Many HIV patients skip medications to drink: study

(Reuters) – About half of HIV patients on antiretroviral therapy skipped their medications whenever they were drinking alcohol, according to a U.S. study – an ill-advised behavior that researchers say could lead to higher viral loads.

The study, published in the Journal of General Internal Medicine, for a year followed nearly 200 people with HIV who were on antiretrovirals and drank alcohol. It found that 51 percent stopped taking their medications while drinking.

Lapses could be due to forgetfulness while under the influence, but a widespread – and erroneous – belief that mixing alcohol and HIV drugs can be toxic appears to play a role.

“The harms caused by missing their medications far outweigh the harms caused by mixing the two, if the person doesn’t have liver disease,” said Seth Kalichman, a professor at the University of Connecticut and lead author of the study.

Drinking has been known to interfere with people’s adherence to their medications, but researchers said the consequences of inconsistent use of HIV medications can be more severe.

Antiretroviral drugs suppress the HIV virus, and patients must take the medications continuously to prevent the virus from surging. Additionally, going on and off the drugs can lead to drug resistance.

“People living with HIV who deliberately stop their medications when they are drinking are at risk for treatment failure,” the researchers wrote.

Kalichman and his colleagues surveyed 178 people – about four out of five of them men – who were currently using antiretroviral therapy and reported that they drank alcohol.

At the beginning of the study, the researchers asked the participants about their alcohol-related beliefs, such as whether they thought their drugs wouldn’t work as well if the two mixed. They also asked whether people would not take both at the same time, either by avoiding alcohol or the medicines.

Over the following year, the team checked in with patients every month to see how well they were sticking to their prescriptions through a pill count, and every other month they called to ask how often the patient had been drinking recently.

Doctors’ offices measured each patient’s level of virus and measures of immune system health.

They found that 51 percent of the patients would avoid the medications when they drank, and half of the people in this group had poor adherence to their prescriptions. In addition, half of the group that skipped pills said they wouldn’t take them again until the alcohol was out of their system.

People who skipped medications while drinking were also more likely to have higher levels of HIV in their bodies and lower numbers of CD4 cells, a measure of immune system health.

“I think it’s pretty well demonstrated that alcohol use is tied to poor adherence, and I think most people think it’s because they’re impaired in some way or they forget… whereas here it shows they’re (often) intentionally missing their medications,” said Catherine Grodensky, a researcher at the Center for AIDS Research at the University of North Carolina.

“And it looks like it’s having some significant impacts on their treatment.”

SOURCE: http://bit.ly/SmCjq9

(Reporting from New York by Kerry Grens at Reuters Health; editing by Elaine Lies)

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Many HIV patients skip medications to drink: study

(Reuters) – About half of HIV patients on antiretroviral therapy skipped their medications whenever they were drinking alcohol, according to a U.S. study – an ill-advised behavior that researchers say could lead to higher viral loads.

The study, published in the Journal of General Internal Medicine, for a year followed nearly 200 people with HIV who were on antiretrovirals and drank alcohol. It found that 51 percent stopped taking their medications while drinking.

Lapses could be due to forgetfulness while under the influence, but a widespread – and erroneous – belief that mixing alcohol and HIV drugs can be toxic appears to play a role.

“The harms caused by missing their medications far outweigh the harms caused by mixing the two, if the person doesn’t have liver disease,” said Seth Kalichman, a professor at the University of Connecticut and lead author of the study.

Drinking has been known to interfere with people’s adherence to their medications, but researchers said the consequences of inconsistent use of HIV medications can be more severe.

Antiretroviral drugs suppress the HIV virus, and patients must take the medications continuously to prevent the virus from surging. Additionally, going on and off the drugs can lead to drug resistance.

“People living with HIV who deliberately stop their medications when they are drinking are at risk for treatment failure,” the researchers wrote.

Kalichman and his colleagues surveyed 178 people – about four out of five of them men – who were currently using antiretroviral therapy and reported that they drank alcohol.

At the beginning of the study, the researchers asked the participants about their alcohol-related beliefs, such as whether they thought their drugs wouldn’t work as well if the two mixed. They also asked whether people would not take both at the same time, either by avoiding alcohol or the medicines.

Over the following year, the team checked in with patients every month to see how well they were sticking to their prescriptions through a pill count, and every other month they called to ask how often the patient had been drinking recently.

