‘Bloodless’ Lung Transplants for Jehovah’s Witnesses

Eric Kayne for The New York Times

SHARING HOME AND FAITH A Houston couple hosted Gene and Rebecca Tomczak, center, in October so she could get care nearby.

HOUSTON — Last April, after being told that only a transplant could save her from a fatal lung condition, Rebecca S. Tomczak began calling some of the top-ranked hospitals in the country.

She started with Emory University Hospital in Atlanta, just hours from her home near Augusta, Ga. Then she tried Duke and the University of Arkansas and Johns Hopkins. Each advised Ms. Tomczak, then 69, to look somewhere else.

The reason: Ms. Tomczak, who was baptized at age 12 as a Jehovah’s Witness, insisted for religious reasons that her transplant be performed without a blood transfusion. The Witnesses believe that Scripture prohibits the transfusion of blood, even one’s own, at the risk of forfeiting eternal life.

Given the complexities of lung transplantation, in which transfusions are routine, some doctors felt the procedure posed unacceptable dangers. Others could not get past the ethics of it all. With more than 1,600 desperately ill people waiting for a donated lung, was it appropriate to give one to a woman who might needlessly sacrifice her life and the organ along with it?

By the time Ms. Tomczak found Dr. Scott A. Scheinin at The Methodist Hospital in Houston last spring, he had long since made peace with such quandaries. Like a number of physicians, he had become persuaded by a growing body of research that transfusions often pose unnecessary risks and should be avoided when possible, even in complicated cases.

By cherry-picking patients with low odds of complications, Dr. Scheinin felt he could operate almost as safely without blood as with it. The way he saw it, patients declined lifesaving therapies all the time, for all manner of reasons, and it was not his place to deny care just because those reasons were sometimes religious or unconventional.

“At the end of the day,” he had resolved, “if you agree to take care of these patients, you agree to do it on their terms.”

Ms. Tomczak’s case — the 11th so-called bloodless lung transplant attempted at Methodist over three years — would become the latest test of an innovative approach that was developed to accommodate the unique beliefs of the world’s eight million Jehovah’s Witnesses but may soon become standard practice for all surgical patients.

Unlike other patients, Ms. Tomczak would have no backstop. Explicit in her understanding with Dr. Scheinin was that if something went terribly wrong, he would allow her to bleed to death. He had watched Witness patients die before, with a lifesaving elixir at hand.

Ms. Tomczak had dismissed the prospect of a transplant for most of the two years she had struggled with sarcoidosis, a progressive condition of unknown cause that leads to scarring in the lungs. The illness forced her to quit a part-time job with Nielsen, the market research firm.

Then in April, on a trip to the South Carolina coast, she found that she was too breathless to join her frolicking grandchildren on the beach. Tethered to an oxygen tank, she watched from the boardwalk, growing sad and angry and then determined to reclaim her health.

“I wanted to be around and be a part of their lives,” Ms. Tomczak recalled, dabbing at tears.

She knew there was danger in refusing to take blood. But she thought the greater peril would come from offending God.

“I know,” she said, “that if I did anything that violates Jehovah’s law, I would not make it into the new system, where he’s going to make earth into a paradise. I know there are risks. But I think I am covered.”

Cutting Risks, and Costs

The approach Dr. Scheinin would use — originally called “bloodless medicine” but later re-branded as “patient blood management” — has been around for decades. His mentor at Methodist, Dr. Denton A. Cooley, the renowned cardiac pioneer, performed heart surgery on hundreds of Witnesses starting in the late 1950s. The first bloodless lung transplant, at Johns Hopkins, was in 1996.

But nearly 17 years later, the degree of difficulty for such procedures remains so high that Dr. Scheinin and his team are among the very few willing to attempt them.

In 2009, after analyzing Methodist’s own data, Dr. Scheinin became convinced that if he selected patients carefully, he could perform lung transplants without transfusions. Hospital administrators resisted at first, knowing that even small numbers of deaths could bring scrutiny from federal regulators.

“My job is to push risk away,” said Dr. A. Osama Gaber, the hospital’s director of transplantation, “so I wasn’t really excited about it. But the numbers were very convincing.”

