Livestrong Tattoos as Reminder of Personal Connections, Not Tarnished Brand





As Jax Mariash went under the tattoo needle to have “Livestrong” emblazoned on her wrist in bold black letters, she did not think about Lance Armstrong or doping allegations, but rather the 10 people affected by cancer she wanted to commemorate in ink. It was Jan. 22, 2010, exactly a year since the disease had taken the life of her stepfather. After years of wearing yellow Livestrong wristbands, she wanted something permanent.




A lifelong runner, Mariash got the tattoo to mark her 10-10-10 goal to run the Chicago Marathon on Oct. 10, 2010, and fund-raising efforts for Livestrong. Less than three years later, antidoping officials laid out their case against Armstrong — a lengthy account of his practice of doping and bullying. He did not contest the charges and was barred for life from competing in Olympic sports.


“It’s heartbreaking,” Mariash, of Wilson, Wyo., said of the antidoping officials’ report, released in October, and Armstrong’s subsequent confession to Oprah Winfrey. “When I look at the tattoo now, I just think of living strong, and it’s more connected to the cancer fight and optimal health than Lance.”


Mariash is among those dealing with the fallout from Armstrong’s descent. She is not alone in having Livestrong permanently emblazoned on her skin.


Now the tattoos are a complicated, internationally recognized symbol of both an epic crusade against cancer and a cyclist who stood defiant in the face of accusations for years but ultimately admitted to lying.


The Internet abounds with epidermal reminders of the power of the Armstrong and Livestrong brands: the iconic yellow bracelet permanently wrapped around a wrist; block letters stretching along a rib cage; a heart on a foot bearing the word Livestrong; a mural on a back depicting Armstrong with the years of his now-stripped seven Tour de France victories and the phrase “ride with pride.”


While history has provided numerous examples of ill-fated tattoos to commemorate lovers, sports teams, gang membership and bands that break up, the Livestrong image is a complex one, said Michael Atkinson, a sociologist at the University of Toronto who has studied tattoos.


“People often regret the pop culture tattoos, the mass commodified tattoos,” said Atkinson, who has a Guns N’ Roses tattoo as a marker of his younger days. “A lot of people can’t divorce the movement from Lance Armstrong, and the Livestrong movement is a social movement. It’s very real and visceral and embodied in narrative survivorship. But we’re still not at a place where we look at a tattoo on the body and say that it’s a meaningful thing to someone.”


Geoff Livingston, a 40-year-old marketing professional in Washington, D.C., said that since Armstrong’s confession to Winfrey, he has received taunts on Twitter and inquiries at the gym regarding the yellow Livestrong armband tattoo that curls around his right bicep.


“People see it and go, ‘Wow,’ ” he said, “But I’m not going to get rid of it, and I’m not going to stop wearing short sleeves because of it. It’s about my family, not Lance Armstrong.”


Livingston got the tattoo in 2010 to commemorate his brother-in-law, who was told he had cancer and embarked on a fund-raising campaign for the charity. If he could raise $5,000, he agreed to get a tattoo. Within four days, the goal was exceeded, and Livingston went to a tattoo parlor to get his seventh tattoo.


“It’s actually grown in emotional significance for me,” Livingston said of the tattoo. “It brought me closer to my sister. It was a big statement of support.”


For Eddie Bonds, co-owner of Rabbit Bicycle in Hill City, S.D., getting a Livestrong tattoo was also a reflection of the growth of the sport of cycling. His wife, Joey, operates a tattoo parlor in front of their store, and in 2006 she designed a yellow Livestrong band that wraps around his right calf, topped off with a series of small cyclists.


“He kept breaking the Livestrong bands,” Joey Bonds said. “So it made more sense to tattoo it on him.”


“It’s about the cancer, not Lance,” Eddie Bonds said.


That was also the case for Jeremy Nienhouse, a 37-year old in Denver, Colo., who used a Livestrong tattoo to commemorate his own triumph over testicular cancer.


