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.”

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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.

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At War Blog: Interview With Gen. John R. Allen on Leaving Afghanistan

The New York Times interviewed Gen. John. R. Allen on Sunday, a week before his scheduled departure from Afghanistan after 19 months as the commander of the American and allied forces.

Following are some of General Allen’s comments. Brief explanations have been provided in brackets.

On his relationship with President Hamid Karzai:

“I wanted him to understand that he was always going to have my loyalty and I was always going to work with him. In fact, I said a number of times, ‘I’m proud to have served you at the same time I served my own leadership, whether it’s a NATO leadership or U.S. leadership.’ Now, I wanted him to believe it because it happened to be true. I think our personalities meshed in that regard.”

“Now, we’ve had some tough times. This has been a time of really dramatic change for the campaign. When I got here, I measured success in how well we and how often we were fighting. Today, it’s a very different environment. The Afghans are virtually entirely in the lead across Afghanistan.”

“This is what I’ve learned about the president. If you listen to him, he’s got some pretty good ideas, and often the controversy that has arisen in the relationships hasn’t been because necessarily you disagree with the ideas. It’s because you haven’t listened to them early enough.”

“And sometimes it’s been strained. I don’t think he ever believed that actions that I have taken were ever intended to disadvantage him as the president, or not do everything I possibly could for the Afghan people. I told him, I’m prepared to die in this country on behalf of his people. I take that very seriously.”

On civilian casualties:

“I’ve met with the families of the casualties that we’ve inflicted. I’ve flown to the villages to personally apologize for the casualties, and do what I can to do the right thing for those families. I’ve taken measures with respect to the employment of certain kinds of fires.” ["Fires” is common military shorthand for a variety of munitions, from bullets to missiles to mortar shells.]

“We had a couple of pretty rough incidents where Afghans were killed by the delivery of aviation fires. I eventually said to President Karzai that civilian structures, tents, potential areas where civilians might be either taking refuge or hiding or living, I’m not going to deliver any more fires on those structures unless my troops are pinned down, can’t move, and the only option they have is to deliver fires on these structures, or I decide, the senior leader out here, I decide to deliver fires on these structures.”

“The civilian causalities as a result of air fires plummeted immediately. It was probably a decision I could have made long before that and none of our forces were put at risk, or at  greater risk because of this.”

On the aftermath of the burning of Korans at Bagram Air Base:

“I have to tell you, I thought this could be it for the relationship.

“I immediately got on the phone to a number of Afghan media outlets, immediately cut a video apologizing for this as sincerely as I could possibly appear and sound because this was going to be bad, it could be really bad. I called the president, I went to see him, apologized to him for this. It was completely inadvertent but this culture deserved that apology. We were in their home, so to speak. We are guests in their home and even though it was an accident, even though it was not intentional, we had made a bad mistake, a real error and the people deserved my apology, the president deserved my apology.

“He accepted it and I think in many respects, the personal nature of our relationship was what tempered the language coming out of the palace, the releases, his own engagement with the media and so on. Because of both of our actions, both of them supporting each other, we were able to keep this from being the result of a bad mistake from being something that could have really fractured the relationship.”

On the fallout in March after an American soldier killed 16 villagers in the southern Afghan district of Panjwai, which he first heard about when he was in the United States to testify before Congress:

“The first phone call was something of the effect of — we’ve got mixed reporting from Panjwai. We think an American soldier maybe shot some people and my response was, ‘All right. Let’s develop the situation quickly. Tell me what we got in front of us because we’ve got to make the Afghans in the loop on this.’ ”

“Then the phone calls started coming in and the numbers started going up and pretty quick and this is as bad a circumstance as you might have imagined.”

“I called President Karzai from home and we had a long conversation about it. I promised him once again that we would take all steps, measures, take all actions necessary to get to the bottom of this and we would do a full and complete investigation and those people necessary would be held accountable.”

“This was still unfolding. Was it one shooter? Was it multiple shooters? There were wild rumors associated with things that he had done in addition to shooting. So the information environment was wide open at this point. And both for the purposes of internal stability in Afghanistan and for the purposes of preserving our relationship we were working very, very hard to confirm what we knew to be the facts and try very hard to get after the rumors that were just flying.”

