Shortcuts: The Meaning in a Drawer Full of Old Family Snapshots

Eric Thayer/Reuters

A resident found photos as she sifted the debris of a house destroyed by Hurricane Sandy in Union Beach, N.J.

I WASN’T going to write about Hurricane Sandy. I was going to write about the changing nature of photographs and our relationship to them in this digital age.

Doug Mills/The New York Times

Picture-taking is now mainly digital, making prints of photos uncommon.

But as I began my research, I came across a Facebook page where lost photos from the storm were posted. Called “Union Beach — Photos and Misplaced Items,” the page shows photos of newborns and birthday parties, weddings and family gatherings.

Starting the morning after the storm devastated her community of Union Beach, N.J., Jeanette Van Houten and her niece have collected over a thousand photos and some photo albums. She is making it her mission to scan and post to Facebook as many as possible, including those turned into the fire department, police station and borough hall.

In addition, she was handed a drawerful of over a thousand family photos that must have been wrenched from a dresser.

About 60 photos have been claimed so far, and some professionals have offered to restore damaged photos free.

“These photos were passed down through families and they survived Sandy, even if the structures they were in didn’t,” Ms. Van Houten said. “They tell our story.”

With the Facebook page, Ms. Van Houten uses newer technology to help people reconnect with their old-fashioned snapshots. And seeing the photographs of mundane scenes and milestones on Facebook, along with the grateful comments from people who got back a bit of their lives, reminded me of both the fragility and strength of photos and their continuing importance in our lives. Judith Dupré, author of “Monuments: America’s History in Art and Memory” (Random House, 2007), and other books, teaches a class at her local library in Mamaroneck, N.Y., called “Stories from My Life,” for older residents. They use photos and stories to write about their lives.

“They bring in a basketful of photos,” Ms. Dupré said. “Each one of these photos contains a story — they’re like a key that opens the door to a life.”

And a printed photo “is a different species than a digital photo,” she said. “I don’t think anyone’s figured out the place of digital photos in terms of memory keeping.”

When an elderly aunt of hers died and left behind lots of photographs, Ms. Dupré said the family took them to the memorial service.

“We had a table and people could select and take what they wanted,” she said. “It was a very moving part of the memorial.”

Of course, even prints can lose their meaning and poignancy through the generations.

And in some cases, as with Hurricane Sandy, photos may be safer in cyberspace than in an album on a bookshelf — as long as you remember to upload them to a site like Flickr, Shutterfly, Snapfish or countless other photo sites available. (And make sure you know how long a site will keep your photos. Some, for example, require you to show some activity at least once a year.) That way, if you lose your hard drive, you don’t lose your photos.

But Ms. Dupré said she worried that photos that existed only online somewhere might die with the photographer.

“I don’t even know what my parents have in terms of digital photography,” she said. She said she put the password to her photos safely away with her will and other documents, so her children can access them.

Now I’m not trying to say that the old-fashioned way is the only way. Photography has constantly evolved. The Brownie camera, first sold by Kodak for $1 in 1900, radicalized photography by making it available to just about everyone.

But, and I know this largely a generational thing, I can’t help but wonder about the ubiquity of the cellphone photo. As Ms. Dupré said, “The infinite number of digital photos that can be taken has devalued the single image and made one-of-a-kind prints that much more precious.”

E-mail: shortcuts@nytimes.com

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Drug Shortages Are Becoming Persistent in U.S.

Paul Davis, the chief of a rural ambulance squad in southern Ohio, was down to his last vial of morphine earlier this fall when a woman with a broken leg needed a ride to the hospital.

The trip was 30 minutes, and the patient was in pain. But because of a nationwide shortage, his morphine supply had dwindled from four doses to just one, presenting Mr. Davis with a stark quandary. Should he treat the woman, who was clearly suffering? Or should he save it for a patient who might need it more?

In the end, he opted not to give her the morphine, a decision that haunts him still. “I just feel like I’m not doing my job,” said Mr. Davis, who is chief of the rescue squad in Vernon, Ohio. He has since refilled his supply. “I shouldn’t have to make those kinds of decisions.”

From rural ambulance squads to prestigious hospitals, health care workers are struggling to keep vital medicines in stock because of a drug shortage crisis that is proving to be stubbornly difficult to fix. Rationing is just one example of the extraordinary lengths being taken to address the shortage, which health care workers say has ceased to be a temporary emergency and is now a fact of life. In desperation, they are resorting to treating patients with less effective alternative medicines and using expired drugs. The Cleveland Clinic has hired a pharmacist whose only job is to track down hard-to-find drugs.

Caused largely by an array of manufacturing problems, the shortage has prompted Congressional hearings, a presidential order and pledges by generic drug makers to communicate better with federal regulators.

The problem peaked in 2011, when a record 251 drugs were declared in short supply. This year, slightly more than 100 were placed on the list, and workers say the battle to keep pharmacy shelves stocked continues unabated. The list of hard-to-find medicines ranges from basic drugs like the heart medicine nitroglycerin to a lidocaine injection, which is used to numb tissue before surgery.

