Dozens killed after 7.9 quake strikes off Guatemala

GUATEMALA CITY (Reuters) - A strong earthquake off the coast of Guatemala shook buildings in the capital and killed at least 39 people on Wednesday, trapping others under rubble and triggering evacuations as far away as Mexico City.

The 7.4 magnitude quake hit at 10:35 a.m. local time (11:35 EDT). A local fire chief said at least some of the dead were buried under debris in a mountainous region near the Mexican border.

Landslides blocked roads in some areas, authorities said, and about 40 houses were severely damaged.

It was the strongest earthquake to hit Guatemala since a 7.5 magnitude quake in 1976 that claimed more than 20,000 lives.

President Otto Perez said that as many as 100 people were unaccounted for, based on reports from relatives.

"These are preliminary figures and we don't have them confirmed," Perez said in Guatemala City. "Our priority is to focus on lives, rescuing people and treating the wounded."

San Marcos state governor Luis Rivera confirmed the deaths of 39 people, adding that the state government offices were almost completely destroyed.

Perez said there had been five aftershocks, with authorities distributing 16,000 emergency rations and mobilizing more than 2,000 soldiers to help with the rescue effort.

Local fire chief Cecilio Chacaj said the bodies of 18 dead had been pulled from rubble in San Marcos and Quetzaltenango, the country's second largest city.

The quake struck off Guatemala's Pacific coast, 15 miles south of Champerico and 101 miles west-southwest of the capital, the U.S. Geological Survey said.

Evacuations in Guatemala City filled the streets with office workers calling friends and relatives on their cell phones, but people soon returned to work.

"It was really big; I felt quite nauseous," said secretary Vanessa Castillo, 32, who was evacuated from her 10th floor office in Guatemala City.

Building janitor Jorge Gamboa said: "I was in the bathroom. When I came out the office was empty and I thought, what's happening? They didn't even say goodbye."

The epicenter was 26 miles below the surface, according to the USGS, which initially reported the quake as magnitude 7.5.

The quake was also felt in El Salvador and more than 765 miles away in Mexico City, where some people also fled offices and homes. Mayor Marcelo Ebrard said the quake was felt strongly in a large part of the city of 20 million people.

The Pacific Tsunami Warning Center said a small tsunami was registered on Guatemala's coast, adding that there was a risk of localized damage within a 62 mile radius.

(With reporting by Nelson Renteria in San Salvador; Writing by Krista Hughes; Editing by Simon Gardner and Christopher Wilson)

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China hauls away activists in congress crackdown

BEIJING (AP) — During her 30-hour train journey to Beijing, Wang Xiulan ducked into bathrooms whenever the conductors checked IDs. Later, as she lay low in the outskirts of the capital, unidentified men caught her in a nighttime raid and hauled her to a police station. She assumed a fake identity to get away, and is now in hiding again.

Wang's not a criminal. She's a petitioner.

She's among many people attempting to bring local complaints directly to the central government in an age-old Chinese tradition that has continued during the Communist Party era. But police never make that easy, and this week, as an all-important leadership transition begins, a dragnet is aimed at keeping anyone perceived as a threat or a troublemaker out of Beijing.

"There is no law in China, especially for us petitioners and ordinary folk," Wang, 50, said in an interview with The Associated Press. "Even common gangsters and hoodlums get to leave after they serve time for crimes, but for us, if we get locked up, we never know when we might be freed."

Authorities want no surprises as the handover of power begins in the capital Thursday. The transition already has been rocked by the party's messiest scandal in decades, involving a former high-flying politician now accused of engaging in graft and obstructing the investigation into his wife's murder of a British businessman.

Rights groups say the wide-ranging crackdown on critics bodes poorly for those who hope the incoming generation of leaders will loosen restrictions on activism.

"China's top political leaders are very nervous, as they have since early this year been consumed by one of the most destabilizing and disharmonious power struggles in decades," said Renee Xia, international director of the Chinese Human Rights Defenders. The group estimates that hundreds or thousands of people have come under some kind of restriction in preparation for the party congress.

Lawyers have been held under illegal house arrest, dissidents sent back to their hometowns and activists questioned. Internet users report difficulties accessing many websites and the failure of software meant to bypass Internet filters.