“Once again, when he could have been angry, when it could have been a very negative conversation, I mean, he was tutorial. He explained to me why this is bad for the relationship, why this is bad for the campaign, and why this will shake the confidence of the Afghan people, his personal gesture of measured conversation with me. He wasn’t angry.”

On why the United States should stay engaged in Afghanistan:

“I put it in the context of this has been worth it. This is bigger than anyone of us. It’s bigger than the president. It’s bigger than the president of Afghanistan, because this isn’t about today. This is about tomorrow. This is about doing all we can to facilitate President Karzai with his desire to be successful. But it’ll be about doing all we can do to set up his successor for success.”

On overcoming the skepticism of officials in Washington, who often express frustration with Mr. Karzai:

“For this president, at this moment of its history, Afghanistan’s history, to be able to hold together these tribes and these ethnic groups with these kinds of challenges has got to be one of the hardest jobs going. And so I try to paint the context of the challenges that he faces, the history from which he originates and how, conceivably, he will interpret our actions. He may not understand what we are trying to do, or may misinterpret what we’re trying to do or say. And frankly, one of the great things about our democracy is also one of the hardest things about our democracy: That is, we don’t always speak with the same voice.

“So he’ll hear a voice from one part of the government, it will be different for another part of the government and he’ll seek to square the differences. It’s not a criticism, it just is who we are. The farther you are away from Kabul, the farther you are away from the palace, the farther you are away from the history of this country in the complexities of society, the easier it is to generalize, frankly.”

On the need for the Afghan government to better serve its people and stamp out corruption within its ranks:

“We’ve worked very hard, obviously, to build a capacity in those. But when your ability to survive the night, or put food on the table was — well, for many years are a function of what tribe you were part of, or what group you were part of. And those patronage networks undertook economic opportunities which made them some respect, criminal patronage networks.

“They can only survive because institutions of governance are weak. And so now, we find ourselves in a death grip here — at this very moment when the future of the country relies on the strength of institutions. The criminal patronage networks recognize that their future, their survival can only be sustained by keeping these institutions weak. That’s the moment we find ourselves in, and the presidential directive on any anti-corruption and government reform and the Mutual Accountability Framework that came out of Tokyo.

“These created very helpful, very useful, both domestic and international expectations for reform. So we need to see us moving past the written word and the spoken word and start moving towards action. I think the president, if he were sitting here would tell you that they have achieved some good action, good results in his presidential decree. The Mutual Accountability Framework is constantly being audited to see that there’s progress on reform. But again, we’re still pretty fresh in the process and we’ve got to let this play out some more.”

On the future of the war and Afghanistan:

“Let me make sure I’m clear on this. Nothing is sure in a post-conflict society. But I think the indicators, as far as I’m concerned, are that we’re on the right trajectory. What you have to understand, what people have to understand is some of these reforms take a very long time. In an environment where human rights were crashed under multiple different invasions or civil wars or the Taliban, creating once again the kind of bias for human rights that we would all expect in the Western society, just doesn’t come easily to this country.

“Nothing will happen in this country without security. And that security is being purchased every single day by the Afghan National Security Forces. And then, on the platform of that security, this president has announced a program or platform that he intends to follow. Now, he’s moving forward in some areas, he’s having resistance in others, but we just have to expect this is going to take time. That’s where huge patience has to come in. That’s where the decade of transformation comes in.”

On the surge of “insider attacks” against Westerners that took place in 2012:

“The losses became to this particular means of attack became very troubling, very significant, and tragic. And while on the tactical level and on the operational level, we were able to deal with the problem. This was becoming a strategic crisis — a strategic crisis in capitals, a strategic crisis for the alliance — and the Taliban saw this. They knew this. They saw that. They saw that the future of the A.N.S.F. relied on our being close, partnered and advising inside the Afghan formations.