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Nokia Unveils Low-Priced Phones

BARCELONA — Nokia on Monday introduced two new low-priced basic cellphones, plus two lower-priced versions of its flagship Lumia Windows smartphone — part of an effort by the former market leader to compete amid an intensifying price war in handsets.

The four new phones — the Lumia 720, Lumia 520, Nokia 301 and Nokia 105 — will help Nokia maintain and perhaps build on its position as the No. 2 maker of cellphones worldwide behind Samsung and fend off challenges by two Chinese manufacturers, Huawei and ZTE, analysts said.

The Lumia 520, selling for €139, or about $183, in Europe and $179 in the United States, is priced 25 percent less lower Nokia’s least-expensive smartphone, the Lumia 620.

“I think that with the Lumia 520, Nokia is really going to take the Windows 8 operating system to a much bigger, mass market,” said Pete Cunningham, an analyst at Canalys, a research firm in Reading, England. “I would expect their volumes of Lumia shipments to now start increasing slowly, but they still have a way to go.”

Samsung overtook Nokia last year as the leading global maker of cellphones, amassing a 23 percent market share. Nokia’s market share slipped to 17.9 percent from 24 percent during 2012, according to the market research firm IDC. Apple ended the year in third place at 9.9 percent, followed by ZTE, with 3.6 percent, and Huawei, with 3.3 percent.

The new handsets, which the company unveiled at the Mobile World Congress industry convention in Barcelona, reinforced Nokia’s strategy of targeting the least-expensive but fastest-growing parts of the market. The Nokia 105, the company’s new basic, entry-level phone, will sell for €15 — less than the price of a pizza in some countries.

T-Mobile U.S.A. has agreed to sell the Lumia 520, a 3G phone with a 4-inch touchscreen, in the United States starting in the second quarter, Nokia said.

In 2012, the global market for cellphones that cost $250 or less grew by 99 percent from its level in 2011, and accounted for more than half of all cellphones sold worldwide, according to IDC. The upper-end segment of smartphones costing more than $250 grew by only 23 percent during the same period.

“Nokia is targeting the right end of the market with new, inexpensive phones,” said Francisco Jeronimo, an analyst with IDC in London. “This is where the growth is.”

Nokia, the global market leader in smartphones as late as 2007 before Apple produced its first iPhone, trailed the likes of Blackberry, LG and Motorola with a roughly 4 percent market share in the fourth quarter, according to IDC. Huawei and ZTE, the No. 3 and No. 5, each sold more than twice as many smartphones as Nokia.

This year for the first time, more consumers around the world will buy a smartphone than a simple, basic cellphone, according to IDC.

Stephen Elop, the Nokia chief executive, said the new, lower-priced Lumia handsets would give the company a full array of smartphones it had been lacking.

“These are less-expensive devices, but they will move in much larger volumes,” Mr. Elop, a former Microsoft executive, said during an interview.

Mr. Elop said Nokia was committed to making some of Lumia’s unique features, such as digital lenses that allow users to enhance their own photos, available throughout the entire Lumia lineup, instead of reserving the most advanced features for the most expensive handsets.

The Nokia-Microsoft alliance that was announced two years ago in February 2011, Mr. Elop said, is gaining momentum. He dismissed the possibility that the company would eventually abandon its software partnership with Microsoft for another operating system, such as the Android system made by Google.

“There’s no doubt in my mind that that was the right decision” to choose Microsoft, Mr. Elop said. The alliance with the world’s largest software maker has set Nokia apart from handset makers relying on Android, Mr. Elop said, preserving an identify and edge for Nokia and its products.

With the Lumia line of smartphones expanding, Nokia can begin to sell Microsoft phones increasingly to businesses, which may already be reliant on Microsoft Windows and e-mail services in their operations, Mr. Elop said.

“Being able to bring those all together I think is a very powerful force,” he said. “And it’s something that’s just beginning.”

Nokia sold 4.4 million Lumia smartphones in the fourth quarter, up from 2.9 million in the third quarter. Mr. Elop declined to say how sales of Lumia had develpoped in the first two months of the year. But he suggested that the three new handsets introduced over the last three months would help sustain sales momentum.

