The Lede: Social Media Images From Tunisia, as an Opposition Leader Is Buried

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Video of Friday’s funeral for Chokri Belaid, a Tunisian opposition leader assassinated two days ago, from the independent news site Nawaat.

Last Updated, 3:44 p.m. Activists, bloggers and journalists in Tunisia posted a stream of images on social networks Friday, showing thousands of mourners packed into the largest cemetery in the capital, Tunis, for the funeral of Chokri Belaid, a leading opposition figure whose assassination two days ago triggered a wave of street protests against the Islamist ruling party.

Among those uploading images of the funeral — which took place as the police fired tear gas at protesters and cars were set alight during clashes outside the graveyard — were my Times colleagues Kareem Fahim and Tara Todras-Whitehill, Thierry Brésillon of the French news site Rue 89, and Tunisian activists including Selim Kharrat of the rights organization Al Bawsala.

In video streamed live during the funeral by the activist blogger Slim Amamou, the 2011 revolutionary chant calling for the downfall of the regime could be heard echoing around the graveyard.

A photograph in a set uploaded to Facebook by the blogger Mon Massir appeared to show that even the late opposition leader’s young daughter was forced to shield her face from the tear gas fired by the police.

After the funeral, as photographs uploaded by Mr. Amamou and the rights activist Amira Yahyaoui showed, the security forces enforced a ban on gathering on the main Avenue Habib Bourguiba in central Tunis.

Emna Chebâane, who also works with the rights organization Al Bawsala, posted video on Facebook showing how the police moved in to clear a small number of protesters from the avenue.

It was not hard to imagine what the kind of protest the authorities were concerned about might look like. Two days earlier, when an ambulance carrying Mr. Belaid’s body to the morgue had passed through the same street, thousands of protesters swarmed around the vehicle. Video posted on YouTube late Wednesday by Jadal, a Tunisian news site, showed that scene.

Video recorded on Wednesday in Tunis as protesters gathered around an ambulance carrying the body of Chokri Belaid, a murdered opposition leader.

There were reports of protests in other parts of Tunisia on Friday, as many workers observed calls for a nationwide strike.

Video uploaded to YouTube by a blogger who said he was in the town of Sousse appeared to show the security forces, and officers in plain clothes, firing tear gas and dragging protesters away from a traffic circle pictured in a Wikipedia entry on the old town.

Video uploaded to YouTube on Friday, said to show the police cracking down on protesters in the Tunisian town of Sousse.

Two clips posted online earlier Friday by the same blogger appeared to show the divisions in Sousse, between supporters and opponents of the new government, which have emerged nationwide. One clip showed a loud march in favor of Ennahda, the Islamist party that now rules Tunisia; in another, a second group of protesters declared that they were committed to “bringing down the regime and avenging the death of Chokri Belaid.”

Video said to show supporters of Tunisia’s Islamist ruling party, marching in Sousse on Friday.

Video of antigovernment protesters, said to have been recorded in the Tunisian city of Sousse on Friday.

Video shot by bloggers for the independent news site Nawaat showed what they described as a demonstration in the city of Bizerte in honor of Mr. Belaid, outside the local headquarters of Ennahda. According to a description on Nawaat’s French-language live blog, the video shows an Islamist calling for calm and telling the demonstrators that the nation’s secularists have lost the struggle for power.

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DealBook: Einhorn Sues Apple Over Plan to Discard Preferred Stock

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9:02 p.m. | Updated

Wall Street has had a long romance with Apple. Now one of the company’s best-known investors is saying: I love you, but you need to change.

The surprising declaration by the billionaire hedge fund manager David Einhorn adds to the growing dissatisfaction with Apple and its once soaring stock.

On Thursday, Mr. Einhorn urged his fellow shareholders to block a plan by Apple to scrap a certain class of stock. He says that the move limits the company’s ability to use its enormous war chest — some $137 billion in cash — to reward investors.

The campaign is an unusually aggressive one for Mr. Einhorn, who came to fame betting against Lehman Brothers. To thwart the proposal, Mr. Einhorn is suing Apple in Federal District Court in Manhattan, claiming that it violated securities rules by tying the plan with two other initiatives that he sees as good corporate governance.

