‘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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Haruhiko Kuroda Expected to Be Named Head of Bank of Japan

TOKYO — A financial policy expert and harsh critic of the Bank of Japan’s efforts to combat deflation is set to be the government’s choice to take over the nation’s central bank.

Toru Hanai/Reuters

Haruhiko Kuroda is a harsh critic of the Bank of Japan’s track record on deflation.

The official, Haruhiko Kuroda, a veteran of global financial circles and current head of the Asian Development Bank, will be nominated as the bank’s governor to take over next month, according to a ruling party lawmaker with knowledge of those plans.

Prime Minister Shinzo Abe has instructed ruling party officials to start negotiating with opposition parties to clear the way for Mr. Kuroda’s appointment, which must be approved by a divided parliament, the lawmaker said.

“This is a critical time for Japan’s economy, and we must avoid, at all costs, a failure to gain parliamentary approval for this appointment,” NHK, the public broadcaster, quoted Mr. Abe as telling ruling party executives Monday morning.

With Mr. Kuroda at its helm, the bank could take much bolder steps to kick-start economic growth. Mr. Kuroda has publicly criticized the Bank of Japan for not going far enough to fight deflation, and has urged the bank to adopt inflation targets and to expand an asset-buying program to pump more cash into the Japanese economy.

Mr. Kuroda’s global experience — as vice minister for international affairs at Japan’s powerful Finance Ministry from 1999 to 2003, and as president of the Manila-based Asian Development Bank starting in 2005 — could also help Tokyo navigate foreign criticism that its monetary policies are intended to weaken the yen to give Japanese exporters a competitive edge.

The yen has weakened by over 10 percent in the last three months as Mr. Abe laid out his monetary agenda, pushing the outgoing central bank governor, Masaaki Shirakawa, to start taking a more aggressive monetary stance. But Mr. Abe had indicated that a change at the bank’s top ranks was needed to break with the bank’s cautious past. On Monday, the yen fell to a 33-month low.

Kikuo Iwata, a professor at Gakushuin University in Tokyo and another vocal critic of the central bank, is set to be tapped for one of its two deputy governor spots, according to the lawmaker. Mr. Iwata is the author of several books, including “Stop Deflation, Now” and “Is the Bank of Japan Really Trustworthy?”

Mr. Kuroda beat out a fellow former senior Finance Ministry official, Toshiro Muto, who had strong backing among both bureaucrats and local politicians but lacks the top-level global contacts. Mr. Muto was also viewed as being more cautious than Mr. Kuroda on monetary policy.

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Paroled sex offenders disarming tracking devices

SACRAMENTO — Thousands of paroled child molesters, rapists and other high-risk sex offenders in California are removing or disarming their court-ordered GPS tracking devices — and some have been charged with new crimes including sexual battery, kidnapping and attempted manslaughter.

The offenders have discovered that they can disable the monitors, often with little risk of serving time for it, a Times investigation has found. The jails are too full to hold them.

"It's a huge problem," said Fresno parole agent Matt Hill. "If the public knew, they'd be shocked."

More than 3,400 arrest warrants for GPS tamperers have been issued since October 2011, when the state began referring parole violators to county jails instead of returning them to its packed prisons. Warrants increased 28% in 2012 compared to the 12 months before the change in custody began. Nearly all of the warrants were for sex offenders, who are the vast majority of convicts with monitors, and many were for repeat violations.

The custody shift is part of Gov. Jerry Brown and the legislature's "realignment" program, to comply with court orders to reduce overcrowding in state prisons. But many counties have been under their own court orders to ease crowding in their jails.

Some have freed parole violators within days, or even hours, of arrest rather than keep them in custody. Some have refused to accept them at all.

Before prison realignment took effect, sex offenders who breached parole remained behind bars, awaiting hearings that could send them back to prison for up to a year. Now, the maximum penalty is 180 days in jail, but many never serve that time.

With so little deterrent, parolees "certainly are feeling more bold," said Jack Wallace, an executive at the California Sex Offender Management Board.

