Israeli strike kills 9 members of Gaza family

GAZA CITY — An Israeli airstrike Sunday killed at least nine members of the same family — mostly women and children — in the deadliest single attack and worst civilian tragedy since the fighting in the Gaza Strip began last week.

Though Israel has expressed pride over its five-day military campaign for limiting civilian casualties, the strike against the Dalu home in Gaza City was likely to test the limits of international support it has received in the battle to stop militants from firing rockets at Israeli cities.

Yet despite immediate condemnation by Hamas, the militant group that controls Gaza, the tragedy did not appear to derail cease-fire negotiations underway in Cairo, where Israeli and Palestinian representatives are meeting. In fact, the high civilian death toll from Sunday's attack only increased the international pressure on both sides to end hostilities, coming on a day both President Obama and British officials raised concerns about the conflict expanding into a ground war.

Israeli military officials said they were targeting a Hamas militant in his home, but provided no further information. The Dalu family was believed to have links to Hamas' military wing and had been targeted by Israel before.

But there were conflicting reports about whether the strike killed the home's owner, Jamal Dalu, or his son Mohamed. Hamas' Health Ministry put the death toll at 11, which may include two neighbors. More than 20 people were injured.

On its website, the military wing of Hamas said that the attack on the family "will not go unpunished" and that the group had begun firing rockets at Israel in response. By Sunday night, Gaza militants had fired 114 rockets at southern Israel during the day, hitting buildings in Beersheba, Sderot and Ashdod. Five people were injured by shrapnel from a rocket in Ofakim, near the Gaza border.

The Israeli missile strike was so strong it destroyed the Dalu family's three-story building, blowing out windows blocks away and sending a charred mattress flying into the street.

For hours panicked neighbors and rescue workers clung to hope of finding survivors. While a bulldozer pulled apart pieces of the collapsed walls, volunteers in orange vests scrambled over the wreckage and searched for signs of life.

In a grim, heart-wrenching scene that played out over 90 minutes, the bodies of four children were pulled out one after another.

Each time they found a body, some of the men would yell excitedly and wave their hands at the bulldozer's driver to stop digging, while others would climb down to retrieve the child. As mobs of onlookers chanted "God is great," a rescue worker would race toward a waiting ambulance with a limp, dust-covered child.

"This is a massacre," shouted a distraught Nasser Dalu, 56, a cousin and neighbor, as he watched his relatives being pulled from debris. "What did these children do?"

Israel Defense Forces said it has launched more than 1,000 airstrikes over the last five days, mostly targeting weapons caches and military compounds, in an attempt to put an end to rocket and mortar attacks on communities in southern Israel.

It expanded its targets to include the homes of Hamas leaders; Gaza officials said 17 homes were attacked on Sunday alone. About the same time that the Dalu house was hit, Israel said it targeted Yiyhe Abia, the head of Hamas' rocket-firing squad, in his home nearby.

Sunday's airstrikes brought the death toll in Gaza to 69 people since Wednesday, including at least 24 civilians, hospital officials said. More than 660 Palestinians have been wounded.

Three Israelis were killed when a projectile fired from Gaza hit their apartment complex Thursday.

The strike on the Dalu home inflamed much of Arab world and within hours "aldalumassacre" had become a Twitter hashtag. Some compared the attack to the 2009 shelling of the Samouni house, when 21 members of the family were killed during the previous Israeli assault on Gaza.

The Dalu strike came at a delicate time in the Gaza conflict, as Egyptian President Mohamed Morsi has been trying to broker a long-term truce between Israel and Hamas. Despite the heated rhetoric and escalating violence, talks continued behind the scenes Sunday night, Hamas officials said.

Without an agreement soon, many fear Israel will launch a ground invasion. Israeli Prime Minister Benjamin Netanyahu told his Cabinet on Sunday that Israel is "prepared for a significant expansion of the operation."

At a news conference in Bangkok, Thailand, Obama urged both sides to resolve their differences "without further escalation of violence in the region."

While repeating his previous statements that Israel has a right to press for an end to attacks on its people, Obama said, "If that can be accomplished without a ramping-up of military activity in Gaza, that's preferable. That's not just preferable for the people of Gaza, it's also preferable for Israelis, because if Israeli troops are in Gaza, they're much more at risk of incurring fatalities or being wounded."