Doctors’ offices measured each patient’s level of virus and measures of immune system health.

They found that 51 percent of the patients would avoid the medications when they drank, and half of the people in this group had poor adherence to their prescriptions. In addition, half of the group that skipped pills said they wouldn’t take them again until the alcohol was out of their system.

People who skipped medications while drinking were also more likely to have higher levels of HIV in their bodies and lower numbers of CD4 cells, a measure of immune system health.

“I think it’s pretty well demonstrated that alcohol use is tied to poor adherence, and I think most people think it’s because they’re impaired in some way or they forget… whereas here it shows they’re (often) intentionally missing their medications,” said Catherine Grodensky, a researcher at the Center for AIDS Research at the University of North Carolina.

“And it looks like it’s having some significant impacts on their treatment.”

SOURCE: http://bit.ly/SmCjq9

(Reporting from New York by Kerry Grens at Reuters Health; editing by Elaine Lies)

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Hey, Gov. Christie: Don’t Rebuild in Harm’s Way

New Jersey Governor Chris Christie, usually a tireless advocate of individual responsibility and self-reliance, has been sending a different message since Hurricane Sandy devastated the Jersey Shore. Now he’s emphasizing a “we’re all in this together” message as he seeks support from his new best friend, President Barack Obama.

Christie wants the federal government—i.e., taxpayers in other parts of the country—to help rebuild the Jersey Shore back to the way it was before Sandy hit. That could be not only hugely expensive, but wasteful as well—because the next big storm could quickly wipe out the investment.

New Jersey’s barrier beaches are really nothing more than glorified sand bars. They’ve shifted shoreward about a mile since Colonial times. Trying to stop the force of nature is, in the long run, futile. “The definition of insanity is doing the same thing over and over again and expecting different outcomes,” says Jeffrey Tittel, director of the New Jersey chapter of the Sierra Club.

Christie has gained a national reputation for fiscal discipline that’s led to talk that he could be the Republican nominee in the 2016 presidential election. But if Christie pushes too hard for federal reconstruction funds, he risks losing his reputation for stand-up frugality. “The people who oppose government the most want the bailouts the most,” observes Tittel, speaking of both Christie and his supporters among shore residents and vacationers.

It’s right and decent for the nation as a whole to supply emergency assistance to the hard-hit communities that line the New Jersey coast. Their pain is real. The question is what happens after the emergency is over and it’s time to plan. Christie has one idea. In a briefing for the media, he said, “I don’t believe in a state like ours, where the Jersey Shore is such a part of life, that you just pick up and walk away.” He also said the government should not decide where building is and is not allowed.

That bravado rings hollow, though, when you stop to consider that Christie is hoping to put other people’s money at risk. Matthew Kahn, a professor at the UCLA Anderson School of Management, asks in a newly posted video: “What if New Jersey had to spend its own money for rebuilding New Jersey? It would build a more robust, resilient New Jersey with fewer people living near the coast.” Adds Kahn: “You take more risk when you are implicitly insured. When you spend your own money and you know you’re on the hook for any damage that occurs, you take more precautions.”

In other words, let the free market work. Shore residents are entitled not only to federal disaster aid that pays for rebuilding such critical infrastructure as roads, water lines, and sewer lines, but also to subsidized flood insurance. If they had to pay for the real cost of insurance from the private market, their premiums would be much higher—so much higher that many would decide a safe little cottage in the Poconos might be a better bet. Taxpayers in South Dakota would be spared having to bail out the Jersey Shore again and again.

Christie is right about one thing: Too many people have too much invested in the Jersey Shore to abruptly abandon the whole area to the seagulls. “The Jersey Shore is integral to our identity, and we have a $ 38 billion tourism economy. A significant portion of that is fueled by our shore,” says Lawrence Hajna, a spokesman for the state’s Department of Environmental Protection.

But at a minimum, Christie shouldn’t be luring more people and more investment into harm’s way by protecting shoreline residents through state and federal aid for rebuilt roads, water and sewer lines, and beach restoration. From fiscal years 2009 through 2012, the Army Corps of Engineers spent $ 436 million on replenishing the sand on beaches. Of that, New Jersey was the No. 1 recipient, with 27 percent of the haul, edging out Florida, according to statistics compiled by Howard Marlowe, a lobbyist who helps beach towns get restoration aid.