The standoff sets up an unusual clash between two sides who can each claim a huge following on Wall Street. In one corner is Apple, whose stock’s almost unearthly growth has bewitched investors across the globe — at least until recently. In the other is Mr. Einhorn, widely regarded as an intelligent investor whose moves inspire legions of copycats. His merely asking a few questions on an earnings call for Herbalife, a nutritional supplement company, last May prompted a plunge in its shares.

So far, each side has remained cordial. Mr. Einhorn called Apple “phenomenal” and contended that his campaign had nothing to do with its recent stock decline. His firm, Greenlight Capital, currently holds 1.3 million shares, now worth nearly $609 million.

“We own more Apple today than we ever have before,” he said in a telephone interview. “We’re optimistic about the company’s prospects, and think too much bad news has been priced in.”

In a response, Apple said that it “welcomes” Mr. Einhorn’s views and added that its management and its board were actively discussing how to return more cash to shareholders.

But the spat underlines recent hand-wringing over Apple, whose stock has proved vulnerable in recent weeks. Over the decade that ended in late September, its share price soared an astounding 18,749 percent, to more than $700. Scores of hedge funds bought into the stock, riding its coat tails to bolster their own returns.

Since about Sept. 21, however, Apple’s stock price has tumbled almost 33 percent, closing on Thursday at $468.22. (Even so, its market capitalization stands at $439.7 billion, making Apple the most valuable public company in the world.)

As the shares have fallen, the volume of criticism has risen.

“Because the stock has sold off from its high, and because Apple’s earnings have declined for the first time in a decade, you’ll hear people become more vocal,” said Walter Piecyk Jr., an analyst at BTIG Research.

Since at least 2005, no shareholder has conducted a formal campaign against an Apple management proposal, according to the data provider FactSet.

Mr. Einhorn’s main concern is Apple’s cash hoard, which is bigger than Intel’s entire market value. Shareholders have long complained that the cash, invested in the likes of Treasury bonds, is increasingly a drag on the stock price and should either be invested in new opportunities for growth or returned to them.

Last spring, the company announced a plan to return $45 billion to shareholders over three years, in the form of share buybacks and a dividend for its common stock. But that will hardly make a dent in a cash pile that swelled by $117 million a day during its most recent quarter.

Mr. Einhorn on Thursday compared Apple to his grandmother, whose experience surviving the Great Depression molded her into an extreme saver who did not leave voice mail messages for fear of using extra cellphone minutes. The company’s own near-death experience in 1997, he said, left a similarly profound scar on its corporate psyche.

As an alternative, he has been proposing since last May what he calls a “win-win” for Apple and its investors. The company, he says, could issue $50 billion in preferred shares to existing shareholders, which would carry a roughly 4 percent annual dividend. Over time, Apple could issue more preferred stock and increase its overall payouts.

The idea, which Mr. Einhorn said had been discussed within his firm for some time, would reward shareholders while ensuring that Apple would spend that additional cash over time. He raised the idea with company executives, including Apple’s chief financial officer, Peter Oppenheimer, over several months, but was rebuffed.

Mr. Einhorn became more aggressive after seeing Apple’s proposal to eliminate so-called blank check preferred stock from its corporate charter. The move would prohibit it from issuing preferred stock without shareholder approval. To Mr. Einhorn, that would sharply limit options for “unlocking value.”

He was further irked by Apple’s tying the plan with two others that he said he would ordinarily support.

In its statement, Apple said that its proposal was actually aimed at making itself more responsive to investors. It added that the plan would not prevent the introduction of precisely the kind of initiative that Mr. Einhorn had discussed.

At least one major investor has sided with Apple. Calpers, the giant California public employee pension fund that is the company’s 43rd-biggest shareholder, said in a statement that the proposal “significantly strengthens share owner rights and deserves full support.”

For his part, Mr. Einhorn said he planned on trying to persuade other shareholders. And he has reconciled himself to Apple’s days of meteoric growth now lying in the past.

“It’s not going to grow 80 percent a year,” he said of the company, “but that doesn’t mean it’s going to go bankrupt.”

