Emmy Awards date announced by CBS

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Hockey Coaches Defy Doctors on Concussions, Study Finds

Despite several years of intensive research, coverage and discussion about the dangers of concussions, the idea of playing through head injuries is so deeply rooted in hockey culture that two university teams kept concussed players on the ice even though they were taking part in a major concussion study.

The study, which will be published Friday in a series of articles in the journal Neurosurgical Focus, was conducted during the 2011-12 hockey season by researchers from the University of Western Ontario, the University of Montreal, Harvard and other institutions.

“This culture is entrenched at all levels of hockey, from peewee to university,” said Dr. Paul S. Echlin, a concussion specialist and researcher in Burlington, Ontario, and the lead author of the study. “Concussion is a significant public health issue that requires a generational shift. As with smoking or seat belts, it doesn’t just happen overnight — it takes a massive effort and collective movement.”

The study is believed to be among the most comprehensive analyses of concussions in hockey, which has a rate of head trauma approaching that of football. Researchers followed two Canadian university teams — a men’s team and a women’s team — and scanned every player’s brain before and after the season. Players who sustained head injuries also received scans at three intervals after the injuries, with researchers using advanced magnetic resonance imaging techniques.

The teams were not named in the study, in which an independent specialist physician was present at each game and was empowered to pull any player off the ice for examination if a potential concussion was observed.

The men’s team, with 25 players and an average age of 22, played a 28-game regular season and a 3-game postseason. The women’s team, with 20 players and an average age of 20, played 24 regular-season games and no playoff games. Over the course of the season, there were five observed or self-reported concussions on the men’s team and six on the women’s team.

Researchers noted several instances of coaches, trainers and players avoiding examinations, ignoring medical advice or otherwise obstructing the study, even though the players had signed consent forms to participate and university ethics officials had given institutional consent.

“Unless something is broken, I want them out playing,” one coach said, according to the study.

In one incident, a neurologist observing the men’s team pulled a defenseman during the first period of a game after the player took two hits and was skating slowly. During the intermission the player reported dizziness and was advised to sit out, but the coach suggested he play the second period and “skate it off.” The defenseman stumbled through the rest of the game.

“At the end of the third period, I spoke with the player and the trainer and said that he should not play until he was formally evaluated and underwent the formal return-to-play protocol,” the neurologist said, as reported in the study. “I was dismayed to see that he played the next evening.”

After the team returned from its trip, the neurologist questioned the trainer about overruling his advice and placing the defenseman at risk.

“The trainer responded that he and the player did not understand the decision and that most of the team did not trust the neurologist,” according to the study. “He requested that the physician no longer be used to cover any more games.”

In another episode, a physician observer assessed a minor concussion in a female player and recommended that she miss the next night’s game. Even though the coach’s own playing career had ended because of concussions, she overrode the medical advice and inserted the player the next evening.

According to the report, the coach refused to speak to another physician observer on the second evening. The trainer was reluctant to press the issue with the coach because, the trainer said, the coach did not want the study to interfere with the team.

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Senate Judiciary Committee Approves Overhaul of Electronic Communications Privacy Act

J. Scott Applewhite/Associated Press

Patrick Leahy, chairman of the Senate Judiciary Committee, is leading an e-mail privacy effort.

The bill is not expected to make it through Congress this year and will be the subject of negotiations next year with the Republican-led House. But the Senate panel’s approval was a first step toward an overhaul of a 1986 law that governs e-mail access and that is widely seen as outdated.

Senator Patrick Leahy, the Vermont Democrat who is chairman of the committee, was an architect of the 1986 law and is leading the effort to remake it. He said at the meeting on Thursday that e-mails stored by third parties should receive the same protection as papers stored in a filing cabinet in an individual’s house.

“Like many Americans, I am concerned about the growing and unwelcome intrusions into our private lives in cyberspace,” Mr. Leahy said. “I also understand that we must update our digital privacy laws to keep pace with the rapid advances in technology.”

Mr. Leahy held a hearing about two years ago on whether and how to update the 1986 law, called the Electronic Communications Privacy Act. But the effort has moved slowly, in part because some law enforcement officials have opposed restricting an investigative tool now used increasingly.

Under the law, authorities need to obtain a search warrant from a judge — requiring them to meet the high standard of showing that there is probable cause to believe that a subject is engaged in wrongdoing — only when they want to read e-mails that have not yet been opened by their recipient and that are fewer than 180 days old.