The Lumia 920, 820 and 620 are new devices that will translate into new sales, he said. “All of those things will contribute to what we hope to see in the future,” he said.

In the fourth quarter, Nokia generated an profit of €202 million, compared with a loss of €1.1 billion a year earlier.

The Nokia 301, a mid-range feature phone, will be introduced in the second quarter and sell for €65. The 3G handset can display streaming video and comes with a 3.2 megapixel camera and panoramic, wide-angle lens. The Nokia 105 will eventually replace the entry-level Nokia 1280, which sold more than 100 million units in the past two years.

The Nokia 720, which will be sold initially in Asia and Europe, is a 3G handset targeting social media users. The phone, which will sell for €249, comes with 8 gigabytes of internal memory and an SD-card slot for additional storage. China Mobile has agreed to sell the handset in China starting in the second quarter, Nokia said.

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India Ink: A Conversation With: Author and Mathematician Manil Suri

The Indian-American author Manil Suri made a splashy entry into the world of writing in 2001 with “The Death of Vishnu,” which became a best seller and was a finalist for the prestigious PEN/Faulkner award. “The Age of Shiva” followed seven years later. This month, the 53-year-old mathematics professor, who teaches at the University of Maryland, Baltimore County, released “The City of Devi,” the final part of a trilogy linked to Hindu gods.

The story is set in a fictional present-day Mumbai, which is in complete disarray because of the threat of a nuclear attack from Pakistan. Residents are leaving the city in droves and police officers are beating people suspected of being Muslims. In the middle of this chaos is Sarita, a recent statistics graduate on a hunt to find her husband, Karun, who disappeared from their apartment.

During her journey, she meets an enigmatic man named Jaz who, unbeknownst to her, is her husband’s former lover. The fast-paced novel cuts between Karun and Sarita’s past lives and the present.

Mr. Suri, who was raised in Mumbai, was in New York City recently to promote the book. He spoke with India Ink about his Kemps Corner upbringing, his slow writing process and his latest work.

What was the inspiration for “The City of Devi”?

It came from the idea of thinking about people who are desperate and willing to take risks to recover a love of theirs as the world might come to an end.

The novel has rich descriptions of the city. How much time did you spend there researching it?

Since I left Bombay, I go back once or twice a year for a few weeks. This book has been in the making for 12 years so I have researched a little bit on each trip.

Tell us about your Mumbai upbringing.

I grew up Kemps Corner and lived in an old crumbling building. I am an only child, and since we were a middle-class family, my parents and I rented one room in a four-bedroom flat which wasn’t so nice. The other three bedrooms were rented by Muslims, and we all shared a toilet and kitchen. I went to Campion school and was around a lot of rich kids so I used to spend a lot of time on my own studying, painting and writing.

You have significant gaps between your books – seven years from the first to the second, and five years for this one. Why did you wait so long between books?

Well, for starters, I am a slow writer. The first book took me five years to write, and the second book took seven years. It was difficult the second time because there was this expectation of following up from the first book, and the pressure was intense. This third book was most difficult in terms of getting the plot strands to behave. I literally drew diagrams plotting the characters and their paths, and I nearly gave up on it twice.

Being a math professor and writer seem like opposite fields. Did both always interest you?

I was always interested in both, but when I was growing up, I was pushed more toward sciences and math. I ended up going into math but used to write as a hobby.

Have you ever contemplated giving up your math career to be a full-time novelist?

I tussled with the idea after the first book and even took time off from teaching just to write but found it wasn’t a good choice for me. I didn’t like being alone all the time, and I missed the math — there was a muscle in the brain that wasn’t exercised enough just by writing.

Like the character Jaz in the book, you’re openly gay. Has that always been the case?

My coming out was around the early 1980s. I came to this country and wasn’t sure if I was or wasn’t but started exploring that side of me.

How did your family take it when you told them?

I came out to my mother first, and she took it fairly well. She has a master’s in psychology so she might have had inklings of it. She has since come and stayed with me and my partner and treats him like a son. She even calls him beta.

