A delicate new balancing act in senior healthcare

When Claire Gordon arrived at Cedars-Sinai Medical Center, nurses knew she needed extra attention.

She was 96, had heart disease and a history of falls. Now she had pneumonia and the flu. A team of Cedars specialists converged on her case to ensure that a bad situation did not turn worse and that she didn't end up with a lengthy, costly hospital stay.

Frail seniors like Gordon account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.

The U.S. population is aging quickly: People older than 65 are expected to make up nearly 20% of it by 2030. Linda P. Fried, dean of the Columbia University Mailman School of Public Health, said now is the time to train professionals and test efforts to improve care and lower healthcare costs for elderly patients.

"It's incredibly important that we prepare for being in a society where there are a lot of older people," she said. "We have to do this type of experiment right now."

At Cedars-Sinai, where more than half the patients in the medical and surgical wards are 65 or older, one such effort is dubbed the "frailty project." Within 24 hours, nurses assess elderly patients for their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.

The Cedars project stands out nationally because medical professionals are working together to identify high-risk patients at the front end of their hospitalizations to prevent problems at the back end, said Herb Schultz, regional director of the U.S. Department of Health and Human Services.

"For seniors, it is better care, it is high-quality care and it is peace of mind," he said.

The effort and others like it also have the potential to reduce healthcare costs by cutting preventable medical errors and readmissions, Schultz said. The federal law penalizes hospitals for both.

Gordon, an articulate woman with brightly painted fingernails and a sense of humor, arrived at Cedars-Sinai by ambulance on a Monday.

Soon, nurse Jacquelyn Maxton was at her bedside asking a series of questions to check for problems with sleep, diet and confusion. The answers led to Gordon's designation as a frail patient. The next day, the project team huddled down the hall and addressed her risks one by one. Medical staff would treat the flu and pneumonia while at the same time addressing underlying health issues that could extend Gordon's stay and slow her recovery, both in the hospital and after going home.

To reduce the chance of falls, nurses placed a yellow band on her wrist that read "fall risk" and ensured that she didn't get up on her own. To prevent bed sores, they got her up and moving as often as possible. To cut down on confusion, they reminded Gordon frequently where she was and made sure she got uninterrupted sleep. Medical staff also stopped a few unnecessary medications that Gordon had been prescribed before her admission, including a heavy narcotic and a sleeping pill.

"It is really a holistic approach to the patient, not just to the disease that they are in here for," said Glenn D. Braunstein, the hospital's vice president for clinical innovation.

Previously, nurse Ivy Dimalanta said, she and her colleagues provided similar care but on a much more random basis. Under the project, the care has become standardized.

The healthcare system has not been well designed to address the needs of seniors who may have had a lifetime of health problems, said Mary Naylor, gerontology professor at the University of Pennsylvania School of Nursing. As a result, patients sometimes fall through the cracks and return to hospitals again and again.

"That is not good for them and that is not good for society to be using resources in that way," Naylor said.

Using data from related projects, Cedars began a pilot program in 2011 and expanded it last summer. The research is continuing but early results suggest that the interventions are leading to fewer seniors being admitted to the intensive care unit and to shorter hospital stays, said Jeff Borenstein, researcher and lead clinician on the frailty project. "It definitely seems to be going in the right direction," he said.

The hospital is now working with Naylor and the University of Pennsylvania to design a program to help the patients once they go home.

"People who are frail are very vulnerable when they leave the hospital," said Harriet Udin Aronow, a researcher at Cedars. "We want to promote them being safe at home and continuing to recover."

In Gordon's case, she lives alone with the help of her children and a caregiver. The hospital didn't want her experiencing complications that would lengthen the stay, but they also didn't want to discharge her before she was ready. Under the health reform law, hospitals face penalties if patients come back too soon after being released.

Patients and their families often are unaware of the additional attention. Sitting in a chair in front of a vase of pink flowers, Gordon said she knew she would have to do her part to get out of the hospital quickly. "You have to move," she said. "I know you get bed sores if you stay in bed."

Gordon said she was comfortable at the hospital but she wanted to go back to her house as quickly as she could. "There's no place like home," she said.