A deadly meningitis outbreak caused by contamination at a large drug producer could worsen the situation, federal officials have warned. The Food and Drug Administration said that shortages of six drugs — medicines used during surgery and to treat conditions like congestive heart failure — could get worse after a big compounding pharmacy closed over concerns about drug safety. The pharmacy, Ameridose, shares some management with the New England Compounding Center, which is at the center of a meningitis outbreak that has claimed 33 lives.

“When you can’t treat basic things — cardiac arrest, pain management, seizures — you’re in trouble,” said Dr. Carol Cunningham, the state medical director for the Ohio Department of Public Safety’s emergency services division. “When you only have five tools in your toolbox and three of them are gone, what do you do?”

Dr. Margaret A. Hamburg, the F.D.A. commissioner, said in an interview this week that she was “guardedly optimistic” that the shortage crisis was abating. “I think there’s been an enormous amount of progress,” she said. “We’re seeing real change in the number of shortages that we’re able to recognize early.” More than 150 new shortages have been prevented this year, according to the agency.

But Erin Fox, who tracks supply levels for a broader range of drugs at the University of Utah, said once a drug became scarce, it tended to stay scarce. The university’s Drug Information Service was actively tracking 282 hard-to-find products by the end of the third quarter of this year, a record.

“The shortages we have aren’t going away — they’re not resolving,” she said. “But the good news is we’re not piling more shortages on top.”

In 2011, prompted by emotional pleas by cancer patients and others who said the drug shortage was threatening lives, President Obama issued an executive order requiring drug makers to notify the F.D.A. when a shortage appeared imminent. The agency also loosened some restrictions on importing drugs, and sped up approvals by other manufacturers to make certain medicines.

A law passed this summer contains several provisions aimed at improving the situation, including expediting approval of new generic medicines and requiring the agency’s enforcement unit to better coordinate with its drug-shortage officials before it takes action against a manufacturer.

Ralph G. Neas, the chief executive of the Generic Pharmaceutical Association, said fixing the drug shortage was complex and would take time, but was a top priority. “One shortage is one shortage too many,” he said. “One patient not getting a critical drug is one patient too many.”

Federal drug officials trace much of the drug shortage crisis to delays at plants that make sterile injectable drugs, which account for about 80 percent of the scarce medicines. Nearly a third of the industry’s manufacturing capacity is not running because of plant closings or shutdowns to fix serious quality issues. Other shortages have been caused by supply disruptions of the raw ingredients used to make the drugs, or by manufacturers exiting the market.

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Drug Shortages Are Becoming Persistent in U.S.

Paul Davis, the chief of a rural ambulance squad in southern Ohio, was down to his last vial of morphine earlier this fall when a woman with a broken leg needed a ride to the hospital.

The trip was 30 minutes, and the patient was in pain. But because of a nationwide shortage, his morphine supply had dwindled from four doses to just one, presenting Mr. Davis with a stark quandary. Should he treat the woman, who was clearly suffering? Or should he save it for a patient who might need it more?

In the end, he opted not to give her the morphine, a decision that haunts him still. “I just feel like I’m not doing my job,” said Mr. Davis, who is chief of the rescue squad in Vernon, Ohio. He has since refilled his supply. “I shouldn’t have to make those kinds of decisions.”

From rural ambulance squads to prestigious hospitals, health care workers are struggling to keep vital medicines in stock because of a drug shortage crisis that is proving to be stubbornly difficult to fix. Rationing is just one example of the extraordinary lengths being taken to address the shortage, which health care workers say has ceased to be a temporary emergency and is now a fact of life. In desperation, they are resorting to treating patients with less effective alternative medicines and using expired drugs. The Cleveland Clinic has hired a pharmacist whose only job is to track down hard-to-find drugs.

Caused largely by an array of manufacturing problems, the shortage has prompted Congressional hearings, a presidential order and pledges by generic drug makers to communicate better with federal regulators.

The problem peaked in 2011, when a record 251 drugs were declared in short supply. This year, slightly more than 100 were placed on the list, and workers say the battle to keep pharmacy shelves stocked continues unabated. The list of hard-to-find medicines ranges from basic drugs like the heart medicine nitroglycerin to a lidocaine injection, which is used to numb tissue before surgery.

A deadly meningitis outbreak caused by contamination at a large drug producer could worsen the situation, federal officials have warned. The Food and Drug Administration said that shortages of six drugs — medicines used during surgery and to treat conditions like congestive heart failure — could get worse after a big compounding pharmacy closed over concerns about drug safety. The pharmacy, Ameridose, shares some management with the New England Compounding Center, which is at the center of a meningitis outbreak that has claimed 33 lives.

“When you can’t treat basic things — cardiac arrest, pain management, seizures — you’re in trouble,” said Dr. Carol Cunningham, the state medical director for the Ohio Department of Public Safety’s emergency services division. “When you only have five tools in your toolbox and three of them are gone, what do you do?”

