Do drunks have to go to the ER?

NEW YORK (Reuters Health) – With the help of a checklist, ambulance workers may be able to safely reroute drunk patients to detoxification centers instead of emergency rooms, according to a new study.

Researchers in Colorado found no serious medical problems were reported after 138 people were sent to a detox center to sleep it off, instead of to an ER.

In 2004, according to the researchers, it’s estimated that 0.6 percent of all U.S. ER visits were made by people without any problems other than being drunk. Those visits ended up costing about $ 900 million.

“Part of the issue has been – as it is in many busy ER departments – there’s a lot of chronic alcoholics that are brought in by ambulance, police or just come in. Often they are brought in because they have not committed a crime or there is limited space in our detoxification center. So the majority were brought to the ER department,” said Dr. David Ross, the study’s lead author from Penrose-St. Francis Health Services in Colorado Springs.

Ross said the ambulance company where he serves as medical director created the checklist with the help of the local detox center, which provided limited medical care by a nurse, and the local hospitals to reduce the number of drunks without medical needs being sent to the local ERs.

They created a checklist with 29 yes-or-no questions, such as whether the patient is cooperating with the ambulance worker’s examination and if the patient is willing to go to the detox center.

The patient was sent to the ER if the ambulance worker checked “no” on any question.

The researchers then went back to look at the patients they transported between December 2003 and December 2005 to see whether or not any of them ended up having serious medical problems at the detox center.

During that two year period, the ambulance workers transported 718 drunks. The detox center received 138 and the local ERs got 580.

Overall, 11 of the patients who were taken to detox were turned away because there was no room, their blood alcohol level exceeded the limit, their family came to pick them up or they were combative.

Another four patients at the detox center were taken to the ER because of minor complications, including chest and knee pain. However, there were no serious complications reported.

“We really believe that we did not miss anybody with a serious illness and injury that didn’t go to the ER as they should have,” said Ross.

But the researchers write in the Annals of Emergency Medicine that their study did have some limitations.

Specifically, the researchers did not plan in advance to do a study when they were creating the checklist, which means their findings are limited to whatever information was collected at the detox center and ERs.

Also, the number of people who were sent to the detox center in their study is relatively small, so it’s hard to tell how many serious complications they’d see among a larger group of people.

“We tried to estimate how likely we would have been to encounter a serious event… We estimated at most we’d encounter three serious adverse events (in 748 patients),” Ross told Reuters Health.

SOURCE: http://bit.ly/QgPCT5 Annals of Emergency Medicine, online November 9, 2012.

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Thanksgiving Day parade offers respite for storm victims

GENEVA (Reuters) - Kris Kristofferson -- Oxford scholar, athlete, U.S. Army helicopter pilot, country music composer, one-time roustabout, film actor, singer, lover of women, three times a husband and father of eight -- seems ready to meet his maker. At least, that was the clear impression he left with an audience of middle-aged-and-upwards fans at a concert in Geneva this week, a message underscored by his 28th and latest album, "Feeling Mortal" and its coffin-dark cover. ...

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Chevy Chase Exiting “Community”

NEW YORK (TheWrap.com) – Chevy Chase is leaving “Community” after a rocky run on the NBC series.

The actor is leaving by mutual agreement with the show’s producers, a person close to the show told TheWrap. He will appear in most of the 13 episodes of the show’s upcoming fourth season, but not the final one or two episodes.

Chase had a very public feud with former showrunner Dan Harmon that included Harmon airing an angry rant by Chase. The situation hardly improved when new showrunners Moses Port and David Guarascio took over this season.

The original “Saturday Night Live” player reportedly used the N-word last month in an on-set rant complaining about the racism of his character, Pierce Hawthorne. Chase asked how far the character’s bigotry would go, and whether he would be forced to say the word. He later apologized.

Chase made little effort to hide his mixed feelings about the show, telling the Huffington Post in March, “I probably won’t be around that much longer, frankly.”

“I have creative issues with this show,” he said. “I always have. With my character, with how far you can take character … just to give him a long speech about the world at the end of every episode is so reminiscent. It’s like being relegated to hell and watching ‘Howdy Doody‘ for the rest of your life. It’s not particularly necessary, but that’s the way they do these things. I think it belies the very pretenses that his character, Jeff, has, that he’s giving these talks. They’re supposed to, in some way, be a little lesson to people who watch sitcoms … to that degree, I can’t stand sitcoms. … I think, if you know me and my humor over the years, you know that this is certainly not my kind of thing.”

