Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

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Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

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Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

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This post has been revised to reflect the following correction:

Correction: February 12, 2013

An earlier version of this article misstated the location of the Medical College of Wisconsin. It is in Milwaukee, not Madison.

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Apple CEO Tim Cook calls shareholder suit a 'silly sideshow'

SAN FRANCISCO — Apple Inc. Chief Executive Tim Cook criticized a rebellious investor for creating a "silly sideshow" by filing a lawsuit a few weeks before the company's annual shareholder conference.

"Frankly, I find it bizarre that we find ourselves being sued for doing something that's good for shareholders," Cook said. "It's a silly sideshow, honestly. My preference would be that everyone take the money they are spending on this and donate it to a worthy cause."

Cook made his remarks during an interview at a Goldman Sachs technology conference Tuesday. The one-hour appearance covered a variety of subjects, including the shareholder dispute, whether Apple had lost its innovation mojo and the continued expansion of its stores.

If Cook was feeling the pressure of a falling stock price and investor anger, he didn't show it. His remarks displayed an unusual amount of passion and even glibness for a man who carries a more buttoned-down reputation.

For instance, Cook talked about his larger view that Apple's long-term advantage lies in its relentless focus on making "great products" that produced moments of "magic." He said competitors would have a difficult time matching Apple's combined strengths in software, hardware and services.

"Innovation is so deeply embedded in Apple's culture, the boldness, the ambition, a belief that there are not limits, the desire among our people to not just make good products, but to make the very best products in the world," Cook said. "It's as strong as ever. It's in the values and the DNA of the company. I feel fantastic about it. There's not a better place for innovation."

But Cook grew feisty when discussing the challenge issued by David Einhorn of Greenlight Capital Inc. Last week, Einhorn went public with his request that Apple issue a special class of stock to shareholders. Einhorn and other shareholders have been pressing Apple to do more with the $120 billion in cash on its balance sheet.

Einhorn also sued to block a proposition that Apple had placed on its annual proxy ballot that would require a shareholder vote before issuing such a stock.

At first, Cook seemed ready to extend an olive branch of sorts to Einhorn, saying his proposal for a special class of stock might have some merit.

"I think it's creative," he said. "We are going to thoroughly evaluate their current proposal. We welcome all ideas from all our shareholders."

But from there, Cook fired back against some of the criticisms leveled by Einhorn, including his remarks that Apple has a "Depression-era mentality" because it's hoarding cash.

Cook listed several areas in which Apple is investing money, including infrastructure, talent and new products, in addition to announcing last year that it would return $45 billion to shareholders in stock dividends.

"Apple doesn't have a Depression-era mentality," he said. "I don't know how a company with a Depression mind-set would have done all of those things."

Cook said the Cupertino, Calif., company is not going to launch a campaign to get the proposition passed, in part because he believes that its pro-shareholder nature should be self-evident to investors.

"You're not going to see a 'Yes on 2' sign in my yard," Cook said. "It's a distraction. And it's not a seminal issue for Apple."

Apple plans to file its response to Einhorn's lawsuit by the end of Wednesday. And a hearing on the matter is set for next week in District Court in New York.

The annual shareholder meeting is scheduled Feb. 27.

Cook repeated that Apple is continuing to consider whether and how it might return more cash to shareholders.

"It's a privilege to be in a position where we can seriously consider returning additional cash to shareholders," he said.

Cook also used the word "privilege" to describe the kind of issues facing Apple's stores.

He reiterated how crucial the stores remain to Apple. And he discussed the company's expansion plans for its stores by noting that they were becoming so popular that their capacity was being strained by the number of visitors.

"Some of our stores aren't big enough," he said. "It's a privilege to have this kind of issue."

Cook said Apple is shutting down 20 stores and moving them to locations where they can be expanded. In addition, the company will open 30 stores at new locations, mostly outside the U.S., including its first in Turkey. Apple will then have stores in 13 countries.

Last year Apple's 400-plus stores attracted about 120 million people. Cook said the stores' popularity reflected the different philosophy that went into creating them.

"It's a retail experience where you walk in and you realize the store is not here for the purposes of selling; it's here for the purpose of serving," he said.

Apple spends about $1 billion annually on capital expenditures related to retail. Cook said the stores have been essential in terms of introducing people to new products. He said it's hard to imagine Apple's iPad tablet becoming as successful as it has without having a place where customers can see and touch something they had never experienced.