“We were very careful in our reaction to insider attacks. Not to wall ourselves off from the Afghans and create distance. I used to tell them, you may not be able to do anything about the linear distance that you have to deal with but there’s a lot you can do about your proximity and the closer you all feel to each other, the more secure you will be. And that’s in an environment where we’re transitioning to being advisers almost entirely across Afghanistan. That has to be one of the operative principles for philosophically how we’re going to live with the Afghans. You treat them like brothers. You live with them like they’re family. That reduces the unknowns, it reduces the potential for cultural affront, and it makes you more secure.”

“That doesn’t mean we’re not going to keep a close eye on the environment. We still have these people called Guardian Angels because there are enemies in the ranks and they’re waiting to take that shot.”

“We took a lot of measures and the numbers are down. But I don’t in any way want anybody to become complacent about the number being down. I don’t want anyone to lift up on the security measures that they’re taking or reduce the attentiveness that they have to the environment around them. So, I want everybody to be attentive and we’re going to periodically refresh our training both at the very lowest levels and for the units coming in. So, we’re not going to give up on this.”

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Signing Day: Ole Miss muscles in on power programs

Alabama. Ohio State. Michigan. Florida. Notre Dame. Mississippi?

Ole Miss muscled in on the powerhouses that usually dominate national signing day, landing some of the most sought-after prospects in the country on college football's annual first-Wednesday-in-February frenzy.

The Rebels, coming off a promising 7-6 season in their first season under coach Hugh Freeze, had the experts swooning by signing three of the bluest chips still on the board and building a well-rounded class otherwise.

"I do think (this class) has the possibility of being a program changer," Freeze said. "But it's all on paper right now.

The day started with defensive end Robert Nkemdiche from Loganville, Ga., rated the No. 1 recruit in the country by just about everyone who ranks them, deciding to join his brother, Denzel, in Oxford, Miss.

"I feel like it's the right place for me," Nkemdiche said after slipping on a red Ole Miss cap. "I feel like they can do special things and they're on the rise. I feel like going to play with my brother, we can do something special."

Nkemdiche originally committed to Clemson last year, then backed off that and narrowed his picks down to LSU, Florida and Mississippi — and the Rebels beat the big boys.

They weren't done. Coaches in the Ole Miss war room were exchanging hugs and high-fives again a couple hours later when Laremy Tunsil, a top-rated offensive tackle from Lake City, Fla., picked the Rebels over Florida State and Georgia.

"Tunsil to Ole Miss I think was the biggest surprise of the whole (recruiting season)," said JC Shurburtt, national recruiting director for 247Sports.com.

And, as if the Ole Miss needed more good news, highly touted defensive back Antonio Conner from nearby Batesville, Miss., chose the Rebels over national champion Alabama.

Ole Miss also landed Laquon Treadwell from Crete, Ill., one of the best receiver prospects in the country. He made a verbal commitment to the Rebels back in December, and sealed the deal Wednesday, the first day high school players can sign binding letters of intent.

The end result was a class good enough to even catch the attention of LeBron James.

"Ole Miss ain't messing around today! Big time recruits coming in. SEC is crazy," the NBA MVP posted on his Twitter account.

Crazy good. While the Rebels racked up, it's important to remember they still have plenty of ground to gain on the rest of their conference.

Nick Saban reloaded the Crimson Tide with a class that Rivals.com ranked No. 1 in the country.

SEC powers Florida, LSU and Georgia pulled in typically impressive classes. SEC newcomer Texas A&M cracked the top 10 of several rankings. Even Vanderbilt, coming off a nine-win season, broke into the top 25.

It's the cycle of life in the SEC, which has won seven straight BCS championships. Stock up on signing day and scoop up those crystal footballs at season's end.

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SLIPPING AWAY FROM USC

Signing day didn't do much to soothe the scars left from a difficult season for Southern California.

NCAA sanctions limited the number of scholarships coach Lane Kiffin and the Trojans could hand out this year, and then as signing day approached USC had several players who had given verbal commitments change their minds.

The most notable defection on signing day was five-star defensive back Jalen Ramsey of Brentwood, Tenn., who flipped to Florida State. Defensive end Jason Hatcher from Louisville, Ky., bailed on USC and signed with Kentucky, and defensive end Torrodney Prevot from Houston not only reneged on his USC commitment, but he landed at Pac-12-rival Oregon.

