Well: Old Age and Motorcycles Are a Dangerous Mix

If you’re over 40 and planning to hop on a motorcycle, take care. Compared with younger riders, the odds of being seriously injured are high.

That is the message of a new study, published this week in the journal Injury Prevention, which found that older bikers are three times as likely to be severely injured in a crash as younger riders.

The percentage of older bikers on the road is quickly rising, and their involvement in accidents is a growing concern. Nationwide, from 1990 to 2003, the percentage of motorcyclists over age 50 soared from roughly 1 in 10 to about 1 in 4. At the same time, the average age of riders involved in motorcycle crashes has also been climbing. Injury rates among those 65 and older jumped 145 percent from 2000 to 2006 alone.

Because of the increase in motorcycle ridership among older Americans, the researchers, led by Tracy Jackson, a graduate student in the epidemiology department at Brown University, wanted a closer look at their injury patterns. So she and her colleagues combed through a federal database of motorcycle crashes that were serious enough to require emergency medical care. That yielded about 1.5 million incidents involving motorcyclists 20 or older from 2001 to 2008.

The researchers then split them into groups: those in their 20s and 30s, another group between 40 and 59, and those 60 and older.

Over all, the study showed that injury rates for all three groups were on the rise. But the rise was steepest for the oldest riders. Compared with the youngest motorcyclists, those who were 60 and older were two and a half times as likely to end up with serious injuries, and three times as likely to be admitted to a hospital. The riders who were middle age were twice as likely as their younger counterparts to be hospitalized.

For older riders, the consequences of a collision were also especially alarming. Older and middle-aged bikers were more likely to sustain fractures and dislocations, and they had a far greater chance of ending up with injuries to internal organs, including brain damage.

The researchers speculated that it was very likely that a number of factors played a role in older riders’ higher injury rates. For one, declines in vision and reaction time may make older riders more prone to mistakes that end up in collisions. Another theory is that older riders tend to ride bigger bikes, “which may be more likely to roll or turn over,” Ms. Jackson said.

Then there is the greater fragility that comes with age. Older riders may be involved in the same types of accidents as younger riders, Ms. Jackson said, but in some cases, a collision that a 20-year-old would walk away from might send a 65-year-old to the hospital.

“Your bones become more brittle, and you lose muscle mass as you get older,” she said. “It could just be a matter of aging and the body being less durable.”

Read More..

Well: Old Age and Motorcycles Are a Dangerous Mix

If you’re over 40 and planning to hop on a motorcycle, take care. Compared with younger riders, the odds of being seriously injured are high.

That is the message of a new study, published this week in the journal Injury Prevention, which found that older bikers are three times as likely to be severely injured in a crash as younger riders.

The percentage of older bikers on the road is quickly rising, and their involvement in accidents is a growing concern. Nationwide, from 1990 to 2003, the percentage of motorcyclists over age 50 soared from roughly 1 in 10 to about 1 in 4. At the same time, the average age of riders involved in motorcycle crashes has also been climbing. Injury rates among those 65 and older jumped 145 percent from 2000 to 2006 alone.

Because of the increase in motorcycle ridership among older Americans, the researchers, led by Tracy Jackson, a graduate student in the epidemiology department at Brown University, wanted a closer look at their injury patterns. So she and her colleagues combed through a federal database of motorcycle crashes that were serious enough to require emergency medical care. That yielded about 1.5 million incidents involving motorcyclists 20 or older from 2001 to 2008.

The researchers then split them into groups: those in their 20s and 30s, another group between 40 and 59, and those 60 and older.

Over all, the study showed that injury rates for all three groups were on the rise. But the rise was steepest for the oldest riders. Compared with the youngest motorcyclists, those who were 60 and older were two and a half times as likely to end up with serious injuries, and three times as likely to be admitted to a hospital. The riders who were middle age were twice as likely as their younger counterparts to be hospitalized.

For older riders, the consequences of a collision were also especially alarming. Older and middle-aged bikers were more likely to sustain fractures and dislocations, and they had a far greater chance of ending up with injuries to internal organs, including brain damage.