"There's no better place to discover and play and learn about our products than in retail," Cook said.

chris.obrien@latimes.com

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Mahony voting for a new pope rankles some Catholics

Nearly two weeks ago, Los Angeles Archbishop Jose Gomez announced he had removed Cardinal Roger Mahony from all public duties amid revelations that he plotted to conceal child molestation by priests from law enforcement.

But Mahony on Monday found himself back at the center of church business, as one of 117 cardinals who will elect a successor to Pope Benedict XVI.

Mahony was quick to weigh in on the papal news — posting a statement on his online blog at 8:38 a.m., two hours before the archdiocese announced that Gomez would issue his own remarks at the midday Mass at the downtown Cathedral of Our Lady of the Angels.

In the posting, Mahony called Benedict an "extraordinary" successor to St. Peter and that he intended to participate in choosing the next pontiff.

"I look forward to traveling to Rome soon to help thank Pope Benedict XVI for his gifted service to the Church, and to participate in the Conclave to elect his successor," Mahony wrote.

Benedict's unexpected decision to step down created an awkward situation in the Los Angeles Archdiocese, which is reeling over newly released documents showing how church leaders handled the abuse cases. Documents show that Mahony and Bishop Thomas Curry worked to shield abusers from police. Both have since issued detailed apologies.

Gomez wrote in a letter to parishioners last month that the priest files were "brutal and painful reading. The behavior described in these files is terribly sad and evil. There is no excuse, no explaining away what happened to these children."

Gomez wrote that Mahony, his predecessor as leader of the archdiocese, "has expressed his sorrow for his failure to fully protect young people entrusted to his care. Effective immediately, I have informed Cardinal Mahony that he will no longer have any administrative or public duties." A church spokesman later clarified that Mahony remained a priest "in good standing" and that he maintained all his powers as a cardinal.

Mahony is one of 11 U.S. cardinals who will vote for the next pope.

Father Thomas Rausch of Loyola Marymount University said Mahony has no choice in the matter: Church law requires him to vote, along with all cardinals under age 80, he said.

"It is a sacred responsibility of every cardinal of the church who is able to attend the conclave to vote," said Tod Tamberg, archdiocese spokesman.

Still, Mahony's role in selecting a pope drew mixed reactions among Catholics in Southern California.

Manuel Vega, a retired Oxnard police officer who as an altar boy was molested from the age of 12 to 15 by Father Fidencio Silva, said Mahony would bring shame on the Catholic Church by going to Rome to vote.

"Mahony is going without clean hands. His hands are dirty ... from covering up years of sexual abuse. How can he be part of the conclave?" Vega asked.

Other Catholics said they were pleased that Mahony would be voting. They said they hoped that he would bring a more liberal and American point of view to the conclave, which will be dominated by the conservative cardinals whom Popes John Paul II and Benedict XVI have appointed over the last three decades.

Jane Argento, a parishioner at Holy Family Church in South Pasadena, said she was livid at Mahony when she read about his actions after the archdiocese's release of sex abuse documents. But she said the relatively liberal Mahony reflected her own Catholic convictions about larger roles for women in the church, among other issues. Mahony, she said, was the architect of a pastoral associate program in Los Angeles that had trained several women to run parishes, including her own.

"I'm relieved that Mahony is going," Argento said. "Frankly, it's one more vote for a more progressive church."

Larry Loughlin, 77, a parishioner and social worker, said it was reasonable that Mahony vote, given church rules, and that he was not the only cardinal accused of failing to remove predatory priests from churches and schools. Others include Cardinal Justin Regali, who was accused of ignoring evidence of sex abuse, including rape, in the Philadelphia archdiocese before retiring in 2011.

"Mahony is not the only cardinal to be accused of protecting priests, it is a worldwide crisis," Loughlin said.

Parishioners who attended Monday's midday Mass at the downtown cathedral said they were saddened by news of Benedict's resignation but hailed it as a chance to renew a church still suffering from the repercussions of the abuse scandals. The scandals also appeared to be on the mind of Gomez, who celebrated the Mass and called for prayer "for anyone who has been hurt by a member of the church" and for "the healing for wounds and restoration of trust."

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'Identity Thief' grabs $34.6M to debut at No. 1

LOS ANGELES (AP) — Jason Bateman and Melissa McCarthy's "Identity Thief" has made off with the weekend box-office title with a $34.6 million debut.

