Well: Think Like a Doctor: The Man Who Wobbled

The Challenge: Can you solve the medical mystery of a man who suddenly becomes too dizzy to walk?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a 56-year-old factory worker with dizziness and panic attacks. I have provided records from his two hospital visits that will give you all the information available to the doctor who finally made the diagnosis.

The first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped a roomful of specialists.

The Patient’s Story:

The middle-aged man clicked his way through the multiple reruns of late-late-night television. He should have been in bed hours ago, but lately he hadn’t been able to get to sleep. Suddenly his legs took on a life of their own. Stretched out halfway to the center of the room, they began to shake and twitch and jump around. The man watched helplessly as his legs disobeyed his mental orders to stop moving. He had no control over them. He felt nauseous, sweaty and out of breath, as if he had been running some kind of race. He called out to his wife. She hurried out of bed, took one look at him and called 911.

The Patient’s History:

By the time the man arrived at Huntsville Hospital, in Alabama, the twitching in his legs had subsided and his breathing had returned to normal. Still, he had been discharged from that same hospital for similar symptoms just two weeks earlier. They hadn’t figured out what was going on then, so they weren’t going to send him home now.

The patient considered himself pretty healthy, but the past year or so had been tough. In 2011, at the age of 54, he had had a mild stroke. He had no medical problems that put him at risk for stroke — no high blood pressure, no high cholesterol, no diabetes. A work-up at that time showed that he had a hole in his heart that allowed a tiny clot from somewhere in his body to travel to the brain and cause the stroke. He was discharged on a couple of blood thinners to keep his blood from making more clots. He hadn’t really felt completely well, though, ever since. His balance seemed a little off, and he was subject to these weird panic attacks, in which his heart would pound and he would feel short of breath whenever he got too stressed. Mostly he could manage them by just walking away and focusing on his breathing. Still, he never felt as if he was the kind of guy to panic.

And he had always been quick on his feet. The first half of his career he had been in the steel business — building huge metal trusses and supports. He and his team put together 60-plus tons of steel structures every day. For the past decade he had been machining car parts. After his stroke, work seemed to get a lot harder.

The Dizziness:

A few weeks ago, he stood up and wham — suddenly the whole world went off-kilter. He felt as if he was constantly about to fall over in a world that no longer lay down flat. His first thought was that he was having another stroke. He went straight to his doctor’s office. The doctor wasn’t sure what was going on and sent him to that same emergency room at Huntsville Hospital. After three days of testing and being evaluated by lots of specialists, his doctors still were not sure what was going on. He hadn’t had a heart attack; he hadn’t had a stroke. There was no sign of infection. All the tests they could think of were normal.

The only abnormal finding was that when he stood up, his blood pressure dropped. Why this happened wasn’t clear, but the doctors in the hospital gave him compression stockings and a pill — both could help keep his blood pressure in the normal range. Then they sent him home. He was also started on an antidepressant to help with the panic attacks he continued to have from time to time.

You can read the report from that hospital admission below.

You can also read the consultation and discharge notes from that hospital visit here.

He had been home for nearly two weeks and still he felt no better. He tried to go back to work after a week or so at home, but after driving for less than five miles, he felt he had to turn around. He wasn’t sure what was wrong; he just knew he didn’t feel right. Then his legs started jumping around, and he ended up back in the hospital.

The Doctor’s Exam:

It was nearly dawn by the time Dr. Jeremy Thompson, the first-year resident on duty that night, saw the patient. Awake but tired, the patient told his story one more time. He had been at home, watching TV, when his legs started jumping on their own and he started feeling short of breath. His wife sat at the bedside. She looked just as worried and exhausted as he did. She told the resident that when he spoke that night at home, his speech was slurred. And when the ambulance came, he could barely walk. He has never missed this much work, she told the young doctor. It’s not like him. Can’t you figure out what’s wrong?

The resident had already reviewed the records from the patient’s previous hospital admissions. He asked a few more questions: the patient had never smoked and rarely drank; his father died at age 80; his mother was still alive and well. The patient exam was normal, as were the studies done in the E.R.

The first E.R. doctor thought that his symptoms were a result of anxiety, culminating in a full-blown panic attack. The resident thought that was probably right. In any case he would discuss the case with the attending in a couple of hours during rounds on the new patients. Till then, he told the worried couple, they should just try to get a little sleep.

An Important Clue:

Dr. Robert Centor was definitely a morning person. His cheerful enthusiasm about teaching and taking care of patients made him a favorite among residents. At 7:30 that morning, he stood outside the patient’s door as Dr. Thompson relayed the somewhat frustrating case of the middle-aged man with worsening dizziness and panic attacks. Then they went into the room to meet the patient. He was a big guy, tall and muscular with the first signs of middle-aged thickening around his middle. His complexion had the look of someone who spent a lot of time outdoors. Dr. Centor introduced himself and pulled up a chair as the rest of the team watched. He asked the patient what brought him to the hospital.

