Software Programs Help Doctors Diagnose, but Can’t Replace Them

SAN FRANCISCO — The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the moment of truth arrived, and the room was silent with anticipation.

At last he spoke. “Lymphoma with secondary hemophagocytic syndrome,” he said. The crowd erupted in applause.

Professionals in every field revere their superstars, and in medicine the best diagnosticians are held in particularly high esteem. Dr. Gurpreet Dhaliwal, 39, a self-effacing associate professor of clinical medicine at the University of California, San Francisco, is considered one of the most skillful clinical diagnosticians in practice today.

The case Dr. Dhaliwal was presented, at a medical  conference last year, began with information that could have described hundreds of diseases: the patient had intermittent fevers, joint pain, and weight and appetite loss.

To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course. He was given new information bit by bit — lab, imaging and biopsy results. Over the course of the session, he drew on an encyclopedic familiarity with thousands of syndromes. He deftly dismissed red herrings while picking up on clues that others might ignore, gradually homing in on the accurate diagnosis.

Just how special is Dr. Dhaliwal’s talent? More to the point, what can he do that a computer cannot? Will a computer ever successfully stand in for a skill that is based not simply on a vast fund of knowledge but also on more intangible factors like intuition?

The history of computer-assisted diagnostics is long and rich. In the 1970s, researchers at the University of Pittsburgh developed software to diagnose complex problems in general internal medicine; the project eventually resulted in a commercial program called Quick Medical Reference. Since the 1980s, Massachusetts General Hospital has been developing and refining DXplain, a program that provides a ranked list of clinical diagnoses from a set of symptoms and laboratory data.

And I.B.M., on the heels of its triumph last year with Watson, the Jeopardy-playing computer, is working on Watson for Healthcare.

In some ways, Dr. Dhaliwal’s diagnostic method is similar to that of another I.B.M. project: the Deep Blue chess program, which in 1996 trounced Garry Kasparov, the world’s best player at the time, to claim an unambiguous victory in the computer’s relentless march into the human domain.

Although lacking consciousness and a human’s intuition, Deep Blue had millions of moves memorized and could analyze as many each second. Dr. Dhaliwal does the diagnostic equivalent, though at human speed.

Since medical school, he has been an insatiable reader of case reports in medical journals, and case conferences from other hospitals. At work he occasionally uses a diagnostic checklist program called Isabel, just to make certain he hasn’t forgotten something. But the program has yet to offer a diagnosis that Dr. Dhaliwal missed.

Dr. Dhaliwal regularly receives cases from physicians who are stumped by a set of symptoms. At medical conferences, he is presented with one vexingly difficult case and is given 45 minutes to solve it. It is a medical high-wire act; doctors in the audience squirm as the set of facts gets more obscure and all the diagnoses they were considering are ruled out. After absorbing and processing scores of details, Dr. Dhaliwal must commit to a diagnosis. More often than not, he is right.

When working on a difficult case in front of an audience, Dr. Dhaliwal puts his entire thought process on display, with the goal of “elevating the stature of thinking,” he said. He believes this is becoming more important because physicians are being assessed on whether they gave the right medicine to a patient, or remembered to order a certain test.

Without such emphasis, physicians and training programs might forget the importance of having smart, thoughtful doctors. “Because in medicine,” Dr. Dhaliwal said, “thinking is our most important procedure.”

He added: “Getting better at diagnosis isn’t about figuring out if someone has one rare disease versus another. Getting better at diagnosis is as important to patient quality and safety as reducing medication errors, or eliminating wrong site surgery.”

Clinical Precision

Dr. Dhaliwal does half his clinical work on the wards of the San Francisco V. A. Medical Center, and the other half in its emergency department, where he often puzzles through multiple mysteries at a time.

One recent afternoon in the E.R., he was treating a 66-year-old man who was mentally unstable and uncooperative. He complained of hip pain, but routine lab work revealed that his kidneys weren’t working and his potassium was rising to a dangerous level, putting him in danger of an arrhythmia that could kill him — perhaps within hours. An ultrasound showed that his bladder was blocked.