British Foreign Secretary William Hague shared Obama's concerns, telling Sky News television that "a ground invasion of Gaza would lose Israel a lot of the international support and sympathy that they have in this situation."

In addition to hitting the homes of Hamas officials, Israel expanded its targets to include buildings used by communications services, leaving several journalists injured early Sunday.

A 1:30 a.m. strike against one building destroyed the 11-floor offices of Al Quds television, a Hamas-affiliated network. Several journalists were seriously wounded, including one whose leg had to be amputated, witnesses said.

Cameraman Mohamed Akhras, 23, said he was working the night shift in case of any breaking stories and had just fallen asleep when the blast buried him and a colleague under furniture and debris.

"Israel targeted us because we are revealing the truth about their crimes," Akhras said, half his face dotted with small shrapnel cuts.

Israeli military officials defended the attacks against the Al Quds site and another Hamas-run communications facility, saying they were trying to destroy rooftop antennas used by militants to communicate.

edmund.sanders@latimes.com

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Justin Bieber dominates at American Music Awards

America proved its Bieber Fever was strong: The teen singer dominated the American Music Awards on Sunday night.

Bieber's wins included the show's top award, artist of the year. His mom joined him onstage as he collected the trophy, beating out Rihanna, Maroon 5, Katy Perry and Drake.

"I wanted to thank you for always believing in me," Bieber said, looking to his mom.

The 18-year-old also won the honor in 2010. He said it's "hard growing up with everyone watching me" and asked that people continue to believe in him.

Bieber and Nicki Minaj performed together — and separately — at the AMAs, and were both multiple winners.

But another collaboration was the night's most colorful performance: Korean rapper PSY and MC Hammer. Hammer joined the buzzed-about pop star for his viral hit "Gangnam Style." PSY rocked traditional "Hammer" pants as they danced to his jam and to Hammer's "Too Legit to Quit."

Bieber won favorite pop/rock male artist in the first award handed out at Sunday's show and gave a shout-out to those who didn't think he would last on the music scene.

"I want to say this is for all the haters who thought I was just here for one or two years. I feel like I'm going to be here for a very long time," he said.

He also won favorite pop/rock album for his platinum-selling third album, "Believe." He gave a stripped down, acoustic performance of "As Long As You Love Me," then transitioned to the dance-heavy "Beauty and a Beat," where Minaj joined him onstage, grinding with the teen for a few seconds.

Minaj, who wore three different wigs and four outfits throughout the night, repeated her AMAs wins from last year, picking up trophies for favorite rap/hip-hop artist and album for "Pink Friday: Roman Reloaded." She was in an all-white get-up, including fur coat and pink hair when she performed her new song "Freedom." The scene was ghostly and snowy, as a choir — also in white — joined her onstage. One background singer stole the performance, belting semi-high notes as Minaj looked on.

As Bieber won his second award, he was kissed on the neck by Jenny McCarthy, who presented the award.

"Wow. I feel violated right now," he said, laughing.

"I did grab his butt," McCarthy said backstage. "I couldn't help it. He was just so delicious. So little. I wanted to tear his head off and eat it."

Bieber's red and black outfit seemed to be the night's theme, as Taylor Swift and Usher wore similar ensembles.

Usher kicked off the three-hour show with green laser lights beaming onstage as he performed a medley of songs, including "Numb," ''Climax" and "Can't Stop, Won't Stop," which featured a smoky floor and a number of backup dancers, as Usher jammed in all black, with the exception of his red shoes. He won favorite soul/R&B male artist.

Swift won her fifth consecutive award for favorite country female artist.

"This is unreal. I want to thank the fans. You guys are the ones who voted on this," she said.

Swift gave a masquerade-themed performance of the pop song "I Knew You Were Trouble." She sang onstage in a light dress while dancers wore mostly black. But then she changed into a red corset and black skirt, matching their dark mood. She even danced and sang on the floor as lights flickered throughout the performance.

Dick Clark, who created the AMAs, was remembered by Ryan Seacrest and an upbeat performance by Stevie Wonder.

"What a producer he was," said Seacrest, as Wonder sang his hits, including "My Cherie Amour."

Carly Rae Jepsen, who performed early in the night, won favorite new artist.

"I am floored. Wow," she said, thanking Bieber and his manager, Scooter Braun.

