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

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

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

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

The Presenting Problem:

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

The Patient’s Story:

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

A Sister’s Visit:

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

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

His blue eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

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Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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Automakers hope to rev up sales of diesel vehicles

Drivers in the U.S. are discovering what Europeans have known for years: Diesel engines are powerful and still get eye-popping fuel economy, especially at highway speeds.

Automakers are rolling out new diesels in the U.S. market, including a diesel version of General Motors Co.'s Chevrolet Cruze, which debuts Thursday at the Chicago Auto Show.

Diesels account for just 3% of U.S. auto sales. But automakers see that increasing as they offer more diesel models, part of the effort to meet increasingly stringent federal fuel economy standards.

GM joins Volkswagen, Audi, Mercedes-Benz and BMW in pitching diesel passenger cars for the U.S. market. This year, Jeep will offer a diesel version of its popular Grand Cherokee sport utility vehicle, and Mazda Motor Corp. will offer a diesel version of the new-generation Mazda6 sedan.

The automakers are using versions of diesel engines they have already developed for Europe and other markets.

Diesels now account for about 20% of VW's sales volume in the U.S. The company welcomes the entrance of new diesel competitors, believing a rising tide will lift all boats.

"This is not a fixed slice of pie that gets divided by the same customers," said Jonathan Browning, chief executive of Volkswagen Group of America. "This will grow the diesel segment, and that's good news for us."

Automakers hope to lure more buyers such as Danny Albarran, a Simi Valley resident who drives a diesel Dodge Ram pickup truck. The Los Angeles City Fire Department engineer learned to appreciate diesels after seeing their reliability and efficiency while driving firetrucks.

"You will see diesel trucks and cars out there regularly get 200,000 to 300,000-plus miles," said Albarran, who also owns a Toyota Prius. "We rarely have true engine trouble with our firetrucks — none of the issues you see with gasoline engines."

Even in everyday vehicles, diesel engines provide more power, better fuel economy, a higher resale value and extra longevity, he said.

The resale value of a compact car with a diesel engine is about 63% of its sticker price after three years, according to ALG, a consulting firm that estimates used car values for the leasing business. That compares with 53% for a compact car with a gasoline engine.

But there are drawbacks.

Consumers pay a premium for that diesel engine — from about $2,000 for a VW hatchback or sedan to more than $5,000 for a luxury car or big truck.

Although the fuel economy for a diesel can be as much as a third better than for a gasoline car, oil companies charge more for diesel. Depending on what's happening in the oil industry, the gap has been as much as 50 cents a gallon over regular-grade gasoline in the last year or so. Diesel has been 20 cents to 30 cents higher for much of the last two years, according to the nonprofit Diesel Technology Forum.

Currently, diesel costs 45 cents, or about 13%, more than regular-grade gasoline, according to the AAA Fuel Gauge Report. About half of all service stations nationwide have at least one diesel fuel pump.

Part of the gap comes from taxes. Federal taxes on diesel fuel are 6 cents a gallon higher than for gasoline, a result of an agreement with the diesel-dependent trucking industry as a way to make up for the extra wear and tear heavy trucks put on the nation's roads.

A growing number of consumers appear willing to accept that extra fuel expense, perhaps inured by the high price of all automotive fuel, said Allen Schaeffer, executive director of Diesel Technology Forum. Sales of diesel vehicles have risen by double digits in 20 of the last 24 months, he said.

Car buyers "are looking at long-term value," Schaeffer said.

Americans have historically shunned diesels. That's because of historically cheap gasoline, compared with other countries, and because the first diesel passenger cars were noisy, smoky, smelly and slow.

"Just recently are we seeing that image begin to change," said Tom Libby, an analyst with automotive research firm R.L. Polk & Co.

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Tunisian opposition leader Chokri Belaid shot dead outside home

Authorities said Tunisian opposition leader Chokri Belaid was shot as he left his house in the capital, Tunis. (Hassene Dridi / Associated Press / December 29, 2010)

By Jeffrey Fleishman

February 6, 2013, 3:41 a.m.

