Hockey Coaches Defy Doctors on Concussions, Study Finds

Despite several years of intensive research, coverage and discussion about the dangers of concussions, the idea of playing through head injuries is so deeply rooted in hockey culture that two university teams kept concussed players on the ice even though they were taking part in a major concussion study.

The study, which was published Friday in a series of articles in the journal Neurosurgical Focus, was conducted during the 2011-12 hockey season by researchers from the University of Western Ontario, the University of Montreal, Harvard and other institutions.

“This culture is entrenched at all levels of hockey, from peewee to university,” said Dr. Paul S. Echlin, a concussion specialist and researcher in Burlington, Ontario, and the lead author of the study. “Concussion is a significant public health issue that requires a generational shift. As with smoking or seat belts, it doesn’t just happen overnight — it takes a massive effort and collective movement.”

The study is believed to be among the most comprehensive analyses of concussions in hockey, which has a rate of head trauma approaching that of football. Researchers followed two Canadian university teams — a men’s team and a women’s team — and scanned every player’s brain before and after the season. Players who sustained head injuries also received scans at three intervals after the injuries, with researchers using advanced magnetic resonance imaging techniques.

The teams were not named in the study, in which an independent specialist physician was present at each game and was empowered to pull any player off the ice for examination if a potential concussion was observed.

The men’s team, with 25 players and an average age of 22, played a 28-game regular season and a 3-game postseason. The women’s team, with 20 players and an average age of 20, played 24 regular-season games and no playoff games. Over the course of the season, there were five observed or self-reported concussions on the men’s team and six on the women’s team.

Researchers noted several instances of coaches, trainers and players avoiding examinations, ignoring medical advice or otherwise obstructing the study, even though the players had signed consent forms to participate and university ethics officials had given institutional consent.

“Unless something is broken, I want them out playing,” one coach said, according to the study.

In one incident, a neurologist observing the men’s team pulled a defenseman during the first period of a game after the player took two hits and was skating slowly. During the intermission the player reported dizziness and was advised to sit out, but the coach suggested he play the second period and “skate it off.” The defenseman stumbled through the rest of the game.

“At the end of the third period, I spoke with the player and the trainer and said that he should not play until he was formally evaluated and underwent the formal return-to-play protocol,” the neurologist said, as reported in the study. “I was dismayed to see that he played the next evening.”

After the team returned from its trip, the neurologist questioned the trainer about overruling his advice and placing the defenseman at risk.

“The trainer responded that he and the player did not understand the decision and that most of the team did not trust the neurologist,” according to the study. “He requested that the physician no longer be used to cover any more games.”

In another episode, a physician observer assessed a minor concussion in a female player and recommended that she miss the next night’s game. Even though the coach’s own playing career had ended because of concussions, she overrode the medical advice and inserted the player the next evening.

According to the report, the coach refused to speak to another physician observer on the second evening. The trainer was reluctant to press the issue with the coach because, the trainer said, the coach did not want the study to interfere with the team.

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A Hospital War Reflects a Tightening Bind for Doctors Nationwide

For decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.

But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.

Today, Boise is a medical battleground.

A little more than half of the 1,400 doctors in southwestern Idaho are employed by St. Luke’s or its smaller competitor, St. Alphonsus Regional Medical Center.

Many of the independent doctors complain that both hospitals, but especially St. Luke’s, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit. In interviews, they said their referrals from doctors now employed by St. Luke’s had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.

Boise’s experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe increasing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.

In Boise, just a few weeks ago, even the hospitals were at war. St. Alphonsus went to court seeking an injunction to stop St. Luke’s from buying another physician practice group, arguing that the hospital’s dominance in the market was enabling it to drive up prices and to demand exclusive or preferential agreements with insurers. The price of a colonoscopy has quadrupled in some instances, and in other cases St. Luke’s charges nearly three times as much for laboratory work as nearby facilities, according to the St. Alphonsus complaint.

Federal and state officials have also joined the fray. In one of a handful of similar cases, the Federal Trade Commission and the Idaho attorney general are investigating whether St. Luke’s has become too powerful in Boise, using its newfound leverage to stifle competition.

Dr. David C. Pate, chief executive of St. Luke’s, denied the assertions by St. Alphonsus that the hospital’s acquisitions had limited patient choice or always resulted in higher prices. In some cases, Dr. Pate said, services that had been underpriced were raised to reflect market value. St. Luke’s, he argued, is simply embracing the new model of health care, which he predicted would lead over the long term to lower overall costs as fewer unnecessary tests and procedures were performed.