"People expected (Prevot) to flip from USC, but they thought it would be to Texas A&M," Shurburtt said.

USC's class won't be lacking blue chippers. Quarterback Max Browne from Washington is considered the next in a long line of topflight Trojans quarterbacks, and Kenny Bigelow from Maryland is rated among the best defensive linemen in the nation.

Kiffin will be banking on quality to make up for the lack of quantity, but that's a precarious way to play a game as uncertain as recruiting.

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IF MOMMA'S NOT HAPPY ...

Alex Collins, a top running back prospect out of Plantation, Fla., announced on Monday night that he was going to Arkansas instead of Miami.

It was considered a huge victory for new Razorbacks coach Bret Bielema.

But on Wednesday morning, when it was time to make it official, Collins' letter of intent didn't come spinning through the fax machine in Fayetteville, Ark.

There were some odd reports about Collins' mother not being happy with her son's decision to go so far from home.

College coaches aren't allowed to talk about specific players before they sign, but Bielema did acknowledge during his signing day news conference that Arkansas' class of 22 players could "grow by one."

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THE BIG TWO

Ohio State and Michigan received two thumbs up from experts on their signing day classes. They all had the Buckeyes and Wolverines around top five in the country.

After that, there was a drop off. Nebraska received solid grades and Penn State, despite NCAA sanctions that limited its class to 17 signees, held up pretty well.

"That's a tribute to the job (Penn State coach) Bill O'Brien and the staff did," Shurburtt said.

But signing day 2013 signaled that Urban Meyer's Buckeyes and Brady Hoke's Wolverines are primed to pull away from most of the Big Ten, and maybe — just maybe — give the league a team or two that can challenge those SEC teams for a national title.

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BUILT TO LAST

Notre Dame followed up its best season in more than two decades with a recruiting class that coach Brian Kelly hopes can keep the Fighting Irish contending for more national titles.

The class includes a famous name in Torii Hunter Jr., the son of the All-Star outfielder. Hunter Jr. is a top-notch receiver prospect, though he broke his leg during an All-Star game and it could be a while before he's back on the football field.

Linebacker Jaylon Smith from Fort Wayne, Ind., is generally regarded as the jewel of a class that experts have ranked among the best in the country.

"I love agreeing with experts," Kelly said.

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BASEBALL OR FOOTBALL?

Oklahoma hopes it has found the next Sam Bradford in Cody Thomas, a pocket passer from Colleyville, Texas.

One small problem. Thomas is also a big-time baseball player who could draw interest in the major league draft this summer.

"We wouldn't have pursued him if we didn't feel there was a great chance he'd be playing football," Oklahoma coach Bob Stoops said.

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QUOTABLE

South Carolina coach Steve Spurrier said recruiting classes "don't always pan out. Of course, they always seem to pan out at Alabama."

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AP Sports Writer David Brandt in Oxford, Miss., and Associated Press Writer Tom Coyne in South Bend, Ind., contributed.

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Follow Ralph D. Russo at www.Twitter.com/ralphdrussoap

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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.

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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.

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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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Chokri Belaid, Tunisian Opposition Figure, Is Killed

A leading Tunisian opposition politician who had been critical of the Islamist-led government was fatally shot outside his home in Tunis Wednesday, the government news agency said.

Hassene Dridi/Associated Press

Chokri Belaid in Tunis in 2010.

Chokri Belaid was shot just as he was leaving his house in the capital city, the state news agency TAP said.

Mr. Belaid, the general secretary of the Democratic Patriotic Party, was one of the leaders of the opposition Popular Front, which had been formed in October to counter the government.

Mr. Belaid has emerged as a chief critic of Ennahda, the moderate Islamist party that leads the government in a coalition with two secular parties. While Ennahda has tried to reassure Tunisians that it would respect liberal democratic values and not impose a strict Muslim moral code, it has faced criticism with an indulgent attitude toward the ultraconservative Islamists known as Salafis.