Given the diagnosis in 2004, Nienhouse had three rounds of chemotherapy, which ended on March 15, 2005, the date he had tattooed on his left arm the day after his five-year anniversary of being cancer free in 2010. It reads: “3-15-05” and “LIVESTRONG” on the image of a yellow band.


Nienhouse said he had heard about Livestrong and Armstrong’s own battle with the cancer around the time he learned he had cancer, which alerted him to the fact that even though he was young and healthy, he, too, could have cancer.


“On a personal level,” Nienhouse said, “he sounds like kind of a jerk. But if he hadn’t been in the public eye, I don’t know if I would have been diagnosed when I had been.”


Nienhouse said he had no plans to have the tattoo removed.


As for Mariash, she said she read every page of the antidoping officials’ report. She soon donated her Livestrong shirts, shorts and running gear. She watched Armstrong’s confession to Winfrey and wondered if his apology was an effort to reduce his ban from the sport or a genuine appeal to those who showed their support to him and now wear a visible sign of it.


“People called me ‘Miss Livestrong,’ ” Mariash said. “It was part of my identity.”


She also said she did not plan to have her tattoo removed.


“I wanted to show it’s forever,” she said. “Cancer isn’t something that just goes away from people. I wanted to show this is permanent and keep people remembering the fight.”


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Sun, sophistication and stainless steel


























































This 15th-floor condominium in the Remington blends contemporary and traditional elements. The kitchen, with professional-grade stainless steel appliances, opens to a sunroom with floor-to-ceiling windows, while hardwood floors and crown molding lend sophistication to the interiors.


Location: 10727 Wilshire Blvd., #1505, Westwood 90024


Asking price: $3.495 million








Year built: 2001


Unit size: Three bedrooms, 3.5 bathrooms, 3,592 square feet


Features: Private elevator, oversized walk-in closet, fireplace, two balconies, washer and dryer, valet parking, community swimming pool


Website: http://www.Remington1505.com


About the area: Last year, 331 condos single-family homes sold in the 90024 ZIP Code at a median price of $527,000, according to DataQuick. That was a 5.5% increase from 2011.


Agent: Shawn Kormondy, Keller Williams, Hollywood Hills, (323) 638-7567


—Lauren Beale


To submit a candidate for Home of the Week, send high-resolution color photos on a CD, written permission from the photographer to publish the images and a description of the house to Lauren Beale, Business, Los Angeles Times, 202 W. 1st St., Los Angeles, CA 90012. Send questions to homeoftheweek @latimes.com.






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'Blade Runner' Oscar Pistorius weeps as he faces murder charge









JOHANNESBURG, South Africa -- Olympic sprinter Oscar Pistorius, the double-amputee revered in South Africa for overcoming his disability to compete in the London Games last year, wept in court Friday as he faced a murder charge in connection with the fatal shooting of his girlfriend.

During the proceedings in Pretoria, Gerrie Nel, one of the National Prosecuting Authority’s most senior advocates, said he would argue the killing of model and law graduate Reeva Steenkamp was premeditated murder, the most serious category of offense under South African law.


Nel is known for prosecuting high-profile cases, including winning the conviction of former police chief and Interpol boss Jackie Selebi on corruption charges.


Pistorius, nicknamed the "Blade Runner" because of the carbon-fiber prosthetic legs he uses to compete, did not enter a formal plea and was remanded into custody at Brooklyn police station in Pretoria until Tuesday, when his bail application is to be heard.








Under South African law, a suspect charged with such a high-level offense would have to prove exceptional circumstances to be granted bail.


In a packed courtroom, members of Pistorius' family struggled to pass through a media scrum and to find seats. The hearing coincided with "Black Friday," a day when people were being urged to wear black to protest rapes and violence against women.


[Updated, 8:35 a.m. Feb. 15: The family and Pistorius' management company later issued a statement denying that the athlete had murdered his girlfriend, saying: "The alleged murder is disputed in the strongest possible terms."


Some details of Pistorius' argument and the state's case are expected Tuesday.]

The famed athlete's court appearance came as South African media reported that he shot Steenkamp, his girlfriend of several months, four times through a bathroom door.


