Gaza ceasefire holds but mistrust runs deep

GAZA/JERUSALEM (Reuters) - A ceasefire between Israel and Hamas held firm on Thursday with scenes of joy among the ruins in Gaza over what Palestinians hailed as a victory, and both sides saying their fingers were still on the trigger.

In the sudden calm, Palestinians who had been under Israeli bombs for eight days poured into Gaza streets for a celebratory rally, walking past wrecked houses and government buildings.

But as a precaution, schools stayed closed in southern Israel, where nerves were jangled by warning sirens - a false alarm, the army said - after a constant rain of rockets during the most serious Israeli-Palestinian fighting in four years.

Israel had launched its strikes last week with a declared aim of ending rocket attacks on its territory from Gaza, ruled by the Islamist militant group Hamas, which denies Israel's right to exist. Hamas had responded with more rockets.

The truce brokered by Egypt's new Islamist leaders, working with the United States, headed off an Israeli invasion of Gaza.

It was the fruit of intensive diplomacy spurred by U.S. President Barack Obama, who sent his secretary of state to Cairo and backed her up with phone calls to Israeli Prime Minister Benjamin Netanyahu and Egyptian President Mohamed Mursi.

Mursi's role in cajoling his Islamist soulmates in Gaza into the U.S.-backed deal with Israel suggested that Washington can find ways to cooperate with the Muslim Brotherhood leader whom Egyptians elected after toppling former U.S. ally Hosni Mubarak, a bulwark of American policy in the Middle East for 30 years.

Mursi, preoccupied with Egypt's economic crisis, cannot afford to tamper with a 1979 peace treaty with Israel, despite its unpopularity with Egyptians, and needs U.S. financial aid.

MORE DEATHS

Despite the quiet on the battlefield, the death toll from the Gaza conflict crept up on both sides.

The body of Mohammed al-Dalu, 25, was recovered from the rubble of a house where nine of his relatives - four children and five women - were killed by an Israeli bomb this week.

That raised to 163 the number of Palestinians killed, more than half of them civilians, including 37 children, during the Israeli onslaught, according to Gaza medical officials.

Nearly 1,400 rockets struck Israel, killing four civilians and two soldiers, including an officer who died on Thursday of wounds sustained the day before, the Israeli army said.

Israel dropped 1,000 times as much explosive on the Gaza Strip as landed on its soil, Defense Minister Ehud Barak said.

Municipal workers in Gaza began cleaning streets and removing the rubble of bombed buildings. Stores opened and people flocked to markets to buy food.

Jubilant crowds celebrated, with most people waving green Hamas flags but some carrying the yellow emblems of the rival Fatah group, led by Western-backed President Mahmoud Abbas.

That marked a rare show of unity five years after Hamas, which won a Palestinian poll in 2006, forcibly wrested Gaza from Fatah, still dominant in the Israeli-occupied West Bank.

Israel began ferrying tanks northwards, away from the border, on transporters. It plans to discharge gradually tens of thousands of reservists called up for a possible Gaza invasion.

But trust between Israel and Hamas remains in short supply and both said they might well have to fight again.

"The battle with the enemy has not ended yet," Abu Ubaida, spokesman of Hamas's armed wing Izz el-Deen Al-Qassam Brigades, said at an event to mourn its acting military chief Ahmed al-Jaabari, whose killing by Israel on November 14 set off this round.

"HANDS ON TRIGGER"

The exiled leader of Hamas, Khaled Meshaal, said in Cairo his Islamist movement would respect the truce, but warned that if Israel violated it "our hands are on the trigger".

Netanyahu said he had agreed to "exhaust this opportunity for an extended truce", but told Israelis a tougher approach might be required in the future.

Facing a national election in two months, he swiftly came under fire from opposition politicians who had rallied to his side during the fighting but now contend he emerged from the conflict with no real gains for Israel.

"You don't settle with terrorism, you defeat it. And unfortunately, a decisive victory has not been achieved and we did not recharge our deterrence," Shaul Mofaz, leader of the main opposition Kadima party, wrote on his Facebook page.

In a speech, Ismail Haniyeh, Hamas's prime minister in Gaza, urged all Palestinian factions to respect the ceasefire and said his government and security services would monitor compliance.