In recent days, Mr. Belaid accused the Islamists of carrying out an attack on a meeting of its members on Saturday. “At the end of our meeting, a group of Ennahda mercenaries and Salafists attacked our activists,” Mr. Belaid said.

Samir Dilou, a government spokesman, was quoted as calling the killing an “odious crime.”

No group immediately took responsibility for the shooting and its cause remained unclear.

It came as Tunisia faces profound social and religious uncertainties following the ouster of a dictatorial regime two years ago that set off what came to be known as the Arab Spring.

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Braun says he used Fla clinic owner as consultant

NEW YORK (AP) — Milwaukee Brewers slugger Ryan Braun said the person who ran the Florida clinic being investigated by Major League Baseball was used only as a consultant on his drug suspension appeal last year.

"I have nothing to hide," Braun said in a statement released by his representatives on Tuesday night.

Earlier in the day, Yahoo Sports reported the 2011 NL MVP's name showed up three times in records of the Biogenesis of America LLC clinic. Yahoo said no specific performance-enhancing drugs were listed next to his name.

The Miami New Times recently released clinic documents that purportedly linked Alex Rodriguez, Gio Gonzalez, Melky Cabrera and other players to purchases of banned drugs from the now-closed anti-aging center.

Rodriguez and Cabrera were on the list with Braun that also included New York Yankees catcher Francisco Cervelli and Baltimore Orioles infielder Danny Valencia.

Braun said his name was in the Biogenesis records because of an issue over payment to Anthony Bosch, who ran the clinic near Miami.

"There was a dispute over compensation for Bosch's work, which is why my lawyer and I are listed under 'moneys owed' and not on any other list," Braun said.

"I have nothing to hide and have never had any other relationship with Bosch," he said. "I will fully cooperate with any inquiry into this matter."

On Tuesday, MLB officials asked the Miami New Times for the records the alternative newspaper obtained for its story.

Asked specifically about Braun's name in the documents before the five-time All-Star released his statement, MLB spokesman Pat Courtney said: "Aware of report and are in the midst of an active investigation in South Florida."

Braun tested positive during the 2011 postseason for elevated testosterone levels. He maintained his innocence and his 50-game suspension was overturned during spring training last year when arbitrator Shyam Das ruled in favor of Braun due to chain of custody issues involving the sample.

With that, Braun became the first major leaguer to have a drug suspension overturned.

"During the course of preparing for my successful appeal last year, my attorneys, who were previously familiar with Tony Bosch, used him as a consultant. More specifically, he answered questions about T/E ratio and possibilities of tampering with samples," Braun said.

The T/E ratio is a comparison of the levels of testosterone to epitestosterone.

Braun led the NL in homers (41), runs (108) and slugging percentage (.595) last season while batting .319 with 112 RBIs and 30 stolen bases. He finished second to San Francisco catcher Buster Posey in MVP balloting."

Cervelli, who spent nearly all of last season in Triple-A, posted a statement on Twitter later Tuesday night.

"Following my foot injury in March 2011, I consulted with a number of experts, including BioGenesis Clinic, for (cont)," Cervelli posted, "(cont)legal ways to aid my rehab and recovery. I purchased supplements that I am certain were not prohibited by Major League Baseball."

An email sent to Valencia's agent was not returned.

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Ipswich Journal: Paul Mason Is One-Third the Man He Used to Be

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, not two-thirds, the weight he was then.

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DealBook: Liberty Global Reaches Deal for Virgin Media

8:07 p.m. | Updated

LONDON – Liberty Global, the international cable company owned by the American billionaire John C. Malone, agreed on Tuesday to buy the British cable company Virgin Media for about $16 billion.

The deal gives Liberty Global access to Europe’s largest cable market, and pits Mr. Malone against Rupert Murdoch, his longtime rival and biggest shareholder in Britain’s largest pay-TV provider British Sky Broadcasting.

Under the terms of the deal, Liberty Global said it had offered a package of cash and stock that it valued at $47.87 for each share in Virgin Media, a 24 percent premium over Virgin Media’s closing price on Monday.