“Community” returns February 7.

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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

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

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Mistrust runs deep despite cease-fire

CAIRO/GAZA (Reuters) - A ceasefire between Israel and Gaza's Hamas rulers took hold on Thursday after eight days of conflict, although deep mistrust on both sides cast doubt on how long the Egyptian-sponsored deal can last.

Even after the ceasefire came into force late on Wednesday, a dozen rockets from the Gaza Strip landed in Israel, all in open areas, a police spokesman said. In Gaza, witnesses reported an explosion shortly after the truce took effect at 9 p.m (2 p.m. Eastern Time), but there were no casualties and the cause was unclear.

The deal prevented, at least for the moment, an Israeli ground invasion of the Palestinian enclave following bombing and rocket fire which killed five Israelis and 162 Gazans, including 37 children.

But 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.

Both sides quickly began offering differing interpretations of the ceasefire, brokered by Egypt's new Islamist government and backed by the United States, highlighting the many actual or potential areas of discord.

If it holds, the truce will give 1.7 million Gazans respite from days of ferocious air strikes and halt rocket salvoes from militants that have unnerved a million people in southern Israel and reached Tel Aviv and Jerusalem for the first time.

At the United Nations, the Security Council called on both Israel and Hamas to uphold the ceasefire and commended Egypt's President Mohamed Mursi and others for brokering the truce.

The council said in a statement it "deplored the loss of civilian lives resulting from this situation and reiterated the need to take appropriate steps to ensure the safety and well-being of civilians and their protection in accordance with international humanitarian law."

"Allahu akbar, (God is greatest), dear people of Gaza you won," blared mosque loudspeakers in Gaza as the truce took effect. "You have broken the arrogance of the Jews."

Fifteen minutes later, wild celebratory gunfire echoed across the darkened streets, which gradually filled with crowds waving Palestinian flags. Ululating women leaned out of windows and fireworks lit up the sky.

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".

Some Israelis staged protests against the deal, notably in the southern town of Kiryat Malachi, where three people were killed by a Gaza rocket during the conflict, army radio said.

Netanyahu said he was willing to give the truce a chance but held open the possibility of reopening the conflict. "I know there are citizens expecting a more severe military action, and perhaps we shall need to do so," he said.

The Israeli leader, who faces a parliamentary election in January, delivered a similar message earlier in a telephone call with U.S. President Barack Obama, his office said.

"AN OPEN PRISON"

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 rejects the Jewish state's right to exist, won a Palestinian election in 2006.

However, Meshaal said the deal covered the opening of all of the territory's border crossings. "The document stipulates the opening of the crossings, all the crossings, and not just Rafah," he said. Israel controls all of Gaza's crossings apart from the Rafah post with Egypt.

Hamas lost its top military commander to an Israeli strike in the conflict and suffered serious hits to its infrastructure and weaponry, but has emerged with its reputation both in the Arab world and at home stronger.

Israel can take comfort from the fact it dealt painful blows to its enemy, which will take many months to recover, and showed that it can defend itself from a barrage of missiles.

"No one is under the illusion that this is going to be an everlasting ceasefire. It is clear to everyone it will only be temporary," said Michael Herzog, a former chief of staff at the Israeli ministry of defense.

"But there is a chance that it could hold for a significant period of time, if all goes well," he told Reuters.

U.S. Defense Secretary Leon Panetta, in a phone call with his Israeli counterpart, praised the performance of a U.S.-backed Israeli anti-rocket system known as "Iron Dome," which the Pentagon said intercepted over 85 percent of rockets fired at Israeli civilians.

Iron Dome "provided decision space for Israel to achieve its strategic goals without forcing further military actions," the Pentagon said in a statement.

Egypt, an important U.S. ally now under Islamist leadership, took center stage in diplomacy to halt the bloodshed. Cairo has walked a fine line between its sympathies for Hamas, an offshoot of the Muslim Brotherhood to which Mursi belongs, and its need to preserve 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 she said showed "responsibility, leadership" in the region.

The Gaza conflict erupted in a Middle East already shaken by last year's Arab uprisings 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.

BUS BOMBING

The ceasefire was forged despite a bus bomb explosion that wounded 15 Israelis in Tel Aviv earlier in the day and despite more Israeli air strikes that killed 10 Gazans. It was the first serious bombing in Israel's commercial capital since 2006.