Rithy Mam, a convicted child stalker, was arrested three times in two months after skipping parole and was freed almost immediately each time. After his third release, his GPS alarm went off and he vanished, law enforcement records show.

The next day, he turned up in a Stockton living room where a 15-year-old girl was asleep on the couch, police said. The girl told police she awoke to find the stranger staring at her and that he asked "Wanna date?" before leaving the home.

Police say Mam went back twice more that week and menaced the girl and her 13-year-old sister, getting in by giving candy to a toddler, before authorities recaptured him in a local park. He is in custody on new charges of child molestation.

Californians voted in 2006 to require that high-risk sex offenders be tracked for life with GPS monitors strapped to their bodies.

The devices are programmed to record offenders' movements and are intended, at least in part, to deter them from committing crimes. The devices, attached to rubber ankle straps embedded with fiber-optic cable, transmit signals monitored by a private contractor.

They are easy to cut off, but an alarm is triggered when that happens, as it is when they are interfered with in other ways or go dead, or when an offender enters a forbidden area such as a school zone or playground. The monitoring company alerts parole agents by text message or email.

Arrest warrants for GPS tamperers are automatically published online. The Times reviewed that data as well as thousands of jail logs, court documents and criminal histories provided by confidential sources. The records show that the way authorities handle violators can vary significantly by county.

San Bernardino County releases more inmates early from its cramped jails than any other county in California, according to state reports. But sex offenders who violate parole there generally serve their terms. A spokeswoman said the county closely reviews criminal histories, and those with past sex offenses are ineligible for early release.

By contrast, parole violators in San Joaquin County are often set free within a day of arrest.

A review of the county's jail logs shows that nine of the 15 sex offenders arrested for violating parole in December and January were let out within 24 hours, including seven who immediately tampered with their trackers and disappeared. One of the nine, a convicted rapist named Robert Stone, was arrested two weeks later on kidnapping charges and returned to jail, where he remains.

Raoul Leyva, a sex offender with a history of beating women, was arrested in April for fleeing parole and ordered to remain jailed for 100 days. He was out in 16 days and soon bolted again, after allowing the battery on his device to go dead, according to the documents reviewed by The Times.

Less than two weeks later, a drug dealer led police to a Stockton apartment where Leyva's girlfriend, 20-year-old Brandy Arreola, had lain for days on the floor, severely beaten and in a coma. Now brain damaged and confined to a wheelchair, Arreola spends her time watching cartoons.

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That Syncing Feeling

“Smart, or stylish?” That’s the question facing casual watch aficionados looking for a new, high-tech addition to their collection.

On one hand (er, wrist), you’ve got the Pebble and other smartwatch upstarts, which come with built-in smartphone connectivity, customizable screens, and burgeoning developer communities eager to feed their app ecosystems. They also, by and large, look like uninspired pieces of mass-produced Chinese plastic, and that’s because they are.

On the “stylish” end of the spectrum is … not much. Except this: Citizen’s Eco-Drive Proximity.

The Citizen learns the current time from your phone, and the watch’s hands spin around to the correct positions.

By all outward appearances, the Proximity looks like any another chronograph in a sea of handsome mechanical watches. It has all the features you’d expect, including a 24-hour dial, day and date, perpetual calendar and second time zone. But housed within its slightly oversized 46mm case is a Bluetooth 4.0 radio, so it’s capable of passing data over the new low-energy connectivity standard appearing in newer smartphones, including the iPhone 5 and 4S. And for now, the Promixity is only compatible with those Apple devices.

Initial pairing is relatively easy. After downloading Citizen’s notably low-rent iOS app, you can link the watch to your phone with a few turns and clicks on the crown.

The gee-whiz feature is the automatic time sync that takes place whenever you land in a different time zone. Once connected, the Citizen learns the current time from your phone, and the watch’s hands spin around to the correct positions — a welcome bit of easy magic, considering the initial setup is a tedious finger dance.

