A delicate new balancing act in senior healthcare

When Claire Gordon arrived at Cedars-Sinai Medical Center, nurses knew she needed extra attention.

She was 96, had heart disease and a history of falls. Now she had pneumonia and the flu. A team of Cedars specialists converged on her case to ensure that a bad situation did not turn worse and that she didn't end up with a lengthy, costly hospital stay.

Frail seniors like Gordon account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.

The U.S. population is aging quickly: People older than 65 are expected to make up nearly 20% of it by 2030. Linda P. Fried, dean of the Columbia University Mailman School of Public Health, said now is the time to train professionals and test efforts to improve care and lower healthcare costs for elderly patients.

"It's incredibly important that we prepare for being in a society where there are a lot of older people," she said. "We have to do this type of experiment right now."

At Cedars-Sinai, where more than half the patients in the medical and surgical wards are 65 or older, one such effort is dubbed the "frailty project." Within 24 hours, nurses assess elderly patients for their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.

The Cedars project stands out nationally because medical professionals are working together to identify high-risk patients at the front end of their hospitalizations to prevent problems at the back end, said Herb Schultz, regional director of the U.S. Department of Health and Human Services.

"For seniors, it is better care, it is high-quality care and it is peace of mind," he said.

The effort and others like it also have the potential to reduce healthcare costs by cutting preventable medical errors and readmissions, Schultz said. The federal law penalizes hospitals for both.

Gordon, an articulate woman with brightly painted fingernails and a sense of humor, arrived at Cedars-Sinai by ambulance on a Monday.

Soon, nurse Jacquelyn Maxton was at her bedside asking a series of questions to check for problems with sleep, diet and confusion. The answers led to Gordon's designation as a frail patient. The next day, the project team huddled down the hall and addressed her risks one by one. Medical staff would treat the flu and pneumonia while at the same time addressing underlying health issues that could extend Gordon's stay and slow her recovery, both in the hospital and after going home.

To reduce the chance of falls, nurses placed a yellow band on her wrist that read "fall risk" and ensured that she didn't get up on her own. To prevent bed sores, they got her up and moving as often as possible. To cut down on confusion, they reminded Gordon frequently where she was and made sure she got uninterrupted sleep. Medical staff also stopped a few unnecessary medications that Gordon had been prescribed before her admission, including a heavy narcotic and a sleeping pill.

"It is really a holistic approach to the patient, not just to the disease that they are in here for," said Glenn D. Braunstein, the hospital's vice president for clinical innovation.

Previously, nurse Ivy Dimalanta said, she and her colleagues provided similar care but on a much more random basis. Under the project, the care has become standardized.

The healthcare system has not been well designed to address the needs of seniors who may have had a lifetime of health problems, said Mary Naylor, gerontology professor at the University of Pennsylvania School of Nursing. As a result, patients sometimes fall through the cracks and return to hospitals again and again.

"That is not good for them and that is not good for society to be using resources in that way," Naylor said.

Using data from related projects, Cedars began a pilot program in 2011 and expanded it last summer. The research is continuing but early results suggest that the interventions are leading to fewer seniors being admitted to the intensive care unit and to shorter hospital stays, said Jeff Borenstein, researcher and lead clinician on the frailty project. "It definitely seems to be going in the right direction," he said.

The hospital is now working with Naylor and the University of Pennsylvania to design a program to help the patients once they go home.

"People who are frail are very vulnerable when they leave the hospital," said Harriet Udin Aronow, a researcher at Cedars. "We want to promote them being safe at home and continuing to recover."

In Gordon's case, she lives alone with the help of her children and a caregiver. The hospital didn't want her experiencing complications that would lengthen the stay, but they also didn't want to discharge her before she was ready. Under the health reform law, hospitals face penalties if patients come back too soon after being released.

Patients and their families often are unaware of the additional attention. Sitting in a chair in front of a vase of pink flowers, Gordon said she knew she would have to do her part to get out of the hospital quickly. "You have to move," she said. "I know you get bed sores if you stay in bed."

