Fire Destroys Offices of Israeli Soccer Team That Recruited Muslims

Integrating Israeli Soccer:
The Times’s Jodi Rudoren looks at lingering racism in the stands of the last Israeli soccer team to field Muslim players.

JERUSALEM — Prime Minister Benjamin Netanyahu of Israel on Friday condemned as “shameful” the recent protests by soccer fans here of their team’s recent recruitment of two Muslim players, hours after the offices of the team were burned in what the police suspect was an arson set by some of those fans.

“We cannot accept such racist behavior,” Mr. Netanyahu said. “The Jewish people, who suffered excommunications and expulsions, need to represent a light unto the nations.”

The team, Beitar Jerusalem, has long been linked to Mr. Netanyahu’s Likud Party, and for 15 years has been notorious for racism and violence, including an incident last spring in which fans stormed a local mall chanting “Death to Arabs” and beat up several Arab employees. Founded in 1936, it is the only one of Israel’s professional soccer teams never to have recruited an Arab player.

The current controversy concerns the team’s addition of two Muslim players from Chechnya. Although one is injured, the other is expected to play for the first time in a match on Sunday against a team from Sakhnin, an Arab-Israeli town.

In anticipation of the Muslim players’ arrival, some fans unfurled a banner at the team’s Jan. 26 game saying “Beitar Pure Forever.” Some critics said the banner was reminiscent of Nazi Germany’s expulsion of Jews from sport, and it led to nationwide soul-searching.

Four fans were indicted on Thursday for incitement. Beitar headquarters were set on fire at 5 a.m. Friday, according to the police, destroying the team’s trophies, commemorative jerseys of former stars, championship flags, photographs and books. “All the history of Beitar Jerusalem,” said the team spokesman, Asaf Shaked. “It’s not damage by money, it’s damage by emotion.”

The mayor of Jerusalem, Nir Barkat, also condemned the violence on Friday, likening the perpetrators to the mafia. Limor Livnat, Israel’s minister of culture and sport, said she would attend Sunday’s game to show support for the team’s management.

Micky Rosenfeld, a police spokesman, said a special investigative team was looking into the arson, which he said “gushed through the offices,” and that the police would not only send hundreds of extra officers to Sunday’s game, but seek to arrest troublemakers beforehand.

Eli Abarbanel, a senior state prosecutor and Beitar fan, said on Israel Radio Friday that the soccer struggle reflected “a broad phenomenon of racism in all of Israeli society,” citing expressions of “joy” on social media after a recent bus accident that killed 20 Palestinian children.

Itzik Kornfein, Beitar’s manager, also said that the dispute had “gone beyond sports” and had “ramifications for Israeli society and for how we look to the world.” Speaking to Israel Radio, Mr. Kornfein vowed not to back down from his decision to integrate the team, saying, “I don’t compromise on the matter of racism” and predicting that “after violence of this kind, people will come to their senses.”

Mr. Shaked, the Beitar spokesman, said management would “continue to fight against this part of the fans” and “continue to hug the two players” in order “to show all the world” that the club is not defined by the slogans shouted from the stands.

“I hope that from this Sunday we’re going to start a new way for the club,” he said. “We call that ‘The New Beitar.’ This is the slogan of the club now: a different Beitar, a new Beitar.”

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DealBook: Helping Start-Ups With Local Support and National Networks

When Will Fuentes planned an extended business trip to Seattle last year, he tapped into the local chapter of a national networking group there. Within hours, Mr. Fuentes, who founded the Arlington, Va., software company Lemur Retail, had secured a work space, introductions and even restaurant recommendations via the group, the Startup America Partnership.“Before I flew out there, I already had five or six meetings set up with potential clients and other key contacts, as well as one potential acquirer,” Mr. Fuentes said.

A couple of years ago, entrepreneurs would have needed several trips to make similar connections outside their own cities. Even in this era of social networks and venture conferences, start-ups are still surprisingly disconnected on a national level.

“Each region has its ties, but in many cases, entrepreneurs are operating in silos,” said Carolynn Duncan, the chief executive of Portland Ten, a mentoring program for early-stage companies, mainly in Oregon. “An entrepreneur in Oregon doesn’t have an easy way to network with entrepreneurs in Washington D.C.”

Startup America, a nonprofit organization with an all-star cast of deep-pocketed backers, is trying to bridge the gap. The organization, which was started in January 2011 as the brainchild of AOL’s co-founder, Steve Case, and the Ewing Marion Kauffman Foundation, wanted to bring a private-sector support to start-ups — without financial strings attached.

