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The first two cars were packed as usual for the morning rush, so tightly that people stood pressed flesh to flesh, sandwiched between bicycles and the few seats, many without so much as a strap to hold onto.

This train didn’t lurch, though. It had trouble stopping at all, overshooting platform after platform and missing at least one station entirely as it rushed toward the end of the line.

The train didn’t come to a halt until it had slammed into a metal barrier at Buenos Aires’ Once station. With eight cars carrying a mass of steel and humanity – more than 1200 people on board – the momentum was devastating. Forty-nine people were killed and 600 were injured.

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Windows exploded and the first cars were crushed into a jumble of glass, metal, plastic and bodies.

The cause wasn’t immediately determined but many pointed to a deteriorating rail system and train cars that lack modern equipment and safety measures. Passengers said the conductor had appeared to be struggling with the brakes before the crash.

The dead included 48 adults and one child – most of whom had crowded into the first two cars to get ahead of the rush-hour crowds on arrival. The injured included 461 who were hospitalised, Transportation Secretary J.P. Schiavi said.

Passengers’ friends and relatives were still rushing around the city hours later, checking emergency rooms and the city’s two largest morgues for some sign of their loved ones.

Ezequiel Mercado, his mother-in-law and 10 other friends and family members frantically searched for his wife, Sabrina Espindola, 29, who didn’t show up for work on Wednesday. They checked nine hospitals before heading to the morgue.

“I went everywhere. She is always with her Blackberry. We are always in contact,” he said. “This morgue is the last place I thought of, but, well, she’s missing. I call her mobile phone, and it rings, rings, but she isn’t responding.”

Schiavi defended the rail system at a news conference.

“It was an accident like those in many other countries,” he said, pointing to a newspaper clipping about a fatal crash in Los Angeles. “In recent years, we’ve made huge investments” in the system.

As Schiavi spoke, riot police faced off against angry passengers in the closed station, where emergency workers spent hours extracting dozens of people trapped inside the train’s first car. Rescuers had to slice open the roof and set up a pulley system to ease them out one by one. Dozens of the injured were lined up on stretchers on the station platform.

The 28-year-old conductor, who survived the crash, was apparently well-rested, Schiavi said, having just begun his workday.

“Tiredness, his age, the problems that a conductor might face” are among the factors being investigated, he said. “This young person had just begun his shift moments before the accident.”

The motorman was hospitalised in intensive care and hasn’t given a statement, Schiavi added.

Passengers said the conductor seemed to struggle with the brakes, missing his stopping marks at station after station.

Concepcion Ortiz, 60, told the Clarin newspaper that in Caballito, the conductor “went past the station and needed to go in reverse”. Jorge Medina told the paper the same thing happened in the Haedo and Ramos Mejia stations.

“We had noticed severe problems in the brakes during the whole trip,” said a man with a broken ankle who gave his name only as Juan, and was interviewed in a wheelchair at Ramos Mejia Hospital, one of a dozen that cared for the injured.

“It was noticeable because when he got to where he needed to stop, he didn’t slow down. In Haedo, almost half the train passed the station; in Liniers he also overran (the platform) and in Floresta he simply went right past it. He never stopped,” the young man told the C5N television channel.

A labour union official said earlier on Wednesday the train had appeared to be in good working order.

“This machine left the shop yesterday and the brakes worked well. From what we know, it braked without problems at previous stations. At this point I don’t want to speculate about the causes,” union chief Ruben Sobrero told Radio La Red.

Schiavi said the train was recorded slowing from about 50km/h to 19km/h about 40 metres before the impact. “We don’t know what happened in those final 40 metres,” he said.

The train slammed into a shock-absorbing barrier at 8.33 am, smashing the front of the engine and crunching the much lighter cars behind it. The second car penetrated nearly six metres into the next, Schiavi said.

Most damaged was the first car, where passengers shared space with bicycles. Survivors said many people were injured in a jumble of metal and glass. Security camera images showed windows exploding as the cars crumpled into each other like an accordion, with a man on the adjacent platform scrambling across the tracks to escape the wreck.

It was Argentina’s deadliest train accident since February 1, 1970, when a train smashed into another at full speed in suburban Buenos Aires, killing 200.