There was work to be done: drain the bladder, correct the potassium level. It would have been easy to dismiss the hip pain as a distraction; it didn’t easily fit the picture. But Dr. Dhaliwal’s instinct is to hew to the ancient rule that physicians should try to come to a unifying diagnosis. In the end, everything — including the hip pain — was traced to metastatic prostate cancer.

“Things can shift very quickly in the emergency room,” Dr. Dhaliwal said. “One challenge of this, whether you use a computer or your brain, is deciding what’s signal and what’s noise.” Much of the time, it is his intuition that helps figure out which is which.

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National Briefing | New England: New Hampshire: Not Guilty Plea in Hepatitis Case

A traveling hospital technologist accused of stealing drugs and infecting patients with hepatitis C through contaminated syringes pleaded not guilty in federal court on Monday. The technologist, David Kwiatkowski, whom prosecutors described as a “serial infector,” was indicted last week on charges of tampering with a consumer product and illegally obtaining drugs. Until May, Mr. Kwiatkowski worked as a cardiac technologist at Exeter Hospital, where 32 patients were given diagnoses of the same strain of hepatitis C he carries. Before that, he worked in 18 hospitals in seven states, moving from job to job despite having been fired twice over accusations of drug use and theft. In addition to the New Hampshire patients, a handful of patients in Kansas and one in Maryland have been found to carry the strain Mr. Kwiatkowski carries.

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National Briefing | New England: New Hampshire: Not Guilty Plea in Hepatitis Case

A traveling hospital technologist accused of stealing drugs and infecting patients with hepatitis C through contaminated syringes pleaded not guilty in federal court on Monday. The technologist, David Kwiatkowski, whom prosecutors described as a “serial infector,” was indicted last week on charges of tampering with a consumer product and illegally obtaining drugs. Until May, Mr. Kwiatkowski worked as a cardiac technologist at Exeter Hospital, where 32 patients were given diagnoses of the same strain of hepatitis C he carries. Before that, he worked in 18 hospitals in seven states, moving from job to job despite having been fired twice over accusations of drug use and theft. In addition to the New Hampshire patients, a handful of patients in Kansas and one in Maryland have been found to carry the strain Mr. Kwiatkowski carries.

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Generic Drug Makers Facing Squeeze on Revenue

They call it the patent cliff.

Brand-name drug makers have feared it for years. And now the makers of generic drugs fear it, too.

This year, more than 40 brand-name drugs — valued at $35 billion in annual sales — lost their patent protection, meaning that generic companies were permitted to make their own lower-priced versions of well-known drugs like Plavix, Lexapro and Seroquel — and share in the profits that had exclusively belonged to the brands.

Next year, the value of drugs scheduled to lose their patents and be sold as generics is expected to decline by more than half, to about $17 billion, according to an analysis by Crédit Agricole Securities.“The patent cliff is over,” said Kim Vukhac, an analyst for Crédit Agricole. “That’s great for large pharma, but that also means the opportunities theoretically have dried up for generics.”

In response, many generic drug makers are scrambling to redefine themselves, whether by specializing in hard-to-make drugs, selling branded products or making large acquisitions. The large generics company Watson acquired a European competitor, Actavis, in October, vaulting it from the fifth- to the third-largest generic drug maker worldwide.

“They are certainly saying either I need to get bigger, or I need to get ‘specialer,’ ” said Michael Kleinrock, director of research development at the IMS Institute for Healthcare Informatics, a health industry research group. “They all want to be special.”

As one consequence of the approaching cliff, executives for generic drug companies say, they will no longer be able to rely as much on the lucrative six-month exclusivity periods that follow the patent expirations of many drugs. During those periods, companies that are the first to file an application with the Food and Drug Administration, successfully challenge a patent and show they can make the drug win the right to sell their version exclusively or with limited competition.

The exclusivity windows can give a quick jolt to companies. During the first nine months of 2012, sales of generic drugs increased by 19 percent over the same period in 2011, to $39.1 billion from $32.8 billion, according to Michael Faerm, an analyst for Credit Suisse. Sales of branded drugs, by contrast, fell 4 percent during the same period, to $174.2 billion from $181.3 billion.