Party girl Ke$ha was glammed up on the red carpet, rocking long, flowy blonde hair and a light pink dress. She switched to her normal attire when she performed her hit single "Die Young." It was tribal, with shirtless dancers in skin-tight pants, silver hair and skeleton-painted faces, who also played the drums. Ke$ha was pants-less, rocking knee-high boots and rolling on the floor as she finished up the song.

Minaj and Christina Aguilera were blonde bombshells, too: Minaj's hair was busy and full of volume and she sported a neon strapless gown to accept her first award. Aguilera wore a blonde bob in a purple dress that matched her eyeshadow.

Aguilera performed a medley of material from her new album and joined Pitbull onstage.

Kelly Clarkson also hit the stage, making a nod to her "American Idol" roots with a number on her dress and three judges looking on as she sang "Miss Independent." Then she went into "Since U Been Gone," ''Stronger" and "Catch My Breath." It's worth noting that "Idol" judge Randy Jackson introduced Clarkson, the first-ever winner of the show. He also advised people to donate through Red Cross for Superstorm Sandy victims.

Fellow "Idol" winner Carrie Underwood won best favorite country album and performed, hitting the right notes while singing "Two Black Cadillacs." She talked about singing competition shows backstage.

"These people that go on these shows are so talented, you know? And I would love to see if so many of the other artists that are out there today would go back and try out for these shows, because they might get their behinds kicked by some of the contestants," she said.

Luke Bryan won favorite country male artist and Lady Antebellum favorite country group.

American Music Awards nominees were selected based on sales and airplay, and fans chose the winners by voting online. At this award show, even the stars were fans: Pink said on the red carpet that she'd like to collaborate with Lauryn Hill. Cyndi Lauper said her musical playlist includes Pink and Minaj. Boy band The Wanted said they were excited to see PSY and Colbie Caillat wanted to watch No Doubt.

"What makes the American Music Awards special is the fans choose the winning artists," said Chester Bennington of Linkin Park, who won favorite alternative rock artist and performed "Burn It Down," as Brandy sang along and Gwen Stefani, Usher and Phillip Phillips bobbed their heads.

David Guetta won the show's first-ever electronic dance music award. Non-televised awards went to Katy Perry for pop/rock female artist, Beyonce for soul/R&B female artist, Adele for adult contemporary artist and Shakira for Latin artist.

Along with Rihanna, Minaj was the top nominee with four nominations.

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AP Entertainment Writer Sandy Cohen contributed to this report from Los Angeles.

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Follow Mesfin Fekadu on Twitter at http://twitter.com/MusicMesfin

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Online:

http://beta.abc.go.com/shows/american-music-awards

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MaleSurvivor Conference Examines Sexual Abuse in Sports

It was the summer before high school, and Christopher Gavagan, then 13, was preparing to leave the safe familiarity of the friends he had known during his boyhood. With a plan to excel at ice hockey, he began training on inline skates, moving through his New York City neighborhood, up and down the streets until, he said, “I turned down the wrong street.”

Gavagan, now a filmmaker, was one of eight panelists who participated Friday in a discussion about young athletes who have been sexually assaulted or abused by their coaches. The panel was part of the MaleSurvivor 13th International Conference, held this year at John Jay College of Criminal Justice. The conference brought together men who have been sexually abused, as well as psychologists, social workers, academics and members of the legal community.

A dour procession of stories about sexual misconduct by coaches toward their male charges has come to light in recent months. Jerry Sandusky, a former assistant football coach at Penn State, was sentenced in October to 30 to 60 years in prison on 45 counts of child molesting. Sugar Ray Leonard wrote in his autobiography last year that he was sexually molested by an Olympic boxing coach. The N.H.L. players Theo Fleury and Sheldon Kennedy were sexually abused as teenagers by their hockey coach Graham James.

The prevalence of sexual abuse among all boys 17 and under has been variously estimated to be as low as 5 percent and as high as 16 percent. For some of the millions of children who participate in sports nationwide, and their parents, sexual assault in a sports context has its own dynamic.

“Sports is a place where parents send their boys to learn skills, to learn how to be teammates and how to work together — to make boys stronger and healthier,” said Dr. Howard Fradkin, author of “Joining Forces,” a book about how men can heal from sexual abuse. “It’s the place where we send our boys to grow up. The betrayal that occurs when abuse occurs in sports is damaging because it destroys the whole intent of what they started out to do.”

When Gavagan, now 38, turned down that fateful street, and stepped briefly into the house of a man recommended as a hockey coach by a couple of female acquaintances, what greeted him, he said, was “a young boy’s dream come true.”