According to a text of the agreement seen by Reuters, both sides should halt all hostilities, with Israel desisting from incursions and targeting of individuals, while all Palestinian factions should cease rocket fire and cross-border attacks.

The deal also provides for easing Israeli curbs on Gaza's residents, but the two sides disagreed on what this meant.

Israeli sources said Israel would not lift a blockade of the enclave it enforced after Hamas won a Palestinian election in 2006, but Meshaal said the deal covered the opening of all of the territory's border crossings with Israel and Egypt.

Israel let dozens of trucks carry supplies into the Palestinian enclave during the fighting. Residents there have long complained that Israeli restrictions blight their economy.

Barak said Hamas, which declared November 22 a national holiday to mark its "victory", had suffered heavy military blows.

"A large part of the mid-range rockets were destroyed. Hamas managed to hit Israel's built-up areas with around a metric tone of explosives, and Gaza targets got around 1,000 metric tonnes," he said.

He dismissed a ceasefire text published by Hamas, saying: "The right to self-defense trumps any piece of paper."

He appeared to confirm, however, a Hamas claim that the Israelis would no longer enforce a no-go zone on the Gaza side of the frontier that the army says has prevented Hamas raids.

(Additional reporting by Noah Browning in Gaza, Ori Lewis, Crispian Balmer and Dan Williams in Jerusalem; Writing by Jeffrey Heller and Alistair Lyon; Editing by Giles Elgood)

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Doctors "ethically bound" not to charge unfair fees: SMC

SINGAPORE: Doctors here are ethically bound not to charge unfair and unreasonable fees for their services, said the Singapore Medical Council's (SMC) lawyers in a 190-page statement.

The statement was a response to prominent surgeon Susan Lim's appeal against her three-year suspension and S$10,000 fine for professional misconduct.

The council had found Dr Lim guilty of 94 charges, the bulk of which involved overcharging the late sister of Brunei's Queen, whose bills amounted to S$24.8 million for care rendered in 2007.

In her appeal, Dr Lim, 57, argued, among several other things, that Singapore does not have any guidelines or a cap on what a doctor can charge a patient.

According to documents submitted to the court, SMC's lawyers from WongPartnership pointed out that "there is an intrinsic ethical limit prohibiting doctors from charging unfair and unreasonable fees".

"Excessive charging undermines the foundation of any profession based on honour, trust and integrity", they said.

Drawing reference from the legal fraternity, SMC's lawyers argued that the principles of honour and integrity apply to the medical profession with or without written rules in their ethical guidelines.

Pointing out that Dr Lim's fees are in "an extraordinary class of exorbitance on its own", they also said that the assessment of a practitioner's fee is determined objectively by her peers.

While Dr Lim has insisted that the fees were agreed between her and her patient, the SMC's disciplinary committee ruled otherwise.

Even if there was a fee agreement, "that does not mean that it is ethical … for a doctor to charge excessive fees", the lawyers said.

"As a concomitant, whilst a fee agreement can be valid under general contract law, that does not mean that the agreement is ethical under the rules of professional conduct," they added.

In the legal profession, for example, the courts have also previously ruled that solicitors might be found guilty of overcharging despite having a fee agreement, the lawyers noted.

They reiterated that the case is not one of inadvertence or negligence - Dr Lim knew what she was doing was wrong.

Not showing remorse, she continued to assert that there was nothing wrong with her conduct, the lawyers said.

They reiterated that "it is not the SMC's intention to make a public example of Dr Lim".

The SMC is charged with the statutory duty to regulate the conduct and ethics of registered medical practitioners, and to uphold the standards and reputation of the medical profession, the lawyers said.

"And it is a matter of fundamental importance… that practitioners refrain from levying grossly excessive, unfair and unreasonable fees that bring the entire profession into disrepute," said the lawyers.

It is "equally important that medical practitioners maintain the highest standards of integrity in their billing practices", they said.

"That, however, is precisely what Dr Lim has not done."

The court is scheduled to hear Dr Lim's appeal in January 2013.

- TODAY/jc

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Map row: India calls China's action 'unacceptable', hits back

NEW DELHI/BEIJING: India on Friday termed as "unacceptable" China depicting Arunachal Pradesh and Aksai Chin as its territory in maps of the country on their new e-passports, a step that led to retaliatory action by New Delhi.