Much of that costly sand has now been washed out to sea, although some should filter back with the tides over the coming months. Environmentalists like Tittel argue that the money would have been better spent on helping people put their houses up on stilts—or moving out of harm’s way entirely.

New Jersey’s problem is a national problem. Even as climate change increases the severity of storms, the exposure along the nation’s coasts keeps increasing. A storm that would have wiped out a handful of fishermen’s shacks a few generations ago now takes out million-dollar homes. According to the U.S. Census Bureau, the nation’s coastal population grew by 40 million, or 84 percent, from 1960 to 2008.

New Jersey has a Coastal Blue Acres program that acquires land that’s vulnerable to storm damage. But it’s lightly funded, with only $ 15 million for coastal acquisition under a 1995 bond act. Overall, New Jersey ranks in the bottom five for smart response to coastal erosion, according to the nonprofit Surfrider Foundation, along with Alaska, California, Louisiana, and Puerto Rico.

Beach replenishment is an example of throwing good money after bad. Marlowe, the sand lobbyist, argues that it’s a good investment. The Army Corps of Engineers, he says, only does projects that cost less than the savings in terms of property that’s protected from harm by wide beaches and dunes. That could well be true. But it begs the question of why the property needing protection is there in the first place. “I’m not going to deny there are people living in hazardous places,” says Marlowe.

Chris Christie should think back to a lesson he undoubtedly learned as a child with a shovel and pail. Go ahead and build a beautiful sand castle on the beach. Just don’t expect anyone else to protect it for you when the tide comes in.

Businessweek.com — Top News

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Canada will push to keep bank capital rules on schedule

OTTAWA (Reuters) – Canada will urge all countries to stick to the agreed schedule for implementing tougher bank capital rules at a November 4-5 meeting of finance ministers and central bankers from the Group of 20 nations, a senior finance ministry official said on Thursday.

The so-called Basel III rules are the world’s regulatory response to the financial crisis, forcing banks to triple the amount of basic capital they hold in a bid to avoid future taxpayer bailouts.

They were to be phased in from January 2013 but areas such as the United States and the European Union are not yet ready and U.S. and British supervisors have criticized them as too complex to work.

The Canadian official, who briefed reports ahead of the meeting on condition that he not be named, said it was imperative that the rules, the timelines and the principles behind them be respected and said Finance Minister Jim Flaherty would make that view known to his G20 colleagues.

Canada sees the European debt crisis as the biggest near-term risk to the global economy, and it also expects the U.S. debt crisis to be top of mind at the talks, the official said.

But the meeting takes place just before the U.S. presidential election and U.S. Treasury Secretary Timothy Geithner will be absent, so it remains unclear how much the G20 can pressure Washington on that front.

Some other countries have also scaled back their delegations, raising doubts about how meaningful the meeting will be.

The official dismissed that argument, saying high-level officials substituting for their ministers allowed for extremely important issues to be addressed anyway.

He said holding each country around the table accountable to its past commitments helped keep the momentum going toward resolving global economic problems.

(Reporting by Louise Egan; Writing by David Ljunggren; Editing by M.D. Golan)

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‘Assassin’s Creed’ stumbles on PlayStation Vita

There’s never been a video game heroine quite like Aveline de Grandpre.

The daughter of an African slave and a French shipping magnate in New Orleans at the end of French and Indian War, Aveline is the deadly but charming protagonist of “Assassin’s Creed III: Liberation” (Ubisoft, for the PlayStation Vita, $ 39.99). She seeks to fight injustice in and around the Big Easy as a member of the series’ secret order of assassins.

The hallmarks of the “Assassin’s Creed” franchise are all gloriously present here in hand-held form: traipsing across a jagged cityscape, dispatching foes with stealthy prowess and plotting against the clandestine group known as the Templars. “Liberation” doesn’t feel like a typical PlayStation Vita game — and that’s both its biggest strength and weakness.

Despite its name, there’s only a tenuous connection to “Assassin’s Creed III,” its sweeping console counterpart. That shouldn’t deter die-hard “Assassin’s Creed” fans from embodying Aveline, who’s armed with iconic hidden blades just like forerunners Altair and Ezio, as well as her own original weapons, such as a blowgun and a parasol loaded with poison darts.