The top 20 movies at U.S. and Canadian theaters Friday through Sunday, followed by distribution studio, gross, number of theater locations, average receipts per location, total gross and number of weeks in release, as compiled Monday by Hollywood.com are:

1. "Identity Thief," Universal, $34,551,025, 3,141 locations, $11,000 average, $34,551,025, one week.

2. "Warm Bodies," Lionsgate, $11,356,090, 3,009 locations, $3,774 average, $36,481,172, two weeks.

3. "Side Effects," Open Road Films, $9,303,145, 2,605 locations, $3,571 average, $9,303,145, one week.

4. "Silver Linings Playbook," Weinstein Co., $6,425,271, 2,809 locations, $2,287 average, $89,519,510, 13 weeks.

5. "Hansel and Gretel: Witch Hunters," Paramount, $5,753,165, 3,285 locations, $1,751 average, $43,836,018, three weeks.

6. "Mama," Universal, $4,229,665, 2,677 locations, $1,580 average, $63,951,810, four weeks.

7. "Zero Dark Thirty," Sony, $4,006,860, 2,562 locations, $1,564 average, $83,567,450, eight weeks.

8. "Argo," Warner Bros., $2,375,344, 1,405 locations, $1,691 average, $123,608,957, 18 weeks.

9. "Django Unchained," Weinstein Co., $2,303,495, 1,502 locations, $1,534 average, $154,516,627, seven weeks.

10. "Bullet to the Head," Warner Bros., $2,078,192, 2,404 locations, $864 average, $8,269,214, two weeks.

11. "Top Gun" in 3-D, Paramount, $1,965,737, 300 locations, $6,552 average, $1,965,737, one week.

12. "Lincoln," Disney, $1,873,537, 1,517 locations, $1,235 average, $173,621,006, 14 weeks.

13. "Parker," FilmDistrict, $1,867,411, 2,004 locations, $932 average, $15,848,064, three weeks.

14. "Life of Pi," Fox, $1,745,744, 924 locations, $1,889 average, $108,530,249, 12 weeks.

15. "Les Miserables," Universal, $1,555,550, 1,447 locations, $1,075 average, $143,983,705, seven weeks.

16. "The Hobbit: An Unexpected Journey," Warner Bros., $1,468,374, 1,001 locations, $1,467 average, $298,333,426, nine weeks.

17. "Parental Guidance," Fox, $1,071,766, 1,219 locations, $879 average, $74,344,256, seven weeks.

18. "Wreck-It Ralph," Disney, $1,065,817, 757 locations, $1,408 average, $184,414,532, 15 weeks.

19. "The Impossible," Summit, $957,594, 739 locations, $1,296 average, $16,668,338, eight weeks.

20. "Quartet," Weinstein Co., $940,930, 244 locations, $3,856 average, $5,000,417, five weeks.

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Online:

http://www.hollywood.com

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Universal and Focus are owned by NBC Universal, a unit of Comcast Corp.; Sony, Columbia, Sony Screen Gems and Sony Pictures Classics are units of Sony Corp.; Paramount is owned by Viacom Inc.; Disney, Pixar and Marvel are owned by The Walt Disney Co.; Miramax is owned by Filmyard Holdings LLC; 20th Century Fox and Fox Searchlight are owned by News Corp.; Warner Bros. and New Line are units of Time Warner Inc.; MGM is owned by a group of former creditors including Highland Capital, Anchorage Advisors and Carl Icahn; Lionsgate is owned by Lions Gate Entertainment Corp.; IFC is owned by AMC Networks Inc.; Rogue is owned by Relativity Media LLC.

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Bloomberg Lauds Companies for Cutting Salt Content

Mayor Michael R. Bloomberg, in the midst of a long-running campaign to change the eating habits of New Yorkers and consumers across the country, declared a victory against salt on Monday, as 21 companies, from Kraft and Goya to FreshDirect, said they had met the first stage in reductions in salt content in foods.

After focusing on reducing trans fats and smoking, Mr. Bloomberg turned his attention to salt in 2010, announcing that about 30 companies had signed up to reduce salt in foods by 25 percent within five years, as a way of lowering consumers’ blood pressure and saving lives lost to heart attack and stroke.

“These companies have a huge presence on our shelves and in our diets,” Mr. Bloomberg said at a news conference at City Hall as he announced the results, surrounded by a half-dozen executives of food companies.

The first stage focused on the low-hanging fruit — salsa, dips, bacon, ketchup, barbecue sauce, cold cuts, processed cheese, salad dressing, canned beans and pizza — foods whose salt content is so high that reducing it up to a point probably would not be noticed by many consumers.