China sprung the surprise on India when it showed these territories as part of its own in the maps on their new e-passports.

The Indian embassy in Beijing responded by issuing visas to Chinese nationals with a map of India including Arunachal and Aksai Chin as part of its territory.

In India's first official reaction, external affairs minister Salman Khurshid said, "We are not prepared to accept it."

"We, therefore, ensure that our flags of disagreement are put out immediately when something happens. We can do it in an agreeable way or you can do it in a disagreeable way," he told NDTV.

China, on its part, sort of fudged the issue with its foreign ministry spokesperson saying that the matter should be dealt with in a "level headed and rational manner" to avoid "unnecessary disruptions" to people to people exchanges.

"Hope the countries regard it in a cool-headed manner. China would like to maintain communication with other counties to ensure convenience of travel for both Chinese and foreigners", she said in Beijing.

After the Chinese government started issuing new e-passports, carrying pages with watermark Chinese maps including Arunachal and Aksai Chin as its parts, India hit back by issuing visas to Chinese nationals with a map of India including these places as part of its territory.

Earlier also, China had triggered a diplomatic row by issuing stapled visas to residents of Jammu and Kashmir, terming it as a "disputed territory" and denied visas to those hailing from Arunachal Pradesh.

Peeved over this action, India lodged a strong protest with China which subsequently reverted to issuing normal visas to residents of Jammu and Kashmir but without officially admitting that they were doing so.

China's claim to Aksai Chin and Arunachal Pradesh, which shares a 1,030km unfenced border with it, is not new.

In 1962, China and India fought a brief war over Aksai Chin and Arunachal Pradesh, but in 1993 and 1996 the two countries signed agreements to respect the Line of Actual Control (LAC) to maintain peace and tranquility.

Significantly, these developments occur even as a high- level team of Chinese diplomats, for the first time, visited Sikkim in connection with consular issues, which was seen as reconfirmation of Beijing's stance of accepting the state as part of India.

The development comes even as Prime Minister Manmohan Singh met his Chinese counterpart Wen Jiabao on the sidelines of the Asean summit in Cambodia where the two leaders discussed ways to move forward on the vexed boundary issue.

National security adviser Shivshankar Menon is expected to visit Beijing soon for the next round of boundary talks at the level of special representatives with his Chinese counterpart Dai Bingguo.

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AP PHOTOS: Simple surgery heals blind Indonesians

PADANG SIDEMPUAN, Indonesia (AP) — They came from the remotest parts of Indonesia, taking crowded overnight ferries and riding for hours in cars or buses — all in the hope that a simple, and free, surgical procedure would restore their eyesight.

Many patients were elderly and needed help to reach two hospitals in Sumatra where mass eye camps were held earlier this month by Nepalese surgeon Dr. Sanduk Ruit. During eight days, more than 1,400 cataracts were removed.

The patients camped out, sleeping side-by-side on military cots, eating donated food while fire trucks supplied water for showers and toilets. Many who had given up hope of seeing again left smiling after their bandages were removed.

"I've been blind for three years, and it's really bad," said Arlita Tobing, 65, whose sight was restored after the surgery. "I worked on someone's farm, but I couldn't work anymore."

Indonesia has one of the highest rates of blindness in the world, making it a target country for Ruit who travels throughout the developing world holding free mass eye camps while training doctors to perform the simple, stitch-free procedure he pioneered. He often visits hard-to-reach remote areas where health care is scarce and patients are poor. He believes that by teaching doctors how to perform his method of cataract removal, the rate of blindness can be reduced worldwide.

Cataracts are the leading cause of blindness globally, affecting about 20 million people who mostly live in poor countries, according to the World Health Organization.

"We get only one life, and that life is very short. I am blessed by God to have this opportunity," said Ruit, who runs the Tilganga Eye Center in Katmandu, Nepal. "The most important of that is training, taking the idea to other people."

During the recent camps, Ruit trained six doctors from Indonesia, Thailand and Singapore.

Here, in images, are scenes from the mobile eye camps:

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Shoppers Descend on Black Friday Deals

Black Friday got off to its earliest start ever as many shoppers cleared the table of Thanksgiving dinner and headed straight to the malls and big-box retailers across the nation to snag goods at bargain prices.