The dream Gavagan glimpsed was embodied in the trophy room of the house.

“It was everything I wanted to be right there,” recalled Gavagan, who is working on a feature-length documentary on sexual abuse in youth sports, in which he interviews other sexual-abuse victims and his own attacker, against whom he has never pressed charges. In addition to the shiny relics that seemed to give testimony to the man’s coaching prowess, Gavagan said, the trophy room had pictures of hockey teams the man had coached and workout equipment — the physical tools promising the chance to get bigger and stronger.

“To a skinny 13-year-old, it was like winning the lottery,” Gavagan said.

Christopher Anderson, the executive director of MaleSurvivor, said sexual abuse — basically nonconsensual touching or sexual language — is devastating under any circumstance, but coach and player often have a special relationship.

“Especially as you progress higher and higher, the coach can become just as important in some ways to an athlete as the relationship with his parents might have,” Anderson said. “In some cases, it’s a substitute for parents.”

He added: “There’s also a fundamentally different power dynamic. When you’re a young star, the coach can literally make or break your career as an athlete.”

But caution has to extend beyond coaches who guide future Olympians, Gavagan said, noting that his coach was not of that caliber.

“The entire grooming process was so subtle,” Gavagan said. “It’s not like when I first went into his house that he tried to grope me.”

First, Gavagan said, the coach said it was all right to curse in that house. On another visit it was fine to have a beer, which led on another day to Playboy magazine and on subsequent days to harder pornography and harder liquor. It was six months before the coach laid an explicitly sexual hand on him, Gavagan said.

“I didn’t feel like a sudden red line had been crossed — the line had been blurred,” Gavagan said, explaining that he avoided his parents when he returned home with liquor on his breath by telling them he was exhausted and going straight to his room. (Unlike many sexual-abuse victims, Gavagan said his parents, with whom the coach had ingratiated himself, were supportive of their son, and his was a loving family. He said that if he had approached them about the coach, they would have listened.)

Another aspect of sexual abuse in sports is the environment, which emphasizes a kind of macho ethic.

“What is most different about abuse is the sports culture itself,” Fradkin said. “It is a culture that promotes teamwork and teaches boys to shrug it off. When a boy or man is abused, he risks being thrown off the team if he should speak the truth because he’ll be seen as being disloyal — and weak.”

At 17, after four years with his coach, Gavagan said he “aged out” of his coach’s target age.

“At the time I had no idea of how it would impact my life, but the unhealthy lessons about relations, trust and the truth set a time bomb that would detonate my relationships for the next 10 years,” Gavagan said.

As a word of caution, Anderson said the lesson for parents should not be that sports are dangerous.

“It should be that there are sometimes dangerous people who gravitate to sporting organizations and our safeguards aren’t good enough yet to adequately protect our children,” he said. “That doesn’t mean that we should be pulling our kids from soccer and baseball and basketball. What it means is that parents need to be vigilant.”

He added: “They need to be proactive with athletic organizations to make sure that policies are in place — such as doing criminal background checks on staff and having a procedure where young athletes can complain about inappropriate behavior — that make sure children are protected.”

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Psychic Temple in Long Beach slated for office conversion

The Psychic Temple, a long-abandoned Long Beach landmark that is one of the city's oldest commercial structures, will be converted to office space as redevelopment attracts new residents and businesses to downtown.

Advertising agency InterTrend Communications will start making improvements this week on the brick building at 224 E. Broadway near Long Beach Boulevard. It is converting the top two floors that were formerly residential spaces into offices for the firm and preparing the ground floor and basement for retail tenants such as a restaurant.

The property in a formerly blighted part of downtown has been a headache for Long Beach officials, who purchased it for the city in 2000 in the hope they could find a developer willing to perform badly needed renovations.

Because it was an official landmark that couldn't be razed, it had a negative assessed value of $350,000, said Julia Huang, chief executive of InterTrend. Her Long Beach company agreed to fix up the property and recently took title after paying the city $1.

"It was truly debilitated, but we just fell in love," Huang said.

Local developer JR van Dijs Inc. is performing the makeover, which will cost about $2 million.

The Romanesque Revival-style building was completed in 1905 by former Baptist preacher W.R. Price, founder of a doctrine he called the New or Practical Psychology. Its motto was "Health and happiness for all."

