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.

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.

Read More..

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.

Read More..

Court Urged to Reverse a Ruling on Terror

The Obama administration on Wednesday urged a federal appeals court to overturn a sweeping ruling by a district judge that blocked the government from enforcing a statute related to the indefinite detention without trial of terrorism suspects.

Appearing before a three-judge panel of the Court of Appeals for the Second Circuit, in Manhattan, Robert M. Loeb, a Justice Department lawyer, said a lawsuit challenging the statute should be dismissed because those who brought it — including a former reporter for The New York Times, Christopher Hedges, who interacts with terrorist groups for his reporting, and several supporters of the antisecrecy group WikiLeaks — had no real-world risk of being detained.

“The plaintiffs’ claims all fail at the outset,” Mr. Loeb said, asserting that the plaintiffs had failed to show an “objectively reasonable fear of being placed in long-term detention.”

But lawyers for the plaintiffs, Carl J. Mayer and Bruce Afran, insisted that their clients had legal standing to challenge the statute — a provision of the National Defense Authorization Act of 2012 — because it interfered with their right to free speech by creating a basis to fear that they might be placed in military detention on the basis of their activities.

The provision authorizes the detention of people who are part of or “substantially supported” Al Qaeda or “associated forces.” When Congress enacted it, lawmakers said the statute merely reaffirmed, and did not expand, the existing detention powers granted a decade earlier in the authorization to use military force against the perpetrators of the Sept. 11, 2001, terrorist attacks.

But lawmakers did not specify whether Americans could be detained without trial and were vague about what kind of conduct was off limits. In September, Judge Katherine B. Forrest of Federal District Court ruled that Congress had expanded the government’s detention powers, saying the 2001 version did not cover mere supporters. A portion of her ruling suggested that the government could be held in contempt if it detained anyone under that theory.

The Obama administration appealed, arguing that her ruling was wrong and put a cloud over its existing detention authority for prisoners picked up in the Afghanistan war zone.

On Wednesday, Judge Raymond J. Lohier, an appellate court judge, pressed Mr. Loeb about whether there had been any authority before the 2011 statute that allowed the government to detain people based upon “substantial support” of a terrorist group.

“To my knowledge it has never been applied that way,” Mr. Loeb replied.

Another judge on the panel, Lewis Kaplan, questioned whether there could be any guarantee that the current policy limits on powers would always be in place.

“The executive branch has been known occasionally to change its mind, isn’t that true?” he asked.

David Rivkin, a lawyer representing three lawmakers, including Senator John McCain, Republican of Arizona, argued that the statute should be upheld because Congress, presidents of both parties and other judges had agreed that the government has, and should have, indefinite detention powers in the war against Al Qaeda.

“The political branches are speaking in unison,” Mr. Rivkin said.

Charlie Savage contributed reporting from Washington.

This article has been revised to reflect the following correction:

Correction: February 7, 2013

An earlier version of this article misstated the fiscal year of the National Defense Authorization Act whose indefinite detention provision is being challenged. It is 2012.

Read More..

Postal Service Plans to End Saturday Delivery

Jim Wilson/The New York Times

A postal worker delivered mail in San Francisco last year.

WASHINGTON — The Postal Service is expected to announce on Wednesday morning that it will stop delivering letters and other mail on Saturdays, but continue to handle packages, a move the financially struggling agency said would save about $2 billion annually as it looks for ways to cut cost.

The agency has long sought Congressional approval to end mail delivery on Saturdays. But Congress, which continues to work on legislation to reform the agency, has resisted. It is unclear how the agency will be able to end the six-day delivery of mail without Congressional approval.

News of the move was first reported by CBS News.

The announcement, which is expected at a Wednesday morning news conference, comes as the agency continues to lose money, mainly due to a 2006 law which requires it to pay about $5.5 billion a year into a future retiree health benefit fund. Last year, for the first time, the agency defaulted on two payments after it had reached its borrowing limit from the Treasury Department. The Postal Service also continues to see a decline in mail volume as more people shift to electronic forms of communication like e-mail and online bill paying services. Packaging is one of the few areas where the agency is seeing growth.