“Every time I get up, I get dizzy,” the man replied. Sure, he had had some balance problems ever since his stroke, he explained, but this felt different – somehow worse. He could hardly walk, he told the doctor. He just felt too unstable.

“Can you get up and show us how you walk?” Dr. Centor asked.

“Don’t let me fall,” the patient responded. He carefully swung his legs over the side of the bed. The resident and intern stood on either side as he slowly rose. He stood with his feet far apart. When asked to close his eyes as he stood there, he wobbled and nearly fell over. When he took a few steps, his heel and toes hit the ground at the same time, making a strange slapping sound.

Seeing that, Dr. Centor knew where the problem lay and ordered a few tests to confirm his diagnosis.

You can see the review report and notes for the patient’s second hospital visit below.

Solving the Mystery:

What tests did Dr. Centor order? Do you know what is making this middle-aged man wobble? Enter your guesses below. I’ll post the answer tomorrow.

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Rules and Regulations: Post your questions and diagnosis in the Comments section below. The correct answer will appear tomorrow on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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Island Air is Ellison's latest buy

How do you follow the purchase of an island in Hawaii?

If you're Oracle Chief Executive Larry Ellison, you buy an airline so you can hop to and from your tropical paradise.

Ellison has been on a shopping spree lately, buying 98% of the island of Lanai in June from Los Angeles billionaire David Murdock and then, in November, buying a beachfront Malibu home from film and TV producer Jerry Bruckheimer.

Ellison's most risky acquisition may be Island Air, which he bought Wednesday through a holding company.

The exact purchase prices of Ellison's recent deals have not been disclosed, but local observers value the 141-square-mile island at more than $500 million and the three-bedroom, three-bath Malibu pad at more than $3.65 million. The details of the airline deal were not announced.

Island Air, a regional carrier serving airports on all major Hawaiian islands, has 245 employees and three turboprop planes, with 224 weekly flights between the islands of Oahu, Maui, Molokai, Lanai and Kauai.

Lanai, the sixth-largest Hawaiian island, was once a pineapple plantation and is still sparsely inhabited. It includes two resort hotels and two golf courses with clubhouses, according to Hawaii's Public Utilities Commission.

But Ellison did not buy the airline just to get to and from his island, airline officials say.

He hopes to expand the businesses to serve locals visiting relatives on the islands and to fly mainland and foreign tourists throughout the island state, airline officials said. The airline plans to retire two 1980s-era planes and expand to four or five new ATR 72 turboprops by the end of the year.

But Ellison should not get his hopes up about pocketing big profits, said Ray Neidl, an aviation analyst for Nexa Capital Partners in Washington, D.C.

"It's a high-risk situation with no significant margins, at least initially," he said of owning an airline.

And if Ellison hopes to expand the business, he should expect to get some resistance from the big carrier on the island, Hawaiian Airlines, Neidl added. "It really depends on what Hawaiian does."

Island Air began in 1980 as Princeville Airways, carrying passengers from Kauai to Honolulu. The history of the carrier has not always been blue skies and soft landings.

"In our 30-plus years, we had our ups and downs, pardon the pun," said Michael Rodyniuk, a senior consultant to the airline.

Like most airlines across the country, he said, Island Air struggled during the economic turmoil between 2008 and 2012 but expects to thrive with a surge in tourism that Hawaii has been enjoying in the past year or so.

The state welcomed a record 8 million visitors in 2012, surpassing the previous high of 7.6 million visitors in 2006.

"All major markets are up," Rodyniuk said.

The previous owner of the airline, California businessman Charles Willis IV, had been looking for a buyer for the airline and had put all 245 employees on notice that layoffs could begin as soon as March 11 if a buyer was not found, he said. "So Mr. Ellison saved 245 jobs," Rodyniuk said.

Forbes ranks Ellison as the third-richest American, with a net worth of $36 billion. He has cut big checks in the past on high-priced properties in Malibu, Lake Tahoe, Rancho Mirage and other locations.

But unlike real estate, air carriers are an investment that can give investors nightmares.

Virgin America, a California-based airline partly owned by millionaire Richard Branson, has been operating for more than five years without recording a profitable year.

California Pacific Airlines is the brainchild of Encinitas businessman Ted Vallas, who has already invested more than $6 million of his own money but has spent the last year trying to clear federal red tape so he can begin selling tickets.

And then there are the 11 other airlines — including American, Delta, United and US Airways — that have filed for bankruptcy since 2000.

