Predicting who's at risk for violence isn't easy

CHICAGO (AP) — It happened after Columbine, Virginia Tech, Aurora, Colo., and now Sandy Hook: People figure there surely were signs of impending violence. But experts say predicting who will be the next mass shooter is virtually impossible — partly because as commonplace as these calamities seem, they are relatively rare crimes.

Still, a combination of risk factors in troubled kids or adults including drug use and easy access to guns can increase the likelihood of violence, experts say.

But warning signs "only become crystal clear in the aftermath, said James Alan Fox, a Northeastern University criminology professor who has studied and written about mass killings.

"They're yellow flags. They only become red flags once the blood is spilled," he said.

Whether 20-year-old Adam Lanza, who used his mother's guns to kill her and then 20 children and six adults at their Connecticut school, made any hints about his plans isn't publicly known.

Fox said that sometimes, in the days, weeks or months preceding their crimes, mass murderers voice threats, or hints, either verbally or in writing, things like "'don't come to school tomorrow,'" or "'they're going to be sorry for mistreating me.'" Some prepare by target practicing, and plan their clothing "as well as their arsenal." (Police said Lanza went to shooting ranges with his mother in the past but not in the last six months.)

Although words might indicate a grudge, they don't necessarily mean violence will follow. And, of course, most who threaten never act, Fox said.

Even so, experts say threats of violence from troubled teens and young adults should be taken seriously and parents should attempt to get them a mental health evaluation and treatment if needed.

"In general, the police are unlikely to be able to do anything unless and until a crime has been committed," said Dr. Paul Appelbaum, a Columbia University professor of psychiatry, medicine and law. "Calling the police to confront a troubled teen has often led to tragedy."

The American Academy of Child & Adolescent Psychiatry says violent behavior should not be dismissed as "just a phase they're going through."

In a guidelines for families, the academy lists several risk factors for violence, including:

—Previous violent or aggressive behavior

—Being a victim of physical or sexual abuse

—Guns in the home

—Use of drugs or alcohol

—Brain damage from a head injury

Those with several of these risk factors should be evaluated by a mental health expert if they also show certain behaviors, including intense anger, frequent temper outbursts, extreme irritability or impulsiveness, the academy says. They may be more likely than others to become violent, although that doesn't mean they're at risk for the kind of violence that happened in Newtown, Conn.

Lanza, the Connecticut shooter, was socially withdrawn and awkward, and has been said to have had Asperger's disorder, a mild form of autism that has no clear connection with violence.

Autism experts and advocacy groups have complained that Asperger's is being unfairly blamed for the shootings, and say people with the disorder are much more likely to be victims of bullying and violence by others.

According to a research review published this year in Annals of General Psychiatry, most people with Asperger's who commit violent crimes have serious, often undiagnosed mental problems. That includes bipolar disorder, depression and personality disorders. It's not publicly known if Lanza had any of these, which in severe cases can include delusions and other psychotic symptoms.

Young adulthood is when psychotic illnesses typically emerge, and Appelbaum said there are several signs that a troubled teen or young adult might be heading in that direction: isolating themselves from friends and peers, spending long periods alone in their rooms, plummeting grades if they're still in school and expressing disturbing thoughts or fears that others are trying to hurt them.

Appelbaum said the most agonizing calls he gets are from parents whose children are descending into severe mental illness but who deny they are sick and refuse to go for treatment.

And in the case of adults, forcing them into treatment is difficult and dependent on laws that vary by state.

All states have laws that allow some form of court-ordered treatment, typically in a hospital for people considered a danger to themselves or others. Connecticut is among a handful with no option for court-ordered treatment in a less restrictive community setting, said Kristina Ragosta, an attorney with the Treatment Advocacy Center, a national group that advocates better access to mental health treatment.

Lanza's medical records haven't been publicly disclosed and authorities haven't said if it is known what type of treatment his family may have sought for him. Lanza killed himself at the school.

Jennifer Hoff of Mission Viejo, Calif. has a 19-year-old bipolar son who has had hallucinations, delusions and violent behavior for years. When he was younger and threatened to harm himself, she'd call 911 and leave the door unlocked for paramedics, who'd take him to a hospital for inpatient mental care.

Now that he's an adult, she said he has refused medication, left home, and authorities have indicated he can't be forced into treatment unless he harms himself — or commits a violent crime and is imprisoned. Hoff thinks prison is where he's headed — he's in jail, charged in an unarmed bank robbery.

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Online:

American Academy of Child & Adolescent Psychiatry: http://www.aacap.org

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AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

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Final day of funerals for Newtown shooting victims

The final three victims of the massacre at Sandy Hook Elementary School will be laid to rest today, ending a somber week of funerals.

A mass will take place today at St. Rose of Lima Catholic Church for Josephine Gay, who had celebrated her 7th birthday on Dec. 11.

Friends and family have been asked to wear Josephine's favorite color, purple, in her honor.

PHOTOS: Victims of Sandy Hook Massacre

A homegoing celebration will take place at The First Cathedral in Bloomfield, Conn., for Ana Marquez-Greene. The 6-year-old with a beaming voice sang in a home video with her brother, who was also at Sandy Hook Elementary School during the massacre, and seemed destined to take after her father, a jazz musician.

Emilie Parker, the budding artist who carried her markers and pencils everywhere, will be laid to rest in Ogden, Utah today.