While many business and postal unions have generally opposed ending Saturday delivery, most Americans support the move.

A New York Times/CBS News poll last year found that about 7 in 10 Americans say they would favor the change as a way to help the post office deal with billions of dollars in debt. The Postal Service continues to suffer losses of $36 million a day and is headed for projected losses of about $21 billion a year by 2016. Last year, the Postal Service had a net loss of $15.6 billion.

The American Postal Workers Union, which represents about 220,000 workers and retirees, said the plan to end six-day delivery will add to the agency’s financial problems.

“The A.P.W.U. condemns the Postal Service’s decision to eliminate Saturday mail delivery, which will only deepen the agency’s congressionally manufactured financial crisis,” said Cliff Guffey, president of the union.

This article has been revised to reflect the following correction:

Correction: February 6, 2013

An earlier version of this article misstated the news organization that first reported the Postal Service’s plans to end Saturday service. It was CBS News, not The Associated Press.

Read More..

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

Paul Nixon Photography

Paul Mason in 2012, two years after gastric bypass surgery stripped him of the unofficial title of “the world’s fattest man.”

IPSWICH, England — Who knows what the worst moment was for Paul Mason — there were so many awful milestones, as he grew fatter and fatter — but a good bet might be when he became too vast to leave his room. To get him to the hospital for a hernia operation, the local fire department had to knock down a wall and extricate him with a forklift.

That was nearly a decade ago, when Mr. Mason weighed about 980 pounds, and the spectacle made him the object of fascinated horror, a freak-show exhibit. The British news media, which likes a superlative, appointed him “the world’s fattest man.”

Now the narrative has shifted to one of redemption and second chances. Since a gastric bypass operation in 2010, Mr. Mason, 52 years old and 6-foot-4, has lost nearly two-thirds of his body weight, putting him at about 336 pounds — still obese, but within the realm of plausibility. He is talking about starting a jewelry business.

“My meals are a lot different now than they used to be,” Mr. Mason said during a recent interview in his one-story apartment in a cheerful public housing complex here. For one thing, he no longer eats around the clock. “Food is a necessity, but now I don’t let it control my life anymore,” he said.

But the road to a new life is uphill and paved with sharp objects. When he answered the door, Mr. Mason did not walk; he glided in an electric wheelchair.

And though Mr. Mason looks perfectly normal from the chest up, horrible vestiges of his past stick to him, literally, in the form of a huge mass of loose skin choking him like a straitjacket. Folds and folds of it encircle his torso and sit on his lap, like an unwanted package someone has set there; more folds encase his legs. All told, he reckons, the excess weighs more than 100 pounds.

As he waits to see if anyone will agree to perform the complex operation to remove the skin, Mr. Mason has plenty of time to ponder how he got to where he is. He was born in Ipswich and had a childhood marked by two things, he says: the verbal and physical abuse of his father, a military policeman turned security guard; and three years of sexual abuse, starting when he was 6, by a relative in her 20s who lived in the house and shared his bed. He told no one until decades later.

After he left school, Mr. Mason took a job as a postal worker and became engaged to a woman more than 20 years older than him. “I thought it would be for life, but she just turned around one day and said, ‘No, I don’t want to see you anymore — goodbye,’ ” he said.

His father died, and he returned home to care for his arthritic mother, who was in a wheelchair. “I still had all these things going around in my head from my childhood,” he said. “Food replaced the love I didn’t get from my parents.” When he left the Royal Mail in 1986, he said, he weighed 364 pounds.

Then things spun out of control. Mr. Mason tried to eat himself into oblivion. He spent every available penny of his and his mother’s social security checks on food. He stopped paying the mortgage. The bank repossessed their house, and the council found them a smaller place to live. All the while, he ate the way a locust eats — indiscriminately, voraciously, ingesting perhaps 20,000 calories a day. First he could no longer manage the stairs; then he could no longer get out of his room. He stayed in bed, on and off, for most of the last decade.

Social service workers did everything for him, including changing his incontinence pads. A network of local convenience stores and fast-food restaurants kept the food coming nonstop — burgers, french fries, fish and chips, even about $22 worth of chocolate bars a day.