But those exclusive periods also make generic drug makers vulnerable to the fickle cycle of patent expiration. “The only issue is it’s a bubble, too,” said Mr. Kleinrock. He said next year, the generic industry would enter a drought that was expected to last about two years.  Of the drugs that are becoming generic, fewer have exclusivity periods dedicated to a single drug maker.

In 2013, for example, the antidepressant Cymbalta, sold by Eli Lilly, is scheduled to be available in generic form. But more than five companies are expected to share in sales during the first six months, according to a report by Ms. Vukhac.

Heather Bresch, the chief executive of Mylan, the second-largest generics company in the United States, said Wall Street analysts were obsessed with the issue. “I can’t go anywhere without being asked about the patent cliff, the patent cliff, the patent cliff,” she said. “The patent cliff is one aspect of a complex, multilayered landscape, and I think each company is going to face it differently.”

Jeremy M. Levin, the chief executive of Teva Pharmaceuticals, the largest global maker of generic drugs, agreed. “The concept of exclusivity — where only one generic player could actually make money out of the unique moment — has diminished,” he said. “In the absence of that, many companies have had to really ask the question, ‘How do I really play in the generics world?’ ”

For Teva, Mr. Levin said, he believes the answer will be both its reach  — it sells 1,400 products, and one in six generic prescriptions in the United States is filled with a Teva product  — and what he says is a reputation for making quality products. That focus will be increasingly important, he said, given recent statements by the F.D.A. that it intends to take a closer look at the quality of generic drugs. Mr. Levin also said he planned to cut costs, announcing last week that he intended to trim from $1.5 to $2 billion in expenses over the next five years.

This article has been revised to reflect the following correction:

Correction: December 4, 2012

An earlier version of this article misstated the country in which the pharmaceutical company Endo is based. It is an American company, not Japanese.

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Syria Moves Its Chemical Weapons and Gets Another Warning

WASHINGTON — The Syrian military’s movement of chemical weapons in recent days has prompted the United States and several allies to repeat their warning to President Bashar al-Assad that he would be “held accountable” if his forces used the weapons against the rebels fighting his government.

The warnings, which one European official said were “deliberately vague to keep Assad guessing,” were conveyed through Russia and other intermediaries.

What exactly the Syrian forces intend to do with the weapons remains murky, according to officials who have seen the intelligence from Syria. One American official provided the most specific description yet of what has been detected, saying that “the activity we are seeing suggests some potential chemical weapon preparation,” which goes beyond the mere movement of stockpiles among Syria’s several dozen known sites. But the official declined to offer more specifics of what those preparations entailed.

Over the weekend, the activity in Syria prompted a series of emergency communications among the Western allies, who have long been developing contingency plans in case they decided to intervene in an effort to neutralize the chemical weapons, a task that the Pentagon estimates would require upward of 75,000 troops. But there were no signs that preparations for any such effort were about to begin.

So far, President Obama has been very cautious about intervening in Syria, declining to arm the opposition groups directly, or even to formally recognize a newly formed coalition of opposition forces that the United States helped create.

But at a news conference in August, Mr. Obama told reporters that any evidence that Mr. Assad was moving the weapons in a threatening way or making use of them is “a red line for us” that could prompt direct American intervention. “That would change my calculus,” he added. “That would change my equation.”

American officials would not say over the weekend whether the activity they were now seeing edged toward the limit set by Mr. Obama. “These are desperate times for Assad, and this may simply be another sign of desperation,” one senior American diplomat, who has been deeply involved in the effort to try to dissuade Mr. Assad’s forces from using the chemical weapons, said Sunday.

A senior Israeli official said the movement of the chemical weapons, and the apparent preparations to use them, could be a bluff, intended as a warning to the West at a moment when NATO and the United States were debating greater support to opposition groups.

“It’s very hard to read Assad,” one senior Israeli official said. “But we are seeing a kind of action that we’ve never seen before,” he said, declining to elaborate.

The White House refused to comment on the intelligence reports, which have been shared with senior members of Congress. But a senior administration official, asked about the concerns, issued a new warning to the Syrians.