Gordon said she was comfortable at the hospital but she wanted to go back to her house as quickly as she could. "There's no place like home," she said.

Two days later, that's where she was.

anna.gorman@latimes.com

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Stars salute MusiCares honoree Bruce Springsteen

LOS ANGELES (AP) — Be it concert or charity auction, Bruce Springsteen can bring any event to a crescendo.

Springsteen briefly took over auctioneering duties before being honored as MusiCares person of the year Friday night, exhorting the crowd to bid on a signed Fender electric guitar by amping up the deal. The 63-year-old rock 'n' roll star moved the bid north from $60,000 by offering a series of sweeteners.

"That's right, a one-hour guitar lesson with me," Springsteen shouted. "And a ride in my Harley Davidson sidecar. So dig in, one-percenters."

That moved the needle past $150,000. He added eight concert tickets and backstage passes with a bonus tour conducted by Springsteen himself. That pushed it to $200,000, but he wasn't done.

"And a lasagna made by my mother!" he shouted as an in-house camera at the Los Angeles Convention Center cut to his 87-year-old mother Adele Ann Springsteen.

And with an extra $250,000 in the musicians charity's coffers, Springsteen sat down and spent most of the evening in the unusual role of spectator as a string of stars that included Elton John, Neil Young, Sting, Kenny Chesney, John Legend, Faith Hill and Tim McGraw, Patti Smith, Jackson Browne took the stage two nights before the Grammy Awards.

"Here's a little secret about Bruce Springsteen: He loves this," host Jon Stewart joked. "There's nothing he'd rather do than come to Los Angeles, put on a suit ... and then have people talking about him like he's dead."

Alabama Shakes kicked things off with "Adam Raised A Cain" and over the course of the evening there were several interesting takes on Springsteen's voluminous 40-year catalog of hits. Natalie Manes, Ben Harper and Charlie Musselwhite played a stripped down "Atlantic City." Mavis Staples and Zac Brown put a gospel spin on "My City of Ruins." John added a funky backbeat to "Streets of Philadelphia." Kenny Chesney offered an acoustic version of "One Step Up."

Jim James and Tom Morello burned through a scorching version of "The Ghost of Tom Joad" that brought the crowd out of their seats as Morello finished the song with a fiery guitar solo. And Mumford & Sons took it the opposite way, playing a quiet, acoustic version of "I'm On Fire" in the round that had the crowd leaning in.

Legend offered a somber piano version of "Dancing in the Dark" and Young shut down the pre-Springsteen portion of the evening with a "Born in the USA" that included two sign-language interpreters dressed as cheerleaders signing along to the lyrics.

"John Legend made me sound like Gershwin," Springsteen said. "I love that. Neil Young made me sound like the Sex Pistols. I love that. What an evening."

Springsteen spoke of the "miracle of music," the importance of musicians in human culture and making sure everyone is cared for. And he joked that he somehow ended up being honored by MusiCares, a charity that offers financial assistance to musicians in need run by The Recording Academy, after his manager called up Grammys producer Ken Ehrlich to seek a performance slot on the show in a "mercenary publicity move."

In the end, though, he was moved by the evening.

"It's kind of a freaky experience, the whole thing," Springsteen said. "This is the huge Italian wedding Patti (Scialfa) and I never had. It's a huge Bar Mitzvah. I owe each and every one of you. You made me feel like the person of the year. Now give me that damn guitar."

He asked the several thousand attendees to move toward the stage — "Come on, it's only rock 'n' roll" — and kicked off his five-song set with his Grammy nominated song "We Take Care Of Our Own." At the end of the night he brought everyone on stage for "Glory Days."

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Online:

http://grammy.com

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Follow AP Music Writer Chris Talbott: http://twitter.com/Chris_Talbott.