Under South African law, a person who fatally shoots an intruder has to prove he or she had a reasonable fear that the intruder posed a real threat to his or her life.

South Africa has one of the highest rates of gun homicides in the world, with killings of women by intimate partners the leading cause of female homicide in the country. About 57% of female homicide victims were killed by their partners in 2009, according to a report last year by the Medical Research Council.


One-third of female homicides were committed by partners with a history of prior violence against their partners, according to the report.

Friends of Steenkamp and Pistorius mourned the incident on social media.

"Drained, confused, I just can't wrap my head around things," one of Pistorius’ close friends, Alex Pilakoutas, posted on Twitter.


Darren Fresco, who described himself as one of Steenkamp’s best friends said he was hoping to wake from a nightmare and hear her infectious laughter again.

"We were just goofing off the other day talking to each other in only the way that we could to each other. My heart is on the verge of exploding with the pain of such a sudden loss of one of my best friends," Fresco, who said he was one of the last people to exchange tweets with Steenkamp, posted on Facebook.

ALSO:

Oscar Pistorius remains in jail facing murder charge

Mexico finds fire-god figure at top of Pyramid of the Sun

Iranian general reportedly assassinated while traveling from Syria


robyn.dixon@latimes.com





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Judge sets May trial date for Kardashian divorce


LOS ANGELES (AP) — Kim Kardashian has a due date for her baby and now a trial date for her divorce from NBA player Kris Humphries.


A judge on Friday set a May 6 trial for the reality TV star who wants to end her marriage before July, when her child with Kanye West is due.


Kardashian filed for divorce on Oct. 31, 2011, after she and Humphries had been married just 72 days. Their lavish, star-studded nuptials were recorded and broadcast by E! Entertainment Television.


The trial is expected to last three to five days and could reveal details about Kardashian's reality show empire, which includes "Keeping Up With the Kardashians" and several spinoffs.


Two judges determined Friday that Humphries' lawyers had adequate time to prepare for the trial.


Humphries wants the marriage annulled based on his claim that Kardashian only married him for the sake of her show.


She denies that allegation and says the case should be resolved through what would be her second divorce.


Humphries' attorney Marshall Waller asked for a delay until basketball season is over.


But Superior Court Judge Scott Gordon refused, saying firefighters, police officers, truck drivers and others have to miss work for trials, and Humphries must do the same if necessary.


Waller filed paperwork Thursday to withdraw from the case but didn't mention that development in court and refused to answer any questions about the document on Friday.


Waller said he was still hoping to obtain and review 13,000 hours of footage from Kardashian's reality shows to try to prove the fraud claim but noted he does not yet have an agreement to receive the footage.


Kardashian's lawyer said her client was ready for trial.


"Let's get this case dispensed with," attorney Laura Wasser said.


Humphries has provided a deposition in the case, as have West and Kardashian family matriarch Kris Jenner.


___


Anthony McCartney can be reached at http://twitter.com/mccartneyAP


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Fat Dad: Baking for Love

Fat Dad

Dawn Lerman writes about growing up with a fat dad.

My grandmother Beauty always told me that the way to a man’s heart was through his stomach, and by the look of pure delight on my dad’s face when he ate a piece of warm, homemade chocolate cake, or bit into a just-baked crispy cookie, I grew to believe this was true. I had no doubt that when the time came, and I liked a boy, that a batch of my gooey, rich, chocolatey brownies would cast him under a magic spell, and we would live happily ever.

But when Hank Thomas walked into Miss Seawall’s ninth grade algebra class on a rainy, September day and smiled at me with his amazing grin, long brown hair, big green eyes and Jimi Hendrix T-shirt, I was completely unprepared for the avalanche of emotions that invaded every fiber of my being. Shivers, a pounding heart, and heat overcame me when he asked if I knew the value of 1,000 to the 25th power. The only answer I could think of, as I fumbled over my words, was “love me, love me,” but I managed to blurt out “1E+75.” I wanted to come across as smart and aloof, but every time he looked at me, I started stuttering and sweating as my face turned bright red. No one had ever looked at me like that: as if he knew me, as if he knew how lost I was and how badly I needed to be loved.