The 6-year-old would have been would one of the first to comfort her classmates at Sandy Hook Elementary School, had a gunman's bullets not claimed her life, her father said.

"My daughter Emilie would be one of the first ones to be standing and giving support to all the victims because that's the kind of kid she is," her father, Robbie Parker, said last Saturday.

"She always had something kind to say about anybody," Parker said. "We find comfort reflecting on the incredible person Emilie was and how many lives she was able to touch."

WATCH: Emilie's father speaks about his daughter

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NKorea says it has detained a US citizen

PYONGYANG, North Korea (AP) — North Korea said Friday that an American citizen has been detained after confessing to unspecified crimes, confirming news reports about his arrest at a time when Pyongyang is facing criticism from Washington for launching a long-range rocket last week.

The American was identified as Pae Jun Ho in a brief dispatch issued by the state-run Korean Central News Agency in Pyongyang. News reports in the U.S. and South Korea said Pae is known in his home state of Washington as Kenneth Bae, a 44-year-old tour operator of Korean descent.

An expert said he is likely to become a bargaining chip for the North, an attempt to draw the U.S. into talks. Five other Americans known to have been detained in North Korea since 2009 were all eventually released.

North Korean state media said Pae arrived in the far northeastern city of Rajin on Nov. 3 as part of a tour.

Rajin is part of a special economic zone not far from Yanji, China, that has sought to draw foreign investors and tourists over the past year. Yanji, home to many ethnic Korean Chinese, also serves as a base for Christian groups that shelter North Korean defectors.

"In the process of investigation, evidence proving that he committed a crime against (North Korea) was revealed. He admitted his crime," the KCNA dispatch said.

The North said the crimes were "proven through evidence" but did not elaborate.

KCNA said consular officials from the Swedish Embassy in Pyongyang visited Pae on Friday. Sweden represents the United States in diplomatic affairs in North Korea since Washington and Pyongyang do not have diplomatic relations.

Karl-Olof Andersson, Sweden's ambassador to North Korea, told The Associated Press he could not comment on the case and referred the matter to the U.S. State Department.

The State Department was not immediately able to provide any additional information about the report.

The operator of a Korean language website for the Korean community in the Northwest, Chong Tae Kim of JoySeattle.com, said the detainee's father lives in Korea and his mother lives in Lynnwood, Washington.

"She hopes the State Department and Swedish Embassy help with his release," he said Friday. "She's trying not to speak to reporters, fearing that could affect her son's release."

The office of U.S. Rep. Suzan DelBene says it has reached out to the mother and is pressing the State Department for information.

"We are very concerned about it and seeing what can be done on our end to help with this," said spokesman Viet Shelton.

State Department spokesman Patrick Ventrell on Friday would only say that they were aware of the detention and that Swedish Embassy in Pyongyang is providing consular services.

"We can, indeed, confirm that a U.S. citizen has been detained in North Korea," Ventrell said, adding that he could not say more because of privacy restrictions.

In Seoul, the Segye Ilbo newspaper reported last week that Bae had been taking tourists on a five-day trip to the North when he was arrested. The newspaper cited unidentified sources.

News of the arrest comes as North Korea is celebrating the launch of a satellite into space on Dec. 12, in defiance of calls by the U.S. and others to cancel a liftoff widely seen as an illicit test of ballistic missile technology.

The announcement of the American's detainment could be a signal from the North that it wants dialogue with the United States, said Cheong Seong-chang, an analyst at the private Sejong Institute in South Korea. He said trips by former U.S. Presidents Bill Clinton and Jimmy Carter to North Korea to secure the release of other detained Americans created a mood for U.S.-North Korea talks.

"North Korea knows sanctions will follow its rocket launch. But in the long run, it needs an excuse to reopen talks after the political atmosphere moves past sanctions," Cheong said.

Cheong said he expects that the American will be tried and convicted in coming months. North Korean leader Kim Jong Un has the power to grant amnesty and will exercise it as a bargaining chip, Cheong said.

Nuland said earlier this week that Washington had been trying to reach out to Kim.

"Instead, that was met not only with an abrogation of agreements that had been made by the previous North Korean regime, but by missile activity both in April and in December," she told reporters.

She said Washington had no choice but to put pressure on Pyongyang, and was discussing with its allies how to "further isolate" the regime.

In April 2009, a North Korean rocket launch took place while two American journalists, Laura Ling and Euna Lee, were in North Korean custody after allegedly trying to sneak into the country across the Tumen River dividing the North from China.

They were sentenced to 12 years of hard labor before being released on humanitarian grounds after Clinton flew to Pyongyang to negotiate their release.

Subsequently, three other Americans were arrested and eventually released by North Korea. All three are believed to have been accused of illegally spreading Christianity.

North Korea has several sanctioned churches in Pyongyang but frowns on the distribution of Bibles and other religious materials by foreigners. Interaction between North Koreans and foreigners is strictly regulated.

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AP writers Foster Klug and Sam Kim in Seoul, South Korea, and Doug Esser in Seattle contributed to this report.

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PSY's 'Gangnam Style' reaches 1B views on YouTube

NEW YORK (AP) — Viral star PSY has reached a new milestone on YouTube.

The South Korean rapper's video for "Gangnam Style" has reached 1 billion views, according to YouTube's own counter. It's the first time any clip has surpassed that mark on the streaming service owned by Google Inc.