Price raised money from members to build the headquarters sometimes referred to as the Psychological Temple. Rifts among cult members soon arose, and Price's name was chiseled off the building's cornerstone after he lost control of the society. In 1911 the brick building was sold at auction.

For decades, the building's upstairs floors were used as a hotel. The property is called the American Hotel on the city's list of historic landmarks.

InterTrend will move about 80 employees there in about a year. It will leave an Ocean Boulevard high-rise to be part of a more pedestrian-oriented downtown, Huang said.

"Long Beach is going through an evolution of street culture," she said. "That was very appealing to us."

Clients of Asian-oriented InterTrend include Toyota Motor Corp., AT&T Inc., State Farm and Walt Disney Co., Huang said.

Private USC housing site is sold

University Gateway, high-end private student housing across the street from USC, has been sold for more than $200 million to a Wisconsin public employees pension fund.

The eight-story complex at 3335 S. Figueroa St. was completed in 2010 by Los Angeles developer Urban Partners, which owned it with real estate investors RCG Longview and Blackstone Real Estate Advisors. Its appraised value before the sale was $89 million, according to real estate data provider CoStar.

University Gateway has 421 units with 1,656 beds available for rent. The residences are 96% leased, according to real estate brokerage CBRE Group Inc., which helped arrange the deal. The complex also has shops and restaurants on the ground floor.

The price set a new national benchmark for the sale of a single student housing complex, said Ryan Reid, head of student housing sales at CBRE. "Urban Partners developed a high-quality asset in an irreplaceable location," he said.

Students pay about $1,000 a month per bed to live at University Gateway. Amenities include a fitness center, rooftop terraces and a sound-proof study room.

Chicago company Blue Vista Capital Partners purchased the property on behalf of the State of Wisconsin Investment Board.

Father, son artists to move L.A. base

Acclaimed and sometimes controversial Los Angeles artist Paul McCarthy and his son Damon will move their base to a new location on the Eastside after the purchase of a 1970s-era industrial building.

Damon McCarthy bought the 150,000-square-foot building at 4540 Worth St. from Trammell Crow Co. for nearly $9 million, he said.

"I make big, crazy art pieces for famous artists, especially my dad," McCarthy said. His 67-year-old father is known for his provocative performance art and large-scale sculpture that often skewers the excesses of American culture.

Paul and Damon McCarthy's work "Rebel Dabble Babble," presented downtown in May, covered two floors and spilled into the parking lot of a downtown gallery. It included original videos and eight rooms based on the 1955 movie "Rebel Without a Cause."

Paul McCarthy Studios will move in next year, said Damon, who employs about 60 workers. "This will be my hub."

The Eastside neighborhoods of Lincoln Heights and El Sereno are in transition from being exclusively industrial to more artistic, said real estate broker Jimmy Chai of Cushman & Wakefield, who represented McCarthy in the deal.

roger.vincent@latimes.com

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Russia vows tough response to U.S. human rights legislation

MOSCOW — Russian officials are promising a tough response to U.S. legislation that would impose sanctions on Russian officials if Congress finds them responsible for violating human rights.

The U.S. House on Friday passed a bill that establishes permanent normal trade relations with Russia, repealing the 1974 Jackson-Vanik amendment, which had imposed limits on trade because of the Soviet Union's treatment of Jews. It had been waived annually since 1989, two years before the Soviet Union collapsed.

But a provision of the legislation named after Russian lawyer Sergei Magnitsky also would impose sanctions on officials responsible for human rights violations.

Magnitsky was a 37-year-old lawyer representing the Britain-based Hermitage Capital Management company in 2008 when he blew the whistle on alleged fraud involving Russian tax officials and police officers. Magnitsky said a tax refund scam had cost Russia about $200 million.

But Magnitsky himself was arrested on charges of organizing tax evasion for Hermitage Capital executives. He was allegedly tortured and denied proper medical treatment, and died in a Moscow prison on Nov. 16, 2009.

The circumstances of his death as well as the purported multimillion-dollar fraud have never been properly investigated, human rights activists say.

If the legislation passed by the House on Friday, the third anniversary of Magnitsky's death, also passes the Senate and is signed by President Obama, U.S. officials will be obligated within 120 days to compile and publish a list of Russian officials involved in Magnitsky's persecution and death, and other violations of human rights in Russia.