President Cristina Fernandez cancelled her day’s agenda due to the accident, which raised fresh doubts about government investment in the train system millions depend on. While largely privatised, the system depends on huge state subsidies, and fares are relatively low compared to other countries in the region.

EATONTOWN — The cars queued up in the semicircular driveway, their occupants ready to lean their heads out of their windows.

The Rev. Charles Schwartz walked up to each driver’s door and, while speaking a few words, dipped his right hand in a bowl of ashes, then, with one finger, carefully drew a cross on the person’s forehead. He repeated the process for passengers on the same side of the car, while volunteer Robert Koenig did the same on the passenger side.

That scene was repeated hundreds of times for two hours during the outdoor Ash Wednesday service at St. Dorothea’s Roman Catholic Church on Broad Street.

The vehicle occupants also were given a pamphlet that contained a Gospel reading, a reflection and a prayer.

This was the second year the drive-through service was offered, Schwartz said, and about halfway through, this year looked to be more successful than last.

“We had about 200 people last year,” Schwartz said.

With about an hour to go Wednesday, church employee Helen Tracey counted more than 190 people.

The outdoor service was one of six the church held Wednesday for the traditional start of Lent. The other five services were offered inside the church, Schwartz said.

Schwartz said he started the practice last year to offer parishioners who were too busy or ill to come to church a way to celebrate the feast.

People who attended the first year, he said, “were quite grateful.”

“I was talking to a woman who brought her mother over, and her mother was in tears because she didn‘t think she was going to be able to go to church on Ash Wednesday,” he said.

For Rosalie Doerflein of Middletown, the drive-through service was perfect, because her work schedule does not allow her the time to attend Mass near her home.

“It’s inconvenient for me to go with me working full time,” she said.

Oceanport resident Peter Jaworski said the outdoor service was “just fantastic.”

“Its a real novel way of continuing the tradition,” he said. “I like Father’s courageousness and inventiveness.”

Schwartz said some people worried last year that the outdoor service would reduce the number of people who attended Mass in the church, but, he said, that does not seem to have happened.

“Our numbers are up a little bit inside,” he said.

A panel of medical experts voted overwhelmingly Wednesday to endorse the controversial weight-loss drug Qnexa, clearing the way for the Food and Drug Administration to approve a new prescription obesity medication for the first time since 1999.

The FDA will issue a final ruling later this year, but the agency typically follows the recommendations of its advisory committees.

The 20-2 vote in favor of Qnexa was a surprising reversal from 2010, when the same advisory committee decided that the drug’s risks of heart problems and birth defects outweighed its weight-loss benefits.

In a clinical trial involving 4,323 people, Qnexa — a combination of the anticonvulsant drug topiramate and the appetite suppressant phentermine — led to an average loss of about 10% of total body weight in the first year of use. Many users also saw improvements in blood pressure.

But the trials also found that that the drug caused a slight increase in heart rate, which can boost the odds of a heart attack or stroke. In addition, researchers detected an increased risk of birth defects — typically cleft lip — in women who became pregnant while taking the drug.

Vivus Inc., the drug’s manufacturer, addressed those concerns by proposing a tightly controlled system for prescribing Qnexa. To prevent birth defects, patients who take the drug will have to undergo monthly pregnancy testing and healthcare providers will get special training on the medication’s risks and benefits. Vivus will also restrict distribution of the drug to registered pharmacies, among other measures.

“We will know who the prescribers are. We will know who has been trained,” Dr. Barbara Troupin, Vivus’ senior director of global medical affairs, told the advisory committee. “We are confident the Qnexa [risk management program] balances the safeguards while allowing access for appropriate patients.”

According to the clinical trial data and previous studies, the risk of having a baby with a cleft lip is two to five times greater in women who took topiramate.

“The simple reality is, if you’re pregnant or planning on getting pregnant, it’s not the right drug for you,” said Joe Nadglowski, chief executive of the Obesity Action Coalition, a patient advocacy group based in Tampa, Fla., that supports approval of Qnexa.

Vivus, based in Mountain View, Calif., proposed a similar program to monitor heart risks in patients. Several panel members strongly encouraged the company to conduct a post-marketing study to help identify the potential cardiovascular risks.

At the panel’s daylong meeting Wednesday in Silver Spring, Md., several members of the Endocrinologic and Metabolic Drugs Advisory Committee said they worried about Qnexa’s side effects but believed the benefits outweighed the risks.