CAIRO -- A leading opponent of Tunisia's Islamist-led government was assassinated in front of his home Wednesday, raising fears of sharpening political turmoil in the country that ignited the Arab Spring movement but remains starkly divided between liberals and Islamists.

Chokri Belaid, head of the Unified Democratic Nationalist Party, was shot on his way to work in the capital, Tunis, according to authorities. No one claimed immediate responsibility for the attack, but it comes as Tunisia faces a troubled economy and a restive transition to democracy after decades of dictatorship.  

"This is a criminal act, and an act of terrorism not only against Belaid but against the whole of Tunisia," Prime Minister Hamadi Jebali told a radio station. Shortly after the killing, hundreds of protesters gathered outside the Interior Ministry.

An outspoken liberal with a bushy mustache, Belaid often criticized Ennahda, the dominant moderate Islamist party, for failing to unite the country's political factions. He had accused Ennahda of not clamping down on increasingly violent ultraconservative Salafis from attacking movie houses, art galleries and institutions they deem as against Islam.

Belaid's family told Tunisian media that he had received repeated death threats.

"Chokri Belaid was killed today by four bullets to the head and chest ... doctors told us that he has died. This is a sad day for Tunisia," Ziad Lakhader, a leader of the opposition Popular Front, was quoted as saying to Reuters.

Tunisian President President Moncef Marzouki, who was traveling in France, said he would cancel a planned trip to Cairo on Thursday and return home.

ALSO:

Bulgarian probe links Hezbollah to Israeli tourist bus attack

Bangladesh war crimes court jails Islamic party leader for life

Ahmadinejad ally linked to human rights abuses arrested in Iran

jeffrey.fleishman@latimes.com

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Elton John, Mumford & Sons to pay tribute to Helm

NEW YORK (AP) — Elton John and Mumford & Sons will hit the Grammys stage to pay tribute to Levon Helm.

The Recording Academy announced Thursday that T Bone Burnett, Mavis Staples, Zac Brown and Brittany Howard of Alabama Shakes will also perform "The Weight" at Sunday's awards ceremony in Los Angeles.

Helm was the drummer and singer for The Band. He died of complications from cancer last year at age 71.

The performers will sing the song during the show's in memoriam tribute, which honors musicians who died last year. Grammys producer Ken Ehrlich said the lineup of performers is a representation of Helm's diverse sound.

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

Paul Nixon Photography

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This article has been revised to reflect the following correction:

Correction: February 6, 2013

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

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Duo's lofty idea yields film spotlighting downtown L.A.

Former film and television producer Leonard Hill was having lunch at Church & State bistro, on the ground floor of the Biscuit Company Lofts, when he spotted an old colleague.

Screenwriter Wendy Kout, who had worked with Hill years before, was visiting a friend who had moved into a loft in the arts district in downtown Los Angeles. Kout had created the ABC show "Anything But Love," starring Jamie Lee Curtis and Richard Lewis. After its four-season run ended in 1992, she became a playwright.

Hill, a former independent television producer and vice president of movies for ABC, gave Kout a tour of the lofts and a run-down area along Industrial Street that he and his partner had redeveloped.

PHOTOS: Location filming in Los Angeles

Kout, who lives in Sherman Oaks, was struck by the theme of transformation, both of a downtown she never knew existed and of Hill's own post-Hollywood career.

When Hill suggested they might work together again, a light went on in her head.

"I said, 'Here we are two repurposed people looking at this repurposed downtown,'" Kout said. "I said, 'Wouldn't that be a great idea for a film?' He said, 'You write it and I'll produce it.' And that's what we did."

The result is the independent feature "Dorfman in Love," a romantic comedy about a young suburbanite (played by Sara Rue, of the ABC comedy "Malibu Country") whose life is transformed when she leaves a dreary existence taking care of her father in the San Fernando Valley and moves into a downtown loft to cat-sit for a friend.

Along with the 2009 indie hit "500 Days of Summer," "Dorfman in Love" is one of the few films to spotlight the changing face of downtown L.A., which has attracted thousands of new residents over the last decade, many of them moving into new lofts and injecting new life into a city not known for having a vibrant downtown.