It shows the enduring popularity of the self-deprecating video that features Park Jae-sang's giddy up-style dance moves. The video has been available on YouTube since July 15, averaging more than 200 million views per month.

Justin Bieber's video for "Baby" held the previous YouTube record at more than 800 million views.

PSY wasn't just popular on YouTube, either. Earlier this month Google announced "Gangnam Style" was the second highest trending search of 2012 behind Whitney Houston, who passed away in February.

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AP IMPACT: Big Pharma cashes in on HGH abuse

A federal crackdown on illicit foreign supplies of human growth hormone has failed to stop rampant misuse, and instead has driven record sales of the drug by some of the world's biggest pharmaceutical companies, an Associated Press investigation shows.

The crackdown, which began in 2006, reduced the illegal flow of unregulated supplies from China, India and Mexico.

But since then, Big Pharma has been satisfying the steady desires of U.S. users and abusers, including many who take the drug in the false hope of delaying the effects of aging.

From 2005 to 2011, inflation-adjusted sales of HGH were up 69 percent, according to an AP analysis of pharmaceutical company data collected by the research firm IMS Health. Sales of the average prescription drug rose just 12 percent in that same period.

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EDITOR'S NOTE — Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.

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Unlike other prescription drugs, HGH may be prescribed only for specific uses. U.S. sales are limited by law to treat a rare growth defect in children and a handful of uncommon conditions like short bowel syndrome or Prader-Willi syndrome, a congenital disease that causes reduced muscle tone and a lack of hormones in sex glands.

The AP analysis, supplemented by interviews with experts, shows too many sales and too many prescriptions for the number of people known to be suffering from those ailments. At least half of last year's sales likely went to patients not legally allowed to get the drug. And U.S. pharmacies processed nearly double the expected number of prescriptions.

Peddled as an elixir of life capable of turning middle-aged bodies into lean machines, HGH — a synthesized form of the growth hormone made naturally by the human pituitary gland — winds up in the eager hands of affluent, aging users who hope to slow or even reverse the aging process.

Experts say these folks don't need the drug, and may be harmed by it. The supposed fountain-of-youth medicine can cause enlargement of breast tissue, carpal tunnel syndrome and swelling of hands and feet. Ironically, it also can contribute to aging ailments like heart disease and Type 2 diabetes.

Others in the medical establishment also are taking a fat piece of the profits — doctors who fudge prescriptions, as well as pharmacists and distributors who are content to look the other way. HGH also is sold directly without prescriptions, as new-age snake oil, to patients at anti-aging clinics that operate more like automated drug mills.

Years of raids, sports scandals and media attention haven't stopped major drugmakers from selling a whopping $1.4 billion worth of HGH in the U.S. last year. That's more than industry-wide annual gross sales for penicillin or prescription allergy medicine. Anti-aging HGH regimens vary greatly, with a yearly cost typically ranging from $6,000 to $12,000 for three to six self-injections per week.

Across the U.S., the medication is often dispensed through prescriptions based on improper diagnoses, carefully crafted to exploit wiggle room in the law restricting use of HGH, the AP found.

HGH is often promoted on the Internet with the same kind of before-and-after photos found in miracle diet ads, along with wildly hyped claims of rapid muscle growth, loss of fat, greater vigor, and other exaggerated benefits to adults far beyond their physical prime. Sales also are driven by the personal endorsement of celebrities such as actress Suzanne Somers.

Pharmacies that once risked prosecution for using unauthorized, foreign HGH — improperly labeled as raw pharmaceutical ingredients and smuggled across the border — now simply dispense name brands, often for the same banned uses. And usually with impunity.

Eight companies have been granted permission to market HGH by the U.S. Food and Drug Administration, which reviews the benefits and risks of new drug products. By contrast, three companies are approved for the diabetes drug insulin.

The No. 1 maker, Roche subsidiary Genentech, had nearly $400 million in HGH sales in the U.S. last year, up an inflation-adjusted two-thirds from 2005. Pfizer and Eli Lilly were second and third with $300 million and $220 million in sales, respectively, according to IMS Health. Pfizer now gets more revenue from its HGH brand, Genotropin, than from Zoloft, its well-known depression medicine that lost patent protection.

On their face, the numbers make no sense to the recognized hormone doctors known as endocrinologists who provide legitimate HGH treatment to a small number of patients.

Endocrinologists estimate there are fewer than 45,000 U.S. patients who might legitimately take HGH. They would be expected to use roughly 180,000 prescriptions or refills each year, given that typical patients get three months' worth of HGH at a time, according to doctors and distributors.

Yet U.S. pharmacies last year supplied almost twice that much HGH — 340,000 orders — according to AP's analysis of IMS Health data.

While doctors say more than 90 percent of legitimate patients are children with stunted growth, 40 percent of 442 U.S. side-effect cases tied to HGH over the last year involved people age 18 or older, according to an AP analysis of FDA data. The average adult's age in those cases was 53, far beyond the prime age for sports. The oldest patients were in their 80s.

Some of these medical records even give explicit hints of use to combat aging, justifying treatment with reasons like fatigue, bone thinning and "off-label," which means treatment of an unapproved condition

Even Medicare, the government health program for older Americans, allowed 22,169 HGH prescriptions in 2010, a five-year increase of 78 percent, according to data released by the Centers for Medicare and Medicaid Services in response to an AP public records request.