Veteran activist Huang Qi, who runs a website on petitioners like Wang, said nearly 1,000 people have contacted him over the past few weeks to complain that authorities have hired thugs to harass and beat them.

"I hope that the Chinese authorities will face up to the social problems," Huang said in an interview. "Using violence will only escalate the resistance."

The crackdown reflects the leadership's nervousness as slowing economic growth exacerbates public outrage over corruption, social injustice, pollution and favoritism toward state-run agencies and the elite at the expense of ordinary people.

Under normal circumstances, petitioners are relatively safe once they reach Beijing's outskirts, though in their home provinces they are almost perpetually on the run from hostile local officials or thugs-for-hire who want to nab them before they can get an audience with central government agencies.

Now, however, even the capital's fringes are off limits.

Wang, a petite woman with shoulder-length hair neatly tied back, has been trying for two decades to draw central government attention to what she says was police mishandling of a serious assault she suffered in her native Harbin. Not only did her attacker go unpunished, but Wang ended up getting dismissed from her job years later.

Wang arrived in late October in Lu Village in Beijing's southwest, where petitioners have sought refuge for years. A police post guards the road into the village, and residents say officers have lately blocked petitioners from entering.

Wang had rented a bed — a wooden plank on bricks — in a tiny concrete room shared with two others. A gang of two dozen men barged in one night at 11 p.m., demanded to see her ID, searched her belongings and grabbed her cellphone.

"I was scared to death when they suddenly barged in here," Wang said, pointing at the door, where the lock had just been replaced.

The men refused to identify themselves and bundled her into a minivan with other petitioners. At another stop, she saw a couple dragged into the vans in their pajamas, the woman wearing only one shoe.

All were taken to a police station in nearby Jiujingzhuang village, where many petitioners say police process them for return to their hometowns. Using someone else's identity, Wang was able to evade police suspicion and was released. Many of the others were sent back, she said.

The raids are having an effect. The compound that houses her room and others now has only a handful of residents, down from about 30.

"They've all been chased away, caught or scared home," said Liu Zhifa, a 67-year-old petitioner from Henan province and one of the holdouts. Liu confirmed Wang's description of the Oct. 31 raid and described his own encounter with thugs breaking his lock and entering his room three times in one night in mid-October.

"I asked them to show their identifications, and they yelled at me, saying 'What right do you have to see our identification? Who do you think you are?" said Liu. "They were ruthless. The authorities and the police are working with people in the underworld."

A police officer who would only give his surname, Wei, answered the phone at a Jiujingzhuang police station (not 'the' because the police station has another name) and denied that authorities were raiding petitioners' villages. "We only act according to the law," Wei said. Questions about the broader crackdown were referred to the Beijing public security bureau, which did not respond to faxed questions.

The crackdown has extended to lawyers such as Xu Zhiyong. He said Beijing authorities have held him under informal house arrest since mid-October, stationing four or five guards outside his apartment in Beijing around the clock.

Xu has campaigned for years against Chinese authorities' use of "black jails," or unofficial detention centers run by local governments to hold petitioners. The government has denied the existence of such facilities, but even the tightly controlled state media have reported on them.

"The illegal restriction of a citizen's personal freedom for a long period of time is criminal behavior," Xu wrote in an email. "In an authoritarian state, this type of crime takes place everywhere."

Authorities in Shanghai also have ratcheted up pressure on critics, sentencing veteran women's rights activist Mao Hengfeng to a year and a half of labor camp. Mao, accused of disturbing social order, had been detained in Beijing in late September, said her husband, Wu Xuewei, who indicated she was being put away to silence her before the party congress.

Even dissidents' relatives have come under pressure. Beijing activist Hu Jia said he was warned by police to leave town, and that even his parents told him that police had told them to escort him to his hometown.

"My parents said to me: 'Hu Jia, you don't know what kind of danger you are in, but we know,'" he recounted in a phone interview from his parents' home in eastern Anhui province. "They said: 'Beijing is a cruel battlefield. If you stay here, you will be the first to be sacrificed. Don't do this.'"

___

Follow Gillian Wong on Twitter at twitter.com/gillianwong

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Exclusive - Amazon to win EU e-book pricing tussle with Apple

BRUSSELS (Reuters) - European Union regulators are to end an antitrust probe into e-book prices by accepting an offer by Apple and four publishers to ease price restrictions on Amazon, two sources said on Tuesday.