But the law gives less protection to messages that a recipient has read and left in his or her account. In some cases, officials may obtain a court order for such material merely by presenting a judge with facts suggesting the messages are relevant to an investigation; in other cases, prosecutors can issue a subpoena demanding the materials without any court involvement.

Senator Leahy’s bill would generally require prosecutors to obtain a search warrant from a judge, under the stricter probable-cause standard, to compel a provider to turn over all categories of e-mails and other private documents.

The Center for Democracy and Technology, a nonprofit organization that advocates for electronic privacy rights, hailed the committee vote as “historic.”

In a statement, Gregory T. Nojeim, director of the center’s program on security and technology, said it “sets the stage for updating the law to reflect the reality of how people use technology in their daily lives. It keeps the government from turning cloud providers into a one-stop convenience store for government investigators and requires government investigators to do for online communications what they already do in the offline world: get a warrant before reading postal letters or searching our homes.“

Still, the ranking Republican on the committee, Senator Charles Grassley of Iowa, argued that the bill does not strike the proper balance between privacy and public safety. He expressed concerns that changing the standard of proof for obtaining e-mails would inhibit certain investigations, such as child pornography or child abduction cases.

Mr. Leahy argued that the bill does not alter criminal and antiterrorism laws related to search warrants, including exceptions in emergencies where time is of the essence. But he also said the bill was a starting point and he was open to further negotiations. The panel approved it by a voice vote.

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America waits for Powerball jackpot winners to reveal themselves

Powerball officials confirmed that there are two winning tickets in the second-biggest lottery in history, sold in Arizona and Missouri.

Someone missing at work on Thursday? For many in Arizona and Missouri, that was just one more reason to speculate on who won the record Powerball lottery whose golden tickets were sold in those states.

And while America was waiting to learn who will share in the estimated $587.5-million jackpot, lottery officials prepared to hold news conferences Thursday to highlight the establishments where the winning tickets were sold. Everybody loves a winner, but in the lottery world, the sellers of winning tickets get to share the lucky spotlight.

On Wednesday night, officials drew the winning numbers -- 5, 16, 22, 23, 29, and 6 as the powerball. Two winning tickets will split the jackpot, the largest in Powerball history and the second-largest lottery prize in U.S. history.

QUIZ: Test your knowledge of Powerball

All that is known so far is that one of the winning tickets was sold in the Kansas City area and the other was in Arizona. The winners have 180 days to claim their prize.

Like many forms of gambling, the lottery runs on selling the dream of instant riches, mainly to people who most likely will never have a chance to earn any amount close to a major jackpot.

That the odds of winning are almost one in 176 million rarely serves as a damper on the frenzy, designed to up the drama and the eventual net proceeds that go to the states who are sponsors. (About $1 of each $2 ticket goes to fund the prizes, with the rest going to the states -- minus the administrative costs to run the lottery.)

The record Powerball lottery was no different. At its peak, tickets were selling at a rate of about 130,000 a minute -- the equivalent of a small city picking numerical combinations (or more likely allowing a machine to randomly choose them). That surge is partly responsible for driving up the jackpot to astronomical heights.

It was also fueled by the lack of a winner in earlier rounds. Wednesday’s jackpot had been increased by 16 consecutive failures to pick a winner, rolling over the pot.

One reason for a delay in winners coming forward may be their need to figure out a financial strategy. Winners can be paid over time, for the full $587.5 million, or all at once, for a cash value of $384.7 million.

There are also tax and investment issues that can require some expertise. For example, with the federal government weighing increased taxation on the rich as one way to solve the issues connected to the so-called fiscal cliff, some people may want to pull the income into this year instead of next.

And of course, if the winning ticket was bought by a group such as an office pool, it may take some time to round up the winners and figure out the next step.

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A Step Toward a Universal Cancer Blood Test

By Jocelyn Kaiser, ScienceNOW

People usually find out that they have cancer after developing symptoms or through a screening test such as a mammogram—signs that may appear only after the cancer has grown or spread so much that it can’t be cured. But what if you could find out from a simple, highly accurate blood test that you had an incipient tumor? By sequencing the abnormal DNA that a tumor releases into a person’s bloodstream, researchers are now one step closer to a universal cancer test. Although the technique is now only sensitive enough to detect advanced cancers, that may be a matter of money: As sequencing costs decrease, the developers of the method say, the test could eventually pick up early tumors as well.