Regulators expressed some skepticism about the results, for patients, of rapid consolidation, although the trend is still too new to know for sure. “We’re seeing a lot more consolidation than we did 10 years ago,” said Jeffrey Perry, an assistant director in the F.T.C.’s Bureau of Competition. “Historically, what we’ve seen with the consolidation in the health care industry is that prices go up, but quality does not improve.”

A Drive to Consolidate

An array of new economic realities, from reduced Medicare reimbursements to higher technology costs, is driving consolidation in health care and transforming the practice of medicine in Boise and other communities large and small. In one manifestation of the trend, hospitals, private equity firms and even health insurance companies are acquiring physician practices at a rapid rate.

Today, about 39 percent of doctors nationwide are independent, down from 57 percent in 2000, according to estimates by Accenture, a consulting firm.

Many policy experts have praised the shift away from independent medical practices as a way of making health care less fragmented and expensive. Systems that employ doctors, modeled after well-known organizations like Kaiser Permanente, are better positioned to coordinate patient care and to find ways to deliver improved services at lower costs, these advocates say. Indeed, consolidation is encouraged by some aspects of the Obama administration’s health care law.

“If you’re going to be paid for value, for performance, you’ve got to perform together,” said Dr. Ricardo Martinez, chief medical officer for North Highland, an Atlanta-based consultant that works with hospitals.

The recent trend is reminiscent of the consolidation that swept the industry in the 1990s in response to the creation of health maintenance organizations, or H.M.O.’s — but there is one major difference. Then, hospitals had difficulty managing the practices, contending that doctors did not work as hard when they were employees as they had as private operators. This time, hospitals are writing contracts more in their own favor.

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Sony sells over half a million PlayStation 3 consoles over Black Friday week

Both Microsoft (MSFT) and Nintendo (NTDOY) had a big week of console sales during Black Friday’s week of shopping madness in the U.S. So how did Sony (SNE) do in comparison? Sony Computer Entertainment of America president and CEO Jack Tretton announced on Thursday that the company sold 525,000 PlayStation 3 consoles and 160,000 PS Vita handhelds during the Black Friday week. Overall PlayStation sales of hardware, software and accessories are up 9% over the same period last year. Tretton was also happy to reveal that subscriptions to its PlayStation Plus grew 259% since last year with customer satisfaction flying high at 95% after Sony added the Instant Game Collection to the service earlier this year.

Sony’s PlayStation 3 and PS Vita sales were largely bolstered by $ 199.99 bundles packaged with free games that the company pushed to retails on Black Friday. The sell-out of the bundles within minutes at retailers such as Amazon (AMZN) is a good indicator that there is huge demand for a sub-$ 200 PlayStation 3. Currently, the lowest-priced PS3 is a second-gen 160GB slim model with an MSRP of $ 249.99. The redesigned third-gen PS3s start at $ 269.99 with a 250GB hard drive.

In terms of which home console did the best over Black Friday, it looks like the Xbox 360′s 750,000 consoles took first place, while Sony came in second with 525,000 PS3s and Nintendo came in third with 400,000 Wii U systems.

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Benghazi Violence Beyond Control of Militias

Esam Omran Al-Fetori/Reuters

Libyan police officers carried the body of Faraj Mohammed el-Drissi, the Benghazi security director, after he was gunned down last week.

BENGHAZI, Libya — The killing was not a shock here, in the city where Libyans started their quest to shake off dictatorship and now struggle, nearly two years later, to douse the simmering violence that is a legacy of the revolt.

One evening last week, a car screeched down a residential street. Three men stepped out and with startling ease gunned down Faraj Mohammed el-Drissi, the man whose job it was to ensure this city’s security.

Mr. Drissi, who had been on the job since October, was among roughly three dozen public servants killed over the last year and a half, including army officers, security agents, officials from the deposed government and the United States ambassador, J. Christopher Stevens. In all the cases, no one has been convicted, and in many, no one has even been questioned. That is unlikely to change anytime soon.

Since Col. Muammar el-Qaddafi was killed more than a year ago, Benghazi has in many ways regained its balance, as residents build long-delayed additions to their homes and policemen direct traffic on some streets. But Mr. Drissi’s killing made it hard to ignore a darker rhythm — one that revolves around killing with impunity. The government is still weaker than the country’s militias, and neither is willing, or able to act.