The film, which was directed by Brad Leong and co-stars Elliott Gould, will be released nationwide March 22 by Brainstorm Media in a limited number of theaters, including at Laemmle Theatres, and will also be made available on the same day on video-on-demand through Direct TV.

PHOTOS: Hollywood Backlot moments

"Dorfman in Love" was filmed over 20 days in the Toy Factory Lofts (using Hill's office as a location) and various downtown sites, including the Central Library, the Los Angeles Flower Market, Little Tokyo, Santee Alley, Pershing Square, Angels Flight Railway, Chinatown, Union Station and a subway line.

"We were really trying to give L.A. its due," said Hill, who became a real estate developer after a long career in the film and TV business. He began as a writer on the very L.A.-centric TV series "Adam-12."

He produced more than 50 network television movies and dramatic series, but after struggling to make it as an independent television producer he embarked on a radical career change.

In 2001, Hill and a partner acquired a former toy factory on Industrial Street and converted it into lofts. After the units were sold, they did the same to a former Nabisco bakery building across the street.

But seeing Kout again rekindled his desire to get back in the film game.

PHOTOS: All-time box-office leaders

"The truth is, old producers die hard," Hill said. "Making movies is more fun than making buildings. I really missed the creative aspect of the business."

Hill served as the film's producer, location manager and also worked with Kout on the idea for the script. He initially pitched Kout on a story called "The Loft," inspired by the classic Billy Wilder film "The Apartment."

Instead, Kout suggested an original story, partly based on her own impressions of growing up in the Valley.

For inspiration, she spent a week in Hill's loft at the Toy Factory building to soak up the neighborhood and visit downtown sites.

"I was a bit like Alice in Wonderland," Kout said. "I discovered all these places that I never knew about, like the Central Public Library, L.A. Flower Market and Angels Flight Railway."

Without glossing over the edgier side of downtown, the film attempts to highlight less familiar aspects of downtown life, such as the public transit system and the diversity of residents, Kout said.

"I was living in the San Fernando Valley, and I came to a place that was magical," she said. "I fell in love with downtown."

richard.verrier@latimes.com

Where the cameras roll: Sample of neighborhoods with permitted TV, film and commercial shoots scheduled this week. Permits are subject to last-minute changes. Sources: FilmL.A. Inc., cities of Beverly Hills, Pasadena and Santa Clarita. Thomas Suh Lauder / Los Angeles Times

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Friends, investigators seek answers in killing of O.C. couple

They met in college, two highly regarded basketball players who seemed to have the same winning touch on the court and off.

After blazing through high school and college with her outside shot, Monica Quan became the assistant women's basketball coach at Cal State Fullerton. Keith Lawrence, whose highlight shots are still there on his college website, became a campus officer at USC.

Now police in Irvine are scrambling for an explanation — and friends are looking for a way to express their shock — after Quan and Lawrence were found shot to death in their parked car on the top floor of a parking structure in an upscale, high-security condominium complex near UC Irvine.

The two had just announced their engagement and had recently moved into a condominium complex near Concordia University, where they played basketball and had gone on to earn their degrees.

Late Sunday, after a passerby noticed two people in the parked car, police said they found Lawrence slumped in the driver's side of his white Kia. Quan was next to him, also dead. The couple were shot multiple times, and authorities said they have tentatively ruled out the possibility of it being a murder-suicide or motivated by robbery. Nothing in the car, police said, seemed to be disturbed.

The couple's friends and family said they were shaken by the violent deaths of two people who seemed to have so much to offer.

Quan was a 2002 graduate of Walnut High School in the San Gabriel Valley, where she set school records for the most three-pointers in a season and a game. She played at Long Beach State and at Concordia, where she graduated in 2007. She went on to earn a master's degree before becoming the assistant coach at Fullerton.

Quan's father was the first Chinese American captain in the LAPD, and went on to become police chief at Cal Poly Pomona.

Quan was known for pulling students aside to offer encouragement, said Megan Richardson, a former player. Marcia Foster, the head basketball coach at Cal State Fullerton, described her assistant as a special person — "bright, passionate and empowering," she said.