Hank, who was a year older than me, was very popular and accomplished. Unlike other boys who were popular for their looks or athletic skills, Hank was smart and talented. He played piano and guitar, and composed the most beautiful classical and rock concertos that left both teachers and students in awe.

Unlike Hank, I had not quite come into my own yet. I was shy, had raggedy messy hair that I tied back into braids, and my clothes were far from stylish. My mother and sister had been on the road touring for the past year with the Broadway show “Annie.” My sister had been cast as a principal orphan, and I stayed home with my dad to attend high school. My dad was always busy with work and martini dinners that lasted late into the night. I spent most of my evenings at home alone baking and making care packages for my sister instead of coercing my parents to buy me the latest selection of Gloria Vanderbilt jeans — the rich colored bluejeans with the swan stitched on the back pocket that you had to lie on your bed to zip up. It was the icon of cool for the popular and pretty girls. I was neither, but Hank picked me to be his math partner anyway.

With every equation we solved, my love for Hank became more desperate. After several months of exchanging smiles, I decided to make Hank a batch of my chocolate brownies for Valentine’s Day — the brownies that my dad said were like his own personal nirvana. My dad named them “closet” brownies, because when I was a little girl and used to make them for the family, he said that as soon as he smelled them coming out of the oven, he could imagine dashing away with them into the closet and devouring the whole batch.

After debating for hours if I should make the brownies with walnuts or chips, or fill the centers with peanut butter or caramel, I got to work. I had made brownies hundreds of times before, but this time felt different. With each ingredient I carefully stirred into the bowl, my heart began beating harder. I felt like I was going to burst from excitement. Surely, after Hank tasted these, he would love me as much as I loved him. I was not just making him brownies. I was showing him who I was, and what mattered to me. After the brownies cooled, I sprinkled them with a touch of powdered sugar and wrapped them with foil and red tissue paper. The next day I placed them in Hank’s locker, with a note saying, “Call me.”

After seven excruciating days with no call, some smiles and the usual small talk in math class, I conjured up the nerve to ask Hank if he liked my brownies.

“The brownies were from you?” he asked. “They were delicious.”

Then Hank invited me to a party at his house the following weekend. Without hesitation, I responded that I would love to come. I pleaded with my friend Sarah to accompany me.

As the day grew closer, I made my grandmother Beauty’s homemade fudge — the chocolate fudge she made for Papa the night before he proposed to her. Stirring the milk, butter and sugar together eased my nerves. I had never been to a high school party before, and I didn’t know what to expect. Sarah advised me to ditch the braids as she styled my hair, used a violet eyeliner and lent me her favorite V-neck sweater and a pair of her best Gloria Vanderbilt jeans.

When we walked in the door, fudge in hand, Hank was nowhere to be found. Thinking I had made a mistake for coming and getting ready to leave, I felt a hand on my back. It was Hank’s. He hugged me and told me he was glad I finally arrived. When Hank put his arm around me, nothing else existed. With a little help from Cupid or the magic of Beauty’s recipes, I found love.


Fat Dad’s ‘Closet’ Brownies

These brownies are more like fudge than cake and contain a fraction of the flour found in traditional brownie recipes. My father called them “closet” brownies, because when he smelled them coming out of the oven he could imagine hiding in the closet to eat the whole batch. I baked them in the ninth grade for a boy that I had a crush on, and they were more effective than Cupid’s arrow at winning his heart.

6 tablespoons unsalted butter, plus extra for greasing the pan
8 ounces bittersweet chocolate, chopped, or semisweet chocolate chips
3/4 cup brown sugar
2 eggs at room temperature, beaten
1 teaspoon vanilla extract
1/4 cup flour
1/2 cup chopped walnuts (optional)
Fresh berries or powdered sugar for garnish (optional)

1. Preheat oven to 350 degrees.

2. Grease an 8-inch square baking dish.

3. In a double boiler, melt chocolate. Then add butter, melt and stir to blend. Remove from heat and pour into a mixing bowl. Stir in sugar, eggs and vanilla and mix well.