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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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Entrepreneur Brian Lee is business partner to the stars

The gig: Lawyer-turned-serial-entrepreneur Brian Lee, 41, is pulling double duty as the chief executive of two celebrity-backed e-commerce websites: ShoeDazzle, co-founded with Kim Kardashian, and Honest Co., co-founded with Jessica Alba. The companies are headquartered in Santa Monica and offer customers monthly subscription plans in addition to typical a la carte shopping for shoes and baby products, respectively.

ShoeDazzle has more than 15 million registered users and last year posted $100 million in revenue, up 80% from 2011; it has raised $66 million from investors including venture capital firm Andreessen Horowitz. Honest Co., launched a year ago, has yet to release membership or financial numbers but has raised $27 million.

From Seoul to L.A.: Lee was born in Seoul. When he was 1, his family immigrated to Huntington Beach, where he grew up.

As an 8-year-old, Lee mapped out his trick-or-treating route on Halloween so he could collect as much candy as possible. When he got home, he separated his loot into Ziploc bags, which he sold at school for 25 cents each.

"Cost of goods: zero. Profit margins: 100%, outside of my own little labor," he said. "I probably did that for five years."

He now lives in Marina del Rey with his wife, Mira; their 4-year-old son, Davis; and their 1-year-old daughter, Madison.

Education: Bachelor's degree in business economics from UCLA in 1993, J.D. from UCLA School of Law in 1996.

Bold cold call: After practicing law for a few years, Lee came up with the idea for LegalZoom, which offers self-help legal documents such as divorce and bankruptcy forms, prenuptial agreements and wills. He wanted a high-profile name to represent the start-up, and decided to approach O.J. Simpson defense attorney Robert Shapiro.

Lee got Shapiro's number from 411 and called him at 10 p.m. "He picked up the phone and said, 'Hi, this is Robert Shapiro, how can I help you?' and I said, 'Well, my name is Brian Lee and I have a business opportunity I'd like to run by you.'... I think he heard the desperation in my voice and he said, 'You've got two minutes.'"

LegalZoom, based in Glendale, launched in 2001.

Online shoe shopping: ShoeDazzle was inspired by Lee's wife, who one day returned from a shopping spree on Robertson Boulevard with a pair of pricey designer shoes. When Lee asked her why she didn't just go to Loehmann's or DSW, she said discount chains didn't provide the type of personalized, one-on-one service that small boutiques did. Lee set out to replicate that experience online and met Kardashian through Shapiro, who is a family friend.

ShoeDazzle launched four years ago as an online subscription business, with members viewing a customized showroom of shoes based on a personal fashion quiz and choosing one new pair to receive every month for $39.95 including shipping.

Taking back the reins: In November, Lee became CEO of ShoeDazzle for a second time. He returned after the departure of Bill Strauss, who scrapped the company's subscription-based business model last year, leading to speculation that the company wasn't doing well.

In his first 100 days on the job, Lee laid off about two dozen employees and hired celebrity fashion stylist Rachel Zoe as the company's chief stylist; ShoeDazzle also began introducing one new shoe style every day. This month the company will roll out an optional $9.95-a-month VIP membership program that includes free shipping, early access to sales, discounts and an extended return policy.

Since a site relaunch in January, orders have increased 30% and repeat visits are up 12%, Lee said. The company sells as many as 250,000 pairs of shoes per month.

From shoes to babies: Lee was approached by Alba when the actress wanted to start an eco-friendly baby products line. Honest Co. sells diapers, shampoo, sunscreen and household items online that are nontoxic and made with organic ingredients.

Caffeine junkie: As the CEO of two companies, Lee arrives at Honest Co. offices by 7 a.m. every day and is there until 9:30 a.m. He then heads over to nearby ShoeDazzle, where he stays until 5 p.m. or so. Then it's back to Honest Co. until about 8 or 9 p.m.

"I drink seven Coca-Colas a day," he said. "Regular Coke, which is really bad for me."