Quan shared a love of basketball with her fiancee, Lawrence, whom she met at Concordia.

He too had been a standout basketball player, starting at Moorpark High, where he played point guard and shooting guard, said Tim Bednar, who coached Lawrence.

Bednar said that Lawrence, who came from a family of athletes, was talented, yet quiet and humble. After Lawrence graduated in 2003, he continued to participate in summer youth camps

When he returned for the camps, Bednar said, he was known as the "best basketball player that ever came through" the school.

"He was awesome with the kids," Bednar said. "They all wanted to be around Keith Lawrence."

Bednar heard from Lawrence when he needed a recommendation to become a police officer after graduating from the Ventura County Sheriff's Academy. In August, he was hired by USC's public safety department.

John Thomas, the executive director and chief of the department, said that Lawrence was an "honorable, compassionate and professional" member of the community.

"We are a better department and the USC campus community is a safer place as a result of his service," Thomas said in a statement.

On Monday night, Quan's friends gathered outside Walnut High School. One clutched a heart-shaped balloon, another carried a collage of her basketball playing days. Still another held a basketball.

Lawrence's friends and family put up a Facebook page. "RIP Keith Lawrence, you will be missed," it said simply. Within hours, 840 had left comments or indicated they "liked" it. Concordia put up a link to Lawrence's game-winning shot that carried the school into a post-season tournament.

Michelle Thibeault, 27, said in a Facebook message that she had known Quan for more than a decade. The two were on the same athletic teams and went to junior high and high school together. "Monica was loved by everyone," she said.

During a somber gathering at the Cal State Fullerton gymnasium Monday, Foster read a brief statement from Quan's brother Ryan.

"We just shared a moment of incredible joy on her recent engagement," he wrote, and then added: "A bright light was just put out."

nicole.santacruz@latimes.com

kate.mather@latimes.com

lauren.williams@latimes.com

Times staff writer John Canalis contributed to this report.

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NJ Gov. Christie, Letterman laugh about fat jokes

TRENTON, N.J. (AP) — New Jersey Gov. Chris Christie and David Letterman have shared some laughs about the many fat jokes the comedian has made about the lawmaker's ample girth.

Christie has termed his plumpness "fair game" for comedians. And during his first appearance on "Late Show with David Letterman" on Monday, the outspoken Republican and potential 2016 presidential contender read two of Letterman's jokes that he said were "some of my personal favorites."

The governor also drew loud laughs when he pulled out a doughnut and started eating it while Letterman asked him if he was bothered by the digs that have been made about his weight. Christie said he wasn't, noting that he laughs at the jokes if he finds them funny.

"Late Show" airs on CBS at 11:35 p.m. Eastern time.

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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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Secondhand designer clothing at discount prices is in fashion

Jaclyn Shanfeld moves from garment to garment with the unbridled joy of a little girl rummaging in her mother's closet.

From the "wall of Chanel" Shanfeld retrieves a light pink and lavender jacket that once fetched $3,200 but was priced for resale at $750. She shows off the unmarked soles of a pair Nicholas Kirkwood boots, originally purchased for $1,500 that are now offered for $700. She unveils a sheer black, sleeveless Alaia gown bought for a special occasion — but never worn. It set back its first buyer $5,400, but it's now available for $650.

These Rodeo Drive castoffs are among the luxury clothes and accessories offered for resale in the digital consignment store Shop-Hers. The online marketplace offers shoppers the opportunity to buy previously owned designer fashions at a discount. Sellers, meanwhile, can create room in their closets and pocket a higher percentage of the proceeds than consignment stores typically offer.

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"I dreamt of a site that catered to secondhand luxury, a site where one could find women all over the country that were just like them aesthetically in order to have the experience of shopping one another's wardrobe," Shanfeld, 29, said.

The online store re-creates the airy shopping experience of an upscale boutique, with fashions from such designers as Alexander Wang, Hermes, Manolo Blahnik, Tom Ford and Zac Posen. Shanfeld and co-founders Jenna Stahl and Thanh Khuu added an element of social networking to help women browse the virtual closets.