More than 10,000 people were wrapped around Macy's flagship store in New York City before the doors opened at midnight this morning. Across the country, up to 147 million people are expected to shop at some point this weekend.

Thousands lined up outside a Target in Chicago ahead of a 9 p.m. start time.

"I'm here because my mom is making me, because she said I couldn't eat any of the Thanksgiving food if I didn't hold her place in line," Alex Horton told ABC News station WLS-TV in Chicago Thursday.

Many critics panned the early start this year, saying it cuts into quality time that should be spent with family and friends.

PHOTOS: Black Friday Shoppers Hit Stores

Chicago resident Claudia Fonseca got creative and took Thanksgiving to go.

"We brought a plate, but that's about it, we've been here since 11 a.m. And that's it," Fonseca told WLS Thursday.

Black Friday makes headlines every year, but not always for the right reason as violence has become linked to the day after Thanksgiving tradition.

AP Photo/Damian Dovarganes

Black Friday Holiday Shopping Bargains and Pitfalls Watch Video

Black Friday Shoppers Brave Long Lines, Short Tempers Watch Video

In Los Angeles, police aren't taking any chances with the LAPD deploying dozens of extra officers around the city to make sure things don't get out of hand.

Ontario Mills shopping mall in Los Angeles opened at midnight last year, but decided to give excited shoppers a two-hour head start to get their hands on the cut-rate deals, especially for electronics.

"This is my first year," Gabriela Mendoza told ABC News station KABC-TV Thursday. "I tried to stay away from this but I've heard it's really exciting so, I'm looking forward to it."

Things have been relatively calmer compared to the incident last year when a woman was accused of unleashing pepper spray on other shoppers in a dash for electronics at Walmart in Los Angeles.

The Black Friday madness kicked off Thursday when a south Sacramento, Calif., Kmart opened its doors at 6 a.m. Thursday. A shopper in a line of people that had formed nearly two hours earlier reportedly threatened to stab the people around him.

At two Kmarts in Indianapolis, police officers were called in after fights broke out among shoppers trying to score vouchers for a 32-inch plasma TV going for less than $200, police told ABC News affiliate RTV6. No injuries or arrest were made.

Stores have taken preventive measures in hopes of shoppers and tempers at ease, where safety is the main concern for everyone involved.

Mall of America has tightened its Black Friday policies and will bar unaccompanied minors from the megamall all day today. After a chair-throwing melee last year after Christmas, which was captured on smartphones and posted online, the mall is taking steps to prevent any repeat.

At the Arden Fair Mall in Sacramento, Calif., security planned to place barricades at the mall entrance to control the crowds and officials planned to double the number of security officers.

ABC News' John Schriffen and Sarah Netter contributed to this report.

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Gaza ceasefire takes hold but mistrust runs deep

GAZA/JERUSALEM (Reuters) - A ceasefire between Israel and Hamas took hold on Thursday with scenes of joy among the ruins in Gaza over what Palestinians hailed as a victory, and both sides saying their fingers were still on the trigger.

Quiet reigned on both sides of the border and Palestinians who had been under Israeli bombardment for eight days poured into the streets of Gaza for a celebratory rally, walking past wrecked houses and government buildings.

But as a precaution, schools stayed closed in southern Israel, where nerves were jangled by warning sirens - a false alarm, the army said - after a constant rain of rockets during the most serious Israeli-Palestinian fighting in four years.

Israel had launched its strikes last week with a declared aim of ending rocket attacks on its territory from Gaza, ruled by the Islamist militant group Hamas which denies Israel's right to exist. Hamas had responded with more rockets.

The truce brokered by Egypt's new Islamist government, working with the United States, prevented - at least for now - an Israeli invasion of Gaza.

Gaza medical officials said 162 Palestinians, more than half of them civilians including 37 children, were killed in the conflict. Nearly 1,400 rockets were fired into Israel, killing four civilians and two soldiers, including an officer who died on Thursday of wounds sustained on Wednesday, the Israeli army said.

Israel's defense minister, Ehud Barak, said it dropped 1,000 times as much explosive on the Gaza Strip as had landed in Israel.