The researchers speculated that it was very likely that a number of factors played a role in older riders’ higher injury rates. For one, declines in vision and reaction time may make older riders more prone to mistakes that end up in collisions. Another theory is that older riders tend to ride bigger bikes, “which may be more likely to roll or turn over,” Ms. Jackson said.

Then there is the greater fragility that comes with age. Older riders may be involved in the same types of accidents as younger riders, Ms. Jackson said, but in some cases, a collision that a 20-year-old would walk away from might send a 65-year-old to the hospital.

“Your bones become more brittle, and you lose muscle mass as you get older,” she said. “It could just be a matter of aging and the body being less durable.”

Read More..

European Leaders Struggle to Bridge Budget Gaps

BRUSSELS — European Union leaders on Friday morning edged closer to agreeing a budget worth nearly €1 trillion, or $1.3 trillion, to support farming, transportation and other infrastructure, as well as big research projects for the 27-nation bloc.

But after 15 hours of talks, the leaders were still seeking unanimity while also attempting to satisfy the wide array of national interests demanding attention.

The budget is negotiated every seven years and involves furious horse-trading as leaders focus on getting the best deal for their own countries’ citizens, rather than emphasizing pan-European considerations.

The marathon session was the second attempt to reach a deal on the funding package, which should run from 2014 to 2020, after the first attempt collapsed in November.

Another failure to strike a deal on a sum of money that represents only about 1 percent of the Union’s Gross Domestic Product would be a severe embarrassment for the leaders, who already have spent years bickering over how to save the euro.

The European Commission, the bloc’s policymaking arm, had sought an increase in the overall budget of around 5 percent to more than €1 trillion.

Herman Van Rompuy, the president of the European Council, which represents E.U. leaders, pruned that sum to about €973 billion at the previous summit in November.

On Friday morning, Mr. Van Rompuy presented further revisions lowering the overall sum to about €960 billion but holding down the amount of cash governments pay up-front to around €908 billion.

That formula was designed, in part, to satisfy countries like Britain and the Netherlands that pay more into the budget than they receive, while also accommodating the demands of countries like France and Italy that want to maintain generous payments for agriculture and infrastructure.

Some of the deepest cuts would be made to pan-European projects to improve transport, energy, and digital services that are overseen by the commission. About €1 billion in cuts would be made to the part of the budget used to employ 55,000 people, including 6,000 translators, most of them in Brussels, who run the Union’s day-to-day affairs.

Expert national advisors were reviewing the proposals on Friday morning, and leaders were expected to reconvene for further talks.

Leaders also were wrestling over demands by some countries to renew a system of rebates that raises the costs for other countries.

One of the complications in the current round of negotiations has been the call for budgetary rigor from leaders like David Cameron, the British prime minister, who says the Union should tighten its belt at a time when many European governments have been compelled to impose stringent budget cuts.

Mr. Cameron, in particular, has earned the enmity of some European leaders by demanding a renegotiation of Britain’s treaty with the Union and promised a referendum on his nation’s membership in 2017.

Reflecting growing irritation with Britain among a number of European leaders, Martin Schulz, the president of the European Parliament, told a news conference late on Thursday night that leaders should not go out of their way to appease Mr. Cameron.

Because Britain could be outside the bloc by later this decade, there was little need to make concessions to Mr. Cameron that potentially jeopardized “the security of our financial planning,” Mr. Schulz suggested.

Mr. Van Rompuy, the president of the European Council, had intended to start the session during the mid-afternoon on Thursday to force leaders to make their complaints clear in a roundtable session rather than being allowed to break into small groups.

But his plan was derailed, and the first roundtable session was delayed until late in the evening, as leaders formed the kind of pre-summit huddles that he seemingly wanted to avoid.

President François Hollande of France was an hour late to a meeting during the afternoon with Mr. Cameron, Angela Merkel, the German chancellor, and Mr. Van Rompuy.

Mr. Hollande’s lateness was a sign of French displeasure with British demands that included strict limits on agriculture spending cherished by French farmers, according to an E.U. diplomat, who spoke on condition of anonymity because of the sensitivity of the talks.