First-time users furnish a profile picture and their measurements to ensure that women of similar size can fit in the items purchased from the seller's digital closets. Then, they select their favorites from among 20 designers. The sizing and fashion preferences help the site recommend "style soul mates," women whose tastes and dimensions most closely match the shopper's own.

When an item is purchased, the seller receives an e-mail alert and has three days to ship the item to Shop-Hers. Upon receipt, the site inspects the item for authenticity and verifies that its condition is as depicted on the site. If it meets expectations, Shop-Hers ships the item to the buyer and sends a follow-up notification to the seller, indicating that the sale is complete and payment is on the way. Shop-Hers keeps an 18% transaction fee.

"I love the site," said Diane Nagler, a publicist who owns her own firm in Denver and was among the site's earliest users. "My first purchase was this amazing, emerald green patent leather Max Mara clutch. I got it for $70 but it retailed for $600 to $800."

Secondhand shops once carried the taint of the declasse, said Adele Meyer, executive director of the National Assn. of Resale Professionals. But now the resale industry accounts for annual revenue of about $13 billion, according to First Research. Online, EBay alone enabled $7.9 billion worth of sales last year of new and used clothing and accessories.

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The digital consignment market is showing momentum. In 2011, e-commerce veteran Julie Wainwright launched the RealReal, a members-only website that acquires new and vintage luxury apparel from stylists in Los Angeles, with backing from well-known venture capital firms. Other ventures caught the attention of Silicon Valley's investment community, including Threadflip, Twice and Thredup, which specializes in children's clothing. Poshmark offers an app that allows iPhone users to resell items from their closets.

Shanfeld launched Shop-Hers.com in November, backed by such notable investors as Brian Lee, founder of Shoedazzle; David Lee, a Silicon Valley angel investor who also backed Twitter; and Shana Fisher, managing partner of High Line Venture Partners, a New York fund that was an early investor in Pinterest.

"Jaclyn's a really extraordinary person, as a founder," Fisher said. "She stands out among the best of them."

Shop-Hers had its genesis when Shanfeld left her job at Vision, a modeling agency where at age 23 she was scouting talent, developing the models' careers and booking jobs.

"Once I left the agency, my salary plummeted. I wasn't making money, but I was used to being able to buy designer clothes," said Shanfeld, who grew up in Beverly Hills, the daughter of a screenwriter and real estate developer — and granddaughter of the late comedian Phil Silvers.

Shanfeld found herself attending a series of weddings and recycling the same dresses. A catty remark from someone she knew — "I saw that dress before. Where did I see it? On you, at a wedding last weekend!" — prompted Shanfeld to explore ways to refresh her wardrobe.

Shanfeld began developing the concept of a high-end online resale store where the women who shop runway shows and designer boutiques could sell the unwanted items crowding their closets — and keep as much as 82% of the proceeds. A mutual friend introduced Shanfeld to Stahl, who had overseen the design of Nordstrom's website. Stahl flew down from her home in Seattle, and they worked for a week designing a mock-up of the site. As Stahl and Khuu, the company's chief technical officer, worked on the site, Shanfeld began assembling the inventory.

"I started thinking who in my life has the kind of closet I would love to tap into," Shanfeld said. "So I made a list of every woman that I knew of that had a fantastic wardrobe."

Through emails and in-person appeals — sometimes she would show up at homes with cupcakes and a bottle of wine —– Shanfeld began finding sellers. Among the first was noted Los Angeles art collector Rosette Delug, whose wardrobe includes Balenciaga, Givenchy, McQueen, Maniac and LJB. For years, she would visit family in Turkey, bringing suitcases of clothes, shoes and purses for her sister and nieces. Then, her daughter began mining for treasures in her mother's closet.

"Now with Jaclyn, I get to clean the rest of my closet and get paid for it!" Delug said in an email interview. "She took the items with her, professionally uploaded, labeled and priced images onto her website. Next thing I know, I was receiving steady deposits of money for items I didn't even miss."

As soon as the checks began arriving, Delug said, she celebrated — by buying a new Chanel leather biker jacket and boots.

dawn.chmielewski@latimes.com

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