"There's no question: a lot gets out," said hormone specialist Dr. Mark Molitch of Northwestern University, who helped write medical standards meant to limit HGH treatment to legitimate patients.

And those figures don't include HGH sold directly by doctors without prescriptions at scores of anti-aging medical practices and clinics around the country. Those numbers could only be tallied by drug makers, who have declined to say how many patients they supply and for what conditions.

First marketed in 1985 for children with stunted growth, HGH was soon misappropriated by adults intent on exploiting its modest muscle- and bone-building qualities. Congress limited HGH distribution to the handful of rare conditions in an extraordinary 1990 law, overriding the generally unrestricted right of doctors to prescribe medicines as they see fit.

Despite the law, illicit HGH spread around the sports world in the 1990s, making deep inroads into bodybuilding, college athletics, and professional leagues from baseball to cycling. The even larger banned market among older adults has flourished more recently.

FDA regulations ban the sale of HGH as an anti-aging drug. In fact, since 1990, prescribing it for things like weight loss and strength conditioning has been punishable by 5 to 10 years in prison.

Steve Kleppe, of Scottsdale, Ariz., a restaurant entrepreneur who has taken HGH for almost 15 years to keep feeling young, said he noticed a price jump of about 25 percent after the block on imports. He now buys HGH directly from a doctor at an annual cost of about $8,000 for himself and the same amount for his wife.

Many older patients go for HGH treatment to scores of anti-aging practices and clinics heavily concentrated in retirement states like Florida, Nevada, Arizona and California.

These sites are affiliated with hundreds of doctors who are rarely endocrinologists. Instead, many tout certification by the American Board of Anti-Aging and Regenerative Medicine, though the medical establishment does not recognize the group's bona fides.

The clinics offer personalized programs of "age management" to business executives, affluent retirees, and other patients of means, sometimes coupled with the amenities of a vacation resort. The operations insist there are few, if any, side effects from HGH. Mainstream medical authorities say otherwise.

A 2007 review of 31 medical studies showed swelling in half of HGH patients, with joint pain or diabetes in more than a fifth. A French study of about 7,000 people who took HGH as children found a 30 percent higher risk of death from causes like bone tumors and stroke, stirring a health advisory from U.S. authorities.

For proof that the drug works, marketers turn to images like the memorable one of pot-bellied septuagenarian Dr. Jeffry Life, supposedly transformed into a ripped hulk of himself by his own program available at the upscale Las Vegas-based Cenegenics Elite Health. (He declined to be interviewed.)

These promoters of HGH say there is a connection between the drop-off in growth hormone levels through adulthood and the physical decline that begins in late middle age. Replace the hormone, they say, and the aging process slows.

"It's an easy ruse. People equate hormones with youth," said Dr. Tom Perls, a leading industry critic who does aging research at Boston University. "It's a marketing dream come true."

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Associated Press Writer David B. Caruso reported from New York and AP National Writer Jeff Donn reported from Plymouth, Mass. AP Writer Troy Thibodeaux provided data analysis assistance from New Orleans.

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AP's interactive on the HGH investigation: http://hosted.ap.org/interactives/2012/hgh

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The AP National Investigative Team can be reached at investigate(at)ap.org

EDITOR'S NOTE _ Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the second of a two-part series.

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NRA: 'Good guy with a gun' could have saved lives at Sandy Hook

The NRA's Wayne LaPierre speaks at Friday's press conference (Chip Somodevilla/Getty Images)

The National Rifle Association on Friday, a full week after the shooting at Sandy Hook Elementary School, gave its first response to the massacre that killed 20 schoolchildren in Newtown, Conn. Wayne LaPierre, the NRA's executive vice president, argued at a press conference in Washington, D.C., that gun control legislation would not prevent similar shootings and offered the organization's own proposal: a nationwide program that would place armed security in every school desiring protection.

"I call on Congress today to appropriate whatever is necessary to put armed police officers in every single school in this nation," LaPierre said. The proposed program, called the National School Shield, would help train and install security at schools nationwide under the leadership of former Arkansas Republican Rep. Asa Hutchinson.

"Innocent lives might have been spared," LaPierre said, if armed security was present at Sandy Hook. "The only thing that stops a bad guy with a gun is a good guy with a gun."

LaPierre, Hutchinson and David Keene, president of the NRA, all declined to take questions from the press and said NRA press officers won't be responding to the media until Monday.

LaPierre in part blamed mass shootings on "vicious, violent video games" such as "Bulletstorm," "Grand Theft Auto," Mortal Kombat" and  "Splatterhouse." He also reached back in time to place blame on movies like "American Psycho" and "Natural Born Killers" for portraying "life as a joke and murder as a way of life."

He added, "In a race to the bottom, media conglomerates compete with one another to shock, violate and offend every standard of civilized society by bringing an ever-more-toxic mix of reckless behavior and criminal cruelty into our homes—every minute of every day of every month of every year.”

He also criticized the media for vilifying guns and gun owners, and for publicizing inaccuracies about guns.

"Why is the idea of a gun good when it’s used to protect the president of our country or our police, but bad when it’s used to protect children in our schools?" he asked.

"It’s our duty to protect them," LaPierre said of the nation's schoolchildren. "It’s our right to protect them."

