michael S. Dell to revive the company that bears his name. Such is the size of the potential deal that Mr.
Dell has called upon Microsoft, one of his most important business partners, to shore up the proposal with additional financial muscle. The question will now turn to whether taking the personal computer maker private will accomplish what years of previous turnaround efforts have not.

The final details were being hammered out on Monday evening, and a deal could be announced as soon as Tuesday. Still, last-minute snags could cause the negotiations to collapse, the people briefed on the matter cautioned.

The consortium is expected to pay between $13.50 and $13.75 a share, these people said. Mr. Dell is expected to contribute his nearly 16 percent stake to the deal, worth about $3.8 billion under the current set of terms. He is also expected to contribute hundreds of millions of dollars in fresh capital from his own fortune.

Silver Lake would likely contribute roughly $1 billion, these people added. Microsoft is expected to put in about $2 billion, though that would likely come in the form of preferred shares or debt.

Dell is also expected to bring home some of the cash that is currently held in offshore accounts to help with the financing.

A spokesman for Dell declined to comment.

For decades, Dell benefited from its status as a pioneer in the market for personal computers. Founded in 1984 in a dormitory room at the University of Texas, the company grew into one of the biggest computer makers in the world, built on the simple premise that customers would flock to customize their machines.

By the late 1990s, its fast-rising stock created a company worth $100 billion and minted a class of “Dellionaires” whose holdings made for big fortunes, at least on paper. Mr. Dell himself amassed a fortune worth an estimated $16 billion and formed a quietly powerful investment firm to manage those riches.

But since then, growing competition has sapped Dell’s strength. Rivals like Lenovo and Samsung have made the PC-making business less profitable. Last month, the market research firm Gartner reported that Dell sold 37.6 million PCs worldwide in 2012, a 12.3 percent drop from the previous year’s shipments. Perhaps more significant is the emergence of the smartphone and the tablet, two classes of devices that have eaten away at sales of traditional computers.

Mr. Dell has sought to move the company into the more lucrative and stable business of providing corporations with software services, spending billions of dollars on acquisitions to lead that transformation. The aim is to refashion Dell into something more like I.B.M. or Oracle. Even so, manufacturing PCs still makes up half of the company’s business.

The company’s stock had fallen in 59 percent in the 10 years ended Jan. 13, the last business day before word of the buyout talks emerged. That has actually made Dell more tempting as a takeover target for its founder and Silver Lake, which see it as undervalued.

A Dell deal would be a watershed moment for the leveraged buyout industry: It would be the largest takeover since the Blackstone Group paid $25 billion for Hilton Hotels in the summer of 2007. No leveraged buyout since the financial crisis has surpassed the $7.2 billion that Kohlberg Kravis Roberts and others paid for the Samson Investment company, an oil and gas driller, in the fall of 2011.

Private equity executives have hungered for the chance to strike a deal worth more than $10 billion, an accomplishment believed difficult because of the sheer size of financing required. Dell will take on more than $15 billion in debt, an enormous amount arranged by no fewer than four banks.

Leading the charge for Dell is Silver Lake, known as one of the biggest investors in technology companies.

But the debt markets have been soaring over the past two years, as the cost of junk bonds has stayed low. Persistent low interest rates has prompted debt buyers to seek investments that carry higher yields

Dell was unusually well-placed to make a deal with private equity. The company carries $4.9 billion in long-term debt, which some analysts have regarded as a manageable amount. And its management has signaled a willingness to bring back at least some of the company’s cash horde that is held overseas, despite potentially ringing up a hefty tax bill.

And then there is the matter of Mr. Dell’s stake. Advisers to Dell have taken pains to structure the transaction to avoid the potential conflicts of interest involved in a chief executive taking his company private, the people briefed on the matter said.

A special committee of Dell’s board has hired an independent investment bank, Evercore Partners, as an adviser who will seek out alternative takeover bids.
It is unclear whether the company’s biggest investors will accept a deal at the levels that the buyer consortium is advocating. Shares of Dell fell 2.6 percent, to $13.27, on Monday after reports of the proposed price range emerged.

Still, an analyst with Sanford C. Bernstein, A. M. Sacconaghi, wrote in a research note last month that he believed Mr. Dell was likely to succeed in at least taking the company private.

