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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Dell’s Largest Investor to Oppose Buyout

(Reuters) - Dell Inc's largest independent shareholder, Southeastern Asset Management, on Friday vowed to fight a $24.4 billion buyout of the No. 3 PC maker led by CEO Michael Dell, cementing opposition to what would be the largest buyout since the start of the financial crisis.

Southeastern's opposition to the deal, which Reuters first reported late on Thursday, sets up a potential battle with billionaire founder Dell and private equity firm Silver Lake, who are pushing a deal to take the company private at $13.65 a share.

Southeastern, run by activist investor Mason Hawkins and owner of 8.5 percent of Dell, including options, argues that the company is worth $24 a share if its financial services division, recent acquisitions and other assets were factored in.

With Southeastern's objection, shareholders representing 11 percent of the Dell shares not held by Michael Dell have now said they will vote against the deal, according to news reports. Billionaire Dell, who created the computer maker out of his college dorm room in 1984, holds a roughly 16 percent stake.

Dell shares reversed course and climbed into positive territory on Friday after the announcement, and closed up 0.74 percent at $13.63.

"We are writing to express our extreme disappointment regarding the proposed go-private transaction, which we believe grossly undervalues the Company," Hawkins and Chief Investment Officer Staley Cates wrote in a letter.

"We retain and intend to avail ourselves of all options at our disposal to oppose the proposed transaction, including but not limited to a proxy fight, litigation claims and any available Delaware statutory appraisal rights."

Representatives of Dell and Silver Lake declined to comment on Southeastern's statement.

Sanford Bernstein analyst Toni Sacconaghi estimates Hawkins' asset management house paid an average of more $20 a share for its stake, meaning a loss of at least $825 million at the current $13.65 offer price.

A LOOMING BATTLE

Under the buyout's terms, a majority of shares not held by Michael Dell must be voted in favor of the deal for it to proceed.

Memphis, Tennessee-based Southeastern believes the Dell board had several alternatives that would have produced a far better outcome for public shareholders, including breaking up the company and selling the units separately.

"Selling multiple business units to strategic buyers could easily exceed $13.65 per share," the letter read.

Dell was regarded as a model of innovation as recently as the early 2000s, pioneering online ordering of custom PCs and working closely with Asian suppliers and manufacturers to assure rock-bottom production costs. But it missed the big industry shift to tablet computers, smartphones and high-powered consumer electronics such as music players and gaming consoles.

Michael Dell struck a deal early this week to take Dell private for $24.4 billion in the biggest leveraged buyout since the financial crisis, partnering with Silver Lake and Microsoft Corp. The aim is to facilitate Dell's difficult transition from a commodity maker of computers into a provider of services to enterprises as a private company, away from Wall Street's scrutiny.

But Southeastern, the most prominent of a clutch of investors, including the Alpine Capital Research and Schneider Capital funds, which have voiced opposition to the buyout, on Friday argued that the company had the capability to pay a $12 special dividend to shareholders, realizing much more value while still retaining significant cash-flow.

It also suggested a Dutch auction or some other structure that would involve a public tender of shares.

Dell has now gone into a go-shop process, during which it can solicit better offers. But Hawkins and Cates argue that Michael Dell's involvement may affect that procedure.

"We are concerned that given the participation of Michael Dell in this transaction, that a traditional go shop process is not sufficient to ensure that the Company receives superior offers," they wrote.

Morningstar analyst Carr Lanphie said it is not a surprise that some investors do not like the offer price, but said the stock would fall sharply if the deal does not go through.

"The point being that if this doesn't go through, you are going to swallow a 35-40 percent decline in share price," Lanphie said. "Then, your chairman just had his attempted buyout rejected.

"Given the management they have lost in the last couple of months, will they be able to continue to grow the company? That is something the investors will need to consider," he added.