“The president has made it clear that the use of chemical weapons in Syria would cross a red line for the United States,” the official said. “We consistently monitor developments related to Syria’s stockpiles of chemical weapons, and are in regular contact with international partners who share our concern.

“The Assad regime must know that the world is watching, and that they will be held accountable by the United States and the international community if they use chemical weapons or fail to meet their obligations to secure them.”

Representative Mike Rogers, a Michigan Republican who heads the House Intelligence Committee, declined to comment on the new intelligence reports but said in a statement late Sunday: “We are not doing enough to prepare for the collapse of the Assad regime, and the dangerous vacuum it will create. Use of chemical weapons by the Assad regime would be an extremely serious escalation that would demand decisive action from the rest of the world."

Several months ago, the United States military quietly sent a task force of more than 150 planners and other specialists to Jordan to help the armed forces there to, among other things, prepare for the possibility that Syria would lose control of its chemical weapons. Turkey has asked NATO for two batteries of the Patriot antimissile system, in part as protection against Syrian missiles that might come into Turkish territory. In making their case, the Turks have raised the possibilities that chemical weapons could be used in the warheads.

This is not the first time activity at stockpile sites has been detected. Defense Secretary Leon E. Panetta said on Sept. 28 that there had been “some movement” of Syria’s chemical weapons stockpiles to put them in more secure locations. “While there’s been some limited movement, again, the major sites still remain in place, still remain secure,” he said at the time.

But the new activity appears to be of a different nature, and officials are no longer willing to say that all the sites remain secure. “We’re worried about what the military is doing,” one official said, “but we’re also worried about some of the opposition groups,” including some linked to Hezbollah, which has set up camps near some of the chemical weapons depots.

Since the crisis began in Syria and concern has been focused on the country’s vast stockpile, the United States and its allies have increased electronic eavesdropping and other surveillance activities of the sites. A senior defense official said that no United States troops had been put on heightened alert in response to the activity, although the Pentagon was prepared to do so, if necessary.

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After Death of Sattar Beheshti, Iranian Blogger, Head of Tehran’s Cybercrimes Unit Is Fired

TEHRAN — Iranian’s national police chief fired the commander of Tehran’s cybercrimes police unit on Saturday for negligence in the death of a blogger in prison.

The dismissal of the commander, Gen. Saeed Shokrian, follows investigations by Parliament and Iran’s judiciary into the unexplained death of the blogger, Sattar Beheshti, 35, who died in early November just a few days after being arrested by the cybercrimes police unit, known here as FATA.

“Tehran’s FATA should be held responsible for the death of Sattar Beheshti,” said Iran’s national police chief, Ismael Ahmadi-Moqaddam, according to the Iranian Labor News Agency.

It is unclear whether General Shokrian will also face judicial charges over the blogger’s death.

The public nature of his dismissal suggests that he will bear most of the responsibility for the death. In similar cases in the past, officials have been punished, but it is rare for them to be named and publicly dismissed on the same day.

Mr. Beheshti’s Web site, My Life for My Iran, criticized Iran’s financial contributions to the Hezbollah movement in Lebanon. Mr. Beheshti posted pictures of Lebanese youths having parties alongside images of Iranians living in poverty.

The exact cause of Mr. Beheshti’s death remains murky. Mr. Ahmadi-Moqaddam said Tuesday that investigations had ruled out torture as a cause of death, saying it was possible that Mr. Beheshti, who in pictures looks big and strong, died of “psychological shock.”

Iranian activists and bloggers say Mr. Beheshti died of injuries following beatings. Iran’s judiciary spokesman, Gholam Hussein Mohseni-Ejei, recently admitted that Mr. Beheshti — while in prison — had lodged a written complaint against an interrogator, in which he accused the man of having beaten him during his detention in Tehran’s Evin prison.

“I, Sattar Beheshti, was arrested by FATA and beaten and tortured with multiple blows to my head and body,” read the document, published by the opposition Kalame Web site. He added, “If anything happens to me, the police are responsible.”