That decision would hand online retailer Amazon a victory in its attempt to sell e-books cheaper than rivals in the fast-growing market publishers hope will boost revenue and increase customer numbers.

"Faced with years of court battles and uncertainty I can understand why some of these guys decided to fold their cards and take the whipping," said Mark Coker, founder of Smashwords, an ebook publisher and distributor that works with Apple.

"It's certainly another win for Amazon," he added. "I have not seen the terms of the final settlement, but my initial reaction is that it places restrictions on what publishers can do, slowing them down just when they need to be more nimble."

A spokesman at the EU Commission said its investigation was not yet finished. Amazon and Apple declined to comment.

In September, Apple and the publishers offered to let retailers set prices or discounts for a period of two years, and also to suspend "most-favored nation" contracts for five years.

Such clauses bar Simon & Schuster, News Corp. unit HarperCollins, Lagardere SCA's Hachette Livre and Verlagsgruppe Georg von Holtzbrinck, the owner of German company Macmillan, from making deals with rival retailers to sell e-books more cheaply than Apple.

The agreements, which critics say prevent Amazon and other retailers from undercutting Apple's charges, sparked an investigation by the European Commission in December last year.

Pearson Plc's Penguin group, which is also under investigation, did not take part in the offer.

The EU antitrust authority, which in September asked for feedback from rivals and consumers about the proposal, has not asked for more concessions, said one of sources.

"The Commission is likely to accept the offer and announce its decision next month," the source said on Tuesday.

Antoine Colombani, spokesman for competition policy at the European Commission, said: "We have launched a market test in September and our investigation is still ongoing."

Amazon declined to comment, while Apple did not respond to an email seeking comment.

Companies found guilty of breaching EU rules could be fined up to 10 percent of their global sales, which in Apple's case could reach $15.6 billion, based on its 2012 fiscal year.

AGGREGATE PRICING

UBS analysts estimate that e-books account for about 30 percent of the U.S. book market and 20 percent of sales in Britain but are minuscule elsewhere. When Amazon launched its Kindle e-reader, it charged $9.99 per book.

Apple's agency model let publishers set prices in return for a 30 percent cut to the maker of iPhone and iPad.

The U.S. Department of Justice is investigating e-book prices. HarperCollins, Simon & Schuster and Hachette have settled, but Apple, Pengin Group and Macmillan have not.

The DOJ settlement required that retailers must at least break even selling all ebooks from a publisher's available list, according to Coker and Joe Wikert, general manager and publisher at O'Reilly Media Inc.

It was not clear if EU regulators will include a similar requirement, which would prohibit Amazon from pricing all ebooks at a loss, said Wikert, a former publishing executive.

In the United States, Amazon will likely price popular titles at a loss and try to make up the difference on a publisher's other ebooks, he said.

Coker said any such rule could be dangerous in Europe, which still has distinct markets.

"It could allow a single retailer to charge full price in a large market like the U.K., and then sell below cost or for free in multiple smaller markets as a strategy to kill regional ebook retailing upstarts before they take root," Coker said.

FROWNING ON ONLINE TRADE CURBS

Antitrust regulators tend to frown on restrictions on online trade and the case is a good example, said Mark Tricker, a partner at Brussels-based law firm Norton Rose.

"This case shows the online world continues to be a major focus for the Commission," he said.

"These markets change very quickly and if you don't stamp down on potential infringements of competition rules, you can have significant consequences."

(Additional reporting by Alistair Barr in San Francisco; Editing by Rex Merrifield, David Goodman and David Gregorio)

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Folk-pop duo The Civil Wars cancel tour

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Study: Stem cells from strangers can repair hearts

LOS ANGELES (AP) — Researchers are reporting a key advance in using stem cells to repair hearts damaged by heart attacks. In a study, stem cells donated by strangers proved as safe and effective as patients' own cells for helping restore heart tissue.

The work involved just 30 patients in Miami and Baltimore, but it proves the concept that anyone's cells can be used to treat such cases. Doctors are excited because this suggests that stem cells could be banked for off-the-shelf use after heart attacks, just as blood is kept on hand now.

Results were discussed Monday at an American Heart Association conference in California and published in the Journal of the American Medical Association.