(Reporting by Poornima Gupta; Editing by Steve Orlofsky, Gary Hill and Dan Grebler)

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IHT Rendezvous: Baron Von Fancy Goes to Paris

PARIS—Baron Von Fancy’s name may belong in an 18th-century German royal court, but he is very much a 20th-century child. He’s a multimedia artist who lives in New York and surfs on the vintage-is-cool wave, using social media as his manager, agent and public relations firm.

His latest exhibition, “A Thing Called Love,” opened on Monday at the Paris Colette shop, a European mecca of all things fashionable, and runs through Feb. 23. It’s his first big break. “I’m honored to be shown in Colette. I couldn’t have asked for more,” said Baron Von Fancy, who is 28, while sipping tea in a cafe across the street from the store.

The exhibition is a collection of handpainted 1950s-looking signs of catchphrases overheard in the subway and in conversation. Some of them are poetic, some are jokes and some clichés. The theme for the show, whose run encompasses Valentine’s Day, is love. “Crazy About You,” “To the Moon and Back,” “Just Kids” (referencing Patti Smith’s book) are a few examples. He added “Bisous,” and “Loin des yeux, loin du coeur,” as a nod to his new French audience. He also redesigned Colette’s Water Bar menu and painted huge murals. The one behind the cash register reads “The Thrill Is Gone.”

Outside, along the wall, he had started painting the words Very Fancy, but the person who was supposed to help him paint was late and he didn’t have time to finish before the opening of the show. Welcome to France, Mr. Fancy.



Baron Von Fancy isn’t – surprise, surprise – his real name. He was born Gordon Stevenson, in New York, in the early 1980s, one of seven siblings and half-siblings. He is not without connections: his father, Charles Stevenson, is an investor; his stepmother is the writer Alex Kuczynski, who contributes to The New York Times. The story behind his strange but catchy moniker is a mix of many anecdotes including a nickname of an ex-girlfriend’s dog and his fancy collection of vintage Versace jeans.

Baron Von Fancy (why call him Gordon when you can call him Baron Von Fancy?) epitomizes Generation Y, also known as Generation Sell. He creates art under both names, but uses Baron Von Fancy as a brand for his more commercial art. As Gordon Stevenson, he paints, dyes waterfalls, and does light installations. When he is Baron, as he says his mother now often calls him, he does lighters, bow ties, socks and his painted signs.

Baron doesn’t whip out a battered Moleskine when he has an idea, he uses Twitter is his notebook. He tweets several times a day, to more than a thousand people, phrases that could end up on a sign in an exhibition.

His Instagram account has more than 4,000 subscribers, and serves as his PR office.

As it happens, Instagram, the photo-sharing application with  90 million users, had a key role in securing his Colette exhibition. 

Several months ago, one of Baron Von Fancy’s friends noticed a picture of a T-shirt on Colette’s Instagram account with what looked like a Baron Von Fancy sign, and notified him. He wrote to Colette’s owner Sarah Andelman and showed her a picture of his art. She agreed the brand they were selling must have copied Baron Von Fancy’s art and invited him to exhibit his work in her store.

“I can’t help but thank Instagram,” says Baron Von Fancy with a laugh. “I realize how crazy that sounds, and people may say I take Instagram too seriously, but it has done so much for me. It has changed my life.”

You can already here a vast group of people shriek and shake their heads at his statement but the fact is that today social media is the way young artists to get themselves known. 

He uses the application to share his vision and show his inspiration, but also to showcase his work.

“All I think of when I wake up in the morning is create,” he says. And although he makes a living writing sentences, he says he’s not a writer, but expresses himself visually. “I’m not very good a keeping a blog, but Instagram is a perfect way to communicate and get visibility.”

Technology has opened many opportunities for him. Through social media, he has started a collaboration with the clothing brand Patagonia (the New York art director followed his Instagram account) and a collaboration with a rapper on socks.

Although Baron Von Fancy is very much an artist of our time, his art is turned toward the past, inspired by old-school classic sign painting. “Today everyone uses computer-generated fonts,” he says, looking out the window at the Parisian store fronts, “but I think that in general there is a real movement of people who are going back to things being made by hand and with care.”