Even if leaders eventually agree to a deal, it faces still more hurdles before it becomes law at the European Parliament, which has the power to veto the budget.

Some of the most influential figures in Parliament have already signaled that they are prepared to reject a budget that foresees spending less on Europe in the years ahead.

Guy Verhofstadt, the head of the alliance of liberals in the Parliament, called on Thursday for a full-revision clause to be inserted into the budget, so that it could be increased after three years if economic conditions improved.

Mr. Schulz, the president of the Parliament, said on Thursday that he would not approve a budget that ended up widening the overall gap between the amount of cash paid up-front by governments and the somewhat higher amounts known as commitments, which make up the overall budget.

Read More..

IHT Rendezvous: 'Rigoletto' in Vegas, 'Manon Lescaut' in the Metro

BRUSSELS—The day after the Metropolitan Opera in New York unveiled a production of Verdi’s “Rigoletto” set in Las Vegas during the 1960s, I was in Belgium, where another exercise in operatic updating is underway at the Théâtre royal de la Monnaie. Here, Mariusz Trelinski’s staging of Puccini’s “Manon Lescaut” — through Feb. 8 — situates the opera in the waiting room of a subway station.

Opera goers are often incensed by productions like these, yet updating is potentially a relatively mild device. Once the new setting is established, the action can play out coherently and essentially traditionally. This happened with “La Bohème” last summer at the Salzburg Festival, staged by Damiano Michieletto.

One could object to the hovel of the bohemians’ Parisian loft, but there was something touching about seeing Anna Netrebko as Mimì crouched in the snow behind a hotdog truck near the city’s peripheral expressway, as she overheard Rodolfo and Marcello discussing her fragile health.

By contrast, La Scala’s recent “Lohengrin” directed by Claus Guth, which focused on the repressiveness of German society at the time of the opera’s composition and, in Mr. Guth’s fanciful interpretation, its bizarre effects on the psyche of the title character, counts as truly radical.

The Met’s take on “Rigoletto” had a widely acknowledged antecedent in Jonathan Miller’s production of the opera for the English National Opera, which was set in New York’s Little Italy and seen in that city on a 1984 tour. The Met’s new production by Michael Mayer is reportedly less successful. Writing in The New York Times, Anthony Tommasini detected “dynamic elements in this colorful, if muddled and ill-defined ‘Rigoletto’” but noted that “there are big holes” in Mr. Mayer’s concept. The criticism is directed not so much at the updating itself but the lack of disciplined follow-through.

The updating of “Manon Lescaut,” which is specified to take place in the 18th century, comes off as inherently misguided. Boris Kudlicka’s chic-looking set is essentially all in black, although city lights are sometimes visible, as if seen from a moving train. A system map is on one wall, pay telephones on another.

The mismatch is apparent from the first measures of Puccini’s sparkling orchestral introduction to Act 1. This is music designed for the outdoors—a public square in Amiens—not a space underground. It announces something special is in the works, not dreary routine. It conveys youthful high spirits, not gloom. Also, the mores of pre-revolutionary France are important in the opera.

Whether Mr. Trelinski’s conception of Manon herself is an outgrowth of his updating, or the other way around, it robs her of her allure. When, early on, the smitten Des Grieux declares his love for her, Manon sits at the end of a bar wearing a red coat and dark glasses and smoking a cigarette—the very image of a prostitute. Manon is a material girl all right, but one with such irresistible femininity she gets what she wants from men without having to market herself. You never sense this here. Further, a demimonde element weighs on the first two acts. Manon’s benefactor, Geronte (the bass Giovanni Furlanetto, in excellent voice), is depicted as a crime figure, and there is some curious activity involving topless girls and golf clubs.

Mr. Trelinski’s approach also intensifies an acknowledged structural weakness of the opera. All the opera’s gaiety is concentrated in the first two acts, whereas Act 3 and 4—in which Manon is deported from France and then dies in the New World—are uniformly gloomy. But here, Acts 1 and 2 are gloomy too.