"The profit margins on airlines, even though they are improving, are not that attractive," Neidl said.

hugo.martin@latimes.com

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Race for L.A. city controller heats up

A previously low-profile race for Los Angeles city controller has begun to heat up as opponents of City Councilman Dennis Zine accuse him of "double dipping" the city's payroll and question why he is considering lucrative tax breaks for a Warner Center developer.

Zine, who for 12 years has represented a district in the southeast San Fernando Valley, is the better known of the major candidates competing to replace outgoing Controller Wendy Greuel.

The others are Cary Brazeman, a marketing executive, and lawyer Ron Galperin. Zine has raised $766,000 for his campaign, more than double that of Galperin, the next-highest fundraiser, and has the backing of several of the city's powerful labor unions.

He also has been endorsed by Mayor Antonio Villaraigosa and several of his council colleagues. Galperin is backed by the Service Employees International Union, one the city's largest labor groups, and Brazeman is supported by retired Rep. Diane Watson and several neighborhood council representatives.

With the primary ballot less than a week away, Brazeman and Galperin have turned up the heat on Zine, hoping to push the race beyond the March 5 vote. If no one wins more than 50% of the ballots cast, the top two vote-getters will face a runoff in the May general election.

In a recent debate, Zine's opponents criticized him for receiving a $100,000 annual pension for his 33 years with the Los Angeles Police Department and a nearly $180,000 council salary. Brazeman and Galperin called it an example of "double dipping" that should be eliminated.

That brought a forceful response from Zine, who shot back that he gives a big portion of his police pension check to charities.

"I am so tired of hearing 'double dipping,' " he said. "I worked 33 years on the streets of Los Angeles. I have given over $300,000 to nonprofits that need it.... That's what's happened with that pension."

In the same debate, Brazeman accused Zine of cozying up to a Warner Center developer by pushing for tax breaks on a project that already has been approved. The nearly 30-acre Village at Westfield Topanga project would add 1 million square feet of new shops, restaurants, office space and a hotel to a faded commercial district on Topanga Canyon Boulevard.

"The councilman proposed to give developers at Warner Center tens of millions of dollars in tax breaks even though it's a highly successful project," he said. "He wants to give it away."

City records show that less than a month after the development was approved in February 2012, Zine asked the council for a study looking at possible "economic development incentives" that could be given to Westfield in return for speeding up street and landscaping enhancements to the project's exterior.

The motion's language notes that similar tax breaks have been awarded to large projects in the Hollywood and downtown areas, and that "similar public investment in the Valley has been lacking." Westfield is paying for the $200,000 study.

Zine defended his decision before the debate audience, saying if the study finds that the city will not benefit, no tax breaks will be awarded. "If there's nothing there, then they get nothing," Zine said.

The controller serves as a public watchdog over the city's $7.3-billion annual operation, auditing the general fund, 500 special fund accounts and the performance of city departments. Those audits often produce recommendations for reducing waste, fraud and abuse.

But the mayor and the council are not obligated to adopt those recommendations, and as a result the job is part accountant, part scolder in chief. All the candidates say they will use their elective position not only to perform audits but also to turn them into action.

Their challenge during the campaign has been explaining how they will do that.

Zine, 65, says his City Hall experience has taught him how to get things done by working with his colleagues. He won't be afraid to publicly criticize department managers, he said, but thinks collaboration works better than being combative.

"You can rant and rave and people won't work with you," he said. "Or you can sit down and talk it out, and you can accomplish things."

Galperin, 49, considers himself a policy wonk who relishes digging into the details to come up with ways to become more efficient with limited dollars and to find ways to raise revenue using the city's sprawling assets. For instance, the city owns two asphalt plants that could expand production and sell some of its material to raise money to fix potholes, he said.

He's served on two city commissions, including one that found millions of dollars in savings by detailing ways to be more efficient. Zine is positioning himself as a "tough guy for tough times," but the controller should be more than that, Galperin said.

"What we really need is some thoughtfulness and some smarts and some effectiveness," he said. "Just getting up there and saying we need to be tough is not going to accomplish what needs to be done."

Brazeman, 46, started his own marketing and public relations firm in West Los Angeles a decade ago and became active in city politics over his discontent with a development project near his home. He has pushed the council to change several initiatives over the last five years, including changes to the financing of the Farmers Field stadium proposal that will save taxpayer dollars, he said.

As controller, he would pick and choose his battles, and, Brazeman said, be "the right combination of constructive, abrasive and assertive."

catherine.saillant@latimes.com

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Greek man charged in NY Dali theft pleads guilty

NEW YORK (AP) — A Greek man has admitted to stealing a Salvador Dali painting from a New York City gallery, only to return it in the mail.

Phivos Istavrioglou pleaded guilty on Tuesday following his arrest in the theft of a work titled "Cartel de Don Juan Tenorio."