Unlike her male predecessors, Aveline assumes different personas to achieve her aims. As an assassin, she can use all weapons and scale buildings; disguised as a slave, she can blend in with crowds and incite riots; and when dressed as a noble lady, she can awkwardly woo men. It’s an inventive touch, but one that frustratingly makes Aveline always feel handicapped.

Most of “Liberation” takes place in New Orleans, beginning in 1768 as a French colony through the American Revolution. For the most part, the game’s story, setting, combat and characters all work remarkably well given the constraints of the platform, and there’s a plethora of side quests, business pursuits and a multiplayer mode to keep things interesting.

With missions focusing on freeing slaves and rioting against Spanish soldiers, “Liberation” doesn’t shy away from the harsh realities of American history in the South. It’s refreshing to see a video game deal with such serious issues while maintaining a sense of adventure. That alone should be enough for Vita owners to give this historical action title a try.

Unfortunately, “Liberation” is too big for its britches. It’s difficult not to wonder how more effective the game could have been if the developers didn’t bend over backward in an effort to replicate the console experience, especially after playing through a smaller section of “Liberation” that’s set outside Louisiana and ultimately proved to be more fun.

The lamest part of “Liberation” is definitely the most unnecessary, namely, using the Vita’s unique control scheme for actions like opening letters by swiping both touchscreens or revealing secret maps by pointing the rear camera toward a bright light. Such novel gimmicks wouldn’t be so disastrous if they consistently worked and weren’t repeated several times.

There are other glitches, too. Some wobbly graphics, disappearing characters, audio dropouts and other assorted bugs mark “Liberation” as a less polished “Assassin’s Creed” experience. Despite the game’s very daring ambitions, Aveline — and “Assassin’s Creed” fans — deserve more than “Liberation” is able to truly deliver on the Vita. Two stars out of four.

___

Online:

http://assassinscreed.ubi.com/

___

Follow AP Entertainment Writer Derrik J. Lang on Twitter at http://www.twitter.com/derrikjlang .

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Evan Rachel Wood marries “Billy Elliot” star Jamie Bell

LOS ANGELES (Reuters) – Hollywood actress Evan Rachel Wood has quietly married Briton Jamie Bell – star of the 2000 “Billy Elliot” dance movie – in a ceremony in California, Wood’s spokeswoman said on Wednesday.

“The bride wore a custom dress by Carolina Herrera. It was a small ceremony with close family and friends,” the spokeswoman said in a statement, adding that the wedding took place on Tuesday.

In a Twitter posting on Wednesday, Wood, best known for her roles in “The Wrestler” and coming of age movie “Thirteen,” said “Words cannot describe the happiness I am feeling. Overwhelming.”

Wood, 25, first began dating Bell about seven years ago. But the pair broke up and Wood went on to have a highly publicized engagement with heavy metal rocker Marilyn Manson, who is almost twice her age.

Wood and Bell, 26, were rumored to have become engaged in January this year, but never confirmed their relationship.

Bell found fame as the teen star of “Billy Elliot” about a ballet dancer growing up in a tough coal mining town in northern England. He won a British BAFTA award for the role and has since appeared in adventure movies like “The Eagle” and “Jumper.”

(Reporting By Jill Serjeant; Editing by Sandra Maler)

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Bellevue Hospital Evacuates Patients

New York City’s Bellevue Hospital Center was evacuating hundreds of patients to other hospitals, according to city officials, making it the latest hospital in the city forced to transfer patients after damage from Superstorm Sandy.

The evacuations from Bellevue — perhaps the best known of the 11 hospitals that make up New York City’s public hospital system — followed other transfers from NYU Langone Medical Center on Monday and Coney Island Hospital on Tuesday.

When Sandy hit the New York area Monday night, Bellevue, located on 1st Avenue and 27th Street in flood-stricken Lower Manhattan, almost lost its generators. At least one got repaired just in time to stave off an evacuation, but it’s been difficult to keep the hospital going.

Photos: Assessing Sandy’s Destruction

Bellevue, its staff and its remaining patients have been struggling along in the aftermath of Sandy with failing power, partially lighted halls and no computers, making it difficult to locate patients within the facility, hospital staff told ABC News today. Staff members spoke of long walks up and down dark stairwells and hallways to treat patients.