Dr. Margaret A. Hamburg, the F.D.A. commissioner, said in an interview this week that she was “guardedly optimistic” that the shortage crisis was abating. “I think there’s been an enormous amount of progress,” she said. “We’re seeing real change in the number of shortages that we’re able to recognize early.” More than 150 new shortages have been prevented this year, according to the agency.

But Erin Fox, who tracks supply levels for a broader range of drugs at the University of Utah, said once a drug became scarce, it tended to stay scarce. The university’s Drug Information Service was actively tracking 282 hard-to-find products by the end of the third quarter of this year, a record.

“The shortages we have aren’t going away — they’re not resolving,” she said. “But the good news is we’re not piling more shortages on top.”

In 2011, prompted by emotional pleas by cancer patients and others who said the drug shortage was threatening lives, President Obama issued an executive order requiring drug makers to notify the F.D.A. when a shortage appeared imminent. The agency also loosened some restrictions on importing drugs, and sped up approvals by other manufacturers to make certain medicines.

A law passed this summer contains several provisions aimed at improving the situation, including expediting approval of new generic medicines and requiring the agency’s enforcement unit to better coordinate with its drug-shortage officials before it takes action against a manufacturer.

Ralph G. Neas, the chief executive of the Generic Pharmaceutical Association, said fixing the drug shortage was complex and would take time, but was a top priority. “One shortage is one shortage too many,” he said. “One patient not getting a critical drug is one patient too many.”

Federal drug officials trace much of the drug shortage crisis to delays at plants that make sterile injectable drugs, which account for about 80 percent of the scarce medicines. Nearly a third of the industry’s manufacturing capacity is not running because of plant closings or shutdowns to fix serious quality issues. Other shortages have been caused by supply disruptions of the raw ingredients used to make the drugs, or by manufacturers exiting the market.

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DealBook: As Labor Talks Collapse, Hostess Turns Out Lights

What might be the last Twinkie in America — at least for a while — rolled off a factory line Friday morning. It was just like the millions that had come before it, golden, cream-filled empty calories, a monument to classic American junk food.

But it is likely to be the last under the current management. After not one but two bankruptcies, Hostess Brands, the beleaguered purveyor of Twinkies, Ho Hos, Sno Balls and Wonder bread, announced plans to wind down operations and sell off its brands.

Since filing for Chapter 11 bankruptcy protection in January, Hostess has been trying to renegotiate its labor contracts in a bid to cut costs. But the talks fell apart, and last week one union went on strike.

The so-called liquidation will probably spell the end of Hostess, an 82-year-old company that has endured wars, countless diet fads and even an earlier Chapter 11 filing. Although the company could theoretically negotiate a last-minute deal with the union, Hostess is moving to shut factories and lay off a large majority of its 18,500 employees.

But Twinkies and the other well-known brands could eventually find new life under a different owner. As part of the process, Hostess is looking to auction off its assets, and suitors could find value in the portfolio.

“The potential loss of iconic brands is difficult,” said the company’s chief executive, Gregory F. Rayburn. “But it’s overshadowed by the 18,500 families that are out of work.”

The company’s current problems stem, in part, from the legacy of its past.

An amalgam of brands and businesses, the company has evolved over the years through acquisitions. In the 1960s and 1970s, the company, then called Interstate, bought more than a dozen regional bakeries scattered across the country. A couple of decades later, it paid $330 million for the Continental Baking Company, picking up a portfolio of brands like Wonder and Hostess.

As the national appetite for junk food waned, the company fell on hard times, struggling against rising labor and commodity costs. In 2004, it filed for bankruptcy for the first time.

Five years later, the company emerged from Chapter 11 as Hostess Brands, so named after its most prominent division. With America’s new health-conscious attitude, it sought to reshape the business to changing times, introducing new products like 100-calorie Twinkie Bites.

But the new private equity backers loaded the company with debt, making it difficult to invest in new equipment. Earlier this year, Hostess had more than $860 million of debt.

The labor costs, too, proved insurmountable, a situation that has been complicated by years of deal-making. The bulk of the work force belongs to 12 unions, including the International Brotherhood of Teamsters and the Bakery, Confectionery, Tobacco Workers and Grain Millers International Union.

The combination of debt and labor costs has hurt profits. The company posted revenue of $2.5 billion in the fiscal year 2011, the last available data. But it reported a net loss of $341 million.

With profits eroding, the company filed for Chapter 11 in January. It originally hoped to reorganize its finances, seeking lower labor costs, including an immediate 8 percent pay cut.

The negotiations have been contentious.

The Teamsters, which has 6,700 members at Hostess, said it played an instrumental role in ousting Hostess’s previous chief executive, Brian J. Driscoll, this year after the board tripled his compensation to $2.55 million. The union also hired a financial consultant, Harry J. Wilson, who had worked on the General Motors restructuring.

While highly critical of management missteps, the Teamsters agreed in September to major concessions, including cuts in wages and company contributions to health care. As part of the deal, the union was to receive a 25 percent share of the company’s stock and a $100 million claim in bankruptcy.