Israel, the United States and the European Union all classify Hamas as a terrorist organization. It seized the Gaza Strip from the Western-backed Palestinian President Mahmoud Abbas in 2007 in a brief but bloody war with his Fatah movement.

"This is a critical moment for the region," Clinton said. "Egypt's new government is assuming the responsibility and leadership that has long made this country a cornerstone for regional stability and peace."

In Amman, U.N. chief Ban Ki-moon urged both sides to stick to their ceasefire pledges. "There may be challenges implementing this agreement," he said, urging "maximum restraint."

(Additional reporting by Noah Browning in Gaza, Ori Lewis, Allyn Fisher-Ilan and Crispian Balmer in Jerusalem, Yasmine Saleh, Shaimaa Fayed and Tom Perry in Cairo, Suleiman al-Khalidi in Amman, Michelle Nichols at the United Nations and Margaret Chadbourn and Phil Steward in Washington.; Writing by Alistair Lyon and David Stamp; Editing by Louise Ireland and Christopher Wilson)

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AP Exclusive: Syrian rebels seize base, arms trove

BASE OF THE 46TH REGIMENT, Syria (AP) — After a nearly two-month siege, Syrian rebels overwhelmed a large military base in the north of the country and made off with tanks, armored vehicles and truckloads of munitions that rebel leaders say will give them a boost in the fight against President Bashar Assad‘s army.

The rebel capture of the base of the Syrian army’s 46th Regiment is a sharp blow to the government’s efforts to roll back rebels gains and shows a rising level of organization among opposition forces.

More important than the base’s fall, however, are the weapons the rebels found inside.

At a rebel base where the much of the haul was taken after the weekend victory, rebel fighters unloaded half a dozen large trucks piled high with green boxes full of mortars, artillery shells, rockets and rifles taken from the base. Parked nearby were five tanks, two armored vehicles, two rocket launchers and two heavy-caliber artillery cannons.

Around 20 Syrian soldiers captured in the battle were put to work carrying munitions boxes, barefoot and stripped to the waist. Rebels refused to let reporters talk to them or see where they were being held.

“There has never been a battle before with this much booty,” said Gen. Ahmad al-Faj of the rebels Joint Command, a grouping of rebel brigades that was involved in the siege. Speaking on Monday at the rebel base, set up in a former customs office at Syria’s Bab al-Hawa border crossing with Turkey, he said the haul would be distributed among the brigades.

For months, Syria’s rebels have gradually been destroying government checkpoints and taking over towns in the northern provinces of Idlib and Aleppo along the Turkish border.

Rebel fighters say that weapons seized in such battles have been essential to their transformation from ragtag brigades into forces capable of challenging Assad’s professional army. Cross-border arms smuggling from Turkey and Iraq has also played a role, although the most common complaint among rebel fighters is that they lack ammunition and heavy weapons, munitions and anti-aircraft weapons to fight Assad’s air force.

It is unclear how many government bases the rebels have overrun during the 20-month conflict, mostly because they rarely try to hold captured facilities. Staying in the captured bases would make them sitting ducks for regime airstrikes.

“Their strategy is to hit and run,” said Elias Hanna, a retired Lebanese army general and Beirut-based strategic analyst. “They’re trying to hurt the regime where it hurts by bisecting and compartmentalizing Syria in order to dilute the regime’s power.”

The 46th Regiment was a major pillar of the government’s force near the northern city of Aleppo, Syria’s economic hub, and its fall cuts a major supply line to the regime’s army, Hanna said. Government forces have been battling rebels for months over control of Aleppo.

“It’s a tactical turning point that may lead to a strategic shift,” he said.

At the 46th Regiment’s base, about 25 kilometers (15 miles) west of Aleppo, the main three-story command building showed signs of the battle — its walls punctured apparently from rebel rocket attacks. The smaller barracks buildings scattered around the compound, about 2.6 square kilometers (1 square mile) in size, had been looted, with mattresses overturned. A number of buildings had been torched.

Reporters from The Associated Press who visited the base late Monday saw no trace of the government troops who had been defending it — other than the dead bodies of seven soldiers.

Two of them, in camouflage uniforms, lay outside the command building. One of them was missing his head, apparently blown off in an explosion.