What’s your feeling on how the acceptance of homosexuality has evolved in India?

I can’t speak for the villages, but I think the environment has changed when it comes to English-speaking middle-class and upper middle-class people living in cities. I don’t think Mumbai was homophobic when I was growing up. I just think that homosexuality wasn’t talked about, which isn’t the case today.

I was just in India promoting this book, and when I went to Kolkata, I was told not to read out loud the homosexual scenes because it is such a conservative city, and, of course, that’s exactly what I did. No one fainted or walked out, so it turned out okay. I read the same scenes in every city I visited, and the audience was fine with it.

This book is part of a trilogy named after Hindu gods. Now that it’s done, what’s next for you?

My next challenge is to combine math and writing by writing a novel about math. I also have some guilt that I cheated Brahma out of his book by naming this one after the mother goddess so I might write a book named after him.

(The interview has been lightly edited and condensed.)

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This post has been revised to reflect the following correction:

Correction: February 25, 2013

An earlier version of the post misstated that Malin Suri is a professor at the University of Maryland. He teaches at the University of Maryland, Baltimore County.

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Major Banks Aid in Payday Loans Banned by States

Major banks have quickly become behind-the-scenes allies of Internet-based payday lenders that offer short-term loans with interest rates sometimes exceeding 500 percent.

With 15 states banning payday loans, a growing number of the lenders have set up online operations in more hospitable states or far-flung locales like Belize, Malta and the West Indies to more easily evade statewide caps on interest rates.

While the banks, which include giants like JPMorgan Chase, Bank of America and Wells Fargo, do not make the loans, they are a critical link for the lenders, enabling the lenders to withdraw payments automatically from borrowers’ bank accounts, even in states where the loans are banned entirely. In some cases, the banks allow lenders to tap checking accounts even after the customers have begged them to stop the withdrawals.

“Without the assistance of the banks in processing and sending electronic funds, these lenders simply couldn’t operate,” said Josh Zinner, co-director of the Neighborhood Economic Development Advocacy Project, which works with community groups in New York.

The banking industry says it is simply serving customers who have authorized the lenders to withdraw money from their accounts. “The industry is not in a position to monitor customer accounts to see where their payments are going,” said Virginia O’Neill, senior counsel with the American Bankers Association.

But state and federal officials are taking aim at the banks’ role at a time when authorities are increasing their efforts to clamp down on payday lending and its practice of providing quick money to borrowers who need cash.

The Federal Deposit Insurance Corporation and the Consumer Financial Protection Bureau are examining banks’ roles in the online loans, according to several people with direct knowledge of the matter. Benjamin M. Lawsky, who heads New York State’s Department of Financial Services, is investigating how banks enable the online lenders to skirt New York law and make loans to residents of the state, where interest rates are capped at 25 percent.

For the banks, it can be a lucrative partnership. At first blush, processing automatic withdrawals hardly seems like a source of profit. But many customers are already on shaky financial footing. The withdrawals often set off a cascade of fees from problems like overdrafts. Roughly 27 percent of payday loan borrowers say that the loans caused them to overdraw their accounts, according to a report released this month by the Pew Charitable Trusts. That fee income is coveted, given that financial regulations limiting fees on debit and credit cards have cost banks billions of dollars.

Some state and federal authorities say the banks’ role in enabling the lenders has frustrated government efforts to shield people from predatory loans — an issue that gained urgency after reckless mortgage lending helped precipitate the 2008 financial crisis.

Lawmakers, led by Senator Jeff Merkley, Democrat of Oregon, introduced a bill in July aimed at reining in the lenders, in part, by forcing them to abide by the laws of the state where the borrower lives, rather than where the lender is. The legislation, pending in Congress, would also allow borrowers to cancel automatic withdrawals more easily. “Technology has taken a lot of these scams online, and it’s time to crack down,” Mr. Merkley said in a statement when the bill was introduced.

While the loans are simple to obtain — some online lenders promise approval in minutes with no credit check — they are tough to get rid of. Customers who want to repay their loan in full typically must contact the online lender at least three days before the next withdrawal. Otherwise, the lender automatically renews the loans at least monthly and withdraws only the interest owed. Under federal law, customers are allowed to stop authorized withdrawals from their account. Still, some borrowers say their banks do not heed requests to stop the loans.