“The objective was to preserve jobs,” said Ken Hall, the Teamsters’ general secretary-treasurer. “When you have a company that’s in the financial situation that Hostess is, it’s just not possible to maintain everything you have.”

But Hostess reached an impasse with the bakery union. Frank Hurt, the union’s president, seemed to lose patience with Hostess’s management, upset that it was in bankruptcy for the second time despite $100 million in labor concessions. He saw little promise that management would turn things around.

“Our members decided they were not going to take any more abuse from a company they have given so much to for so many years,” said Mr. Hurt. “They decided that they were not going to agree to another round of outrageous wage and benefit cuts and give up their pension only to see yet another management team fail and Wall Street vulture capitalists and ‘restructuring specialists’ walk away with untold millions of dollars.”

About a month ago, Mr. Rayburn said, the bakers union stopped returning the company’s phone calls altogether. For its part, the bakery union said the company had taken an overly aggressive approach. David Durkee, the union’s secretary-treasurer, said Hostess had given an ultimatum. “They said, ‘If you do not ratify this, we are going to liquidate based on your vote.’ ”

With the company standing firm, the bakery union struck last week, affecting nearly two-thirds of the company’s factories across the country. The Teamsters drivers honored the picket line, further shutting down the operations. The company gave union members until 5 p.m. on Thursday to return to work.

Mr. Rayburn said the financial strain of the strike was too much for the company, which had already reached the limits of its bankruptcy financing. Over the last week, Hostess lost tens of millions of dollars as many customers’ orders went unfilled. And its lenders would not open their wallets one more time.

By Thursday morning, Hostess’s executives were ensconced in the company’s headquarters in Irving, Tex., still hoping that enough employees would return to work to resume production. A small number of workers had already crossed the picket lines that had sprung up at most of the baker’s factories, but more than 10 plants remained well below their necessary capacity.

Mr. Rayburn’s deadline of 5 p.m. passed without either side backing down. Soon after, executives asked the company’s legal advisers to finish the court motions that would begin the liquidation. Papers had been drawn up well before that afternoon.

Around 7 p.m., Mr. Rayburn had his final discussions with the company’s board and his senior managers and made the call to begin winding down.

“We were trying to focus on where people were having success, but I had to make a call,” Mr. Rayburn said.

A version of this article appeared in print on 11/17/2012, on page B1 of the NewYork edition with the headline: A Push to Save the Twinkies: As Labor Talks Collapse, Hostess Turns Out Lights.

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Israel Girds for Ground Assault in Gaza; Egypt’s Premier Visits

GAZA CITY — After a morning of heavy rocket fire from Gaza into Israel, the Israeli military seemed to be edging closer toward a ground invasion of Gaza on Friday, saying forces were “on standby” and “ready to enter should it be decided that a ground operation is necessary.”

In a statement, the Israeli military said paratrooper and infantry brigades had completed final preparations for a potential ground operation that would be the first since the winter of 2008-09, when Israel drew broad international reproach for an invasion that claimed 1,400 Palestinian lives for the loss of 13 Israelis.

The statement came after scores of rockets were fired into Israel, striking major cities of the south, causing widespread panic and damage and shattering plans for a temporary cease-fire during a remarkable visit to Gaza by the Egyptian prime minister that showed the shifting dynamics of Middle East politics since the turmoil of the so-called Arab Spring.

Word of the potential invasion emerged shortly before a rocket from Gaza struck somewhere near Tel Aviv after sirens wailed. It was the second such attempt to strike at the city in two days. Hamas said it fired a single “homemade” projectile toward Tel Aviv.

The rapidly escalating confrontation between Gaza and Israel followed an Israel airstrike on Wednesday that killed the top commander of Hamas, and the tit-for-tat violence is widely seen as a potential catalyst for broader hostilities at a time of spreading turmoil in Syria and elsewhere in the region.

The Israeli military said that Col. Amir Baram, commander of the Israeli Defense Forces’ paratroopers brigade, had addressed his forces during a preparatory briefing in the field, saying: “We are already 48 hours into an operation that we knew would have to happen. We have spoken about it during training, exercises and conferences. There is now doubt that we have to operate. This is why we enlisted, and why we have trained.”

Witnesses on the Gaza-Israel border said tanks had massed in several places.

Early on Friday, the Israeli military said it had called up 16,000 army reservists after Defense Minister Ehud Barak authorized the call-up of 30,000 reservists, if needed, to move against what it considers an unacceptable security threat from smuggled rockets amassed by Hamas, which does not recognize Israel’s right to exist.

It was not initially clear whether the show of Israeli force on the ground in fact portended an invasion or was meant as more of an intimidation tactic to further pressure Hamas leaders, who had all been forced into hiding on Wednesday after the Israelis killed the group’s military chief, Ahmed al-Jabari, in a pinpoint aerial bombing. But Israel’s preparations seemed to pick up on Friday after the persistent attempts to land rockets in Tel Aviv added new urgency while Hamas itself seemed emboldened by Egypt’s support.

“The time in which the Israeli occupation does whatever it wants in Gaza is gone,” said Ismail Haniya, the Hams prime minister.

