Hockey Coaches Defy Doctors on Concussions, Study Finds

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Senate Judiciary Committee Approves Overhaul of Electronic Communications Privacy Act

J. Scott Applewhite/Associated Press

Patrick Leahy, chairman of the Senate Judiciary Committee, is leading an e-mail privacy effort.

The bill is not expected to make it through Congress this year and will be the subject of negotiations next year with the Republican-led House. But the Senate panel’s approval was a first step toward an overhaul of a 1986 law that governs e-mail access and that is widely seen as outdated.

Senator Patrick Leahy, the Vermont Democrat who is chairman of the committee, was an architect of the 1986 law and is leading the effort to remake it. He said at the meeting on Thursday that e-mails stored by third parties should receive the same protection as papers stored in a filing cabinet in an individual’s house.

“Like many Americans, I am concerned about the growing and unwelcome intrusions into our private lives in cyberspace,” Mr. Leahy said. “I also understand that we must update our digital privacy laws to keep pace with the rapid advances in technology.”

Mr. Leahy held a hearing about two years ago on whether and how to update the 1986 law, called the Electronic Communications Privacy Act. But the effort has moved slowly, in part because some law enforcement officials have opposed restricting an investigative tool now used increasingly.

Under the law, authorities need to obtain a search warrant from a judge — requiring them to meet the high standard of showing that there is probable cause to believe that a subject is engaged in wrongdoing — only when they want to read e-mails that have not yet been opened by their recipient and that are fewer than 180 days old.

But the law gives less protection to messages that a recipient has read and left in his or her account. In some cases, officials may obtain a court order for such material merely by presenting a judge with facts suggesting the messages are relevant to an investigation; in other cases, prosecutors can issue a subpoena demanding the materials without any court involvement.

Senator Leahy’s bill would generally require prosecutors to obtain a search warrant from a judge, under the stricter probable-cause standard, to compel a provider to turn over all categories of e-mails and other private documents.

The Center for Democracy and Technology, a nonprofit organization that advocates for electronic privacy rights, hailed the committee vote as “historic.”

In a statement, Gregory T. Nojeim, director of the center’s program on security and technology, said it “sets the stage for updating the law to reflect the reality of how people use technology in their daily lives. It keeps the government from turning cloud providers into a one-stop convenience store for government investigators and requires government investigators to do for online communications what they already do in the offline world: get a warrant before reading postal letters or searching our homes.“

Still, the ranking Republican on the committee, Senator Charles Grassley of Iowa, argued that the bill does not strike the proper balance between privacy and public safety. He expressed concerns that changing the standard of proof for obtaining e-mails would inhibit certain investigations, such as child pornography or child abduction cases.

Mr. Leahy argued that the bill does not alter criminal and antiterrorism laws related to search warrants, including exceptions in emergencies where time is of the essence. But he also said the bill was a starting point and he was open to further negotiations. The panel approved it by a voice vote.

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U.S. Is Weighing Stronger Action in Syrian Conflict

Francisco Leong/Agence France-Presse — Getty Images

Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.

WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.

While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.

The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”

But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.

Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.

Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”

The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.

In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.

“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.

France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.

American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.

“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”

Jessica Brandt contributed reporting from Cambridge, Mass.

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Peter Swire Named Mediator in Internet ‘Do Not Track’ Effort

Over the last few months, an international effort to give consumers more control over the collection of their online data has devolved into acrimonious discussions, name-calling and witch hunts.

Andrew Spear for The New York Times

Peter Swire, a law professor at Ohio State, was named as a mediator by the World Wide Web Consortium. The international group is trying to come up with standards that would allow Internet users to keep their online activities private from advertisers.

The idea was to work out a global standard for “Do Not Track,” a computer browser setting that would allow Internet users to signal Web sites, advertising networks and data brokers that they did not want their browsing activities tracked for marketing purposes.

But some industry executives involved in the negotiations have questioned the agenda of privacy advocates, saying their efforts threaten to undermine an advertising ecosystem that fuels free online products and services. At the same time, some technology experts and privacy advocates have accused industry executives of stalling and acting in bad faith.

Into this rancorous battle steps a new mediator, Peter Swire, a professor of law at Ohio State University and a former White House privacy official during the Clinton administration. On Wednesday, the World Wide Web Consortium, or W3C, the international consortium that has been trying to develop technical Do Not Track standards, said that Mr. Swire would take over as co-chairman of its Tracking Protection Working Group.