Part of the problem in protecting schools, he also said, is the designation of gun-free school zones. The zones "tell every insane killer in America that schools are the safest place to inflict maximum mayhem with minimum risk," he said.

Gun control advocates immediately decried the NRA's views as extreme and dangerous.

"Their press conference was a shameful evasion of the crisis facing our country," New York City Mayor Michael Bloomberg, an independent, said in a statement. "Instead of offering solutions to a problem they have helped create, they offered a paranoid, dystopian vision of a more dangerous and violent America where everyone is armed and no place is safe."

Bloomberg said NRA members support background checks for gun ownership because of gun violence. "As a country, we must rise above special interest politics," he added.

On Capitol Hill, Democratic Sen. Richard Blumenthal of Connecticut, who conceded that armed security could be "helpful in some instances, noted in a statement that "the NRA’s statement is sadly and shamefully inadequate—calling for more guns and rejecting real action against gun violence. At a defining, historic moment demanding courageous leadership, the NRA has declined to step forward as a credible and constructive partner."

The press conference, despite the tight security at the Willard InterContinental Hotel where it was held, was interrupted twice by gun control protesters later identified as members of anti-war group Code Pink. A man rose from the press area in front of LaPierre during his speech and held up a pink cloth displaying the words "NRA Killing Our Kids." Later, a woman identified as Code Pink founder Medea Benjamin, unfurled a sign reading "NRA blood on your hands,” and shouted, "Reckless behavior coming from the NRA" and other comments as she was dragged out of the room.

A large security staff dressed in suits and wearing earpieces lined the perimeter of the makeshift stage as well as the room. Security staffers moved to sit directly in front and behind of LaPierre following the Code Pink protests as other security members stepped forward into the seating area.

Prior to the conference, gun control protesters as well as PETA protesters and others lined the street in front of the hotel entrance waving signs and shouting.

Pressure on lawmakers from gun-control advocates has increased in the wake of the shooting. President Barack Obama on Friday released a web video in response to an outpouring of White House petitions calling on the president to respond to gun violence.

“We hear you," Obama said in the video. "I will do everything in my power as president to advance these efforts, because if there’s even one thing we can do as a country to protect our children, we have a responsibility to try. But as I said earlier this week, I can’t do it alone. I need your help.”

Obama tasked Vice President Joe Biden to review potential gun legislation and other measures on which to act next session. Biden spoke Thursday to law enforcement leaders about banning assault weapons, though no further details were released on the private discussion.

California Sen. Dianne Feinstein has pledged to introduce a new federal assault weapons ban in January and has received support from several gun-rights advocates and from the White House.

Olivier Knox contributed to this report.

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Pakistani polio workers get police protection

LAHORE, Pakistan (AP) — Under police guard, thousands of health workers pressed on with a polio immunization program Thursday after nine were killed elsewhere in Pakistan by suspected militants who oppose the vaccination campaign.

Immunizations were halted in some parts of Pakistan and the U.N. suspended its field participation everywhere until better security was arranged for its workers. The violence risks reversing recent progress fighting polio in Pakistan, one of three countries in the world where the disease is endemic.

The Taliban have denied responsibility for the shootings. Militants have accused health workers of acting as spies for the U.S., alleging the vaccine is intended to make Muslim children sterile.

Taliban commanders in Pakistan's troubled northwest tribal region also said earlier this year that vaccinations can't go forward until the U.S. stops drone strikes in the country.

Insurgent opposition to the campaign grew last year after it was revealed that a Pakistani doctor ran a fake vaccination program to help the CIA track down and kill al-Qaida founder Osama bin Laden, who was hiding in the town of Abbottabad in the country's northwest.

There were a few attacks on polio workers in July, but the current level of violence is unprecedented. A polio worker died Thursday after being shot in the head in the northwestern city of Peshawar a day earlier, said health official Janbaz Afridi.

His death raised to nine the number of Pakistanis working on the campaign who have been killed this week. Six of the workers gunned down were women, three of whom were teenagers. Two other workers were critically wounded. All the attacks occurred in northwest Khyber Pakhtunkhwa province and the southern city of Karachi.

Despite the threat, local officials in the eastern city of Lahore continued the vaccination drive Thursday under police escort, said one of the top government officials in the city, Noorul Amin Mengal. About 6,000 Pakistani health workers were escorted by 3,000 police as they fanned out across the city, he said.

"It would have been an easy thing for us to do to stop the campaign," he said. "That would have been devastating."

Saddaf Malik, one of the polio workers in Lahore, said the killings sent a shudder of fear through him and his colleagues.

"We will carry on with our job with determination, but we want the government to adopt measures to ensure the security of polio vaccinators," he said.

This week's killings occurred as the government and the U.N. began a vaccination drive Monday targeting high-risk areas in the country's four provinces and the semiautonomous tribal region, part of an effort to immunize 34 million children under age 5. The campaign was scheduled to end Wednesday in most parts of the country, except for Lahore, where it ran a day longer.

Government officials ended the drive early in parts of Khyber Pakhtunkhwa and in Sindh province, where Karachi is the capital, said Elias Durry, the U.N. World Health Organization's senior coordinator for polio in Pakistan. The campaign ran its full course in the provinces of Baluchistan and Punjab, where Lahore is the capital, as well as in the tribal region, he said.