Advice to entrepreneurs: "Believe in the idea with 100% certainty," Lee said. "But also don't be scared to change that idea and pivot very quickly. Because as an entrepreneur, nothing ever goes to plan."

For instance, Lee said that in the early days of LegalZoom, the company created do-it-yourself software programs such as Estate Planning in a Box that it hoped to sell at Staples and OfficeMax. When LegalZoom realized that Internet-based downloading was the future, it dropped those plans.

"We spent a lot of resources on it," he said, "but we weren't afraid at all to just cut it."

andrea.chang@latimes.com

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Big Bear locked down amid manhunt

The bustling winter resort of Big Bear took on the appearance of a ghost town Thursday as surveillance aircraft buzzed overhead and police in tactical gear and carrying rifles patrolled mountain roads in convoys of SUVs, while others stood guard along major intersections.

Even before authorities had confirmed that the torched pickup truck discovered on a quiet forest road belonged to suspected gunman Christopher Dorner, 33, officials had ordered an emergency lockdown of local businesses, homes and the town's popular ski resorts. Parents were told to pick up their children from school, as rolling yellow buses might pose a target to an unpredictable fugitive on the run.

By nightfall, many residents had barricaded their doors as they prepared for a long, anxious evening.

PHOTOS: A tense manhunt amid tragic deaths

"We're all just stressed," said Andrea Burtons as she stocked up on provisions at a convenience store. "I have to go pick up my brother and get him home where we're safe."

Police ordered the lockdown about 9:30 a.m. as authorities throughout Southern California launched an immense manhunt for the former lawman, who is accused of killing three people as part of a long-standing grudge against the LAPD. Dorner is believed to have penned a long, angry manifesto on Facebook saying that he was unfairly fired from the force and was now seeking vengeance.

Forest lands surrounding Big Bear Lake are cross-hatched with fire roads and trails leading in all directions, and the snow-capped mountains can provide both cover and extreme challenges to a fugitive on foot. It was unclear whether Dorner was prepared for such rugged terrain.

Footprints were found leading from Dorner's burned pickup truck into the snow off Forest Road 2N10 and Club View Drive in Big Bear Lake.

San Bernardino County Sheriff John McMahon said that although authorities had deployed 125 officers for tracking and door-to-door searches, officers had to be mindful that the suspect may have set a trap.

"Certainly. There's always that concern and we're extremely careful and we're worried about this individual," McMahon said. "We're taking every precaution we can."

PHOTOS: A fugitive's life on Facebook

Big Bear has roughly 400 homes, but authorities guessed that only 40% are occupied year-round.

The search will probably play out with the backdrop of a winter storm that is expected to hit the area after midnight.

Up to 6 inches of snow could blanket local mountains, the National Weather Service said.

FULL COVERAGE: Sweeping manhunt for rampaging ex-cop

Gusts up to 50 mph could hit the region, said National Weather Service meteorologist Mark Moede, creating a wind-chill factor of 15 to 20 degrees.

Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.

"He could be anywhere at this point," McMahon said. When asked if the burned truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Craig and Christine Winnegar, of Murrieta, found themselves caught up in the lockdown by accident. Craig brought his wife to Big Bear as a surprise to celebrate their 28th wedding anniversary. Their prearranged dinner was canceled when restaurant owners closed their doors out of fear.

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Tyler, Fleetwood go to privacy hearing in Hawaii

HONOLULU (AP) — Rock stars Steven Tyler and Mick Fleetwood appeared Friday at a Hawaii legislative hearing to push a bill aimed at protecting celebrities' privacy.

The so-called Steven Tyler Act would give celebrities or anyone else the power to sue paparazzi who take photos or video of their private lives in an offensive way.

Tyler says he had his manager draft the bill and requested that Sen. Kalani English introduce it on his behalf.

The former "American Idol" judge recently bought a multi-million dollar home in English's district on Maui.