Two days later, that's where she was.

anna.gorman@latimes.com

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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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Business Week in Pictures

Phil Libin, the chief executive of Evernote, during a staff meeting at Evernote’s headquarters in Redwood City, Calif. Evernote is among the privately held Silicon Valley start-ups that are worth more than $1 billion. An unprecedented number of high technology start-ups, easily 25 and possibly exceeding 40, have crossed that threshold. Many employees are quietly growing rich, or at least building a big cushion against a crash, as they sell shares to outside investors. Airbnb, Pinterest, SurveyMonkey and Spotify are among the better-known privately held companies that have reached $1 billion.

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Big Bear locked down amid manhunt

The bustling winter resort of Big Bear took on the appearance of a ghost town Thursday as surveillance aircraft buzzed overhead and police in tactical gear and carrying rifles patrolled mountain roads in convoys of SUVs, while others stood guard along major intersections.

Even before authorities had confirmed that the torched pickup truck discovered on a quiet forest road belonged to suspected gunman Christopher Dorner, 33, officials had ordered an emergency lockdown of local businesses, homes and the town's popular ski resorts. Parents were told to pick up their children from school, as rolling yellow buses might pose a target to an unpredictable fugitive on the run.

By nightfall, many residents had barricaded their doors as they prepared for a long, anxious evening.

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"We're all just stressed," said Andrea Burtons as she stocked up on provisions at a convenience store. "I have to go pick up my brother and get him home where we're safe."

Police ordered the lockdown about 9:30 a.m. as authorities throughout Southern California launched an immense manhunt for the former lawman, who is accused of killing three people as part of a long-standing grudge against the LAPD. Dorner is believed to have penned a long, angry manifesto on Facebook saying that he was unfairly fired from the force and was now seeking vengeance.

Forest lands surrounding Big Bear Lake are cross-hatched with fire roads and trails leading in all directions, and the snow-capped mountains can provide both cover and extreme challenges to a fugitive on foot. It was unclear whether Dorner was prepared for such rugged terrain.

Footprints were found leading from Dorner's burned pickup truck into the snow off Forest Road 2N10 and Club View Drive in Big Bear Lake.

San Bernardino County Sheriff John McMahon said that although authorities had deployed 125 officers for tracking and door-to-door searches, officers had to be mindful that the suspect may have set a trap.

"Certainly. There's always that concern and we're extremely careful and we're worried about this individual," McMahon said. "We're taking every precaution we can."

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Big Bear has roughly 400 homes, but authorities guessed that only 40% are occupied year-round.

The search will probably play out with the backdrop of a winter storm that is expected to hit the area after midnight.

Up to 6 inches of snow could blanket local mountains, the National Weather Service said.

FULL COVERAGE: Sweeping manhunt for rampaging ex-cop

Gusts up to 50 mph could hit the region, said National Weather Service meteorologist Mark Moede, creating a wind-chill factor of 15 to 20 degrees.

Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.

"He could be anywhere at this point," McMahon said. When asked if the burned truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Craig and Christine Winnegar, of Murrieta, found themselves caught up in the lockdown by accident. Craig brought his wife to Big Bear as a surprise to celebrate their 28th wedding anniversary. Their prearranged dinner was canceled when restaurant owners closed their doors out of fear.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”

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Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Correction: The patient’s eyes were brown, not blue.

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DealBook: Southeastern Asset Management to Fight Dell's Takeover

7:44 p.m. | Updated One of the biggest investors in Dell said on Friday that it would oppose the company’s plans to go private, setting up a major potential roadblock for the biggest buyout since the financial crisis.

Southeastern Asset Management, Dell’s largest outside shareholder, argued in a letter to the board that the $24.4 billion takeover bid was too low.

The company’s founder, Michael S. Dell, and the investment firm Silver Lake, are offering $13.65 a share. Southeastern, which has an 8.5 percent stake in Dell, contends that the company is worth closer to $24 a share.

To block the “ill-advised transaction,” Southeastern laid out a range of possible tactics, including a proxy fight and lawsuits. The firm also pushed the board to “aggressively” look for alternative proposals. Dell has 45 days to solicit other bids as part of the so-called go-shop process.

A Dell spokesman said in a statement on Friday that a special committee of the company’s board had considered various options with the help of advisers before accepting the management buyout.

“Based on that work, the board concluded that the proposed all-cash transaction is in the best interests of stockholders,” said the spokesman, David Frink. “The transaction offers an attractive and immediate premium for stockholders and shifts the risks facing the business to the buyer group.”