Mr. Trelinski, who is artistic director of the Teatr Wielki in Warsaw, where the production originated, is a respected director with some notable achievements. I have admired his double bill of Bartok’s “Bluebeard’s Castle” and Tchaikovsky’s “Iolanta,” which will be seen at the Met in a future season. His work here has some redeeming aspects, especially in Act 4. Puccini’s setting for this act—a vast desert near the outskirts of New Orleans—is one of opera’s most implausible, so it is no great loss to see it supplanted. Fascinatingly, Mr. Trelinski ensures that Des Grieux suffers here as much as Manon does, as he becomes delusional and, apparently, starts to see double. A second Manon appears, whom Des Grieux cannot seem to distinguish from the first.

Carlo Rizzi presides over a colorful reading of the score and a cast headed by an excellent pair of lovers in Eva-Maria Westbroek and Brandon Jovanovich. When the two sang their big duet in Act 2, you could forget about the production and become wrapped up in Puccini’s drama. Ms. Westbroek’s commanding soprano is a bit large for Manon, whose music can profit from greater tonal delicacy. Still, she offers some splendid singing, apart from some difficulty on top, and gives an especially gripping account of Manon’s final aria, “Solo, perduta, abbandonata.”

In this production Des Grieux emerges as the more emotionally vibrant lover, and Mr. Janovich’s clear, virile singing makes the most of the opportunity. Unfortunately, he was in ill health and departed the performance after Act 2, but the intervention of Hector Sandoval, the alternate Des Grieux, allowed the performance, which was streamed to movie theaters, to continue without a hitch. He sang well and knew intricacies of the staging, flaws and all.

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Bits Blog: Apple's iPad Dominated PC Market During Holiday Season

The iPad is defined as a tablet, but you might as well call it a personal computer. Over the holiday season, about one in six people buying computers around the world bought Apple’s tablet, according to research from Canalys.

The report, released Wednesday, said that when tablets were included, worldwide PC shipments over the fourth quarter increased 12 percent compared with the previous year. Apple led the computer market with 22.9 million iPads and 4.1 million Macs sold. Hewlett-Packard was in a distant second place with 15 million PCs shipped, and Lenovo shipped about 14.8 million computers.

Amazon and Samsung are quickly gaining traction in the computer market with their tablets. Amazon shipped 4.6 million tablets, including its Kindle Fire, over the quarter, and Samsung shipped 7.6 million. Over all, tablet shipments accounted for about one-third of the PC market over the quarter.

IDC, the research firm, reported similar numbers on PC shipments over the fourth quarter, but did not include tablets in its analysis.

Typically research firms don’t count tablets as a PC, because they are quite different from traditional laptops and desktops. But when sales of these two categories are stacked side by side, the numbers give perspective for how quickly the tablet is dissolving the old-school PC.

The Canalys report certainly makes the late Steve Jobs sound prescient. When he introduced the iPad 2 in 2011, he said tablet devices were ushering people into a “post-PC” era:

A lot of folks in this tablet market are rushing in and they’re looking at this as the next PC. The hardware and the software are done by different companies. And they’re talking about speeds and feeds just like they did with PCs.

And our experience and every bone in our body says that that is not the right approach to this. That these are post-PC devices that need to be even easier to use than a PC. That need to be even more intuitive than a PC. And where the software and the hardware and the applications need to intertwine in an even more seamless way than they do on a PC.

It appears that era has already arrived.

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This post has been revised to reflect the following correction:

Correction: February 6, 2013

An earlier version of this post incorrectly stated the number of iPads sold in the fourth quarter of 2012. Apple sold 22.9 million iPads during that period, not 27 million.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His blue eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

---

Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Read More..

Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His blue eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

---

Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Read More..

Profound Weight of Layoffs Seen in Survey

Layoffs have touched nearly every American household in some fashion over the last few years, according to new survey data to be released Thursday by the John J. Heldrich Center for Workforce Development at Rutgers University.

Joe Raedle/Getty Images

Lissette Marquez, center, and Amiel Ali looked for jobs last week in Miami with the help of a South Florida Workforce customer service representative, Nelson Munoz, left.

While about 8 percent of Americans are unemployed, nearly a quarter of Americans say they were laid off at some point during the recession or afterward, according to the survey. More broadly, nearly eight in 10 say they know someone in their circle of family and friends who has lost a job.