“Net net, we believe that if a deal goes to a shareholder vote it will likely be approved,” he wrote — cautioning that victory is dependent on activist investors not clamoring for a significantly higher price.

But going private may not solve all of the company’s problems. Mr. Sacconaghi said that a leveraged buyout makes sense so long as Dell is able to stanch bleeding in its PC business and bring back some of its overseas cash over time.

The bigger question is whether Mr. Dell will undertake more drastic changes at the company once it is away from the glare of the public markets. Analysts at Barclays wrote last month that shedding unattractive businesses, like its consumer PC arm, would make a take-private more attractive.

Absent big moves, the strain of the additional debt could starve Dell of the cash it needs to tackle additional acquisitions to complete its transformation into an enterprise software company.

Biggest Private Equity-Backed Leveraged Buyouts

DEAL, IN BILLIONS	TARGET	BUYER	ANNOUNCED
Source: Thomson Reuters *At time of deal, including assumption of debt, not adjusted for inflation.
$44.3	TXU	Morgan Stanley, Citigroup, Lehman Brothers Holdings, Kohlberg Kravis Roberts, Texas Pacific Group and Goldman Sachs	February 2007
37.7	Equity Office Properties Trust	Blackstone Group	November 2006
32.1	HCA	Bain Capital, Kohlberg Kravis Roberts and Merrill Lynch Global Private	July 2006
30.2	RJR Nabisco	Kohlberg Kravis Roberts	October 1988
30.1	BAA	Grupo Ferrovial SA, Caisse de Depot et Placement and GIC Special Invest	March 2006
27.6	Harrah’s Entertainment	Texas Pacific Group and Apollo Management	October 2006
27.4	Kinder Morgan	GS Capital Partners, The Carlyle Group and Riverstone Holdings	May 2006
27.2	Alltel	TPG Capital and GS Capital Partners	May 2007
27.0	First Data	Kohlberg Kravis Roberts	April 2007
26.7	Hilton Hotels	Blackstone Group	July 2007

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Medical clinic workers struggle with burnout

Every day after work, Sandeep Lehil changes out of her lab coat and blue scrubs and sits cross-legged on a large, black pillow in her airy, quiet Los Feliz apartment. She takes two deep breaths and tries not to think about the patients she so desperately wants to help.

She pushes out thoughts of the man with heart problems who left her exam room in an ambulance. And the patient who walked out when she told him his tests indicated he could have HIV. And the woman who Lehil fears is addicted to pain pills.

"Meditation is the only thing that keeps me sane," said Lehil, a nurse practitioner in South Los Angeles. "It's like clearing your head of the anxieties and troubles you've had that day."

Lehil, 28, and others like her at community clinics throughout the U.S. are key players in the push to lower the nation's healthcare spending. They conduct physicals, refill medications and manage chronic diseases for low-income patients, providing the care necessary to keep them from requiring more costly medical treatment.

The jobs are demanding — providers spend long hours treating patients who have multiple chronic illnesses and often have gone years without care. Administrators have trouble finding enough doctors, nurse practitioners and physician assistants to staff their clinics.

That is expected to cause a major roadblock next year, when the bulk of the national healthcare reform law takes effect, aiming to help 30 million uninsured Americans gain coverage. In preparation, clinics — expected to get an influx of new patients — are stepping up recruitment and trying to hold on to the care providers they have. But burnout is common, and staff members often leave for less-stressful, higher-paying positions elsewhere.

"The workforce shortage is certainly one of the top challenges we are facing currently, and the expansion hasn't even occurred yet," said Carmela Castellano-Garcia, president of the California Primary Care Assn., which represents community clinics.

Lehil graduated in May from Johns Hopkins University with a master's degree in nursing and an idealistic goal: to make a difference in a medically underserved community. In July she started as a nurse practitioner at T.H.E. Clinic, a community health center in South Los Angeles.

Lehil said the work is fulfilling but draining, and busier than she ever could have anticipated. By the end of the week, she said, "it's almost like running on empty."