The government has approximately 250,000 people working on the campaign, said Durry. Most of them have other jobs, such as teaching or working as government clerks, and sign on to the vaccination drive to earn a little more money, about $2.50 per day, officials said.

The WHO and UNICEF have about 2,000 people between them who provide technical assistance to the polio teams across the country and educate locals about the program, said Durry and Michael Coleman, a UNICEF spokesman in Pakistan. The U.N. staff were pulled out of the field and asked to work from home Wednesday.

Workers were only able to immunize about 9 million children this week out of a target of 18.3 million because of the violence, said Durry.

Polio usually infects children living in unsanitary conditions, attacks the nerves and can kill or paralyze. Pakistan, Afghanistan and Nigeria remain the last battlegrounds for the fight against the disease.

There is no history of attacks on polio workers in Afghanistan, even though the country also faces a domestic Taliban insurgency. Muslim leaders in Nigeria have spoken out against polio vaccination in the country in the past, also claiming it makes children sterile. Many now support the campaign, but some Nigerians remain suspicious.

Prevention efforts have managed to reduce the number of cases in Pakistan to 56 this year, compared with 190 in 2011, a drop of about 70 percent. Most of the news cases in Pakistan are in the northwest, where the presence of militants makes it difficult to reach children. Clerics and tribal elders have been recruited to support polio vaccinations to try to open up areas previously inaccessible to health workers.

Israrullah Khan, a villager who attended the funeral of the polio worker who died Thursday, said most of the clerics and Islamic political parties in Khyber Pakhtunkhwa were in favor of the campaign.

"We don't understand why these attacks have suddenly started," Khan said. "It's very sad because they were trying to save our children's future for very low wages."

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Associated Press writers Jamal Khan in Peshawar, Pakistan, Zaheer Babar in Lahore, Pakistan, Adil Jawad in Karachi, Pakistan, and Munir Ahmed in Islamabad contributed to this report.

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New Miss Universe says win shows confidence is all

LAS VEGAS (AP) — The 20-year-old Rhode Islander who brought the Miss Universe crown back to the U.S. for the first time in 15 years is hoping that her quick rise through the beauty pageant ranks and onstage stumble will show women that anything is possible.

Self-described "cellist-nerd" Olivia Culpo is assuming her new role as Miss Universe 2012 following her victory over 88 beauty queens from around the world Wednesday night at the Planet Hollywood casino on the Las Vegas Strip.

She tells The Associated Press that her yearlong transformation from Boston University sophomore to pageant winner proves that women can accomplish anything to which they set their minds.

She says she is glad she tripped slightly during the evening gown competition because it proves that confidence and poise matter more than perfect performance.

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AP IMPACT: Steroids loom in major-college football

WASHINGTON (AP) — With steroids easy to buy, testing weak and punishments inconsistent, college football players are packing on significant weight — 30 pounds or more in a single year, sometimes — without drawing much attention from their schools or the NCAA in a sport that earns tens of billions of dollars for teams.

Rules vary so widely that, on any given game day, a team with a strict no-steroid policy can face a team whose players have repeatedly tested positive.

An investigation by The Associated Press — based on interviews with players, testers, dealers and experts and an analysis of weight records for more than 61,000 players — revealed that while those running the multibillion-dollar sport say they believe the problem is under control, that control is hardly evident.

The sport's near-zero rate of positive steroids tests isn't an accurate gauge among college athletes. Random tests provide weak deterrence and, by design, fail to catch every player using steroids. Colleges also are reluctant to spend money on expensive steroid testing when cheaper ones for drugs like marijuana allow them to say they're doing everything they can to keep drugs out of football.

"It's nothing like what's going on in reality," said Don Catlin, an anti-doping pioneer who spent years conducting the NCAA's laboratory tests at UCLA. He became so frustrated with the college system that it was part of the reason he left the testing industry to focus on anti-doping research.

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EDITOR'S NOTE — Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the first of a two-part series.

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While other major sports have been beset by revelations of steroid use, college football has operated with barely a whiff of scandal. Between 1996 and 2010 — the era of Barry Bonds, Mark McGwire, Marion Jones and Lance Armstrong — the failure rate for NCAA steroid tests fell even closer to zero from an already low rate of less than 1 percent.

The AP's investigation, drawing upon more than a decade of official rosters from all 120 Football Bowl Subdivision teams, found thousands of players quickly putting on significant weight, even more than their fellow players. The information compiled by the AP included players who appeared for multiple years on the same teams.

For decades, scientific studies have shown that anabolic steroid use leads to an increase in body weight. Weight gain alone doesn't prove steroid use, but very rapid weight gain is one factor that would be deemed suspicious, said Kathy Turpin, senior director of sport drug testing for the National Center for Drug Free Sport, which conducts tests for the NCAA and more than 300 schools.

Yet the NCAA has never studied weight gain or considered it in regard to its steroid testing policies, said Mary Wilfert, the NCAA's associate director of health and safety.

The NCAA attributes the decline in positive tests to its year-round drug testing program, combined with anti-drug education and testing conducted by schools.

The AP's analysis found that, regardless of school, conference and won-loss record, many players gained weight at exceptional rates compared with their fellow athletes and while accounting for their heights.

Adding more than 20 or 25 pounds of lean muscle in a year is nearly impossible through diet and exercise alone, said Dan Benardot, director of the Laboratory for Elite Athlete Performance at Georgia State University.