“This to me is why the recession was so all-consuming and is likely to influence the American psyche,” said Cliff Zukin, a public policy and political science professor at Rutgers and co-author of the report. “Almost everyone, four out of five, were directly or one step removed from unemployment and all that goes with it financially, socially, psychologically.”

The survey presented a bleak view of the economic future.

A majority of Americans say they think it will be at least six years before the economy is made whole again, if ever. Three in 10 said the economy would never fully recover from the Great Recession.

“Despite significant improvements in the nation’s labor market, American workers’ concerns about unemployment, the job market, job security and the future of the economy have not changed much since we conducted a similar survey in August 2010,” the report said.

Just a third of Americans surveyed in this poll, conducted from Jan. 9-16, said they thought the economy would be better next year, the same share that said so two years earlier.

Of those laid off in recent years, nearly a quarter said they still had not found a job. Re-employment rates for older workers have been particularly bad, with nearly two-thirds of unemployed people 55 and older saying they actively sought a job for more than a year before finding one or had still not found work.

Not surprisingly, those who are unemployed are especially downbeat about many economic issues in addition to their own finances. Of those who were jobless and looking for work, 31 percent said their jobless benefits had run out and 58 percent said they were concerned their benefits would run out before they found work.

Of those who have found work, nearly half say their current job is a step down from the one they lost, and a slim majority say they earn less than they did in their previous job. A quarter of those re-employed said they thought that the hit to their standard of living would be permanent.

The reliance on one’s personal network and savings rather than the social safety net showed up frequently in the survey data.

More people reported borrowing money from friends and family than reported using food stamps. A third cut back on doctors’ visits or medical treatment. A quarter of the unemployed said they had enrolled in retraining programs of some kind; half of them reported paying for the education on their own or through family assistance. Twenty-three percent received some type of government financing for their training programs.

Unemployed workers were more likely than employed workers to say that the government is primarily responsible for helping the jobless. But even then, a majority of the unemployed thought that workers and employers were more responsible for getting people back to work than the government was.

Americans over all were also somewhat less critical of bankers this time than they were two years earlier. About one in three (35 percent) respondents attributed high unemployment levels to the actions of Wall Street, compared with 45 percent in 2010.

Americans were most likely to attribute high unemployment to cheap foreign labor. Four in 10 also said they believed illegal immigrants were taking Americans’ job opportunities — which does not bode well for political support for an amnesty program now being discussed in Washington.

Most people surveyed lost at least some of their savings. Asked about their financial health, six in 10 Americans said their finances would not improve in the next few years; just 16 percent said their family finances were already back to prerecession levels or suffered no loss in the first place.

More educated, better-off people were substantially more likely to report being as financially secure as they were before the recession began.

Responses are based on an online survey conducted by GfK using a nationally representative sample of 1,090 adults. The margin of sampling error is plus or minus three percentage points.

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IHT Rendezvous: IHT Quick Read: Feb. 6

NEWS Individual strikes by Predator and Reaper drones are almost never discussed publicly by U.S. officials. But the clandestine war will receive a rare moment of public scrutiny on Thursday, when its chief architect, John O. Brennan, the White House counterterrorism adviser, faces a Senate confirmation hearing as President Obama’s nominee for C.I.A. director. Robert F. Worth reports from Sana, Yemen, and Mark Mazzetti and Scott Shane from Washington.

Bulgaria’s interior minister announced that two of the people behind a July 18 bombing, which killed five Israeli tourists, a Bulgarian bus driver and the bomber, were believed to be members of the military wing of Hezbollah. The finding could have wide-reaching repercussions for Europe’s détente with the Lebanese militant group. Nicholas Kulish and Matthew Brunwasser report from Sofia, and Eric Schmitt from Washington.

President Mahmoud Ahmadinejad made the first visit by an Iranian leader to Egypt since the two countries broke off diplomatic relations three decades ago. Kareem Fahim and Mayy El Sheikh report from Cairo.

The House of Commons voted overwhelmingly to approve a bill legalizing same-sex marriage in Britain, indicating that the bill is assured of passage as it moves through further legislative stages. John F. Burns and Alan Cowell report from London.