Mr. Ahmadi-Moqaddam said that Mr. Beheshti was given tranquilizers while in the prison’s clinic, but that when handed over to the cybercrimes unit its officers denied him the same tranquilizers. “This might be regarded as neglect,” he said. “However, there were no signs of beatings on his body.”

Official statements on the cause of death have been contradictory. An influential member of Parliament who earlier denied that Mr. Beheshti had been tortured in any way told the Tabnak Web site that the blogger had been beaten, but died of shock and fear.

“Definitely he was beaten inside the FATA detention center,” the lawmaker, Alaeddin Borujerdi, told the Web site, “but he didn’t die as a result of these beatings.” He also stressed that the cybercrimes unit must change the way it deals with prisoners.

Iranian activists who have been in contact with Mr. Beheshti’s family say his relatives were not allowed to see his body before a hurried funeral on Nov. 6 in his hometown, Robat Karim, 30 miles southwest of the capital, Tehran.

In Mr. Beheshti’s final post, on Oct. 29, a day before his arrest, he said he was being threatened by security officials. “They told me that if I didn’t close my big mouth my mother should prepare to wear black clothes,” for mourning.

The Iranian Parliament’s special investigator into the case, Mehdi Davatgari, said he welcomed the commander’s removal. “This move shows the civil rights of our citizens are our top priority,” he said.

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Call That Kept Nursing Home Patients in Sandy’s Path

Chang W. Lee/The New York Times

Workers were shocked that nursing and adult homes in areas like Rockaway Park, Queens, weren’t evacuated.

Hurricane Sandy was swirling northward, four days before landfall, and at the Sea Crest Health Care Center, a nursing home overlooking the Coney Island Boardwalk in Brooklyn, workers were gathering medicines and other supplies as they prepared to evacuate.

Then the call came from health officials: Mayor Michael R. Bloomberg, acting on the advice of his aides and those of Gov. Andrew M. Cuomo, recommended that nursing homes and adult homes stay put. The 305 residents would ride out the storm.

The same advisory also took administrators by surprise at the Ocean Promenade nursing home, which faces the Atlantic Ocean in Queens. They canceled plans to move 105 residents to safety.

“No one gets why we weren’t evacuated,” said a worker there, Yisroel Tabi. “We wouldn’t have exposed ourselves to dealing with that situation.”

The recommendation that thousands of elderly, disabled and mentally ill residents remain in more than 40 nursing homes and adult homes in flood-prone areas of New York City had calamitous consequences.

At least 29 facilities in Queens and Brooklyn were severely flooded. Generators failed or were absent. Buildings were plunged into a cold, wet darkness, with no access to power, water, heat and food.

While no immediate deaths were reported, it took at least three days for the Fire Department, the National Guard and ambulance crews from around the country to rescue over 4,000 nursing home and 1,500 adult home residents. Without working elevators, many had to be carried down slippery stairwells.

“I was shocked,” said Greg Levow, who works for an ambulance service and helped rescue residents at Queens. “I couldn’t understand why they were there in the first place.”

Many sat for hours in ambulances and buses before being transported to safety through sand drifts and debris-filled floodwaters. They went to crowded shelters and nursing homes as far away as Albany, where for days, they often lacked medical charts and medications. Families struggled to locate relatives.

The decision not to empty the nursing homes and adult homes in the mandatory evacuation area was one of the most questionable by the authorities during Hurricane Sandy. And an investigation by The New York Times found that the impact was worsened by missteps that officials made in not ensuring that these facilities could protect residents.

They did not require that nursing homes maintain backup generators that could withstand flooding. They did not ensure that health care administrators could adequately communicate with government agencies during and after a storm. And they discounted the more severe of the early predictions about Hurricane Sandy’s surge.

The Times’s investigation was based on interviews with officials, health care administrators, doctors, nurses, ambulance medics, residents, family members and disaster experts. It included a review of internal State Health Department status reports. The findings revealed the striking vulnerability of the city’s nursing and adult homes.