Municipal workers in Gaza began cleaning streets and removing the rubble of buildings bombed in Israel's air strikes. Stores opened and people flocked to markets to buy food.

"Israel learnt a lesson it will never forget," said 51-year-old Khalil al-Rass from Beach refugee camp in the city of Gaza.

Jubilant crowds celebrated in Gaza, in a rare show of Palestinian unity five years after a brief civil war in which Hamas, elected to govern in a 2006 poll, wrested the territory from the rival Fatah movement that controls the West Bank.

Most of those celebrating on Thursday waved green Hamas flags but there were also hundreds with the yellow emblems of Fatah, led by Western-backed President Mahmoud Abbas.

He phoned Gaza chief and prime minister, Ismail Haniyeh, to "congratulate him on the victory and extend condolences to the families of the martyrs", Haniyeh's office said.

In rocket-hit towns in southern Israel, schools remained closed as a precaution. Nerves were jangled when warning sirens sounded, in what the military quickly said was a false alarm.

Trust was in short supply. The exiled leader of Hamas, Khaled Meshaal, said his Islamist movement would respect the truce if Israel did, but would respond to any violations.

"If Israel complies, we are compliant. If it does not comply, our hands are on the trigger," he told a news conference in Cairo.

Israeli Prime Minister Benjamin Netanyahu said he had agreed to "exhaust this opportunity for an extended truce", but told his people a tougher approach might be required in the future.

Facing a national election in two months, he swiftly came under fire from opposition politicians who had rallied to his side during the fighting but now contend he emerged from the conflict with no real gains for Israel.

"You don't settle with terrorism, you defeat it. And unfortunately, a decisive victory has not been achieved and we did not recharge our deterrence," Shaul Mofaz, leader of the main opposition Kadima party, wrote on his Facebook page.

BLOCKADE

Israel planned to discharge gradually tens of thousands of reservists called up for a possible Gaza invasion. The first tanks were seen being ferried north, away from the border, on transporters on Thursday.

In a speech, Haniyeh appealed to all Palestinian groups in Gaza to respect the ceasefire and cautioned that the "relevant government and security services" would monitor compliance.

Both sides quickly began offering differing interpretations of the ceasefire, which highlighted the many actual or potential areas of discord.

According to a text of the agreement seen by Reuters, both sides should halt all hostilities, with Israel desisting from incursions and targeting of individuals, while all Palestinian factions should cease rocket fire and cross-border attacks.

The deal also provides for easing Israeli restrictions on Gaza's residents, who live in what British Prime Minister David Cameron has called an "open prison".

The text said procedures for implementing this would be "dealt with after 24 hours from the start of the ceasefire".

Israeli sources said Israel would not lift a blockade of the enclave it enforced after Hamas, which preaches the Jewish state's destruction, won a Palestinian election in 2006.

However, Meshaal said the deal covered the opening of all of the territory's border crossings.

Israel let dozens of trucks carry supplies into the Palestinian enclave during the fighting. Residents there have long complained that Israeli restrictions blight their economy.

HAMAS HOLIDAY

Meshaal thanked Egypt for mediating and praised Iran for providing Gazans with financing and arms.

"We have come out of this battle with our heads up high," he said, adding that Israel had been defeated and failed in its "adventure".

Barak said Hamas, which declared November 22 a national holiday, had suffered a heavy military blow, including the death of its top commander, killed in an air strike at the start of the operation on November 14.

"A large part of the mid-range rockets were destroyed. Hamas managed to hit Israel's built-up areas with around a metric tonne of explosives, and Gaza targets got around 1,000 metric tonnes," Barak told Israel Radio.

"So whoever misses what is happening in Gaza does not understand that this entire agreement is a paper bridge for the defeated so that they can explain to their public how they can even show their faces after what they were hit with for a week."

Some Israelis staged protests against the deal, notably in the southern town of Kiryat Malachi, where three civilians were killed by a rocket from Gaza last week, army radio said.

Interviewed on Israel's Army Radio, Barak dismissed a ceasefire text published by Hamas as "a piece of paper which I don't remember anyone going around with - there's no signature on it".