More than 35% of American adults are obese, including about 5% who are morbidly obese, and an additional 33% are overweight, according to the Centers for Disease Control and Prevention in Atlanta. Those extra pounds are more than just a cosmetic issue; they also increase one’s risk of diabetes, heart disease, stroke, osteoarthritis, certain types of cancers and possibly dementia.

“The most encouraging thing is that just about every member really heard the message about the need to treat obesity,” said Ted Kyle, the advocacy committee chairman of the Obesity Society. “Obesity is not a trivial disease.”

Only one prescription diet drug is available in the United States. That drug, orlistat, blocks absorption of fat and is sold under the trade name Xenical. Qnexa appears to work by suppressing appetite and increasing feelings of fullness.

It’s not clear why the medication raises heart rate, but such an increase is typically viewed as a marker of cardiovascular risk, said Dr. Michael S. Lauer, director of the division of cardiovascular sciences at the National Heart, Lung and Blood Institute and a member of the advisory panel.

Lauer cast one of the two votes against approval, saying that the FDA should first ask Vivus to complete a study that provided detailed cardiovascular risk data. Otherwise, he said, FDA approval “would be a decision based on hopes, surrogates and suppositions.”

“We have seen many cases in medicine where we thought we understood the pathology of disease … and we turned out to be wrong,” Lauer said. “With an epidemic as serious as obesity, we need to do this right.”

If approved by the FDA, Qnexa would be targeted for people with a body mass index of 30 or above, or a BMI of 27 or above for people who also have weight-related health problems, such as diabetes or sleep apnea. A BMI of 25 to 29 indicates a person is overweight, and 30 or greater is considered obese.

The vote sent Vivus shares soaring to more than $21 in after-hours trading, double the official closing price of $10.55.

shari.roan@latimes.com

The diet drug Qnexa has cleared a major hurdle toward eventual Food and Drug Administration approval. An independent panel of medical experts who advise the agency voted Wednesday that Qnexa’s significant weight-loss benefit outweighed its potential risks.

The hearing was held in Silver Spring, Md. The surprisingly positive 20-2 vote in favor of approval moves the decision on Qnexa into the hands of the FDA, which will issue a final ruling later this year.

The agency typically follows the recommendations of an advisory committee but is not bound by it. If approved, as is now expected, Qnexa would be the first prescription diet drug to reach the market since 1999. The drug, made by Vivus Inc.of Mountain View, Calif., is a combination of the anticonvulsant topiramate and the appetite suppressant phentermine.

Studies show the medications produced an average of about 10% loss of body weight in the first two years of use. “The benefits of that degree of weight loss have been clear and unambiguous,” said Dr. Stephen Smith, scientific director at the Translational Research Institute in Orlando, Fla., who was not involved in the vote. “We fully understand the topiramate risk, and the phentermine risk we have a pretty good handle on as well.” The committee’s vote, he said, “recognizes that doing nothing in obesity has it consequences.”

More than 35% of American adults are obese and another third are overweight. Only one prescription diet drug is available in the United States. However, both topirimate and phentermine have side effects. Last year, the FDA reclassified topiramate as a class D drug, meaning it carries risks to a fetus but may still be acceptable for use in pregnant women despite the risks.

Clinical trials on Qnexa also showed an increased risk of birth defects — typically cleft lip — in women who became pregnant on the drug. The study also found that users have an increase in heart rate. These side effects led to a thumbs-down vote when Qnexa came before the FDA advisory committee in 2010. The FDA subsequently denied approval in October 2010, citing potential safety problems.

But officials for Vivus Inc. have proposed a tightly controlled system for prescribing Qnexa to prevent birth defects, including healthcare provider training, monthly pregnancy testing, a patient medication guide and limits on which pharmacies can dispense the medication, such as registered mail-order pharmacies.

“We will know who the prescribers are. We will know who has been trained,” said Dr. Barbara Troupin, senior director of global medical affairs for Vivus. “We are confident the Qnexa [risk management program] balances the safeguards while allowing access for appropriate patients.” Moreover, the panel strongly encouraged that Vivus conduct a post-marketing study to better understand the potential cardiovascular side effects of Qnexa.

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