Ivy Brodsky, 37, thought she had figured out a way to stop six payday lenders from taking money from her account when she visited her Chase branch in Brighton Beach in Brooklyn in March to close it. But Chase kept the account open and between April and May, the six Internet lenders tried to withdraw money from Ms. Brodsky’s account 55 times, according to bank records reviewed by The New York Times. Chase charged her $1,523 in fees — a combination of 44 insufficient fund fees, extended overdraft fees and service fees.

For Subrina Baptiste, 33, an educational assistant in Brooklyn, the overdraft fees levied by Chase cannibalized her child support income. She said she applied for a $400 loan from Loanshoponline.com and a $700 loan from Advancemetoday.com in 2011. The loans, with annual interest rates of 730 percent and 584 percent respectively, skirt New York law.

Ms. Baptiste said she asked Chase to revoke the automatic withdrawals in October 2011, but was told that she had to ask the lenders instead. In one month, her bank records show, the lenders tried to take money from her account at least six times. Chase charged her $812 in fees and deducted over $600 from her child-support payments to cover them.

“I don’t understand why my own bank just wouldn’t listen to me,” Ms. Baptiste said, adding that Chase ultimately closed her account last January, three months after she asked.

A spokeswoman for Bank of America said the bank always honored requests to stop automatic withdrawals. Wells Fargo declined to comment. Kristin Lemkau, a spokeswoman for Chase, said: “We are working with the customers to resolve these cases.” Online lenders say they work to abide by state laws.

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The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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The Texas Tribune: Advocates Seek Mental Health Changes, Including Power to Detain

Matt Rainwaters for Texas Monthly

The Sherman grave of Andre Thomas’s victims.

SHERMAN — A worried call from his daughter’s boyfriend sent Paul Boren rushing to her apartment on the morning of March 27, 2004. He drove the eight blocks to her apartment, peering into his neighbors’ yards, searching for Andre Thomas, Laura Boren’s estranged husband.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

For more articles on mental health and criminal justice in Texas, as well as a timeline of the Andre Thomas case: texastribune.org

Matt Rainwaters for Texas Monthly

Laura Boren

He drove past the brightly colored slides, swings and bouncy plastic animals in Fairview Park across the street from the apartment where Ms. Boren, 20, and her two children lived. He pulled into a parking spot below and immediately saw that her door was broken. As his heart raced, Mr. Boren, a white-haired giant of a man, bounded up the stairwell, calling out for his daughter.

He found her on the white carpet, smeared with blood, a gaping hole in her chest. Beside her left leg, a one-dollar bill was folded lengthwise, the radiating eye of the pyramid facing up. Mr. Boren knew she was gone.

In a panic, he rushed past the stuffed animals, dolls and plastic toys strewn along the hallway to the bedroom shared by his two grandchildren. The body of 13-month-old Leyha Hughes lay on the floor next to a blood-spattered doll nearly as big as she was.

Andre Boren, 4, lay on his back in his white children’s bed just above Leyha. He looked as if he could have been sleeping — a moment away from revealing the toothy grin that typically spread from one of his round cheeks to the other — except for the massive chest wound that matched the ones his father, Andre Thomas (the boy was also known as Andre Jr.), had inflicted on his mother and his half-sister as he tried to remove their hearts.

“You just can’t believe that it’s real,” said Sherry Boren, Laura Boren’s mother. “You’re hoping that it’s not, that it’s a dream or something, that you’re going to wake up at any minute.”

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

“It was last fully revised in 1985, and clearly the mental health system has changed drastically since then,” said Susan Stone, a lawyer and psychiatrist who led the two-year Texas Appleseed project to study and recommend reforms to the code. Lawmakers have said that although the code may need to be revamped, it will not happen in this year’s legislative session. Such an undertaking requires legislative studies that have not been conducted. But advocates are urging legislators to make a few critical changes that they say could prevent tragedies, including giving hospitals the right to detain someone who is having a mental health crisis.