4. Add flour. Mix well until very smooth. Add chopped walnuts if desired. Pour batter into greased baking pan.

5. Bake for 35 minutes, or until set and barely firm in the middle. Allow to cool on a rack before removing from pan. Optional: garnish with powdered sugar, or berries, or both.

Yield: 16 brownies


Dawn Lerman is a New York-based health and nutrition consultant and founder of Magnificent Mommies, which provides school lectures, cooking classes and workshops. Her series on growing up with a fat father appears occasionally on Well.

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Latinos crucial to Herbalife's financial health









The future of Herbalife is riding on Latinos.


The Los Angeles company estimates that Latinos account for about 60% of its U.S. sales made through its network of independent distributors. And a growing slice of those sales are coming from informal nutrition clubs run out of people's homes and strip mall shops.


It's a cultural phenomenon that got its start in Mexico and is quickly catching on among immigrants who have moved to Southern California. Budding entrepreneurs like Angel Perez, a 27-year-old from Inglewood, are forming the backbone to Herbalife's growth.





Perez runs her nutrition club out of a tiny, aging retail shop that from the outside shows no signs that she's even open for business. But behind a single glass front door, covered by a green curtain, there's a lively atmosphere inside.


Colombian singer Shakira's voice blares from overhead speakers. "Hola! Como estas?" Perez says before blending an Herbalife meal-replacement shake for a customer. She charges $4 for a protein shake, hot tea and glass of aloe vera juice — part of a weight-loss effort she said has helped her shed dozens of pounds.


But these nutrition clubs — and Herbalife's business structure — have come under intense scrutiny.


The company is in the middle of a Wall Street battle between two billionaire activist investors. On one side, hedge fund manager Bill Ackman contends the company is a pyramid scheme in which most of the independent salespeople lose money and get stuck with a product that nobody wants. Ackman said he wagered $1 billion that the company would fail, shorting an eye-popping 20% of the company's shares.


Betting against him is Carl Icahn, who dismisses pyramid scheme accusations with high praise about Herbalife's business model. Icahn disclosed this week that he bought nearly 13% of the company's shares, and was talking to executives about taking the company private.


At the heart of this battle: Herbalife's army of salespeople.


Among the biggest accusations facing the company is that it targets low-income members of minority communities, including Latinos, by making unachievable promises of vast wealth from selling its line of protein powders, vitamins, supplements and beauty products.


One of Ackman's biggest allegations is that most distributors end up with garages filled with products they cannot sell. Meanwhile, the distributors who brought them into the business get rich for recruiting them.


Herbalife, founded in 1980, has faced such criticism for decades. The debate centers on the way the company compensates its distributors, allowing them to profit from their own sales as well as sales made by distributors they've recruited — and distributors those distributors have recruited.


The company challenges the criticism, saying it's a legitimate company that sells nutritious products while offering entrepreneurs like Perez a chance to build their own businesses.


Herbalife President Des Walsh said the company does not target any specific demographic. The company's popularity among Latinos exploded in recent years, he said, when U.S. distributors imported the nutrition club concept from Mexico, which is second to the United States in Herbalife sales.


"This wasn't a company focus on the Latino community," Walsh said. "This was the Latino community in the United States seeing and hearing of the tremendous success of nutrition clubs in Mexico and then seeking to replicate that here."


Its marketing efforts do hit the Latino community. The company recently signed a 10-year, $44-million sponsorship of the Los Angeles Galaxy professional soccer team, which has a massive Latino fan base. Each year, it holds a national convention in Spanish called "Extravaganza Latina."


Before nutrition clubs started in Mexico, the only way for consumers to buy Herbalife products was in bulk containers to be used at home. A cheaper alternative is being served up at the nutrition clubs, where consumers can buy single servings and drink them in social settings, surrounded by other people with similar weight-loss goals.


This concept has taken off among Latinos, who are taught at an early age that natural remedies such as herbs and juices are a better option than U.S.-style medicine, said Alexandro Jose Gradilla, chair of the Chicano Studies Department at Cal State Fullerton. That makes Herbalife products popular among immigrants.