Prosecutors say the fashion industry publicist walked into the Manhattan gallery in June, put the painting valued at about $150,000 in a shopping bag and walked out. He anonymously mailed the piece back to the United States from Greece after seeing news coverage of the theft.

Under the plea deal, Istavrioglou avoids additional jail time if he remains incarcerated until his formal sentencing on March 12. He also must pay more than $9,000 in restitution.

His lawyer said it was a stupid thing to do.

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The New Old Age Blog: Is the Pope Frail?

White-haired at 85, Pope Benedict XVI looks a bit hunched in photos. He has had a pacemaker for years, the Vatican recently confirmed for the first time — an indicator of long-standing heart problems. His older brother has said that age is taking its toll.

Observers have noticed the pope’s reduced energy. The Times has reported that he was ferried to the altar at St. Peter’s for Midnight Mass Christmas Eve on a “wheeled platform,” then appeared to doze off during the service.

Visiting Mexico last year, he awoke at night and couldn’t locate a light switch in his room, then fell — such a familiar scenario for caregivers of old people — and bloodied his head when he hit the bathroom sink.

Beyond these few facts, we know very little about the health problems that have led Benedict to announce his retirement after his final audience on Wednesday. We don’t even really know if his flagging stamina — “the certainty that my strengths, due to an advanced age, are no longer suited to an adequate exercise” of leading the church, as he put it — was the true reason behind his resignation. But people have been describing him as tired and increasingly frail.

In geriatrics, “frailty” has a specific meaning: It’s a syndrome, a collection of physiological symptoms that drain people’s reserves, leaving them less able to withstand stressors — like a long trek through St. Peter’s Basilica or around a foreign country.

Geriatricians diagnose frailty when a patient meets three of five criteria: Unintentional weight loss of more than 10 pounds in the past year. Weakness, as measured by a test of handgrip strength. Self-reported exhaustion. Slowness, calculated by how long it takes to walk 15 feet. Low physical activity.

“You feel a sense of vulnerability,” said Linda Fried, dean of the Mailman School of Public Health at Columbia University and a leading frailty researcher for 20 years. With significantly lower energy, “It’s harder to push the envelope.”

Frailty’s prevalence increases with age, “from a tiny proportion of people in their 60s, about three percent, to up to a quarter or a third of people 85 and older,” Dr. Fried said. Doctors have learned to pay attention because of the unhappy consequences. “It’s strongly associated with higher mortality, as well as loss of mobility, falls and other kinds of disability,” she said.

Is Benedict frail? Certainly he is reporting that he is exhausted, but does he fit the other criteria? “The pope has probably never done a grip strength test,” said Ken Covinsky, a geriatrician at the University of California, San Francisco.

But the odds are high that he has health problems, even if they’re unacknowledged by Vatican spokesmen. In the United States, at least, nearly half of those over 65 have two or more chronic diseases, like diabetes, hypertension and emphysema. “It would be a rare 85-year-old with only one thing wrong with him,” Dr. Covinsky said.

And frailty is one of those conditions that indicate all is not well.

People often recognize frailty, even without data on walking speed. “I’ve tested it out myself over the years” when speaking to groups, Dr. Fried reported. “I ask people what they’re seeing, and there’s great consistency between the things they picture and what science has measured.”

Frail elders, people tell her, are thin (although overweight people can also be frail), weak, slow, fragile-looking. “The term people use is, they look like they could be knocked over by a feather,” she said.

So if observers in Vatican City say Benedict looks frail, well, maybe he is.

But I’m pursuing this subject not to ask experts to diagnose the pope from afar, but to point out that paying attention to frailty makes sense for the rest of us and our elders. It’s one of the conditions people can do something about.

In frailty’s early stages, “there’s great potential to reverse it or slow it,” Dr. Fried said. The key is exercise. “You have to walk and move, maintain strength and muscle mass,” she said. “We don’t have a drug to prescribe, but even if we did, there’s no question in my mind that exercise will always be the foundation.”

The pope has said that he plans to move into the Mater Ecclesiae convent within the Vatican once it’s renovated for him. We have to assume the nuns, and perhaps a couple of physical therapists, will provide excellent care there.

“Often, people with frailty can live a pretty good life with good home care and social support, and almost every country does better at that than the United States,” Dr. Covinsky said. Our lack of a workable, affordable system of long-term care for the elderly and disabled poses a national crisis.

This is where being a former pope — something that is so rare that it shocked the world — may be a good way to live out one’s days.

“In the U.S., he could get M.R.I.’s and all kinds of expensive tests,” Dr. Covinsky noted. “But Medicare won’t pay for a home health aide four hours a day.” Luckily, the Vatican probably will provide it.