The watch can also notify you of incoming communications. Once you’ve configured the mail client (it only supports IMAP accounts), you’ll get notified whenever you get a new e-mail — there’s a slight vibration and the second hand sweeps over to the “mail” tab at the 10-o’clock position. If a phone call comes in, the second hand moves to the 11-o’clock marker. If the Bluetooth connection gets lost because the watch or phone is outside the 30-foot range, you get another vibration and the second hand moves to the “LL” indicator. And really, that’s the extent of the functionality around notifications.

But notable in its absence is the notification I’d like the most: text message alerts. And it’s not something Citizen will soon be rectifying because the dials and hardware aren’t upgradable.

I also experienced frequent connection losses, particularly when attending a press conference with scads of Mi-Fis and tethered smartphones around me. This caused dozens of jarring vibrations both on my wrist and in my pocket, followed by a raft of push notifications on my phone informing me of the issue. Reconnecting is easy (and generally happens automatically), but the lack of stability in certain environments matched with the limited capabilities of the notifications had me forgetting to reconnect and not even worrying about it later on.

But actually, I’m OK with that. I still like the fact that it never needs charging. Even though there aren’t any solar cells visible on the dial, the watch does have them. They’re hidden away beneath the dial, and yet they still work perfectly. And even when its flagship connectivity features aren’t behaving, it’s still a damn handsome watch. It feels solid, and it looks good at the office, out to dinner, or on the weekend — something very few other “smart” watches on the market can claim.

However, those things can be said of almost all of Citizen’s EcoDrive watches. The big distinguishing feature here is the Bluetooth syncing and notifications, and they just don’t work that well.

WIRED A smart watch you won’t be embarrassed to wear. Charges using light. Combines classic styling with cutting-edge connectivity. Subtle notifications keep you informed without dominating your attention.

TIRED Loses Bluetooth connection with disturbing frequency. Limited notification abilities. No text message alerts. Janky iPhone app.

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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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Genetically modified foods: Who has to tell?

Consumers who believe they have a right to know whether their food contains genetically modified ingredients are pressing lawmakers, regulators and voters to require labels on altered foods. But even if they succeed, experts say there's no guarantee that labels identifying genetically engineered foods would ever appear on packages.

"People are usually surprised to learn that there is no legal right to know," said Michael Rodemeyer, an expert on biotechnology policy at the University of Virginia in Charlottesville.

A variety of rules and regulations control the words that appear on food packages. Such rules must be balanced against companies' constitutionally protected right of commercial speech, experts said.

"It's an unsettled area in the law," said Hank Greely, director of the Stanford Center for Law and the Biosciences in Palo Alto. "If I were a betting man, I think the odds are good that the Supreme Court would ... strike down a GMO labeling requirement."

Consumers do have the right to know some things about foods, and it's the job of the Food and Drug Administration to enforce the various rules. Labels must carry an accurate name for the food, as well as its weight and manufacturer, a list of ingredients and, since 1990, that panel of calories and breakdown of basic nutrients that some people pore over and others blithely ignore.

And labels cannot be false or misleading. Consumers have a right to know that a product contains the nutrients they'd reasonably expect to find in a food with that name: An orange lacking vitamin C (should anyone desire to create such a thing) would have to be labeled as such.

They also have the right to know when a food contains something new that makes it materially different, such as an allergen or unexpected nutrient. Soybean varieties that are genetically engineered to contain high amounts of the monounsaturated fat oleic acid must bear labels that make that property clear, said FDA spokesperson Morgan Liscinsky.

But there is no requirement that food producers use those labels to say how they raised those oleic acid levels, according to the FDA. They could have done it through conventional breeding or by irradiating plant tissue to create mutations or by fusing cells together in a dish — or with genetic engineering.

When Flavr Savr tomatoes became the first genetically modified plants sold in supermarkets in 1994, they had stickers that informed shoppers that they were "made from genetically engineered seeds." Calgene Inc., the company that produced the tomatoes, even provided brochures and a toll-free number that consumers could call to learn more about the product, said Belinda Martineau, a geneticist at UC Davis who worked at Calgene in the 1990s.