“It is impossible for members of a brigade to arrest another,” said Wanis al-Sharif, the top Interior Ministry official in eastern Libya. “And it would be impossible that I give the order to arrest someone in a militia. Impossible.”

The violence was thrown into sharp relief after the September attack on the United States intelligence and diplomatic villas. Libyan and American officials accused militants associated with Libya’s ubiquitous militias, and specifically, members of Ansar al-Shariah.

“The killing of the ambassador brought back the true reality of this insecure state,” said Ali Tarhouni, a former Libyan finance minister who leads a new political party. “It was a major setback, to this city and its psyche.”

Justice itself is a dangerous notion here and throughout Libya, where a feeble government lacks the power to protect citizens or to confront criminal suspects. It barely has the means to arm its police force, let alone rein in or integrate the militias or confront former rebel fighters suspected of killings.

“Some had to do with personal grudges,” said Judge Jamal Bennor, who serves as Benghazi’s justice coordinator. But most were like the killing of Mr. Drissi. “This was a political assassination,” he said.

Adding to the feeling of lawlessness are the revelations that foreign intelligence services, like the C.I.A., are active around the country without answering to anyone, people here said. Every day, an American drone circles Benghazi, unsettling and annoying residents. Police officers share Kalashnikovs. The courts are toothless. Libyan and American investigators, faced with Benghazi’s insecurity, are forced to interview witnesses hundreds of miles away, in the capital, Tripoli.

And so the government is forced to reckon with the militias, who by virtue of their abundant weapons hold the city’s real power. Men like Wissam bin Hamid, 35, who before the revolution owned an automobile workshop, is now the leader of an umbrella group of former rebel fighters. Some groups, like Mr. Hamid’s, operate with the government’s blessing, while others are called rogue. The distinctions often seem arbitrary, but either way, the militias are effectively a law unto themselves.

Mr. Hamid and others insist that they are loyal to the state. Leading political figures said they respected Mr. Hamid but had concerns about many of the other militia leaders, among them hard-line Islamists.

The militias are called on for crucial tasks, including safeguarding elections. Mr. Hamid’s militia, a branch of a group called Libya Shield, has been called on to enforce order hundreds of miles away from Benghazi, in towns beyond the government’s reach. The militia has also worked with American officials: they escorted intelligence officers and diplomats away from the besieged villas on Sept. 11, and later, provided protection for American investigators visiting the city in search of evidence in the attack, Mr. Hamid said.

Osama al-Fitory and Suliman Ali Zway contributed reporting.

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Steelers QB Roethlisberger testing hurt shoulder

PITTSBURGH (AP) — Ben Roethlisberger doesn't sound like a guy who plans on playing against the Baltimore Ravens on Sunday.

The injured Pittsburgh Steelers quarterback said Thursday he's still in significant pain from the sprained right shoulder and dislocated ribs that have forced him to sit out Pittsburgh's last two games.

Roethlisberger said "there's always a chance" he could play against the Ravens but isn't sure his injured arm will cooperate. When asked if the issue is pain or arm strength, Roethlisberger said "both."

The Steelers (6-5) are 0-2 since Roethlisberger left in the third quarter of a 16-13 overtime win against Kansas City on Nov. 12. It's unlikely Pittsburgh can catch the Ravens (9-2) even with a win this week, but Roethlisberger said that won't affect the team's decision on whether to rest him another week or not.

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Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

This article has been revised to reflect the following correction:

Correction: November 29, 2012

An earlier version of this article misstated the number of traits included in the proposed criteria for narcissistic personality disorder.   The final proposal relies on two personality traits, not four.

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U.S. Growth Revised Up, but Year-End Slowdown Is Feared

Even as the government said that the United States economy grew faster than first estimated in the third quarter, economists warned that the rate of expansion could slow sharply before the end of the year as worries mount about the fiscal impasse in Washington.

Nam Y. Huh/Associated Press

An employee on the assembly line this month at Generac Power Systems in Whitewater, Wis., a maker of residential generators.

The Commerce Department said Thursday that gross domestic product expanded at an annual rate of 2.7 percent in the three months ended Sept. 30, well above the 2 percent estimate it initially made in late October. But the revision was driven by increased inventory accumulation and a jump in federal spending — factors unlikely to be repeated in the current fourth quarter, economists said.

What’s more, the revised figures show spending by businesses on equipment and software declined by 2.7 percent in the third quarter, the first decrease since the end of the recession in mid-2009 and a sign of just how cautious many companies have become amid the uncertainty in Washington and slowing growth in Asia and Europe.