“Supporting start-ups throughout the country is the only way to make sure the American economy is firing on all cylinders,” said Mr. Case, who is the chairman of the partnership.

Start-ups are a crucial driver for job creation in the United States. From March 1994 to March 2010, businesses less than one year old created 3.9 million jobs a year on average, according to the Bureau of Labor Statistics, though that number has declined during the recent economic weakness.

The Small Business Administration and United States Chamber of Commerce have long been a resource for start-ups, but these government agencies have a broad mandate. There is a “growing recognition,” said Mr. Case, that high-growth start-ups — those with the potential to be national or international companies — have different needs and requirements than traditional small businesses.

Startup America’s initial focus was to provide support to start-ups through deals on goods and services, like 40 percent off FedEx shipping and free flights on American Airlines. But the group quickly realized that start-ups needed more practical help, like sharing best practices and networking.

Soon after the partnership’s start, entrepreneurs around the country starting contacting Startup America, asking how they could create their own networks and reach out to counterparts in other states. “Most of these regions were already coming up with their own initiatives or thinking about them,” said the organization’s chief executive, Scott Case, a founder and former chief technology officer of Priceline.com (and no relation to Steve Case). “We’re helping to stitch together all these parts.”

Taking cues from the entrepreneurs, Startup America has turned its attention to building such a network. Nearly 12,000 members are now affiliated with local Startup America initiatives in 30 states. The partnership expects to add another 10 states this year.

Each Startup America region is spearheaded by local “champions” who come together several times a year at national conferences, communicate via Google groups and have access to an online “idea center” where they can brainstorm about, say, bringing in outside capital or hosting a start-up conference. These envoys are all “founder types” at different stages of their careers, Scott Case said. “Some have exited companies and are looking to continue to feed that creative drive. Others understand that if they can strengthen their community, they can strengthen their own company.”

Brooks Bell, founder of an eponymous 22-employee digital consulting business based in Raleigh, N.C., became involved with the partnership in 2011 after realizing that many potential clients considered her area a backwater. “I realized that was impacting my company’s brand, too,” she said.

Mrs. Bell pointed out that other national groups, like Entrepreneurs’ Organizations, offer resources for high-growth companies. Yet, their emphasis is typically on supporting individuals rather than elevating the region and networking nationally. “They also tend to focus on early-stage companies,” she said. Until Startup America, she added, “there weren’t a lot of opportunities for early-stage companies to interact with funded companies.”

Though Startup America regions work off the same blueprint, each takes a slightly different approach. In Maryland, the staff and champions volunteer virtually. Startup Tennessee partnered with the Entrepreneur Center in Nashville, which runs a nonprofit incubator program. Startup Colorado works out of Silicon Flatirons, a center for law, technology and entrepreneurship at the University of Colorado Law School, and finds partners to finance specific projects.

Although the regional chapters operate independently, they benefit from the credibility of a national organization. “It’s helping elevate our start-ups nationally and get them in front of audiences we never would have,” said Andy Stoll, an entrepreneur in the Iowa City, Iowa, area, where rebuilding from the floods in 2008 has helped generate a boom in start-up activity.

“To have the opportunity to sit in a room with their board and have Steve Case ask me, ‘What are the three things that those of us at this table can do to really help support the Indiana community?’ is amazing and a humbling experience,” said Michael Coffey, a partner at DeveloperTown, an Indianapolis design and development firm that works with companies of all sizes.

In the end, it’s all about business.

Aaron Schwartz, a co-founder of the San Francisco-based Modify Watches, initially joined Startup America for the discounts. Now, he’s also tapping into the partnership to network, including finding corporate clients who order custom watches and vendors. “I now have a contact in Tennessee who has offered to look into manufacturing our watches there,” he said

Mr. Fuentes of Lemur Retail found two potential clients, both national chains, through his connections in Seattle last year; he’s currently in talks with those companies. He’s also helping his Northwest counterparts make inroads in the Washington area. He likens the experience to a fraternity or alumni organization of entrepreneurs.

“When people contact me from my high school or college, I pick up the phone,” he said. “This is no different.”

A version of this article appeared in print on 02/08/2013, on page B5 of the NewYork edition with the headline: Helping Start-Ups With Local Support and National Networks.

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The New Old Age: The Executor's Assistant

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 no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age: The Executor's Assistant

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 no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

---

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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DealBook: Helping Start-Ups With Local Support and National Networks

When Will Fuentes planned an extended business trip to Seattle last year, he tapped into the local chapter of a national networking group there. Within hours, Mr. Fuentes, who founded the Arlington, Va., software company Lemur Retail, had secured a work space, introductions and even restaurant recommendations via the group, the Startup America Partnership.“Before I flew out there, I already had five or six meetings set up with potential clients and other key contacts, as well as one potential acquirer,” Mr. Fuentes said.