The takeover ranks as one of the 10 largest cable deals of all time, according to figures from the data provider Thomson Reuters.

“Virgin Media will add significant scale and a first-class management team in Europe’s largest and most dynamic media and communications market,” Mike Fries, Liberty Global’s president and chief executive, said in a statement.

“After the deal, roughly 80 percent of Liberty Global’s revenue will come from just five attractive and strong countries — the U.K., Germany, Belgium, Switzerland and the Netherlands.”

News of the talks, confirmed earlier in the day in a statement by Virgin Media, came amid heightened merger and acquisition activity in the European television business. As European broadcasters suffer from stagnant or falling advertising revenue, American media conglomerates, looking to expand their international presence, are playing a significant role.

Mr. Malone and Mr. Murdoch have gone head-to-head before. From 2004 to 2006, they fought for control of DirecTV, the American satellite television provider.

The clash ended with Mr. Malone yielding a stake that he had built up in News Corporation. But the Liberty Group, which has operations in 13 countries, completed its purchase of a controlling stake in DirecTV from News Corporation in a cash-and-equity deal worth roughly $11 billion.

In recent years, Liberty Global has been expanding its presence in Europe and has operations from Ireland to Romania, though it failed last month in its bid to acquire the Telenet Group of Belgium for $2.7 billion. Liberty Global owns a 58 percent stake in Telenet.

Since early 2010, Liberty has bought two German rivals to build its operations in Europe’s largest economy.

In response, News Corporation has been expanding its global cable business, including the $2.1 billion acquisition of Consolidated Media, the Australian pay-television company, late last year.

Since the beginning of the financial crisis, Virgin Media, whose commercials feature the Olympic sprinting star Usain Bolt, has announced job cuts and invested in its broadband structure to reduce costs and increase its market share in Britain’s competitive cable market.

The company’s market capitalization stands at more than $10 billion. Including debt, its enterprise value is around $19.4 billion, according Thomson Reuters. Shares of Virgin Media, which are primarily traded on the Nasdaq, were up nearly 18 percent to $45.61 on the news of the Liberty talks.

Virgin’s shares have jumped almost 90 percent in the last 12 months, as more consumers sign up for so-called bundled services, including Internet and cellphone contracts. Virgin Media will announce its earnings on Wednesday.

Analysts warned that it would be difficult for Liberty Global to make additional savings between its current European operations and those of Virgin Media because Liberty does not have a business in Britain.

They said Liberty waited to make its move until Virgin made several upgrades to its network and restructured its debt. While Virgin has been gaining market share, it has 4.9 million customers, or roughly half the number of subscribers as its larger rival, BSkyB, according to filings by the companies.

The British billionaire Richard Branson, whose Virgin brand is used for a variety of products and services, including airlines and banks, owns less than 3 percent of Virgin Media.

News of the talks also came amid heightened merger and acquisition activity in the European television business. In December, Discovery Communications agreed to pay $1.7 billion for the Scandinavian operations of a large German commercial television company.

According to news reports this week, the majority owners of the German company are considering a sale. American media companies, including Time Warner, have been mentioned as potential buyers.

Analysts say the flurry of activity is driven by a desire among pay-television companies and broadcasters to diversify revenue sources that are coming under increased pressure. So broadcasters are setting up pay-television channels, and cable and satellite companies are looking to new content delivery platforms, like the Internet.

While commercial broadcasters remain powerful in Germany, Britain is the most lucrative pay-television market in Europe, according to Screen Digest, a research firm.

The deal for Virgin Media is expected to close during the second quarter of this year.

LionTree Advisors, Credit Suisse and the law firms Shearman & Sterling and Ropes & Gray advised Liberty Global, while Goldman Sachs, JPMorgan Chase and the law firms Fried Frank and Milbank advised Virgin Media.

Mark Scott reported from London, and Eric Pfanner from Paris.

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This post has been revised to reflect the following correction:

Correction: February 5, 2013

Because of an editing error, an earlier version of this article misstated the first name of the leader of News Corporation. He is Rupert Murdoch, not Richard.

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