The study used a specific type of stem cells from bone marrow that researchers believed would not be rejected by recipients. Unlike other cells, these lack a key feature on their surface that makes the immune system see them as foreign tissue and attack them, explained the study's leader, Dr. Joshua Hare of the University of Miami.

The patients in the study had suffered heart attacks years earlier, some as long as 30 years ago. All had developed heart failure because the scar tissue from the heart attack had weakened their hearts so much that they grew large and flabby, unable to pump blood effectively.

Researchers advertised for people to supply marrow, which is removed using a needle into a hip bone. The cells were taken from the marrow and amplified for about a month in a lab at Baltimore's Johns Hopkins University, then returned to Miami to be used for treatment, which did not involve surgery.

The cells were delivered through a tube pushed through a groin artery into the heart near the scarred area. Fifteen patients were given cells from their own marrow and 15 others, cells from strangers.

About a year later, scar tissue had been reduced by about one-third. Both groups had improvements in how far they could walk and in quality of life. There was no significant difference in one measure of how well their hearts were able to pump blood, but doctors hope these patients will continue to improve over time, or that refinements in treatment will lead to better results.

The big attraction is being able to use cells supplied by others, with no blood or tissue matching needed.

"You could have the cells ready to go in the blood bank so when the patient comes in for a therapy — there's no delay," Hare said. "It's also cheaper to make the donor cells," and a single marrow donor can supply enough cells to treat as many as 10 people.

Dr. Elliott Antman of Harvard-affiliated Brigham and Women's Hospital in Boston who heads the heart conference, praised the work.

"That opens up an entire new avenue for stem cell therapy, like a sophisticated version of a blood bank," he said. There's an advantage in not having to create a cell therapy for each patient, and it could spare them the pain and wait of having their own marrow harvested, he said.

The study was sponsored by the National Institutes of Health. Hare owns stock in a biotech company working on a treatment using a mixture of cells.

Juan Lopez received his own cells in the study, and said it improved his symptoms so much that at age 70, he was able to return to his job as an engineer and sales manager for a roofing manufacturer and ride an exercise bike.

"It has been a life-changing experience," said Lopez, who lives in Miami. "I can feel day by day, week by week, month by month, my improvement. I don't have any shortness of breath and my energy level is way up there. I don't have any fluid in my lungs."

And, he said happily, "My sex drive has improved!"

___

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

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Race for the White House: Join us live

(Reuters) - New Orleans Hornets head coach Monty Williams has been fined $25,000 by the National Basketball Association (NBA) for public criticism of the NBA's concussion policy, the league said on Tuesday. Williams was penalized for comments he made before Saturday's game against the Chicago Bulls when Hornets center Anthony Davis, the first overall pick in the 2012 draft, was sidelined by a mild concussion. "Now, they treat everybody like they have white gloves and pink drawers and it's getting old," Williams told reporters on Saturday. "It's just the way the league is now. ...

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Elephant in South Korean zoo imitates human speech

SEOUL, South Korea (AP) — An elephant in a South Korean zoo is using his trunk to pick up not only food, but also human vocabulary.

An international team of scientists confirmed Friday what the Everland Zoo has been saying for years: Their 5.5-ton tusker Koshik has an unusual and possibly unprecedented talent.

The 22-year-old Asian elephant can reproduce five Korean words by tucking his trunk inside his mouth to modulate sound, the scientists said in a joint paper published online in Current Biology. They said he may have started imitating human speech because he was lonely.

Koshik can reproduce "annyeong" (hello), "anja" (sit down), "aniya" (no), "nuwo" (lie down) and "joa" (good), the paper says.

One of the researchers said there is no conclusive evidence that Koshik understands the sounds he makes, although the elephant does respond to words like "anja."

Everland Zoo officials in the city of Yongin said Koshik also can imitate "ajik" (not yet), but the researchers haven't confirmed the accomplishment.

Koshik is particularly good with vowels, with a rate of similarity of 67 percent, the researchers said. For consonants he scores only 21 percent.

Researchers said the clearest scientific evidence that Koshik is deliberately imitating human speech is that the sound frequency of his words matches that of his trainers.

Vocal imitation of other species has been found in mockingbirds, parrots and mynahs. But the paper says Koshik's case represents "a wholly novel method of vocal production" because he uses his trunk to reproduce human speech.