But those labels were there only because Calgene decided to put them there. The FDA had scrutinized the process by which the company engineered the DNA in the tomatoes and decided that the technology itself didn't amount to a material change. Regulators concluded that Flavr Savr had the appearance, nutrients, flavor and texture of a tomato (although not, as it turned out, an especially tasty one).

"It was still a tomato," said Fred Degnan, a food lawyer with the firm King & Spalding in Washington, D.C., who has worked on biotechnology and labeling issues at the FDA. "They couldn't require it to be labeled in a way that implied it was different from a regular tomato."

Courts have ruled that forcing companies to label GM products violates their 1st Amendment right of free speech. In a 1996 case, a federal appeals court blocked a Vermont law that required dairy producers to label milk from cows that had been treated with a growth hormone made by genetically engineered bacteria. The hormone helped cows produce more milk, but the milk itself was the same as milk from untreated cows, the FDA determined. Because the law required labels to contain information that wasn't "material" to the product, it was unconstitutional, the 2nd Circuit Court of Appeals ruled in a 2-1 decision.

Labels can be required only if they alert consumers to a change that affects a food's composition or nutrition, its physical properties (such as shelf life), or the qualities that influence the sensory experience of smelling, tasting and eating it, the FDA says.

It is not a definition that sits well with all.

Andrew Kimbrell, executive director of the Washington-based advocacy group Center for Food Safety, said that approach reflects "19th century science." His group has petitioned the FDA to update its rules so that any product created via genetic engineering would be considered altered enough to require a label.

Such a change would also give companies more leeway to label their products as free of genetically modified ingredients: Today they can do so only if the label doesn't imply that there's something wrong with GM foods or that GMO-free foods are superior (although many companies skirt the rules).

"We need to know we have an agency using 21st century regulations to deal with 21st century technology," Kimbrell said.

The FDA's stance on labeling genetically modified foods differs starkly from that of European regulators, who require foods with genetically engineered ingredients to bear labels. Most scientists believe that the FDA's approach is rational — but perhaps it's too rational if the goal is to encourage public acceptance of the technology, said Jennifer Kuzma, a science policy expert at the Humphrey School of Public Affairs at the University of Minnesota.

"This is something that people want to see on labels," Kuzma said. "My view is that consumers deserve a choice when it comes to something that is important to them, even though there may not be a scientific basis for doing it."

Rodemeyer, the expert on biotechnology policy, says he thinks food producers made a tactical mistake by deciding not to label their genetically modified products voluntarily.

"When you don't label, you're always raising suspicion you're trying to hide something," he said.

Since most processed foods contain oil, sugar, syrups, emulsifiers, flour, cornmeal and protein that are derived from GM crops, virtually every product sold in the last 15 years would have carried a label. By now, those labels would have lost all meaning, Rodemeyer said: "If they would have all held their noses and jumped together, this wouldn't be an issue."

science@latimes.com

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Asteroid Impact Craters on Earth as Seen From Space

Asteroid impact craters are among the most interesting geological structures on any planet. Many other planets and moons in our solar system, including our own moon, are pock-marked with loads of craters. But because Earth has a protective atmosphere and is geologically active — with plate tectonics and volcanic eruptions, mostly relatively young oceanic crust, and harsh weathering from wind and water — impact structures don’t last long and can be tough to come by.

But on a few old pieces of continent, especially in arid deserts, the marks of asteroids have been preserved. One well-known example is our own Barringer crater, also known as Meteor Crater, in Arizona. The images here show some of the biggest, oldest and most interesting impact craters on the planet.

Aorounga crater, pictured above and below, is one of the best preserved impact craters on Earth, thanks in part to its location in the Sahara Desert in Chad. The 10 mile-wide crater is probably around 350 million years old. The stripes are alternating rock ridges and sand layers, known as yardangs, caused by persistent unidirectional wind. The image above was taken by astronauts in the International Space Station in July. The radar image below, taken from the space shuttle in 1994, reveals that Aorounga may be one of two or three craters.