The opposition highlights the conflict facing Dell and its investors.

Many shareholders bought the company at lofty prices, watching the value of their shares erode. Analysts estimated that Southeastern paid more than $20 a share on average, meaning that the asset management firm would lose over $800 million if the current deal was completed.

Still, the takeover values Dell at price that the company has not touched for months. Its stock has not reached $14 since late May, and it lingered below $10 for two months late last year.

The company also faces continued pressure in its operations. Its core PC business is ceding ground to lower-cost rivals, as well as new entrants like tablets and smartphones.

Additionally, its effort to sell servers to big companies has been hurt by the changing industry dynamics, including the move to cloud computing.

Management buyouts have long been regarded skeptically by investors. The concern is that they enrich executives at the expense of other shareholders. The takeovers of companies like J. Crew and Affiliated Computer Services spurred a number of lawsuits by irate investors.

Southeastern and its founder, O. Mason Hawkins, generally keep a low profile and shun the press. But the money manager, based in Memphis, has been more outspoken of late.

The firm stepped into the spotlight last year when it called on Chesapeake Energy to entertain takeover offers, after the company ran into financial difficulties and faced criticism for the compensation plan of its co-founder, Aubrey McClendon. Southeastern and another activist investor, Carl C. Icahn, eventually won seats on Chesapeake’s board. Last month, Mr. McClendon was forced to retire under pressure from the board.

In its letter to Dell’s board, Southeastern said that it would support a number of alternatives. The investor, for example, outlined a plan to pay out a special dividend to shareholders or a buyout that would allow existing investors to keep a piece of the company.

But Southeastern said the current deal, hashed out over six months, “falls significantly short,” adding that it “appears to be an effort to acquire Dell at a substantial discount to intrinsic value at the expense of public shareholders.”

Dell’s board was mindful of potential conflicts — legal and otherwise — that its founder faced in trying to buy back the company he founded nearly three decades ago. To assess the deal, it formed a special committee of its board, led by Alex J. Mandl, which was advised by two sets of financial advisers.

JPMorgan Chase served as the principal investment bank for the committee, negotiating with Silver Lake.

Evercore Partners is overseeing a 45-day go-shop period intended to flush out rival suitors for the company. The company itself was advised by Goldman Sachs.

To help further minimize conflicts, JPMorgan refrained from providing financing for the deal. And Evercore’s advisory fee is set up in a way that encourages the bank to find a higher bid.

“The go-shop process provides stockholders an opportunity to determine if there are alternatives that are superior to the present offer,” the Dell spokesman said in a statement.

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Friend: Ex-cop 'last guy' expected to be murder suspect

Those who knew Christopher Jordan Dorner during college expressed shock at the news that the former college football player is allegedly responsible for shootings that have left three people dead and two wounded.

Dorner attended Southern Utah University from 1997 to 2001 and graduated with a bachelor of science with a major in political science and a minor in psychology, a university spokesman said.

Neil Gardner, an assistant athletic director who works with the student athletes in media relations, interacted with Dorner when he was on the school’s football team during the 1999 and 2000 seasons. Gardner said Dorner was a backup running back who didn’t play a lot, but was “never a disgruntled guy.”

PHOTOS: Manhunt for ex-LAPD officer

“When he was in college he was a great kid,” Gardner said. “He was a kid you hoped would do well. He was polite. I liked him.” 

Jamie Usera, an attorney in Salem, Ore., said he met Dorner in the spring of 1998 at Southern Utah. Usera, who grew up in Alaska, said he and Dorner, an African American from Southern California, bonded over their shared feelings of culture shock that came with being outsiders on the predominantly white, Mormon campus.

Usera and Dorner eventually joined the football team as running backs and became good friends, Usera said. They shared long hours on the practice field, but neither saw much playing time and both decided to quit the team after two years.

PHOTOS: Manhunt for ex-LAPD officer

The friendship endured throughout their remaining years at the school. Usera said he introduced Dorner to the world of hunting and other outdoor sporting. Usera recalled frequent trips into the Utah desert to hunt rabbits with Dorner.

Nothing about Dorner in college raised any red flags that he was mentally unstable or capable of such violence, Usera said.

“He was a typical guy. I liked him an awful lot,” Usera said. “Nothing about him struck me as violent or irrational in any way.  He was opinionated, but always seemed level-headed.”