"The paradise of Hawaii is a magnet for celebrities who just want a peaceful vacation," Tyler said in a statement emailed to The Associated Press a day ahead of the hearing. "As a person in the public eye, I know the paparazzi are there and we have to accept that. But when they intrude into our private space, disregard our safety and the safety of others, that crosses a serious line that shouldn't be ignored."

More than two-thirds of the state Senate co-sponsored the measure. Britney Spears and Avril Lavigne are among more than a dozen celebrities who submitted testimony supporting the bill along with the Aerosmith and Fleetwood Mac rockers.

The stars say paparazzi have made simple activities like cooking with family and sunbathing elusive luxuries and the bill would give them peace of mind.

National media organizations oppose the measure and say the law would infringe on constitutional rights.

The National Press Photographers Association said the bill is "well-meaning but ill-conceived."

The New York-based organization represents numerous national media organizations, including the Society of Professional Journalists, the Associated Press Media Editors and the American Society of News Editors.

The Motion Picture Association of America also opposes the bill, saying it could make it harder to police movie piracy.

The bill would open up photographers, videographers and distributors to civil lawsuits if they take, sell or disseminate photos or videos of someone during private or family moments "in a manner that is offensive to a reasonable person."

The bill doesn't specify whether public places, like Hawaii's beaches, would be exempt. The bill says it would apply to people who take photos from boats or anywhere else within ocean waters.

Hawaii's Senate Judiciary Committee hearing marks the first time lawmakers will discuss the bill publicly. English has said the bill is not intended to limit beach photos.

The state's largest newspaper, the Honolulu Star-Advertiser, published an editorial Thursday that called lawmakers who support the bill "star-struck."

The newspaper said the bill might not affect only journalists.

"It could also make lawbreakers out of anyone taking photographs in public places, be it an ordinary photojournalist or someone with a camera phone," the editorial said.

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Anita Hofschneider can be reached at http://twitter.com/ahofschneider

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Online:

Text of bill: http://1.usa.gov/YfbJqi

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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.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”

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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.

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Stocks close higher; S&P 500 highest since Nov. `07

The Standard and Poor's 500 edged up to a five-year high Friday, extending a rally that started in January.

The S&P 500 rose 8.54 points to 1,517.93, closing 0.3 percent up for the week. The index is at its highest since November 2007 and has advanced for six weeks, the longest streak of gains since August.

The Dow Jones industrial average rose 48.92 points, or 0.4 percent, to 13,992.97. The Nasdaq composite climbed 28.74 points, or 0.9 percent, to finish the week at 3,193.87.

The Dow had its best January in almost two decades, and closed above 14,000 on Feb. 1 for the first time since 2007. The index is up 6.8 percent so far this year; the S&P 500 is up 6.4 percent.

A last-minute budget deal in Washington to avoid the “fiscal cliff” of tax hikes and spending cuts helped powered the rally, as did as optimism about the housing sector and gradual improvements in the jobs market.

The S&P 500 finished the week higher despite logging its biggest daily decline in almost three months Monday following worrying news from Europe.

The index fell 1.2 percent that day as bond yields in Spain and Italy rose on concern that the region's politicians will drag Europe back into crisis. European Central Bank President Mario Draghi's cautious comments about the region's economy also weighed on markets Thursday.

“Everybody seems to be saying this market needs to correct,” said Robert Pavlik, chief market strategist at Banyan Partners. “Nobody wants to be in it, but nobody wants to be out of it.”

Largely positive corporate earnings reports and a report that showed that the U.S. trade deficit narrowed sharply in December provided more fuel for the market's advance Friday.

The trade deficit fell nearly 21 percent in December from November to $38.6 billion, the smallest in nearly three years, as exports rose while oil imports plummeted. The smaller trade gap means the economy likely performed better in the final three months of last year than first reported last week.

“The trade balance was surprisingly very good,” said Phil Orlando, chief market strategist at Federated Investors.

The government estimated that the U.S. economy contracted at an annual rate of 0.1 percent in the last three months of 2012. Orlando estimates that may now be revised to growth of 0.5 percent.