To learn the art of handmade signs, Baron Von Fancy turned toward a old Latvian man called Fred who has a sign store in Queens, New York, and who taught him his art. “I sat there and looked at how he moved his hand,” he explains.

Fred has always worked in Queens, and has no idea what Colette is. He has no idea that this show means his student plays with the big boys now. “He doesn’t even get why I use most of my catchphrases,” says Baron Von Fancy.

But that is exactly what Baron Von Fancy does, and why he’s representative of his generation. He takes something basic and old, and turns into something nostalgically new and cool. Fancy, as it were.

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Armstrong sued for $12 million bonus

AUSTIN, Texas (AP) — A Dallas promotions company sued Lance Armstrong on Thursday, demanding he repay $12 million in bonuses and fees it paid him for winning the Tour de France.

SCA Promotions had tried in a 2005 legal dispute over the bonuses to prove Armstrong cheated to win before it ultimately settled and paid him.

Armstrong recently acknowledged using performance-enhancing drugs after the U.S. Anti-Doping Agency in 2012 detailed a sophisticated doping program by his Armstrong's teams. Armstrong was stripped of his seven Tour de France victories and given a lifetime ban from sports.

Now, the company contends in its lawsuit, Armstrong and agent Bill Stapleton lied and conspired to cheat SCA out of millions. The lawsuit notes that Armstrong repeatedly testified under oath in the 2005 dispute that he did not use steroids, other drugs or blood doping methods to win, all of which he now admits to doing.

"It is time now for Mr. Armstrong to face the consequences of his actions," said the lawsuit, which demands a jury trial. "He admits he doped; he admits he bullied people; he admits he lied."

Armstrong won the Tour de France every year from 1999-2005. The SCA lawsuit seeks to recover $9.5 million in bonus money for winning the race from 2002-2004 and another $2.5 million paid to Armstrong for other costs and fees.

The lawsuit names Armstrong, Stapleton and Tailwind Sports, Inc., the team's management entity, as defendants.

Tim Herman, an attorney for Armstrong and Stapleton, did not immediately return telephone messages. Herman has previously noted that SCA previously settled its case with Armstrong and said it should not be allowed to reopen the matter.

An Armstrong spokesman referred to the original settlement signed in February 2006 by SCA President Robert Hamman and Stapleton, both for himself and Armstrong, that states "No party may challenge, appeal or attempt to set aside" the agreement, which is "fully and forever binding."

SCA counters that the case can be reopened because Armstrong's repeated lies under oath prevented it from proving he doped.

"Had SCA — or the Arbitration Panel — known the truth, the arbitration award and settlement never would have occurred," the lawsuit said.

According to the lawsuit, Stapleton and Herman both said in the original dispute that if Armstrong was to be stripped of his titles by official action, SCA would have no obligation to pay or could come after its money.

The 35-page filing also goes after Armstrong's televised interview with Oprah Winfrey last month in which he tearfully recounted having to tell his 13-year-old son the doping allegations were true.

In 2006, Armstrong told the arbitration panel that he didn't dope because he wouldn't want his son to someday follow him into a dirty sport.

"So how could I put my son into this completely dark, dirty underworld of deceit and deception would make no sense to me. I would never do that," Armstrong said, according to the lawsuit.

Separately, USADA chief executive Travis Tygart said Wednesday the agency has been in contact with him Armstrong and is giving him more time to decide if he wants to cooperate with its investigators and tell more about what he knows of doping in cycling.

USADA extended its original Wednesday deadline to Feb. 20 to work out an interview with investigators under oath.

Just two weeks ago, Herman had strongly suggested Armstrong would not be interested in talking with USADA investigators. Tygart said it was Armstrong who asked for more time.

"We understand that he does want to be part of the solution and assist in the effort to clean up the sport of cycling," Tygart said in a statement. "We have agreed to his request for an additional two weeks to work on details to hopefully allow for this to happen."

The agency has said cooperating in its cleanup effort is the only path open to Armstrong if his lifetime ban from sports is to be reduced.