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Deficit hawks' 'generational theft' argument is a sham

Here's a phrase you can expect to be hearing a lot in the national debate over fiscal policy, as we move past the "sequester," which is the crisis du jour, and toward the budget cliff/government shutdown deadline looming at the end of March:

"Generational theft."

The core idea the term expresses is that we're spending so much more on our seniors than our children that future generations are being cheated. An important corollary is that the government debt we incur today will come slamming down upon the shoulders of our children and grandchildren.

The generational theft trope has already been receiving a vigorous workout in the press. Earlier this month, the Washington Post gave great play to a study by the Urban Institute stating that the federal government spends $7 on the elderly for every dollar it spends on kids. As we shall see, this is true as far as it goes, but it doesn't go nearly far enough to render an accurate picture of government spending.

The National Journal, another influential publication in Washington, picked up the theme last week by observing that because the sequester exempts Social Security and Medicare from budget cuts, the automatic spending reductions it mandates will fall disproportionately on education and other such boons to the young. This will "deepen the budget's generational imbalance."

This is also a bedrock argument of the anti-deficit organizations, such as Fix the Debt, associated with hedge fund billionaire Peter G. Peterson. For decades he has pursued a wearisome and spectacularly self-interested campaign to cut Social Security and Medicare benefits for the working class so taxes won't go up too much on the wealthy.

One of those organizations, called "The Can Kicks Back," promotes a "Millennial-driven campaign to fix the national debt." But backstopping its twenty- and thirty-something leaders is an advisory board comprising such Peterson frontmen as Morgan Stanley board member Erskine Bowles and former Sen. Alan Simpson (R-Wyo.). These guys are "millennials" only if we're talking about the last millennium before this one.

So here's the truth about the "generational theft" theme: It's wrong on the numbers and wrong on the implications.

Let's start with that 7-to-1 spending ratio on seniors versus children. Among the flaws in the calculation is that the vast majority of government dollars spent on children comes from state and local governments, which pay most of the cost of education. On a per capita basis, state and local spending on kids swamps the federal government's spending 8 to 1.

Moreover, there are twice as many children 18 and under as seniors 65 and over (this 2008 figure also comes from the Urban Institute report). Put the numbers together and you discover that spending by governments at all levels in 2008 came to about $1 trillion on seniors and $936 billion on children. In other words, very close to 1 to 1.

The notion underlying the comparison of spending on seniors and children is that "if you save a dollar on Social Security it would be transferred automatically to children," observes Theodore R. Marmor, an emeritus professor of public policy at Yale and a long-term student of social welfare programs. He traces this notion to deficit hawks and dismisses it as "not naive, but cynical."

That's because most of the spending on seniors is in Social Security and Medicare, and therefore has been largely paid for by those very beneficiaries over the course of their working lives.

Payroll taxes have more than covered what today's average retiree will receive back from Social Security. They won't cover the average payout on Medicare, but that's an artifact of uncontrolled healthcare costs, not of the structure of Medicare itself. Changing the terms of that program, say by raising the eligibility age (currently 65) won't save money and may actually raise costs.

In other ways, treating Social Security and Medicare spending on the one hand and spending on kids on the other as though they're opposite sides of a zero-sum game is just an act of ideological legerdemain aimed at undermining those programs.

If America wants to spend more on children, it's plenty rich enough to do so without eating away at the income of their grandparents. The money can come from the defense budget, farm supports or dozens of other places, even higher income taxes.

Let's not forget, too, that the people who will really suffer from gutting Social Security won't be today's seniors, who will escape the worst of the cutbacks — they'll be today's young people, for whom Social Security would become much less supportive when they retire.

What about the debt load we're supposedly imposing on future generations? This is another transparently Petersonian feat of sleight of hand, based on the assertion that while it's we who incur the debt, it's our children who will have to pay if off.

All the hand-wringing over today's borrowing conveniently assumes that the debt buys nothing, which makes it easier for debt hawks to pretend that it's only an expense and not an investment.

But money borrowed for the stimulus has bought jobs and unemployment benefits, which have helped sustain families through the Great Recession. (At least a few of those families have children, wouldn't you guess?)

In a larger sense, money borrowed by every generation is typically invested in programs and infrastructure — highway, schools, research and conservation, for example — that will add to future generations' wealth.

It's the persistence of the "generational theft" claim, which bubbles up every few years, that exposes its ideological roots.

It's a fundamental piece of a decades-long campaign to distract Americans into thinking that the threat to their way of life comes from a war of old against young, rather than an intra-generational class war in which the vast majority of economic gains from improvements in worker's productivity has flowed to the wealthy, not to the workers.