Zhu Ruifeng, who became a celebrity of sorts after posting online a sex video involving a Chinese government official, says he will release more videos involving others. Andrew Jacobs reports from Beijing.

Dell announced that had agreed to go private in a $24 billion deal led by its founder and the investment firm Silver Lake, in the biggest leveraged buyout since the financial crisis. Michael J. de la Merced and Quentin Hardy report.

Liberty Global, the international cable company owned by the American billionaire John C. Malone, agreed to buy the British cable company Virgin Media for about $16 billion. Mark Scott reports from London and Eric Pfanner from Paris.

Asia Pulp and Paper, one of the largest pulp and paper producers in the world, said that it had stopped clearing natural forests across its supply chains in Indonesia, accelerating an earlier commitment to do so by 2015. Sara Schonhardt reports from Jakarta.

ARTS Have you ever awakened from a dream wanting to replay events? That’s just the start of the appeal of the West End revival of “Old Times,” the Harold Pinter play being presented with its two exemplary actresses, Kristin Scott Thomas and Lia Williams, swapping roles. Matt Wolf reviews from London.

The Netherlands Opera perseveres in presenting imaginative repertory absorbingly staged. Last week it turned to a masterpiece of the 19th century with an uplifting new production of Rossini’s final opera, “Guillaume Tell.” George Loomis reviews from Amsterdam.

SPORTS The Olympic champion Lindsey Vonn, whose record-breaking ski racing career has frequently mixed stirring triumph with frightening spills, tore two knee ligaments in a tumbling crash Tuesday and will need reconstructive surgery. Kelley McMillan reports from Schladming, Austria, and Bill Pennington from New York.

When England and Brazil face off Wednesday in London, the two soccer teams will feature players who will have the chance to show they now have the responsibility to match their sizable talents. Rob Hughes reports from London.

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DealBook: Dell Goes Private in $24 Billion Buyout, Largest Since 2007

9:22 p.m. | Updated

For Dell, a $24.4 billion deal to take itself private is a bold move out of Wall Street’s harsh spotlight as it tries to remake itself in a world where personal computers are no longer the big business in technology.

Yet the buyout — which was announced on Tuesday and would be the biggest by far since the days of the recession — is a huge gamble. It will saddle Dell with $15 billion of new debt, and it does nothing to divert the forces reshaping the technology industry and undercutting the company’s business.

Fifteen years ago, Dell made enormous profits from selling customized PCs directly to customers. Six years ago, it was the world’s leading maker of personal computers. Today, it is in third place, behind Hewlett-Packard and Lenovo, and falling.

Dell’s share of an already contracting market for PCs slipped to just 10.7 percent last year, from 16.6 percent six years earlier.

No-name rivals from Taiwan and China grind earnings to razor-thin margins. Android smartphones and iPads, not Windows laptops and desktops, are the best-selling and most moneymaking devices.

And while a shift to cloud computing has increased demand for data centers — an opportunity for Dell to sell servers — big customers like Google and Facebook build their own equipment cheaply. The rise of cloud services has also prompted many companies to forgo buying additional machines, instead relying on rented time and applications running on faraway computer networks.

Dell’s share of the market for servers, slipped about one percentage point, to 22.2 percent of 9.5 million servers sold in 2011. The greater problem in this segment is the pressure on profit margins. Shaw Wu, an analyst with Sterne Agee, estimates operating margins on servers, once about 15 percent, are now “in the high single digits, compared with the mid-single digits for PCs.” It is likely that servers will soon have PC-like margins, he said.

Michael S. Dell is betting his stake in the company and some $700 million of his fortune that he can meet those challenges and turn around a business he started in 1984 in his dormitory room at the University of Texas.

“Dell’s transformation is well under way, but we recognize it will still take more time, investment and patience,” Mr. Dell wrote in a memo to employees on Tuesday. “I believe that we are better served with partners who will provide long-term support to help Dell innovate and accelerate the company’s transformation strategy.”

Mr. Dell’s investment means he will maintain control of the company if its shareholders approve the deal. The private equity firm Silver Lake, one of the most prominent investors in technology companies, is contributing about $1 billion in cash.