A couple of years ago, entrepreneurs would have needed several trips to make similar connections outside their own cities. Even in this era of social networks and venture conferences, start-ups are still surprisingly disconnected on a national level.

“Each region has its ties, but in many cases, entrepreneurs are operating in silos,” said Carolynn Duncan, the chief executive of Portland Ten, a mentoring program for early-stage companies, mainly in Oregon. “An entrepreneur in Oregon doesn’t have an easy way to network with entrepreneurs in Washington D.C.”

Startup America, a nonprofit organization with an all-star cast of deep-pocketed backers, is trying to bridge the gap. The organization, which was started in January 2011 as the brainchild of AOL’s co-founder, Steve Case, and the Ewing Marion Kauffman Foundation, wanted to bring a private-sector support to start-ups — without financial strings attached.

“Supporting start-ups throughout the country is the only way to make sure the American economy is firing on all cylinders,” said Mr. Case, who is the chairman of the partnership.

Start-ups are a crucial driver for job creation in the United States. From March 1994 to March 2010, businesses less than one year old created 3.9 million jobs a year on average, according to the Bureau of Labor Statistics, though that number has declined during the recent economic weakness.

The Small Business Administration and United States Chamber of Commerce have long been a resource for start-ups, but these government agencies have a broad mandate. There is a “growing recognition,” said Mr. Case, that high-growth start-ups — those with the potential to be national or international companies — have different needs and requirements than traditional small businesses.

Startup America’s initial focus was to provide support to start-ups through deals on goods and services, like 40 percent off FedEx shipping and free flights on American Airlines. But the group quickly realized that start-ups needed more practical help, like sharing best practices and networking.

Soon after the partnership’s start, entrepreneurs around the country starting contacting Startup America, asking how they could create their own networks and reach out to counterparts in other states. “Most of these regions were already coming up with their own initiatives or thinking about them,” said the organization’s chief executive, Scott Case, a founder and former chief technology officer of Priceline.com (and no relation to Steve Case). “We’re helping to stitch together all these parts.”

Taking cues from the entrepreneurs, Startup America has turned its attention to building such a network. Nearly 12,000 members are now affiliated with local Startup America initiatives in 30 states. The partnership expects to add another 10 states this year.

Each Startup America region is spearheaded by local “champions” who come together several times a year at national conferences, communicate via Google groups and have access to an online “idea center” where they can brainstorm about, say, bringing in outside capital or hosting a start-up conference. These envoys are all “founder types” at different stages of their careers, Scott Case said. “Some have exited companies and are looking to continue to feed that creative drive. Others understand that if they can strengthen their community, they can strengthen their own company.”

Brooks Bell, founder of an eponymous 22-employee digital consulting business based in Raleigh, N.C., became involved with the partnership in 2011 after realizing that many potential clients considered her area a backwater. “I realized that was impacting my company’s brand, too,” she said.

Mrs. Bell pointed out that other national groups, like Entrepreneurs’ Organizations, offer resources for high-growth companies. Yet, their emphasis is typically on supporting individuals rather than elevating the region and networking nationally. “They also tend to focus on early-stage companies,” she said. Until Startup America, she added, “there weren’t a lot of opportunities for early-stage companies to interact with funded companies.”

Though Startup America regions work off the same blueprint, each takes a slightly different approach. In Maryland, the staff and champions volunteer virtually. Startup Tennessee partnered with the Entrepreneur Center in Nashville, which runs a nonprofit incubator program. Startup Colorado works out of Silicon Flatirons, a center for law, technology and entrepreneurship at the University of Colorado Law School, and finds partners to finance specific projects.

Although the regional chapters operate independently, they benefit from the credibility of a national organization. “It’s helping elevate our start-ups nationally and get them in front of audiences we never would have,” said Andy Stoll, an entrepreneur in the Iowa City, Iowa, area, where rebuilding from the floods in 2008 has helped generate a boom in start-up activity.

“To have the opportunity to sit in a room with their board and have Steve Case ask me, ‘What are the three things that those of us at this table can do to really help support the Indiana community?’ is amazing and a humbling experience,” said Michael Coffey, a partner at DeveloperTown, an Indianapolis design and development firm that works with companies of all sizes.

In the end, it’s all about business.