T.H.E. Clinic has eight full-time providers but needs 11. There are ongoing advertisements, and the clinic is "constantly fighting" for family practice providers, often competing with nearby centers, said human resources director Lilia Marin-Alvarez. To find new clinicians, T.H.E. Clinic and others rely heavily on the National Health Service Corps, which offers scholarships and loan repayment for those willing to work in underserved areas.

While still in school, Lehil saw an ad for T.H.E. Clinic. The name — To Help Everyone — immediately appealed to her. Lehil interviewed and, soon after, accepted a job offer. Now, Marin-Alvarez said she just has to make sure Lehil stays.

Lehil speaks quickly and walks with purpose. She wears Crocs, red-rimmed glasses and a loose ponytail, and she has several tattoos, including the infinity sign on her wrist and a flock of birds on her back. A stethoscope rests on her neck and two silver bangles on her wrist.

Raised in a tight-knit, professional Indian family in San Jose, Lehil attended UC Berkeley as an undergraduate and majored in public health. Her parents wanted her to be a doctor, but she decided to become a nurse practitioner, in part because medical school would have taken too long.

When Lehil started working at T.H.E. Clinic, she wondered how she could possibly see two dozen or more patients in a day. "It's not like they have one thing wrong with them," she said.

She took the time she needed, but it resulted in longer waits. When her patients became frustrated, Lehil just apologized and smiled.

During the first few weeks, she left each Friday with a dull headache, which she tried to shake off before Monday morning. To better manage the stress, Lehil started meditating an hour a day, at home and at the Zen Center of Los Angeles. She also moved to Los Feliz so she could take walks in Griffith Park in her free time.

On a Tuesday in the fall, Lehil arrives at work before 8 a.m. so she can get a head start on reviewing lab results and medications for the patients she expects to see that day. Hand sanitizer, a bottle of water and a clipboard filled with papers sit on her desk. She picks up a thermos and takes a sip. She wants to switch to green tea, but not today. She has 15 patients scheduled for this morning and 12 others this afternoon. "Today's a black tea day," she said.

For 10 hours, she moves quickly from one patient to the next, starting every visit the same way: "Hi, I'm Sandeep. I'm here to help you."

To save time each day, Lehil starts triaging, addressing her patients' most urgent health issues and saving the others for future visits. This morning, Mitchell Chambers, an expressive and friendly man, has come to see her. He has high blood pressure, is at risk for diabetes and has undergone open heart and gastric bypass surgeries. She notes all of it in his chart but focuses on one thing: his high cholesterol, which hasn't been treated.

She hands him a flier about nutrition and urges him to stop smoking and start exercising. She also writes him a prescription. Chambers, 50, makes a thumbs-up sign and promises to try to follow her instructions. "I'm in your hands," he says.

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Wired Science Space Photo of the Day: Wheatley Crater on Venus

Magellan radar image of Wheatley crater on Venus. This 72 km diameter crater shows a radar bright ejecta pattern and a generally flat floor with some rough raised areas and faulting. The crater is located in Asteria Regio at 16.6N,267E.

Image: NASA/GSFC [high-resolution]

Caption: NASA

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Keys sings national anthem on piano at Super Bowl

Alicia Keys performed a lounge-y, piano-tinged — and live — version of the national anthem ahead of the Super Bowl on Sunday.

The Grammy-winning singer played the piano as she sang “The Star Spangled Banner” in a long red dress with her eyes shut. Her publicist said the performance was live, days after halftime performer Beyonce admitted singing along to a prerecorded track at the Inauguration.

Keys’ version was soft and featured additional lyrics: She added “living in the home” before belting “home of the brave” as she finished the song.

Before Keys hit the field, Jennifer Hudson performed “America the Beautiful” with the 26-member Sandy Hook Elementary School chorus, a performance that had some players on the sideline on the verge of tears.

The students wore green ribbons on their shirts in honor of the 20 first-graders and six adults who were killed in a Dec. 14 shooting rampage at the school in Newton, Conn.

The students began the song softly before Hudson, whose mother, brother and 7-year-old nephew were shot to death five years ago, jumped in with her gospel-flavored vocals. She stood still in black and white as the students moved to the left and right, singing background.

Keys and Hudson warmed up the field for Beyonce, who is set to perform at the half-time show.

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