Initially, the Egyptian initiative was portrayed as a potential harbinger of reduced hostilities, and, as Prime Minister Hesham Kandil of Egypt prepared to travel to Gaza, Israel agreed to a temporary conditional cease-fire for the visit. But the truce never took root.

Israel Radio said Palestinian militants fired 25 rockets into southern Israel, one of them striking a house. There were no immediate reports of casualties.

What sounded like airstrikes by Israeli F-16s were also audible in Gaza City. The Israeli military said no such strikes had taken place, but the Hamas Health Ministry reported that two people, including a child, were killed in the north of Gaza City while the Egyptian delegation was on the ground, pushing the Palestinian death toll in three days of aerial bombardment to 21.

Three Israelis were killed in a rocket attack on Thursday in Kiryat Malachi, a small town in southern Israel, when a rocket fired from Gaza struck their apartment building.

Mr. Kandil’s visit produced dramatic imagery to underpin the Egyptian government’s support for Hamas, which Israel, the United States and much of the West consider to be a terrorist organization.

Mr. Kandil and Mr. Haniya visited the Al Shifa hospital amid a huge scrum of bodyguards and journalists, saying they had carried the body of Mohammed Yasser, one of eight children who Palestinian health officials say have been killed in the surge of violence since a top Hamas commander was killed in an Israeli airstrike on Wednesday.

“This is the blood of our children on our clothes,” Mr. Haniya said as he showed spatters on his clothing, “These are the Egyptian and the Palestinian blood united together.”

Like President Mohamed Morsi of Egypt on Thursday, Mr. Kandil walked a delicate line between support for Hamas, condemnation of Israel and a quest for calm in a region increasingly threatened by the spillovers from Syria’s civil war, as well as by the long-festering impasse between the Israelis and Palestinians.

Jodi Rudoren reported from Gaza City, Isabel Kershner from Jerusalem, and Alan Cowell from Paris. Reporting was contributed by Fares Akram from Gaza, Rick Gladstone from New York, Rina Castelnuovo from Gaza-Israel border, Mayy El Sheikh and David D. Kirkpatrick from Cairo, Gabby Sobelman from Jerusalem, and Elisabeth Bumiller from Bangkok.

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Gadgetwise Blog: Q&A: Removing Programs on a Mac

Windows computers have the Add/Remove Program option and many programs include uninstaller software, but how do you uninstall a Mac program?

Some Mac programs do come with their own uninstaller programs to remove the software from the computer. If the program you want to delete does not offer that utility, you can get rid of it in other ways.

Just dragging the program’s icon out of the Applications folder to the Mac’s desktop Trash can — and then going to the Finder’s File menu and choosing Empty Trash — gets rid of the program and many of its associated files. Some Mac application icons contain many more files than just the program itself; just right-click on an icon in the Applications folder and choose Show Package Contents from the menu to see what lies beneath.

Some programs leave other files around the Mac’s system, though, and just deleting the application’s icon from the computer may leave some digital detritus on your drive. If you are comfortable with poking around in OS X, tutorials like those from Cult of Mac or Raw Computing show where to look in your clean-up mission. For a more automatic approach, free or inexpensive utility apps like AppDelete, AppZapper and CleanApp can take care of the job for you.

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For Alzheimer’s, Detection Advances Outpace Treatment Options

Joshua Lott for The New York Times

Awilda Jimenez got a scan for Alzheimer’s after she started forgetting things. It was positive.

When Awilda Jimenez started forgetting things last year, her husband, Edwin, felt a shiver of dread. Her mother had developed Alzheimer’s in her 50s. Could his wife, 61, have it, too?

He learned there was a new brain scan to diagnose the disease and nervously agreed to get her one, secretly hoping it would lay his fears to rest. In June, his wife became what her doctor says is the first private patient in Arizona to have the test.

“The scan was floridly positive,” said her doctor, Adam S. Fleisher, director of brain imaging at the Banner Alzheimer’s Institute in Phoenix.

The Jimenezes have struggled ever since to deal with this devastating news. They are confronting a problem of the new era of Alzheimer’s research: The ability to detect the disease has leapt far ahead of treatments. There are none that can stop or even significantly slow the inexorable progression to dementia and death.

Families like the Jimenezes, with no good options, can only ask: Should they live their lives differently, get their affairs in order, join a clinical trial of an experimental drug?

“I was hoping the scan would be negative,” Mr. Jimenez said. “When I found out it was positive, my heart sank.”

The new brain scan technology, which went on the market in June, is spreading fast. There are already more than 300 hospitals and imaging centers, located in most major metropolitan areas, that are ready to perform the scans, according to Eli Lilly, which sells the tracer used to mark plaque for the scan.

The scans show plaques in the brain — barnaclelike clumps of protein, beta amyloid — that, together with dementia, are the defining feature of Alzheimer’s disease. Those who have dementia but do not have excessive plaques do not have Alzheimer’s. It is no longer necessary to wait until the person dies and has an autopsy to learn if the brain was studded with plaques.