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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

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Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

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

Improving markets lifted the fortunes of Kohlberg Kravis Roberts in the fourth quarter, as the investment firm reported a 22 percent rise in profit.

K.K.R. said on Thursday that it earned $347.7 million for the quarter, as all of its businesses showed strong gains. For the year, the firm reported earning $2.1 billion.

The fourth-quarter profit, reported as economic net income and which includes unrealized gains from investments, comes out to 48 cents a share. That is more than double the 20-cents-a-share average of analyst estimates compiled by Capital IQ.

Private equity firms have benefited from an improvement in the markets, which have bolstered the value of their own holdings. Last week, the Blackstone Group reported a 43 percent increase in fourth-quarter earnings.

K.K.R. said the value of its investments rose 4 percent for the quarter and 24 percent for the year.

The strongest performers among the firm’s investments included Alliance Boots, a British pharmacy chain; HCA, the giant hospital operator that went public last year; and the Nielsen Company, the media measurement company.

The improved market conditions also make selling portfolio companies a more attractive prospect, letting the firms harvest tangible returns from their investments. That was reflected in K.K.R.’s results, as it reported a nearly fourfold increase in distributable earnings for the quarter, to $546.3 million. That metric tracks how much a firm actually pays to its limited partners.

And K.K.R.’s assets under management rose 13.9 percent from the third quarter, to $75.5 billion.

The firm’s co-founders and co-chairmen, Henry R. Kravis and George R. Roberts, said in a statement that the growth of their private equity portfolio outpaced the Standard & Poor’s 500-stock index by about 7 percent last year.

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India Ink: Your Suggestions on Curbing Violence Against Women in India

The trial of five of the six suspects in the New Delhi gang rape case that has captured worldwide attention began on Tuesday, just as the Indian government moved to strengthen its sexual assault laws in response to public outrage.

Last week, we asked you to weigh in on what needs to be done to end the problem of sexual assault and violence against women in India, and you offered a wide range of solutions. Some readers suggested castration of child rapists. Others offered support for the death penalty in violent cases. One argued that women should change how they dress and that boys who reached a mature age should be encouraged to marry.

Overwhelmingly, your comments contended that change depended on reforming the police and the justice system and addressing deep-rooted cultural attitudes.

“While none can forget or forgive the perpetrators of such a heinous crime, we tend to forget that the reason for them to occur is a brutal and corrupt police force. A force that knows no accountability,” wrote Gautam Nellore Reddy from Bangalore, India.

The police should be treated as “an accessory to the crime if they don’t register a complaint” and as an accomplice if they suppress information, Mr. Reddy wrote.

In addition to holding the police accountable for how they handle – or fail to handle – cases of violence against women, as well as arguing the need for more female police officers, Vijayendra Kumar of Washington encouraged changes in India’s court system.

“It may be a good idea to have [a] special unit for handling all violence against women and the unit should be headed by a woman,” Mr. Kumar wrote. “It is also very necessary to establish courts dealing with women’s issues with a mandate that judgments be delivered in a time-bound manner.”

A number of readers, including Mr. Kumar, said that reforms in the police and judicial systems would only be partial fixes. To address the abuse and violence further, they responded, India needs a change in mind-set and attitudes.

“Fast-track courts, greater women police, a sensitized male police force, all these actions are merely applying Band-Aids to a broken leg,” wrote Dr. Shireen Hyrapiet of Oregon State University. “There exists a culture of the inferiority of women which cannot and will not change unless the government and people are on the same page and equally committed to bringing about change.”

Some also suggested bringing about such a change in attitudes through education, media and social practices.

Annu Palakunnathu Matthew, a photography professor at the University of Rhode Island, grew up in India and remembers facing sexism as a young person.

“I called those years ‘my angry young woman’ days,” she wrote in a comment to The Times, adding that India now needs a cultural shift of attitudes. “Expecting women to, for example, wear long overcoats is not a serious way to resolve the problem.”