While parties on both sides welcomed the move, many said they were doubtful that Mr. Swire could bring opponents to agreement, especially at a time when some industry groups are questioning whether the W3C is an appropriate forum.

On one hand, industry executives have an interest in protecting “behavioral” ads, marketing pitches that use data about an individual’s online activities to tailor ads to that person. On the other hand, consumer advocates argue that Internet users should be able to limit that kind of online surveillance.

Mr. Swire, a former chief counselor for privacy at the Office of Management and Budget, said he hoped to strike a balance that was palatable to both sides. He said he viewed a Do Not Track system as a kind of digital equivalent to the Do Not Call list, a national registry in the United States through which consumers may opt out of phone solicitations.

“People can choose not to have telemarketers call them during dinner. The simple idea is that users should have a choice over how their Internet browsing works as well,” Mr. Swire said in a phone interview. But he added: “The overarching theme is how to give users choice about their Internet experience while also funding a useful Internet.”

Still, Mr. Swire may not be able to overcome the bitterness that remains among the negotiating parties after months of public accusations, personal attacks and recriminations.

Earlier this year at an event at the White House, industry representatives publicly committed to incorporating and honoring a browser-based Do Not Track system under certain conditions. The conditions included a requirement that individual users would actively choose to turn on a don’t-track-me setting. Industry groups also said any system should still permit companies to collect information about users’ browsing activities for market research and product development purposes.

But after months of wrangling with consumer advocates, industry representatives now say the W3C is not an appropriate forum for them to work out policy details, arguing that the group’s expertise is more technical than practical.

In an online discussion forum for the working group, for example, senior industry executives have suggested that respected technology experts are out of touch with commercial reality.

“The advocacy side of the group tends to lean toward absolutist terms and solutions,” Shane Wiley, the vice president for privacy and data governance at Yahoo, wrote in a message in September to Ed Felten, a professor of computer science and public affairs at Princeton University. “The real world isn’t that easy even if it feels that way in a classroom or a small lab.”

Then there are the technologists who say industry executives are playing down the privacy risks of online data-mining.

“For want of a better metaphor: you are the climate change skeptic of computer privacy,” Jonathan Mayer, a graduate student in computer science and law at Stanford University, wrote last month to Yahoo’s Mr. Wiley. “Unlike some of the more patient members of the group, I long ago ceased pretending you’re negotiating in good faith.”

Now the industry has begun an effort to distance itself from the W3C process and promote its own self-regulatory program that allows consumers to decline targeted advertising by installing opt-out buttons from dozens of member companies.

“We’ve seen the W3C falter,” said Mike Zaneis, the general counsel for the Interactive Advertising Bureau, an industry trade group. “So industry is redoubling its efforts to come up with a meaningful standard for browser controls.”

As the debate rages on, newer iterations of popular browsers like Microsoft’s Internet Explorer and Google’s Chrome have already installed Do Not Track settings for their users. But in the absence of accepted global standards for these systems, ad networks and data brokers are not yet honoring the don’t-track-me browser flags. Even Microsoft’s and Google’s own ad services don’t respond to such signals coming from their own browsers.

Although Mr. Swire said he hoped to spur progress, for the moment Do Not Track browser settings have no more significance than emoticons.

“Do Not Track is a work in progress,” Mr. Swire said. “So is the Internet.”

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Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

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Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

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Medicare Is Faulted in Electronic Medical Records Conversion

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

Mike Spencer/Wilmington Star-News, via Associated Press

Celeste Stephens, a nurse, leads a session on electronic records at New Hanover Regional Medical Center in Wilmington, N.C.

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

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Bombings Are Said to Kill Dozens Near Syria’s Capital

Francisco Leong/Agence France-Presse — Getty Images

Rebels celebrated on top of a downed Syrian jet in Daret Azzeh, 20 miles west of Aleppo, on Wednesday.

DUBAI, United Arab Emirates — Syrian state media said on Wednesday that 34 people and possibly many more had died in twin car bombings in a suburb populated by minorities only a few miles from the center of Damascus, the capital, as the civil war swirls from north to south claiming ever higher casualties. One estimate by the government’s opponents put the death toll at 47.