David Einhorn's Lawsuit Against Apple by

A version of this article appeared in print on 02/08/2013, on page B1 of the NewYork edition with the headline: Investor Sues Apple Over Plan For Stocks.
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European Leaders Struggle to Bridge Budget Gaps

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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.


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Well: Old Age and Motorcycles Are a Dangerous Mix

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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.”

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Well: Old Age and Motorcycles Are a Dangerous Mix

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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.”

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At War Blog: U.S. and Allies Conduct Drills in Persian Gulf, a Signal to Iran

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Deterring Iran is a delicate balance of diplomacy, sanctions and military muscle-flexing, all intended to send a strong signal – without proving so provocative that the region is pushed toward war. One piece of the effort – halting the proliferation of illicit weapons – got a practice run in the Persian Gulf this week.

Although the exercise did not explicitly name an adversary, geography certainly pointed to Iran, as well as to militants of Al Qaeda still operating in the region. The exercise, which ended Thursday, included a headquarters simulation to test the policy-making and coordination among the American military and two dozen nations that joined, as well as an extensive component of military drills at sea, in the air and on land.

Pentagon officials do not hide the fact that halting suspected smugglers, and boarding their vessels and inspecting them, is in some ways easier than knitting together a coalition of countries to operate under the decade-old Proliferation Security Initiative.

While there may be quiet agreement that Iran is a threat to regional stability, many nations – especially Iran’s neighbors – want to avoid any appearance of belligerence that might make relations even worse. In fact, several of the countries in this week’s exercise declined to officially confirm their participation.

That alliance cohesion problem is not new. When the Proliferation Security Initiative was begun by the administration of President George W. Bush, South Korea initially refused to join, for fear of angering North Korea. The government in Seoul eventually reversed the decision, and South Korea is among the nonproliferation program’s current members, a number that has expanded to 102 nations from the original 11.

Separate from this current multinational exercise, American and Yemeni officials disclosed last week that a joint operation had interdicted a boat carrying a large load of explosives and weapons, including shoulder-launched antiaircraft weapons. Intelligence indicated that the shipment came from Iran and was destined for Houthi insurgent militants inside Yemen.

Even before the proliferation exercise ended this week, the American military’s Central Command announced the scheduling of another exercise to practice mine countermeasures and maritime security in waters of the Middle East. Those skills would be necessary if Iran tried to close the Strait of Hormuz. More than 20 nations will participate in the exercise, set to begin in May.

But budget difficulties in Washington may make sustaining a large American military presence in the region more difficult. The Pentagon announced this week that, temporarily at least, there would be only one aircraft carrier strike group on patrol in the region, down from the usual two. The reason: the Defense Department needs to save money.

Related Coverage:

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Gadgetwise Blog: This Robot Does Do Windows

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The robots at this year’s Consumer Electronics Show fell largely into two categories: floor cleaners and toys. But there was an exception.

That was a robot taken cleaning to new heights – literally. It is the Winbot 7 Series from Ecovacs, and this robot does do windows.

The Winbot works much like any of the floor cleaning robots, only it works on vertical surfaces. Stick it outside on your window glass and it figures out the size of your window, then travels in a zigzag pattern to clean the surface.

The Winbot has to be plugged into an electrical outlet that feeds a powerful vacuum motor that keeps it stuck to the glass as it creeps around. There is a safety tether to keep the Winbot from bombing pedestrians below if it were to lose power. If the Winbot encounters a problem it sounds an alarm.

The Winbot has a damp cleaning pad on its leading edge that is followed by a squeegee and a drying pad in back. The reusable pads could require machine washing after a single large dirty window, but more typically the company said they needed a wash every few months.

The price of replacement parts and cleaning solution have not been yet determined. The Winbot becomes available in April at a list price of $300 for the 710 model that cleans framed windows, and $400 for the 730 model that cleans framed and frameless windows.

They will be available through the Ecovacs Web site.

This post has been revised to reflect the following correction:

Correction: February 7, 2013

Because of incorrect information from a company representative, an earlier version of this post misstated the prices of Winbot robots. The Winbot 710 costs $300, not $200, and the Winbot 730 costs $400, not $300.

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Profound Weight of Layoffs Seen in Survey

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

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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

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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..

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