The new work is part of a wave of research on using either cells shed into the blood by tumors or free-floating tumor DNA in blood to track the growth and spread of tumors and tailor treatments. The free tumor DNA tests generally rely on looking for known alterations in cancer genes to distinguish cancerous DNA from normal DNA. Seeking a way to detect tumor DNA without knowing its genetic makeup beforehand, postdoctoral researcher Rebecca Leary and others in the labs of Victor Velculescu and Luis Diaz at the Johns Hopkins University School of Medicine in Baltimore, Maryland, and collaborators at other institutions took advantage of an observation they and others have made: No matter the type of cancer, tumor cells almost invariably have substantially altered chromosomes, such as swapped pieces and extra copies of certain genes. This suggests that a test that could detect any chromosomal abnormalities in a person’s blood could serve as a general test for cancer.

Now, the researchers have shown that their idea has promise. First, they isolated the free DNA in blood samples from 10 people with advanced colon or breast cancer. Then, using next-generation DNA sequencing methods, they read the entire genome of the DNA in the blood. (The approach was similar to a new test that can detect Down syndrome in a fetus from a pregnant woman’s blood sample by looking for just an extra copy of chromosome 21.) The cancer patients all had DNA with chromosomal alterations in their blood, whereas none of 10 healthy controls tested positive, according to the team’s report today in Science Translational Medicine.

“There are multiple uses of this approach,” Velculescu says. His group initially hopes to track whether a patient’s tumor is responding to treatment or regrows after surgery. The test could also be used to decide what drug a patient should get without biopsying her tumor—in some patients, the Hopkins team detected extra copies of two genes known to drive cancer, ERBB2 and CDK6, which can be targeted with existing drugs.

The test isn’t that cheap or quick at the moment: Each of the 10 patients’ tests in the study cost several thousand dollars just for sequencing and took a month, including the time for analysis. And early detection is still a ways off. The technique has to sift through large amounts of DNA from normal cells that is also floating in blood to find tumor-associated sequences; the portion of DNA in the cancer patients’ blood that came from tumors ranged from 47.9% to as low as 1.4%. The test might have to work on blood samples with less than 0.1% tumor DNA to detect small, curable tumors, the researchers suggest. But that is just a matter of doing more sequencing, Velculescu says. And as sequencing costs continue to drop, “in the very near future, this could end up being extremely cheap,” he adds.

“The approach has tremendous promise and, should the sequencing strategy become economical, it could have important applications in early cancer detection,” says Daniel Haber of Massachusetts General Hospital in Boston who works on using circulating tumor cells to detect and monitor cancer.

Carlos Caldas of the Cancer Research UK Cambridge Research Institute, who, like the Hopkins group, is working on sequencing free tumor DNA in blood, says the new study is the latest showing “that circulating tumor DNA is going to have a great future in all aspects of cancer management. … This is an exploding field.” He thinks such tests could reach the clinic within 5 to 10 years.

This story provided by ScienceNOW, the daily online news service of the journal Science.

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Russian court bans “extremist” Pussy Riot video

MOSCOW (Reuters) – A Russian court ruled on Thursday that video footage of the Pussy Riot punk group protesting against President Vladimir Putin in a church was “extremist” and should be removed from websites.

The demonstration last February offended many Russian Orthodox Christians. But Putin has been criticized by U.S. and European leaders over what they saw as disproportionate jail sentences imposed on three Pussy Riot members. Their trial was also seen by Putin’s critics as part of a clampdown on dissent.

The Moscow court said it had based its ruling on conclusions by a panel of experts who studied the video, showing band members in colorful mini-skirts and ski masks dancing in front of the altar of Moscow’s main Russian Orthodox cathedral.

Judge Marina Musimovich said the footage “has elements of extremism; in particular there are words and actions which humiliate various social groups based on their religion”. She said it also had calls for mutiny and “mass disorder”.

The verdict said that free distribution of the video could ignite racial and religious hatred.

The court’s ruling applies to other videos released by the band, including a performance in Moscow’s Red Square, where calls for mass disorder could be heard. Such calls were not made inside the church.

The websites are now likely to be included in a state register and could be blocked if the banned content is not removed.

The Russian communications regulator Roskomnadzor said that once the court decision takes effect it will monitor how it is implemented.

Three members of Pussy Riot convicted in August of hooliganism motivated by religious hatred for their “punk prayer”, which the Russian Orthodox Church has cast as part of a concerted attack on the church and the faithful.

The women said the protest, in which they burst into Christ the Saviour Cathedral and called on the Virgin Mary to rid Russia of Putin, was not motivated by hatred and was meant to mock the church leadership’s support for the longtime leader.