In 1983, zoo officials in Kazakhstan reportedly claimed that a teenage elephant named Batyr could reproduce Russian to utter 20 phrases, including "Batyr is good." But there was no scientific study on the claim.

Researchers believe Koshik learned to reproduce words out of a desire to bond with his trainers after he was separated from two other elephants at age 5.

Koshik emerged as a star among animal enthusiasts and children in South Korea after Everland Zoo claimed in 2006 that he could imitate words, two years after his trainers noticed the phenomenon. His growing reputation prompted Austrian biologist Angela Stoeger-Horwath and German biophysicist Daniel Mietchen to study him in 2010, zoo officials said.

Oh Suk-hun, a South Korean veterinarian who co-authored the research paper with Stoeger-Horwath and Mietchen, said the elephant apparently started imitating human speech to win the trust of his trainers.

In April, a children's science book called "Joa Joa, Speaking Elephant" was published. The cover photo showed Koshik opening his mouth wide while raising a trunk over his trainer's head.

Researchers said Koshik was trained to obey several commands and "exposed to human speech intensively" by trainers, veterinarians and zoo visitors.

Shin Nam-sik, a veterinary professor at Seoul National University who has seen Koshik, agreed with researchers' finding that the elephant was able to mimic human speech.

"In Koshik's case, the level of intimacy between him and his trainer was the key factor that made the elephant want to sound like a human," Shin said.

Kim Jong-gab, Koshik's chief trainer, said the elephant was timid for a male when he first came to Everland Zoo, so trainers often slept in the same area with him. Kim thinks that contact helped Koshik feel closer to humans.

Kim said he has another phrase he wants to teach Koshik: "Saranghae," or "I love you."

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Apple sells three million iPads over first weekend

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Composer, Pulitzer winner Carter dies in NY at 103

NEW YORK (AP) — Classical composer Elliott Carter, whose challenging, rhythmically complex works earned him widespread admiration and two Pulitzer Prizes, died Monday at age 103.

His music publishing company, Boosey & Hawkes, called him an "iconic American composer." It didn't give the cause of his death.

In a 1992 Associated Press interview, Carter described his works as "music that asks to be listened to in a concentrated way and listened to with a great deal of attention."

"It's not music that makes an overt theatrical effect," he said then, "but it assumes the listener is listening to sounds and making some sense out of them."

The complex way the instruments interact in his compositions created drama for listeners who made the effort to understand them, but it made them difficult for orchestras to learn. He said he tried to give each of the musicians individuality within the context of a comprehensible whole.

"This seems to me a very dramatic thing in a democratic society," he said.

While little known to the general public, he was long respected by an inner circle of critics and musicians. In 2002, The New York Times said his string quartets were among "the most difficult music ever conceived," and it hailed their "volatile emotions, delicacy and even, in places, plucky humor."

Carter had remained astonishingly active, taking new commissions even as he celebrated his 100th birthday in December 2008 with a gala at Carnegie Hall.

"I'm always proud of the ones I've just written," he said at the time.

In 2005, his "Dialogues," which had premiered the previous year, was a finalist for the Pulitzer Prize in music. And in 2006, his "Boston Concerto" was nominated for a Grammy Award as best classical contemporary composition.

Carter won his first Pulitzer Prize in 1960 for his Second String Quartet; his second award was in 1973 for his Third String Quartet. The Juilliard String Quartet chose to mark its 45th anniversary in 1991 with a concert of all four Carter string quartets. A fifth quartet came out in 1995.

When the first National Medal of Arts awards were given in 1985, Carter was one of 10 people honored, along with such legends as Martha Graham, Ralph Ellison and Georgia O'Keeffe. The awards were established by Congress in 1984.

The New Grove Dictionary of American Music said that at its best, Carter's music "sustains an energy of invention that is unrivaled in contemporary composition."

Carter said he found Europeans more receptive to his works than his fellow Americans because music in Europe is not purely entertainment but part of the culture, "something that people make an effort to understand."

The lack of widespread attention didn't seem to bother him.

"I don't think it means anything to be popular," he said. "When we see the popular tastes and the popular opinion constantly being manipulated by all sorts of different ways, it seems to me popularity is a meaningless matter."

In 1992, Carter said his favorite piece of music was his Concerto for Orchestra, written in 1969. It was commissioned by the New York Philharmonic for its 125th anniversary season.