The rest were in a nearby clinic. Four dead soldiers were on stretchers set on the floor, one with a large gash in his arm, another with what appeared to be a large shrapnel hole in the back of his head. The last lay on a gurney in another room, his arms and legs bandaged, a bullet hole in his cheek and a splatter of blood on the wall and ceiling behind him as if he had been shot where he lay.

It could not be determined how or when the soldiers had been killed.

The final assault that took the base came after more than 50 days of siege that left the soldiers inside demoralized, according to fighters who took part.

Working together and communicating by radio, a number of different rebels groups divided up the area surrounding the base and each cut the regime’s supply lines, said Abdullah Qadi, a rebel field commander. Over the course of the siege, dozens of soldiers defected, some telling the rebels that those inside were short of food, Qadi said.

The rebels decided to attack Saturday afternoon when they felt the soldiers inside were weak and the rebels had enough ammunition to finish the battle, Qadi said. The battle was over by nightfall on Sunday. Seven rebel fighters were killed in the battle, said al-Faj of the rebels’ Joint Command. Other rebel leaders gave similar numbers.

It remains unclear how many soldiers remained in the base when the rebels launched their attack and what happened to them.

Al-Faj said all soldiers inside were either killed or captured. He said he didn’t know how many were killed, but that the rebels had taken about 50 prisoners, all of whom would be tried in a rebel court. Aside from the 20 prisoners seen at the rebel’s Bab al-Hawa base, the AP was unable to see any other captured soldiers.

The Syrian government does not respond to requests for comment on military affairs and said nothing about the base’s capture. It says the rebels are terrorists backed by foreign powers that seek to destroy the country.

Disorganization has plagued the Syrian opposition since the start of the anti-Assad uprising in March 2011, with exile groups pleading for international help even when they have no control over those fighting inside of Syria.

A newly formed Syrian opposition coalition received a boost Tuesday, when Britain officially recognized it as the sole representative of the Syrian people.

The National Coalition of the Syrian Revolutionary and Opposition Forces was formed in the Gulf nation of Qatar on Oct. 11 under pressure from the United States for a stronger, more united opposition body to serve as a counterweight to more extremist forces.

British Foreign Secretary William Hague said Tuesday the body’s members gave assurances to be a “moderate political force committed to democracy” and that the West must “support them and deny space to extremist groups.”

The United States and the European Union have both spoken well of the body but stopped short of offering it full recognition.

Key to the body’s success will be its ability to build ties with the disparate rebel groups fighting inside Syria. Many rebel leaders say they don’t recognize the new body, and a group of extremist Islamist factions on Monday rejected it, announcing that they had formed an “Islamic state” in Aleppo.

Anti-regime activists say nearly 40,000 people have been killed since Syria’s crisis started 20 months ago.

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Associated Press write Elizabeth Kennedy contributed reporting from Beirut, Lebanon.

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Scott Derrickson to direct feature adaptation of hit video game “Deus Ex: Human Revolution”

LOS ANGELES (TheWrap.com) – Scott Derrickson (“Sinister,” “The Exorcism of Emily Rose“) has signed on to direct the big screen adaptation of the hit Square Enix video game, “Deus Ex: Human Revolution,” for CBS Films, the company announced on Thursday.

Derrickson will also write the screenplay for the film with C. Robert Cargill (“Sinister.”)

Roy Lee and Adrian Askarieh are attached to produce the film, with John P. Middleton serving as the executive producer.

Set in the near future, when dramatic advances in science, specifically human augmentation, have triggered a technological renaissance, “Deus Ex: Human Revolution” follows Adam Jensen, an ex-SWAT security specialist who must embrace mechanical augments in order to unravel a global conspiracy.

“‘Deus Ex’ is a phenomenal cyberpunk game with soul and intelligence,” said Derrickson. “By combining amazing action and tension with big, philosophical ideas, ‘Deus Ex‘ is smart, ballsy, and will make one hell of a movie. Cargill and I can’t wait to bring it to the big screen.”

The “Deus Ex” franchise was originally introduced in June 2000. Its latest entry, “Deus Ex: Human Revolution,” launched in 2011, ranked number one across global sales charts and earned over 100 industry awards.

Developed by Eidos-Montréal and published by Square Enix, “Deus Ex: Human Revolution” will serve as the primary template for the film.

Derrickson and Cargill, pictured above, are represented by WME and managed by Brillstein Entertainment Partners.