Band members Nadezhda Tolokonnikova and Maria Alyokhina are serving two-year jail sentences over the protest last February. A third member, Yekaterina Samutsevich, walked free last month when her sentence was suspended on appeal.

“To me this is a clear attribute of censorship – censorship of art and censorship of culture, of the protest culture which is very important for any country, let alone for Russia,” Samutsevich told reporters outside court.

“Now of course the fact that they will be blocking all Pussy Riot videos as I understand, all photos – this is horrible. Naturally, I will lodge an appeal and I will try to do it today,” she added.

Putin, a former KGB officer who has cultivated close ties with the Orthodox church over 13 years in power, has rebuffed Western criticism about the prison terms meted out.

(Additional reporting Valery Stepchenkov; Editing by Mark Heinrich)

Music News Headlines – Yahoo! News

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Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

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Medicare Is Faulted in Electronic Medical Records Conversion

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

Mike Spencer/Wilmington Star-News, via Associated Press

Celeste Stephens, a nurse, leads a session on electronic records at New Hanover Regional Medical Center in Wilmington, N.C.

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

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Norquist: GOP concern over tax pledge just 'impure thoughts'

Grover Norquist on Wednesday rebuffed claims that his anti-tax crusade is losing steam, calling statements from prominent Republicans hinting at their departure from his anti-tax pledge "impure thoughts."

Norquist, president of Americans for Tax Reform, met with Politico’s Mike Allen to offer his thoughts on the looming “fiscal cliff,” and the growing narrative that Republicans, after years of tying themselves to ATR’s pledge not to raise taxes, may be ready to jump ship.

Most recently, Rep. Tom Cole (R-Okla.) said in a private meeting with the House Republican whip team Tuesday morning that Republicans should take the opportunity to extend President George W. Bush’s tax cuts for 98% of Americans, calling it an “early Christmas present” for taxpayers.

And on Sunday, Sen. Lindsay Graham (R-S.C.) and Rep. Peter King (R-N.Y.) joined Sen. Saxby Chambliss (R-Ga.) in voicing concern over continued adherence to Norquist’s pledge.

House Speaker John A. Boehner (R-Ohio) responded to Cole on Wednesday, saying that though Cole is a friend and supporter, he disagrees entirely with his stance. “The goal here is to grow the economy and control spending. You’re not going to grow the economy if you raise tax rates on the top two rates,” Boehner said.

Though Norquist commented that Cole’s recommendation was “an interesting tactic,” he remained firm that his pledge remains viable, saying that anyone suggesting that opposing tax increases is no longer in vogue is “an idiot.”

The pledge, Norquist claimed, “takes weasel words out” of campaign promises to cut taxes, and provides voters a clear picture of a candidate's stance, a stance he said the Republican Party has built its brand upon.

Norquist said that signing the pledge is about informing voters and entrenching a preexisting policy stance, instead of an oath of fealty to ATR and its champion cause.

“They don’t need my permission to raise taxes,” he said, adding that such power lies in the hands of voters.

And he dismissed claims that the pledge’s powers extend beyond the promises tied to its concise wording.

“It doesn’t solve all of the world’s problems; it doesn’t design tax reform,” Norquist said.

But Norquist did design a general road map for Republicans to use in fiscal cliff negotiations.

“You need to have this conversation in public, you need to be online so you can have the moral higher ground,” he said, recommending that the GOP aim for a temporary extension of Bush’s tax cuts, with comprehensive tax reform to follow soon after.

“If the Republicans lose in such a way that they have their fingerprints on the murder weapon, then you have a problem,” he said, adding that public debate over the fiscal cliff would allow Republicans a chance to turn the tide against President Obama and the Democrats, so long as they maintain “credible clarity” in espousing their low-tax vision.

Norquist said he worries about conceding any ground to Democrats on tax increases.

“What the Democrats do is trickle-down taxation,” he said. “They tax the rich and then they screw everybody.”

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Beyond Iron Dome: Israel Preps New Anti-Missiles, Eyes Lasers

Israel just proved that its new Iron Dome system can repel Hamas’ short-range rockets and missiles. The bad news: Those weapons are nothing compared to the more advanced missiles that Hezbollah and Iran can throw at Israel, which would surely overwhelm Iron Dome. That’s why Israel, and America, are already looking into the missile defense systems that come after Iron Dome — including ones that rely on lasers.