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

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

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

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

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

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

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

Rebels hailed the event as the culmination of their long pursuit of effective antiaircraft weapons, though it was not clear if the downing on Tuesday was an isolated tactical success or heralded a new phase in the war that would present a meaningful challenge to the Syrian government’s air supremacy. In Damascus, the official SANA news agency said the explosions in Jaramana outside the city at around 7 a.m. were the work of “terrorists,” the word used by the authorities to denote rebel forces seeking the overthrow of President Bashar al-Assad. Photographs on the SANA Web site showed wreckage and flames in what looked like a narrow alleyway with cars covered in chunks of debris from damaged buildings. The agency said the bombings were in the main square of Jaramana, which news reports said is largely populated by members of the Christian and Druse minorities. Residents said the neighborhood was home to many families who have fled other parts of Syria because of the conflict and to some Palestinian families. The blasts caused “huge material damage to the residential buildings and shops,” SANA said.

The photographs on the Web site showed shattered windows at the Abou Samra coffee house and gurneys laden with injured people clogging what seemed to be a hospital corridor.

SANA said two bombings in other neighborhoods caused minor damage. Activists reported that there were four explosions and said they were all “huge.”

Footage broadcast on Syria’s private Addounia channel and state television showed damage scarring gray six-story apartment houses above tangles of wrecked cars as ambulances arrived to transport the wounded and rescuers spraying rubble with fire hoses. The camera panned over bloodstained sidewalks.

The blasts seemed initially at least to shift the focus of the fighting from the north, where insurgents have claimed string of tactical breakthroughs in recent days, to areas ringing Damascus.

In the north in recent days, the insurgents also claimed to have seized air bases and a hydroelectric dam, apparently seeking both to expand their communications lines and to counter the government’s supremacy in the air.

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

The explosions reflected the dramatic shift since Syria’s uprising began in March 2011 as a peaceful protest centered on the southern town of Dara’a. It has since spread across the land in a full-blown civil war pitting government forces against a rebel army of Army defectors, disaffected civilians and what the authorities say are foreign jihadists.

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

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Bits Blog: Apple Fires a Manager Over Its Misfire on Maps

8:51 p.m. | Updated

Apple has fired a manager who oversaw its mobile mapping service, continuing to clean house after a bad stumble.

Eddy Cue, senior vice president for Internet software and services at Apple, fired the manager, Richard Williamson, according to two people briefed on the matter who did not want to be named to avoid Apple’s ire. The firing happened shortly before Thanksgiving, according to one of these people.

Trudy Muller, an Apple spokeswoman, declined to comment. Mr. Williamson did not respond to a message sent to him through the business networking site LinkedIn, which as of Tuesday evening still had a profile listing him as Apple’s senior director of iOS platform services.

Apple had been using Google’s mapping service in its mobile software, but in an update released in September it replaced Google’s maps with its own. The new service added some features, like turn-by-turn directions and sharper graphics, but it was widely criticized over incorrect addresses, misplaced landmarks and misleading driving directions.

In a rare move, Timothy D. Cook, Apple’s chief executive, publicly apologized for the deficiencies of the service and recommended that disappointed customers use mapping services from Apple’s rivals while the company worked out the kinks.

Some early problems with the maps have been fixed. When providing directions for travel from San Francisco to Sausalito, Calif., Apple’s maps used to say the trip required taking a ferry; now it shows a simple drive on the freeway. The Flatiron building in New York and the Washington Monument are no longer a block or two from their rightful homes. But some directions still lead drivers astray, and flaws in the 3-D imagery persist; for example, the London Eye still has no spokes.

The firing of Mr. Williamson, which was first reported by Bloomberg News, follows a management shake-up at Apple in late October, when Mr. Cook fired Scott Forstall, the former head of Apple’s mobile software development. Mr. Cook made the change after months of simmering tensions between Mr. Forstall and other executives, which were exacerbated by the map problems.

As part of that shake-up, Mr. Cook gave Mr. Cue oversight of Apple Maps, along with Siri, the company’s voice-activated assistant technology in the iPhone.

Apple prepared for years to shift to its own mapping system. It acquired three start-ups and formed a partnership with TomTom, a Dutch maker of navigation systems. Tony Costa, a Forrester analyst, said Apple’s move was a necessary one, because iPhone owners were the most active users of mobile maps.