Usera said he and Dorner frequently had lively discussions. A recurring theme was race relations in the U.S., and the two often had heated but respectful arguments about the extent of racism in the county, Usera said.

A manifesto that police say was published on what they believe was Dorner’s Facebook page  made reference to Usera. A section read:

“James Usera, great friend, attorney, father, husband, and the most cynical/blatant/politically incorrect friend a man can have. Best quality about you in college and now is that you never sugar coated the truth. I will miss our political discussions that always turned argumentative. Thanks for introducing me to outdoor sports like fishing, hunting, mudding, and also respect for the land and resources. Us city boys don’t get out much like you Alaskans. You even introduced me to PBR. A beer, that when you’re a poor college student is completely acceptable to get buzzed off of. I’m sorry I’ll never get to go on that moose and bear hunt with you. I love you bro.”

Usera could not recall Dorner ever discussing a dream or plan to become a police officer. He remembered his friend talking excitedly with a Marine or Navy recruiter on campus when he was either considering enlisting or after he had already made the decision to do so.

The two lost touch quickly after graduating, Dorner said, but later reconnected out of the blue about four years ago with a phone call. Dorner made passing reference to his discipline problems with the LAPD but did not go into detail. Usera said Dorner did not seem troubled during the 10- to 15-minute conversation. A few text messages followed in the days after the call, but Usera said he had not heard from Dorner since.

“Of all the people I hung out with in college, he is the last guy I would have expected to be in this kind of situation.”

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Keep breasts, buttocks under wraps, CBS tells Grammy performers

LOS ANGELES (Reuters) – Grammy performers have been told to cover up at Sunday’s big music awards show, and keep their buttocks, nipples and genitals under wraps. Their politics can’t show either.

In a “wardrobe advisory,” broadcaster CBS also asked musicians and audience members likely to appear on camera at the February 10 Grammy Awards ceremony to avoid wearing brand names on T-shirts as well as clothing with political or activist slogans.

“Please be sure that buttocks and female breasts are adequately covered. Thong type costumes are problematic. Please avoid exposing bare flesh under curves of the buttocks and buttock crack,” said the memo issued by CBS standards and practices department and obtained by entertainment industry website Deadline.com on Wednesday.

“Obscenity or partially seen obscenity on wardrobe is unacceptable for broadcast,” the note added.

The warning follows a lengthy court battle over indecency and obscenity standards on U.S. network television.

CBS, a unit of CBS Corp, was fined $ 550,000 by the Federal Communications Commission for airing a glimpse of Janet Jackson‘s breast when her costume slipped while singing at the Super Bowl half-time show in 2004.

The fine was later thrown out and that decision was upheld by the U.S. Supreme Court in June 2012. CBS has expressed “deep regret” for the incident.

The annual Grammy Awards ceremony honors the best musicians of the year, but is also a major promotional showcase for rising stars and upcoming albums.

In 2010, singer Pink performed upside down in a flesh-colored bodysuit, while Rihanna last year wore a plunging black dress on the red carpet.

Performers at Sunday’s three-hour show in Los Angeles include Rihanna, Justin Timberlake, Maroon 5, Frank Ocean, Alicia Keys and Elton John.

(Reporting By Jill Serjeant; Editing by Doina Chiacu)

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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

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Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

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DealBook: Helping Start-Ups With Local Support and National Networks

When Will Fuentes planned an extended business trip to Seattle last year, he tapped into the local chapter of a national networking group there. Within hours, Mr. Fuentes, who founded the Arlington, Va., software company Lemur Retail, had secured a work space, introductions and even restaurant recommendations via the group, the Startup America Partnership.“Before I flew out there, I already had five or six meetings set up with potential clients and other key contacts, as well as one potential acquirer,” Mr. Fuentes said.

A couple of years ago, entrepreneurs would have needed several trips to make similar connections outside their own cities. Even in this era of social networks and venture conferences, start-ups are still surprisingly disconnected on a national level.

“Each region has its ties, but in many cases, entrepreneurs are operating in silos,” said Carolynn Duncan, the chief executive of Portland Ten, a mentoring program for early-stage companies, mainly in Oregon. “An entrepreneur in Oregon doesn’t have an easy way to network with entrepreneurs in Washington D.C.”