The Israelis can justly say their system worked better than American and Israeli skeptics (and Hamas) anticipated. Five Iron Dome batteries destroyed some 421 Qassam rockets and Iranian-made Fajr-5 missiles launched from Gaza, for an interception rate of between 80 and 90 percent. (Hamas fired over 1,500 projectiles, but Iron Dome ignores those that don’t impact populated areas.) It kept Israeli casualties far below Palestinian ones and might have convinced Prime Minister Benjamin Netanyahu he didn’t need to re-invade Gaza. All this for a cost of under $30 million per interception.

All this has Israel pumping its fist. Uzi Rubin, a former Israeli missile defense official, boasted that Iron Dome outperformed the U.S.’ Patriot missile and showcased “Jewish genius with blue and white [i.e., Israeli] technology.” (Iron Dome was jointly developed with the U.S., but whatever.) And already Rafael, the company behind Iron Dome, is pledging to up its success rate to 95 percent in the next several months as it and the Israel Defense Forces sift through the launch data.

The thing is, Hamas is peanuts. Its Qassams and Fajr-5s are unguided systems, unsophisticated compared to the missile arsenals of Hezbollah and Iran, which include ballistic missiles. Even a souped-up Iron Dome would probably be overwhelmed by those. So as encouraged as Israel is by Iron Dome’s success, it’s already scaling upward, to more powerful interceptor-based missile defenses intended to blunt a layered assault from Hamas to Hezbollah to Iran. Some, however, doubt that a bullet is the right instrument for stopping another bullet, and would prefer to use the laser weapons the U.S. is developing.

Just days after Wednesday’s ceasefire with Hamas, it prominently tested Iron Dome’s big brother, called David’s Sling (and sometimes “Magic Wand”). Whereas Iron Dome’s stated maximum range is 45 miles (and is probably shorter in reality), David’s Sling’s interceptors are designed to hit incoming missiles from up to 200 miles away. If it works as intended, David’s Sling should protect Israel against the longer-range missiles that Hezbollah possesses M600, Zelzal, other Fajr models; and perhaps even the Scud ballistic missiles Israel contends Hezbollah got from Iran or Syria.

David’s Sling and Iron Dome have another brother, the Arrow. The Arrow has been in development for years and was originally conceived of as a Scud-stopper. Like some American anti-ballistic missile systems, the Arrow family of defenses is designed to stop a ballistic missile upon re-entry into the Earth’s atmosphere — principally, Iran’s Shehab-3. Over the summer, Israel upgraded the hardware, software, sensor array, interceptors and “Green Pine” radar on the Arrow-2; and an Arrow-3 is on the horizon that can reach twice its predecessor’s altitude. That’s likely intended to blunt the impact of Iran’s forthcoming the Iranian Sejjil-2 medium-range ballistic missile.

You can think of Iron Dome as the bantamweight, David’s Sling/Magic Wand as the middleweight and the Arrow as the heavyweight. And viewed together, you can see what Israel fears: a concerted barrage from Iran and its proxies that comprises everything from unguided Qassam rockets to Sejjil-3 ballistic missiles. That scenario brought U.S. Patriot missile batteries, Aegis ships and some 3,500 troops to Israel last month for the largest joint missile-defense exercises ever between the two allies, and you might hear more on the subject on Thursday, when outgoing Defense Minister Ehud Barak visits the Pentagon.

But some think hitting a bullet with another bullet is the wrong paradigm for missile defense. One Ha’aretz writer, Reuben Pedatzur, pines for Northrop Grumman’s Skyguard chemical laser, which would burn through projectiles after picking them up on radar. In the pre-Iron Dome days, residents of southern Israel once sued the Israeli government to bring Skyguard to their communities. And it’s worth noting that on Tuesday, rival Lockheed Martin claimed its own developmental laser system, the Area Defense Anti-Munitions, shot down four “small caliber” rockets from about a mile away in recent testing.

Except that laser-based missile defenses have been promised for decades and are never quite there yet. Rubin, the former Israeli missile defense official, blasted Skyguard in Ha’aretz on Tuesday as “simply unrealistic,” noting that the U.S. doesn’t even use it in Afghanistan, where its bases are frequently rocketed. And the U.S. Navy, which has sunk a lot of money into developing laser defenses for ships, still doesn’t consider its most mature solid-state lasers ready to burn through missiles this decade.

Still, David’s Sling and the upgraded Arrow have years to go before they’re ready, and their own trials by fire might not go as well as Iron Dome’s. Meanwhile, Hezbollah is pledging to launch “thousands of rockets” if Israel attacks, and the threat of a war with Iran hasn’t abated. If Hezbollah, or Iran, follow through on that threat, Iron Dome’s limits might become as visible as its successes just were.

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