“To leave those people in Google’s hands is just something Apple can’t do,” Mr. Costa said. “Their ability to control and evolve and innovate with maps was limited by their dependence on Google.”

While they wait for Apple’s maps to get better, some Apple customers have also been waiting for Google to release its own maps app for Apple devices. People working on the app say they are seeking to finish it by the end of the year.

Tyler Bell, a product director of Factual, a company that Apple has listed as one of its data providers for business listings, said mapping services had become extremely challenging to produce because smartphone owners demand more from maps than ever before.

Apple, or any company that provides maps, has to collect data from many different vendors and then stitch it together to overlay onto a map, he said. Often there are duplicate entries, or locations are labeled or placed differently depending on the vendor. Along with using computer algorithms to cobble together the data, human testers are needed to smooth things out.

“All these things need to be improved, and it’s a never-ending problem,” Mr. Bell said. He added that he felt Apple had the proper tools in place to quickly improve its database, like a system that allows users to report problems.

But Marc Prioleau, a managing director of Prioleau Advisors, which provides consulting services for mapping companies, said it would take Apple a long time to fix its maps fully because of the scale and complexity of the effort.

Google had a huge head start, he said, because it began doing maps for stationary computers, a less demanding task, and could gradually build on the data as smartphones and tablets emerged.

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F.D.A. May Tap Experts on Energy Drinks

The Food and Drug Administration said in a letter released on Tuesday that it was likely to seek advice from outside experts to help determine whether energy drinks posed particular risks to teenagers or people with underlying health problems.

The letter appears to signal a change in the agency’s approach to the drinks, which contain high levels of caffeine.

Previously, F.D.A. officials have said that they were investigating possible risks posed by popular products like 5-Hour Energy, Monster Energy and Red Bull. But an agency spokeswoman, Shelly Burgess, said the new letter was the first time that the F.D.A. had said it might turn to outside experts.

The F.D.A. letter, which was released Tuesday by Senator Richard J. Durbin of Illinois and Senator Richard Blumenthal of Connecticut, follows disclosures that the agency received reports of 18 deaths and over 150 injuries that mentioned the possible involvement of energy drinks.

The filing of such reports with the F.D.A. does not prove that a product was responsible for a death or an injury. Energy drink makers have said their products are safe and were not responsible for the health problems.

The officials said a review of the drinks might be “greatly enhanced by also engaging specialized expertise” from an outside group, like the Institute of Medicine, which is part of the National Academy of Sciences.

Industry analysts said the letter indicated that the F.D.A. did not plan any immediate actions on energy drinks, an interpretation that set off a rally on Tuesday in the stock of Monster Beverage, the producer of Monster Energy. Company shares closed at $51.97, up over 13 percent. Any regulatory outcome is likely to be “benign,” Judy Hong, an analyst at Goldman Sachs, said in a note to investors, according to Bloomberg News.

In Canada, however, the use of an outside panel led to limits on caffeine levels in energy drinks.

In their letter, F.D.A. officials indicated that an outside review would focus on the possible risks posed by high levels of caffeine, a stimulant, to certain groups. They reiterated that daily consumption of significant levels of caffeine, which is found in products like coffee and tea, is safe.

“Areas of particular focus would include such matters as the vulnerability of certain populations to stimulants and the incidence and consequence of excessive consumption” of energy drinks, especially by young people, F.D.A. officials wrote.

In Canada, an expert panel made several recommendations, including arguing that such beverages be labeled “stimulant drug-containing drinks.”

Health Canada, that country’s counterpart to the F.D.A., did not adopt many of the group’s recommendations, but it has put in place new rules limiting caffeine levels in cans of energy drinks to 180 milligrams.

Some larger-size cans of energy drinks sold in the United States, like the 24-ounce can of Monster Energy and the 20-ounce can of Red Bull, have caffeine levels above that limit.

An eight-ounce cup of coffee, depending on how it is made, can contain from 100 to 150 milligrams of caffeine.

In the new letter, F.D.A. officials also said that studies that had examined other ingredients, like taurine, that are often used in energy drinks had determined those substances were safe. The agency also said that a survey suggested that energy drinks constitute a small portion of the caffeine consumed in this country, even by teenagers.

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