From the time Mr. Thomas was 10, he had told friends he heard demons in his head instructing him to do bad things. The cacophony drove him to attempt suicide repeatedly as an adolescent, according to court records. He drank and abused drugs to try to quiet the noise.

bgrissom@texastribune.org

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DealBook: Judge Sides With Einhorn and Halts an Apple Shareholder Vote

9:26 p.m. | Updated

A federal judge on Friday ordered Apple to halt collecting shareholder votes on a contentious proposal to change some of its corporate charter, handing a victory to the hedge fund manager David Einhorn.

The ruling issued Friday touches on a fairly narrow legal point. But it signals a clear victory for Mr. Einhorn, who has taken up a fight with Apple over using some of the $137 billion in its corporate treasury to make additional payouts to shareholders.

Mr. Einhorn’s hedge fund firm, Greenlight Capital, has sued Apple in Federal District Court in Manhattan, arguing that the company improperly tied together several shareholder issues to be put for a vote into one proposal. Such bundling violated rules set by the Securities and Exchange Commission, lawyers for the hedge fund argued.

At the heart of the hedge fund’s complaint was that Apple combined a plan to eliminate its ability to issue preferred stock without shareholder approval with two other initiatives that Greenlight favored. By allowing the vote to proceed, lawyers for the firm argued, Greenlight was being forced to vote against its own interests.

The judge overseeing the case, Richard Sullivan, firmly agreed with that interpretation.

“Given the language and purpose of the rules, it is plain to the court that Proposal No. 2 impermissibly bundles ‘separate matters’ for shareholder consideration,” Judge Sullivan wrote in his order. The judge said at a hearing on Tuesday that he was leaning toward Mr. Einhorn’s point of view on the matter.

His ruling comes just days before the company’s shareholder meeting next Wednesday. It will also prevent Apple from accepting shareholder votes on Proposal No. 2, which had included Apple’s plans to eliminate its preferred shares. Some shareholder rights advocates have contended that preferred shares have been used as an anti-takeover tactic by boards and have pushed for their elimination.

Mr. Einhorn’s bigger goal has been to persuade Apple to return some of its billions sitting in cash to shareholders as a way to unlock the company’s value. Greenlight Capital has contended that the company has far more cash than it will ever need, and that preferred shares could provide additional payouts worth about $61 a share, while still leaving the company with an enormous war chest.

“We know they embrace innovation and can recognize it when they see it, even if it isn’t the kind of innovation people usually think of when they think of Apple,” Mr. Einhorn said in a conference call with analysts on Thursday.

Mr. Einhorn said that Apple should issue preferred shares, that would augment a stock dividend and buyback program that the company already has in place.

Although Apple was once the stock market darling for its meteoric rise, in recent months, share prices have sagged.

In a statement on Friday, Greenlight praised the judge’s ruling. “This is a significant win for all Apple shareholders and for good corporate governance,” the firm said. “We are pleased the court has recognized that Apple’s proxy is not compliant with the S.E.C.’s rules.”

Apple will now most likely have to break Proposal No. 2 into its separate elements and resubmit them to a vote.

“We are disappointed with the court’s ruling,” said Steve Dowling, a spokesman for Apple. “Proposal No. 2 is part of our efforts to further enhance corporate governance and serve our shareholders’ best interests. Unfortunately, due to today’s decision, shareholders will not be able to vote on Proposal No. 2 at our annual meeting next week.”

Apple had argued that the plan in its entirety was actually shareholder-friendly, and enjoyed the backing of prominent investors like the California Public Employees’ Retirement System.

Anne Simpson, the Calpers director of global governance, said in a statement: “We continue to support Apple in their efforts, and believe that the implementation of majority voting and shareholder approval for the issuance of new stock — preferred or otherwise — is worth waiting for.”

Ruling for Greenlight Capital in Battle With Apple

A version of this article appeared in print on 02/23/2013, on page B4 of the NewYork edition with the headline: U.S. Judge Halts an Apple Shareholder Vote.