On Sunday, Oct. 28, the day before Hurricane Sandy arrived, Mr. Bloomberg ordered a mandatory evacuation in Zone A, the low-lying neighborhoods of the city. But by that point, Mr. Bloomberg, relying on the advice of the city and state health commissioners, had already determined that people in nursing homes and adult homes should not leave, officials said.

The mayor’s recommendations that health care facilities not evacuate startled residents of Surf Manor adult home in Coney Island, said one of them, Norman Bloomfield. He recalled that another resident exclaimed, “What about us! Why’s he telling us to stay?”

The commissioners made the recommendation to Mr. Bloomberg and Mr. Cuomo because they said they believed that the inherent risks of transporting the residents outweighed the potential dangers from the storm.

In interviews, senior Bloomberg and Cuomo aides did not express regret for keeping the residents in place.

“I would defend all the decisions and the actions” by the health authorities involving the storm, said Linda I. Gibbs, a deputy mayor. “I feel like I’m describing something that was a remarkable, lifesaving event.”

Dr. Nirav R. Shah, the state health commissioner, who regulates nursing homes, said: “I’m not even thinking of second-guessing the decisions.”

Still, officials in New Jersey and in Nassau County adopted a different policy, evacuating nursing homes in coastal areas well before the storm.

Contradictory Forecasts

The city’s experience with Tropical Storm Irene last year weighed heavily on state and city health officials and contributed to their underestimating the impact of Hurricane Sandy, according to records and interviews.

Before Tropical Storm Irene, the officials ordered nursing homes and adult homes to evacuate. The storm caused relatively minor damage, but the evacuation led to millions of dollars in health care, transportation, housing and other costs, and took a toll on residents.

As a result, when Hurricane Sandy loomed, the officials were acutely aware that they could come under criticism if they ordered another evacuation that proved unnecessary.

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Call That Kept Nursing Home Patients in Sandy’s Path

Chang W. Lee/The New York Times

Workers were shocked that nursing and adult homes in areas like Rockaway Park, Queens, weren’t evacuated.

Hurricane Sandy was swirling northward, four days before landfall, and at the Sea Crest Health Care Center, a nursing home overlooking the Coney Island Boardwalk in Brooklyn, workers were gathering medicines and other supplies as they prepared to evacuate.

Then the call came from health officials: Mayor Michael R. Bloomberg, acting on the advice of his aides and those of Gov. Andrew M. Cuomo, recommended that nursing homes and adult homes stay put. The 305 residents would ride out the storm.

The same advisory also took administrators by surprise at the Ocean Promenade nursing home, which faces the Atlantic Ocean in Queens. They canceled plans to move 105 residents to safety.

“No one gets why we weren’t evacuated,” said a worker there, Yisroel Tabi. “We wouldn’t have exposed ourselves to dealing with that situation.”

The recommendation that thousands of elderly, disabled and mentally ill residents remain in more than 40 nursing homes and adult homes in flood-prone areas of New York City had calamitous consequences.

At least 29 facilities in Queens and Brooklyn were severely flooded. Generators failed or were absent. Buildings were plunged into a cold, wet darkness, with no access to power, water, heat and food.

While no immediate deaths were reported, it took at least three days for the Fire Department, the National Guard and ambulance crews from around the country to rescue over 4,000 nursing home and 1,500 adult home residents. Without working elevators, many had to be carried down slippery stairwells.

“I was shocked,” said Greg Levow, who works for an ambulance service and helped rescue residents at Queens. “I couldn’t understand why they were there in the first place.”

Many sat for hours in ambulances and buses before being transported to safety through sand drifts and debris-filled floodwaters. They went to crowded shelters and nursing homes as far away as Albany, where for days, they often lacked medical charts and medications. Families struggled to locate relatives.

The decision not to empty the nursing homes and adult homes in the mandatory evacuation area was one of the most questionable by the authorities during Hurricane Sandy. And an investigation by The New York Times found that the impact was worsened by missteps that officials made in not ensuring that these facilities could protect residents.

They did not require that nursing homes maintain backup generators that could withstand flooding. They did not ensure that health care administrators could adequately communicate with government agencies during and after a storm. And they discounted the more severe of the early predictions about Hurricane Sandy’s surge.