The officials on the so-called Magnitsky list will be denied U.S. visas and current visas will be revoked. Their financial assets in the United States will be frozen.

The Russian Foreign Ministry said the legislation could damage relations with the United States.

"The passage of the Magnitsky Act is another attempt of flagrant politicizing the issue of human rights," the ministry's envoy on human rights, Konstantin Dolgov, said Saturday in an interview with Voice of Russia radio station. "The American side over and over again attempts to accuse Russia of violating human rights in [Sergei] Magnitsky's case, ignoring the exhaustive explanations about the course of the case's investigation."

Dmitry Peskov, President Vladimir Putin's spokesman, said late Friday that the legislation would elicit an "equally tough response."

Lilia Shevtsova, a senior researcher with the Moscow Carnegie Center, said there was little left of the U.S.-Russia relationship to be damaged by the latest dispute.

"Moscow however may take advantage of it to more actively play the role of the spoiler in respect to America in global politics," Shevtsova said. "The Kremlin will try to use the situation to intensify its ongoing crackdown on the opposition inside the country."

Pavel Palazhchenko, senior advisor to former Soviet President Mikhail Gorbachev, said he was puzzled by Russia's tough reaction.

"My guess is that the authorities, including the Foreign Ministry, misjudged the internal dynamics in the U.S., betting that the administration, which never likes Congress micromanaging foreign policy, would object to the Magnitsky Act," he said.

Palazhchenko said Russia was rapidly using up any goodwill left in the West, but he predicted that Obama would do some damage control before his planned visit to Moscow next year.

sergei.loiko@latimes.com

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Lady Gaga tweets some racy images before concert

BUENOS AIRES, Argentina (AP) — Lady Gaga's tweets were getting a lot of attention ahead of her Buenos Aires concert Friday night.

The Grammy-winning entertainer has more than 30 million followers on Twitter and that's where she shared a link this week to a short video showing her doing a striptease and fooling around in a bathtub with two other women.

She told her followers that it's a "surprise for you, almost ready for you to TASTE."

Then, in between concerts in Brazil and Argentina, she posted a picture Thursday on her Twitter page showing her wallowing in her underwear and impossibly high heels on top of the remains of what appears to be a strawberry shortcake.

"The real CAKE isn't HAVING what you want, it's DOING what you want," she tweeted.

Lady Gaga wore decidedly unglamorous baggy jeans and a blouse outside her Buenos Aires hotel Thursday as three burly bodyguards kept her fans at bay. Another pre-concert media event where she was supposed to be given "guest of honor" status by the city government Friday afternoon was cancelled.

After Argentina, she is scheduled to perform in Santiago, Chile; Lima, Peru; and Asuncion, Paraguay, before taking her "Born This Way Ball" tour to Africa, Europe and North America.

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News Analysis: Steroids and Back Pain: An Uneasy Match

RANDALL KINNAIRD’S legal clients had steroids injected into their backs last summer for a wide range of reasons. Of the 25, one got three shots in a two-month period when pain never totally disappeared. Another got one as a preventive measure because she was going on a trip to Europe and was worried that cobblestones would aggravate an old injury.

Now the 25 — or their survivors — have engaged Mr. Kinnaird, one of Nashville’s leading lawyers, to sue the New England Compounding Center. Three have died, one is paralyzed, several more are still hospitalized and all suffer blinding headaches — victims of the meningitis that resulted from vials of steroid medicine contaminated by fungus.

The New England Compounding Center certainly seems deserving of its current status as the prime culprit in a tragic outbreak that has killed 32 and sickened 438. The bottles of supposedly sterile steroid medication it shipped were reportedly so tainted that white fuzz could be seen floating in some vials.

But, experts say, the now notorious Compounding Center has a nationwide network of unwitting enablers and accomplices: There are the doctors who overprescribe an invasive back-pain therapy that, in studies, has not proved useful for many of the patients who get it. And there are the patients, living in an increasingly medicalized society, who want a quick fix for life’s aches and pains.

The use of steroid injections to treat back pain has skyrocketed in the past 15 years — out of proportion to growth in the number of patients with back pain, or the aging of the population. The frequency of steroid injections dispensed to Medicare patients rose 121 percent from 1997 to 2006. Washington State found that the use of back injections grew 12.6 percent between 2006 and 2009, at a cost to the state of $56 million. Some people received more than 10 shots a year.