Mr. Bloomberg called them “some of America’s most beloved and iconic foods,” suggesting that the cuts might have a disproportionately salutary effect. But Dr. Thomas A. Farley, the city’s health commissioner, said he did not know how much salt the results so far had removed from the average person’s diet.

One side effect of the salt reduction drive is that food companies are looking for salt substitutes to make food taste better.

The main way to do that is to add potassium chloride instead of sodium chloride, said Russ Moroz, vice president for research at Kraft Foods. But because potassium tends to have a bitter, mineral taste, other ingredients have to be added. He said these were proprietary secrets, and he declined to name them.

Potassium is good, Dr. Farley said, because it lowers blood pressure and most people do not get enough of it. It is removed from fruits and vegetable during processing, he said. Mr. Bloomberg said he thought fears of additives were overdone.

But a salt industry scientist said Monday that too much potassium could be bad for the kidneys, and that the “cocktail of chemical constituents” added to balance the bitterness and enhance the salty taste could present unknown risks, as those ingredients were undisclosed.

“They do it with one eye on the lab and the other eye on the label,” said Morton Satin, vice president for science and research at the Salt Institute, a trade association. “They make sure it’s below the level that the F.D.A. requires for it to be on the label.”

Mr. Satin said that the link between high blood pressure and salt was just “a theory,” and that reducing salt too much could have harmful effects, like iodine deficiency in children, a cause of mental retardation, and diabetes.

Some companies said reducing salt proved to be a popular marketing tool. Goya reported that it had reduced salt in its regular canned beans by 5 or 6 percent, without any drop in sales. “We tasted them, and you really wouldn’t notice the difference,” Joseph Perez, senior vice president of Goya Foods, said Monday.

Mr. Bloomberg said it might surprise many people to know that bread and rolls were the “biggest contributor” to salt in the diet. Eating a muffin, he said, could be worse than eating a small bag of Lays potato chips.

Bread makers are hard to spot on the list of companies that have pledged to reduce salt, perhaps, Mr. Satin said, because it is more difficult to make bread without salt. However, some companies, like Au Bon Pain, have reduced salt in some baked goods.

On an irreverent note, Mr. Bloomberg said that he loved Subway sandwiches and would eat his favorite, the Italian B.M.T. — it includes salami, pepperoni and ham — regardless of the salt content, but that he was glad that it now contained 27 percent less.

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TV commercial actors feeling pinched as they pitch products

In a nearly 30-year television career, Frank Crim has appeared in more than 150 commercials, pitching Honda SUVs, Jack in the Box hamburgers, Allstate insurance, and Capital One credit cards.

The Oklahoma City native has played a plumber, a trash collector, a chef, a cab driver and a demon.

But lately Crim is having to book more jobs to make the same money he did a decade ago.

"I still don't make enough money to buy a house," said Crim, who makes about $60,000 a year and shares an apartment in the San Fernando Valley. "I'm not asking for the moon, just enough to make a livable wage."

PHOTOS: Celebrities by The Times

Even as the advertising industry rebounds in the wake of the Great Recession — commercial production reached a record level in Los Angeles last year — middle-class actors hired to pitch products for Ford or Budweiser are having a tougher time making ends meet.

They're being pinched by a variety of forces. Celebrities are taking spots once occupied by lesser-known actors. Lucrative network television residuals — the fees that actors get when their work is rerun — have eroded as advertisers shift spending to cable television shows like "Mad Men" and "Breaking Bad" that pay lower rates.

Many actors feel overexposed and underpaid too when their TV commercials go viral on the Internet.

Those are among the issues confronting negotiators for SAG-AFTRA as they meet in New York this week to begin bargaining on a new three-year contract with advertising agencies. The current contract, which covers about $1 billion in annual earnings for commercial actors, expires March 31.

The negotiation is being closely watched: It is the first since the Screen Actors Guild merged a year ago with its smaller sister union, the American Federation of Television and Radio Artists. SAG-AFTRA leaders face pressure to make good on their vow that a combined union would have more leverage in negotiations to extract improved pay and benefits for their more than 165,000 members, many of whom rely on commercial and voice-over jobs to supplement income from television and film work.

About 50,000 people work under the commercials contract.

Representatives of SAG-AFTRA and a joint policy committee of the American Assn. of Advertising Agencies and the Assn. of National Advertisers declined to comment on the upcoming talks, which begin Thursday.