Shares of LinkedIn, the online professional networking service, jumped $26.39, or 21.3 percent, to $150.40 after the company reported fourth-quarter results late Thursday that beat analysts' forecasts. AOL soared $2.31 to $33.72 after the Internet company said its quarterly revenue grew for the first time in eight years, helped by strength in worldwide advertising.

Currently, analysts are expecting earnings for the fourth quarter of 2012 to rise 6.5 percent for S&P 500 companies, according to data from S&P Capital I&Q. That's an increase from the 2.4 percent growth rate recorded for the preceding quarter.

Stocks have benefited as investors poured a net $4.1 billion into stock mutual funds since the start of the year, according to data provided by Lipper.

“I'm very encouraged by the fact, that finally, for the first time in many years, individual investors seem to be participating in this,” said David Kelly, chief global strategist at J.P. Morgan Funds.

The yield on the 10-year note, which moves inversely to its price, fell one basis point to 1.95 percent.

Trading volume was light as Wall Street braced for what is forecast to be the largest winter storm in more than a year. Up to 2 feet of snow forecast along the densely populated Interstate 95 corridor from the New York City area to Boston and beyond.

Among other stocks making big moves;

— Microchip Technology, a semiconductor maker, jumped $2.45, or 7.2 percent, to $36.39 after its earnings beat estimates. The company said it was seeing “exceptionally strong” bookings.

— Moody's slumped $3.62, or 7.7 percent, to $43.37 even after reporting that fourth-quarter net income jumped 66 percent and revenue blew away expectations. Many are expecting the ratings agency will be the next target of the Justice Department, which filed a suit against rival Standard & Poor's for its actions before the housing market collapse.

— Activision Blizzard, which makes “Call of Duty” and other video games, rose $1.35, or 11.2 percent, to $13.41. The company posted sharply higher earnings and revenue in the fourth quarter, surpassing Wall Street's expectations.

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Ex-cop at center of manhunt called 'depraved,' 'cowardly'

The fired LAPD officer suspected of terrorizing Southern California in a bloody rampage opened fire on two Riverside police officers with a rifle in a "cowardly ambush" early Thursday morning, Riverside police Chief Sergio Diaz told reporters at a morning news conference.

A 34-year-old officer who was an 11-year veteran of the department was killed in the attack. He was training a 27-year-old officer, who was shot in the upper body but survived, Diaz said. Their names were not released.

Diaz, a former Los Angeles Police Department deputy chief, said he believed the attack was random, coming less than 20 minutes after the suspect -- identified as Christopher Jordan Dorner -- had opened fire on two LAPD officers in Corona near the Magnolia Street exit ramp on Interstate 15.

PHOTOS: The Manhunt

Those officers were among 41 special details dispatched to protect LAPD officers whom Dorner, in an online manifesto, allegedly threatened to hunt down in revenge for being dismissed from the force.

"My opinion of the suspect is unprintable,'' Diaz said. "The manifesto I think speaks for itself as evidence enough of a depraved and abandoned mind and heart.''

The suspect allegedly opened fire as the Riverside officers were stopped at red light at the intersection of Magnolia Avenue and Arlington Boulevard around 1:35 p.m. Bullets pierced the patrol car's windshield, hitting both officers in the chest, Diaz said.

Law enforcement officers from agencies around the Inland Empire descended on Riverside after the shooting to assist with the manhunt. Officers tooting rifles and shotguns stood vigil outside the Riverside police station, which has been placed on "high alert.''

Diaz described the situation as surreal.

"We're hoping to wake up and find this is a bad dream,'' he said

Corona police Chief Michael Abel said the suspect opened fire on two LAPD officers after they were flagged down by a resident who recognized Dorner's Nissan Titan pickup truck. After a short pursuit, Dorner shot at the officers with a rifle, grazing one on the head. The LAPD officers returned fire but their patrol car was disabled and they could not continue the pursuit.