The economist Dean Baker observes, for example, if the federal hourly minimum wage had merely kept up with productivity growth after 1969 rather than stagnating (and getting eaten away by inflation) it would be more than $16.54, and we wouldn't be arguing about whether the country can "afford" an increase to $9.

The "generational theft" argument is a sham. It's an attempt to get around the fact, so distasteful to the enemies of government social programs, that Social Security and Medicare are hugely popular. As Marmor observes, if you can't put across the case that these programs are undesirable, "you have to make them look uncontrollable, ungovernable, and therefore unaffordable."

The argument has been tried out on several generations in the past, and they've seen through it. Today's generation should see through it too.

Michael Hiltzik's column appears Sundays and Wednesdays. Reach him at mhiltzik@latimes.com, read past columns at latimes.com/hiltzik, check out facebook.com/hiltzik and follow @latimeshiltzik on Twitter.

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Mike Piazza softens stance on Dodgers' Vin Scully

PHOENIX—

— Calling Vin Scully "a class act" and saying he had "the utmost respect" for him, Mike Piazza on Monday defended what he wrote in his recently released autobiography about the Hall of Fame broadcaster.

In his book, "Long Shot," Piazza described Scully as instrumental in turning the fans of Los Angeles against him during the contract stalemate that led to his trade to the Florida Marlins in 1998. Piazza wrote that Scully "was crushing me" on the air, a charge Scully vehemently denied.

"I can't say that I have regrets," Piazza said. "I was just trying to explain the situation."

The former All-Star catcher was at the Dodgers' spring-training facility with Italy's World Baseball Classic team, for which he is a coach. Scully was also at the complex, to call the Dodgers' 7-6 victory over the Chicago Cubs.

"I'd love to see him," Piazza said.

The two didn't meet.

"I always liked him," Scully said. "I admired him. I think either he made a mistake or got some bad advice. I still think of him as a great player and I hope he gets into the Hall of Fame. I really do. Whatever disappointment I feel, I'll put aside."

Scully declined to comment further on Piazza or his book.

Piazza complimented Scully as he tried to defend what he wrote.

"Vin is a class act; he's an icon," Piazza said. "To this day, I have the utmost respect for him. But the problem is, you have to go back in time and understand that at that point in time in my career with the Dodgers was a very tumultuous time. I was more or less telling my version of the story, at least what I was experiencing. And I said at the end of the book, it's not coming from a place of malice or anger. I think anybody who remembers that time knows it was a very tumultuous time."

Piazza said his intent wasn't to blame Scully.

"I don't think anybody who read the passage from start to finish felt that way," Piazza said. "Anybody who reads it knows it wasn't me blaming. That was definitely not the only factor. There were other factors. The team made the mistake, I made the mistake, of speaking publicly."

Piazza acknowledged that he never heard Scully's broadcasts and that his impressions of them were based on what he heard from others.

"My perception was that he was given the Dodgers' versions of the negotiations, which, I feel, wasn't 100% accurate," Piazza said.

In his book, Piazza also took issue with how Scully asked him about his contract demands during a spring-training interview. Piazza said Monday that he was "taken aback" by the line of questioning because he previously hadn't talked publicly about the negotiations.

To reach the practice fields at Camelback Ranch on Monday, Piazza had to pass through a gantlet of Dodgers fans. Piazza said he wasn't nervous.

"I did a book signing a couple of weeks ago in Pasadena and the fans were really nice," he said.

Piazza denied that he hadn't returned to Dodger Stadium in recent years out of fear of being booed, as Tom Lasorda told The Times last month.

Piazza said he always associated the Dodgers with the O'Malley family, which sold the team to News Corp. in 1998.

"Since then, obviously, they've taken on a different identity," Piazza said.

Piazza was noncommittal about visiting the ballpark in the future. "We'll see," he said. "I'll never say never."

Wouldn't it be harder to return now that his portrayal of Scully has upset fans?

"I don't know," he said. "I can't answer that."

Piazza also spoke about falling short of being elected to the Hall of Fame in his first year of eligibility.

"I definitely couldn't lie and say I wasn't a little disappointed," he said.

He is hopeful he will one day be inducted. "I trust the process," he said.

Piazza wouldn't say whether he thought Barry Bonds and Roger Clemens deserved to be in the Hall of Fame. Both players, who have been linked to performance-enhancing drugs, also were denied election.

Piazza has denied using performance-enhancing drugs and has never faced detailed allegations that he did. Asked if he was upset that the indiscretions of others might have altered others' perceptions of him, he replied, "Unfortunately, that's the way life is sometimes. I can't control and worry about what people think."

dylan.hernandez@latimes.com

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Singer Morrissey says no to Kimmel, 'Duck Dynasty'

LOS ANGELES (AP) — The TV series "Duck Dynasty" is coming between Morrissey and Jimmy Kimmel.

