I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes...
Wall Street Edges Ahead
Label: BusinessStocks opened slightly higher on Wall Street on Friday after a trio of positive economic data points, but gains were expected to be modest. The Standard & Poor’s 500-stock index added 0.2 percent in early trading, the Dow Jones industrial average rose 0.2 percent and the Nasdaq composite index jumped 0.4 percent. Data showed that Chinese exports grew more than expected in January,...
Feb
07
Manhunt underway for ex-LAPD officer suspected of shooting 3 cops
Label: World A manhunt involving multiple law enforcement agencies was underway early Thursday after three police officers were shot -- one...
Well: Think Like a Doctor: A Confused and Terrified Patient
Label: HealthThe 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 brown 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
DealBook: K.K.R. Profit Rises 22% on Investment Gains
Label: BusinessImproving markets lifted the fortunes of Kohlberg Kravis Roberts in the fourth quarter, as the investment firm reported a 22 percent rise in profit.
K.K.R. said on Thursday that it earned $347.7 million for the quarter, as all of its businesses showed strong gains. For the year, the firm reported earning $2.1 billion.
The fourth-quarter profit, reported as economic net income and which includes unrealized gains from investments, comes out to 48 cents a share. That is more than double the 20-cents-a-share average of analyst estimates compiled by Capital IQ.
Private equity firms have benefited from an improvement in the markets, which have bolstered the value of their own holdings. Last week, the Blackstone Group reported a 43 percent increase in fourth-quarter earnings.
K.K.R. said the value of its investments rose 4 percent for the quarter and 24 percent for the year.
The strongest performers among the firm’s investments included Alliance Boots, a British pharmacy chain; HCA, the giant hospital operator that went public last year; and the Nielsen Company, the media measurement company.
The improved market conditions also make selling portfolio companies a more attractive prospect, letting the firms harvest tangible returns from their investments. That was reflected in K.K.R.’s results, as it reported a nearly fourfold increase in distributable earnings for the quarter, to $546.3 million. That metric tracks how much a firm actually pays to its limited partners.
And K.K.R.’s assets under management rose 13.9 percent from the third quarter, to $75.5 billion.
The firm’s co-founders and co-chairmen, Henry R. Kravis and George R. Roberts, said in a statement that the growth of their private equity portfolio outpaced the Standard & Poor’s 500-stock index by about 7 percent last year.
R.I.P., Barney: How 'Barney Cam' made George W. Bush's dog a Web star
Label: World"Mr. Orr, this is the White House operator."
As a White House spokesman, I received phone calls like this all the time. But this was the first time the president's secretary had ordered me to report to the Oval Office immediately. Before 7 a.m. on a Saturday.
It was December 2003. Iraq was all over the news. We were closing in on the capture of Saddam Hussein. But — and the nation should be thankful — this wasn't my domain.
President George W. Bush had another reason for calling for me now.
Barney Cam.
How it happened
Whenever I'm asked to speak about my tenure in the White House, the conversation always shifts to Barney, the Scottish terrier whom the president regarded as the son he never had.
After Barney died Friday at age 12, I found myself thinking about how he became an Internet sensation.
In 2002, the White House was still closed to the public after the attacks of Sept. 11. I ran the White House website, and we wanted to use the Internet to better connect with citizens.
Our first attempt to bring people in to the White House — virtually — was a big hit. Millions of viewers went to our site to see President Bush give a personal video tour of the Oval Office.
During a brainstorming session, my deputy, Jane Cook, mentioned that the theme for the White House Christmas was "All Creatures Great and Small" — a tribute to presidential pets.
People liked our videos. People loved Barney. Why not strap a video camera to the first dog's head, chase him through the White House so viewers can see the Christmas decorations from his vantage point, and stream it over the Internet?
I decided to pitch the idea at the morning communications meeting in the West Wing, where a couple of dozen communication staffers gather to plan the day.
When Dan Bartlett, counselor to the president, asked me what was on my agenda, I swallowed hard and then said, "As you know, Dan, White House tours are still closed due to terrorist concerns. And the theme for this year's Christmas at the White House is 'All Creatures Great and Small.'
"So it's only logical that we have a Barney Cam, Dan, which is where we strap a video camera on Barney's head and have him run through the White House looking at decorations while Christmas music is playing in the background."
I smiled.
Dan looked at me as though I'd grown another head.
After about 10 seconds of dead silence, Press Secretary Ari Fleischer chimed in: "That. Is. Awesome."
His validation was all it took.
"Brilliant!"
Amazon Launches Its Own Currency to Make It Easier to Spend on the Kindle
Label: TechnologyFollowing in the footsteps of Microsoft and Nintendo, Amazon has announced its own virtual currency for game, app, and in-app purchases, called Amazon Coins, on the Kindle Fire HD. The e-commerce giant is billing it as a way for developers to make more money by making it easier for shoppers to buy apps and games.