In nearly all the rarest cases of weight gain in the AP study, players were offensive or defensive linemen, hulking giants who tower above 6-foot-3 and weigh 300 pounds or more. Four of those players interviewed by the AP said that they never used steroids and gained weight through dramatic increases in eating, up to six meals a day. Two said they were aware of other players using steroids.

"I ate 5-6 times a day," said Clint Oldenburg, who played for Colorado State starting in 2002 and for five years in the NFL. Oldenburg's weight increased over four years from 212 to 290.

Oldenburg told the AP he was surprised at the scope of steroid use in college football, even in Colorado State's locker room. "There were a lot of guys even on my team that were using." He declined to identify any of them.

The AP found more than 4,700 players — or about 7 percent of all players — who gained more than 20 pounds overall in a single year. It was common for the athletes to gain 10, 15 and up to 20 pounds in their first year under a rigorous regimen of weightlifting and diet. Others gained 25, 35 and 40 pounds in a season. In roughly 100 cases, players packed on as much 80 pounds in a single year.

In at least 11 instances, players that AP identified as packing on significant weight in college went on to fail NFL drug tests. But pro football's confidentiality rules make it impossible to know for certain which drugs were used and how many others failed tests that never became public.

Even though testers consider rapid weight gain suspicious, in practice it doesn't result in testing. Ben Lamaak, who arrived at Iowa State in 2006, said he weighed 225 pounds in high school. He graduated as a 320-pound offensive lineman and said he did it all naturally.

"I was just a young kid at that time, and I was still growing into my body," he said. "It really wasn't that hard for me to gain the weight. I love to eat."

In addition to random drug testing, Iowa State is one of many schools that have "reasonable suspicion" testing. That means players can be tested when their behavior or physical symptoms suggest drug use. Despite gaining 81 pounds in a year, Lamaak said he was never singled out for testing.

The associate athletics director for athletic training at Iowa State, Mark Coberley, said coaches and trainers use body composition, strength data and other factors to spot suspected cheaters. Lamaak, he said, was not suspicious because he gained a lot of "non-lean" weight.

But looking solely at the most significant weight gainers also ignores players like Bryan Maneafaiga.

In the summer of 2004, Bryan Maneafaiga was an undersized 180-pound running back trying to make the University of Hawaii football team. Twice — once in pre-season and once in the fall — he failed school drug tests, showing up positive for marijuana use but not steroids.

He'd started injecting stanozolol, a steroid, in the summer to help bulk up to a roster weight of 200 pounds. Once on the team, he'd occasionally inject the milky liquid into his buttocks the day before games.

"Food and good training will only get you so far," he told the AP recently.

Maneafaiga's former coach, June Jones, said it was news to him that one of his players had used steroids. Jones, who now coaches at Southern Methodist University, believes the NCAA does a good job rooting out steroid use.

On paper, college football has a strong drug policy. The NCAA conducts random, unannounced drug testing and the penalties for failure are severe. Players lose an entire year of eligibility after a first positive test. A second offense means permanent ineligibility for sports.

In practice, though, the NCAA's roughly 11,000 annual tests amount to a fraction of all athletes in Division I and II schools. Exactly how many tests are conducted each year on football players is unclear because the NCAA hasn't published its data for two years. And when it did, it periodically changed the formats, making it impossible to compare one year of football to the next.

Even when players are tested by the NCAA, experts like Catlin say it's easy enough to anticipate the test and develop a doping routine that results in a clean test by the time it occurs. NCAA rules say players can be notified up to two days in advance of a test, which Catlin says is plenty of time to beat a test if players have designed the right doping regimen. By comparison, Olympic athletes are given no notice.

Most schools that use Drug Free Sport do not test for anabolic steroids, Turpin said. Some are worried about the cost. Others don't think they have a problem. And others believe that since the NCAA tests for steroids their money is best spent testing for street drugs, she said.

Doping is a bigger deal at some schools than others.

At Notre Dame and Alabama, the teams that will soon compete for the national championship, players don't automatically miss games for testing positive for steroids. At Alabama, coaches have wide discretion. Notre Dame's student-athlete handbook says a player who fails a test can return to the field once the steroids are out of his system.

The University of North Carolina kicks players off the team after a single positive test for steroids. Auburn's student-athlete handbook calls for a half-season suspension for any athlete caught using performance-enhancing drugs.

At UCLA, home of the laboratory that for years set the standard for cutting-edge steroid testing, athletes can fail three drug tests before being suspended. At Bowling Green, testing is voluntary.

At the University of Maryland, students must get counseling after testing positive, but school officials are prohibited from disciplining first-time steroid users.

Only about half the student athletes in a 2009 NCAA survey said they believed school testing deterred drug use. As an association of colleges and universities, the NCAA could not unilaterally force schools to institute uniform testing policies and sanctions, Wilfert said.

"We can't tell them what to do, but if went through a membership process where they determined that this is what should be done, then it could happen," she said.

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Associated Press writers Ryan Foley in Cedar Rapids, Iowa; David Brandt in Jackson, Miss.; David Skretta in Lawrence, Kan.; Don Thompson in Sacramento, Calif., and Alexa Olesen in Shanghai, China, and researchers Susan James in New York and Monika Mathur in Washington contributed to this report.