“It’s Katrina-esque in there,” one nurse told ABC News.

Similar conditions existed at Metropolitan Hospital, another city facility that was running on backup generator power. That hospital is located on 1st Avenue and East 97th Street in Manhattan.

NYU Medical Center Forced to Evacuate Over 200 Patients Watch Video

For two days, the Bellevue staff and the city have been poised for an eventual evacuation, and that time now seems to have come, along with another quest for beds.

Hurricane Sandy: Full Coverage

“We learned this morning that Bellevue will now have to evacuate because of damage that it has sustained,” New York Mayor Michael Bloomberg told reporters. “They didn’t think the damage was that bad, and we did have a generator going, and the National Guard helped carry fuel up to the roof, because that’s where the fuel tank was and they were running out.

“But the bottom line is that when they got into the basement they realized there was more damage,” Bloomberg added. “It’s going to affect something like 500 patients. They had already discharged patients that didn’t require critical care. We are in the process of finding beds to move these patients to now and I want to thank the greater New York hospital association for their help in the process of relocating patients.”

The Mount Sinai Medical Center in Manhattan’s East Harlem neighborhood further uptown told ABC News it would be accepting some of Bellevue’s patients. The patients likely will be received at Mount Sinai’s emergency room.

Earlier, when Mount Sinai could no longer reach anyone at Bellevue, it sent a medical team of eight to Bellevue, a Mount Sinai spokesman told ABC News. When the group arrived, two cardiac physicians told the Mount Sinai team they had two very serious patients that needed help. Both of those patients were to be moved to Mount Sinai, along with other patients.

Today, Bellevue nurses could be seen walking up and down stairs with food trays and medicine. Some had to hike to the 17th floor, where some patients have “serious conditions.”

7 Devastating Hurricanes: Where Will Sandy Rank?

The highest floor patients had to be carried from was 18th floor, New York City Health and Hospital Corporation President Alan Aviles told reporters this evening. The National Guard was instrumental in carrying fuel up to the hospital’s rooftop generator and patients down the stairs, Aviles added.

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Bellevue Hospital Evacuates Patients

New York City’s Bellevue Hospital Center was evacuating hundreds of patients to other hospitals, according to city officials, making it the latest hospital in the city forced to transfer patients after damage from Superstorm Sandy.

The evacuations from Bellevue — perhaps the best known of the 11 hospitals that make up New York City’s public hospital system — followed other transfers from NYU Langone Medical Center on Monday and Coney Island Hospital on Tuesday.

When Sandy hit the New York area Monday night, Bellevue, located on 1st Avenue and 27th Street in flood-stricken Lower Manhattan, almost lost its generators. At least one got repaired just in time to stave off an evacuation, but it’s been difficult to keep the hospital going.

Photos: Assessing Sandy’s Destruction

Bellevue, its staff and its remaining patients have been struggling along in the aftermath of Sandy with failing power, partially lighted halls and no computers, making it difficult to locate patients within the facility, hospital staff told ABC News today. Staff members spoke of long walks up and down dark stairwells and hallways to treat patients.

“It’s Katrina-esque in there,” one nurse told ABC News.

Similar conditions existed at Metropolitan Hospital, another city facility that was running on backup generator power. That hospital is located on 1st Avenue and East 97th Street in Manhattan.

NYU Medical Center Forced to Evacuate Over 200 Patients Watch Video

For two days, the Bellevue staff and the city have been poised for an eventual evacuation, and that time now seems to have come, along with another quest for beds.

Hurricane Sandy: Full Coverage

“We learned this morning that Bellevue will now have to evacuate because of damage that it has sustained,” New York Mayor Michael Bloomberg told reporters. “They didn’t think the damage was that bad, and we did have a generator going, and the National Guard helped carry fuel up to the roof, because that’s where the fuel tank was and they were running out.

“But the bottom line is that when they got into the basement they realized there was more damage,” Bloomberg added. “It’s going to affect something like 500 patients. They had already discharged patients that didn’t require critical care. We are in the process of finding beds to move these patients to now and I want to thank the greater New York hospital association for their help in the process of relocating patients.”

The Mount Sinai Medical Center in Manhattan’s East Harlem neighborhood further uptown told ABC News it would be accepting some of Bellevue’s patients. The patients likely will be received at Mount Sinai’s emergency room.