Android and iOS app developer Zak Tanjeloff agrees that Amazon Coins could put more cash in developer’s bank accounts. ”Any time you reduce the friction in buying an app or an in-app purchase, developers see better sales,” he says. It could also open the door for more in-app promos, where consumers can win coins and use them for future in-app purchases, which would help developers earn even more money, Tanjeloff says.
One Amazon Coin equals one U.S. penny, meaning a 99 cent game will cost 99 coins, a $1.99 app costs 199 coins, and so on. By converting coins to pennies instead of dollars, Amazon is giving developers the flexibility to sell in-app purchases for less than a dollar if they choose. It also means that mentally converting your Amazon Coin balance to real dollars won’t be too hard, a problem that’s plagued Microsoft Points and Nintendo Points.
With Amazon already accepting two forms of payment for Kindle purchases (credit/debit cards and gift cards), it begs the question: why another Amazon specific currency? One answer is that virtual currency takes the sting out of a purchase, it’s not real money after all, thus encouraging us to buy more. Perhaps more to the point, and the audience, the virtual coins also make it easy for kids to buy games and apps on the Kindle Fire without badgering their parents for real money – at least not until the coins run out.
It’s well-documented that we spend more money with credit cards than we do with cash, because instead of forking over a $100 bill, you’re merely swiping a card and not watching the money fly from your wallet. Likewise, it’s easy to forget you’re spending real money when you pay with virtual currency, because you’re thinking in terms of coins or points, not cash. Since you’ve already pre-paid for your Amazon Coins, several small purchases hardly feel like a drain on your bank account, at least until it’s time to reload your balance. “Using virtual currency takes the user one level away from actual dollars, which can lure them to spend more,” says Tanjeloff. “It’s like when you get chips at a casino, it’s easy to forget that you’re playing with real money.” In the long run, that could help developers boost their app sales and rake in more cash (they get 70 percent of every Amazon Appstore purchase), if shoppers are more willing to dole out Amazon Coins instead of dollars.
Though Amazon didn’t offer any details on why it thinks consumers will adopt its virtual currency, it makes sense that the company would have kids and parents in mind. Amazon knows that more kids are getting their hands on tablets like the Kindle Fire, and parents don’t want to constantly field requests to buy a new app or pay a few dollars for in-app characters or special features. Right now, if you want to keep your kids away from your credit card on a Kindle, you can buy an Amazon gift card and load it into the Amazon App Store on the tablet.
That means the move into Amazon Coins is less about utility, and more about convenience. Instead of buying a gift card and loading it, a process that is frustratingly difficult on the Kindle Fire, but easier to do online, Amazon promises it will give shoppers a quick way to reload Amazon Coins, though didn’t elaborate on how that will work. That could make Amazon Coins enticing to parents, who could load an account with several dollars’ worth of Coins each month and let their kids spend them at will without any hassle.
The news is already spurring criticism from folks who have had unfavorable experiences with Microsoft Points and Nintendo Points, neither of which have a one to one currency conversion. Microsoft Points (MSP) – used to buy games, music, and video on the Xbox and other Microsoft devices – have a conversion rate of 80 MSP to one U.S. dollar, and 1000 Nintendo Points equals one dollar. That’s led countless gamers to complain that buying anything with MSPs or NPs makes the purchase process too complicated or confusing. Amazon penny-per-coin approach won’t suffer from that problem, but it may still be an uphill battle with people who have been burned by virtual currency.
Amazon Coins officially launch in May and Amazon will give “tens of millions of dollars’ worth of free Amazon Coins to spend on developers’ apps on Kindle Fire in the Amazon Appstore,” the company says. Developers have until April 25 to submit their app to run on the new Coins currency when it launches.
Ipswich Journal: Paul Mason Is One-Third the Man He Used to Be
Label: Health
Paul Nixon Photography
Paul Mason in 2012, two years after gastric bypass surgery stripped him of the unofficial title of “the world’s fattest man.”
IPSWICH, England — Who knows what the worst moment was for Paul Mason — there were so many awful milestones, as he grew fatter and fatter — but a good bet might be when he became too vast to leave his room. To get him to the hospital for a hernia operation, the local fire department had to knock down a wall and extricate him with a forklift.
That was nearly a decade ago, when Mr. Mason weighed about 980 pounds, and the spectacle made him the object of fascinated horror, a freak-show exhibit. The British news media, which likes a superlative, appointed him “the world’s fattest man.”
Now the narrative has shifted to one of redemption and second chances. Since a gastric bypass operation in 2010, Mr. Mason, 52 years old and 6-foot-4, has lost nearly two-thirds of his body weight, putting him at about 336 pounds — still obese, but within the realm of plausibility. He is talking about starting a jewelry business.
“My meals are a lot different now than they used to be,” Mr. Mason said during a recent interview in his one-story apartment in a cheerful public housing complex here. For one thing, he no longer eats around the clock. “Food is a necessity, but now I don’t let it control my life anymore,” he said.