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Contact the Washington investigative team at DCinvestigations (at) ap.org.

Whether for athletics or age, Americans from teenagers to baby boomers are trying to get an edge by illegally using anabolic steroids and human growth hormone, despite well-documented risks. This is the first of a two-part series.

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Snowstorm triggers deadly Iowa pileup

DES MOINES, Iowa (AP) — The first widespread snowstorm of the season crawled across the Midwest on Thursday, with whiteout conditions stranding holiday travelers and sending drivers sliding over slick roads — including into a fatal 25-vehicle pileup in Iowa.

The storm, which dumped a foot of snow in parts of Iowa and Wisconsin, was part of a system that began in the Rockies earlier in the week before trekking into the Midwest. It was expected to move across the Great Lakes overnight before moving into Canada.

On the southern edge of the system, a tornado destroyed several homes in Arkansas, and strong winds peeled roofs off buildings and toppled trucks in Alabama and led to flight cancellations in Texas.

In Iowa, drivers were blinded by blowing snow and didn't see vehicles that had slowed or stopped on Interstate 35 about 60 miles north of Des Moines, state police said. A chain reaction of crashes involving semitrailers and passenger cars closed down a section of the highway. At least one person was killed.

"It's time to listen to warnings and get off the road," said Iowa State Patrol Col. David Garrison.

Thomas Shubert, a clerk at a store in Gretna near Omaha, Neb., said his brother drove him to work in his truck, but some of his neighbors weren't so fortunate.

"I saw some people in my neighborhood trying to get out. They made it a few feet, and that was about it," Shubert said.

Along with Thursday's fatal accident in Iowa, the storm was blamed for road deaths in Kansas and Wisconsin. In southeastern Utah, a woman who tried to walk for help after her car became stuck in snow died Tuesday night.

The heavy, wet snow made some unplowed streets in Des Moines nearly impossible to navigate in anything other than a four-wheel drive vehicle. Even streets that had been plowed were snow-packed and slippery. Eight jackknifed semitrailers were reported on a section of Interstate 80 east of the city.

The storm made travel difficult from Kansas to Wisconsin, forcing road closures, including part of Interstate 29 in northern Missouri and part of Interstate 80 in Nebraska. Iowa and Wisconsin activated National Guard troops to help rescue stranded drivers.

Those who planned to fly before the Christmas holiday didn't fare much better.

Shanna Tinsley, 17, and Nicole Latimer, 20, were both headed to the Kansas City area to see their families for the holiday when their flight Thursday morning out of Milwaukee's General Mitchell International Airport was canceled. Neither cared about a white Christmas.

"It would be cool I guess, but I'd rather be there than stuck without family with a white Christmas," Latimer said.

Added Tinsley, "Wisconsin is full of snow, you see it all the time."

In Chicago, commuters began Thursday with heavy fog and cold, driving rain, and forecasters said snow would hit by mid-afternoon.

Airlines delayed and canceled hundreds of flights out of Chicago's O'Hare and Midway international airports. Southwest Airlines, which has a hub at Midway, canceled all of its flights after 4:30 p.m.

In Texas, American Airlines reported 120 cancellations in Dallas because of thunderstorms.

Before the storm, several cities in the Midwest had broken records for the number of consecutive days without measurable snow.

In the Des Moines suburb of Urbandale, Kristin Isenhart, 38, said her three kids, ages 9, 5 and 3, were asking about going outside to play after school was canceled for the day.

"They are thrilled that it snowed," she said. "They've asked several times to go outside, and I might bundle them up and let them go."

As far as the region's drought, meteorologists said the storm wouldn't make much of a dent. It takes a foot or more of snow to equal an inch of water, said Brian Fuchs, a climatologist at the National Drought Mitigation Center.

Meanwhile, tens of thousands of people lost power in Arkansas, Iowa and Nebraska as heavy snow and strong winds pulled down lines. Smaller outages were reported in Alabama, Kansas, Missouri, Illinois and Louisiana.

"The roads have been so bad our crews have not been able to respond to them," said Justin Foss, a spokesman for Alliant Energy, which had 13,000 customers without power in central Iowa. "We have giant four-wheel-drive trucks with chains on them, so when we can't get there it's pretty rough."

Tom Tretter and his wife, Pat, had been without power since Wednesday night, and temperatures Thursday were dropping. The retired seniors were shoveling their steep driveway Thursday afternoon and scraping ice off the walkway to their Des Moines home.

"It's getting cold in the house," Tom Tretter said, leaning on his shovel in the driveway. "And I'm getting too old for this."

Blake Landau, a cook serving eggs, roast beef sandwiches and chili to hungry snowplow drivers at Newton's Paradise Cafe in downtown Waterloo, Iowa, said he has always liked it when it snows on his birthday. He turned 27 on Thursday.

"It's kind of one of those things where it's leading up to Christmas time," Landau said. "We don't know when we get our first snowfall, and I hope we get it by my birthday. It's nice to have a nice snowy Christmas."

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Beck reported from Omaha, Neb. Associated Press writers Scott Mayerowitz in New York; Carrie Antlfinger in Milwaukee; Heather Hollingsworth in Kansas City, Mo.; Jason Keyser in Chicago; Barbara Rodriguez in Des Moines; and Ryan J. Foley in Iowa City, Iowa contributed to this report.

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