Many insurers, including Medicare, will not yet pay for the new scans, which cost several thousand dollars. And getting one comes with serious risks. While federal law prevents insurers and employers from discriminating based on genetic tests, it does not apply to scans. People with brain plaques can be denied long-term care insurance.

The Food and Drug Administration, worried about interpretations of the scans, has required something new: Doctors must take a test showing they can read them accurately before they begin doing them. So far, 700 doctors have qualified, according to Eli Lilly. Other kinds of diagnostic scans have no such requirement.

In another unusual feature, the F.D.A. requires that radiologists not be told anything about the patient. They are generally trained to incorporate clinical information into their interpretation of other types of scans, said Dr. R. Dwaine Rieves, director of the drug agency’s Division of Medical Imaging Products.

But in this case, clinical information may lead radiologists to inadvertently shade their reports to coincide with what doctors suspect is the underlying disease. With Alzheimer’s, Dr. Rieves said, “clinical impressions have been misleading.”

“This is a big change in the world of image interpretation,” he said.

Like some other Alzheimer’s experts, Dr. Fleisher used the amyloid scan for several years as part of a research study that led to its F.D.A. approval. Subjects were not told what the scans showed. Now, with the scan on the market, the rules have changed.

Dr. Fleisher’s first patient was Mrs. Jimenez. Her husband, the family breadwinner, had lost his job as a computer consultant when the couple moved from New York to Arizona to take care of Mrs. Jimenez’s mother. Paying several thousand dollars for a scan was out of the question. But Dr. Fleisher found a radiologist, Dr. Mantej Singh Sra of Sun Radiology, who was so eager to get into the business that he agreed to do Mrs. Jimenez’s scan free. His plan was to be the first in Arizona to do a scan, and advertise it.

After Dr. Sra did the scan, the Jimenezes returned to Dr. Fleisher to learn the result.

Dr. Fleisher, sad to see so much plaque in Mrs. Jimenez’s brain, referred her to a psychiatrist to help with anxiety and suggested she enter clinical trials of experimental drugs.

But Mr. Jimenez did not like that idea. He worried about unexpected side effects.

“Tempting as it is, where do you draw the line?” he asks. “At what point do you take a risk with a loved one?”

At Mount Sinai Medical Center in New York, Dr. Samuel E. Gandy found that his patients — mostly affluent — were unfazed by the medical center’s $3,750 price for the scan. He has been ordering at least one a week for people with symptoms ambiguous enough to suggest the possibility of brain plaques.

Most of his patients want their names kept confidential, fearing an inability to get long-term care insurance, or just wanting privacy.

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Automated Bidding Systems Test Old Ways of Selling Ads

Publishers and broadcasters have long tried to offer advertisers the right audience for their products. Want to sell pick-ups to people who like sports? Buy ads at halftime during a football game. Selling luggage or airline tickets? Buy ads in the travel section of a newspaper or Web site.

In digital advertising, that formula is being increasingly tested by fast-paced, algorithmic bidding systems that target individual consumers rather than the aggregate audience publishers serve up. In the world of “programmatic buying” technologies, context matters less than tracking those consumers wherever they go. And that kind of buying is the reason that shoe ad follows you whether you’re on Weather.com or on a local news blog.

That shift is punishing traditional online publishers, like newspaper, broadcast and magazine sites, who are receiving a much lower percentage of ad dollars as marketers use programmatic buying across a much broader canvas. Some sites, like CNN.com, refuse to even accept advertising through programmatic buying because they do not want to cede control over what ads will appear.

“It’s allowing advertisers to assign value to media rather than publishers,” said Ben Winkler, the chief digital officer at OMD, an agency in the Omnicom Media Group. Publishers, he said, “can’t control the price, but they can control the quality of the content and the audience on that site.”

About 10 percent of the display ads that consumers see online have been sold through programmatic bidding channels, according to Walter Knapp, the executive vice president of platform revenue and operations at Federated Media, one of the world’s largest digital advertising networks.

Advertisers like Nike, Comcast, Progressive and Procter & Gamble are now using the programmatic buying, and luxury advertisers are starting to follow. According to data from Forrester Research, all ads traded on exchanges, as programmatic ads are, increased more than 17.5 percent to about 629 billion impressions (the number of times an ad appears) in 2012, from 535 billion in 2011.

That growth is affecting publishers of all stripes, but few are willing to discuss their internal numbers. “For a publisher to admit they’ve been hurt is tough for the big guys,” said John Ebbert, the executive editor and publisher of the Web site AdExchanger.

When The New York Times Company announced its earnings last month, the company posted a profit, but said that digital advertising fell 2.2 percent. Jim Follo, the company’s senior vice president and chief financial officer, attributed the dip, in part, on a “shift toward ad exchanges, real-time bidding and other programmatic buying channels that allow advertisers to buy audience at scale.”

Programmatic buying began as a way for advertisers to place lower-cost ads for products like teeth-whitening products and belly fat pills that filled up the back pages of Web sites. But the practice has gained in sophistication and breadth, with major advertisers and many of the world’s largest ad agencies creating private exchanges to automate the buying and selling of ads.