The singer and animal rights activist says he canceled his appearance Tuesday on ABC's "Jimmy Kimmel Live" because "Duck Dynasty" cast members will be on the talk show.

Morrissey says he can't perform on a show with what he called people who "amount to animal serial killers."

A&E's "Duck Dynasty" reality show follows a Louisiana family with a business selling duck calls and decoys.

A&E did not immediately respond to requests for comment from it and the Robertson family.

A person familiar with the Kimmel show's plans confirmed that Morrissey was to appear. The person lacked authority to discuss the matter publicly and spoke on condition of anonymity.

The person says Morrissey's performance will be rescheduled.

ABC says the Churchill band will perform Tuesday on Kimmel's show but declined comment on the switch.

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Reach AP Television Writer Lynn Elber at http://www.twitter.com/lynnelber .

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Horse Meat in European Beef Raises Questions on U.S. Exposure

The alarm in Europe over the discovery of horse meat in beef products escalated again Monday, when the Swedish furniture giant Ikea withdrew an estimated 1,670 pounds of meatballs from sale in 14 European countries.

Ikea acted after authorities in the Czech Republic detected horse meat in its meatballs. The company said it had made the decision even though its tests two weeks ago did not detect horse DNA.

Horse meat mixed with beef was first found last month in Ireland, then Britain, and has now expanded steadily across the Continent. The situation in Europe has created unease among American consumers over whether horse meat might also find its way into the food supply in the United States. Here are answers to commonly asked questions on the subject.

Has horse meat been found in any meatballs sold in Ikea stores in the United States?

Ikea says there is no horse meat in the meatballs it sells in the United States. The company issued a statement on Monday saying meatballs sold in its 38 stores in the United States were bought from an American supplier and contained beef and pork from animals raised in the United States and Canada.

“We do not tolerate any other ingredients than the ones stipulated in our recipes or specifications, secured through set standards, certifications and product analysis by accredited laboratories,” Ikea said in its statement.

Mona Liss, a spokeswoman for Ikea, said by e-mail that all of the businesses that supply meat to its meatball maker  issue letters guaranteeing that they will not misbrand or adulterate their products. “Additionally, as an abundance of caution, we are in the process of DNA-testing our meatballs,” Ms. Liss wrote. “Results should be concluded in 30 days.”

Does the United States import any beef from countries where horse meat has been found?

No. According to the Department of Agriculture, the United States imports no beef from any of the European countries involved in the scandal. Brian K. Mabry, a spokesman for the department’s Food Safety and Inspection Service, said: “Following a decision by Congress in November 2011 to lift the ban on horse slaughter, two establishments, one located in New Mexico and one in Missouri, have applied for a grant of inspection exclusively for equine slaughter. The Food Safety and Inspection Service (F.S.I.S.) is currently reviewing those applications.”

Has horse meat been found in ground meat products sold in the United States?

No. Meat products sold in the United States must pass Department of Agriculture inspections, whether produced domestically or imported. No government financing has been available for inspection of horse meat for human consumption in the United States since 2005, when the Humane Society of the United States got a rider forbidding financing for inspection of horse meat inserted in the annual appropriations bill for the Agriculture Department. Without inspection, such plants may not operate legally.

The rider was attached to every subsequent agriculture appropriations bill until 2011, when it was left out of an omnibus spending bill signed by President Obama on Nov. 18. The U.S.D.A.  has not committed any money for the inspection of horse meat.

“We’re real close to getting some processing plants up and running, but there are no inspectors because the U.S.D.A. is working on protocols,” said Dave Duquette, a horse trader in Oregon and president of United Horsemen, a small group that works to retrain and rehabilitate unwanted horses and advocates the slaughter of horses for meat. “We believe very strongly that the U.S.D.A. is going to bring inspectors online directly.”

Are horses slaughtered for meat for human consumption in the United States?

Not currently, although live horses from the United States are exported to slaughterhouses in Canada and Mexico. The lack of inspection effectively ended the slaughter of horse meat for human consumption in the United States; 2007 was the last year horses were slaughtered in the United States. At the time financing of inspections was banned, a Belgian company operated three horse meat processing plants — in Fort Worth and Kaufman, Tex., and DeKalb, Ill. — but exported the meat it produced in them.

Since 2011, efforts have been made to re-establish the processing of horse meat for human consumption in the United States. A small plant in Roswell, N.M., which used to process beef cattle into meat has been retooled to slaughter 20 to 25 horses a day. But legal challenges have prevented it from opening, Mr. Duquette said. Gov. Susana Martinez of New Mexico opposes opening the plant and has asked the U.S.D.A. to block it.