He appeared to confirm, however, a key Hamas claim that the Israelis would no longer enforce a no-go zone on the Gaza side of the frontier that the army says has prevented Hamas raids:

"If there are no attacks along the border ... then I tell you that there is no problem with them working the farmland on the perimeter up to the fence," Barak said.

But should the Palestinians exploit such measures to breach the truce, Israel would be "free to act," he said, adding: "The right to self-defense trumps any piece of paper."

CAIRO

Egypt, an important U.S. ally now under Islamist leadership, took centre stage in diplomacy to halt the bloodshed. Cairo has walked a fine line between sympathies for Hamas, an offshoot of the Muslim Brotherhood that produced President Mohamed Mursi and much of his government, and preserving its 1979 peace treaty with Israel and its ties with Washington, its main aid donor.

Announcing the agreement in Cairo, Egyptian Foreign Minister Mohamed Kamel Amr said mediation had "resulted in understandings to cease fire, restore calm and halt the bloodshed".

U.S. Secretary of State Hillary Clinton, standing beside Amr, thanked Mursi for peace efforts that showed "responsibility, leadership" in the region.

Gaza erupted in a Middle East already shaken by last year's Arab revolts that toppled several veteran U.S.-backed leaders, including Egypt's Hosni Mubarak, and by a civil war in Syria, where President Bashar al-Assad is fighting for survival.

Israel, the United States and the European Union all classify Hamas as a terrorist organization. But its stance is popular with many Palestinians and has kept the movement competitive with Fatah.

(Additional reporting by Noah Browning in Gaza, Ori Lewis, Allyn Fisher-Ilan, Crispian Balmer and Dan Williams in Jerusalem and Marwa Awad, Yasmine Saleh, Shaimaa Fayed and Tom Perry in Cairo; Writing by Jeffrey Heller; Editing by Peter Graff)

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Newly-launched Clifford Capital says it has "decent pipeline" of projects

SINGAPORE: Specialist finance firm Clifford Capital launches its operations Thursday on a firm footing.

The company, backed by a consortium of shareholders that includes Temasek Holdings, DBS Bank, Standard Chartered Bank, Sumitomo Mitsui Banking Corporation, Manulife through its unit, John Hancock Life Insurance Company and Prudential Assurance Company Singapore, said it already has a "decent pipeline" of transactions which are spread across broad geographic regions.

The firm, which provides financing to Singapore corporates in bidding for large, long-tenor projects overseas, expects to operate at a steady state within the next two to three years.

Tharman Shanmugaratnam, Singapore Deputy Prime Minister and Finance Minister, Chairman at Monetary Authority of Singapore said: "We are well placed -- the community here, of financial institutions, multilateral development institutions, government working together with Clifford Capital and professional specialists -- we are well placed as a community in Singapore to help to catalyse the development of infrastructural finance in Asia and beyond."

The company aims to have 80 percent of its portfolio comprising projects that involves Singapore-based firms.

These refer to companies listed or incorporated in Singapore with a material presence in the city state.

In turn, the Singapore government will back debt instruments issued by Clifford Capital with a guarantee.

Clive Kerner, CEO of Clifford Capital said: "The debt is guaranteed by the government of Singapore, which is in turn, triple A.

"If you compare that situation with many of the banks in the world at the moment, I'm not sure there are any banks that actually have triple A credit rating, so what that will do is give us a very low cost of funding and we think we'll be able to pass that benefit on to our clients in the form of attractive financing solutions."

Over the next decade, the Asian Development Bank estimates that there will be about US$8.3 trillion worth of infrastructure investment in Asia.

But at the same time, the cost of funding these investments is up.

Ray Ferguson, CEO of Standard Chartered Bank Singapore said: "The rules around Basel III and banks make long term financing harder for banks to provide, particularly financing beyond the sort of five-year level, because it's very difficult for us to get matching deposits.

"So Clifford can come in take the longer term tranches of some of those deals."

For a start, Clifford Capital will focus on financing the infrastructure and offshore and marine sectors with an average deal size of US$50 to US$100 million.

These are the sectors which Singapore firms have the competitive advantage.

- CNA/lp

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Trinamool's no-confidence motion a small game: IAC

KOLKATA: India Against Corruption(IAC) leader Yogendra Yadav today said the failed attempt by Trinamool Congress to bring a no-confidence motion against the UPA government in Parliament was a 'small game' to prove that it is different.