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Insurgents Launch 4 Attacks in Afghanistan

KABUL — Afghan intelligence agents on Sunday shot and killed a man in a sport utility vehicle that officials said had been packed with explosives, foiling what they described as an attempt to set off a massive explosion in a neighborhood of narrow streets lined with foreign embassies.

At about the same time, Taliban suicide attackers set off three separate car bombs in two provinces near the capital. But the bombs did minimal damage,  officials said, and the toll from the Sunday violence was low. In addition to the two attackers and the suspect, two security guards and a police officer were also killed and five other people wounded, including one attacker who managed to flee.

A spokesman for the Taliban, Zabiullah Mujahid, said the insurgents were behind the three successful bombings. But he disavowed knowledge of the attempt in Kabul, saying Taliban commanders in the city had no plans for an attack on Sunday.

While it is not unusual for the Taliban to deny having a hand in a failed attack, much about the attempted bombing Sunday remained murky, with officials hailing Afghan security forces for acting quickly but offering only the barest details about how the man identified as a bomber was spotted.

The police chief of Kabul, Gen. Mohammed Ayoub Salangi, said the suspect was in a Toyota sport utility vehicle and was trying to pass through a checkpoint when he was recognized by agents from the country’s intelligence service, the National Directorate of Security.

The man “was gunned down,” General Salangi said. The agents had to act quickly, he added, saying that there was no time to inspect the vehicle or question the suspect because that would have given him the chance to detonate the explosives.

General Salangi, who in an earlier statement said there were two men in the car, did not say how or why the agents recognized the man. But he added that the car bomb was quickly defused and carted away.

The bombing attempt, in the Wazir Akbar Khan neighborhood, led some embassies to did briefly lock down the streets on which they are located and on which they control security. The spot where the man was shot were was less than a mile from the United States Embassy and the headquarters of the American-led coalition, neither of which offered any comment.

Earlier in the day, in Jalalabad, a city in eastern Afghanistan, a single bomber in a Toyota Corolla directly targeted the Security Directorate, officials said, detonating his explosive-laden vehicle outside a building used by the intelligence agency. Two guards were killed and a third was wounded, said Hazrat Mohammad Mashraqiwal, a police spokesman in Jalalabad.

Later on Sunday, two people in another car laden with explosives tried to enter the district governor’s compound in Baraki Barak district of Logar Province, south of Kabul. But they were stopped by police officers guarding the compound, prompting one man to jump and make a run for it and the other to set off the car bomb, said Abdul Rahim Amin, the governor.

One police officer was wounded in the attack, along with the man who fled.

Earlier in Logar, around dawn, a minivan packed with explosives was set off at a police post near the provincial capital, Pul-e-Alam. One officer was killed and two others wounded, an official said.

Sharifullah Sahak contributed reporting.

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Many States Say Cuts Would Burden Fragile Recovery

States are increasingly alarmed that they could become collateral damage in Washington’s latest fiscal battle, fearing that the impasse could saddle them with across-the-board spending cuts that threaten to slow their fragile recoveries or thrust them back into recession.

Some states, like Maryland and Virginia, are vulnerable because their economies are heavily dependent on federal workers, federal contracts and military spending, which will face steep reductions if Congress allows the automatic cuts, known as sequestration, to begin next Friday. Others, including Illinois and South Dakota, are at risk because of their reliance on the types of federal grants that are scheduled to be cut. And many states simply fear that a heavy dose of federal austerity could weaken their economies, costing them jobs and much-needed tax revenue.

So as state officials begin to draw up their budgets for next year, some say that the biggest risk they see is not the weak housing market or the troubled European economy but the federal government. While the threat of big federal cuts to states has become something of a semiannual occurrence in recent years, state officials said in interviews that they fear that this time the federal government might not be crying wolf — and their hopes are dimming that a deal will be struck in Washington in time to avert the cuts.

The impact would be widespread as the cuts ripple across the nation over the next year.

Texas expects to see its education aid slashed hundreds of millions of dollars, which could force local school districts to fire teachers, if the cuts are not averted. Michigan officials say they are in no position to replace the lost federal dollars with state dollars, but worry about cuts to federal programs like the one that helps people heat their homes. Maryland is bracing not only for a blow to its economy, which depends on federal workers and contractors and the many private businesses that support them, but also for cuts in federal aid for schools, Head Start programs, a nutrition program for pregnant women, mothers and children, and job training programs, among others.