In a project called “Bollywood Satirized,” Ms. Matthew uses digital technology to alter Indian movie posters and make a commentary on gender norms and traditional roles in Indian society. A poster labeled #DELHIRAPE she created in response to the recent case displays the headline “From the Director of ‘Out of Touch Politicians.’ ”

Others who responded to our question said they believed that cultural change could be brought about by focusing on the lessons Indian children learn at home as well as through improving their education about sexual assault in schools.

A reader who gave the name Swathi recommended that the Indian media put out public service announcements with male movie stars and athletes promoting the message, “Real men do not rape.”

Another reader, David Raney of Chapel Hill, N.C., presented a particularly creative idea. He said that Indian society should start practicing a new ritual based around respecting women. One day, he said, should be set aside each week to honor women and give them flowers to wear around their necks.

“This would at least be a physical ritual,” Mr. Raney wrote, because “in India, rituals create change.”

More reader responses on this topic can be found here. Please post your own ideas and opinions below.

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Migrant workers at Sochi Olympic sites face abuses

SOCHI, Russia (AP) — One year ahead of the Winter Olympics in Sochi, the roads in the Black Sea resort and its surrounding mountains are lined with migrants from Central Asia doing the grunt work that Russians find too low-paid and physically demanding.

Tens of thousands of migrant workers from Uzbekistan, Tajikistan and Kyrgyzstan are a key element in Russia's intense drive to build facilities for the 2014 Sochi Games. The event is viewed as the country's biggest construction project and a matter of national pride — for President Vladimir Putin, in particular.

But many migrants, whose pay typically provides for their entire families back home, complain that Russian contractors are cheating them and withholding their wages. Most of the foreign laborers speak poor Russian and many are afraid to assert their rights.

Human Rights Watch on Wednesday released a report drawing a vivid picture of the routine abuse faced by Sochi migrant workers: underpayment, withheld wages and the absence of employment contracts. The report came out a day before Putin and Olympic officials mark the one-year countdown to the games with a spectacular ice show.

For Eshkobil Ashurov of Tajikistan, working in Sochi has been a boon and a bane. The 27-year-old steel-fitter has been able to send money home to his wife, children, parents and sisters in his impoverished homeland — but that's only when his employers actually pay him.

In December, he said, he walked off his previous job after going 40 days without pay. He said 40 of the 100 men in his work group also weren't paid and most of them left Sochi.

Ashurov found another construction job in the mountain area where the outdoor Olympic competitions will be held, but it's still a difficult life. He typically works 10 hours a day, seven days a week and earns about 30,000 rubles ($1,000 a month). He sends 27,000 rubles of that home, leaving him little to live on besides his employer-provided accommodation and food.

"We're here to work," he said in an interview. "You get back, spend some time at home and go back here to work."

Ashurov's situation is common, according to Semyon Simonov, who runs a two-man advocacy group for migrants in Sochi that provides free legal help. But it's hard to tell how many workers truly are affected.

Federal Migration Service chief Konstantin Romodanovsky recently said that out of 74,000 people involved in construction in Sochi, only 16,000 are foreigners.

But the actual figure of foreign laborers in Sochi is likely much higher. According to Simonov, who contrasted official statistics on work permits with data on foreigners registered in the area, about 50,000 people may be working in Sochi without work permits.

Simonov and Human Rights Watch list the withholding of wages, the failure to provide employment contracts and excessive working hours as the most common rights violations that migrants in Sochi face.

In the HRW report, researcher Jane Buchanan said millions will be watching the 2014 Games unaware that "many migrants toiled in exploitative, abusive conditions to build these shimmering facades and luxurious interiors." The rights group called on the International Olympic Committee to set up a working group to monitor and prevent the mistreatment of workers.

Olympstroi, the Russian state company responsible for building the Olympic venues, said in a statement it has carried out more than 1,300 work inspections since 2011 but has identified only five cases of "wage irregularities."