Programmatic buying includes a number of different technologies and strategies, but it essentially allows advertisers to bid, often in real time, on ad space largely based on the value they have assigned to the consumer on the other side of the screen. Say, for example, that Nike wants to sell running gear to a particular consumer who has a high likelihood of buying shoes based on the data it has collected, including the type of Web sites that consumer typically visits. Because the ad-buying is done through computer trading, the price for that space can change rapidly.

“Accessing media is a commodity now,” said Sheldon Gilbert, the founder and chief executive of Proclivity Media, a company that specializes in digital advertising technologies. “Instead of having to commit four months in advance, you can now bid and buy an individual impression in real time.”

In the short run, the growth in programmatic buying has forced overall ad prices to fall. A media buyer who would have once spent $50,000 worth of advertising on a publisher’s site, at, say, an $8 cost-per-thousand, can now buy ad impressions on any Web site on which they happen to find their intended audience and pay less per ad, Mr. Ebbert said.

“There is no scarcity of premium online,” said Dan Salmon, an equity research analyst at BMO Capital Markets. “There’s only one Super Bowl, but there are lots of different places to buy banner ads online.”

While the “halo effect” of buying an ad against premium content has not disappeared entirely — many advertisers still want front-page placement on popular Web sites — the shift is prompting publishers to rethink how they sell their ads.

Clark Fredricksen, the vice president for communications at eMarketer, a data company, said that publishers were “going to have to double down to prove the value of their inventory as they compete with other, cheaper inventory.”

And some publishers are jumping into the game themselves. During the most recent AOL earnings call, Tim Armstrong, the company’s chairman and chief executive, said it was bullish on programmatic buying, despite being a publisher itself with properties that include TechCrunch and The Huffington Post. The company trades its ads through its own ad network, Ad.com, and others like it.

“We will continue to invest in people and technology to capture the programmatic business of advertising,” Mr. Armstrong said.

Like AOL, Weather.com is also aggressively moving into programmatic bidding. “Instead of thinking of us a publisher, think of us as a marketing engine,” said Curt Hecht, the chief global revenue officer for the Weather Company.

Neal Mohan, the vice president for product management at Google, which sells advertising though its DoubleClick network, says that in the long run, publishers could see higher returns from programmatic advertising. In the last year, the number of advertisers and publishers using the DoubleClick platform has doubled, Mr. Mohan said, while the rates for those using the platform have increased 11 percent. But that means publishers will have to play by different rules.

“Context still matters and so does placement,” Mr. Ebbert said. “But it’s only one element.”

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Attacks Resume After Israeli Assault Kills Hamas Leader

KIRYAT MALACHI, Israel — Israel and Hamas widened their increasingly deadly conflict over Gaza on Thursday, as a militant rocket killed three civilians in an apartment block in this small southern town. The deaths are likely to lead Israel to intensify its military offensive on Gaza, now in its second day of airstrikes.

In Gaza, the Palestinian death toll rose to 11 as Israel struck what the military described as medium- and long-range rocket and infrastructure sites and rocket-launching squads. The military said it had dispersed leaflets over Gaza warning residents to stay away from Hamas operatives and facilities, suggesting that more was to come.

The regional perils of the situation sharpened, meanwhile, as President Mohamed Morsi of Egypt warned on Thursday that his country stood by the Palestinians against what he termed Israeli aggression, echoing similar condemnation on Wednesday.

“The Egyptian people, the Egyptian leadership, the Egyptian government, and all of Egypt is standing with all its resources to stop this assault, to prevent the killing and the bloodshed of Palestinians,” Mr. Morsi said in nationally televised remarks before a crisis meeting of senior ministers. He also said he had contacted President Obama to discuss strategies to “stop these acts and doings and the bloodshed and aggression.”

In language that reflected the upheaval in the political dynamics of the Middle East since the overthrow of Hosni Mubarak last year, Mr. Morsi said: “Israelis must realize that we don’t accept this aggression and it could only lead to instability in the region and has a major negative impact on stability and security in the region.”

The thrust of Mr. Morsi’s words seemed confined to diplomatic maneuvers, including calls to the United Nations secretary general, Ban Ki-moon, the head of the Arab League and President Obama.

In his conversation with Mr. Obama, Mr. Morsi said, he “clarified Egypt’s role and Egypt’s position; our care for the relations with the United States of America and the world; and at the same time our complete rejection of this assault and our rejection of these actions, of the bloodshed, and of the siege on Palestinians and their suffering.”

Mr. Obama had agreed to speak with Israeli leaders, Mr. Morsi said. Thursday’s deaths in Kiryat Malachi were the first casualties on the Israeli side since Israel launched its assault on Gaza, the most ferocious in four years, in response to persistent Palestinian rocket fire.

Southern Israel has been struck by more than 750 rockets fired from Gaza this year that have hit homes and caused injuries. On Thursday, a rocket smashed into the top floor of an apartment building in Kiryat Malachi, about 15 miles north of Gaza. Two women and a man were killed, according to rescue officials and Army Radio. A baby was among the injured and several Israelis were hospitalized with shrapnel wounds after rockets hit other southern cities and towns, they said.