Selling the products for profit is also a good fit for Latinos because it allows distributors to take advantage of relationships within the close-knit immigrant community, Gradilla said.


Herbalife spokeswoman Barbara Henderson said in a statement that the company "follows all applicable laws in dealing with distributors, whether Latino or not," but she did not elaborate further.





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Oscar Pistorius remains in jail facing murder charge









JOHANNESBURG, South Africa -- South African athlete Oscar Pistorius, who made history last year as the first double amputee runner to compete in the Olympics using prosthetic blades, will spend the night in jail Thursday after he was charged with murder in the death of his girlfriend at his house, prosecutors said.


The National Prosecuting Authority said Pistorius would remain in custody until his hearing Friday, when police intend to oppose bail.


Reeva Steenkamp, a 30-year-old model, died after being shot several times in the head and arm in Pistorius’ house in an upscale suburb in Pretoria.








PHOTOS: Pistorius in the London Olympics


Pistorius was ushered from the home by police Thursday morning with a gray hoodie covering his head and obscuring most of his face.


South Africans were in shock about the accusation against Pistorius, who became a hero during his long battle for the right to compete in the Olympics. After a controversy on whether the blades he uses to walk and run gave him an advantage in races, Pistorius was granted the right to compete in the London 2012 Olympic Games.


South Africa has one of the world's highest rates of murder and violent crime, and many South Africans keep guns at home to guard against intruders.


The Afrikaans-language newspaper Beeld suggested that Pistorius mistook his girlfriend for a burglar and killed her accidentally.


However, a police spokeswoman, Brig. Denise Beukes, said police were “surprised” at reports the killing was accidental, adding that that version hadn’t come from police, according to the South African Press Assn.


"I confirm there had been previous incidents of a domestic nature at his place,” said Beukes, adding that police couldn’t comment on the decision to oppose bail.


Beukes said police had interviewed neighbors who heard sounds at Pistorius’ home earlier in the evening, and also at the time the incident reportedly took place.


Pistorius’ father, Henke Pistorius, said his son was sad. But the older Pistorius said he didn’t know the facts.


“I don’t know nothing. It will be extremely obnoxious and rude to speculate,” he said in a radio interview. “If anyone makes a statement, it will have to be Oscar.”


An advertisement for Nike, one of Pistorius’ major sponsors, was removed from his official website Thursday. It had shown the athlete in a green lycra athletic suit and the slogan, “I am the bullet in the chamber."


ALSO:


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British case of new virus suggests person-to-person transmission





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'Melrose' actress gets 3 years for deadly NJ crash


SOMERVILLE, N.J. (AP) — A former "Melrose Place" actress who was drunk when her SUV plowed into a car and killed a woman was sentenced Thursday to three years in prison, infuriating the victim's relatives, who had hoped for the 10-year maximum.


"What a travesty!" the victim's husband, Fred Seeman, yelled after the sentence was read.


"This is not justice," the victim's 26-year-old son, Ford Seeman, told the judge before he stormed out of the courtroom.


A jury in November convicted Amy Locane-Bovenizer of vehicular homicide in the 2010 death of 60-year-old Helene Seeman in Montgomery Township.


Locane-Bovenizer will be eligible for parole after 2 1/2 years and will be credited the 81 days she has already served. She also had her license suspended for five years and will be on probation for three years after her release. She must pay several thousand dollars in fines.


Locane-Bovenizer, who didn't testify at the trial, appeared in 13 episodes of TV's "Melrose Place" and in movies including "Cry-Baby," ''School Ties" and "Secretary."


Prosecutors say she was driving with a blood-alcohol level nearly three times the legal limit when her SUV slammed into a Mercury Milan driven by Fred Seeman as he was turning into his driveway. Fred Seeman's wife, Helene, was killed, and he was seriously injured.


During the trial, the defense argued that Fred Seeman was making a slow turn, which contributed to the crash. They maintained that it was an accident, not a crime.


The defense also shifted blame to a third motorist who they say distracted the actress by honking at her and chasing her after being rear-ended. They said the chase led Locane-Bovenizer to drive 20 miles over the speed limit on a dark two-lane road.