The increase in treatment has not led to less pain over all, researchers say, and is a huge expense at a time of runaway health costs. “There are lots of places doing lots of injections for conditions that haven’t been shown to benefit,” says Dr. Janna Friedly, a researcher at the University of Washington, who added, “Sadly, some of the patients who got meningitis were probably in that category — they did not have conditions where steroid injections were indicated.”

Studies are at best inconclusive about exactly which groups of back-pain patients are likely to benefit from steroid shots. Though some patients clearly get much-needed relief, health researchers are nearly unanimous that the treatment is vastly overused in the United States.

But Dr. Laxmaiah Manchikanti, head of the American Society of Interventional Pain Physicians, said the increasing number of spine injections was just part of “an exponential increase in all interventional techniques” and is a good thing, reflecting a better understanding of chronic pain and patients’ demands for improved pain relief.

Though doctors are still arguing, most academic researchers say there is no evidence that steroid injections are useful in easing straightforward chronic low back pain. Professional guidelines say such shots should generally not be used for back pain that is less than four to six weeks old, which studies show almost always gets better with noninvasive treatments. Although many Medicare patients get spinal injections to treat a condition called spinal stenosis, a narrowing of spaces between bones of the spine, Dr. Friedly said, shots are not used for that condition in many European countries.

Spinal injections, which can cost between $600 and $2,500, including the fees for treatment rooms, have been fostered and promoted by the rising number of pain clinics and pain specialists — mostly anesthesiologists and rehab doctors — who invest in extra training to learn procedures like spinal injections.

“There used to be only a small number of people who did this, but that’s gone way up, and reimbursement has gone up, too,” says Scott Forseen, a doctor who studies the treatment of back pain at the Georgia Health Sciences University. The number of spinal injections given in any geographical area correlates better with the number of local specialists trained in the procedure rather than the amount of back pain, Dr. Friedly says. There is an old saying in medicine: “When you go to Midas, you get a muffler.”

The shots — which may include a steroid and an anesthetic — are often dispensed at for-profit pain clinics owned by the physicians holding the needle. “There’s a lot of concern about perverse financial incentive,” Dr. Friedly added.

Mr. Kinnaird’s clients got their injections at the St. Thomas Outpatient Neurosurgery Clinic, a limited-liability corporation half owned by doctors, which occupied a floor of one of Nashville’s major hospitals. It gave 5,000 injections a year, or about 20 each business day, and epidural steroid injections are listed on its Web site as its “top procedure.”

Since guidelines for injections are being disputed among doctors’ groups, it is hard in most cases to say if a particular patient should or should not have been offered an injection, says Marc Lipton, a Michigan attorney who is representing more that 20 patients with fungal meningitis. Though he believes that steroid shots are overused, he says many of the patients he represents were treated appropriately, for example, receiving an injection for pain from a herniated disc in an attempt to stave off back surgery. He and other lawyers are, for now, targeting the Compounding Center in product liability lawsuits.

But, says Dr. Forseen: “You have to use injections selectively, and selectivity has gone way down. In some places, people get injections because they’ve walked in the door.”

Patients have proved eager consumers of the new medical offering, desirous of a quick cure rather than waiting the weeks or months for the normal healing process to occur.

Mr. Kinnaird, the lawyer, says: “If I hurt my back in the ’70s, my doctor would say, go to the beach, get a few beers, relax, you’ll be fine. Now if you hurt your back, you go to the doctor and right away there’s an M.R.I., and they need to fix something. Maybe you should take an injection.”

And steroid shots are not a cure-all, even for the conditions for which doctors agree an attempt is worthwhile: low back pain accompanied by signs of nerve injury like tingling or weakness in a leg. One-third of such patients will get better, one-third will show some improvement and some will show no improvement at all, Dr. Forseen said.

When Oregon’s Health Evidence Review Commission earlier this year explored narrowing reimbursement for injections to certain conditions, it got an earful of public comment from groups like the International Spine Intervention Society.

“Obviously they are not utilizing the literature correctly,” said Dr. Manchikanti, adding that attempts to limit the shots were motivated in part by an effort to control costs and by competition from other medical specialties.

Private insurers vary considerably in coverage for the procedure, though some will pay after two weeks of back pain.

Back pain is, of course, a debilitating condition. And modern medicine has produced some miraculous cures. But from now on when doctors and patients are tempted to say “what’s the harm in trying an injection” to dispense with a nagging back — they will be more aware of just how big the risk can be.