Images: NASA

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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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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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Gunfire and deadly crash rattle the Las Vegas Strip

LAS VEGAS — A spectacular predawn crash on the Strip — triggered when bullets fired from a black Range Rover peppered a Maserati — hit this resort city right between the eyes. In the end, three people were dead and a major intersection under lockdown during a three-state manhunt for the shooters, leaving even casino veterans used to the extraordinary scratching their heads.

The mayhem was sparked, witnesses told police, by a quarrel early Thursday at a hotel valet stand.

The two vehicles left the Aria resort hotel and were heading north on Las Vegas Boulevard at 4:20 a.m., an hour when the casino marquees shine brightly but the gambling thoroughfare is largely empty. At Harmon Avenue, occupants inside the Range Rover opened fire on the Maserati, police said.

The silver-gray sports car, which was struck several times, sped into the intersection at Flamingo Road, ramming a Yellow cab. The taxi exploded, killing the driver and a passenger. Four other vehicles in the intersection were also involved in the crash and explosion, but officers offered no details.

"Omg Omg Omg that car just blew up!" one witness tweeted shortly after the crash, posting a photo of the wreckage. "God Bless their Souls! Omg!"

The driver of the Maserati died later at a hospital, police said. A passenger in the vehicle received minor injuries and was being interviewed by investigators. At least three others were also injured.

Police in Nevada, California, Arizona and Utah were on alert for the distinctive black Range Rover SUV, described as having dark-tinted windows, black rims and out-of-state paper dealer plates.

"We are going to pursue these individuals and prosecute them," Clark County Sheriff Doug Gillespie said at an afternoon news conference. "This act was totally unacceptable. It's not just tragic but unnecessary — the level of violence we see here in Las Vegas and across America."

Authorities had not publicly identified the dead. But a Las Vegas television station late Thursday identified the taxi driver as Michael Boldon, 62, who the station said had recently moved here from Michigan to care for his 93-year-old mother.

The victim's son, who drives a limousine, told Fox News 5 that he last talked with his father after 3 a.m., and later called his cellphone shortly after the crash to warn him to avoid the Strip. But there was no answer.

The station also identified the driver of the Maserati as Ken Cherry, a rap artist from Oakland who also is known as "Kenny Clutch." The station quoted family members identifying Cherry as the driver. An Internet video of a Cherry song called "Stay Schemin" shows two men in a vehicle on the Strip.

Police had more questions than answers.

"It began with a dispute at a nearby hotel and spilled onto the streets," said Capt. Chris Jones of the Las Vegas Police Robbery and Homicide Division.

The morning's events threw the Strip into disarray all day. The gambling boulevard's busiest and best-known intersection was cordoned off by yellow police tape until nightfall, keeping traffic and curious pedestrians away from the carnage. Even skywalks were blocked off.

While slot machines beeped and card games continued inside casinos around the accident scene — including the Bellagio, Caesars Palace and Paris Las Vegas — hotel bell captains were fielding questions from tourists who had awakened to news of the crash and the Strip shutdown. The alleys and side streets between nearby hotels were clogged with pedestrians who inched along on narrow sidewalks, past delivery doors, many making their own paths between the landscaped bushes and palm trees.

Even casino industry workers were thrown into turmoil. Hotel maids and dealers who finished their midnight shifts after dawn were left without bus service home. "I'm stranded," said Tiruselam Kefyalew, 25, a maid. "What a day to leave my cellphone at home."

Limousine drivers who normally prowl the city's gambling core improvised detours. Some said the police blockade would cost them $500 or more in lost business and tips.

"Most people understand, but you have your complainers," said Jim DeSanto, a limo driver who waited for fares outside Bally's casino. "Those people will complain, even when everything is perfect."

Well after noon, guests peered out nearby hotel windows and others leaned into the street to glimpse the crime scene.

"Hey, honey, it must have happened right here," one man told his wife as they left Caesars around noon. The tourist, who would only say that he had arrived from Tampa, Fla., the previous evening, had looked out his hotel window at 4:30 to see a vehicle in flames.

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