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Xoma’s drug combo lowers high blood pressure in late-stage study

(Reuters) – Xoma Corp said its experimental combination of two drugs met the main goal of lowering hypertension better than a treatment based on either of the drugs alone in a late-stage study, sending the biotechnology company‘s shares up 6 percent.

The combination of perindopril arginine and amlodipine besylate showed statistically significant reduction in sitting systolic and diastolic blood pressure after six weeks of treatment, compared with either drugs alone, Xoma said.

The company is likely to file a new drug application for the combination in 2013, said RBC Capital Markets analyst Adnan Butt.

Xoma said it does not plan to market the product directly but intends to sublicense it to a third party.

“The next thing we expect is for the company to get a partnership for this drug. The terms could include an upfront payment and possible royalties on product sales,” Butt said.

He added that the result would be a modest positive but the key driver is the company’s experimental anti-inflammatory drug gevokizumab. The drug is being tested in a late-stage study for treatment of non-infectious uveitis, an inflammation of the middle layer of the eye.

Xoma’s partner, French pharmaceutical company Les Laboratoires Servier, already markets the combination under the trade name Coveram in 91 countries outside the United States.

Perindopril and amlodipine each target different cardiovascular functions and are, therefore, used in combination to treat high blood pressure, Xoma said. The company bought the rights to Servier’s perindopril franchise in January.

The combination was well tolerated in the trial, and there were no serious adverse events, Xoma said.

Shares of the company rose to $ 2.84 in extended trade. They closed nearly 3 percent higher at $ 2.68 on Tuesday on the Nasdaq.

(Reporting By Vrinda Manocha in Bangalore; Editing by Sriraj Kalluvila)

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Clinton presses on with Israel-Hamas truce efforts

JERUSALEM (AP) — JERUSALEM (AP) — The U.S. secretary of state will try on Wednesday to wring an elusive truce deal from Israel and Gaza's militant Hamas rulers after earlier efforts to end more than a week of fighting broke down amid a furious spasm of violence.

With thousands of Israeli ground troops massed on the Gaza border and awaiting a possible order to invade, Hillary Rodham Clinton joined other world diplomats in shuttling between Jerusalem, the West Bank and Cairo, trying to piece together a deal that would satisfy the two foes after a week of fighting and mounting casualties.

After meeting with Israeli Prime Minister Benjamin Netanyahu in Jerusalem Tuesday night, Clinton is heading to the West Bank on Wednesday morning and later to Cairo.

The two sides had seemed on the brink of a deal following a swirl of diplomatic activity also involving the U.N. chief and Egypt's president. But sticking points could not be resolved as talks — and violence — stretched into the night.

Israeli aircraft pounded Gaza with at least 30 strikes overnight, hitting government ministries, smuggling tunnels, a banker's empty villa and a Hamas-linked media office.

At least four strikes within seconds of each other pulverized a complex of government ministries the size of a city block, rattling nearby buildings and shattering surrounding windows. Hours later, clouds of acrid dust still hung over the area and smoke still rose from the rubble.

The impact of the blast demolished the nearby office of attorney Salem Dahdouh, who was searching through files buried in the debris.

"Where are human rights?" he asked, saying officials negotiating a cease-fire ought to see the devastation.

In downtown Gaza City, another strike leveled the empty, two-story home of a well-known banker and buried a police car parked nearby in rubble.

"This is an injustice carried out by the Israelis," said the house's caretaker, Mohammed Samara. "There were no resistance fighters here. We want to live in peace. Our children want to live in peace. We want to live like people in the rest of the world."

Medics said a child living in the area was killed, raising the Palestinian death toll to at least 138. Five Israelis have also been killed by Palestinian rocket fire, which continued early Wednesday.

The Israeli military said its targets included the Ministry of Internal Security, which it says served as one of Hamas' main command and control centers, a military hideout used as a senior operatives' meeting place and a communications center.

Washington blames Hamas rocket fire for the outbreak of violence and has backed Israel's right to defend itself, but has cautioned that an Israeli ground invasion could send casualties soaring.

"In the days ahead, the United States will work with our partners here in Israel and across the region toward an outcome that bolsters security for the people of Israel, improves conditions for the people of Gaza and moves toward a comprehensive peace for all people of the region," she said Tuesday night in Jerusalem, speaking alongside Netanyahu.