"It particularly expresses a picture of the United States as an evolving world of not only people but of nature," he said.

Among his early works were two ballets, "The Minotaur" and "Pocahontas," and his First Symphony. His First String Quartet in 1951 started him on the road to greater critical attention.

Besides composing, Carter wrote extensively about 20th-century music. A collection of articles, "The Writings of Elliott Carter: An American Composer Looks at Modern Music," was published in 1977.

Carter as born in New York in 1908. As a young man he became acquainted with composer Charles Ives, who encouraged his ambitions. He studied literature at Harvard and then studied music in Paris under famed teacher Nadia Boulanger, who also guided Leonard Bernstein, Aaron Copland and Virgil Thompson.

As Carter turned 100, he recalled a visit to the hall in 1924 to see the New York premiere of Igor Stravinsky's revolutionary work "The Rite of Spring."

"I thought it was the greatest thing I ever heard, and I wanted to do like that, too," Carter recalled. "Of course, half the audience walked out, which was even more pleasant to me. It seemed much more exciting than Beethoven and Brahms and the rest of them."

In 1939, he married sculptor Helen H. Frost Jones. They had one son. He is survived by his son and a grandson.

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Study: Stem cells from strangers can repair hearts

LOS ANGELES (AP) — Researchers are reporting a key advance in using stem cells to repair hearts damaged by heart attacks. In a study, stem cells donated by strangers proved as safe and effective as patients' own cells for helping restore heart tissue.

The work involved just 30 patients in Miami and Baltimore, but it proves the concept that anyone's cells can be used to treat such cases. Doctors are excited because this suggests that stem cells could be banked for off-the-shelf use after heart attacks, just as blood is kept on hand now.

Results were discussed Monday at an American Heart Association conference in California and published in the Journal of the American Medical Association.

The study used a specific type of stem cells from bone marrow that researchers believed would not be rejected by recipients. Unlike other cells, these lack a key feature on their surface that makes the immune system see them as foreign tissue and attack them, explained the study's leader, Dr. Joshua Hare of the University of Miami.

The patients in the study had suffered heart attacks years earlier, some as long as 30 years ago. All had developed heart failure because the scar tissue from the heart attack had weakened their hearts so much that they grew large and flabby, unable to pump blood effectively.

Researchers advertised for people to supply marrow, which is removed using a needle into a hip bone. The cells were taken from the marrow and amplified for about a month in a lab at Baltimore's Johns Hopkins University, then returned to Miami to be used for treatment, which did not involve surgery.

The cells were delivered through a tube pushed through a groin artery into the heart near the scarred area. Fifteen patients were given cells from their own marrow and 15 others, cells from strangers.

About a year later, scar tissue had been reduced by about one-third. Both groups had improvements in how far they could walk and in quality of life. There was no significant difference in one measure of how well their hearts were able to pump blood, but doctors hope these patients will continue to improve over time, or that refinements in treatment will lead to better results.

The big attraction is being able to use cells supplied by others, with no blood or tissue matching needed.

"You could have the cells ready to go in the blood bank so when the patient comes in for a therapy — there's no delay," Hare said. "It's also cheaper to make the donor cells," and a single marrow donor can supply enough cells to treat as many as 10 people.

Dr. Elliott Antman of Harvard-affiliated Brigham and Women's Hospital in Boston who heads the heart conference, praised the work.

"That opens up an entire new avenue for stem cell therapy, like a sophisticated version of a blood bank," he said. There's an advantage in not having to create a cell therapy for each patient, and it could spare them the pain and wait of having their own marrow harvested, he said.

The study was sponsored by the National Institutes of Health. Hare owns stock in a biotech company working on a treatment using a mixture of cells.

Juan Lopez received his own cells in the study, and said it improved his symptoms so much that at age 70, he was able to return to his job as an engineer and sales manager for a roofing manufacturer and ride an exercise bike.

"It has been a life-changing experience," said Lopez, who lives in Miami. "I can feel day by day, week by week, month by month, my improvement. I don't have any shortness of breath and my energy level is way up there. I don't have any fluid in my lungs."

And, he said happily, "My sex drive has improved!"

___

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

___

Online:

Heart Association: http://www.heart.org

JAMA: http://www.jama.ama-assn.org

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