“They didn’t deliver bags of crisps,” he said of potato chips. “They delivered cartons.”

His life became a cycle: eat, doze, eat, eat, eat. “You didn’t sleep a normal sleep,” he said. “You’d be awake most of the night eating and snacking. You totally forgot about everything else. You lose all your dignity, all your self-respect. It all goes, and all you focus on is getting your next fix.”

He added, “It was quite a lonely time, really.”

He got infections a lot and was transported to the hospital — first in a laundry van, then on the back of a truck and finally on the forklift. For 18 months after a hernia operation in 2003, he lived in the hospital and in an old people’s home — where he was not allowed to leave his room — while the local government found him a house that could accommodate all the special equipment he needed.

This article has been revised to reflect the following correction:

Correction: February 6, 2013

The headline on an earlier version of this article misstated Paul Mason’s current weight relative to what he weighed nearly a decade ago. He is now about one-third of the weight he was then, not two-thirds.

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State of the Art: Microsoft’s Surface Pro Works Like a Tablet and a PC

For decades, Microsoft has subsisted on the milk of its two cash cows: Windows and Office. The company’s occasional ventures into hardware generally haven’t ended well: (*cough*) Zune, Kin Phone, Spot Watch (*cough*).

But the new Surface Pro tablet, which goes on sale Saturday, seemed to have more going for it than any Microsoft hardware since the Xbox.

Everybody knows what a tablet is, right? It’s a black touch-screen slab, like an iPad or an Android tablet. It doesn’t run real Windows or Mac software — it runs much simpler apps. It’s not a real computer.

But with the Surface Pro ($900 for the 64-gigabyte model, $1,000 for a 128-gig machine), Microsoft asks: Why not?

The Surface Pro looks like a tablet. It can work like a tablet. You can hold it in one hand and draw on it with the other. It even comes with a plastic stylus that works beautifully.

But inside, the Pro is a full-blown Windows PC, with the same Intel chip that powers many high-end laptops, and even two fans to keep it cool (they’re silent). As a result, the Pro can run any of the four million Windows programs, like iTunes, Photoshop, Quicken and, of course, Word, Excel and PowerPoint.

The Surface Pro is beautiful. It’s clad in matte-black metal, beveled at the edges like a Stealth helicopter. Its connectors immediately suggest its post-iPad capabilities, like a memory-card slot for expanded storage. The screen is bright and beautiful, with 1080p high-definition resolution (1,080 by 1,820) — but when you connect the tablet to a TV or desktop monitor, it can send out an even bigger, sharper picture (2,550 by 1,440). There’s one USB 3.0 jack in the tablet, and a second ingeniously built into the power cord, so you can charge your phone as you work. Or you can connect anything you’d connect to a PC: external drives, flash drives, keyboard, mouse, speakers, cameras and so on.

Are you getting it? This is a PC, not an iPad.

As though to hammer home that point, Microsoft has endowed the Surface Pro with two unusual extras that complete the transformation from tablet to PC in about two seconds.

First, this tablet has a kickstand. It’s a thin metal flap that disappears completely when closed, but holds the tablet at a nice angle when you’re working or watching a movie.

Second, you can buy Microsoft’s now-famous keyboard cover. There are two models, actually. One is about as thick as a shirt cardboard. You can type on it — slowly — but you’re tapping drawings of keys, not actual keys. It’s called the Touch Cover ($100 with Surface purchase).

The other keyboard, the Type Cover ($130) is thicker — a quarter-inch — but its keys really travel, and it has a trackpad. You can really type on this thing.

Either keyboard attaches to the tablet with a powerful magnetic click. For tablet use, you can flip either keyboard around to the back; it disables itself so you don’t type gibberish by accident.

And if you really want to go whole hog with the insta-PC idea, you should also spring for the matching Touch Wedge mouse. It’s a tiny $40 cordless wedge, not much bigger than the AA battery that powers it, with supercrisp buttons and a touch surface on top for scrolling.

Now, when I wrote a first-look post on my blog last month , I was surprised by the reader reactions. Over and over, they posted the same argument:

“For that money, I could buy a very nice lightweight laptop with a dedicated keyboard and much more storage. Why should I buy Surface Pro when I can have more for less?”