"These are small games played by political parties who want to put up a show in Parliament. They try to show that they are different from others when they are not," the political analyst working with activist Arvind Kejriwal told reporters here.

"There are small differences between TMC and UPA which are exaggerated. I don't know why should we be interested in these games," he said when asked to comment on TMC's opposition to FDI in multi-brand retail and other issues.

Kejriwal is scheduled to announce his political party on November 26.

TMC's no-confidence motion in the Lok Sabha against the UPA government over FDI in retail flopped earlier in the day in the absence of requisite numbers.

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Study finds mammograms lead to unneeded treatment

Mammograms have done surprisingly little to catch deadly breast cancers before they spread, a big U.S. study finds. At the same time, more than a million women have been treated for cancers that never would have threatened their lives, researchers estimate.

Up to one-third of breast cancers, or 50,000 to 70,000 cases a year, don't need treatment, the study suggests.

It's the most detailed look yet at overtreatment of breast cancer, and it adds fresh evidence that screening is not as helpful as many women believe. Mammograms are still worthwhile, because they do catch some deadly cancers and save lives, doctors stress. And some of them disagree with conclusions the new study reached.

But it spotlights a reality that is tough for many Americans to accept: Some abnormalities that doctors call "cancer" are not a health threat or truly malignant. There is no good way to tell which ones are, so many women wind up getting treatments like surgery and chemotherapy that they don't really need.

Men have heard a similar message about PSA tests to screen for slow-growing prostate cancer, but it's relatively new to the debate over breast cancer screening.

"We're coming to learn that some cancers — many cancers, depending on the organ — weren't destined to cause death," said Dr. Barnett Kramer, a National Cancer Institute screening expert. However, "once a woman is diagnosed, it's hard to say treatment is not necessary."

He had no role in the study, which was led by Dr. H. Gilbert Welch of Dartmouth Medical School and Dr. Archie Bleyer of St. Charles Health System and Oregon Health & Science University. Results are in Thursday's New England Journal of Medicine.

Breast cancer is the leading type of cancer and cause of cancer deaths in women worldwide. Nearly 1.4 million new cases are diagnosed each year. Other countries screen less aggressively than the U.S. does. In Britain, for example, mammograms are usually offered only every three years and a recent review there found similar signs of overtreatment.

The dogma has been that screening finds cancer early, when it's most curable. But screening is only worthwhile if it finds cancers destined to cause death, and if treating them early improves survival versus treating when or if they cause symptoms.

Mammograms also are an imperfect screening tool — they often give false alarms, spurring biopsies and other tests that ultimately show no cancer was present. The new study looks at a different risk: Overdiagnosis, or finding cancer that is present but does not need treatment.

Researchers used federal surveys on mammography and cancer registry statistics from 1976 through 2008 to track how many cancers were found early, while still confined to the breast, versus later, when they had spread to lymph nodes or more widely.

The scientists assumed that the actual amount of disease — how many true cases exist — did not change or grew only a little during those three decades. Yet they found a big difference in the number and stage of cases discovered over time, as mammograms came into wide use.

Mammograms more than doubled the number of early-stage cancers detected — from 112 to 234 cases per 100,000 women. But late-stage cancers dropped just 8 percent, from 102 to 94 cases per 100,000 women.

The imbalance suggests a lot of overdiagnosis from mammograms, which now account for 60 percent of cases that are found, Bleyer said. If screening were working, there should be one less patient diagnosed with late-stage cancer for every additional patient whose cancer was found at an earlier stage, he explained.

"Instead, we're diagnosing a lot of something else — not cancer" in that early stage, Bleyer said. "And the worst cancer is still going on, just like it always was."

Researchers also looked at death rates for breast cancer, which declined 28 percent during that time in women 40 and older — the group targeted for screening. Mortality dropped even more — 41 percent — in women under 40, who presumably were not getting mammograms.

"We are left to conclude, as others have, that the good news in breast cancer — decreasing mortality — must largely be the result of improved treatment, not screening," the authors write.

The study was paid for by the study authors' universities.