Aaron Schwartz, a co-founder of the San Francisco-based Modify Watches, initially joined Startup America for the discounts. Now, he’s also tapping into the partnership to network, including finding corporate clients who order custom watches and vendors. “I now have a contact in Tennessee who has offered to look into manufacturing our watches there,” he said

Mr. Fuentes of Lemur Retail found two potential clients, both national chains, through his connections in Seattle last year; he’s currently in talks with those companies. He’s also helping his Northwest counterparts make inroads in the Washington area. He likens the experience to a fraternity or alumni organization of entrepreneurs.

“When people contact me from my high school or college, I pick up the phone,” he said. “This is no different.”

A version of this article appeared in print on 02/08/2013, on page B5 of the NewYork edition with the headline: Helping Start-Ups With Local Support and National Networks.

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Way of the World: Theorizing About Taxing High Earners

NEW YORK — Academics can be dismissive of the concerns of the popular media. But when it comes to the growth of the superrich, the tabloids may have gotten it right.

The numbers tell the story. According to a study by John Van Reenen of the London School of Economics and Brian Bell of Oxford University, the share of national income earned by the top 1 percent in the United States surged to 18.3 percent in 2007, from 8 percent in 1979. In Britain, the trend was almost identical: The top 1 percent received 15.4 percent of the national income in 2007 compared with 5.9 percent in 1979. And these figures exclude capital gains.

“A lot of the action has been at the very top end of the distribution, the top 1 percent or the top 0.1 percent,” Mr. Van Reenen, director of the Center for Economic Performance at the L.S.E., told me. “It shows you that the media’s focus on the very rich and on bankers’ bonuses wasn’t misplaced.”

But while much of the shift in income distribution has been at the apex of the pyramid, that is not where most academic research on rising income inequality has been focused.

If anything, Mr. Van Reenen said, academics “have tended to focus on the bottom of the distribution, much more than the top.”

Mr. Van Reenen and some like-minded colleagues have been working to fill that gap. Their efforts made it to the economic major leagues in January, when Mr. Van Reenen convened a panel discussion on extreme wage inequality at the prestigious annual get-together of the American Economic Association.

One of the most striking findings will probably give comfort to the plutocrats: In contrast to previous generations, the superrich today tend to have earned their fortunes rather than inherited them.

Steven Kaplan of the University of Chicago and Joshua Rauh of Stanford University in California studied Forbes magazine’s annual list of the 400 richest Americans. They found that in 1982, just 40 percent of these plutocrats had built their own businesses. By 2011, the superrich had gotten much richer — the combined wealth of the Forbes 400 was $92 billion in 1982 and had surged to $1.53 trillion by 2011 — and many more of them had, as the meme of the 2012 U.S. presidential election campaign had it, built it themselves: 69 percent.

“This isn’t the Downton Abbey rentier class,” explained Mr. Van Reenen, who has found a similar trend in Britain. “These incomes come from the labor market. You can say it is a triumph of the human capitalists over the physical capitalists.”

Among economists who study the surge in pay at the top, it is pretty much a truth universally acknowledged that taxes should rise at the summit, too. “Economics would suggest that when you have big increases in inequality, the top tax rate should rise,” Mr. Van Reenen said. “That seems very right and very reasonable.”

The impact and the structure of higher taxes for the rich are a more complicated and controversial issue. Timothy Besley and Maitreesh Ghatak, both of the London School of Economics, make a robust case for higher taxes on bankers’ bonuses. Their work is theoretical, but beyond the campus green, what may be particularly interesting is the way they frame the wider debate.

“Little undermines the case for a market economy more than the perception that there is injustice in the rewards that it generates,” they argue in a recent paper. “The greatest clamor for reform should come from those who support the market system.”

“We have shown that some form of bonus taxation in the financial sector is optimal above and beyond standard progressive income taxation,” they conclude. “We have identified a form of taxation that we believe makes the market system both fairer and more efficient.”

This robustly pro-market rationale for higher taxes on bankers, who like to think of themselves as the very embodiment of capitalism, is eye-catching, particularly for anyone who spends much time in the United States, where higher taxes and more efficient markets are usually portrayed as being anathema to one another.

Emmanuel Saez, an economist at the University of California, Berkeley, who is one of the pioneering students of incomes at the very top, has offered an even more provocative suggestion. At the American Economic Association meeting, he argued that when tax rates at the top are low, “top earners extract more pay at the expense of the 99 percent.” Higher tax rates for the rich, he suggested, “reduce the pretax income gap without hurting economic growth.”

This is a truly radical idea: that higher taxes at the top can reduce pretax inequality and not weaken the economy as a whole.