Why? Because the Surface Pro does things most laptops can’t do. Like it weighs two pounds, with touch screen. Or work in portrait orientation, like a clipboard. Or remain comfortable in one hand as you make medical rounds, take inventory or sketch a portrait. Or stay in a bag as it goes through airport security (the TSA says tablets are O.K. to stay in).

You also hear: “But haven’t there been full-blown PC tablets before?”

Yes, there are a couple. But without the kickstand and keyboard cover, they can’t change instantly into a desktop computer.

So it’s true: for this much money, you could buy a very nice laptop. You could also buy a five-day cruise, a Gucci handbag or 250 gallons of milk. They just happen to be different beasts.

All right then: the Surface Pro is fast, flexible and astonishingly compact for what it does; that much is unassailable. But in practice, there are some disappointments and confusions.

E-mail: pogue@nytimes.com

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IHT Rendezvous: Turkey Hints at a Breakup With Europe

LONDON — A half century after taking the first steps toward becoming an integral part of Europe, Turkey may be ready to give up.

After heavy hints that Ankara is looking eastwards to a closer alliance with Asia, Recep Tayyip Erdogan, the prime minister, said this week that membership in the European Union was not a must for Turkey.

“It is not the Apocalypse if they do not let us in the E.U.,” Mr. Erdogan told reporters during a visit to Budapest on Wednesday, as he launched his latest broadside against the Union’s alleged delaying tactics to keep his country out.

His remarks followed a news conference earlier this week in Prague, where Mr. Erdogan described the delay in granting membership to Turkey as “unforgivable.”

These and similar expressions of frustration have come as Turkey approaches the 50th anniversary of an agreement with what was then the European Economic Community, which was to have led to eventual full membership in the bloc.

Mr. Erdogan set the tone in a television interview last month in which he accused the E.U. of dragging its feet because Turkey was an Islamic nation.

As my colleague Andrew Finkel wrote from Istanbul, the prime minister also “threw the diplomatic equivalent of a cream pie” into the debate by suggesting Turkey join the Shanghai Cooperation Organization instead.

Membership of the S.C.O., which groups Russia, China and central Asian states, is not widely viewed as a viable alternative to joining Europe. Andrew wrote that Mr. Erdogan’s proposal prompted Turkish columnists to ask whether he might be bluffing in an attempt to put pressure on the Europeans.

The same question was posed this week by Pravda.ru, a Russian news Web site: “The first thought about the purpose of such statements is the fact that Turkey is trying to express its disappointment with the stalled negotiations on accession to the E.U.”

But it did not rule out the possibility that Mr. Erdogan might be seeking power “wherever his country’s economic strength is consistent with its geopolitical needs as a global player,” in contrast to a weak Europe that was preoccupied with its internal problems.

Washington has suggested that Turkish membership in the S.C.O., a security organization viewed as an anti-American bulwark in Central Asia, might be problematic in view of the Turkish role in N.A.T.O.

“Obviously it would be interesting, given the fact that Turkey is also a N.A.T.O. member,” Victoria Nuland, the State Department spokeswoman, said last week.

Hugh Pope, the International Crisis Group’s project director in Turkey, suggested that Mr. Erdogan was courting popularity by bashing the Union.

Turks are frustrated not only by delays in the membership process, he told Rendezvous, but also by the draconian visa regulations they face when traveling to Europe. Potshots aimed at Turkey by European critics were also deeply offensive to Turks, he said.

“But joining the E.U. is not rocket science,” he added, emphasizing that Turkey had to meet the requirements of the club if it wanted to join. This would include making domestic reforms and changing its policy on Cyprus, an E.U. state that it refuses to recognize.

Mr. Erdogan’s recent remarks on Europe might not indicate that Turkey is quite ready to break off the world’s longest engagement.

Murat Yetkin, of the Turkish daily newspaper Hurriyet, commented on Wednesday: “It is…clear that Turkey-E.U. relations cannot go on like this any longer; another chapter this year, a pointless agreement the next.”