The IOC reiterated its "long-standing commitment" to follow up cases of mistreatment or abuse and said it has been in contact with Human Rights Watch. In a statement, the IOC said it brought the issue of migrant workers to the attention of the Sochi organizing committee and had received information on the topic from Olympstroi.

"We can confirm that Olympstroi has carried out more than 1,300 work inspections since 2011 and that a small number of cases regarding wage irregularities were identified and dealt with satisfactorily," the IOC said. "'We would continue to urge HRW to furnish us with the details of cases that allow us to deal with them on a case-by-case basis and to push for action when necessary.'"

Simonov said his group was collecting complaints and documenting rights abuses about the migrants.

"The most sensitive thing for them is when they don't get paid," he said. "They don't mind the miserable conditions they live in. They're willing to put up with this as long as they get paid."

Up in the mountains in the Krasnaya Polyana area where Ashurov works, 37-year-old Dilya Saipova from Kyrgyzstan was meeting with a potential employer, hoping for a better position than her odd jobs cleaning and working in a kitchen, which she said was strenuous and underpaid.

Local employers "can't pull these things off" with Russians, Saipova said, because "Russians have a law and they can assert their rights using that law."

Workers in Sochi "consistently" spoke about employers failing to pay full wages and in some cases failing to pay workers at all, the HRW report said.

The Olympic venues where workers interviewed by Human Rights Watch reported abuse are the Olympic Stadium, the Olympic Village and the media center in the coastal cluster. Simonov's group is working on a complaint concerning the media center filed by 20 Uzbek workers seeking back wages worth a total of 1 million rubles ($33,000) from a subcontractor.

Dmitry Chernyshenko, head of the Sochi organizing committee, has denied any mistreatment of workers at Olympic sites.

"If there are some violations and people go to prosecutors — believe me in Russia the law is always on the side of laborers, not on the side of the employer," he said in an interview.

Sochi Mayor Anatoly Pakhomov also dismissed the claims of rights abuses in his city, saying that "conflicts like this are very few."

"If the violations of labor laws were widespread, the online community would be all over it. We don't see anything big in the Internet," he said.

Simonov meets with migrant workers at his one-room office in a dilapidated Sochi neighborhood overlooking the construction site of a new railway terminal. He believes that Sochi authorities and contractors do not realize how important the migrants are to the games.

"At the end of the day, it's only thanks to them that we're getting the Olympic venues built," he said. "No one else will be building them, where would you get so many workers from? Locals don't want these jobs."

Interviewed by Simonov, Ashurov smiles when he is asked if he would like to attend the opening of the 2014 Sochi Games, which run from Feb. 7-23.

"I don't know. I would rather go home and see my family," he said.

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Personal Health: Effective Addiction Treatment

Countless people addicted to drugs, alcohol or both have managed to get clean and stay clean with the help of organizations like Alcoholics Anonymous or the thousands of residential and outpatient clinics devoted to treating addiction.

But if you have failed one or more times to achieve lasting sobriety after rehab, perhaps after spending tens of thousands of dollars, you’re not alone. And chances are, it’s not your fault.

Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.

According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.

A groundbreaking report published last year by the National Center on Addiction and Substance Abuse at Columbia University concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” The report added, “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”

The Columbia report found that most addiction treatment providers are not medical professionals and are not equipped with the knowledge, skills or credentials needed to provide the full range of evidence-based services, including medication and psychosocial therapy. The authors suggested that such insufficient care could be considered “a form of medical malpractice.”

The failings of many treatment programs — and the comprehensive therapies that have been scientifically validated but remain vastly underused — are described in an eye-opening new book, “Inside Rehab,” by Anne M. Fletcher, a science writer whose previous books include the highly acclaimed “Sober for Good.”

“There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches,” A. Thomas McLellan, co-founder of the Treatment Research Institute in Philadelphia, told Ms. Fletcher.

Ms. Fletcher’s book, replete with the experiences of treated addicts, offers myriad suggestions to help patients find addiction treatments with the highest probability of success.