Earlier, when Mount Sinai could no longer reach anyone at Bellevue, it sent a medical team of eight to Bellevue, a Mount Sinai spokesman told ABC News. When the group arrived, two cardiac physicians told the Mount Sinai team they had two very serious patients that needed help. Both of those patients were to be moved to Mount Sinai, along with other patients.

Today, Bellevue nurses could be seen walking up and down stairs with food trays and medicine. Some had to hike to the 17th floor, where some patients have “serious conditions.”

7 Devastating Hurricanes: Where Will Sandy Rank?

The highest floor patients had to be carried from was 18th floor, New York City Health and Hospital Corporation President Alan Aviles told reporters this evening. The National Guard was instrumental in carrying fuel up to the hospital’s rooftop generator and patients down the stairs, Aviles added.

Health News Headlines – Yahoo! News

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New York state asks Washington to cover all storm costs

NEW YORK/WASHINGTON (Reuters) – New York state on Wednesday asked the U.S. federal government to pay all the costs of cleaning up and repairing damage from massive storm Sandy that tore through the Northeast this week and crippled New York City.

Governor Andrew Cuomo said he is asking fellow Democrat, President Barack Obama, to pay 100 percent of the estimated $ 6 billion bill, at a time that state and local government budgets remain constrained by a weak economic recovery.

That would be a significant change from last year when the federal government covered about 75 percent of the $ 1.2 billion cost paid by New York to clean up after storm Irene hit the region.

The two U.S. senators from neighboring New Jersey, the other state hit hardest by the storm, also asked that the federal government cover more than the usual share of the cost, given the size of the disaster and the financially strapped local coffers.

“Recent storms in New Jersey have already placed a significant burden on our state and local governments, which have been forced to pay for disaster response and will need federal assistance for recovery from Hurricane Sandy,” Senator Frank Lautenberg and Senator Robert Menendez, both Democrats, wrote in a letter to Obama.

“While we understand the federal share is typically 75 percent of these total costs, the unprecedented and extraordinary extent of damage Hurricane Sandy has caused to our state merits an adjustment to this cost-share to 90 to 100 percent federal coverage,” the two senators said.

New Jersey Governor Chris Christie, a Republican, did not reply to request of comments.

Obama and Christie toured storm-stricken parts of New Jersey on Wednesday, taking in scenes of flooded roads from the air and telling residents they were moving quickly to get them help.

‘WE CAN’T PRINT MONEY’

New York top finance official, Comptroller Thomas DiNapoli, said Washington should foot the bill, because of lingering financial pressures on state and local governments from the 2007-09 recession.

“I think the focus will have to be on Washington, for obvious reasons,” DiNapoli told Reuters in an interview.

“They have greater resources. They can print money; we can’t do that here. And given the fact this is not just a New York disaster, it’s really a national disaster, it’s probably for the federal government to step up and play a significant role.”

“The problem is the state is limited in its resource capacity. We just put out the mid-year report a week or two ago and it really showed tax revenues are down,” DiNapoli said.

Most U.S. states must balance their budgets, unlike the federal government, and it is up to Obama to decide if federal funds can cover all the costs.

“The president has the discretion to go higher. Seventy-five percent is a floor not a ceiling,” said Matt Mayer, a former senior official at the Department of Homeland Security.

If Obama accepts covering all the costs, this would be announced by Federal Emergency management Agency, Mayer said.

Former President George W. Bush allowed 100 percent reimbursement of costs in some states after Hurricane Katrina struck in 2005, Mayer, who worked at DHS during Bush’s presidency, told Reuters.

Cuomo said in a letter to Obama that “initial estimates project up to $ 6 billion in lost economic revenue in the greater metropolitan area and the state” due to disruption to business in the world’s financial hub.

Cuomo added that “the significant impact from Hurricane Sandy plainly warrants providing this assistance.”

The state, he said, was still battling multi-building fires, tunnel closures, and power outages at hospitals and other vital facilities. Plus there are destroyed homes and people needing shelter.

“Moreover, the cost to restore the complex electrically driven subway and rail transportation systems after total inundation from saltwater flooding will place a tremendous financial burden on New York state,” Cuomo said in the letter.