The Times’s investigation was based on interviews with officials, health care administrators, doctors, nurses, ambulance medics, residents, family members and disaster experts. It included a review of internal State Health Department status reports. The findings revealed the striking vulnerability of the city’s nursing and adult homes.

On Sunday, Oct. 28, the day before Hurricane Sandy arrived, Mr. Bloomberg ordered a mandatory evacuation in Zone A, the low-lying neighborhoods of the city. But by that point, Mr. Bloomberg, relying on the advice of the city and state health commissioners, had already determined that people in nursing homes and adult homes should not leave, officials said.

The mayor’s recommendations that health care facilities not evacuate startled residents of Surf Manor adult home in Coney Island, said one of them, Norman Bloomfield. He recalled that another resident exclaimed, “What about us! Why’s he telling us to stay?”

The commissioners made the recommendation to Mr. Bloomberg and Mr. Cuomo because they said they believed that the inherent risks of transporting the residents outweighed the potential dangers from the storm.

In interviews, senior Bloomberg and Cuomo aides did not express regret for keeping the residents in place.

“I would defend all the decisions and the actions” by the health authorities involving the storm, said Linda I. Gibbs, a deputy mayor. “I feel like I’m describing something that was a remarkable, lifesaving event.”

Dr. Nirav R. Shah, the state health commissioner, who regulates nursing homes, said: “I’m not even thinking of second-guessing the decisions.”

Still, officials in New Jersey and in Nassau County adopted a different policy, evacuating nursing homes in coastal areas well before the storm.

Contradictory Forecasts

The city’s experience with Tropical Storm Irene last year weighed heavily on state and city health officials and contributed to their underestimating the impact of Hurricane Sandy, according to records and interviews.

Before Tropical Storm Irene, the officials ordered nursing homes and adult homes to evacuate. The storm caused relatively minor damage, but the evacuation led to millions of dollars in health care, transportation, housing and other costs, and took a toll on residents.

As a result, when Hurricane Sandy loomed, the officials were acutely aware that they could come under criticism if they ordered another evacuation that proved unnecessary.

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Advertising: Ford Plan to Revive Lincoln Hinges on a New Brand

An unusual ad campaign features Abraham Lincoln, the president for whom the car brand is named.

DEARBORN, Mich. — In the fiercely competitive world of luxury cars, the Ford Motor Company’s Lincoln brand has long been stuck in the slow lane, with stodgy models, older buyers and a distinct lack of pizazz.

But Ford is determined to change that. On Monday, the company will announce upgraded customer service initiatives, a new brand name for Lincoln that plays down the Ford connection and an unusual advertising campaign that features Abraham Lincoln, the president for whom the brand is named.

Ford’s chief executive, Alan R. Mulally, will begin the rebranding effort at an event outside Lincoln Center in Manhattan — the first in a series of moves meant to reverse Lincoln’s seemingly perpetual state of decline.

Ford will formally rechristen the brand as the Lincoln Motor Company and introduce a television spot that begins with an image of Lincoln, stovepipe hat and all. The brand’s first Super Bowl commercial is in the works, as is a revamped Web site that links consumers to a Lincoln “concierge” who can arrange test drives or set up appointments at dealerships.

Mr. Mulally will also announce the on-sale date in early 2013 for the radically redesigned Lincoln MKZ sedan, as well as plans for three new vehicles down the road.

If it seems like an all-out grab for attention, well, that’s exactly the point, said James D. Farley Jr., Ford’s head of global sales and marketing and the newly named chief of the Lincoln revival effort.

“The most important thing is for people to be aware that there is a transition going on,” Mr. Farley said. “We have to shake them up.”

The shake-up is long overdue and critically important to Ford, the nation’s second-largest car company behind General Motors.

As recently as the 1990s, Lincoln was the top-selling luxury automotive brand in the United States. Its large Town Car sedan and hulking Navigator S.U.V. defined the brand, and sales topped more than 230,000 vehicles a year.