However, he wrote, “it seems that neither Turkey nor the E.U. wants to be the first to declare divorce. Perhaps because both sides know that it would be a strategically wrong move.”

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DealBook: Dell Announces $24 Billion Buyout, Biggest Since 2007

9:32 a.m. | Updated

Dell announced on Tuesday that it had agreed to go private in a $24.4 billion deal led by its founder and the investment firm Silver Lake, in the biggest leveraged buyout since the financial crisis.

Under the terms of the deal, the buyers’ consortium, which also includes Microsoft, will pay $13.65 a share in cash. That is roughly 25 percent above where Dell’s stock traded before word emerged of the negotiations of its sale.

Michael S. Dell will contribute his stake of roughly 14 percent toward the transaction, and will contribute additional cash through his private investment firm, MSD Capital. Silver Lake is expected to contribute about $1 billion in cash, while Microsoft will loan an additional $2 billion.

Dell’s board is said to have met on Monday night to vote on the deal. In its statement, the company said Mr. Dell recused himself from any discussions about a transaction and did not vote.

As a newly private company – now more firmly under the control of Mr. Dell – the computer maker will seek to revive itself after years of decline. The takeover represents Mr. Dell’s most drastic effort yet to turn around the company he founded in a college dormitory room in 1984 and expanded into one of the world’s biggest sellers of personal computers.

But the advent of new competition, first from other PC manufacturers and then smartphones and the iPad, severely eroded Dell’s business. Such is the concern about the company’s future that Microsoft agreed to lend some of its considerable financial muscle to shore up one of its most important business partners.

“I believe this transaction will open an exciting new chapter for Dell, our customers and team members,” Mr. Dell said in a statement. “Dell has made solid progress executing this strategy over the past four years, but we recognize that it will still take more time, investment and patience, and I believe our efforts will be better supported by partnering with Silver Lake in our shared vision.”

Still, analysts have expressed concern that even a move away from the unyielding scrutiny of the public markets will not let Mr. Dell accomplish what years of previous turnaround efforts have failed to achieve.

Nevertheless, the transaction represents a watershed moment for the private equity industry, reaching heights unseen over the past five years. It is the biggest leveraged buyout since the Blackstone Group‘s $26 billion takeover of Hilton Hotels in the summer of 2007, and it is supported by more than $15 billion of debt financing raised by no less than four banks.

“Michael Dell is a true visionary and one of the pre-eminent leaders of the global technology industry,” Egon Durban, a managing partner at Silver Lake, said in a statement. “Silver Lake is looking forward to partnering with him, the talented management team at Dell and the investor group to innovate, invest in long-term growth initiatives and accelerate the company’s transformation strategy to become an integrated and diversified global I.T. solutions provider.”

Mr. Dell first approached the board about taking the company private in August. That prompted the board to form a special committee, with JPMorgan Chase and the law firm Debevoise & Plimpton as advisers. It was charged with considering alternatives to a management buyout, including other deals or borrowing money to pay out a special dividend.

To help ward off accusations of self-dealing by Mr. Dell, the special committee has hired an independent investment bank, Evercore Partners, specifically to oversee a 45-day “go shop” period in which the company will solicit other potential buyers.

“The special committee and its advisers conducted a disciplined and independent process intended to ensure the best outcome for shareholders,” Alex J. Mandl, the head of the Dell independent committee, said in a statement. “Importantly, the go-shop process provides a real opportunity to determine if there are alternatives superior to the present offer from Mr. Dell and Silver Lake.”

But beating Mr. Dell comes at a price. Would-be rivals that successfully make an acceptable bid within the go-shop period must pay a $180 million termination fee. If such an offer comes after the 45-day window, that payout grows to $450 million.

Dell itself was advised by Goldman Sachs and the law firm Hogan Lovells, while Mr. Dell retained Wachtell, Lipton, Rosen & Katz as legal counsel. Silver Lake was advised by Bank of America Merrill Lynch, Barclays, Credit Suisse, RBC Capital Markets and the law firm Simpson Thacher & Bartlett.

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The New Old Age Blog: In Blended Families, Responsibility Blurs

Every year, Fran McDowell waited for the summer week when she would sing in a choral festival in the North Carolina mountains, then spend a few days in a lakeside cabin with close women friends.