The LAPD officer who was shot was hospitalized and a full recovery is expected, said LAPD Dep. Chief Jose Perez. He was not identified.

Diaz's news conference, held in a Riverside police station near the Tyler Mall, was flooded with television news crews and other media.

Diaz said the department decided to delay releasing the names of the slain and wounded officers because of fears that Dorner, in his quest to hunt down police officers and their relatives, may target their families.

With the city on edge, Diaz urged parents to continue sending their children to school -- which he said was the safest place for them -- and for local businesses to stay open. There's no evidence that Dorner remained in Riverside, or that that he was targeting anyone in the city, Diaz said.

Diaz said he did not know the suspect while he was with the LAPD, and did not have any role in the grievance proceeding that led to Dorner's dismissal in 2009.

"We're going to find him. You can't have this many people looking for you and not be found,'' Diaz said.

Some schools in the area were closed.

A note posted on the Notre Dame Catholic High School website said the school was closed because of the shooting. The school is not far from the scene of the attack.

Meanwhile, a spokeswoman with the Riverside Unified School District said officials were trying to reassure parents that the district's campuses were safe and that they were working closely with authorities.

"Of course, we are being vigilant, even more extra than we normally do," said district spokeswoman Jacquie Paul.

Despite the outreach some parents have chosen to keep their children at home, she said.

PHOTOS: The Manhunt

The district oversees about 42,000 students from kindergarten through high school. She said students would be excused if their parents decided to keep them home. 

"We're very understanding of parents who are nervous, because we understand where they are coming from."

Assistant Supt. David Hansen of the Corona Norco Unified School District said some parents in his district had also kept their students home.

Hansen said all schools were operating normally. He said a automatic phone message was sent to parents telling them that officials were aware if the shootings, and to ensure them they were working closely with police.

"There's anxiety all around because this has been on the news," Hansen said.

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Afghan boys from nominated film to walk red carpet

KABUL, Afghanistan (AP) — Fawad Mohammadi has spent half his life peddling maps and dictionaries to foreigners on a street of trinket shops in Kabul. Now the 14-year-old Afghan boy with bright green eyes is getting ready for a trip down the red carpet at the Oscars.

It will also be his first time out of the country and his first time on a plane.

Mohammadi was plucked from the dingy streets of the Afghan capital to be one of the main stars of "Buzkashi Boys," a coming-of-age movie filmed entirely in a war zone and nominated in the Best Live Action Short Film category.

The movie is about two penniless young boys — a street urchin and a blacksmith's son — who are best friends and dream of becoming professional players of buzkashi, a particularly rough and dangerous game that somewhat resembles polo: Horseback riders wrangle to get a headless goat carcass into a circular goal at one end of the field.

It's also part of an American director's effort to help revive a film industry devastated by decades of civil war and by the Taliban, an Islamic fundamentalist movement that banned entertainment and burned films and theaters during its five years in power.

Sam French, a Philadelphia native who has lived in Afghanistan for about five years, said his 28-minute movie was initially conceived as a way of training local film industry workers — the first installment in his nonprofit Afghan Film Project.

"We never dreamed of having the film come this far and get an Oscar nomination," French, 36, said in a telephone interview from Los Angeles, where he is preparing for the Feb. 24 Academy Awards and raising money to fly the two young co-stars in for the ceremony.

The two boys playing the main characters — Mohammadi and Jawanmard Paiz — can barely contain their excitement about going to the Oscars.

"It will be a great honor for me and for Afghanistan to meet the world's most famous actors," said Mohammadi, whose real-life dream is to become a pilot. He's also hoping to go see the cockpit during the flight.

The farthest Mohammadi has ever traveled was to the northern Afghan city of Mazar-i-Sharif when he was younger.

Mohammadi's father died a few years ago, leaving him with his mother, five brothers and a sister. He started selling chewing gum when he was about 7 years old and soon expanded his trade to maps and dictionaries.