Outside the seminar room, however, these elegant ideas may run into political opposition intensified by the trends within the 1 percent that these same economists have documented.

“It may have a political effect,” Mr. Van Reenen said of the shift from inherited fortunes to self-made ones. “You feel you’ve earned it. This does make people more strongly inclined to resist taxation.”

Chrystia Freeland is editor of Thomson Reuters Digital.

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I.H.T. Special: Social Media Firms Move to Capitalize on Popularity in Middle East

Suhaib Salem/Reuters

Egyptian protesters look at Facebook during a demonstration in Cairo on January 14.

DUBAI — For its most recent advertising push, the Saudi Arabian telecommunications giant Mobily did not turn to the street or television to engage with customers. Mobily paid to promote itself on Twitter.

The use of social media exploded during the Arab Spring as people turned to cyberspace to express themselves. On the back of that, social media networks, including Twitter, Facebook and LinkedIn, have moved into the region commercially, setting up offices to sell advertising products to companies like Mobily, which has over 200,000 Twitter followers, to capitalize on the growing audience.

“In Saudi, social media gets everyone talking to everyone, which is something we just don’t have in the streets here,” said Muna AbuSulayman, a Saudi development consultant and formerly a popular television talk show host, who has over 100,000 followers on Twitter.

“It’s a unique opportunity that lets people have conversations in a boundary-less way that wasn’t possible before,” Ms. AbuSulayman said. “In addition to promoting social and political discussion, it carries a powerful economic incentive for businesses, too.”

The rise of social media in the Arab world is changing the game for regional advertisers, pushing growth in digital advertising in a part of the world where traditional methods like television and print advertising have so far remained dominant.

Digital advertising in the Middle East and North Africa accounts for only about 4 percent of the region’s total advertising spending, at a value of $200 million, according to the most recent available estimate, but it has become the fastest-growing media platform in the region, said a study by the business services firm Deloitte Touche Tohmatsu, published in 2011. Deloitte’s Arab Media Outlook projected growth in digital advertising spending in the region of 35 percent a year over the next three years, generating about $580 million across the region by 2015.

“The fact is that consumers are online, so brands need to be online,” said Reda Raad, chief operating officer of TBWA\Raad, the Middle East arm of the global advertising agency TBWA. “The use of digital channels has continued to increase dramatically after the Arab Spring and advertising on social media has become a highly targeted, cost-efficient way of communicating with consumers.”

Major brands, including Pepsi Arabia, are taking note. Saudi Arabia has the highest number of Twitter users in the Arab world, holding 38 percent of the region’s two million users, according to a report by the Dubai School of Government’s Arab Social Media Report released in June. In the past year alone, the number of Twitter users in the Arab world tripled, according to Shailesh Rao, Twitter’s vice president for international operations.

Thanks to the platform’s popularity in Saudi Arabia, Egypt, Kuwait and the United Arab Emirates, Arabic is now the fastest-growing language on the Twitter platform.

“We prioritized a list of regions where we wanted to have a business presence, and the Mideast rises toward the top because the region’s user base is one of the fastest-growing in the world,” Mr. Rao said during an interview. “This represents a huge opportunity for brands looking for a large audience that is rapidly growing.”

Twitter has formed a partnership with the Egyptian digital advertising company Connect Ads to market and sell advertising services across the Middle East and North Africa region. Connect Ads will offer brand managers and marketers Twitter’s products, which include promoted tweets, promoted accounts and promoted trends.

Through these, a brand can reach broad Twitter audiences or more narrowly defined geographic or demographic segments. They can even target users of specific smartphone brands, like iPhones. Brands that have signed up so far include Mobily, Pepsi Arabia, the resort company Atlantis The Palm, and the events portal Dubai Calendar.

“Companies can learn a few things about their customers by optimizing for country and targeting those with specific interests,” said Mohamed El Mehairy, managing director of Connect Ads.

“They can probably uncover this type of information through market research,” he added, but it would come “at a higher expense and with more time and effort.”

This article has been revised to reflect the following correction:

Correction: February 7, 2013

A previous version of this article misspelled the name of the advertising agency TBWA. It is TBWA, not TWBA.

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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 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.

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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.

Correction: The patient’s eyes were brown, not blue.

Read More..

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

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

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

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

The Presenting Problem:

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

The Patient’s Story:

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

A Sister’s Visit:

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

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

His 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 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.

Correction: The patient’s eyes were brown, not blue.

Read More..

DealBook: K.K.R.'s Earnings Rise 22% on Investment Gains

Improving 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.

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