Last month, the two houses of the Oklahoma Legislature passed separate bills to override a law against the slaughter of horses for meat but kept the law’s ban on consumption of such meat by state residents. California, Illinois, New Jersey, Tennessee and Texas prohibit horse slaughter for human consumption.

Is there a market for horse meat in the United States?

Mr. Duquette said horse meat was popular among several growing demographic groups in the United States, including Tongans, Mongolians and various Hispanic populations. He said he knew of at least 10 restaurants that wanted to buy horse meat. “People are very polarized on this issue,” he said. Wayne Pacelle, chief executive of the Humane Society of the United States, disagreed, saying demand in the United States was limited. Italy is the largest consumer of horse meat, he said, followed by France and Belgium.

Is horse meat safe to eat?

That is a matter of much debate between proponents and opponents of horse meat consumption. Mr. Duquette said that horse meat, some derived from American animals processed abroad, was eaten widely around the world without health problems. “It’s high in protein, low in fat and has a whole lot of omega 3s,” he said.

The Humane Society says that because horse meat is not consumed in the United States, the animals’ flesh is likely to contain residues of many drugs that are unsafe for humans to eat. The organization’s list of drugs given to horses runs to 29 pages.

“We’ve been warning the Europeans about this for years,” Mr. Pacelle said. “You have all these food safety standards in Europe — they do not import chicken carcasses from the U.S. because they are bathed in chlorine, and won’t take pork because of the use of ractopamine in our industry — but you’ve thrown out the book when it comes to importing horse meat from North America.”

The society has filed petitions with the Department of Agriculture and Food and Drug Administration, arguing that they should test horse meat before allowing it to be marketed in the United States for humans to eat.

This article has been revised to reflect the following correction:

Correction: February 25, 2013

An earlier version of this article misstated how many pounds of meatballs Ikea was withdrawing from sale in 14 European countries. It is 1,670 pounds, not 1.67 billion pounds.

This article has been revised to reflect the following correction:

Correction: February 25, 2013

An earlier version of this article misstated the last year that horses were slaughtered in the United States. It is 2007, not 2006.

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Coordinated healthcare could save California $110 billion, group says

California could cut $110 billion in healthcare spending over the next decade, saving the average household $800 a year, by quickly moving away from conventional fee-for-service medicine and embracing more coordinated care, a new report says.

These findings released Tuesday come from the Berkeley Forum, a new group of healthcare executives, state officials and academics that studied California's healthcare market for the last year in hopes of finding ways to make care better and more affordable. The main recommendations are not entirely new, and these shifts are already underway in response to the federal healthcare law and pressure from employers to tame runaway medical costs.

But the group's report does quantify how much work remains to be done and the potential savings if major changes are made in how doctors and hospitals are paid. Health-policy experts at UC Berkeley convened this group, which included high-ranking executives from Kaiser Permanente, Anthem Blue Cross, Cedars-Sinai Medical Center and other industry players.

"This could be a game changer in the state," said Stephen Shortell, dean of the School of Public Health at UC Berkeley and a coauthor of the report. "These are the CEOs of big insurers, big health systems and large medical groups saying it's time for a change, and these are the people who can get things done."

The Berkeley Forum calls for a major shift toward "global budgets," in which physicians and hospitals provide care under preset amounts that are adjusted to reflect the health of their patients. These payments would also be tied to providers' performance on several quality measures.

This is similar to the "capitated" payments managed-care companies and HMOs have used for years in California. HMOs already cover 44% of California's population, which is about double the nationwide rate.

Despite that high penetration, the report's authors found that 78% of the state's healthcare costs, or about $245 billion annually, are still paid through fee-for-service arrangements, which can encourage medical providers to perform unnecessary tests and procedures. The report calls for reducing the share of fee-for-service payments to 50% by 2022.

The Berkeley Forum also says California should double the share of the state's population receiving integrated care from medical providers to 60% within the next decade. The most visible example of integrated care in California is Kaiser Permanente, the Oakland nonprofit that coordinates care across its hospitals and physician groups.

Other health insurers, hospitals and doctors are collaborating in similar ways through accountable-care organizations, medical homes and other initiatives that have strong backing from Medicare. Shortell acknowledged that there are "legitimate concerns" about this integration leading to higher prices as hospitals, clinics and physician groups rapidly consolidate.

The $110 billion in healthcare savings targeted by the group would amount to 2.5% of overall spending of $4.4 trillion over 10 years in California, according to the report. Those savings would mean an extra $800 annually for every California household.

Overall, the report found that 53% of the state's healthcare dollars are spent on just 5% of the population, illustrating the high cost of treating certain chronically ill patients.

Pam Kehaly, president of Anthem Blue Cross in California, said this industrywide collaboration "puts us on a path to improving the ailing California healthcare system."

chad.terhune@latimes.com

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