Gov. Bob McDonnell of Virginia, a Republican, warned in a letter to President Obama on Monday that the automatic spending cuts would have a “potentially devastating impact” and could force Virginia and other states into a recession, noting that the planned cuts to military spending would be especially damaging to areas like Hampton Roads that have a big Navy presence. And he noted that the whole idea of the proposed cuts was that they were supposed to be so unpalatable that they would force officials in Washington to come up with a compromise.

“As we all know, the defense, and other, cuts in the sequester were designed to be a hammer, not a real policy,” Mr. McDonnell wrote. “Unfortunately, inaction by you and Congress now leaves states and localities to adjust to the looming threat of this haphazard idea.”

The looming cuts come just as many states feel they are turning the corner after the prolonged slump caused by the recession. Gov. Martin O’Malley of Maryland, a Democrat, said he was moving to increase the state’s cash reserves and rainy day funds as a hedge against federal cuts.

“I’d rather be spending those dollars on things that improve our business climate, that accelerate our recovery, that get more people back to work, or on needed infrastructure — transportation, roads, bridges and the like,” he said, adding that Maryland has eliminated 5,600 positions in recent years and that its government was smaller, on a per capita basis, than it had been in four decades. “But I can’t do that. I can’t responsibly do that as long as I have this hara-kiri Congress threatening to drive a long knife through our recovery.”

Federal spending on salaries, wages and procurement makes up close to 20 percent of the economies of Maryland and Virginia, according to an analysis by the Pew Center on the States.

But states are in a delicate position. While they fear the impact of the automatic cuts, they also fear that any deal to avert them might be even worse for their bottom lines. That is because many of the planned cuts would go to military spending and not just domestic programs, and some of the most important federal programs for states, including Medicaid and federal highway funds, would be exempt from the cuts.

States will see a reduction of $5.8 billion this year in the federal grant programs subject to the automatic cuts, according to an analysis by Federal Funds Information for States, a group created by the National Governors Association and the National Conference of State Legislatures that tracks the impact of federal actions on states. California, New York and Texas stand to lose the most money from the automatic cuts, and Puerto Rico, which is already facing serious fiscal distress, is threatened with the loss of more than $126 million in federal grant money, the analysis found.

Even with the automatic cuts, the analysis found, states are still expected to get more federal aid over all this year than they did last year, because of growth in some of the biggest programs that are exempt from the cuts, including Medicaid.

But the cuts still pose a real risk to states, officials said. State budget officials from around the country held a conference call last week to discuss the threatened cuts. “In almost every case the folks at the state level, the budget offices, are pretty much telling the agencies and departments that they’re not going to backfill — they’re not going to make up for the budget cuts,” said Scott D. Pattison, the executive director of the National Association of State Budget Officers, which arranged the call. “They don’t have enough state funds to make up for federal cuts.”

The cuts would not hit all states equally, the Pew Center on the States found. While the federal grants subject to the cuts make up more than 10 percent of South Dakota’s revenue, it found, they make up less than 5 percent of Delaware’s revenue.

Many state officials find themselves frustrated year after year by the uncertainty of what they can expect from Washington, which provides states with roughly a third of their revenues. There were threats of cuts when Congress balked at raising the debt limit in 2011, when a so-called super-committee tried and failed to reach a budget deal, and late last year when the nation faced the “fiscal cliff.”

John E. Nixon, the director of Michigan’s budget office, said that all the uncertainty made the state’s planning more difficult. “If it’s going to happen,” he said, “at some point we need to rip off the Band-Aid.”

Fernanda Santos contributed reporting.

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Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

“Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews,” said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

“Remotely piloted aircraft pilots may stare at the same piece of ground for days,” said Jean Lin Otto, an epidemiologist who was a co-author of the study. “They witness the carnage. Manned aircraft pilots don’t do that. They get out of there as soon as possible.”

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force’s preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported “high operational stress.” Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

“The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance,” she said.

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