“It’s a nice headline number,” said Nigel Gault, chief U.S. economist at IHS Global Insight, of the 2.7 percent rate, “but it exaggerates the underlying momentum in the economy. Sustainable improvements in growth are not driven by inventories.”

The two biggest growth areas in the third quarter — inventory growth and federal spending — “are likely to be minuses in the fourth quarter,” he said. Mr. Gault expects the annual rate to sink to 1 percent this quarter, hurt by a fiscal stalemate in Washington as well as the aftereffects of Hurricane Sandy.

To be sure, there were signs of optimism in Thursday’s data. Residential fixed investment rose 14.2 percent, a sign that the housing recovery is gaining steam. Indeed, a separate report Thursday from the National Association of Realtors showed pending home sales rose to a two-and-a-half-year high.

And not all economists took a pessimistic view. “The economy certainly hasn’t taken off, but it’s nowhere close to a stall,” said David Kelly, chief global strategist for JPMorgan Funds. “The economy is still underperforming its full potential, but once we get past the ‘fiscal cliff’ uncertainty, we could see stronger growth next year.”

The new estimate of growth represents a substantial increase in the level of the second quarter, when the economy grew at a rate of just 1.3 percent. It also marks the fastest rate of expansion since the fourth quarter of 2011, when the economy grew at a 4.1 percent annual pace.

This was the second of the government’s three estimates of quarterly growth. The final figure is scheduled for Dec. 20.

“Over all, it was a disappointing report,” said Michelle Meyer, senior United States economist with Bank of America Merrill Lynch.  The accumulation of inventories went from subtracting 0.1 percentage points from the initial estimate to adding 0.8 percentage points, she said.

    “A lot of that inventory build was unintentional, which suggests a downside risk for the fourth quarter,” she said.  “Businesses had expected stronger sales and consumer spending and were caught off guard."

    Ms. Meyer said she expected the economy to grow by 1 percent in the fourth quarter and 1 percent in the first quarter of 2013, well below the level needed to bring down the unemployment rate, which stood at 7.9 percent in October.

    On Thursday, the government also reported that first-time unemployment claims dropped by 23,000 to 393,000 last week. But Ms. Meyer cautioned that these figures were much more volatile than usual because of the Thanksgiving holiday as well as Hurricane Sandy.

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Microsoft CEO defends its innovation record, financial results

BELLEVUE, Washington (Reuters) – Microsoft Corp Chief Executive Steve Ballmer defended his company’s record on innovation and financial performance at the annual shareholders’ meeting, but conceded that he should have moved faster to get into the booming tablet market dominated by Apple Inc‘s iPad.

Bill Gates, co-founder and now chairman of the world’s largest software company, was one of the first to champion tablet-sized devices more than 10 years ago, but Microsoft failed to come up with a product that worked as well as the iPad. Gates was silent throughout the meeting, attended by about 450 shareholders.

“We’re innovating on the seam between software and hardware,” said Ballmer, asked why his company had fallen behind rival Apple. “Maybe we should have done that earlier.”

A month ago, Microsoft launched the Surface tablet – its first own-brand computer – but has not revealed sales figures.

In the tablet market, “we see nothing but a sea of upside,” Ballmer said, an acknowledgement that until now Microsoft has effectively had zero presence in the tablet market.

“I feel pretty good about our level of innovation,” he added.

Ballmer said smartphones running Microsoft’s new Windows software were selling four times as much as they did at this time last year. Microsoft has never given sales numbers of Windows phones, primarily made by Nokia, Samsung and HTC.

Windows currently has 2 to 4 percent of the global smartphone market, according to various independent data providers. Its overall market share will not likely grow in proportion to its own sales, given that sales of other smartphones – mostly running Google’s Android system – are also growing quickly.

Ballmer, flanked by Gates and Chief Financial Officer Peter Klein, was asked by several shareholders to explain Microsoft’s lackluster share price, which has been stuck for a decade, and has been outperformed by Apple and Google Inc stock in recent years.

“I understand your comment,” he told one shareholder. He went on to explain that Microsoft had “done a phenomenal job of driving product volumes” and was focusing on profiting from that growth.

He suggested that whether investors recognized that value at any given time was out of his hands.

“The stock market‘s kind of a funny thing,” he said, adding that Microsoft had handed back $ 10 billion in dividends and share buybacks to investors in the last fiscal year.