Startup America, a nonprofit organization with an all-star cast of deep-pocketed backers, is trying to bridge the gap. The organization, which was started in January 2011 as the brainchild of AOL’s co-founder, Steve Case, and the Ewing Marion Kauffman Foundation, wanted to bring a private-sector support to start-ups — without financial strings attached.

“Supporting start-ups throughout the country is the only way to make sure the American economy is firing on all cylinders,” said Mr. Case, who is the chairman of the partnership.

Start-ups are a crucial driver for job creation in the United States. From March 1994 to March 2010, businesses less than one year old created 3.9 million jobs a year on average, according to the Bureau of Labor Statistics, though that number has declined during the recent economic weakness.

The Small Business Administration and United States Chamber of Commerce have long been a resource for start-ups, but these government agencies have a broad mandate. There is a “growing recognition,” said Mr. Case, that high-growth start-ups — those with the potential to be national or international companies — have different needs and requirements than traditional small businesses.

Startup America’s initial focus was to provide support to start-ups through deals on goods and services, like 40 percent off FedEx shipping and free flights on American Airlines. But the group quickly realized that start-ups needed more practical help, like sharing best practices and networking.

Soon after the partnership’s start, entrepreneurs around the country starting contacting Startup America, asking how they could create their own networks and reach out to counterparts in other states. “Most of these regions were already coming up with their own initiatives or thinking about them,” said the organization’s chief executive, Scott Case, a founder and former chief technology officer of Priceline.com (and no relation to Steve Case). “We’re helping to stitch together all these parts.”

Taking cues from the entrepreneurs, Startup America has turned its attention to building such a network. Nearly 12,000 members are now affiliated with local Startup America initiatives in 30 states. The partnership expects to add another 10 states this year.

Each Startup America region is spearheaded by local “champions” who come together several times a year at national conferences, communicate via Google groups and have access to an online “idea center” where they can brainstorm about, say, bringing in outside capital or hosting a start-up conference. These envoys are all “founder types” at different stages of their careers, Scott Case said. “Some have exited companies and are looking to continue to feed that creative drive. Others understand that if they can strengthen their community, they can strengthen their own company.”

Brooks Bell, founder of an eponymous 22-employee digital consulting business based in Raleigh, N.C., became involved with the partnership in 2011 after realizing that many potential clients considered her area a backwater. “I realized that was impacting my company’s brand, too,” she said.

Mrs. Bell pointed out that other national groups, like Entrepreneurs’ Organizations, offer resources for high-growth companies. Yet, their emphasis is typically on supporting individuals rather than elevating the region and networking nationally. “They also tend to focus on early-stage companies,” she said. Until Startup America, she added, “there weren’t a lot of opportunities for early-stage companies to interact with funded companies.”

Though Startup America regions work off the same blueprint, each takes a slightly different approach. In Maryland, the staff and champions volunteer virtually. Startup Tennessee partnered with the Entrepreneur Center in Nashville, which runs a nonprofit incubator program. Startup Colorado works out of Silicon Flatirons, a center for law, technology and entrepreneurship at the University of Colorado Law School, and finds partners to finance specific projects.

Although the regional chapters operate independently, they benefit from the credibility of a national organization. “It’s helping elevate our start-ups nationally and get them in front of audiences we never would have,” said Andy Stoll, an entrepreneur in the Iowa City, Iowa, area, where rebuilding from the floods in 2008 has helped generate a boom in start-up activity.

“To have the opportunity to sit in a room with their board and have Steve Case ask me, ‘What are the three things that those of us at this table can do to really help support the Indiana community?’ is amazing and a humbling experience,” said Michael Coffey, a partner at DeveloperTown, an Indianapolis design and development firm that works with companies of all sizes.

In the end, it’s all about business.

Aaron Schwartz, a co-founder of the San Francisco-based Modify Watches, initially joined Startup America for the discounts. Now, he’s also tapping into the partnership to network, including finding corporate clients who order custom watches and vendors. “I now have a contact in Tennessee who has offered to look into manufacturing our watches there,” he said

Mr. Fuentes of Lemur Retail found two potential clients, both national chains, through his connections in Seattle last year; he’s currently in talks with those companies. He’s also helping his Northwest counterparts make inroads in the Washington area. He likens the experience to a fraternity or alumni organization of entrepreneurs.

“When people contact me from my high school or college, I pick up the phone,” he said. “This is no different.”

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