The apartment house was close to a field in a blue-collar neighborhood and the rocket tore open top-floor apartments, leaving twisted metal window frames and bloodstains.

Nava Chayoun, 40, who lives on the second floor, said her husband, Yitzhak, ran up the stairs immediately after the rocket struck and saw the body of a woman on the floor. He rescued two children from the same apartment and afterward, she said, she and her family “read psalms.”

It was the first time that a building in Kiryat Malachi had been struck and the farthest north a projectile had landed in the current violence. With schools closed after Wednesday’s turmoil, residents said, many people had stayed home with their children.

Residents said people living on the lower floors of the apartment house had taken cover in stairwells, as the police urged residents to do when they heard warning sirens, but those on the top floor apparently had not. The police said 180 rockets had been fired at southern Israel since Wednesday.

Isabel Kershner reported from Kiryat Malachi, Israel, and Fares Akram from Gaza. Reporting was contributed by Rina Castelnuovo from Kiryat Malachi; Mayy El Sheikh and David D. Kirkpatrick from Cairo; Gabby Sobelman from Jerusalem; Rick Gladstone from New York; and Alan Cowell from Paris.

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State of the Art: A Review of New Activity-Tracking Bands From Nike and Jawbone

Maybe you’ve heard: Americans are becoming less fit and more fat. There are all kinds of theories about why — bigger meal portions, omnipresent corn syrup and sugar, fewer pickup stickball games after school. But people are starting to think that in many cases, body weight might somehow be linked to diet and exercise.

Now, studies have shown that if there’s some visible, omnipresent monitor of your negative behavior — spending too much money, eating too much food, using too much power in your home — you’re far more likely to correct it.

That’s the idea behind personal activity-tracking bracelets like the Nike FuelBand ($150) and the improved Jawbone Up band ($130). They make you constantly aware of how active you are (or aren’t). They let you compare your data with friends online, establishing a friendly rivalry or at least guilt. And they therefore motivate you to make changes that add up: park farther away, take the stairs, get off one bus stop early.

There are plenty of other fitness trackers, including clip-onto-clothing trackers (like the FitBit and Striiv) and wristwatchlike gadgets (like Motorola’s MotoActiv). But the beauty of the bracelets is that you can leave them on — asleep, in the shower, shirtless or even all three — and so you’re more likely to stick with the program.

Now, those who follow the wearable, accelerometer-based fitness-tracking gadget industry are no doubt scratching their heads right about now. The Up band? Wasn’t that a bracelet that came out about a year ago, and crashed and burned in a humiliatingly public epidemic of hardware failures? Didn’t Jawbone, a company known for Bluetooth speakers and earpieces, pull Up off the market, offering a generous mea culpa (“You can receive a full refund for UP. This is true even if you decide to keep your UP band”)?

Yes.

The company says that after months of testing and millions of dollars in research, it realized that the original band, billed as waterproof, actually wasn’t quite. Water, sweat and shower soap managed to seep inside and short out the components.

The new Up band, the company swears, is bulletproof. Or at least really, truly waterproof. The company says it redesigned 17 parts and made 28 improvements in the manufacturing process. The new band looks identical — it’s still a stiff, rubber, overgrown C in a choice of colors, with ends that overshoot each other — but inside, it’s far better shielded and enclosed. (It’s also $30 more expensive.)

The corresponding iPhone app has had some work done, too. The central conceit is a Facebook-style timeline of your life. Each “post” represents a day’s worth of activity, or a night of sleep, or a meal. (You can enter nonstep-based workouts manually, like biking or weights.) Your friends’ health developments can show up in your stream, too.

That doesn’t mean that the app is ready for its close-up. It’s fairly baffling, housing as it does duplicate hidden menus, and it has its share of bugs and quirks. Why, on a screen that’s much taller than it is wide, are your progress graphs inch-tall bars swimming in empty space? And wow — if you did a situp every time you got the “Sorry, there was an error connecting with the UP server” message, you’d have abs of concrete. (An Android app is in the works.)

What’s great, though, is that the Up’s ambitions extend beyond simple activity tracking. If you do a double press on the button at the end of the band when you go to bed, for example, the bracelet does an impressive job of tracking your night of sleep: how long it takes you to drift off, how many times you wake up, how many hours you spend in light and deep sleep.

A related, extremely useful feature: when you need a power nap (a 25-minute quick sleep, whose refreshing qualities have been well documented in studies), the band doesn’t start counting until it sees that you’re actually asleep. So you actually get 25 minutes, after which the band vibrates to rouse you. That’s something the average pedometer doesn’t do.

You can track your food intake in any of three ways: by taking a photo of what you eat, by scanning the bar code on its package (the app instantly and correctly identifies it) or by choosing from a categorized list of common foodstuffs. It’s still fairly manual — no wristband can tell what you’re shoving into your mouth — so most people probably won’t bother.

E-mail: pogue@nytimes.com

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