Several shareholders at the meeting in Bellevue, an upscale suburb of Seattle, complimented the executives on how they had grown and managed the company.

Microsoft’s shares rose almost 18 percent during fiscal 2012, which ended in June of this year, compared with a 3 percent rise in the Standard & Poor’s 500.

Despite such fluctuations, Microsoft’s shares stand around the same level they did 10 years ago.

To see a graphic on U.S. tech share price performance, 1990 to present, click on http://link.reuters.com/rug53t

(Reporting by Bill Rigby; Editing by Gary Hill)

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As Opposition Meets in Cairo, More Violence Mars Syria

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Bonds, Clemens, Sosa on Hall ballot for first time

NEW YORK (AP) — The most polarizing Hall of Fame debate since Pete Rose will now be decided by the baseball shrine's voters: Do Barry Bonds, Roger Clemens and Sammy Sosa belong in Cooperstown despite drug allegations that tainted their huge numbers?

In a monthlong election sure to become a referendum on the Steroids Era, the Hall ballot was released Wednesday, and Bonds, Clemens and Sosa are on it for the first time.

Bonds is the all-time home run champion with 762 and won a record seven MVP awards. Clemens took home a record seven Cy Young trophies and is ninth with 354 victories. Sosa ranks eighth on the homer chart with 609.

Yet for all their HRs, RBIs and Ws, the shadow of PEDs looms large.

"You could see for years that this particular ballot was going to be controversial and divisive to an unprecedented extent," Larry Stone of The Seattle Times wrote in an email. "My hope is that some clarity begins to emerge over the Hall of Fame status of those linked to performance-enhancing drugs. But I doubt it."

More than 600 longtime members of the Baseball Writers' Association of America will vote on the 37-player ballot. Candidates require 75 percent for induction, and the results will be announced Jan. 9.

Craig Biggio, Mike Piazza and Curt Schilling also are among the 24 first-time eligibles. Jack Morris, Jeff Bagwell and Tim Raines are the top holdover candidates.

If recent history is any indication, the odds are solidly stacked against Bonds, Clemens and Sosa. Mark McGwire and Rafael Palmeiro both posted Cooperstown-caliber stats, too, but drug clouds doomed them in Hall voting.

Some who favor Bonds and Clemens claim the bulk of their accomplishments came before baseball got wrapped up in drug scandals. They add that PED use was so prevalent in the 1980s, 1990s and early 2000s that it's unfair to exclude anyone because so many who-did-and-who-didn't questions remain.

Many fans on the other side say drug cheats — suspected or otherwise — should never be afforded the game's highest individual honor.

Either way, this election is baseball's newest hot button, generating the most fervent Hall arguments since Rose. The discussion about Rose was moot, however — the game's career hits leader agreed to a lifetime ban in 1989 after an investigation concluded he bet on games while managing the Cincinnati Reds, and that barred him from the BBWAA ballot.

The BBWAA election rules allow voters to pick up to 10 candidates. As for criteria, this is the only instruction: "Voting shall be based upon the player's record, playing ability, integrity, sportsmanship, character, and contributions to the team(s) on which the player played."

That leaves a lot of room for interpretation.

"Everyone has their own way of dealing with the issue, and in the absence of hard and fast rules, there will continue to be a wide diversity of opinions," Stone said.

Clemens was acquitted this summer in federal court on six counts that he lied and obstructed Congress when he denied using performance-enhancing drugs.

Bonds was found guilty in 2011 by a federal court jury on one count of obstruction of justice, ruling he gave an evasive answer in 2003 to a grand jury looking into the distribution of illegal steroids. Bonds is appealing the verdict.

McGwire is 10th on the career home run list with 583, but has never received even 24 percent in his six Hall tries. Big Mac has admitted to using steroids and human growth hormone.

Palmeiro is among only four players with 500 homers and 3,000 hits, yet has gotten a high of just 12.6 percent in his two years on the ballot. He drew a 10-day suspension in 2005 after a positive test for PEDs, and said the result was due to a vitamin vial given to him by teammate Miguel Tejada.

Biggio topped the 3,000-hit mark — which always has been considered an automatic credential for Cooperstown — and spent his entire career with the Houston Astros.

"Hopefully, the writers feel strongly that they liked what they saw, and we'll see what happens," Biggio said last week.

Schilling was 216-146 and won three World Series championships, including his "bloody sock" performance for the Boston Red Sox in 2004.

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