In the West Bank, Clinton was to meet with Palestinian President Mahmoud Abbas. The U.S. considers Hamas, which has killed hundreds of Israelis in suicide and other attacks, to be a terror group and does not meet with its officials.

While Abbas does not have any practical influence in Gaza, his West Bank government would be instrumental in implementing any new arrangements on the Gaza border that would be part of a cease-fire pact. Israel and Egypt slammed shut the border after the militant group seized the territory from Abbas in June 2007, hoping to disrupt Hamas rule. Both sides have since eased the restrictions, but many remain.

Hamas official Izzat Risheq predicted a truce deal would be reached Wednesday, but the movement wouldn't discuss what the problems were.

Israeli media quoted Defense Minister Ehud Barak as telling a closed meeting that Israel wanted a 24-hour test period of no rocket fire to see if Hamas could enforce a truce among its forces and other Gaza militant groups.

Palestinian officials briefed on the negotiations said Hamas wanted assurances of a comprehensive deal that included new arrangements for prying open Gaza's heavily restricted borders — and were resisting Israeli proposals for a phased agreement. The officials spoke on condition of anonymity because they were not authorized to talk to the media.

Israel launched the offensive on Nov. 14 following months of rocket salvoes from the territory into southern Israel, which has endured attacks for the past 13 years. For its opening salvo, it assassinated Hamas' military chief, then followed up by bombarding the militant-run territory to its south with more than 1,500 airstrikes that initially targeted rocket launchers and weapons storage sites, then widened to include wanted militants and symbols of Hamas power.

Defying Israel's claims that they've been badly battered, the militants have so far fired more than 1,400 rockets at Israel, drawing upon newly developed and smuggled weapons to extend the reach of their attacks toward Tel Aviv and Jerusalem, Israel's largest cities. The number of Israelis within rocket range leapt to 3.5 million from 1 million.

Dozens of civilians are among the more than 130 Palestinians killed in a week of fighting. Four Israeli civilians and a soldier have been killed by rocket fire — a toll possibly kept down by a U.S.-funded rocket defense system that has shot down hundreds of Gaza projectiles.

In a meeting with Netanyahu, U.N. chief Ban Ki-moon condemned Palestinian rocket attacks, but urged Israel to show "maximum restraint."

"Further escalation benefits no one," he said before returning to Egypt, which is mediating the truce talks.

Israel demands an end to rocket fire from Gaza and a halt to weapons smuggling into the territory through tunnels under the border with Egypt. It also wants international guarantees that Hamas will not rearm or use Egypt's Sinai region, which abuts both Gaza and southern Israel, to attack Israelis.

Hamas wants Israel to halt all attacks on Gaza and lift tight restrictions on trade and movement in and out of the territory that have been in place since it seized the territory. Israel has rejected such demands in the past.

Egypt's new Islamist government is playing a key role in the negotiations to broker a deal between the two sides, which shun each other. It is also expected to play a pivotal role in maintaining any deal, performing a difficult balancing act as an ideological ally of Hamas, recipient of U.S. aid and one of just two of Israel's Arab neighbors to have made peace with Israel.

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Laub reported from Gaza City. AP writer Ibrahim Barzak contributed to this report from Gaza City.

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Turbulence on Cuba-Italy flight leaves 30 bruised

ROME (AP) — An airliner flying from Havana to Milan abruptly plunged some 1,000 meters (3,300 feet) when it hit unusually strong turbulence over the Atlantic on Monday, terrifying passengers and leaving some 30 people aboard with bruises and scrapes, airline officials said.

The flight continued to Milan’s Malpensa airport after the plane’s captain determined that it suffered no structural damage and two passengers who are physicians found no serious injuries, Giulio Buzzi, head of the pilots division at Neos Air, told Sky TG24 TV.

The ANSA news agency quoted bruised passenger Edoardo De Lucchi as saying meals were being served when suddenly there was “10 seconds of terror.” He recounted how plates went flying and some passengers not wearing seatbelts bounced about.

Buzzi had said that the drop measured some 3,000 meters (10,000 feet) in a cloudless sky. But Milan daily’s Corriere della Sera’s web site, quoting Neos official Davide Martini, later reported that the plane first bounced up some 500 meters (1,650 feet), then dropped some 1,000 meters (3,300 feet) to some 500 meters (1,650 feet) below the original altitude.

Europe News Headlines – Yahoo! News

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