And Microsoft, seeking to shore up one of its most important business partners, has agreed to lend Dell $2 billion. Microsoft itself is under pressure, with longtime suppliers flirting with rivals to its Windows operating system.

“Microsoft is committed to the long term success of the entire PC ecosystem and invests heavily in a variety of ways to build that ecosystem for the future,” the software giant said in a statement.

Despite taking on an additional $15 billion in debt, Mr. Dell and Silver Lake argue that the company will survive, thanks to the cash that the PC business still generates.

A. M. Sacconaghi, an analyst with Bernstein Research, estimated that the amount of debt Dell will pay is less than what it has spent in stock dividends and share repurchases. “This debt load is manageable,” he said, “as long as the cash flow from PCs holds up.”

People involved in the transaction said that the buyers had prepared for potential further declines in the PC business, but intend on at least maintaining the company’s position. Dell’s cash from operations has held steady for four of the last five years, coming in at $5.5 billion for the most recent fiscal year.

The size of the transaction evoked the frothy deal-making days before the financial crisis. Dell would be the biggest buyout since the Blackstone Group’s $26 billion takeover of Hilton Hotels in the summer of 2007. Yet few expect a resurgence in giant leveraged buyouts. While the continued availability of cheap financing makes such deals possible, financiers caution that Dell represents a special case because of the founder’s big equity stake.

The deal is the biggest test yet for Mr. Dell, 47, who has a fortune estimated at $16 billion. After a three-year absence, he returned as chief executive of the company in 2007, vowing to restore his creation. His strategy has focused on moving into the business of data centers and corporate software services, marked by numerous acquisitions that have cost billions of dollars.

So far, that has yielded little. Dell’s shares have fallen 31 percent over the last five years, closing on Tuesday at $13.42 — below the buyout’s offer price of $13.65.

But that strategy will largely remain in place if the management buyout is completed. The company will cut its PC offerings further and buy more companies involved in corporate computing for small and medium-size businesses, said Brian T. Gladden, Dell’s chief financial officer.

Though Mr. Dell has bemoaned his company’s dismal stock performance for years, his plan to take it private began in earnest only last year. The billionaire maintains a home in Hawaii near the residences of two prominent private equity executives, Egon Durban of Silver Lake and George R. Roberts of Kohlberg Kravis Roberts, and began floating the idea of a deal with them, people briefed on the matter said.

By August, Mr. Dell formally approached the board with a proposal to take the company private, prompting directors to form a special committee to study alternatives to a deal, these people said. One priority was keeping the process devoid of conflicts of interest to head off potential legal challenges, including the hiring of JPMorgan Chase to provide advice and Evercore Partners to solicit other suitors.

The committee considered ways to keep the company public, including borrowing money to buy back shares, but concluded that the management buyout was the most attractive option.

Mr. Dell had aligned himself with Silver Lake, which he let handle virtually all of the board negotiations, these people said. Mr. Durban used his close ties with Steven Ballmer, the chief executive of Microsoft and to whom he had sold the video chatting service Skype for $8.5 billion, to bring in Microsoft as a partner.

Microsoft was wary of getting involved, fearing fracturing relationships with other partners, according to a person briefed on its deliberations. The software company insisted on providing a loan instead of taking equity in the newly private Dell. Silver Lake also hired four banks to arrange the $15 billion in financing.

By the time word of the deal talks leaked last month, the two sides had the outline of a final proposal. But Dell’s special board committee, led by Alex J. Mandl, battled with the buyers on price until Monday night, pressing for the highest possible bid.

Hamstringing them was a lack of other potential buyers. The committee’s advisers had unsuccessfully approached both K.K.R. and TPG Capital, another big investment firm, hoping to flush out another offer. And despite the talk last month, no strategic buyer emerged as a rival.

Secrecy was important. Mr. Dell was known in talks as “Mr. Denali” — a nickname he liked so much he referred to himself by it regularly — while the PC maker was “Osprey” and Silver Lake was “Salamander.”

Nick Wingfield and Andrew Ross Sorkin contributed reporting.

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