But since then, Lincoln has been left in the dust by the German category leaders BMW and Mercedes-Benz, and Toyota’s Lexus division. This year, Lincoln ranks eighth in the American luxury segment, with sales down 2 percent, to 69,000, vehicles in the first 10 months of the year.

Its crosstown rival G.M. has had much better success reviving its Cadillac brand.

“Cadillac has been stabilized, but Lincoln is still muddling about,” said Jack Trout, president of the marketing firm Trout and Partners. “The big question is, how can Lincoln convince people it is more than just a gussied-up Ford?”

That task has now fallen to Mr. Farley, who left Toyota five years ago to join Ford just as Mr. Mulally’s transformation of the company was under way. Since then, Ford has introduced a succession of sleeker, more fuel-efficient and technology-laden models that have lifted sales and made it among the most profitable car companies in the world.

Lincoln, however, has not benefited from the turnaround. It accounts for only 3 percent of Ford’s total sales, down from 8 percent during the brand’s heyday. And since Ford has sold off foreign luxury divisions like Volvo and Jaguar, Lincoln is the sole upscale brand in the company.

“There is nothing more frustrating for us than to have someone who loves their Ford car and S.U.V., but goes out to buy a luxury model from another brand because we don’t have one,” Mr. Farley said.

The Lincoln comeback effort starts with the midsize MKZ, which has been redesigned with a sweeping grille, tapered body style and an all-glass retractable roof. It will be followed by three other new models, including a larger sedan and S.U.V.

But the brand’s image needs much more than better cars. Under Mr. Farley’s direction, a newly formed team of 200 people is intent on establishing the Lincoln Motor Company as a boutique luxury line known for personalized service.

Every customer who reserves an MKZ, for example, will be presented with an elegant gift upon receiving the car. Choices include a selection of wines and Champagne, custom-made jewelry or sunglasses, or a one-night stay at a Ritz-Carlton hotel.

Lincoln’s Web site will also have a consultant available 24 hours a day for live discussions about the products and to streamline the buying process. Prospective buyers will be given an opportunity for a “date night” with Lincoln, which includes a two-day test drive and a free meal at a restaurant.

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Tunnel Collapse Outside Tokyo Traps Motorists

Kyodo News, via Associated Press

A surveillance camera within the Sasago tunnel showed rescue workers at the scene of a collapse on Sunday.

TOKYO — At least seven people were feared dead after part of a highway tunnel collapsed Sunday in eastern Japan, trapping them in their vehicles and starting a fire that filled the tunnel with thick, black smoke.

Franck Robichon/European Pressphoto Agency

Fire fighters and rescue personnel gathered at the entrance to the Sasago tunnel, west of Tokyo.

Three vehicles appear to have been crushed under concrete that fell from the ceiling of the three-mile Sasago Tunnel near the city of Otsuki in Yamanashi Prefecture, about 50 miles west of Tokyo, the national government’s disaster management agency said. Agency and police officials said it remained unclear why the 150- to 200-foot section of eight-inch-thick concrete, weighing about 180 tons, suddenly fell.

A vehicle carrying six people caught fire, emitting heavy smoke that initially prevented firefighters from entering the tunnel. But even after putting out the blaze, rescuers had to temporarily suspend efforts to reach the trapped vehicles because of the danger of a further collapse, officials said.

They said rescue efforts resumed later in the day, though progress was slow because firefighters were still moving carefully.

Officials said a 28-year-old woman managed to flee from the vehicle that caught fire. She told firefighters that five other people remained trapped in her vehicle. It was unknown how many people were in the other vehicles besides the drivers, who were apparently also still trapped inside.

One of the other vehicles appeared to be a truck belonging to a food wholesaler, officials said. They said the driver called his company right after the accident to ask for help, but subsequent attempts to reach him by his cellphone failed.

The operator of the highway, Central Nippon Expressway, held a news conference to apologize for the accident. The police said they had opened an investigation into the cause of the collapse and whether professional negligence by the operator was a factor.

The accident closed a section of the Chuo Expressway, a vital transportation artery connecting Tokyo to western Japan. Such long tunnels — usually lined with smooth, white concrete — are a common sight on highways in this mountainous island nation.

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