The judge lowered the maximum sentence citing the hardship on Locane-Bovenizer's two young children. One has a serious medical and mental disability. The defense went into detail about how her sick child was deteriorating physically and psychologically since the actress' incarceration and about how a prolonged sentence would make it worse.


"I'm just glad her little girls will have their mother back soon," Locane-Bovenizer's mother, Helen Locane, said as she walked out of the courtroom.


In an emotionally charged statement, Fred Seeman told the court that the defense contention that his vehicle was turning slowly added "salt on the wound," and he said he was appalled that Locane-Bovenizer took no responsibility for killing his wife.


The actress, in turn, apologized to Seeman's family and said she did take full responsibility.


"I am truly sorry for all of the pain I have caused," she said, struggling to get through her statement, as she looked toward the family that packed one side of the courtroom while her friends and family packed the other. "My own suffering will never go away."


Judge Robert Reed said that he had no sympathy for the actress but that the children should not suffer even more because of her actions.


The Seeman family said after the sentencing that the decision was a "mockery" and only added to the suffering they've endured since the accident.


"What's one more punch in the gut?" Ford Seeman said.


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Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

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Senate Democrats back Cordray renomination









WASHINGTON — Senate Democrats said Thursday that they were united in opposing Republican efforts to weaken the Consumer Financial Protection Bureau and told President Obama they supported the renomination of Richard Cordray to head the agency.


"It is time to confirm Richard Cordray as CFPB director to give the American people the protections they deserve and the marketplace the certainty it needs to help strengthen our economic recovery," Senate Banking Committee Chairman Tim Johnson (D-S.D.) told reporters.


Johnson organized a letter signed by 52 of 53 Senate Democrats and the chamber's two independents, Bernie Sanders of Vermont and Angus King of Maine, telling Obama they backed his decision to renominate Cordray and that they oppose Republican attempts to change the bureau's structure.





The only Democrat who did not sign the letter was Mark Pryor of Arkansas. But with 54 senators backing him, Cordray would have enough votes to be confirmed if Republicans allowed a vote.


Nearly all Senate Republicans, enough to mount a successful filibuster, said this month they would block the confirmation of any nominee to head the bureau unless its structure was changed.


Republicans complained that the agency, the centerpiece of the 2010 Dodd-Frank financial reform law, is too powerful.


They want the single-director position to be replaced by a bipartisan commission. They want the bureau's funding to be part of the congressional appropriations process instead of flowing directly from the Federal Reserve. And they want to make it easier for other banking regulators to block actions by the consumer bureau.


"Far too much power is vested in the sole CFPB director without any meaningful checks and balances," the 43 Republican senators, led by Minority Leader Mitch McConnell (R-Ky.) wrote to Obama on Feb. 3.


The same threat, issued in 2011, led Obama to install Cordray with a controversial recess appointment a year ago, along with three members of the National Labor Relations Board.


Last month, a federal appeals court ruled that Obama's NLRB appointments violated the Constitution because the Senate had not formally adjourned. The lawsuit challenging the appointments did not include Cordray, but it is widely believed that it would affect his appointment as well.


The Obama administration is almost certain to appeal the decision to the Supreme Court.


Obama has renominated Cordray to the position; the recess appointment term expires at the end of this year.


The court decision and the renewed filibuster threat had led to speculation that Democrats might be willing to negotiate changes to the bureau's structure. But in Thursday's letter, Democrats said they did not intend to give in.


"As supporters of strong and effective consumer protection, we oppose efforts to weaken the CFPB through structural changes, including as the price for Senate approval of Director Cordray's nomination," the letter said.


Sens. Jack Reed (D-R.I.) and Elizabeth Warren (D-Mass.) joined Johnson in releasing the letter.


"They want to hold up his nomination for the sole purpose of trying to weaken the agency. We've now got 54 senators saying no," said Warren, who came up with the idea for the agency and helped launch it before being elected in November.


"American families deserve a strong watchdog, and Rich Cordray deserves a vote now," she said.


jim.puzzanghera@latimes.com





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