A physician and a reporter for The New York Times.

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Black Friday: A survival guide

Shopping

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Black Friday, the most buzzed-about shopping day of the year, is starting even earlier this holiday season as retailers try to get a jump on the competition.

The official kickoff to the Christmas shopping rush, the day after Thanksgiving brings out millions of bargain hunters looking to score new tablets, flat-panel TVs, clothes and toys. Last year retailers raked in an estimated $11.4 billion on Black Friday, up 6.6% from 2010.

This year, major retailers including Wal-Mart and Toys R Us are opening their doors as early as 8 p.m. on Thanksgiving Day. That’s too bad for store employees, but good news if you’re a shopaholic who doesn’t mind hitting the shops before the turkey has cooled.

For those of you who are planning to brave the crowds, whether you’re a first-timer or a seasoned veteran, here’s a guide to surviving the Black Friday rush.


-- Andrea Chang

Photo credit: Francine Orr / Los Angeles Times

Photo credit: Mark Boster / Los Angeles Times

Photo credit: Mark Boster / Los Angeles Times

Photo credit: Brian van der Brug / Los Angeles Times

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Veteran L.A. County sheriff's deputy charged with murder

After spending much of his life putting people behind bars, a veteran L.A. County sheriff's deputy stood in handcuffs Thursday, charged with gunning down a former neighbor who apparently got into a fight with his son.

Francisco Gamez, 41, is accused of shooting Armando "Cookie" Casillas, a well-known figure in his blue-collar neighborhood in Sylmar.

Gamez was off duty, sitting in his car, when he allegedly fired two shots on the night of June 17, killing Casillas and narrowly missing a second man, prosecutors said.

Gamez, a 17-year veteran who worked as a detective in West Hollywood, was allegedly furious over a fight between his 20-year-old son and Casillas, 38, prosecutors said. The younger Gamez had called his father to the scene, authorities said.

Casillas was later found by relatives lying near his home, and died later at Providence Holy Cross Medical Center.

Gamez was removed from duty in July after witnesses and evidence tied the detective to the slaying, authorities said. He was arrested Wednesday and led handcuffed from his San Fernando home by his former co-workers.

On Thursday he was formally charged with murder, attempted murder and discharging a firearm from an occupied vehicle. Gamez could face 75 years to life in prison if convicted of all charges.

In court, where he stood handcuffed in a plexiglass cage, sheriff's deputies peeked into the room to gawk at their former colleague. Sheriff Lee Baca described the whole thing as "deeply disturbing."

Gamez is being held on $4-million bail.

On Beaver Street in Sylmar, where the shooting occurred, Casillas' photo sat in a frame in the midst of a makeshift memorial, along with a cross and a potted plant with U.S. and Mexican flags and candles.

"He was a sweetheart, and very generous," said Patsy Telles-Cabrera, who lived across the street from Casillas for years. "He would check in on my parents." She left a box of chocolates at the growing shrine.

"It never should have happened," said one neighbor. "This is a family neighborhood."

sam.quinones@latimes.com

richard.winton@latimes.com

Times staff writer Wesley Lowery contributed to this report.

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Ruckus Wireless prices IPO at high end of range: market source

(Reuters) – WiFi products maker Ruckus Wireless Inc priced its initial public offering at $ 15 per share, the high end of its expected price range, a market source told Reuters.

The company, which is backed by Google Inc‘s Motorola Mobility LLC and venture capital firm Sequoia Capital, raised $ 126 million by selling 8.4 million shares.

Ruckus offered 7 million shares while selling shareholders, including Telus Corp, offered 1.4 million shares.

The Sunnyvale, California-based company, which makes wireless LAN products for both indoor and outdoor use, competes with Meru Networks Inc and Aruba Networks Inc.

The company’s customers include Time Warner Cable Inc, Towerstream Corp, Tikona Digital Networks and Bright House Networks.

Goldman Sachs & Co and Morgan Stanley are the lead underwriters to the offering.

The company’s shares are expected to begin trading on the New York Stock Exchange on Friday under the ticker symbol “RKUS”.

(This story was fixed to correct description of Sequoia Capital to venture capital firm in paragraph 2)

(Reporting by Sharanya Hrishikesh and Ashutosh Pandey in Bangalore; Editing by Sriraj Kalluvila)

Wireless News Headlines – Yahoo! News

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