In New York alone nearly 2 million homes and businesses are still without power.

Cuomo said federal support is key to making sure state and local governments can respond effectively to the disaster.

New York state is rated AA by Standard and Poor’s and Aa2 by Moody’s and its outstanding debt is the second highest among states, after California.

(Additional reporting by Michael Connor in Miami; writing by Tiziana Barghini in New York; Editing by Mary Milliken and Bob Burgdorfer)

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Clinton calls for overhaul of Syrian opposition

ZAGREB (Reuters) – The United States called on Wednesday for an overhaul of Syria‘s opposition leadership, saying it was time to move beyond the Syrian National Council and bring in those “in the front lines fighting and dying”.

Secretary of State Hillary Clinton, signaling a more active stance by Washington in attempts to form a credible political opposition to Syrian President Bashar al-Assad, said a meeting next week in Qatar would be an opportunity to broaden the coalition against him.

“This cannot be an opposition represented by people who have many good attributes but who, in many instances, have not been inside Syria for 20, 30, 40 years,” she said during a visit to Croatia.

“There has to be a representation of those who are in the front lines fighting and dying today to obtain their freedom.”

Clinton’s comments represented a clear break with the Syrian National Council (SNC), a largely foreign-based group which has been among the most vocal proponents of international intervention in the Syrian conflict.

U.S. officials have privately expressed frustration with the SNC’s inability to come together with a coherent plan and with its lack of traction with the disparate internal groups which have waged the 19-month uprising against Assad’s government.

Senior members of the SNC, Free Syrian Army (FSA) and other rebel groups ended a meeting in Turkey on Wednesday and pledged to unite behind a transitional government in coming months.

“It’s been our divisions that have allowed the Assad forces to reach this point,” Ammar al-Wawi, a rebel commander, told Reuters after the talks outside Istanbul.

“We are united on toppling Assad. Everyone, including all the rebels, will gather under the transitional government.”

Mohammad Al-Haj Ali, a senior Syrian military defector, told a news conference after the meeting: “We are still facing some difficulties between the politicians and different opposition groups and the leaders of the Free Syrian Army on the ground.”

Clinton said it was important that the next rulers of Syria were both inclusive and committed to rejecting extremism.

“There needs to be an opposition that can speak to every segment and every geographic part of Syria. And we also need an opposition that will be on record strongly resisting the efforts by extremists to hijack the Syrian revolution,” she said.

Syria’s revolt has killed an estimated 32,000. A bomb near a Shi’ite shrine in a suburb of Damascus killed at least six more people on Wednesday, state media and opposition activists said.

NEW LEADERSHIP

The meeting next week in Qatar’s capital Doha represents a chance to forge a new leadership, Clinton said, adding the United States had helped to “smuggle out” representatives of internal Syrian opposition groups to a meeting in New York last month to argue their case for inclusion.

“We have recommended names and organizations that we believe should be included in any leadership structure,” she told a news conference.

“We’ve made it clear that the SNC can no longer be viewed as the visible leader of the opposition. They can be part of a larger opposition, but that opposition must include people from inside Syria and others who have a legitimate voice which must be heard.”

The United States and its allies have struggled for months to craft a credible opposition coalition.

U.S. President Barack Obama’s administration has said it is not providing arms to internal opponents of Assad and is limiting its aid to non-lethal humanitarian assistance.

It concedes, however, that some of its allies are providing lethal assistance – a fact that Assad’s chief backer Russia says shows western powers are intent on determining Syria’s future.

Russia and China have blocked three U.N. Security Council resolutions aimed at increasing pressure on the Assad government, leading the United States and its allies to say they could move beyond U.N. structures for their next steps.

Clinton said she regretted but was not surprised by the failure of the latest attempted ceasefire, called by international mediator Lakhdar Brahimi last Friday. Each side blamed the other for breaking the truce.

“The Assad regime did not suspend its use of advanced weaponry against the Syrian people for even one day,” she said.

“While we urge Special Envoy Brahimi to do whatever he can in Moscow and Beijing to convince them to change course and support a stronger U.N. action we cannot and will not wait for that.”

Clinton said the United States would continue to work with partners to increase sanctions on the Assad government and provide humanitarian assistance to those hit by the conflict.

(Additional reporting by Ayla Jean Yackley; editing by Andrew Roche)

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