"This study is important because what it really highlights is that the biology of the cancer is what we need to understand" in order to know which ones to treat and how, said Dr. Julia A. Smith, director of breast cancer screening at NYU Langone Medical Center in New York. Doctors already are debating whether DCIS, a type of early tumor confined to a milk duct, should even be called cancer, she said.

Another expert, Dr. Linda Vahdat, director of the breast cancer research program at Weill Cornell Medical College in New York, said the study's leaders made many assumptions to reach a conclusion about overdiagnosis that "may or may not be correct."

"I don't think it will change how we view screening mammography," she said.

A government-appointed task force that gives screening advice calls for mammograms every other year starting at age 50 and stopping at 75. The American Cancer Society recommends them every year starting at age 40.

Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer, said the study should not be taken as "a referendum on mammography," and noted that other high-quality studies have affirmed its value. Still, he said overdiagnosis is a problem, and it's not possible to tell an individual woman whether her cancer needs treated.

"Our technology has brought us to the place where we can find a lot of cancer. Our science has to bring us to the point where we can define what treatment people really need," he said.

___

Online:

Study: http://www.nejm.org/doi/full/10.1056/NEJMoa1206809

Screening advice: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

___

Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Cease-Fire Holds Between Hamas and Israel

With a tenuous cease-fire in place and no rocket fire between Israel and Hamas for the first time in more than a week, Palestinians have begun to clean up rubble and damage inflicted by Israeli missiles.

People in Gaza filled the streets Thursday morning, inspecting damage to homes and businesses. Overnight, gunfire erupted in the crowded streets of the Palestinian enclave to celebrate the announcement of a cease-fire in the bloody conflict between Israel and Hamas, the Palestinian militant political group that essentially controlsl the Gaza Strip.

FULL COVERAGE: Israel-Gaza Conflict

"It's a nice message from Palestinians - don't mess with Palestinians," said Jalal Marzen Wednesday night during a celebration outside Gaza's Al-Shifa Hospital. He and others pointed to the targeting of Tel Aviv by Hamas rockets as a shifting in the balance of power, arguing Israel's calculations would be forced to change ahead of the next flare-up. "It's huge, it's huge for us!" Marzen exclaimed.

Later, however, Israeli officials said several missiles from Gaza flew into Israel after the cease-fire. Israel did not respond with the air srikes that have blanketed Gaza in the past week.

Hamas has declared Nov. 22 a national holiday and said it would be celebrated every year.

"We call on everyone to celebrate, visit the families of martyrs, the wounded, those who lost homes," Hamas said.

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A sense of normalcy returned to Gaza Thursday morning, with traffic again clogging busy intersections and stores opening for business.

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"For first time, the Israeli people felt what bombs mean, what rockets mean, what war means, what killing people means," said clothing store owner Bassem Diazeda, who said he only became a supporter of Hamas since the escalation.

The fighting came to an end after a meeting between Egyptian President Mohammed Morsi and U.S. Secretary of State Hillary. Clinton, who said Egypt and the U.S. would help support the peace process going forward.
The eight days of fighting left more than 160 Palestinians and five Israelis dead.

The concern now among top diplomats is whether the cease-fire will hold while Israeli Prime Minister Benjamin Benjamin Netanyahu and Hamas leaders work on a long term solution for peace. Israel is demanding an end to rocket fire from Gaza, while Hamas wants an end to Israel's blockade of Gaza and targeted assassinations, the kind that launched Israel's operation "Pillar of Defense."

Hamas was not the only group firing rockets from Gaza into Israel. Other militant groups in Gaza, such as Islamic Jihad, fired rockets during the eight-day assault. A splinter Palestinian group took responsibility for Wednesday's bus bombing in Tel Aviv that wounded 23 people.

So the question is whether Hamas can control the more rogue groups in Gaza and stake out a real leadership role.

Clinton said that Egypt and the U.S. would help support the peace process going forward.

"Ultimately, every step must move us toward a comprehensive peace for people of the region," Clinton said.

An Israeli official told ABC News that the cease-fire would mean a "quiet for quiet" deal in which both sides stop shooting and "wait and see what happens."

"I agree that that it was a good idea to give an opportunity to the cease-fire ... in order to enable Israeli citizens to return to their day-to-day lives," Netanyahu said.

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