That getaway grew more complicated to arrange — but perhaps more necessary — after her husband, Herb Beadle, was diagnosed with Alzheimer’s disease. They had a “gloriously happy” marriage — her first, his second — for 11 years, and she was more than willing to care for him in sickness as in health. But he could no longer manage alone in their Atlanta home.

For a few years, other family members pitched in to allow Ms. McDowell her cherished vacation. Eventually, though, she had to ask her husband’s daughter, a medical professional in another state, to take him into her home for a week.

She said no, then yes. Then, the day before Ms. McDowell was to drive him there, her stepdaughter again refused, leaving no time for alternate arrangements. If this had been her biological child, “I would have said, ‘Come on, don’t do this to me,’” Ms. McDowell said. Instead, reluctant to make waves, she canceled her trip.

“I think confrontation is riskier for stepparents,” she told me. “I was the compliant one who would bite my tongue rather than say what I thought.”

Ms. McDowell never told her stepdaughter, or anyone in the family, how angry and disappointed she was, or how difficult it was becoming to care for their father, who died three years ago at 86. She told the members of her dementia caregivers support group instead.

It was that group’s leader, Moira Keller, who e-mailed me to suggest this topic. A clinical social worker with the Sixty Plus program at Piedmont Atlanta Hospital, she wrote that “one of the biggest challenges I have is blended families in later life.”

Though I’ve written about the way the 1970s’ spike in divorces could complicate caregiving for adult children — more households to sustain, more siblings to either help or hinder — I hadn’t considered the impact on the older people themselves.

But Ms. Keller seems to be onto something. “The generation most likely to have stepchildren” — the boomers — “don’t need much care yet,” said Merril Silverstein, a Syracuse University sociologist co-editing a coming issue of the Journal of Marriage and the Family on stepfamilies in later life. “The crunch will come in 10 or 20 years.”

Initially, many adult children whose divorced or widowed parents remarry seem delighted, Ms. Keller said when we spoke. “They’re thrilled that Mom or Dad isn’t alone,” she said. “It’s a wonderful thing — until somebody gets sick.”

Then, she has found, “it gets really blurry. Who’s going to do what?” Grown children don’t have much history with these new spouses; they often feel less responsibility to intervene or help out, and stepparents may be unwilling to ask. Perhaps it’s unclear whether children or new spouses have decision-making authority.

“Older couples in this situation fall through the cracks,” Ms. Keller said.

Research shows that the ties which lead adult children to become caregivers — depending on how much contact they have with parents, how nearby they live, how obligated they feel — are weaker in stepchildren, Dr. Silverstein said. Money sometimes enters the equation too, Ms. Keller added, if biological children resent a parent’s spending their presumed inheritance on care for an ailing stepparent.

Adela Betsill, another of Ms. Keller’s support group members, married her longtime partner five years ago — her second marriage, his third. She has since given up her interior design business to care for Robert who, at 72, has also developed Alzheimer’s disease. His two children have had little involvement — perhaps because she’s just 49 and presumed able to handle everything.

Thus, though Robert’s son works from an office in their home, if Ms. Betsill needed to go out and asked him to remind his father to eat lunch, “he might, or he might not,” she said. “I don’t think he realizes it’s a burden.” So she has not asked.

Would it be different if she were his biological mother and he saw her wearing out under the strain? She thinks so, but it’s hard to know. After all, biological families also experience plenty of conflict and avoidance as elders age.

Still, that sense of reciprocity we often hear from caregivers — she took care of me when I was young, so I need to help out now that she’s old — doesn’t apply in late-life stepfamilies. Ms. Betsill didn’t raise this man, or his half sister.

Older couples who marry or remarry often discuss their finances, Ms. Keller has found. (An elder attorney, Craig Reaves, discussed the legal consequences here.) But illness and dependence may prove even more difficult subjects to broach.

“If I could yell one thing from a mountaintop,” Ms. Keller said, “it’s to talk about this stuff, too. Who’s going to take care of you if you become sick? Talk about that while you’re still healthy.”

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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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