But the negotiations could be contentious. In 2000 actors staged a six-month strike, mainly over how they were to be paid for commercials shown on network and cable television.

PHOTOS: Hollywood backlot moments

SAG at that time was dominated by a hard-line group. SAG-AFTRA Co-President Roberta Reardon, who is chairing the negotiating committee, and chief negotiator David White, the union's executive director, are known as moderates who eschew outward confrontations with employers.

That was evident last week when the union sounded a conciliatory tone after the board approved a package of bargaining proposals.

"While there are difficult issues to negotiate ahead, we anticipate a productive dialogue with our bargaining partners and expect a result that is positive for our members," White said.

But the advertisers policy committee has warned members to prepare for a possible strike.

"Consider rescheduling production planned for March 31, 2013, through June 2013 to dates prior to March 31, 2013, to account for any possible impasse and strike," lead negotiator Doug Wood said in a memo in December. "This is of particular concern if you are planning production for the rollout of a new campaign or a planning a celebratory production."

Although SAG-AFTRA officials have declined to publicly discuss their package of proposals, sources close to the confidential negotiations said the union is seeking annual wage increases and higher pay for commercials shown on the Internet, as well as larger health and pension contributions. It's unclear how receptive advertisers will be to the demands, having agreed to $36 million in pay increases over three years in the previous contract negotiation in 2009.

But many veteran commercial actors fear being left behind as advertising migrates to new media.

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Gen. Joseph Dunford becomes U.S. commander in Afghanistan

KABUL, Afghanistan — Gen. Joseph F. Dunford Jr. took over Sunday as the newest and probably last U.S. commander in Afghanistan, charged with ending America's longest war even as insurgents continue to challenge the U.S.-backed Afghan government.

Dunford, a four-star Marine officer, arrives as the U.S.-led NATO coalition has closed three-quarters of its 800 bases and as it watches to see whether the Afghan security forces it trained can keep the Taliban insurgency at bay.

A ceremony inside the coalition's heavily guarded compound in Kabul marked the end of the 19-month tenure of Gen. John R. Allen, whose command was marred by a rash of deadly "insider" attacks by Afghan forces against their U.S. and NATO trainers and by strained relations with Afghan President Hamid Karzai.

But in remarks tinged with emotion Sunday, Allen pointed to significant progress, including the growth of the Afghan security forces, an increase in Afghan-led military operations, a sharp reduction in civilian casualties and the withdrawal of about 35,000 U.S. troops.

"This is victory," Allen said. "This is what winning looks like, and we should not shrink from using those words."

Allen was cleared of wrongdoing last month in a Pentagon inquiry into emails he exchanged with a woman who was linked to the sex scandal that forced the resignation of CIA Director David H. Petraeus. Allen has been nominated to lead North Atlantic Treaty Organization forces in Europe.

By replacing Allen with Dunford, the respected but low-key assistant commandant of the Marine Corps, President Obama hopes to repair ties with Karzai so they can cement a long-term security deal that could see several thousand U.S. troops remain in Afghanistan beyond the withdrawal of combat forces next year.

Embracing Allen at the ceremony, Dunford stressed continuity in the mission.

"What's not changed is the will of this coalition," he said. "What's not changed is the growing capability of our Afghan partners."

Obama is expected to spell out plans for the troop withdrawal and a post-2014 U.S. military presence in Afghanistan as early as his State of the Union message Tuesday. Although White House officials have said it's possible that no U.S. troops would remain, Pentagon officials are calling for a residual force that would focus on counter-terrorism and supporting Afghan forces.

Dunford will have a key seat at the table as U.S. officials try to work out the security agreement, which will hinge on earning assurances from Afghan leaders that they won't release prisoners currently in U.S. custody and will guarantee U.S. troops immunity from prosecution in Afghan courts. The failure to reach an immunity guarantee was a main reason no U.S. troops remained in Iraq after the war ended there.

About 65,000 U.S. troops remain in Afghanistan, down from a high of 100,000. Despite flagging U.S. support for the war, military commanders contend that removing the remaining troops precipitously could cause Afghan security forces to collapse.

In his Senate confirmation hearing in November, Dunford offered no prescriptions for troop levels but cautioned against withdrawing too quickly, saying it could destabilize the region.

U.S. officials recently estimated that a residual American force could number from 6,000 to 9,000 troops — fewer than the 15,000 senior military commanders had wanted. Experts say that Dunford will be charged with figuring out how such a force could achieve U.S. strategic aims.