But the road to a new life is uphill and paved with sharp objects. When he answered the door, Mr. Mason did not walk; he glided in an electric wheelchair.
And though Mr. Mason looks perfectly normal from the chest up, horrible vestiges of his past stick to him, literally, in the form of a huge mass of loose skin choking him like a straitjacket. Folds and folds of it encircle his torso and sit on his lap, like an unwanted package someone has set there; more folds encase his legs. All told, he reckons, the excess weighs more than 100 pounds.
As he waits to see if anyone will agree to perform the complex operation to remove the skin, Mr. Mason has plenty of time to ponder how he got to where he is. He was born in Ipswich and had a childhood marked by two things, he says: the verbal and physical abuse of his father, a military policeman turned security guard; and three years of sexual abuse, starting when he was 6, by a relative in her 20s who lived in the house and shared his bed. He told no one until decades later.
After he left school, Mr. Mason took a job as a postal worker and became engaged to a woman more than 20 years older than him. “I thought it would be for life, but she just turned around one day and said, ‘No, I don’t want to see you anymore — goodbye,’ ” he said.
His father died, and he returned home to care for his arthritic mother, who was in a wheelchair. “I still had all these things going around in my head from my childhood,” he said. “Food replaced the love I didn’t get from my parents.” When he left the Royal Mail in 1986, he said, he weighed 364 pounds.
Then things spun out of control. Mr. Mason tried to eat himself into oblivion. He spent every available penny of his and his mother’s social security checks on food. He stopped paying the mortgage. The bank repossessed their house, and the council found them a smaller place to live. All the while, he ate the way a locust eats — indiscriminately, voraciously, ingesting perhaps 20,000 calories a day. First he could no longer manage the stairs; then he could no longer get out of his room. He stayed in bed, on and off, for most of the last decade.
Social service workers did everything for him, including changing his incontinence pads. A network of local convenience stores and fast-food restaurants kept the food coming nonstop — burgers, french fries, fish and chips, even about $22 worth of chocolate bars a day.
“They didn’t deliver bags of crisps,” he said of potato chips. “They delivered cartons.”
His life became a cycle: eat, doze, eat, eat, eat. “You didn’t sleep a normal sleep,” he said. “You’d be awake most of the night eating and snacking. You totally forgot about everything else. You lose all your dignity, all your self-respect. It all goes, and all you focus on is getting your next fix.”
He added, “It was quite a lonely time, really.”
He got infections a lot and was transported to the hospital — first in a laundry van, then on the back of a truck and finally on the forklift. For 18 months after a hernia operation in 2003, he lived in the hospital and in an old people’s home — where he was not allowed to leave his room — while the local government found him a house that could accommodate all the special equipment he needed.
This article has been revised to reflect the following correction:
Correction: February 6, 2013
The headline on an earlier version of this article misstated Paul Mason’s current weight relative to what he weighed nearly a decade ago. He is now about one-third of the weight he was then, not two-thirds.
Postal Service Plans to End Saturday Delivery
Label: Business
Jim Wilson/The New York Times
A postal worker delivered mail in San Francisco last year.
WASHINGTON — The Postal Service is expected to announce on Wednesday morning that it will stop delivering letters and other mail on Saturdays, but continue to handle packages, a move the financially struggling agency said would save about $2 billion annually as it looks for ways to cut cost.
The agency has long sought Congressional approval to end mail delivery on Saturdays. But Congress, which continues to work on legislation to reform the agency, has resisted. It is unclear how the agency will be able to end the six-day delivery of mail without Congressional approval.
News of the move was first reported by CBS News.
The announcement, which is expected at a Wednesday morning news conference, comes as the agency continues to lose money, mainly due to a 2006 law which requires it to pay about $5.5 billion a year into a future retiree health benefit fund. Last year, for the first time, the agency defaulted on two payments after it had reached its borrowing limit from the Treasury Department. The Postal Service also continues to see a decline in mail volume as more people shift to electronic forms of communication like e-mail and online bill paying services. Packaging is one of the few areas where the agency is seeing growth.
While many business and postal unions have generally opposed ending Saturday delivery, most Americans support the move.
A New York Times/CBS News poll last year found that about 7 in 10 Americans say they would favor the change as a way to help the post office deal with billions of dollars in debt. The Postal Service continues to suffer losses of $36 million a day and is headed for projected losses of about $21 billion a year by 2016. Last year, the Postal Service had a net loss of $15.6 billion.
The American Postal Workers Union, which represents about 220,000 workers and retirees, said the plan to end six-day delivery will add to the agency’s financial problems.
“The A.P.W.U. condemns the Postal Service’s decision to eliminate Saturday mail delivery, which will only deepen the agency’s congressionally manufactured financial crisis,” said Cliff Guffey, president of the union.
This article has been revised to reflect the following correction:
Correction: February 6, 2013
An earlier version of this article misstated the news organization that first reported the Postal Service’s plans to end Saturday service. It was CBS News, not The Associated Press.
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