He learned to speak English hustling foreigners on Chicken Street, the main tourist area in Kabul with shops selling multicolor rugs, lapis bowls and other crafts and souvenirs, and gained a reputation for being polite, helpful and trustworthy. He was even able to enroll in a private school, thanks to the generosity of some other foreigners unrelated to the film project.

In the movie Mohammadi plays the blacksmith's son, Rafi, whose father wants him to follow in his footsteps.

"His life was so much harder than mine," Mohammadi said. "The blacksmith made him go out on the streets. I came myself here (to Chicken Street). My family didn't make me come. I wanted to make money to feed myself and to feed my family. He didn't have a home. They lived in the blacksmith shop."

Ironically it's not Mohammadi but Paiz, the youngest son of a well-known Afghan actor, who plays the homeless boy Ahmad.

Paiz, also 14, already was an experienced actor: He's appeared in films since the age of 5 and has gone to the Cannes Film Festival.

Paiz and Mohammadi had a lot to learn from each other and became friends. He gave Mohammadi tips for acting and handling himself in live interviews, while Fawad taught him about life outside his sheltered surroundings.

"When I saw Fawad was such a good actor even though he was a street boy and he was so brave in acting, I was very surprised and I said to myself, 'Everybody can achieve what they desire to do,'" Paiz said during an interview this week, shivering in the snow-covered courtyard of the Afghan Film Institute while a local TV series was being filmed nearby.

French, who co-wrote the script and produced "Buzkashi Boys" with Martin Roe of the Los Angeles-based production company Dirty Robber, launched a fundraising drive that's raised almost $10,000 so far to help bring the boys to Los Angeles for the ceremony. Any extra money will be placed in a fund to provide for Mohammadi's education and help his family. The boys will travel with an escort and will stay with the extended Afghan family of one of the film's producers, French said.

French said he's aware of the pitfalls in working with child actors from developing countries.

The makers of "Slumdog Millionaire," the rags-to-riches blockbuster about three poor Indian children, have struggled to make a better life for the young stars, and four boys who acted in "The Kite Runner" had to leave Afghanistan out of concern they could be ostracized or subject to violence because of a rape scene in the movie.

French said he and others involved in the "Buzkashi Boys" took pains to involve the community and made sure to avoid any scenes that could be offensive.

"We're not filmmakers who just do a film and leave. We remain there and present," he said. "We had lots and lots of tea with lots and lots of people."

The Academy of Motion Picture Arts and Sciences says there have been three documentary features nominees filmed at least in part in Afghanistan since 2007 — all about the U.S. military. The Kite Runner, which was nominated for original score in 2007, was set in Afghanistan but not filmed there.

Afghanistan had a burgeoning film industry starting in the early 20th century, but it suffered from fighting during the civil war and the Taliban campaign to stamp out entertainment. Actors and film industry workers like Paiz's father and the actor who plays the blacksmith, Wali Talash, fled the country. They returned only after the 2001 U.S.-led assault that ousted the Islamic movement and its al-Qaida allies.

Talash, 56, said he hopes the "Buzkashi Boys" will show the world the rich culture of Afghanistan, which too few in the world know beyond reports of roadside bombs and suicide attacks.

"I hope if this movie wins that it will be an earthquake that will shake the industry and help Afghan filmmakers get back on their feet," he said.

Mohammadi, meanwhile, says he knows the money and fame he earned from the movie can carry him only so far. He still sells maps, though not so often as before, because he has school.

"For my work I used to know a lot of foreigners and I still do, but before they used to know me as a map seller. Now they know me as an actor," he said, waving a plastic-covered map as weary Afghans walked by on the muddy street. "Most of them take pictures with me and sometimes they buy maps from me even if they don't need any just because they spotted me in the movie."

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Associated Press writer Steve Loeper in Los Angeles contributed to this report.

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Online:

Fundraising site — https://rally.org/buzkashiboys

Film website — http://www.buzkashiboys.com/

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