"A major challenge will be identifying a mission that those troops can perform that's useful and doable with that small number," said Stephen Biddle, a defense analyst and professor at George Washington University.

Even as the war winds down, challenges remain. The insider attacks that killed 61 NATO troops in 2012 have dissipated, but only after U.S. troops scaled back joint operations with Afghan forces, hampering training efforts. By next year, Afghan forces are expected to be in the lead of all security operations, but the Taliban, though weakened, retains the ability to attack in Kabul and other strategic areas.

Experts say that Dunford, who earned the nickname "Fighting Joe" when he led a charge from Kuwait into Baghdad during the 2003 invasion of Iraq, could clash with a second-term Obama Cabinet, whose members — including Secretary of State John F. Kerry and, if he's confirmed, Chuck Hagel as Defense secretary — have not been strong supporters of a large long-term U.S. presence in Afghanistan.

"It's going to be extremely difficult for a commanding general who's not going to have many partners in the administration," said Thomas Donnelly, a military expert at the American Enterprise Institute, a conservative Washington think tank.

"It's a bit of a thankless task, for sure."

shashank.bengali@latimes.com

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Gotye, Kimbra win record of the year Grammy

LOS ANGELES (AP) — Last year's biggest hit is also the Grammy winner for record of the year: Gotye's "Somebody That I Used to Know" earned one of the night's top trophies.

It was Gotye's third award Sunday night. It sold more than 7 million single tracks.

Prince presented the Australian singer with the award. Gotye said the pop icon was a big inspiration.

Gotye and Kimbra also won best pop duo/group performance for "Somebody That I Used to Know." Gotye's "Making Mirrors" picked up best alternative music album.

Gotye's three wins match The Black Keys, Kanye West and Jay-Z. The Black Keys' Dan Auerbach is the leader with four wins.

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For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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18 accused in huge credit card scam were patient, authorities say

NEWARK, N.J. — Many scam artists are looking for ways to get rich quick.

Then there are the 18 people authorities said spent years meticulously creating fake identities, building up their credit scores and credit card limits, and borrowing money they never repaid in what may be one of the nation's largest credit card fraud rings.

The 18 were charged last week in what authorities said was a sprawling international scam in which at least $200 million was stolen using at least 7,000 identities and 25,000 credit cards. The enterprise spanned 28 states and eight countries, authorities said.

The elaborate fraud involved an outlay of patience and meticulous planning rarely seen in such a large credit card fraud case, authorities and industry analysts said.

"What they did was very painstaking, very sophisticated and took a lot of time," said Paul Fishman, the U.S. attorney in Newark, who announced the arrests Tuesday.

The scam started at least as early as 2007, Fishman said. The group created thousands of fake identities, sometimes using real Social Security numbers. One credit card was opened with the identity of a 6-year-old boy; others used Social Security numbers of people who were willing to leave the United States for a fee, Fishman said.

"You have to pull a lot of stuff together. You have to have a phone service and address where you're paying bills," said Avivah Litan, a vice president and analyst at Gartner Research. "They have to do a lot of background work to look like a real person."

The group then opened credit cards with small credit limits. The users purchased everyday items like groceries and paid off the bills so they could increase their credit score. That way, they were able to give the impression that they were a trusted customer, giving them access to a higher credit limit and cash advance checks.

Litan said one of the most impressive aspects of the scam was that the defendants were able to access so much credit during the financial crisis. They probably had to appear to be sterling customers in order to pump up their credit limits so high.

"They did this the last few years when credit was hard to come by," Litan said. "The banks don't give you $50,000 right away."

Authorities allege the defendants added one another and sham businesses as authorized users on credit card accounts, giving more people access to good credit. They received credit card machines with the scam businesses and paid themselves with the cards, Fishman said, and three jewelry stores in Jersey City were allegedly complicit in the scheme.

The defendants then maxed out the cards, buying electronics, jewelry and luxury cars. They also took out loans or cashed the checks and never paid back the money, authorities said.

Authorities did not directly say how the fraud came to light, but a co-conspirator was named in court documents, indicating that someone may have been cooperating.

Al Pascual, senior analyst at Javelin Strategy and Research, said it would be very unlikely for credit bureaus to have caught such a fraud if the cards were initially being used responsibly and paid off. Red flags also would not have been raised if accounts were opened using legitimate Social Security numbers that did not have any prior credit accounts, like a child.

"The activity itself shouldn't have garnered any notice until they stopped paying the bills," Pascual said.

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