Often, Ms. Fletcher found, low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan. Indeed, their revolving-door experiences with treatment helped prompt Ms. Fletcher’s exhaustive exploration in the first place.

In an interview, Ms. Fletcher said she wanted to inform consumers “about science-based practices that should form the basis of addiction treatment” and explode some of the myths surrounding it.

One such myth is the belief that most addicts need to go to a rehab center.

“The truth is that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually,” she wrote.

Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”

Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, “You don’t treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it.”

Dr. Willenbring now practices in St. Paul, where he is creating a clinic called Alltyr “to serve as a model to demonstrate what comprehensive 21st century treatment should look like.”

“While some people are helped by one intensive round of treatment, the majority of addicts continue to need services,” Dr. Willenbring said. He cited the case of a 43-year-old woman “who has been in and out of rehab 42 times” because she never got the full range of medical and support services she needed.

Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.

“We have some pretty good drugs to help people with addiction problems, but doctors don’t know how to use them,” he said. “The 12-step community doesn’t want to use relapse-prevention medication because they view it as a crutch.”

Before committing to a treatment program, Ms. Fletcher urges prospective clients or their families to do their homework. The first step, she said, is to get an independent assessment of the need for treatment, as well as the kind of treatment needed, by an expert who is not affiliated with the program you are considering.

Check on the credentials of the program’s personnel, who should have “at least a master’s degree,” Ms. Fletcher said. If the therapist is a physician, he or she should be certified by the American Board of Addiction Medicine.

Does the facility’s approach to treatment fit with your beliefs and values? If a 12-step program like A.A. is not right for you, don’t choose it just because it’s the best known approach.

Meet with the therapist who will treat you and ask what your treatment plan will be. “It should be more than movies, lectures or three-hour classes three times a week,” Ms. Fletcher said. “You should be treated by a licensed addiction counselor who will see you one-on-one. Treatment should be individualized. One size does not fit all.”

Find out if you will receive therapy for any underlying condition, like depression, or a social problem that could sabotage recovery. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”

Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.

Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, “Get Your Loved One Sober,” with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol.

This is the first of two articles on addiction treatment.

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After Posting Lower Profit, Glaxo to Cut Costs

LONDON (Reuters) — GlaxoSmithKline plans to cut costs in its struggling European drugs division and promised investors a return to growth this year, after failing to deliver a hoped-for recovery in sales and profits in 2012.

The company, Britain’s biggest drug maker, said Wednesday that a new program to restructure European operations, drug manufacturing and research would save at least £1 billion (about $1.6 billion) annually by 2016, with related charges of £1.5 billion.

After putting a number of major drug patent losses behind it, Glaxo had originally banked on pulling out of its trough in 2012. In the event, sales were held back by larger-than-expected drug price cuts in austerity-hit Europe.

The company reported that its net profit fell 35 percent, to £839 million (about $1.35 billion), from £1.28 billion in the fourth quarter a year earlier. Sales in the quarter fell 3 percent, to £6.80 billion. Excluding onetime items, Glaxo said it earned 32.6 pence a share, up 4 percent.

Analysts had forecast sales of £6.88 billion and earnings of 31.3 pence a share, according to a survey by Thomson Reuters. Glaxo’s chief executive, Andrew P. Witty, hopes to do better this year. He predicted on Wednesday that earnings per share, after stripping out some items, would grow by 3 to 4 percent at constant exchange rates in 2013, with sales rising about 1 percent. “2013 should be the first in a series of growth years for G.S.K.,” Mr. Witty told reporters.

Still, the forecast increase in sales and earnings this year was less than some analysts had hoped. A Deutsche Bank analyst, Mark Clark, also noted Glaxo gave a cautious outlook for profit margins, since these are expected to improve only “over the medium term.”

Europe has been a weak point for many drug makers, but Glaxo’s portfolio has been particularly hard hit by government budget cuts. As a result, Mr. Witty said he was taking action to ”reduce costs, improve efficiencies and reallocate resources.”

The action in Europe will involve some job cuts, but he declined to go into details.

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